trauma - emergency resuscitation, perioperative anesthesia, surgical management (wilson, grande,...

TRAUMAEmergency ResuscitationPerioperative Anesthesia

Surgical ManagementVolume 1

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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.

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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



Jose A. Acosta, MD, FACS

Associate Professor of Surgery

Division of Trauma and Critical Care


Naval Medical Center San Diego


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



Richard P. Dutton, MD, MBA

Associate Professor of Anesthesiology


University of Maryland School of Medicine

Director of Trauma Anesthesiology R Adams Cowley Shock-Trauma Center


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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



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


Director, Division of Trauma and Critical Care


Naval Medical Center San Diego


Past Naval Medical Commander

Fallujah and Ramadi, Iraq

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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



Section B: Resuscitation Suite / Trauma ED Management

Richard P. Dutton, MD, MBA

Associate Professor of Anesthesiology


University of Maryland School of Medicine

Director of Trauma Anesthesiology

R Adams Cowley Shock-Trauma Center


Section C: Anesthetic Management and Damage Control for Trauma

Christopher M. Grande, MD, MPH

Executive Director

International TraumaCare (ITACCS)


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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



Bruce Potenza, MD, FACS


Director of Burns, Division of Trauma, Burns and Critical Care


University of California San Diego School of Medicine

La Jolla California

Director UC San Diego Burn Unit



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



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TRAUMAEmergency ResuscitationPerioperative Anesthesia

Surgical Management

edited by

William C. Wilson, MD, MAClinical Professor

Director of Anesthesiology Critical Care ProgramDepartment of Anesthesiology and Critical Care

University of California, San Diego School of MedicineLa Jolla, California

Director of Trauma AnesthesiaAssociate Director Surgical Intensive Care Unit

UC San Diego Medical CenterSan Diego, California, U.S.A.

Christopher M. Grande, MD, MPHExecutive Director

International TraumaCare (ITACCS)Baltimore, Maryland, U.S.A.

David B. Hoyt, MD, FACSJohn E. Connolly Professor and Chairman

Department of SurgeryUniversity of California, School of Medicine

Irvine, CaliforniaUC Irvine Medical CenterOrange, California, U.S.A.

New York London

Volume 1

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Informa Healthcare USA, Inc.270 Madison AvenueNew York, NY 10016

2007 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business

No claim to original U.S. Government worksPrinted in the United States of America on acidfree paper10 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.

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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.

Foreword

From my recent perspective as the 17th surgeon general ofthe United States, along with my prior experiences as atrauma surgeon, combat experienced U.S. Army SpecialForces medical specialist, paramedic, police officer, andregistered nurse, I have witnessed numerous developmentsover the last three decades in the fields of trauma and criticalcare. Despite these significant advances, trauma remainsthe chief cause of death and disability of individualsbetween 1 and 44 years of age; hence, much work remainsto be done.

Trauma is a worldwide phenomenon with profoundpublic health implications and numerous existent chal-lenges, including the need for an increased emphasis onaccident prevention; overcoming barriers to care for the indi-gent, the elderly, and rural populations; and streamliningand improving disaster response effectiveness.

This two-volume book provides comprehensive cover-age of all realms of modern trauma management, includingthe important aforementioned areas of care, which continueto impact the outcomes for these vulnerable populations.

Volume 1 focuses on initial management and isdivided into sections that mirror the continuum of care,including prehospital, resuscitation suite, and perioperativemanagement. The prehospital section includes chapters ontrauma mechanisms, epidemiology, scoring and triage, andtransport. The authors acknowledge that optimal manage-ment algorithms for this early phase of care can differbased on the setting (urban/rural) and the prevailinggeographical, political, and financial conditions. Hospital-based components of management (e.g., primary survey,secondary survey, etc.) are meticulously reviewed, includingspecific chapters on the critical elements of care (e.g.,airway management, fluid therapy, etc.). The perioperativesection details the anesthetic and surgical priorities, butsurgical technical details are minimized in favor of globalmanagement guidelines, which are important to allmembers of the care team. Important trauma-related con-ditions are also fully reviewed.

Volume 2 encompasses the critical care managementof trauma and other surgical conditions. These topics are

arranged in sections according to organ systems, with eachchapter dedicated to a specific lesion or critical illness con-dition. Recent evidence-based principles are fully character-ized, including the management of abdominal compartmentsyndrome, tight glucose control, adrenal suppression, andthromboembolism, etc. In addition, chapters covering post-traumatic stress disorder, family centered care, rehabilita-tion, and palliation at the end of life provide a breadth ofcoverage not present in other trauma books.

Chapters in both volumes are co-authored by expertsfrom complimentary specialties, with surgeons, anesthesiol-ogists, emergency medicine physicians, and pulmonologistsinvolved throughout. Specialty sections are written bymedical or surgical sub-specialists with extensive traumaand critical care experience. Interdisciplinary collaborationis further evident with chapters co-authored or edited byexperienced nurses, pharmacists, and social workers, aswell as occupational, physical, and respiratory therapists,among others.

The editors are eminently qualified and have suc-ceeded in producing an authoritative and comprehensivebook on trauma. Drs. Wilson, Grande, and Hoyt have eachconducted important research and have published andlectured extensively on numerous trauma-related topicsover the last two decades. They have assembled a superbtable of contents and an expert array of contributors andassociate editors. The editors have also insured that rec-ommendations are evidence based where possible. Accord-ingly, the novice will learn in depth about the scientificbasis of the guidelines provided here, and the expert willbe updated on the latest thinking in trauma management.

In summary, this two-volume book is an extremelyvaluable contribution because of the importance of thesubject, the fact that the topic has not been so comprehen-sively covered in one book until now, and because of thewisdom and insight of the editors.

Vice Admiral Richard Henry Carmona, MD, MPH, FACS17th Surgeon General of the United States of America

v

Foreword

The modern-day management of trauma is multidis-ciplinary and requires teamwork. The specialists involvedinclude emergency physicians, anesthesiologists, radiol-ogists, surgeons, toxicologists, and critical care specialistsalong with paramedics, nurses, and technical staff.

Those involved in the management of trauma havea need for a comprehensive book that spans the entire spec-trum of trauma management by all specialists, includingprehospital, perioperative, and critical care. This two-volume book, edited by Wilson, Grande, and Hoyt, doesprecisely that. Along with a superbly designed table ofcontents, the editors have recruited a world-class group ofcontributors from all specialties to write the chapters. Theeditors are abundantly qualified to oversee a work of thismagnitude in terms of academic and intellectual strength,as well as in terms of clinical expertise.

Volume 1 covers the areas of prehospital, emergencydepartment, and perioperative management. Other impor-tant trauma-related conditions (e.g., alcohol and drug intoxi-cation, burns, near drowning, environmental conditions)and management of unique populations of trauma patients(e.g., pediatric, geriatric, and obstetric) are also reviewedby experts in this volume. In addition to reviewing thekey conditions, this volume contains clear guidelines for

medical and surgical decision making in the various stagesof care.

In Volume 2, the critical care management of trauma isreviewed. This volume proceeds in a logical systems-basedpresentation of the conditions and complications commonlyencountered in a modern trauma or surgical intensivecare unit. All of the evidence-based measures recommendedto improve outcomes in critically ill patients are included. Inaddition, emerging topics such as the remote evaluation andmanagement of trauma and critical illness are introduced.

As the only book to cover the full spectrum oftrauma management, this two-volume set is strongly rec-ommended for all students and clinically active physiciansengaged in the management of trauma and surgicalcritical care.

Peter J. F. Baskett, BA, MB, BCh, BAO,FRCA, FRCP, FCEM

Consultant Anaesthetist Emeritus, Frenchay Hospitaland the Royal Infirmary, Bristol, U.K.

Editor-in-Chief, ResuscitationPast President, International Trauma Anaesthesia

and Critical Care Society

vi

Foreword

Three decades ago, as an impressionable resident physician-in-training at the University of Washington in Seattle, I wasasked to respond with the citys emergency medical servicespersonnel on 9-1-1 emergency calls. Working out of theHarborview Emergency-Trauma Center, I soon began torecognize how the outcomes of those with severe injuryare often determined, for better or for worse, in the firstfew minutes after injury. After accompanying hundreds ofpatients from the incident scene, in the back of ambulances,in the emergency centers, and in operating rooms and inten-sive care units, I soon learned that a continuity of optimizedcare must be stewarded by an integrated team of expertsfrom many disciplines. In turn, I have always stressed thatan interdependent chain of survival/recovery had to becreated with each link being strong and solidly connectedto each other. I have been fortunate to train, performresearch, and provide care in all of those arenas, and thusappreciate the tremendous expertise and demands requiredof each team member at each and every link.

This two-volume book (edited by Wilson, Grande, andHoyt) is, in many ways, the first book to examine that entirespectrum of trauma care. Accordingly, as an emergencymedicine physician originally trained in surgical criticalcare and trauma fellowships to challenge sacred cows withclinical trials, and as a prehospital care trauma specialistwho has since spent many a night responding to out-of-hospital 9-1-1 incidents, I am now honored to write aforeword for this book. For those of us who have cometo understand the chain of care and the impact of earlydecision making on long-term outcomes, this book is atremendous gift.

Volume 1 discusses many of the areas with which Iam quite familiar, namely the initial treatment priorities inprehospital care, the resuscitation suite, and the periopera-tive period. These chapters are very current, includingrecent citations emphasizing the need for only a few assistedrescue breaths in conditions of severe circulatory impair-ment, while also minimizing initial intravascular fluidinfusion 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 oftrauma and the other emergency surgical conditionscommonly encountered in modern surgical intensive careunits. Recent evidence-based principles of care are providedfor virtually every condition for which such data exist.In addition, there are chapters focusing on the patientstransition to recovery following the critical care period,including physical, occupational, and psychological rehabili-tation. For example, it addresses screening and treatment ofposttraumatic stress disorder.

Complementing the breadth of material, the chaptersare co-written by experts from all of the relevant pivotal spe-cialties, ranging from resuscitologists, emergency medicinedoctors, anesthesiologists, and orthopedists to the spectrumof surgeons, intensivists, psychiatrists, and rehabilitationexperts. In addition, the co-authors hail from around theglobe, emphasizing the international appeal, perspective,and orientation of this extremely inclusive, contemporarybook.

Finally, I should also say that the editors are exception-ally well qualified for a book of this magnitude. They areall experienced investigators, authors, and internationallecturers on the many topics covered. In summary, thistwo-volume book should be considered as mandatoryreading for every clinician actively involved in the careand management of trauma patients.

Paul E. Pepe, MD, MPH, FACEP, FCCMProfessor of Surgery, Medicine, Public Health

and Riggs Family Chair in Emergency Medicine,University of Texas Southwestern Medical Center

and the Parkland Emergency Trauma CenterDirector, City of Dallas Medical Emergency Services

for Public Safety, Public Health, and Homeland SecurityDallas, Texas, U.S.A.

vii

Foreword

Physicians involved in the care of injured patients comefrom many different disciplines and are sometimes calledtraumatologists. Emergency medical services personnel,emergency physicians, anesthesiologists, surgeons, intensi-vists, and hospital administrators are all concerned with abroad spectrum of trauma management. This two-volumebook, edited by Wilson, Grande, and Hoyt, joins relativelyfew such comprehensive books on this subject and describesmanagement of the trauma patient from a multidisciplinarystandpoint, and emphasizes the anesthesiologists physio-logic perspective.

Internationally, the anesthesiologist is often the resus-citation or reanimation physician, with major responsibil-ities in the ambulance and in the evaluation area ofhospitals, often without a specific trauma service. The tableof contents reflects an international group of contributorsassembled by the editors to author the chapters. Theeditors have ensured academic and intellectual strengthand clinical expertise. They are to be commended for achiev-ing such attention to detail in the first edition.

Dr. William C. Wilson, a trauma anesthesiologist andintensivist, is internationally recognized in the areas oftrauma airway management, respiratory gas exchange,thoracic anesthesia, and monitoring. As editor-in-chief, Dr.Wilsons editorial leadership is evident in the clear organiz-ation of the book, fluency of the writing, and balance ofcoverage.

Dr. Christopher Grande, a clinically active traumaanesthesiologist and intensivist, is the executive director ofInternational Trauma Care (ITACCS). He has publishedextensively in the area of trauma anesthesia and criticalcare for decades. Doctor Grandes editorial influence is evi-denced by the expert international coverage of many topics.

Dr. Hoyt is a world-renowned trauma surgeon andsurgical intensivist. He has been an active leader of numer-ous prestigious surgical trauma organizations, includingpast president of the American Association for the Surgeryof Trauma and the Shock Society, as well as chairman ofthe American College of Surgeons Committee on Trauma.

He is the current president of the Pan American TraumaSociety. Dr. Hoyts experience and wisdom are reflectedin his careful editorial oversight of this comprehensivetwo-volume treatise on trauma care.

Volume 1 covers the areas of prehospital care, resusci-tation, perioperative management, and associated traumaconditions. It is logically organized, covering the keyconditions, and provides clear guidelines for medical andsurgical decision making, including global operative con-siderations. However, by design, esoteric technical detailsof surgical procedures are omitted in favor of generalmanagement concepts and principles supported by recentliterature. 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 oftrauma and is a logical, systems-based presentation of theproblems commonly encountered in a modern intensivecare unit. This volume reviews medical conditions, the roleof psychological factors, the family, rehabilitation, andethics. In addition, emerging topics such as remote evalu-ation and management are introduced.

Because of the fundamental importance of the subjectmatter along with the editorial review, this two-volume setrepresents a compelling resource in the management oftrauma and is highly recommended for all clinicians withprimary responsibility for resuscitation and managementof trauma patients.

Kenneth L. Mattox, MD, FACSProfessor and Vice Chair

Michael E. DeBakey Department of SurgeryBaylor College of Medicine

Chief of SurgeryBen Taub General Hospital

Houston, Texas, U.S.A.

viii

Preface

OVERVIEWOF BOTH VOLUMES

Trauma is the leading cause of death in the young (ages144) in the United States and the chief reason for lostyears of productive life among citizens living in industrial-ized countries. Despite the enormous importance of thesubject matter, no single text has yet been published thatfully covers all phases of trauma management.

The purpose of this book is to bring together in onesource a description of modern clinical management prin-ciples for the care of the trauma patient. This two-volumeset, Trauma, Volume 1: Emergency Resuscitation, PerioperativeAnesthesia, Surgical Management and Trauma, Volume 2:Critical Care, thoroughly encompasses the entire spectrumof trauma management from the prehospital phasethrough critical care and rehabilitation.

A comprehensive table of contents, at the front of eachvolume, encapsulates the organization of the entire book(providing a macroscopic view), and also details the sectionsand sub-headings within each chapter (providing a micro-scopic view). The extensive index at the back of the book isorganized to provide expeditious referral to specific pagesthat cover the subject matter of interest. The reader is encour-aged to utilize both the very detailed table of contents andthe index as needed to quickly locate topics.

Each chapter in this work incorporates importantfeatures that greatly enhance information communicationand learning. The chapters are generously illustrated withfigures and tables to facilitate synthesis of importantconcepts. In addition, key points are highlighted within thetext and are summarized at the end of each chapter forquick review. Care has been taken to minimize redundancyby maximizing appropriate cross-referencing throughout.Another useful aspect of each chapter is the Eye to theFuture section, which reviews emerging concepts and newresearch findings likely to impact clinical management.

The contributors to these volumes are both authorita-tive (having performed original research and authorednumerous publications on their subject matter) and haveextensive clinical experience. The authorship considered asa whole is truly international, with contributors from allcontinents. Furthermore, both civilian and military consider-ations are reviewed whenever relevant. The majority ofchapters have multi-specialty co-authorship by experts intrauma surgery, trauma anesthesiology, emergency medi-cine, and numerous other medical and surgical specialties.In addition, chapters have multidisciplinary involvementby experts in physical medicine, rehabilitation, nursing,and pharmacy, among other disciplines. The scientificsoundness is further insured by the multiple layers ofeditorial oversight; every chapter has been reviewed by atleast three experts in the field (principal, associate andsection editors). The high level of scientific accuracy and

the reader-friendly nature of these two volumes are expectedto facilitate learning in order to improve the care provided totrauma patients around the globe.

VOLUME1

Volume 1 is divided into five sections and begins to tell thetrauma story. Section A (Preparation and Prehospital Care)provides the background knowledge and prehospital con-cepts required to manage trauma patients in both civilianand military settings. Section B instructs the traumatologiston what must be accomplished and accomplished quicklyin the trauma resuscitation suite. Section C explores theprinciples of anesthetic management for trauma, includingpreoperative evaluation, preparation, and monitoring,along with the decision-making processes employed forselecting general or regional anesthetic techniques intrauma patients.

Section D details the perioperative anesthetic andsurgical priorities for specific injuries. This section focuseson the most important areas of management in a systematicfashion, including chapters on maxillofacial, brain, penetrat-ing neck, cardiothoracic, and cervical and thoracic vertebralspine injuries, along with abdominal, pelvic, and extremitytrauma. Each organ system receives specific focus as wellas discussion within the context of the overall managementstrategy for severely injured patients.

Section E surveys the numerous trauma-associatedconditions with important time-sensitive diagnostic andmanagement considerations. This section includes dis-cussions on the management of intoxication due to alcohol,drugs, poisoning, and envenomations. Anaphylaxis andallergy are discussed with specific implications for thetrauma patient. Burn injuries are extensively reviewed, asare cold- and heat-related injuries, near-drowning, andweapons of mass destruction. In addition, the less frequentlyencountered trauma demographics (e.g., pediatrics, geria-trics, obstetrics) each have their own dedicated chapters.Finally, the pitfalls in trauma management and the elementsconstituting the tertiary survey are fully described.

The absolute necessity to begin at the beginning whenlearning trauma management, including the principles ofprehospital care and initial resuscitation and perioperativemanagement concepts, makes this volume a must referencefor the serious traumatologist and all others involved inthis phase of the trauma story.

William C. Wilson, MD, MAChristopher M. Grande, MD, MPH

David B. Hoyt, MD, FACS

ix

Acknowledgments

The editors would like to express gratitude to our familiesand loved ones for their unwavering support during themany years of planning and production of this book.Without their sacrifices, encouragement, and love, thistwo-volume book could not have been completed.

The associate editors and numerous section editorshave likewise sacrificed time from their families and otherprofessional responsibilities during their dedicated workon this important project. We cannot over express ourgratitude for their contributions, or for our delight in thesuperb job accomplished by these gifted experts. Due totheir diligence, this book has achieved a level of editorialoversight seldom found in multi-authored books.

Essential to the production of this work was thesuperb administrative assistance provided by Paul Hobsonand Bertha Englund. Paul, in particular, must be acknowl-edged for his dedicated support, working weekends andlate into many evenings throughout the process of chapterformatting and editing. In addition, the contributions madeby Linda Kesselring, Jan Bailey, and Sereyrathana Kengduring the early stages of this project were critical to the ulti-mate success of the book. The excellent administrativesupport of Linda Collins throughout the project was likewiseessential.

Also vital to the development of this book has been theassistance of ITACCS (International TraumaCare), whose

membership has contributed numerous chapters, andwhose leadership has supported this project throughout itsdevelopment.

Finally, we would like to acknowledge the expertassistance provided by our publishers at Informa Health-care. The professionalism of this organization has beensuperb, starting at the top with Sandra Beberman, andthroughout the publication process with the able assistanceof Vanessa Sanchez and Joe Stubenrauch. The professionalsat the Egerton Group (Joanne Jay and Paula Garber)were likewise essential to the production of this book. Inparticular, Mrs. Garber, editorial supervisor, must becommended for providing excellent attention to detail, astrong work ethic, and calm, kind leadership throughoutthe typesetting and final editing. Geoffrey Greenwoodmust also be acknowledged for helping us initiate thisproject many years ago. Each of these individuals hasserved to kindly and expertly assist our navigationthrough the ardors of the publication process, and we aregrateful to them all.

William C. Wilson, MD, MAChristopher M. Grande, MD, MPH

David B. Hoyt, MD, FACS

xi

Contents

Foreword Richard Henry Carmona . . . . vForeword Peter J. F. Baskett . . . . viForeword Paul E. Pepe . . . . viiForeword Kenneth L. Mattox . . . . viiiPreface . . . . ixAcknowledgments . . . . xiContributors . . . . xxxiii

SECTION A: PREPARATION AND PREHOSPITAL CARESection Editor: Irving Jake Jacoby

1. History of Trauma . . . . 1Panna Sanga, Adolph H. Giesecke, WilliamC. Wilson, and Anne J. Sutcliffe

B Introduction . . . . 1B Prehistory . . . . 2B Early Civilizations, 3000 B.C. 200 A.D. . . . . 2

Egyptians . . . . 2Greeks . . . . 3The Romans . . . . 4

B Dark and Middle Ages and Middle EasternMedical Advances, 2001500 . . . . 6

B Renaissance Era, 1500 . . . . 8B History of Analgesia Through Antiquity

(Through the 1700s) . . . . 12B Epoch of Inhalation Anesthesia, 1800 . . . . 12

The Mexican War of 1845 . . . . 13The American Civil War . . . . 14

B Discovery of Antiseptic Strategies, 1848 . . . . 15B Epoch of Regional Anesthesia, 1884 . . . . 16B Epoch of Intravenous Anesthesia and

Antibiotics, 1934 . . . . 17B Epoch of Fluid Therapy for Trauma, 1950 . . . . 18B Epoch of Precision Monitoring and Resuscitation

for Anesthesia and Trauma, 1986 . . . . 19B Epoch of Emergency Medical Services

(Current Era) . . . . 20B Summary . . . . 21

Key Points . . . . 21B References . . . . 22

2. Mechanisms and Epidemiology of Trauma . . . . 25Bruce Potenza and Jerry Nolan

B Introduction . . . . 25B Mechanisms of Trauma . . . . 26

Precipitating Agents of Injury . . . . 26Biomechanical Forces Generated by Various

Mechanisms . . . . 28Blunt Trauma . . . . 28Penetrating Trauma . . . . 28Gunshot Wounds (Combination of Penetrating

and Blunt Biomechanics) . . . . 28Thermal Injuries . . . . 29Caustic ChemicalRelated Injury . . . . 29

Electrical Injuries . . . . 30Blast Injuries . . . . 30Radiation Injury . . . . 31

Injury Intent . . . . 31Intentional . . . . 31Unintentional . . . . 31

B Scope of Injury and Death Due toTrauma . . . . 31

Injury Pyramid . . . . 32Years of Productive Life Lost and Disability

Adjusted Life Years . . . . 33Trauma Data Base Organizations and

Coding . . . . 33B Demographic Factors . . . . 34

Age-Specific Injury Mechanisms . . . . 34Socioeconomic Status . . . . 34Gender . . . . 35

B Leading Mechanisms of Injury . . . . 35Unintentional Injuries . . . . 35

Motor Vehicle Collisions . . . . 35Pedestrians Struck by a Motor Vehicle . . . . 36Falls . . . . 36Drowning . . . . 36Bicycle . . . . 36Fires and Burns . . . . 36

Intentional Injuries . . . . 36Assault . . . . 37Homicide . . . . 37Suicide . . . . 37War-Related Injuries . . . . 37

B Public Health Approach to InjuryPrevention . . . . 37

B Eye to the Future . . . . 39B Summary . . . . 39


3. Prehospital Care and Trauma Systems . . . . 43Erika Frischknecht Christensen, Charles D. Deakin,Gary M. Vilke, and Freddy K. Lippert

B Introduction . . . . 43B Models of Prehospital Trauma Care . . . . 43

Staffing Models of Prehospital Care . . . . 43Background . . . . 43United States and Canadian Model . . . . 43Central European Model . . . . 44

Comparison of Prehospital Staffing Models . . . . 44Skill Levels and Training of Prehospital

Providers . . . . 45Integration of Prehospital and In-Hospital

Systems . . . . 45Communication Between Hospitals and

Field Units . . . . 46Dispatch . . . . 46On-Scene Communication . . . . 46

B System Management Strategies . . . . 46Overview of Management Strategies . . . . 46Prehospital Mortality Data Drives

Resuscitation Priorities . . . . 47

xiii

Organizational Influences on the System ofPrehospital Care . . . . 47Overview . . . . 47Evidence for Scoop and Run . . . . 47Evidence for Field Stabilization . . . . 47Optimum Mode of Transport . . . . 48

B Prehospital Management Priorities . . . . 48Airway . . . . 48Breathing . . . . 49Circulation . . . . 49

B Communication of Patient Information tothe Trauma Team . . . . 50Prearrival Report . . . . 50Transfer of Care and Patient Information . . . . 51

Mechanism . . . . 51Injuries . . . . 51Vital Signs . . . . 51Treatment . . . . 51

B Trauma Center and Trauma SystemConcepts . . . . 51Background . . . . 51Defining Trauma Centers and Systems . . . . 51Effectiveness of Trauma Centers and Trauma

Systems . . . . 54B Eye to the Future . . . . 54B Summary . . . . 55


4. Trauma Scoring and Triage . . . . 59Daniela Levin, Costas Bachtis, Jose A. Acosta,and Irving Jake Jacoby

B Introduction . . . . 59B Trauma Scoring Definition and

Categorization . . . . 59B Frequently Used Scoring Systems . . . . 60

Glasgow Coma Scale . . . . 60Trauma Score and Revised Trauma Score . . . . 61Organ Injury Scale . . . . 62Abbreviated Injury Scale . . . . 62Injury Severity Score . . . . 62Anatomical Profile . . . . 63Pediatric Scoring . . . . 63Acute Physiological and Chronic Health

Evaluation . . . . 64B Quality Assessment Systems . . . . 65

Trauma ScoreInjury Severity Score . . . . 65A Severity Characterization of Trauma . . . . 65

B Trauma Registries . . . . 66Major Trauma Outcome Study . . . . 66The Utstein Style: Uniformity in Scoring . . . . 66

B Triage Definitions and General Concepts . . . . 67B Triage Applications . . . . 67

Use of Disaster Medical Assistance Teams . . . . 67Out-of-Hospital Triage Principles . . . . 68In-Hospital (Secondary) Triage . . . . 72

B Limitations and Pitfalls of Triage . . . . 73B Special Triage Situations . . . . 74

Civilian Mass Casualty:START/JumpSTARTTM . . . . 74

Nuclear Incidents . . . . 75Biological Agent Release . . . . 75Chemical Agent Release . . . . 76Pediatrics . . . . 78War . . . . 78



5. Resuscitation Suite and OperatingRoom Readiness . . . . 83Sanjeev V. Chhangani, Peter J. Papadakos,William C. Wilson, Wasif Ali, and Jose A. Acosta

B Introduction . . . . 83B Physical Plan of Trauma Resuscitation

Suite . . . . 83Equipment . . . . 84

Airway Cart . . . . 84Procedure Cart . . . . 84Monitors . . . . 84Immobilization Devices . . . . 85Other Equipment . . . . 86

Pharmacologic Agents . . . . 86Communication . . . . 87Preassigned Roles of Trauma Team Members . . . . 89Noise Level Expectations . . . . 89ATLS Training of Personnel . . . . 89Laboratory Support . . . . 91

Blood Bank . . . . 91Clinical Laboratory . . . . 91Radiology . . . . 91Ultrasonography . . . . 91

B Intrahospital Transport . . . . 91Pretransport Patient Evaluation . . . . 92Transport Monitoring . . . . 92

Data Management . . . . 92Coordination of Care . . . . 93

B Physical Plan of Trauma Operating Room . . . . 93Equipment . . . . 94

Anesthesia Machine and Anesthesia Cart . . . . 94Fluid-Warming Devices . . . . 94Procedure and Invasive Line Carts . . . . 94Other Equipment . . . . 95

Pharmacologic Agents . . . . 95Laboratory and Blood Bank

Support Personnel . . . . 95Additional Anesthesia Monitoring and

Support Personnel . . . . 95B Military Resuscitation and Operating Room

Considerations . . . . 96B Eye to the Future . . . . 98B Summary . . . . 98


6. Trauma Team Performance . . . . 101Paul Barach and Matthew B. Weinger

B Introduction . . . . 101B Team Definition and Relevance in

Trauma . . . . 101Team Competence . . . . 101Team Member Conflict

Resolution . . . . 102B Organization of the Modern Trauma Team . . . . 102

The Trauma Team Leader . . . . 102Other Members of the Trauma Team . . . . 103

B Human Factors in the TraumaEnvironment . . . . 103

xiv Contents

Sleep Deprivation and Fatigue . . . . 104Stress and Job Performance . . . . 104Environmental Factors (e.g., Noise, Clutter,

Disorganization) . . . . 105Interpersonal Communication . . . . 105

B Keys to Expert Decision Making forTrauma . . . . 105Correct Decision Making with

Incomplete/Conflicting Data . . . . 105Situation Awareness . . . . 106

B Team Training Techniques . . . . 106Traditional Team Training Exercises . . . . 106Cross Training . . . . 107Team Model Training . . . . 107Trauma Crew Resource Management . . . . 107Simulators for Trauma Team Training and

Assessment . . . . 108Value of Realistic Patient Simulators . . . . 108Importance of Scenario Design . . . . 108Components of a Simulation-Based Training

Course . . . . 108

B Evaluating Trauma TeamPerformance . . . . 108Paucity of Validated Competency Assessment

Metrics . . . . 109Video Analysis of Trauma Care . . . . 109

B Eye to the Future . . . . 109Increased Emphasis upon Computerized

Simulation . . . . 109Incorporating Military and Aviation Industry

Lessons . . . . 110B Summary . . . . 110


7. Transport of the Trauma Patient . . . . 115Jose A. Acosta, Maureen McCunn, William Beninati,William C. Wilson, and Joseph F. Rappold

B Introduction . . . . 115Overview . . . . 115Transportation Guidelines . . . . 116Determining Appropriateness of

Transport . . . . 116B Prehospital and Interhospital

Transport Modes . . . . 117Ground Travel . . . . 117Rotary-Wing Transport . . . . 118Fixed-Wing Transport . . . . 118Miscellaneous Modes of

Transportation . . . . 118B Preparation . . . . 120

Transport Team Members . . . . 120Equipment . . . . 120Safety Considerations . . . . 120

B Potential TransportComplications . . . . 121Hemodynamic Stability . . . . 122Airway and Respiratory

Compromise . . . . 124Intracranial Pressure Considerations . . . . 124Physiological Stresses of Flight . . . . 125

B Long-Range Air TransportConsiderations . . . . 126Trapped Gas . . . . 126

Decompression Sickness/AirEmbolism . . . . 126

Casts/Compartment Syndrome . . . . 126Damage Control/Abdominal Compartment

Syndrome . . . . 127Burns . . . . 127Infection Control . . . . 127

B Special Circumstances . . . . 128Disaster/Mass Casualty . . . . 128Contaminated Casualties . . . . 128Combat MEDEVAC and Transport . . . . 128



SECTION B: RESUSCITATION SUITE/TRAUMA ED MANAGEMENTSection Editor: Richard P. Dutton

8. Primary Survey: Initial ResuscitationPriorities . . . . 135Eran Tal-Or, Koichi Tanigawa, Andreas R. Thierbach,Herbert Kuhnigk, and Moshe Michaelson

B Introduction . . . . 135B Airway Maintenance with Cervical Spine

Protection . . . . 135Assessment . . . . 135Basic Airway Management . . . . 136

Supplemental Oxygen and Chin-Lift/Jaw-Thrust Maneuvers . . . . 136

Oropharyngeal and NasopharyngealAirways . . . . 137

Aspiration Precautions and SuctionDevices . . . . 137

Cervical Spine Precautions . . . . 137

Definitive Airway Management . . . . 138Rapid Sequence Induction . . . . 138Alternative Emergency Airway Devices . . . . 139Surgical Airway . . . . 139Confirmation of Tracheal

Intubation . . . . 139

B Breathing Assessment and Maintenance . . . . 140Physical Examination . . . . 140

Inspection . . . . 140Palpation/Percussion . . . . 141Auscultation . . . . 141

Imaging Aids to Breathing Assessment . . . . 141Life-Threatening

Thoracic Injuries . . . . 143Tension Pneumothorax . . . . 143Massive Hemothorax/Tube

Thoracostomy . . . . 143Sucking Chest Wounds . . . . 143Flail Chest . . . . 143Cardiac Tamponade/Pericardial

Drainage . . . . 144

Mechanical Ventilation in the ResuscitationSuite . . . . 144

B Circulation Assessment and HemorrhageControl . . . . 145Assessment . . . . 145

Definition of HemodynamicStability . . . . 145

Circulation Assessment Principles . . . . 145

Contents xv

Circulatory Depression from NonhemorrhagicCauses . . . . 146

Management of Compensated HemorrhagicShock . . . . 147Shock Prediction and Prevention . . . . 147

Maintenance of Blood Pressure and TissuePerfusion . . . . 147

Management of Uncontrolled HemorrhagicShock . . . . 147

Diagnostic Testing and MonitoringAdjuncts . . . . 147Hemoglobin Measurements . . . . 147Invasive Blood Pressure Monitoring . . . . 147Central Venous Pressure . . . . 147Arterial Blood Gas and Base Deficit . . . . 148Lactate Level . . . . 148FAST Versus DPL Versus CT Scan . . . . 148CT Scan . . . . 148

B Disability . . . . 148General Considerations . . . . 148History . . . . 148

Mechanism of Injury . . . . 148Patient History . . . . 149

Physical Examination . . . . 149Level of ConsciousnessGlasgow

Coma Scale . . . . 149Pupil Examination . . . . 149Motor Examination . . . . 150Sensory Function and Other

Symptoms . . . . 150

B Exposure/Environmental Control . . . . 150Exposure . . . . 150Environmental Control . . . . 150



9. Definitive Airway Management . . . . 155William C. Wilson, Anushirvan Minokadeh, Jonathan L.Benumof, Michael Frass, and Pedro Barbieri

B Introduction . . . . 155B Equipment and Drug Preparation . . . . 155

Oxygen: Critical During Trauma AirwayManagement . . . . 155Treatment of Hypoxemia . . . . 156Preoxygenation: Maximizing

PaO2 During Apnea . . . . 156

Ventilation and IntubationEquipment . . . . 157

Suction Equipment . . . . 158Functioning Intravenous Catheter . . . . 158Monitoring and Endotracheal Tube

Confirmation Devices . . . . 158Vasopressors and Inotropes . . . . 159Portable Storage Unit for Trauma

Resuscitation . . . . 159B Definition of the Difficult Airway . . . . 159

Historical Indicators of AirwayDifficulty . . . . 160

Pathologic/Anatomic Predictors of AirwayDifficulty . . . . 160

B Airway Examination Principles . . . . 161The 11-Step Airway Exam of

Benumof . . . . 161Abbreviated Trauma Airway Exam . . . . 161

B Conventional Trauma AirwayManagement . . . . 161Patient Preparation and Positioning . . . . 161Mask Ventilation . . . . 163

Types of Masks Used for Ventilation . . . . 163Mask Ventilation Techniques . . . . 163

Oropharyngeal and NasopharyngealAirways . . . . 163

Laryngeal Mask Airway . . . . 163Rigid Direct Laryngoscopy . . . . 164

In-Line Cervical Immobilization . . . . 165Rapid Sequence Intubation (RSI)

Principles . . . . 165Modified Rapid Sequence Intubation

Techniques . . . . 167

B The Difficult Trauma Airway . . . . 167Awake Techniques (Cooperative/Stable

Patients) . . . . 167Adjunts for Unstable, Uncooperative, or

Apneic Patients with DifficultAirways . . . . 168Esophageal-Tracheal-Combitube . . . . 168Laryngeal Mask Airway . . . . 168Rigid Bronchoscope . . . . 170Surgical Airway Options . . . . 171

Blind Intubation Techniques (Not Recommendedwith Stridor) . . . . 173Blind Nasal Intubation . . . . 173Light Wand . . . . 175Retrograde Wire . . . . 175

Regional Anesthesia in the Trauma Patientwith Known Difficult Airway . . . . 175

B Fiberoptic Bronchoscopy: Techniques andPitfalls . . . . 175Patient Selection . . . . 176Patient Preparation . . . . 177

Positioning for FiberopticBronchoscopy . . . . 177

Intravenous Analgesia, Sedation, andAntisialagogue . . . . 177

Local Anesthesia and Vasoconstriction . . . . 177

Techniques of Fiberoptic Intubation . . . . 178Awake Nasal Technique . . . . 178Oral Technique . . . . 180

B Difficult Airway Algorithms . . . . 181The ASA Difficult Airway Algorithm . . . . 181

Recognition of the Difficult Airway . . . . 181Awake Limb of the ASA Difficult Airway

Algorithm . . . . 183Uncooperative/Unstable/Anesthetized Limb

of the ASA Difficult Airway Algorithm . . . . 183

ASA Difficult Airway Algorithm Modifiedfor Trauma . . . . 183

Five Common Trauma Difficult IntubationScenarios . . . . 184Traumatic Brain Injury/Intoxication . . . . 184Cervical-Spine Injury . . . . 185Airway Disruption . . . . 185Maxillofacial Trauma . . . . 188Airway Compression . . . . 188

B Emergency Intubation Complications . . . . 189Failure to Intubate or Ventilate . . . . 190Unrecognized Esophageal

Intubation . . . . 191Direct Confirmation of Intratracheal Tube

Position . . . . 191Indirect Confirmation of Intratracheal Tube

Position . . . . 191End-Tidal CO2 Measurement . . . . 191

xvi Contents

Hemodynamic Compromise . . . . 191Causes of Preinduction Increases of

Catecholamines . . . . 192Causes of Hypotension Following Induction

and Intubation . . . . 192Techniques to Limit Hypotension Following

Intubation . . . . 192

Aspiration of Gastric Contents . . . . 192Creating a C-Spine Injury in a Patient with an

Unstable Neck . . . . 192B Eye to the Future . . . . 193B Summary . . . . 194


10. Intravenous Access . . . . 197Robert E. Johnstone, Joseph F. Talarico,Edward E. Cornwell III, and Nelson Tang

B Introduction . . . . 197B Determinants of Intravenous

Flow Rate . . . . 197B Peripheral Intravenous Access . . . . 199

General Considerations . . . . 199Technique . . . . 199

B Central Venous Access . . . . 200General Considerations . . . . 200Complications . . . . 200Internal Jugular Vein Catheterization . . . . 201

General . . . . 201Advantages and Disadvantages . . . . 201Complications . . . . 201Technique 1: Middle Approach . . . . 202Technique 2: Posterior Approach

(Alternate) . . . . 203

Subclavian Vein Catheterization . . . . 203General . . . . 203Advantages and Disadvantages . . . . 203Complications . . . . 203Technique . . . . 204

Femoral Vein Catheterization . . . . 204General . . . . 204Advantages and Disadvantages . . . . 204Complications . . . . 204Technique . . . . 204

B Saphenous Vein Cutdown . . . . 205B Intraosseous Infusion . . . . 205B Intratracheal Administration of

Drugs . . . . 206B Other Infusion Considerations . . . . 206B Special Lines and Maneuvers . . . . 207

Pringle Maneuver . . . . 208Atriocaval Shunts and Atrial Lines . . . . 209Arterial Catheters . . . . 210



11. Fluid Resuscitation Strategy . . . . 215Richard P. Dutton and Robert S. Howard

B Introduction . . . . 215Early vs. Late Resuscitation . . . . 215Recent Advances and Controversies . . . . 215

B Physiology of Hemorrhage . . . . 216Neuroendocrine Response to

Hypotension . . . . 216Cellular Response to Ischemia . . . . 216

Hibernation vs. Apoptosis andNecrosis . . . . 216

The No-Reflow Phenomenon . . . . 216Reperfusion Injury . . . . 217

Organ System Response to Ischemia . . . . 217Cardiovascular System . . . . 217Gastrointestinal System . . . . 218Hepatic System . . . . 218Renal System . . . . 218Central Nervous System . . . . 218Pulmonary System . . . . 218Musculoskeletal System . . . . 218Immune/Hematopoetic System . . . . 219

B Basics of Management . . . . 219Optimum Monitoring . . . . 219

Vital Signs . . . . 219Laboratory Studies . . . . 220Pressure Measurement . . . . 220Measures of Perfusion . . . . 220

Adequate Intravenous Access . . . . 221Warming . . . . 221Availability of Resuscitation Fluids and Blood

Products . . . . 221Personnel . . . . 221Control of Hemorrhage . . . . 222

Bleeding into the Chest . . . . 222Bleeding into the Abdomen . . . . 222Bleeding into the Retroperitoneum . . . . 222Bleeding into Long Bone

Compartments . . . . 222Bleeding Outside the Body . . . . 222

B Resuscitation Fluid Choices . . . . 222Crystalloids . . . . 222

Lactated Ringers Solution . . . . 222Normal Saline . . . . 223Plasmalyte-Aw . . . . 223

Colloids . . . . 223Albumin . . . . 224Gelatins . . . . 224Starch Solutions . . . . 224Dextrans . . . . 224

Crystalloids vs. Colloids . . . . 224Hypertonic Saline . . . . 225Blood Products . . . . 225

Packed Red Blood Cells . . . . 225Plasma . . . . 225Platelets . . . . 225

Blood Substitutes . . . . 226Perfluorocarbons . . . . 226Hemoglobin-Based Oxygen

Carriers . . . . 226

B Guideposts and Endpoints forResuscitation . . . . 227Perfusion Targets for Early Resuscitation . . . . 227

Blood Pressure . . . . 227Lactate and Base Deficit . . . . 227Central Venous and Pulmonary Artery

Pressure . . . . 227Transesophageal Echocardiography . . . . 227End-Organ Perfusion . . . . 227

Perfusion Targets for Late Resuscitation . . . . 227B Controversies in Early Resuscitation . . . . 228

Controlled Hypotension? . . . . 228Wait and Resuscitate or Go to the Operating

Room? . . . . 228

Contents xvii

What Is the Appropriate TransfusionThreshold? . . . . 228

B Special Cases in Fluid Resuscitation . . . . 228Elderly Patients . . . . 228Head-Injured Patients . . . . 228Patients with Cardiac Dysfunction . . . . 229

B Eye to the Future . . . . 229Better Monitors . . . . 229Improved Hemorrhage Control . . . . 229Better FluidsBlunting Reperfusion

Injury . . . . 229Ringers Ethyl Pyruvate Solution . . . . 229Pentoxifylline . . . . 230

B Summary . . . . 231Key Points . . . . 231

B References . . . . 232

12. Initial Circulation Assessment and ShockPrevention . . . . 235Denzil W. Hawkinberry and Anushirvan Minokadeh

B Introduction . . . . 235B Clinical Assessment . . . . 235

History . . . . 235Examination . . . . 236

Mental Status . . . . 236Pulses . . . . 236Blood Pressure . . . . 236Skin Color . . . . 237Urine Output . . . . 237Capnography . . . . 238Focused Assessment with Sonography for

Trauma . . . . 238

B Laboratory Based Assessmentof Circulation . . . . 239Hematocrit and Hemoglobin . . . . 239Blood Gas Analysis . . . . 239

B Invasive Monitors in CirculatoryAssessment . . . . 240Central Venous Catheter . . . . 240Pulmonary Artery Catheter . . . . 241

B Prevention of Shock . . . . 241Definition of Shock and Objectives for

Prevention . . . . 241When Oxygen Delivery Is Adequate, Shock Is

Rare . . . . 241Definition and Terminology of Oxygen

Delivery . . . . 241Response to Initial Fluid Resuscitation . . . . 242

B Complications of MassiveResuscitation . . . . 243Dilutional Anemia . . . . 243Dilutional Coagulopathy . . . . 243Electrolyte Abnormalities . . . . 243Hypothermia . . . . 243



13. Resuscitative Thoracotomy . . . . 247Jeffrey M. Farrier, Rohan Lall, and Raul Coimbra

B Introduction . . . . 247B Definitions . . . . 247B Resuscitative Thoracotomy: Objectives . . . . 248

B Emergency Thoracotomy: Indications . . . . 249Accepted Indications . . . . 249

Penetrating Thoracic Injury . . . . 249Blunt Thoracic Injury . . . . 249Penetrating Nonthoracic Injury . . . . 250

Contraindications . . . . 250B Technical Aspects . . . . 250B Complications . . . . 251B Results and Outcomes . . . . 251B Eye to the Future . . . . 252B Summary . . . . 252


14. Secondary Survey: Comprehensive TraumaEvaluation . . . . 255James I. Merlino, James D. Polk, Jose A. Acosta, andWilliam F. Fallon, Jr.

B Introduction . . . . 255B Timing, Overview, and Decision

Making . . . . 255Comprehensive Evaluation of the Trauma

Patient . . . . 255Timing of the Secondary Survey . . . . 256Decision Making/Prioritizing Injury

Management . . . . 256Advanced Triage . . . . 256Continuous Reassessment . . . . 256Elimination of Missed Injuries . . . . 257

B Patient History . . . . 257Prehospital History . . . . 257Mechanism of Injury . . . . 257Past Medical/Surgical History . . . . 258Medications/Allergies . . . . 258Social History . . . . 258Review of Systems . . . . 258

B Physical Examination . . . . 259Neurological . . . . 259Head/Maxillofacial . . . . 259Neck . . . . 259Chest . . . . 260Abdomen . . . . 260Pelvis/Perineum/Rectum/Vagina . . . . 260Thoracolumbar Spine . . . . 260Extremities . . . . 260Vascular Assessment . . . . 260

B Adjuncts to the Secondary Survey . . . . 260Additional Imaging . . . . 260Additional Laboratory Tests . . . . 260Special Diagnostic Procedures . . . . 261

B Continued Assessment and Planning . . . . 261Overview . . . . 261Input from Consultants . . . . 261Diagnostics and Subsequent

Imaging . . . . 261B Missed Injuries . . . . 261

The Importance of Missed Injuries . . . . 261Strategies for Reducing Missed

Injuries . . . . 262Patient Mental Status . . . . 262Documentation . . . . 262The Tertiary Survey . . . . 262



xviii Contents

15. Cervical Spine: Initial Evaluation andManagement . . . . 267Tudor H. Hughes, Jose A. Acosta, Steven R. Garfin,William C. Wilson, and Alexandra K. Schwartz

B Introduction . . . . 267B Epidemiology . . . . 267B Anatomy . . . . 268

Divisions . . . . 268Bony Elements . . . . 269Ligamentous Support . . . . 270

B Injuries to the Cervical Spine . . . . 270Structural Types . . . . 270

Fractures . . . . 270Ligamentous DisruptionPredicted by

Subluxation/Dislocation Pattern . . . . 271Spinal Cord Injury Without Radiographic

Abnormality . . . . 272

Cervical Spine Fractures and DislocationsClassified by Biomechanical Forces . . . . 272Flexion Injuries . . . . 272Flexion Rotation . . . . 276Extension . . . . 276Vertical Compression . . . . 277

B History and Physical Exam . . . . 278High-Risk Activities Associated with

C-Spine Injury . . . . 278C-Spine Injuries Relationship to Restraint

Devices . . . . 278Motor and Sensory Exam . . . . 279Advanced Trauma Life Support Screening

Approach . . . . 279B Radiographic Trauma Evaluation . . . . 279

Essential Views . . . . 279Cross Table Lateral . . . . 280Open-Mouth Odontoid View . . . . 283AnteriorPosterior View . . . . 283

Additional Views Relegated to Stable PatientSituations . . . . 283Swimmers View . . . . 283Oblique Views . . . . 283Flexion-Extension Lateral Views . . . . 283

Advanced Imaging Modalities . . . . 284Computed Tomography . . . . 284Magnetic Resonance Imaging . . . . 285

B Airway Management . . . . 285B General Approach and Management

Algorithms . . . . 286Awake Patient . . . . 286

The National Emergency X-RadiographyUtilization Study . . . . 287

The Canadian Cervical Spine Rule Study . . . . 287National Emergency X-Radiography

Utilization Study and Canadian CervicalSpine Rule . . . . 288

Obtunded Patient . . . . 288B Eye to the Future . . . . 289B Summary . . . . 289


16. Diagnostic Imaging for Trauma . . . . 293Mary L. Grebenc, David L. Levin, and Susan Kaplan

B Introduction . . . . 293B Basic Concepts of Diagnostic Imaging . . . . 293

Radiation Exposure . . . . 293Patient Exposure . . . . 293

Exposure of Health Care Personnel . . . . 293

Contrast Toxicity . . . . 294B Initial Screening of the Trauma Patient . . . . 294

Screening Studies in the Trauma ResuscitationSuite . . . . 294Radiographs . . . . 294Abbreviated Contrast Studies . . . . 296Ultrasonography . . . . 296

Imaging Studies in the Operating Room . . . . 296Imaging Studies in the Radiology Suite . . . . 296

B Imaging for Specific PathologicalConditions . . . . 297Head Trauma . . . . 297

Anatomy . . . . 297Diagnostic Imaging . . . . 297Common Traumatic Brain Injuries . . . . 297

Spine and Spinal Cord Trauma . . . . 299Anatomy . . . . 299Diagnostic Imaging . . . . 300Cervical Spine Trauma . . . . 301Thoracolumbar Spine Trauma . . . . 302

Thoracic Trauma . . . . 303Evaluation of the AP Chest Radiograph . . . . 303Aortic Injury and Mediastinal Hematoma . . . . 303Pneumothorax and Pneumomediastinum . . . . 304Hemothorax . . . . 305Pulmonary Contusion . . . . 305Rib Fractures . . . . 305Cardiac Injuries . . . . 305Tracheobronchial Injury . . . . 306Esophageal Injury . . . . 307Diaphragmatic Injury . . . . 307Imaging of Nonacute Trauma . . . . 308

Abdominal Trauma . . . . 309Anatomy . . . . 309Focused Assessment with Sonography for

Trauma . . . . 309Computed Tomography . . . . 310Diagnostic Peritoneal Lavage . . . . 312Specific Injuries . . . . 312

Pelvic Trauma . . . . 315Anatomy . . . . 315Classification of Pelvic Fractures . . . . 316Diagnostic Imaging of Pelvic Trauma . . . . 316Organ Injury in Pelvic Trauma . . . . 317

Extremity Trauma . . . . 317Anatomy . . . . 317Diagnostic Imaging . . . . 317Upper Extremity . . . . 317Lower Extremity . . . . 317Complications of Extremity Injuries . . . . 318

Trauma in Pregnancy . . . . 318Pediatric Trauma . . . . 318

Spinal Injury . . . . 318Long-Bone Injuries . . . . 319Child Abuse . . . . 319



SECTION C: ANESTHETIC MANAGEMENT AND DAMAGE CONTROLFOR TRAUMASection Editor: Christopher M. Grande

17. Preoperative Evaluation, Preparation, andMonitoring . . . . 325Beverly J. Newhouse and Carla St. Laurent

B Introduction . . . . 325

Contents xix

B Preoperative Evaluation . . . . 325Prehospital Information Sources . . . . 325Triage to Operating Room vs. Trauma

Resuscitation Suite . . . . 326Priorities During the Primary Survey . . . . 326Information Garnered During the Secondary

Survey . . . . 327Systematic Review of Potential High-Risk

Injuries . . . . 328Airway Injury . . . . 329Maxillofacial Trauma . . . . 329Head Injury . . . . 329Cervical Spine Injury . . . . 330Chest Injury/Aspiration . . . . 330Abdominal, Retroperitoneal, and Pelvic

Injury . . . . 331Extremity Injury . . . . 331Burn Injury . . . . 331

B Preoperative Preparation . . . . 332Preparation of the Trauma Patient . . . . 332Preparation of the Operating Room . . . . 332Selecting a General vs. Regional

Anesthetic . . . . 333B Monitoring Considerations . . . . 333

Monitoring Standards . . . . 333Neurological Monitoring . . . . 333Respiratory Monitoring . . . . 335Hemodynamic Monitoring . . . . 338Electrocardiogram Monitoring . . . . 341Urine Output . . . . 341Temperature Monitoring and Warming

Devices . . . . 341Hematological Monitoring . . . . 342Neuromuscular Blockade Monitoring . . . . 343Fetal Monitoring . . . . 344

B Eye to the Future . . . . 345Auditory Evoked Potential Index . . . . 345Sublingual Capnometry . . . . 345Noninvasive Blood Hemoglobin

Measurement . . . . 345Noninvasive Pulmonary Gas Exchange

Parameters . . . . 345Noninvasive Cardiac Output Monitoring . . . . 345Continuous Noninvasive Blood Pressure

Monitoring . . . . 345Continuous Arterial Blood Gas Analysis . . . . 346



18. Ongoing Resuscitation Endpoints andStrategies . . . . 353Lewis J. Kaplan and Heatherlee Bailey

B Introduction . . . . 353B Cellular Physiology of Hypoperfusion . . . . 353

Mitochondria as the Powerhouse of the Cell . . . . 353Aerobic vs. Anaerobic Respiration . . . . 354

B Goals of Resuscitation . . . . 354Limited Resuscitation Concept . . . . 354Trauma Resuscitation Priorities . . . . 355Damage Control Surgery and Operative

Resuscitation . . . . 355Surgical Intensive Care Unit: Resuscitation

Completion . . . . 355

B Hypothermia . . . . 355Known Benefits and Role in Metabolic

Preservation . . . . 355Potential Problems . . . . 356Induced Hypothermia, Following Trauma . . . . 356

B Review of Resuscitation Endpoints . . . . 356Physical Exam . . . . 356Biochemical Markers . . . . 356

AcidBase Correlation with Survival . . . . 357Lactate as an Arbiter of Hypoperfusion . . . . 357Strong Ion Gap (SIG) Correlation with Trauma

Mortality . . . . 357

Limitations of Using Volume Requirementsas Resuscitation Endpoints . . . . 357

Pulmonary Artery Catheters and Surrogates . . . . 358Transesophageal Echocardiography . . . . 359Esophageal Doppler Monitoring

(Cardiac Output) . . . . 359End Tidal CO2 (PET CO2) . . . . 359Tissue-Specific Endpoints of Resuscitation . . . . 359

Near-Infrared Spectroscopy . . . . 359Sublingual Capnometry . . . . 360Gastric Tonometry . . . . 360

B Blunt vs. Penetrating Trauma . . . . 360B Best Indicators of Resuscitation Success . . . . 360B Eye to the Future . . . . 361B Summary . . . . 361


19. General Anesthesia for Trauma . . . . 365Cheryl Hilty, Anushirvan Minokadeh,and William C. Wilson

B Introduction . . . . 365B Review of Trauma Condition Dictates

Anesthetic Management . . . . 365Airway (with Spinal Cord Protection) . . . . 365Breathing . . . . 365Circulation (with Hemorrhage Control) . . . . 366Disability (Assume Unstable Cervical Spine) . . . . 366Exposure and Environmental

Considerations . . . . 366Full StomachConsiderations

(Increased Risk for Emesis and Aspiration) . . . . 367Drug Intoxication Considerations . . . . 367Suspicion of Occult Injuries . . . . 367Continued Reassessment . . . . 367

B Induction of Anesthesia . . . . 367Preoxygenation . . . . 367Choice of Induction Drugs . . . . 367

Etomidate . . . . 368Ketamine . . . . 369Propofol . . . . 370Thiopental . . . . 371

Neuromuscular Blockade DrugSelection . . . . 372Succinylcholine . . . . 372Rocuronium . . . . 373

Management of Patients HemodynamicallyUnable to Tolerate General Anesthesia . . . . 373Scopolamine and Other Belladonna Alkaloids . . . . 373Titration of Other Agents . . . . 374

B Maintenance of General Anesthesia . . . . 374Inhalation Drugs . . . . 374

Nitrous Oxide . . . . 374Volatile Anesthetics . . . . 375

xx Contents

Intravenous Agents (Total Intravenous Agents) . . . . 376Opioid-Based Techniques . . . . 376Other TIVA Infusion Drugs . . . . 377

Neuromuscular Blocking Drugs . . . . 377B Emergence and Postoperative Planning . . . . 377

Extubation Considerations . . . . 377Conditions Suitable for Tracheal

Extubation . . . . 377Conditions Dictating Retention of

Endotracheal Tube . . . . 377

Postoperative Sedation and Analgesia . . . . 378B Transfer of Care . . . . 378

Transport . . . . 378Report to Critical Care Team . . . . 379

B Eye to the Future . . . . 379Xenon . . . . 379Hydrogen Sulfide . . . . 379



20. Regional Anesthesia for Trauma . . . . 385Daniel Wambold, Edward R. Mariano, andAndrew D. Rosenberg

B Introduction . . . . 385B Risks and Benefits of Regional

Anesthesia . . . . 385B Historical Use of Regional Anesthesia

in War Zones . . . . 386B Determining Appropriateness of Regional

Anesthesia for Trauma . . . . 387B Techniques for Identifying Peripheral Nerves

for Blockade . . . . 388Surface Electrical Stimulation for Nerve

Localization . . . . 388Insulated Needle: Nerve StimulatorMediated

Nerve Localization . . . . 388B Peripheral Nerve Blocks of the Upper

Extremity . . . . 389General Considerations and Brachial Plexus

Anatomy . . . . 389Interscalene Block . . . . 390

Clinical Applications . . . . 390Side Effects/Complications . . . . 390

Technique: Method of Winnie . . . . 390

Infraclavicular Block . . . . 391Clinical Applications . . . . 391Side Effects/Complications . . . . 391

Raj Technique . . . . 391Coracoid Technique . . . . 392

Axillary Block . . . . 392Clinical Applications . . . . 392Side Effects/Complications . . . . 392Technique . . . . 393

Elbow and Wrist Blocks . . . . 393Elbow Blocks . . . . 393Wrist Blocks . . . . 394

Intravenous Regional Anesthesia (Bier Block) . . . . 395Clinical Applications . . . . 395Side Effects/Complications . . . . 395Technique . . . . 395

B Peripheral Nerve Blocks of the LowerExtremity . . . . 395General Considerations and Anatomy . . . . 395Femoral Nerve Block . . . . 396

Clinical Applications . . . . 396

Effects/Complications . . . . 396Technique . . . . 396

Lateral Femoral Cutaneous Nerve Block . . . . 397Clinical Applications . . . . 397Side Effects/Complications . . . . 397Technique . . . . 397

Fascia Iliaca Block . . . . 397Clinical Applications . . . . 397Side Effects/Complications . . . . 397Technique . . . . 397

Sciatic Nerve Blocks . . . . 397Clinical Applications . . . . 397Side Effects/Complications . . . . 398Techniques . . . . 398

Ankle Block . . . . 400Clinical Applications . . . . 400Side Effects/Complications . . . . 400Technique . . . . 400



21. Damage Control . . . . 405Rao R. Ivatury and Ajai K. Malhotra

B Introduction . . . . 405B Patient Selection . . . . 405B Stages of Damage Control . . . . 405

Stage I: Limited Operation (Control of Hemorrhageand Contamination) . . . . 405

Stage II: Resuscitation (Restoration of PhysiologicHomeostasis) . . . . 406

Stage III: Re-operation (Removal of Packs,Definitive Repair) . . . . 406

B Damage Control (Stage I) Operative Priorities forThoracic, Abdominal, and Extremity Injuries . . . . 406Thoracic Considerations . . . . 406

Pulmonary Hemorrhage . . . . 406Cardiac Hemorrhage . . . . 406Aorta and Great Vessels . . . . 406

Abdominal Considerations . . . . 407Liver Hemorrhage . . . . 407Splenic Hemorrhage . . . . 407Pancreatic Injuries . . . . 407Contamination Control from the

Gastrointestinal Tract . . . . 408Renal Hemorrhage . . . . 408Urinary Collecting System Injuries . . . . 408Internal Reproductive Organ Injuries . . . . 408Hemorrhage from Major Abdominal

Vessels . . . . 408Diffuse Abdominal Bleeding . . . . 408

Extremity Injuries . . . . 408Temporary Closure Principles . . . . 409

B Resuscitation Considerations in the SurgicalIntensive Care Unit (Stage II) . . . . 409Shock (Metabolic Acidosis) and

Resuscitation Endpoints . . . . 409Hypothermia . . . . 411Coagulopathy . . . . 411Unplanned Interventions: Emergent Surgery

and/or Angiography . . . . 411B Re-operation: Removal of Packs, Washout,

Definitive Repair . . . . 412General Considerations . . . . 412Operative Strategies for the Difficult-to-Close

Abdomen . . . . 412

Contents xxi

B Cumulative Experience: SupportingDamage Control . . . . 413

B Too Much, Too Often: The Criticism ofDamage Control . . . . 413



SECTION D: ANESTHETIC AND SURGICAL CONSIDERATIONSFOR SPECIFIC INJURIESSection Editors: William C. Wilson and Bruce Potenza

22. Maxillofacial Injuries . . . . 417John T. Moloney

B Introduction . . . . 417Historical Management Review . . . . 417Epidemiology . . . . 417

B Anatomy of Maxillofacial Structures . . . . 418Normal Anatomy of the Face . . . . 418Anatomy of the Base of the Skull . . . . 418

B Mechanisms of Injury and Injury Patterns . . . . 419Blunt . . . . 419Penetrating . . . . 420

B Forces Involved . . . . 420B Common Maxillofacial Injuries . . . . 420

Mandible . . . . 420LeFort Fractures . . . . 420

LeFort I . . . . 420LeFort II . . . . 421LeFort III . . . . 421

Nose . . . . 421Nasoethmoidal Fracture . . . . 421Zygoma . . . . 421Orbit Injuries . . . . 421Fractured Base of Skull . . . . 422

Signs . . . . 423

B Associated Injuries . . . . 423Head Injury . . . . 424Cervical Spine . . . . 424Eyes . . . . 424

Intraocular Pressure . . . . 424Anesthesia and Intraocular Pressure . . . . 425Intraocular Air . . . . 426Oculocardiac Reflex . . . . 426

Ears . . . . 426Blast Injuries and Associated Injuries . . . . 426Barotrauma . . . . 427

Other . . . . 427B Resuscitation . . . . 427B Assessment . . . . 427

Clinical Signs . . . . 427X Ray/Orthopantomogram and

Computed Tomography . . . . 427B Airway Management . . . . 427

Urgent/Semiurgent . . . . 427Elective . . . . 428

Nasotracheal Intubation . . . . 428Tracheostomy . . . . 428Submental Intubation . . . . 428

Teeth Wiring/Banding Issues . . . . 429B Airway Evaluation . . . . 429

Awake vs. Asleep . . . . 429Methods to Facilitate Tracheal Intubation . . . . 429

Fiberoptic Bronchoscope . . . . 429

Bullard Laryngoscope . . . . 429

Cricothyroidectomy vs. Tracheostomy . . . . 429B Antibiotics . . . . 429B Eye to the Future . . . . 429B Summary . . . . 430


23. Traumatic Brain Injury . . . . 433Gus G. Atkins and John C. Drummond

B Introduction . . . . 433B Resuscitation of the Head-Injured Trauma

Patient . . . . 433Initial Brain Resuscitation Priorities: Airway,

Breathing, and Circulation, then IntracranialPressure . . . . 433

Determining Need for Immediate Intubation . . . . 433Cervical Spine Uncertainty Is Common Following

Traumatic Brain Injury . . . . 434Rapid Sequence Induction Drugs in Traumatic

Brain Injury . . . . 434B Management of the Head-Injured Trauma Patient

During Surgery and the PerioperativePeriod . . . . 435Intracranial Pressure Monitoring . . . . 435

Patients Undergoing Craniotomy . . . . 436Nonneurological Surgery in the Traumatic

Brain Injury Patient . . . . 436

Blood Pressure Management . . . . 437Fluid Management . . . . 439

Hypertonic Crystalloids . . . . 439Colloidal Solutions . . . . 439Blood Glucose Management . . . . 440

CO2 Management . . . . 440Choice of Anesthetic Agents . . . . 441Jugular Venous Saturation Monitoring . . . . 442Hypothermia . . . . 442



24. Penetrating Neck Trauma . . . . 447Vance E. Shearer and Randall S. Friese

B Introduction . . . . 447B History . . . . 447B Anatomy . . . . 447B Prevalence . . . . 449B Evaluation . . . . 449

Primary Survey . . . . 449Secondary Survey . . . . 449Diagnostic Work-Up . . . . 450Radiologic Evaluation . . . . 451

Plain Films . . . . 451Arteriography . . . . 451Computed Tomography . . . . 451Duplex Ultrasound . . . . 451FluoroscopyEsophagogram . . . . 452

Endoscopic Evaluation . . . . 452Laryngoscopy/Bronchoscopy . . . . 452Pharyngoscopy/Esophagoscopy . . . . 452

Exploration: Indications for Surgery AreControversial . . . . 452Decision MakingWhich Patients Require

Neck Exploration? . . . . 452

xxii Contents

Technical Considerations and IncisionPlanning . . . . 454

B Management of Specific Injuries . . . . 456Vascular . . . . 456

Carotid Injury . . . . 456Vertebral Artery . . . . 457Venous Injuries . . . . 458

Laryngotracheal . . . . 458Pharyngoesophageal . . . . 458Gland Injuries . . . . 459Thoracic Duct . . . . 459

B Anesthetic Management . . . . 459Preoperative Considerations . . . . 459Airway Management . . . . 460

General Considerations . . . . 460Intubation Techniques . . . . 460

B Airway Management Considerations forSpecific Injuries . . . . 462Airway Trauma . . . . 462Vascular Injury . . . . 462Cervical Spine Injury . . . . 462

B Intraoperative and HemodynamicManagement . . . . 462Intravenous Access and Monitoring . . . . 462Monitoring . . . . 462Specific Injuries . . . . 463

Carotid Artery Injury . . . . 463Cervical Spinal Cord Injury . . . . 463

Management of Venous Air Embolism . . . . 463B Anesthetic Drugs and Techniques . . . . 464

Induction of Anesthesia . . . . 464Maintenance of Anesthesia . . . . 464Emergence and Postoperative Care . . . . 464



25. Cardiothoracic Trauma . . . . 469Yanping Duan, Charles E. Smith, and John J. Como

B Introduction . . . . 469B Incidence . . . . 469B Pathophysiology . . . . 469

Penetrating . . . . 469Blunt . . . . 470Respiratory and Hemodynamic Effects . . . . 470

B Perioperative Assessment and Managementof Specific Thoracic Injuries . . . . 470Airway . . . . 470

Laryngeal Injury . . . . 470Tracheobronchial Injury . . . . 471

Breathing . . . . 472Tension Pneumothorax . . . . 472Open Pneumothorax

(Sucking Chest Wound) . . . . 473Massive Hemothorax . . . . 473Flail Chest . . . . 474Pulmonary Contusion . . . . 475Air Embolism . . . . 475Blast Injuries . . . . 476

Circulation . . . . 476Cardiac Tamponade and Penetrating

Cardiac Injury . . . . 476Blunt Cardiac Injury . . . . 478Emergency Thoracotomy . . . . 479

Diaphragmatic Trauma . . . . 482Video-Assisted Thoracoscopic Surgery . . . . 483

Other Chest Trauma . . . . 483Traumatic Asphyxia . . . . 483Esophageal Rupture . . . . 484Rib, Sternum, and Scapular

Fractures . . . . 484

B Anesthetic Considerations forCardiothoracic Trauma . . . . 484Preoperative Evaluation . . . . 484Specific Anesthetic Agents . . . . 485

Induction Agents . . . . 485Maintenance of Anesthesia . . . . 485Neuromuscular Relaxants . . . . 485

Fluids and Blood . . . . 485Intraoperative Problems . . . . 486

Hypoxemia . . . . 486Hypotension . . . . 486Hypothermia . . . . 487Multiple Surgical Teams . . . . 487

B Indications for and Use of One-LungVentilation . . . . 487Complications . . . . 489

Difficult Intubation . . . . 489Trauma to the Airway . . . . 489Malposition . . . . 489Hypoxemia . . . . 489

B Monitoring Considerations forCardiothoracic Trauma . . . . 490Standard Monitoring . . . . 490Invasive Monitoring . . . . 490Transesophageal Echocardiography . . . . 491

B Pain Management . . . . 491Intravenous Opioids . . . . 492Patient-Controlled Analgesia . . . . 492Nerve Blocks . . . . 492Pleural Catheter . . . . 492Epidural Analgesia . . . . 492

Beneficial Effects . . . . 492Limitations . . . . 493Choice of Agent . . . . 493Complications . . . . 493

Other Methods . . . . 493B Postoperative Considerations Following

Cardiothoracic Trauma . . . . 494Adult Respiratory Distress Syndrome

(ARDS) . . . . 494Sepsis/Multiple System Organ Failure . . . . 494Associated Severe Head Injury . . . . 495Deep Venous Thrombosis . . . . 495



26. Cervical and Thoracic VertebralSpine Trauma . . . . 501Christine C. Nieman, Raman Dhawan,and William C. Wilson

B Introduction . . . . 501B Epidemiology . . . . 501

Mechanism of Injury . . . . 501Anatomic Considerations . . . . 501

B Pathophysiology . . . . 502Primary Insult . . . . 502Secondary Insult . . . . 502

B Preoperative Evaluation . . . . 502Acute Spine InjuryEvaluation Evolves from

the Primary Survey . . . . 502

Contents xxiii

Airway Considerations . . . . 503Breathing Assessment . . . . 503Circulation Considerations . . . . 503Disability (Neurologic Evaluation and Acute

Injury Stabilization) . . . . 504Exposure and Environmental

Awareness . . . . 505

Chronic Spinal Cord InjuryEvaluation ShiftsToward Assessment of CompensatoryChanges . . . . 505Autonomic Hyperreflexia . . . . 505Cardiovascular System Alterations . . . . 505Respiratory Dysfunction . . . . 506Urologic System . . . . 506

B Preoperative Preparation, Airway, andInduction . . . . 506Emergency Surgery, Unstable Spine

(Rapid Sequence Intubation, In-LineImmobilization) . . . . 506

Stable Patient, Unstable Cervical Spine(Awake Endotracheal Tube, AwakePositioning) . . . . 506

Stable Patient, Unstable Thoracic Spine[Awake Positioning, General EndotrachealAnesthesia (GETA) /2 DLT] . . . . 506

Current Strategies to Avoid Paralysis . . . . 507B Overview of Intraoperative Management

and Monitoring . . . . 508Cervical Spine Surgery . . . . 508Thoracic Spine Surgery . . . . 508

B Somatosensory and Motor-EvokedPotential Monitoring . . . . 508Basic Concepts . . . . 508Anesthesia and Somatosensory-Evoked

Potentials . . . . 508General Considerations . . . . 508Somatosensory-Evoked Potentials

Technique of University of CaliforniaSan Diego . . . . 510

Anesthesia and Motor-EvokedPotentials . . . . 511General Considerations . . . . 511Motor-Evoked Potentials Technique of

University of California SanDiego . . . . 512

B Anesthesia-Related Complications in SpineSurgery . . . . 512Airway Swelling . . . . 512Prone Positioning . . . . 512Transcranial Motor-Evoked Potential

Stimulation . . . . 512B Eye to the Future . . . . 512

Thoracoscopic Surgery and ImmediateStabilization/Decompression . . . . 512

Gene Therapy and Anti-inflammatoryDrugs . . . . 513



27. Abdominal Trauma . . . . 517John R. Richards, Jose A. Acosta, andWilliam C. Wilson

B Introduction . . . . 517B Anatomic Considerations . . . . 517

B Classification of Injuries . . . . 517Blunt Abdominal Trauma . . . . 517Penetrating Abdominal Trauma . . . . 518

B Prehospital Care . . . . 519B Hospital Resuscitation and Diagnosis . . . . 519

History and Physical Examination . . . . 519Laboratory Studies . . . . 520Diagnostic Studies . . . . 520

Chest Radiograph . . . . 520Pelvis Radiograph . . . . 520UltrasoundFocused Assessment with

Sonography for Trauma Exam . . . . 520Diagnostic Peritoneal Lavage . . . . 521Computed Tomography . . . . 521Diagnostic Laparoscopy . . . . 521Exploratory Laparotomy . . . . 522Emergency Thoracotomy . . . . 522Other Diagnostic Procedures . . . . 522

B Anesthetic and Surgical Implicationsof Specific Organ Injury . . . . 522Solid Organ Injuries . . . . 522Hollow Organ Injuries . . . . 522Abdominal Vascular Injuries . . . . 523Retroperitoneal Injuries . . . . 523Rupture of the Diaphragm . . . . 523Pregnancy . . . . 523

B Combined Injuries . . . . 523Abdomen and Head Injuries . . . . 523Abdomen and Chest Injuries . . . . 523Abdomen and Pelvic Fracture or Extremity

Injuries . . . . 523B Preparation for Anesthesia and Surgery . . . . 524

Establishing or Confirming Presenceof Definitive Airway . . . . 524

Intravenous Access . . . . 524Evaluation of Preoperative Volume Status . . . . 524Review of Available Lab and Radiographic

Data . . . . 524Monitoring for Major Abdominal Injury . . . . 524Positioning for Abdominal

Trauma Surgery . . . . 524B Induction and Maintenance of Anesthesia . . . . 524

General Anesthesia for Abdominal Trauma . . . . 524Induction . . . . 525Maintenance . . . . 525

Neuraxial Regional Anesthesia and AbdominalTrauma . . . . 526

B Adjunctive Management andComplications . . . . 526Administration of Shed Abdominal Blood . . . . 526Massive Transfusion . . . . 526Thermal Management . . . . 526Neuromuscular Blockade . . . . 526AcidBase Management . . . . 526Antibiotics . . . . 526Other Intraoperative Complications . . . . 527

B Considerations Related to the SurgicalApproach . . . . 527Standard Approach to Exploratory

Laparatomy . . . . 527Pringle Maneuver . . . . 527AtrialCaval Shunt Placement . . . . 527Damage Control, Anesthetic Catch-Up,

and Planned Reoperation . . . . 527B Nonoperative Management . . . . 528

xxiv Contents

B Postoperative Intensive Care UnitConsiderations . . . . 528Abdominal Compartment Syndrome . . . . 528Deep Venous Thrombosis Screening,

Prophylaxis, and Therapy . . . . 528Sepsis . . . . 528Late Complications . . . . 529



28. Pelvic Trauma . . . . 533Alexandra K. Schwartz, Jonathan Dreier,Tudor H. Hughes, Devenend Mangar,and Enrico M. Camporesi

B Introduction . . . . 533B Pelvic Anatomy . . . . 533

Bones and Ligaments . . . . 533Musculature . . . . 534Nerve Plexi . . . . 535Arterial Blood Supply . . . . 535Venous Drainage . . . . 536Pathophysiology of Retroperitoneal Hemorrhage

Following Pelvic Fracture . . . . 536Genitourinary System . . . . 536

B Initial Management . . . . 536Prehospital Care . . . . 536Primary Survey . . . . 537

General Pelvic TraumaConsiderations . . . . 537

Circulatory Access, Evaluation, andControl of Hemorrhage . . . . 537

Ongoing Resuscitation, Disability, andExposure . . . . 538

B Grading of Pelvic Fractures . . . . 539B Diagnostic Evaluation and Treatment

Planning . . . . 539Secondary Survey (Pelvic Fracture

Considerations) . . . . 539Radiographic Evaluation and Other Imaging

Modalities . . . . 540Distinguishing Intraperitoneal from

Retroperitoneal Hemorrhage . . . . 543Stabilization of the Pelvis . . . . 544Angiographic Embolization of Pelvic Vascular

(Retroperitoneal) Hemorrhage . . . . 545B Definitive Therapy Following

Hemorrhage Control . . . . 546B Anesthetic Considerations . . . . 547B Critical Care Management . . . . 548B Eye to the Future . . . . 548B Summary . . . . 549


29. Extremity Trauma . . . . 553Samir Agarwal, Alexandra K. Schwartz,William C. Wilson, Irving Jake Jacoby,John Bramhall, and Jose A. Acosta

B Introduction . . . . 553B Initial Evaluation and Stabilization . . . . 554

Initial Evaluation . . . . 554

Early Resuscitation and TransfusionConsiderations . . . . 554

Evaluation of Vascular Integrity . . . . 555Tourniquet Use . . . . 555Extremity Immobilization, Splinting, and

Traction . . . . 556B Types of Injury and Treatment Options . . . . 556

Lacerations . . . . 556Fractures . . . . 556

Closed Fractures . . . . 556Open Fractures . . . . 557

Dislocations . . . . 557Nerve Avulsion Injuries . . . . 559

Plexus Injury . . . . 559Peripheral Nerve Injury . . . . 559

Traumatic Amputation . . . . 560Crush Injury/Mangled Extremity . . . . 561High-Pressure Injection Injuries . . . . 563Bites . . . . 563Tendon Disruption . . . . 564

B Special Problems . . . . 564Compartment Syndrome . . . . 564Rhabdomyolysis . . . . 564Extremity Infections . . . . 565

Simple Cellulitis or AbscessFormations . . . . 565

Necrotizing Soft Tissue Infections . . . . 566

B Anesthetic Considerations . . . . 569Basic Considerations for General vs. Regional

Techniques . . . . 569Benefits of Regional Anesthesia in

Suitable Candidates . . . . 569Improved Postoperative Analgesia . . . . 569Reduced Postoperative Pneumonia . . . . 569Improved Wound Healing and

Graft Survival . . . . 570



SECTION E: SPECIAL CONDITIONS ASSOCIATED WITH TRAUMASection Editor: Raul Coimbra

30. Drug and Alcohol Intoxication in Trauma . . . . 575David J. Penney and Michael J. A. Parr

B Introduction . . . . 575B Drugs of Abuse and Trauma . . . . 575

MarijuanaTetrahydrocannabinol . . . . 575Benzodiazepines . . . . 576Lysergic Acid Diethylamide . . . . 576Phencyclidine . . . . 576Volatile Solvents . . . . 576

Solvent Abuse . . . . 576

Cocaine . . . . 577Opioids . . . . 579Amphetamines . . . . 580Amphetamine Derivatives . . . . 580Adulterants . . . . 581

B Alcohol and Trauma . . . . 581Recognition of Intoxication . . . . 581Acute Intoxication Effects . . . . 581

Contents xxv

Central Nervous System . . . . 582Respiratory System . . . . 582Cardiovascular System . . . . 582Metabolic Effects . . . . 582

Anesthetic Agent Requirements . . . . 583Injury Outcome . . . . 583Sequelae of Chronic Alcohol Abuse . . . . 583Alcohol Withdrawal Syndrome . . . . 584

B Toxicology Screening . . . . 584B Management Principles . . . . 585

Emergency Management Principles . . . . 585Drug-Specific Factors . . . . 585Patient Factors . . . . 585Health-Care Provider Factors . . . . 585



31. Poisoning and Toxic Exposure . . . . 591Richard F. Clark, William C. Wilson,William H. Richardson, and Tri C. Tong

B Introduction . . . . 591B General Approach to the Patient with

Poisoning or Toxic Exposure . . . . 591Discovering Clues to the Source of Toxic

Exposure . . . . 591History . . . . 591Physical Examination . . . . 591Laboratory Studies . . . . 592Autonomic Syndromes . . . . 592

Decontamination Principles . . . . 593Internal Bowel Decontamination . . . . 593Blood-Cleansing Techniques of

Internal Decontamination . . . . 595External Decontamination . . . . 597

B Inhaled Toxic Gases and Vapors . . . . 597Oxygen Toxicity . . . . 597

Oxygen-Induced Seizures . . . . 597Oxygen-Induced Pulmonary Toxicity . . . . 597

Carbon Dioxide Absorbent Toxicity . . . . 598Toxic Gases Associated with Combustion

and Oxidation . . . . 598Toxic Gases of Industry . . . . 599

Methylbromide . . . . 599Chlorine . . . . 599Cyanide . . . . 599

War Gases and Personal Protection Spra

trauma - emergency resuscitation, perioperative anesthesia, surgical management (wilson, grande,...

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