Manual of DSTC

Manual of Definitive Surgical
Trauma Care
This page intentionally left blank
Manual of Definitive
Surgical Trauma Care
Third edition
Edited by
Kenneth D Boffard BSc(Hons) FRCS FRCPS FCS(SA)

Professor & Clinical Head, Department of Surgery,
Johannesburg Hospital and University of the Witwatersrand,
South Africa
First published in Great Britain in 2003 by Hodder Arnold
Second edition 2007
This third edition published in 2011 by

Hodder Arnold, an imprint of Hodder Education, a division of Hachette UK
338 Euston Road, London NW1 3BH
http://www.hodderarnold.com
2011 IATSIC (International Association for Trauma Surgery and Intensive Care)
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Contents
Board of contributors xvii

Preface xxi
Introduction xxiii
Injury prevention
Training in the management of severe trauma xxiii
The Advanced Trauma Life Support course xxiii
Surgical trauma training beyond ATLS xxiii
Surgical training courses in trauma xxiv
The DSTC course xxv
Summary xxv
References xxv
Part 1: overview 1
1 Overview 3
1.1 Resuscitation in the emergency department 3
1.2 Management of major trauma 3
1.2.1 Resuscitation 3
1.2.2 Management of penetrating trauma 7
1.3 Emergency department surgery 8
1.3.1 Craniofacial injuries 8
1.3.2 Chest trauma 9
1.3.3 Abdominal trauma 9
1.3.4 Pelvic trauma 10
1.3.5 Long bone fractures 10
1.3.6 Peripheral vascular injuries 10
1.4 Summary 10
1.5 References 11
1.6 Recommended reading 11
Part 2: Physiology and metabolism 13
2 Resuscitation physiology 15
2.1 Metabolic response to trauma 15
2.1.1 Definition of trauma 15
2.1.2 Initiating factors 15
2.1.3 Immune response 16
2.1.4 Hormonal mediators 18
2.1.5 Effects of the various mediators 20
2.1.6 The anabolic phase 22
vi | Manual of Definitive Surgical Trauma Care
2.1.7 Clinical and therapeutic relevance 22

2.2 Shock 22
2.2.1 Definition of shock 22
2.2.2 Classification of shock 22
2.2.3 Measurements in shock 25
2.2.4 End points in shock resuscitation 29
2.2.5 Post-shock and multiple organ failure syndromes 30
2.2.6 Management of the shocked patient 30
2.2.7 Prognosis in shock 34
2.2.8 Recommended protocol for shock 35
2.3 References 35
Part 3: transfusion in trauma 37
3 Transfusion in trauma 39
3.1 Indications for transfusion 39
3.1.1 Oxygen-carrying capacity 39
3.1.2 Volume expansion 39
3.2 Transfusion fluids 39
3.2.1 Fresh whole blood 39
3.2.2 Component therapy (platelets, FFP, cryoprecipitate) 40
3.3 Effect of transfusing blood and blood products 40
3.3.1 Metabolic effects 41
3.3.2 Effects of microaggregates 41
3.3.3 Hyperkalaemia 41
3.3.4 Coagulation abnormalities 41
3.3.5 Other risks of transfusion 41
3.4 Action 42
3.4.1 Current best standards of practice 42
3.4.2 Reduction in the need for transfusion 43
3.4.3 Transfusion thresholds 43
3.4.4 Transfusion ratios 43
3.4.5 Adjuncts to enhance clotting 43
3.4.6 Monitoring the coagulation status 44
3.5 Autotransfusion 45
3.6 Red blood cell substitutes 46
3.6.1 Perfluorocarbons 46
3.6.2 Haemoglobin solutions 46
3.7 Massive haemorrhage/massive transfusion 47
3.7.1 Definition 47
3.7.2 Protocol 47
3.8 References 49
Part 4: damage control surgery 51
4 Damage control surgery 53

4.1 Damage control 53
4.1.1 Stage 1: Patient selection 53
4.1.2 Stage 2: Operative haemorrhage and contamination control 54
Contents | vii
4.1.3 Stage 3: Physiological restoration in the ICU 56

4.1.4 Stage 4: Operative definitive surgery 56
4.1.5 Stage 5: Abdominal wall reconstruction if required 56
4.1.6 Re-laparotomy 56
4.1.7 Delayed closure 57
4.1.8 Outcomes 57
4.2 Abdominal compartment syndrome 57
4.2.1 Definition of ACS 57
4.2.2 Pathophysiology 58
4.2.3 Causes of raised IAP 58
4.2.4 Effect of raised IAP on individual organ function 59
4.2.5 Measurement of IAP 59
4.2.6 Treatment 60
4.2.7 Surgery for raised IAP 61
4.2.8 Management algorithm 61
4.2.9 World Society of the Abdominal Compartment Syndrome 61
4.3 References 63
4.4.1 Damage control 63
4.4.2 Abdominal compartment syndrome 63
Part 5: Specific Organ Injury 65
5 The neck 67
5.1 Overview 67
5.2 Management principles 67
5.2.1 Initial assessment 67
5.2.2 Use of diagnostic studies 68
5.3 Treatment 69
5.3.1 Mandatory versus selective neck exploration 69
5.3.2 Treatment based on anatomical zones 69
5.3.3 Rules 70
5.4 Access to the neck 70
5.4.1 Incision 71
5.4.2 Carotid artery 71
5.4.3 Midline visceral structures 72
5.4.4 Root of the neck 72
5.4.5 Collar incisions 72
5.4.6 Vertebral arteries 72

6 The chest 73
6.1 Overview 73
6.1.1 Introduction: the scope of the problem 73
6.1.2 The spectrum of thoracic injury 73
6.1.3 Pathophysiology of thoracic injuries 74
6.1.4 Applied surgical anatomy of the chest 74
6.1.5 Paediatric considerations 76
6.1.6 Diagnosis 77
6.1.7 Management 77
viii | Manual of Definitive Surgical Trauma Care
6.1.8 Emergency department thoracotomy 85

6.1.9 Surgical approaches to the thorax 87
6.2 Access to the thorax 87
6.2.1 Anterolateral thoracotomy 87
6.2.2 Median sternotomy 88
6.2.3 The clamshell thoracotomy 89
6.2.4 Posterolateral thoracotomy 89
6.2.5 Trapdoor thoracotomy 89
6.3 Emergency department thoracotomy 89
6.3.1 Requirements 89
6.3.2 Approach 90
6.3.3 Emergency procedures 90
6.3.4 Definitive procedures 91
6.4 Summary 92
6.5 References 92
93
7 The abdomen 93
7.1 The trauma laparotomy 93
7.1.1 Overview 93
7.1.2 The trauma laparotomy 94
7.1.3 Closure of the abdomen 100
7.1.4 Haemostatic adjuncts in trauma 101
7.1.5 Briefing for operating room scrub nurses 102
7.1.6 Summary 102
7.2 The bowel 102
7.2.1 Stomach 103
7.2.2 Small bowel 103
7.2.3 Large bowel 103
7.2.4 Mesentery 104
7.2.5 Adjuncts 104
7.3 The liver and biliary system 105
7.3.1 Overview 105
7.3.2 Resuscitation 105
7.3.3 Diagnosis 105
7.3.4 Liver injury scale 106
7.3.5 Management 106
7.3.6 Surgical approach 107
7.3.7 Complications 111
7.3.8 Injury to the retrohepatic vena cava 112
7.3.9 Injury to the bile ducts and gallbladder 113
7.4 The spleen 113
7.4.1 Overview 113
7.4.2 Anatomy 113
7.4.3 Diagnosis 114
7.4.4 Splenic injury scale 114
7.4.8 Outcome 117
Contents | ix
7.5 The pancreas 117

7.5.1 Overview 117
7.5.2 Anatomy 117
7.5.3 Mechanisms of injury 117
7.5.4 Diagnosis 118
7.5.5 Pancreas injury scale 119
7.5.8 Adjuncts 123
7.5.9 Pancreatic injury in children 123
7.5.11 Summary of evidence-based guidelines 124
7.6 The duodenum 124
7.6.1 Overview 124
7.6.2 Mechanism of injury 125
7.6.3 Diagnosis 125
7.6.4 Duodenal injury scale 126
7.7 Abdominal vascular injury 130
7.7.1 Overview 130
7.7.2 Injuries of the aorta and vena cava 130
7.7.3 Retroperitoneal haematoma in the abdomen 130
7.7.5 Shunting 134
7.8 The urogenital system 135
7.8.1 Overview 135
7.8.2 Renal injuries 135
7.8.3 Ureteric injuries 139
7.8.4 Bladder injuries 140
7.8.5 Urethral injuries 141
7.8.6 Scrotal injury 142
7.8.7 Gynaecological injury and sexual assault 142
7.8.8 Injury of the pregnant uterus 143
7.9 References 143
7.10.1 The trauma laparotomy 146
7.10.2 The liver 147
7.10.3 The spleen 147
7.10.4 The pancreas 147
7.10.5 The duodenum 147
7.10.6 Abdominal vascular injury 147
7.10.7 Urogenital system 147

8 The pelvis 148
8.1 Introduction 148
8.2 Anatomy 148
8.3 Classification 148
8.3.1 Type A 149
8.3.2 Type B 149
x | Manual of Definitive Surgical Trauma Care
8.3.3 Type C 149

8.4 Clinical examination and diagnosis 149
8.5 Resuscitation 150
8.5.1 Haemodynamically normal patients 150
8.5.2 Haemodynamically stable patients 150
8.5.3 Haemodynamically unstable patients 150
8.5.4 Laparotomy 150
8.6 Pelvic packing 151
8.6.1 Technique of extraperitoneal pelvic packing 151
8.7 Complex pelvic injuries 152
8.7.1 Diagnosis 152
8.7.2 Surgery 152
8.8 Associated conditions 152
8.8.1 Head injuries 152
8.8.2 Intra-abdominal injuries 152
8.8.3 Urethral injuries 152
8.8.4 Anorectal injuries 153
8.9 Summary 154
8.10 References 154

9 Extremity trauma 155
9.1 Overview 155
9.2 Management of severe injury to the extremity 155
9.3 Key issues 155
9.3.1 Management of open fractures 155
9.3.2 Severity of injury (Gustilo classification) 155
9.3.3 Sepsis and antibiotics 155
9.3.4 Venous thromboembolism 156
9.3.5 Timing of skeletal fixation in polytrauma patients 156
9.4 Massive limb trauma; life versus limb 157
9.4.2 Scoring systems 159
9.5 Compartment syndrome 160
9.6 Fasciotomy 160
9.6.1 Four-compartment fasciotomy 161
9.6.2 Fibulectomy 161
9.7 Complications of major limb injury 161
9.8 Summary 162
9.9 References 162
Part 6: ADDITIONal (OPtional) modules 163
10 Critical care of the trauma patient 165

10.2 Goals of trauma ICU care 165
10.3 Phases of ICU care 165
10.3.1 Resuscitative phase (first 24 hours post-injury) 165
10.3.2 Early life support phase (2472 hours post-injury) 166
Contents | xi
10.3.3 Prolonged life support (>72 hours post-injury) 166

10.3.4 Recovery phase (separation from the ICU) 167
10.4 Hypothermia 167
10.4.1 Rewarming 167
10.5 Systemic inflammatory response syndrome 168
10.6 Multisystem organ dysfunction syndrome 169
10.7 Coagulopathy of major trauma 169
10.8 Recognition and treatment of raised ICP 170
10.9 Recognition of acute renal failure 170
10.10 Evaluation of metabolic disturbances 170
10.11 Pain control 170
10.12 Family contact and support 171
10.13 ICU tertiary survey 171
10.13.1 Evaluation for occult injuries 171
10.13.2 Assess co-morbid conditions 171
10.14 Nutritional support 171
10.14.1 Access for enteral nutrition 172
10.15 Preventive measures in the ICU 172
10.15.1 Stress ulceration 172
10.15.2 Deep vein thrombosis and pulmonary embolus 172
10.15.3 Infection 172
10.16 Antibiotics 173
10.17 Respiration 174
10.18 Organ donation 174
10.19 References 174

11 Austere conditions and battlefield surgery 176
11.2 Injury patterns 176
11.3 Emergency medical service systems 177
11.3.1 Incident management and multiple casualties 178
11.4 Triage 179
11.4.1 Forward surgical teams and triage 180
11.5 Mass casualties 180
11.6 Evacuation 181
11.7 Resuscitation 181
11.7.1 Overview 181
11.7.2 Damage control resuscitation 183
11.7.3 Damage control surgery in the military setting 183
11.8 Blast injury 184
11.8.1 Diagnosis and management of primary blast injuries 184
11.9 Battlefield analgesia 185
11.10 Battlefield anaesthesia 185
11.10.1 Damage control anaesthesia in the military setting 186
11.11 Critical care 186
11.12 Translating military experience to civilian trauma care 186
11.13 Summary 187
xii | Manual of Definitive Surgical Trauma Care

11.15.1 Ballistics: history, mechanisms, ballistic protection and casualty management 187
11.15.2 Blast injury 188
11.15.3 War surgery 188

12 Ultrasound in trauma 189
12.1 Focused abdominal sonography for trauma 189
12.2 Applications of ultrasound in trauma 189
12.2.1 Ultrasound in abdominal trauma 189
12.2.2 Ultrasound in thoracic trauma 189
12.2.3 Other applications of ultrasound 190
12.3 Pitfalls 190
12.4 Summary 190

13 Minimally invasive surgery in trauma 191
13.1 Thoracic injury 191
13.2 Diaphragmatic injury 191
13.3 Abdominal injury 191
13.3.1 Screening for intra-abdominal injury 191
13.3.2 Splenic injury 192
13.3.3 Liver injury 192
13.3.4 Bowel injury 190
13.4 Risks of laparoscopy in trauma 192
13.5 Summary 192
13.6 References 192

14 Burns 194
14.1 Overview 194
14.2 Anatomy 194
14.3 Depth of the burn 195
14.3.1 Superficial burn (erythema) 195
14.3.2 Superficial partial thickness burn 195
14.3.3 Deep partial thickness burn 195
14.3.4 Indeterminate partial thickness burn 195
14.3.5 Full thickness burn 196
14.4 Area of the burn 196
14.5 Management 196
14.5.1 Safe retrieval 196
14.5.2 First aid 196
14.5.3 Emergency department 197
14.5.4 Definitive management 199
14.6 Special areas 201
14.6.1 Face 201
14.6.2 Hands 201
14.6.3 Perineum 201
14.6.4 Feet 202
14.7 Adjuncts in burn care 202
14.7.1 Nutrition in the burned patients 202
Contents | xiii
14.7.2 Ulcer prophylaxis 202

14.7.3 Venous thromboembolism prophylaxis 202
14.7.4 Antibiotics 202
14.8 Criteria for transfer 203
14.9 Summary 203
14.11.1 Websites 203

15 Head trauma 204
15.1 Injury patterns 204
15.2 Depressed skull fractures 204
15.3 Penetrating injury 204
15.4 Adjuncts to care 204
15.5 Burr holes 206
15.6 Summary 207
15.7 References 207

16 Special patient situations 208
16.1 Paediatrics 208
16.1.1 Introduction 208
16.1.2 Injury patterns 208
16.1.3 Pre-hospital 208
16.1.4 Resuscitation room 208
16.1.5 Specific organ injury 209
16.1.6 Analgesia 210
16.2 The elderly 210
16.2.1 Definition and response to trauma 210
16.2.2 Physiology 210
16.2.3 Influence of co-morbid conditions 211
16.2.4 Multiple medications polypharmacy 211
16.2.5 Analgesia 211
16.2.6 Outcome 211
16.3 Futile care 211

17 Interventional radiology in trauma 213
17.2 Pelvic fractures 213
17.3 Blunt splenic injuries 213
17.4 Liver injuries 213
17.5 Aortic rupture and injury to middle-sized arteries 213

Appendices 215
Appendix A Trauma systems 217

A.1 Introduction 217
xiv | Manual of Definitive Surgical Trauma Care
A.2 The inclusive trauma system 217

A.3 Components of an inclusive trauma system 218
A.3.1 Administration 218
A.3.2 Prevention 218
A.3.3 Public education 218
A.4 Management of the injured patient within a system 219
A.5 Steps in organizing a system 219
A.5.1 Public support 219
A.5.2 Legal authority 219
A.5.3 Establish criteria for optimal care 219
A.5.4 Designation of trauma centres 219
A.5.5 System evaluation 219
A.6 Results and studies 219
A.6.1 Panel review 220
A.6.2 Registry study 220
A.6.3 Population-based studies 220
A.7 Summary 220
A.8 References 220
A.9 Recommended reading 220

Appendix B Trauma scores and scoring systems 221
B.1 Introduction 221
B.2 Physiological Scoring Systems 221
B.2.1 Glasgow Coma Scale 221
B.2.2 Revised Trauma Score 221
B.2.3 Paediatric Trauma Score 222
B.3 Anatomical Scoring Systems 222
B.3.1 Abbreviated Injury Scale 222
B.3.2 Injury Severity Score 223
B.3.3 New Injury Severity Score 223
B.3.4 Anatomic Profile 223
B.3.5 ICD-based Injury Severity Score 224
B.3.6 Organ Injury Scaling System 224
B.3.7 Penetrating Abdominal Trauma index 224
B.4 Outcome analysis 224
B.4.1 Glasgow Outcome Scale 224
B.4.2 Major Trauma Outcome Study 225
B.4.3 A Severity Characterization of Trauma 226
B.5 Summary 226
B.6 Scaling System for Organ-specific Injuries 226
B.7 References 239

Appendix C Definitive Surgical Trauma Care course: course requirements and syllabus 241
C.1 Background 241
C.2 Course development and testing 241
C.3 Course details 242
C.3.1 Ownership 242
C.3.2 Mission statement 242
C.3.3 Application to hold a course 242
C.3.4 Eligibility to hold a course 242
Contents | xv
C.3.5 Course material and overview 242

C.3.6 Course director 242
C.3.7 Course faculty 242
C.3.8 Course participants 243
C.3.9 Practical skill stations 243
C.3.10 Course syllabus 243
C.3.11 Course certification 243
C.4 IATSIC recognition 243
C.5 Course information 243

Appendix D Definitive Surgical Trauma Care course: core surgical skills 244
D.1 The neck 244
D.2 The chest 244
D.3 The abdominal cavity 244
D.4 The liver 245
D.5 The spleen 245
D.6 The pancreas 245
D.7 The duodenum 245
D.8 The genitourinary system 245
D.9 Abdominal vascular injuries 246
D.10 Peripheral vascular injuries 246

Appendix E: Briefing for operating room scrub nurses 247
E.1 Introduction 247
E.2 Preparing the operating room 247
E.2.1 Environment 247
E.2.2 Blood loss 247
E.2.3 Instruments 248
E.2.4 Cleaning 248
E.2.5 Draping 248
E.2.6 Adjuncts 248
E.3 Surgical procedure 249
E.3.1 Instruments 249
E.3.2 Special instruments and improvised gadgets 249
E.4 Abdominal closure 249
E.5 Instrument and swab count 249
E.6 Critical incident stress issues 250
E.7 Conclusion 250
E.8 References 250
E.9 Recommended reading 250
250
Index 251
Board of contributors
Philip Barker Peter Danne

Emeritus Professor of Military Surgery Associate Professor
Honorary Consultant Trauma Surgeon Department of Surgery
Johannesburg Hospital Royal Melbourne Hospital
South Africa Melbourne
Australia
Chris Bleeker
Consultant Anaesthesiologist Stephen Deane
Radboud University Nijmegen Medical Centre Professor of Surgery
Nijmegen, Netherlands School of Medicine and Public Health
University of Newcastle;
Douglas Bowley Clinical Chair
Consultant Surgeon and Senior Lecturer Division of Surgery
Academic Department of Military Surgery and Trauma John Hunter Hospital
Royal Centre for Defence Medicine Locked Bag 1, HRMC
Birmingham
UK Elias Degiannis
Professor of Surgery
Adam Brooks Chris Hani Baragwanath Hospital
Consultant HPB Surgeon University of the Witwatersrand;
Nottingham University Hospitals NHS Trust Trauma Directorate
Nottingham Chris Hani Baragwanath Academic Hospital
UK Johannesburg
South Africa
Howard Champion
Professor of Surgery Abe Fingerhut
Professor of Military and Emergency Medicine First Department of Surgery
Uniformed Services University of the Health Sciences Hippocration Hospital
Bethesda, MD University of Athens Medical School
USA Athens
Greece
Ian Civil
Consultant Surgeon Megan Fisher
Auckland City Hospital Consultant Urologist
Auckland Vincent Pallotti and Kingsbury Hospitals
New Zealand Cape Town
South Africa
xviii | Manual of Definitive Surgical Trauma Care
Sascha Floh Lenworth M Jacobs

Consultant Surgeon Professor of Surgery
Department of Trauma and Hand Surgery University of Connecticut School of Medicine;
University of Duesseldorf Director, Trauma Program
Germany Hartford Hospital
Hartford, CT
Tina Gaarder USA
Consultant Surgeon and Head
Department of Traumatology Donald H. Jenkins
Oslo University Hospital Mayo Clinic
Norway Rochester, MN
USA
Jacques Goosen
Adjunct Professor Christoph Kaufmann
Head, Johannesburg Hospital Trauma Unit Professor of Surgery
University of the Witwatersrand East Tennessee State University
Johannesburg Johnson City, TN
South Africa USA
Jan Goris Ari Leppaniemi

Academisch Ziekenhuis Department of Abdominal Surgery
Nijmegen Meilahti Hospital
The Netherlands University of Helsinki
Helsinki
Timothy Hardcastle Finland
Consultant Trauma Surgeon
Inkosi Albert Luthuli Central Hospital; Sten Lennquist
Honorary Senior Lecturer in Surgery Professor of Surgery Emeritus
University of KwaZulu-Natal Durban University of Linkping
South Africa Sweden
Gareth Hide Peter F Mahoney

Consultant Surgeon Defence Professor of Anaesthesia and Critical Care
Sunninghill Hospital Royal Centre for Defence Medicine
Sandton Birmingham
Johannesburg; UK
Part-Time Consultant And Lecturer
Johannesburg Hospital Trauma Unit Ronald V. Maier
University of the Witwatersrand Professor and Vice Chair of Surgery
Johannesburg Harborview Medical Center
South Africa University of Washington
Seattle, WA
David Hoyt USA
Executive Director
American College of Surgeons Ernest E. Moore
Chicago, IL Bruce Rockwell Distinguished Chair of Trauma Surgery
USA Denver Health;
Professor and Vice Chairman of Surgery
University of Colorado Denver
Denver, Colorado
USA
Board of contributors | xix
David Mulder Nigel Tai

McGill University Consultant Vascular Surgeon
Montreal, Quebec Royal London Hospital
Canada London
UK
Pl Nss
Consultant Paediatric Surgeon Donald D Trunkey
Oslo University Hospital Ulleval Emeritus Professor of Surgery
Oslo Oregon Health Sciences University
Norway Portland, OR
USA
Graeme Pitcher
Clinical Associate Professor Fernando Turgano
Department of Surgery Head, General Surgery 2 and Emergency Surgery
Division of Pediatric Surgery University Hospital Gregorio Maran
University of Iowa Childrens Hospital Madrid
Iowa City Spain
USA
Selman Uranues
Frank Pleni Professor of Surgery
Consultant Trauma Surgeon Medical University of Graz
Chris Hani Baragwanath Academic Hospital and Graz
Department of Surgery Austria
University of the Witwatersrand
Johannesburg Pantelis Vassiliu
South Africa Lecturer of Surgery
4th Surgical Clinic
Charles W Schwab Attikon Hospital
Professor of Surgery University of Athens
Chief: Division of Traumatology and Surgical Critical Greece
Care
Hospital of the University of Pennsylvania Arie B van Vugt
Philadelphia, PA Traumasurgeon
USA Medisch Spectrum Twente
Enschede, Netherlands
Elmin Steyn
Consultant Surgeon Adrian O Wilson
Head of Emergency Centres Director
Vincent Palotti and Christiaan Barnard Memorial African Foundation for Research and Interdisciplinary
Hospitals Training and Ageing
Cape Town Harare
South Africa Zimbabwe
Michael Sugrue
Consultant Surgeon
Letterkenny General and Galway University Hospital
Ireland
Preface
Unless they deal with major trauma on a particularly fre- The resources, both physical and intellectual, within
quent basis, few surgeons can attain and sustain the level the hospital, and the ability to anticipate and identify
of skill necessary for decision-making in major trauma. the specific problems associated with patients with
This includes both the intellectual decisions, and the multiple injuries
manual dexterity required to perform all the manoeuvres The limitations in providing specialist expertise within
for surgical access and control. These can be particularly the time frame required.
challenging and may be infrequently required, yet rapid
In 1993, five surgeons (Howard Champion, USA;
access to, and control of sites of haemorrhage following
Stephen Deane, Australia; Abe Fingerhut, France; David
trauma can be a life-saving surgical intervention. Many
Mulder, Canada; and Don Trunkey, USA), members of the
situations require specialist trauma expertise, yet often
International Society of Surgery Socit Internationale
this is simply not available within the time frame in which
de Chirurgie (ISS-SIC) and the International Association
it is required
for Trauma Surgery and Intensive Care (IATSIC), met
In years past, many surgeons honed their skills in war,
in San Francisco during the meeting of the American
and translated them into the techniques required in peace.
College of Surgeons. It was apparent that there was a
In the twenty-first century, this has changed, so that most
specific need for further surgical training in the technical
surgeons work in an environment of peace, while a few
aspects of surgical care of the trauma patient, and that
serve in lower key conflicts. In many countries, the inci-
routine surgical training was too organ-specific or area-
dence of injury, particularly from vehicle-related trauma,
specific to allow the development of appropriate judge-
has fallen below the numbers recorded when records were
ment and decision-making skills in traumatized patients
first kept. Many injuries are now treated non-operatively,
with multiple injuries. Particular attention needed to be
so operative exposure and the skills required are reduced
directed to those who were senior trainees or had com-
as well. Occasionally, for this reason, the decision not to
pleted their training.
operate is based on inexperience or insecurity, rather than
It was believed that a short course focusing on the life-
on good clinical judgement.
saving surgical techniques and surgical decision-making
It is not enough to be a good operator. The effective
was required for surgeons, in order to further train the
practitioner is part of a multidisciplinary team that plans
surgeon who dealt with major surgical trauma on an
for, and is trained to provide, the essential medical and
infrequent basis to deal with major trauma. This course
surgical response required in the management of the
would meet a worldwide need, and would supplement
injured patient.
the well-recognized and accepted American College of
Planning the response requires a clear understanding of:
Surgeon Advanced Trauma Life Support (ATLS) course.
The causation, including mechanism of injuries The experience that Sten Lennquist had gained offering
occurring within the local population 5-day courses for surgeons in Sweden was integrated into
The initial, pre-hospital and emergency department the programme development, and prototype courses were
care of the patient offered in Paris, Washington and Sydney.
The condition in which the patient is delivered to the At International Surgical Week in Vienna in 1999,
hospital and subsequently to the operating theatre, IATSICs members approved a core curriculum, and a
which will be determined by the initial response, manual that forms the basis of the Definitive Surgical
which itself may determine outcome Trauma CareTM (DSTC) course. The manual was first
xxii | Manual of Definitive Surgical Trauma Care
published in 2003, a second edition in 2007, and this for their very great efforts put into the preparation, edit-
third edition in 2011. The manual is updated approxi- ing, dissection, redissection and assembly of the manual
mately every 4 years. and the course.
Initial DSTC courses were then launched in Austria This third edition had been revised and updated, tak-
(Graz), Australia (Melbourne and Sydney) and South ing into account new evidence-based information. The
Africa (Johannesburg). The material presented in these increased (and occasionally harmful) role of non-oper-
courses has been refined and a system of training devel- ative management has been recognized, with additional
oped using professional education expertise, and the information, including the role of interventional radi-
result forms the basis of the standardized DSTC course ology. With the increased need for peace-keeping, and
that now takes place. A unique feature of the course is modern asymmetrical conflicts, each carrying its own
that while the principles are standardized, the course can, spectrum of injury, the military module has been substan-
once it has been established nationally in a country, be tially updated.
modified to suit the needs and circumstances of the envi- The book is divided into sections:
ronment in which the care takes place.
Physiology and the metabolic response to trauma
The Education Committee of IATSIC has an
Transfusion in trauma (new)
International DSTC Subcommittee that oversees the qual-
Damage control and the abdominal compartment
ity and content of the courses. However, the concept of the
syndrome
DSTC course has remained the same. In addition to the
Chapters on each anatomical area or organ system,
initial founding countries (Australia, Austria and South
divided into both an overview of the problems
Africa), courses have been delivered in more than 24 coun-
and pitfalls specific to the system, and the surgical
tries across the world, with new participants joining the
techniques required to deal with major injury in that
IATSIC programme each year. The course and its manuals
area
are presented in English, Portuguese, Spanish and Thai.
Additional modules that cover specific aspects of
The DSTC course is designed to support those who,
specialized care, including burns, head injury and the
whether through choice or necessity, must deal with
extremes of age
major surgical injury and may not necessarily have the
A separate appendix for the use of operating room
experience or expertise required. The requirements for a
scrub nurses, which has been added to the appendices.
DSTC course or the establishment of a DSTC programme
can be found in Appendix C of this manual. This manual is dedicated to those who care for the
A Board of Contributors, made up of those who have injured patient and whose passion is to do it well.
contributed to the DSTC programme, continues to sup- Ken Boffard
port and update this manual. I would like to thank them Editor
Introduction
Injury (trauma) remains a major health problem Training in the management of severe
worldwide, and in many countries it continues to trauma
grow. The care of the injured patient should ideally be
a sequence of events involving education, prevention, The Advanced Trauma Life Support course
acute care and rehabilitation. In addition to improving
all aspects of emergency care, improved surgical skills The Advanced Trauma Life Support (ATLS) programme
will save further lives and contribute to minimizing of the American College of Surgeons is probably the most
disability. widely accepted trauma programme in the world, with
The standard general surgical training received in nearly 60 national programmes taking place at present,
the management of trauma is often deficient, partly and more than one million physicians trained.
because traditional surgical training is increasingly Kobayoshi wrote that many of the surgeons in Japan
organ-specific, concentrating on superspecialties have a high standard of surgical skills before entering
such as vascular, hepatobiliary or endocrine surgery, traumatology, but that each emergency care centre sees
and partly because, in most developed training pro- only a few hundred major trauma cases per year. Many
grammes, there is a limited exposure to the range of trauma cases, especially associated with non-penetrating
injured patients. trauma, are treated non-operatively, resulting in insuffi-
cient operative exposure for the training of young trauma
surgeons.1
Injury prevention Barach et al. reported that the ATLS was introduced to
Israel in 1990, and that, by the time of their paper, over
Injury prevention can be divided into three parts: 4000 physicians had been trained. In 1994, the Israeli
Primary prevention education and legislation are used Medical Association scientific board accredited the
to reduce the incidence of injury, for example driving ATLS programme and mandated that all surgery resi-
under the influence of alcohol. dents become ATLS-certified.2 Arreola-Risa and Speare
Secondary prevention minimizing the incidence reported that there were no formal post-residency train-
of injury through design, for example seatbelts, ing programmes in Mexico. The ATLS course has been
helmets, etc. successfully implemented, and there was at that time
Tertiary prevention once the injury has occurred, a 2-year waiting list.3 Jacobs described the development
minimizing the effects of that injury by better and of a trauma and emergency medical services system in
earlier care. Jamaica. There was a significant need for a formalized
trauma surgical technical educational course that could
Although primary and secondary prevention of injury be embedded in the University of the West Indies.4
will undoubtedly play some of the major roles in the
reduction of mortality and morbidity due to trauma,
there will also be a need to minimize tertiary injury to Surgical trauma training beyond atls
patients as a result of inadequate or inappropriate man-
agement. This will require training in the techniques of Trauma in both well-developed and developing coun-
advanced management of physical injury. tries continues to be a major public health problem
xxiv | Manual of Definitive Surgical Trauma Care
and financial burden, both in the pre-hospital setting ventilation is controlled, but the deaths occur in hospital
and within the hospital system. In addition to increas- from uncontrollable bleeding. Not only do the various
ing political and social unrest in many countries, and an techniques for orthopaedic haemostasis, such as stabili-
increasing use of firearms for interpersonal violence, the zation of fractures, pelvic fixation and the management of
car has become a substantial cause of trauma worldwide. major cranial injury, have an important place in the initial
These socio-economic determinants have resulted in a management of trauma patients, but the surgical control
large number of injured patients. of bleeding and a clear understanding of the physiology of
In the United States, trauma affects both the young trauma are essential.
and the elderly. It is the third leading cause of death for Military conflicts occur in numerous parts of the world.
all ages, and the leading cause of death from age 1 to 44 These conflicts involve not only the superpowers, but
years.5 Persons under the age of 45 account for 61 per cent also the military of a large number of other countries. It
of all injury fatalities and 65 per cent of hospital admis- is essential that the military surgeon be well prepared to
sions. However, persons aged 65 and older are at a higher manage any and all penetrating injuries that occur on the
risk of both fatal injury and a more protracted hospital battlefield. The increasing dilemma that is faced by the
stay. About 50 per cent of all deaths occur minutes after military is that modern conflicts are in general asynchro-
injury, and most immediate deaths are because of mas- nous, with only one side in uniform, small and well con-
sive haemorrhage or neurological injury. Autopsy data tained, and do not produce casualties in large numbers or
have demonstrated that central nervous system injuries on a frequent basis. For this reason, it is difficult to have
account for 4050 per cent of all injury deaths, and haem- a large number of military surgeons who can immediately
orrhage accounts for 3035 per cent. Motor vehicles and be deployed to perform highly technical surgical proce-
firearms accounted for 29 per cent and 24 per cent of all dures in the battlefield arena or under austere conditions.
injury deaths, respectively, in 1995.6,7 It is increasingly difficult for career military surgeons to
In South Africa, there is a high murder rate (56 per gain adequate exposure to battlefield casualties, or indeed
100000 population) and a high motor vehicle accident penetrating trauma in general, and, increasingly, many
rate.8 military training programmes are looking to their civilian
There are other areas of the world, such as Australia and counterparts for assistance.
the United Kingdom, where penetrating trauma is unu- These statistics mandate that surgeons responsible for
sual, and sophisticated injury prevention campaigns have the management of these injured patients, whether mili-
significantly reduced the volume of trauma. However, tary or civilian, are skilled in the assessment, diagnosis
there is a significant amount of trauma from motor and operative management of life-threatening injuries.
vehicles, falls, recreational pursuits and injury affecting There remains a poorly developed appreciation among
the elderly. The relatively limited exposure of surgeons many surgeons of the potential impact that timely and
to major trauma has reduced their expertise in this field, appropriate surgical intervention can have on the out-
mandating a requirement for designated trauma hospi- come of a severely injured patient. Partly through lack
tals and specific skill development in the management of of exposure, and partly because of other interests, many
major trauma. surgeons quite simply no longer have the expertise to deal
Furthermore, there are multiple areas of the develop- with such life-threatening situations. For these reasons, a
ing world in the West Indies, South America, the Asia- course needs to be flexible in order to accommodate the
Pacific region and Africa where general surgical training local needs of the country in which it is being taught.
may not necessarily include extensive operative education There is thus an increasing need to provide the surgical
and psychomotor technical expertise in terms of trauma skills and techniques necessary to resuscitate and manage
procedures. There are other countries where thoracic sur- these patients surgically not only in the emergency depart-
gery is not an essential part of general surgical training. ment, but also during the period after ATLS is complete.
Therefore general surgeons called upon to definitively
control thoracic haemorrhage may not have had the tech-
niques required incorporated into their formal surgical Surgical training courses in trauma
training.
With improving pre-hospital care across the world, The Advanced Trauma Operative Management Course
patients who would previously have died are reach- of the American College of Surgeons was developed by
ing hospital alive. In many situations, their airway and Lenworth M Jacobs about 10 years ago, and is a 1-day
Introduction | xxv
course comprising a didactic lecture series followed by Didactic lectures designed to introduce and cover the
exercises on live, anaesthetized animal models. It is an key concepts of surgical resuscitation, the end points
effective method of increasing surgical competence and and an overview of the best access to organ systems.
confidence in the operative management of penetrating Cadaver sessions in which use is made of fresh or
injuries to the chest and abdomen. preserved human cadavers and dissected tissue. These
The Definitive Surgical Trauma CareTM (DSTC) was are used to reinforce the vital knowledge of human
developed on the initiative of six international surgeons anatomy related to access in major trauma. Other
from 1993, and is owned by the International Association alternatives are available if local custom or legislation
for Trauma Surgery and Intensive Care (IATSIC), an does not permit the use of such laboratories
Integrated Society of the International Society of Surgery Animal laboratories where possible, use is made of
in Lupsingen, Switzerland. It comprises a 3-day course live, anaesthetized animals, prepared for surgery. The
with short didactic lectures followed by extensive opera- instructor introduces various injuries. The objects
tive discussion, group discussions, case discussions and of the exercise are to both improve psychomotor
operative exercises on live anaesthetized animals. The skills and teach new techniques for the preservation
emphasis is on both the surgical techniques used in of organs and the control of haemorrhage. The
trauma and, additionally, on the surgical decision-mak- haemorrhagic insult is such that it is a challenge to
ing required to choose the best method of management. both the veterinary anaesthetist and the surgeon to
The course currently takes place in 24 countries, and in maintain a viable animal. This creates the real-world
four languages (English, Portuguese, Spanish and Thai). scenario of managing a severely injured patient in the
operating room.
Case presentations this component is a strategic
The DSTC course thinking session illustrated by case presentations.
Different cases are presented that allow free
discussion between the students and the instructors.
Course objectives These cases are designed to put the didactic and
By the end of the course, the student will have received psychomotor skills that have been learned into the
training to allow: context of real patient management scenarios.
Enhanced knowledge of the surgical physiology of the

trauma patient Summary
Enhanced surgical decision-making in trauma
Enhanced surgical techniques in the management of The course is therefore designed to prepare the relatively
major trauma fully trained surgeon to manage difficult surgically cre-
An improved awareness of the treatment possibilities ated injuries that mimic the injuries that might present to
in major trauma and their evidence base. a major trauma centre. The course fulfils the educational,
cognitive and psychomotor needs for mature surgeons,
surgical trainees and military surgeons, all of whom need
Description of the course
to be comfortable in dealing with life-threatening pen-
A prerequisite of the DSTC course is a complete under- etrating and blunt injury, irrespective of whether it is in
standing of all the principles outlined in a general surgi- the military or the civilian arena.
cal training, and also the ATLS course. For this reason,
there are no lectures on the basic principles of trauma sur-
gery, or the initial resuscitation of the patient with major References
injuries.
The course consists of a core curriculum, designed to be 1 Kobayashi K. Trauma care in Japan. Trauma Q 1999;14:249
an activity lasting 2 days. In addition to the core curricu- 52.
lum, there are a number of modules that can be added to 2 Barach P, Baum E, Richter E. Trauma care in Israel. Trauma
the course to allow it to be more suited to local conditions Q 1999;14:26981.
in the area in which it is being taught. 3 Arreola-Risa C, Speare JOR. Trauma care in Mexico. Trauma
The course consists of a number of components: Q 1999; 14:21120.
xxvi | Manual of Definitive Surgical Trauma Care
4 Jacobs LM. The development and implementation of comparison of death rates in two periods, 1983 through
emergency medical and trauma services in Jamaica. Trauma 1985 and 1987 through 1989. JAMA 1992;267:30548.
Q 1999;14:2215. 7 Bonnie RJ, Fulco C, Liverman CT. Reducing the Burden of
5 Fingerhut LA, Warner M. Injury Chartbook. Health, United Injury, Advancing Prevention and Treatment. Institute of
States. 19961997. Hyattsville, MD: National Center for Medicine. Washington, DC: National Academy Press, 1999:
Health Statistics,1997. 4159.
6 Fingerhut LA, Ingram DD, Felman JJ. Firearm homicide 8 Brooks AJ, Macnab C, Boffard KD. Trauma care in South
among black teenagers in metropolitan counties: Africa. Trauma Q 1999;14:30110.
Part 1
Overview
Overview 1
1.1Resuscitation in the of these patients either bleed to death or die from primary
emergency department or secondary injuries to the central nervous system. In
order to reduce this mortality, the surgeon must promptly
Patients with life-threatening injuries represent approxi- restore adequate tissue oxygenation and perfusion, iden-
mately 1015 per cent of all patients hospitalized for tify and control any haemorrhage, diagnose and evacuate
injuries.1 Some authors have defined severe trauma as mass intracranial lesions, and treat cerebral oedema. The
a patient who has an Injury Severity Score greater than first physician to treat a severely injured patient must
15.24 For triage purposes, information available in the start the resuscitation immediately and collect as much
pre-hospital phase and primary survey should be used. information as possible. In addition to patient symptoms,
A standardized approach, utilizing the MIST hand necessary information includes mechanism of injury and
over, should be used (Table 1.1). the presence of pre-existing medical conditions that may
influence the critical decisions to be made.
Table 1.1 The MIST handover
Unfortunately, the collection of information requires
M Mechanism of injury time. Time is usually not available, and the work-up of the
I Injuries observed
critically injured patient often must be rushed. In order to
maximize resuscitative efforts and to avoid missing life-
S Vital signs
threatening injuries, various protocols for resuscitation
T Therapy instituted
have been developed, of which the Advanced Trauma Life
Support Course (ATLS)6 is a model. We use the ATLS as a
Deforming and destructive injuries can be obvious, paradigm for assessment, resuscitation and prioritization
but the surgeon or physician initially treating the patient of the patients injuries.
must promptly conduct a systematic work-up, so that all Guideline times for the length of stay in the emergency
wounds, including occult mortal injuries, can be treated department (ED) should be as follows:
optimally.
For the unstable patient, time in the ED should be no
longer than 15 minutes.
The unstable patient should either be in the operating
1.2Management of major trauma room or the intensive care unit (ICU) within 15 minutes.
For the stable patient, time in the ED should be no
The principles of management for patients suffering
longer than 30 minutes.
major trauma are:
The stable patient should be in the computed
Simultaneous assessment and resuscitation tomography (CT) scanner or ICU within 30 minutes.
A complete physical examination
Diagnostic studies if the patient becomes
haemodynamically stable 1.2.1 Resuscitation
Life-saving surgery.
Resuscitation is divided into two components:
Time is working against the resuscitating physician:
62 per cent of all trauma patients who die in hospital die The primary survey and initial resuscitation
within the first 4 hours of hospitalization.5 The majority The secondary survey and continuing resuscitation.
4 | Manual of Definitive Surgical Trauma Care
All patients undergo the primary survey of airway, contusion, cardiac tamponade, and tracheal-bronchial
breathing and circulation. Only those patients who injury must be identified, and treatment must be insti-
become haemodynamically stable will progress to the tuted within minutes after arrival. Clinical diagnosis of
secondary survey, which focuses on a complete physical these conditions is much more difficult than is preached,
examination that directs further diagnostic studies. The and immediate availability of an X-ray of the chest is vital.
great majority of patients who remain haemodynamically
unstable require immediate operative intervention. Circulation
Simultaneous with airway management, a quick assess-
1.2.1.1 Primary survey ment of the patient will determine the degree of shock
present. Shock is a clinical diagnosis and should be appar-
The priorities of the primary survey are:
ent. A quick first step is to feel an extremity. If shock is
Establishing a patent airway with cervical spine control present, the extremities will be cool and pale, lack venous
Adequate ventilation filling and have poor capillary refill. The pulse will be
Maintaining circulation (including cardiac function thready, and consciousness will be diminished. At the
and intravascular volume) same time, the status of the neck veins must be noted. A
Assessing the global neurological status. patient who is in shock with flat neck veins is assumed to
have hypovolaemic shock until proven otherwise. If the
neck veins are distended, the most likely possibilities are:
Airway
Patients with extensive trauma who are unconscious or in Tension pneumothorax
shock benefit from immediate endotracheal intubation.7,8 Pericardial tamponade
To prevent spinal cord injury, the cervical spine must Myocardial contusion (cardiogenic shock)
not be excessively flexed or extended during intubation. Myocardial infarct (cardiogenic shock)
Oral endotracheal intubation is successful in the major- Air embolism.
ity of injured patients. A few patients require nasotra-
cheal intubation performed by an experienced physician. Pitfall
During intubation, firm compression of the cricoid car- Note that the absence of distended neck veins does not
tilage against the cervical spine occludes the oesophagus exclude these diagnoses because the circulating volume
and may reduce the risk of aspirating vomitus. On rare may be so depleted that the circulation is too empty.
occasions, bleeding, deformity or oedema from maxillo- Tension pneumothorax always should be the number
facial injury will require emergency cricothyroidotomy or one diagnosis in the physicians differential diagnosis of
planned tracheostomy. Patients likely to require a surgical shock since it is the life-threatening injury that is easi-
airway include those with a laryngeal fracture and those est to treat in the ED. A simple tube thoracostomy is the
with a penetrating injury of the neck or throat. The airway definitive management.
priorities are to clear the upper airway, to establish high- Pericardial tamponade is most commonly encoun-
flow oxygen initially with a bag mask, and to proceed tered in patients with penetrating injuries to the torso.
immediately to endotracheal intubation in the majority, Approximately 25 per cent of all patients with cardiac
and to a surgical airway in a few. injuries will reach the ED alive. The diagnosis is often
obvious. The patient has distended neck veins and poor
peripheral perfusion, and a few will have pulsus paradoxus.
Breathing Ultrasonography may establish the diagnosis in a very
Patients with respiratory compromise are not always easy few patients with equivocal findings. Pericardiocentesis
to detect. Simple parameters, such as the respiratory rate is an occasionally useful diagnostic or therapeutic aid.
and adequacy of breathing on simple clinical parameters, Proper treatment is immediate thoracotomy, preferably
should be examined within the first minute after arrival. in the operating room, although ED thoracotomy can be
One of the most important things is to detect a tension life-saving.9
pneumothorax, necessitating direct drainage by needle Myocardial contusion is a rare cause of cardiac failure
thoracostomy followed by the insertion of a chest tube. in the trauma patient.
The major threats to life, for example a tension pneumo Myocardial infarction from coronary occlusion is not
thorax, massive haemothorax, flail chest and pulmonary uncommon in the elderly.
Overview | 5
Air embolism10,11 is a syndrome that has relatively and has premorbid conditions. Blood gas determinations
recently been appreciated as important in injured should be obtained early during resuscitation.
patients; it represents air in the systemic circulation The third priority is to determine where the patient
caused by a bronchopulmonary venous fistula. Air embo- may have occult blood loss. Three sources for hidden
lism occurs in 4 per cent of all major thoracic injuries. blood loss are the pleural cavities, which can be elimi-
Thirty-five per cent of the time it is due to blunt trauma, nated as a diagnosis by rapid chest X-ray, the thigh and
usually a laceration of the pulmonary parenchyma by a the abdomen, inclusive of the retroperitoneum and pelvis.
fractured rib. In 65 per cent of patients, it is due to gun- A fractured femur should be clinically obvious. However,
shot wounds or stab wounds. The surgeon must be vigi- assessment of the abdomen by physical findings can
lant when pulmonary injury has occurred. Any patient be extremely misleading. Fifty per cent of patients with
who has no obvious head injury but has focal or later- significant haemoperitoneum have no clinical signs.12,13
alizing neurological signs may have air bubbles occlud- Common sense dictates that if the patients chest X-ray
ing the cerebral circulation. The observation of air in is normal and the femur is not fractured, the patient who
theretinal vessels on fundoscopic examination confirms remains in shock must be suspected of having ongoing
cerebral air embolism. haemorrhage in the abdomen or pelvis. Most of these
Any intubated patient on positive-pressure ventilation unstable patients require immediate laparotomy to avoid
who has a sudden cardiovascular collapse is presumed to death from haemorrhage. An important caveat is not to
have either tension pneumothorax or air embolism to the delay mandated therapeutic interventions to obtain non-
coronary circulation. Doppler monitoring of an artery critical diagnostic tests.
can be a useful aid in detecting air embolism. Definitive The fourth priority for the resuscitating physician is to
treatment requires immediate thoracotomy followed by consider activation of the massive bleeding protocol and
clamping of the hilum of the injured lung to prevent fur- order resuscitation fluids, starting with crystalloids and
ther embolism, followed by expansion of the intravascular adding type-specific whole blood or blood components as
volume. Open cardiac massage, intravenous adrenaline soon as possible.14,15
(epinephrine) and venting the left heart and aorta with a The fluid used to resuscitate a hypotensive patient
needle to remove residual air may be required. The pulmo- will depend on the patients response to fluid load. The
nary injury is definitively treated by oversewing the lacera- rapid responder may require no more than crystalloids
tion or resecting a lobe. to replace the volume deficit. The transient responder
If the patients primary problem in shock is blood loss, may need the addition of colloid or blood. The only prac-
the intention is to stop the bleeding. If this is not possible, tical way to measure atrial filling pressure in the ED and
the priorities are: immediately in the operating room is by central venous
pressure monitoring. In elderly patients with extensive
To gain access to the circulation
traumatic injuries, early cardiac flow monitoring is help-
To obtain a blood sample from the patient
ful. Resuscitation should be directed to achieve adequate
To determine where the volume loss is occurring
oxygen delivery and oxygen consumption.
To give resuscitation fluids
Crystalloid, synthetic colloids such as gelatins and dex-
To prevent and treat coagulopathy
trans, as well as blood are available to replace volume in
To prevent hypothermia.
hypotensive patients. It is clear that patients requiring mas-
Access is preferably central, via the subclavian route (an sive transfusions need the oxygen-carrying capacity of red
8 French Gauge [FG] introducer, more commonly used cells. Data suggest that trauma leads to leaky cells in the
for passing a pulmonary artery catheter, can be used), pulmonary capillary bed, and the use of colloid puts these
via percutaneous cannulation of the femoral vein with a patients at further risk. The use of starches in the bleeding
large-bore catheter or an 8FG introducer (the equivalent patient has specific negative effects on coagulation.
can be done at elbow level). Alternative ways to gain access Bickell and colleagues16 found that the survival in
to the circulation are by a surgical cutdown on the saphe- patients with penetrating torso trauma was improved if
nous vein at the ankle. fluid replacement was delayed. He suggested that imme-
As soon as the first intravenous line has been estab- diate volume replacement in these patients might disrupt
lished, baseline blood work is obtained that includes hae- blood clot that had obliterated a bleeding vessel.
matocrit, toxicology, blood type and crossmatch, and a Research continues on the use of haemoglobin oxygen
screening battery of laboratory tests if the patient is older carriers as effective substitutes for blood.
Although whole blood is preferred, it is commonly dif- language is an indication of functioning cerebral hemi-
ficult to obtain whole blood from modern blood banks, spheres. If the patient attempts to protect himself from a
forcing the use of blood components. Loss of more than 2 painful insult, this also implies cortical function. Arousal
units of blood should invoke a predefined massive bleed- is a crude function that is simple wakefulness. Eye-
ing protocol (most current massive transfusion protocols opening, either spontaneous or in response to stimuli, is
aim at predefined ratios of packed red blood cells:fresh indicative of arousal and is a brainstem function. Coma is
frozen plasma:platelets mimicking whole blood) and a pathological state in which both awareness and arousal
monitored by frequent coagulation tests, conventional are absent. Eye-opening does not occur, no comprehensi-
laboratory tests (platelet count, International Normalized ble speech is detected, and the extremities move neither to
Ratio, prothrombin time, partial thromboplastin time and command nor appropriately to noxious stimuli.
fibrinogen) and more functional tests (TEG or RoTEM) By assessing all six components and making sure the
when available (see Chapter 3, Transfusion in trauma). four primary reflexes (ankle, knee, biceps and triceps) are
The criteria for adequate resuscitation are simple and assessed, and repeating this examination at frequent inter-
straightforward: vals, it is possible to both diagnose and monitor the neuro-
logical status in the ED. An improving neurological status
Keep the atrial filling pressure at normal levels.
reassures the physician that resuscitation is improving
Give sufficient fluid to achieve adequate urinary
cerebral blood flow. Neurological deterioration is strong
output (0.5mL/kg per hour in the adult, 1.0mL/kg
presumptive evidence of either a mass lesion or significant
per hour in the child).
neurological injury. A CT scan of the head is the definitive
Maintain peripheral perfusion.
test for head injury and should be done as soon as possible.
The only practical way to measure atrial filling pressure
in the ED and immediately in the operating room is by Environment
central venous pressure monitoring. In elderly patients
The clothes are to be removed in order to examine the
with extensive traumatic injuries, placing a pulmonary
whole patient. A log-roll should be considered, especially
artery catheter or utilizing a cardiac computer may be
after penetrating injuries, in order to identify all wounds.
prudent because it will be used to direct a sophisticated
The patient is at risk of hypothermia, and warming meas-
multifactorial resuscitation in the operating room or
ures should be promptly instituted.
ICU. Resuscitation should be directed to achieve adequate
The body temperature of trauma patients decreases
oxygen delivery and oxygen consumption. An important
rapidly, and if the on-scene time has been prolonged, for
caveat is not to delay mandated therapeutic interventions
example by entrapment, patients arrive in the resuscita-
to obtain non-critical diagnostic test results.
tion room hypothermic. This is aggravated by the admin-
Neurological status (disability) istration of cold fluid, the presence of abdominal or chest
wounds, and the removal of clothing. Most patients will be
The next priority during the primary survey is to quickly
expected to drop their core temperature by 2C per hour
assess neurological status and to initiate diagnostic and
unless protected. All fluids need to be at body temperature
treatment priorities. The key components of a rapid neu-
or above, and rapid infusor devices are available that will
rological evaluation are:
warm fluids at high flow rates prior to infusion. Patients can
Determine the level of consciousness be placed on warming mattresses, and their environment
Observe the size and reactivity of the pupils kept warm using warm air blankets. Early measurement of
Check eye movements and oculovestibular responses the core temperature is important to prevent heat loss that
Document skeletal muscle motor responses will predispose to problems with coagulation. Hypothermia
Determine the pattern of breathing will shift the oxygen dissociation curve to the left, reduce
Perform a peripheral sensory examination. oxygen delivery, reduce the livers ability to metabolize cit-
rate and lactic acid, and may produce arrhythmias.
A decreasing level of consciousness is the single most
The minimum diagnostic studies that should be con-
reliable indication that the patient potentially has a seri-
sidered in the haemodynamically unstable patient after
ous head injury or secondary insult (usually hypoxic or
the primary survey include:
hypotensive) to the brain. Consciousness has two com-
ponents: awareness and arousal. Awareness is manifest Chest X-ray
by goal-directed or purposeful behaviour. The use of Plain film of the pelvis.
Overview | 7
Focused abdominal sonography for trauma (FAST) Whether the patient has bled into the abdomen
examination may be helpful: Whether the bleeding has stopped.
To assess whether there is blood in the chest or abdomen Thus, serial investigations of a quantitative nature will
To exclude cardiac tamponade. allow the best assessment of these patients. Computed
tomography scanning is the modality of choice, pro-
It must be emphasized that resuscitation should not
vided there is awareness of the fact that the patient may
cease during these films, and the resuscitating team must
decompensate.
wear protective lead aprons. Optimally, the X-ray facilities
are juxtaposed to the ED, but the basic X-rays can all be The haemodynamically unstable patient
obtained with a portable machine.
Efforts must be made to try to define the cavity where
bleeding is taking place, for example chest, pelvis or
1.2.1.2Secondary survey abdominal cavity. Negative chest and pelvic X-rays leave
the abdomen as the most likely source.
Finally, if the patient stabilizes, a secondary survey and Diagnostic modalities are, of necessity, limited. FAST is
diagnostic studies are carried out. However, if the patient aiming at detecting free fluid in the abdomen and pericar-
remains unstable, he or she should be taken immediately dium, but is operator-dependent haemodynamic insta-
to the operating room in order to achieve surgical hae- bility caused by intraperitoneal haemorrhage is likely to
mostasis, or to the surgical ICU. be readily found, but a negative FAST does not exclude
The patient must have a full top-to-toe and front-to- intra-abdominal bleeding. Diagnostic peritoneal lavage
back examination. If the patient has been haemodynami- (DPL) remains one of the most sensitive, cheapest, and
cally unstable, the site of the bleeding is traditionally: most readily available modalities to confirm the presence
of blood in the abdomen. Importantly, DPL and FAST
Blood on the floor, and four more
can be performed without moving the patient from the
External bleeding (blood on the floor) and four more. resuscitation area, since an unstable patient cannot have
Bleeding into the chest (exclude by chest X-ray) a CT scan, even if it were to be readily available.
Bleeding into the abdomen During resuscitation, standard ATLS guidelines should
Bleeding into the pelvis (exclude by clinical be followed. These should include a:
examination and pelvic X-ray)
Nasogastric tube or orogastric tube
Bleeding into the extremities (exclude by clinical
Urinary catheter.
examination and long bone X-ray).
Investigation and assessment of the abdomen can be 1.2.2Management of penetrating trauma

based on three groups:
Many forces can act on the torso to cause injury to the
The patient with a normal abdomen
outer protective layers or the contained viscera. Penetrating
An equivocal group requiring further investigation
trauma is most often due to knives, missiles and impale-
The patient with an obvious injury to the abdomen.
ment. Knife wounds and impalement usually involve low-
velocity penetration, and mortality is directly related to the
The haemodynamically normal patient organ injured. Secondary effects such as infection are due
There is ample time for a full evaluation of the patient, to the nature of the weapon and the material (i.e. clothing
and a decision can be made regarding surgery or non- and other foreign material) that the missile carries into the
operative management. Computed tomography scanning body tissue. Infection is also influenced by spillage of con-
is currently the modality of choice. tents from an injury to a hollow viscous organ. In contrast,
missile injuries can cause more extensive tissue destruc-
tion, related to the kinetic energy (KE) that is expressed as:
The haemodynamically stable patient
KE = MV2
The stable patient, who is not haemodynamically normal,
but who is maintaining blood pressure, and other param- where M = mass, and V = velocity.
eters with resuscitation, will benefit from investigations Perhaps more appropriate is the concept of wounding
aimed at establishing: energy (WE), expressed as:
WE = M (VEN VEX)2 the diaphragm and/or mediastinum. It is recommended

that an unfolded paper clip be placed on any anterior
where M = mass, VEN = velocity on entry, and VEX = veloc-
penetrating injury, and a folded one on any posterior
ity on exit.
injury (Figure1.1).2
Velocity is important in determining final kinetic
energy. If the exit velocity is high, very little injury is
imparted to the tissue. Thus, bullets are designed so that
the missile expands or shatters upon impact, imparting all
1.3Emergency department
of its energy to the tissue. Other characteristics of the mis-
surgery
sile may contribute to tissue destruction, including yaw,
The emergency management of a critically injured trauma
tumble and pitch. It has been appreciated that tumbling
patient continues to be a substantial challenge. It is essen-
may be particularly important in higher velocity weapons
tial to have a very simple, effective plan that can be put
(>800m/s). Shotgun blasts can be the most devastating
into place to meet the challenges presented by resus-
since almost all of the energy is imparted to the tissue.
citating the moribund patient. ATLS principles apply
An equally important component of the physical
throughout.
examination is to describe the penetrating wound. It is
As a basic consideration, for all major trauma victims
imperative that surgeons do not label the entrance or exit
with a systolic blood pressure of less than 90 mmHg,
wounds unless common sense dictates it. An example is
there is a 50 per cent likelihood of death, which, in one-
a patient with a single penetrating missile injury with no
third of cases, will occur within the next 30 minutes. If
exit. However, in general, it is best to describe whether the
death is likely to occur in the next 5 minutes, it is essen-
wound is circular or ovoid and whether or not there is
tial to determine in which body cavity the lethal event will
surrounding stippling (powder burn) or bruising from
occur, as the only chance of survival will be the immediate
the muzzle of a weapon. Similarly, stab wounds should
control of haemorrhage.
be described as longitudinal, triangular-shaped (hunt-
If death is likely to occur in the next hour, there is time
ing knives) or circular depending on the instrument
to proceed with an orderly series of investigations and,
used. Experience has shown that surgeons who describe
time permitting, radiographic or other diagnostic aids,
wounds as entrance or exit may be wrong as often as 50
to determine precisely what is injured, and to effect an
per cent of the time. Experience with forensic pathology is
operative plan for the management of this life-threaten-
required to be more accurate.
ing event.
It is good practice to place metallic objects, such as
paper clips, on the skin pointing to the various wounds
on the chest wall, which aid the surgeon in determin-
1.3.1Craniofacial injuries
ing the missile track.17 This also can be useful for stab
wounds. Tracking the missile helps the surgeon to deter-
It is unusual, but possible, to exsanguinate from a mas-
mine which visceral organs may be injured and, in par-
sive scalp laceration. For this reason, it is essential to
ticular, whether or not there is potential transgression of
gain control of the vascular scalp laceration with rapidly
placed surgical clips or primary pressure and immediate
suturing.
The more common cause of death is from intracranial
mass lesions. Extradural haematomas and subdural hae-
matomas can be rapidly lethal. A rapid diagnosis of an
ipsilateral dilated pupil with contralateral plegia is diag-
nostic of mass lesion with significant enough intracra-
nial pressure to induce coning. This requires immediate
decompression. Time can be saved by hyperventilation to
induce hypocarbia and concomitant vasoconstriction.
Attention should be paid to monitoring the end-tidal
carbon dioxide, as a proxy for arterial partial pressure of
carbon dioxide (Paco2), which should not be allowed to fall
Figure 1.1 The use of markers to show the wound track. below 30mmHg (5kPa). This should decrease intracranial
Overview | 9
volume, and therefore intracranial pressure. There should proceed immediately with a left anterior thoracotomy
be an immediate positive effect that usually lasts long in an attempt to relieve the tamponade and control the
enough to obtain a three-cut CT scan to determine a spe- penetrating injury to the heart. If there is an obvious
cific site of the mass lesion and the type of haematoma. penetrating injury to either the left or the right ventri-
This will direct the surgeon specifically to the location of cle, a Foley catheter can be introduced into the hole and
the craniotomy for removal of the haematoma. the balloon distended to create tamponade. The end of
Intravenous mannitol should be administered as a the Foley should be clamped. Great care should be taken
bolus injection in a dose of 0.51.0g/kg. This should not to apply minimal traction on the Foley just enough to allow
delay any other diagnostic or therapeutic procedures. sealing. Excessive traction will pull the catheter out and extend
In the event of severe facial (and often associated severe the wound by tearing the muscle. Once the bleeding is con-
neck) injuries, surgical control of the airway may be neces- trolled, the wound can be easily sutured with pledgetted
sary, using ATLS-described techniques. sutures.
Transected aorta is usually diagnosed with a widened
mediastinum and confirmed with an arteriogram or a CT
1.3.2Chest trauma scan (see Chapter 6, The chest). Once the diagnosis has
been made, it is essential to repair the aorta in the oper-
Lethal injuries to the chest include tension pneumotho- ating room as soon as possible. In general, it is useful to
rax, cardiac tamponade and transected aorta. maintain control of hypotension in the 100mmHg range
Tension pneumothorax is diagnosed clinically with so as not to precipitate free rupture from the transection.
hypertympany on the side of the lesion, deviation of the NB: Abdominal injury generally takes priority over thoracic
trachea away from the lesion and decreased breath sounds aortic injury.
on the affected side. There is usually associated elevated Massive haemorrhage from the intercostal vessels sec-
jugular venous pressure in the neck veins. This is a clini- ondary to multiple fractured ribs will frequently stop
cal diagnosis, and once made, an immediate needle tho- without operative intervention. This is also true for most
racostomy or tube thoracostomy should be performed to bleeding from the pulmonary system. It is essential to
relieve the tension pneumothorax. The tube should then attempt to collect shed blood from the hemithorax into
be placed to underwater seal. an autotransfusion collecting device so that the blood can
The diagnosis of cardiac tamponade is frequently diffi- be returned to the patient.
cult to make clinically. It is usually associated with hypo-
tension and elevated jugular venous pressure. There are
usually muffled heart sounds, but this is difficult to hear 1.3.3Abdominal trauma
in a noisy resuscitation suite. Placing a central line with
resultant high venous pressures can confirm the diagno- Significant intra-abdominal or retroperitoneal haemor-
sis. If ultrasound is available, this is a helpful diagnos- rhage can be a reason to go rapidly to the operating room.
tic adjunct. Once the diagnosis is made, the tamponade The abdomen may be distended and dull to percussion. A
needs to be relieved if the patient is hypotensive. In the definitive diagnosis can be made with a grossly positive
event of a penetrating injury to the heart or blunt rupture DPL, ultrasound or CT scan. The decision to operate for
of the heart, there is usually a substantial clot in the peri- bleeding should be based on the haemodynamic status.
cardium. A needle pericardiocentesis may be able to aspi- Ultrasound (FAST) is a useful tool as it is specific for
rate a few millilitres of blood, and this, along with rapid blood in the peritoneum, but it is operator-dependent.
volume resuscitation to increase preload, can buy enough Sensitivity for haemoperitoneum varies in recent lit-
time to move to the operating room. erature. A positive FAST result in an unstable patient
It is far better to perform a thoracotomy in the operat- is an indication for laparotomy. Conversely, a negative
ing room, either through an anterolateral approach or a FAST result does not exclude intra-abdominal bleed-
median sternotomy, with good light and assistance and ing, and repeat FAST or other investigations need to be
the potential for autotransfusion and potential bypass, considered.
than it is to attempt heroic emergency surgery in the Diagnostic peritoneal lavage is easy to perform and
resuscitation suite. However, if the patient is in extremis gives a highly sensitive but non-specific answer immedi-
with blood pressure in the 40mmHg or lower range ately. A volume of 10mL of grossly positive blood on ini-
despite volume resuscitation, there is no choice but to tial aspiration of the DPL catheter, or a cell count in the
lavage fluid of over 105 red cells per cubic millimetre man- is external fixation. The immediate treatment for a
dates immediate laparotomy in the haemodynamically patient who is hypotensive from haemorrhage from a
unstable patient. Because of its high sensitivity, a negative femoral fracture is to put traction on the distal limb,
DPL excludes the presence of over 20mL of blood in the pulling the femur into alignment. This not only realigns
abdominal cavity. the bones but also reconfigures the cylindrical nature of
The CT scanner is highly sensitive and very specific the thigh. This has an immediate tamponading effect on
for the type, character and severity of injury to a specific the bleeding in the muscles of the thigh. It is frequently
organ. However, patients whose condition is unstable necessary to maintain traction with a Thomas or Hare
should not be considered. traction splint. Attention should be paid to the distal
Non-operative management has become the treatment pulses to be sure that there is continued arterial inflow.
of choice in haemodynamically stable patients with liver If the pulses are absent, an arteriogram should be per-
and spleen injuries regardless of injury grade (see the formed to determine whether there are any injuries to
sections in Chapter 7 (The abdomen) on the individual major vascular structures. A determination is then made
organ systems). as to the timing of arterial repair and bony fixation.
Re-establishing perfusion to the limb takes priority over
fracture treatment.
1.3.4 Pelvic trauma
Pelvic fractures can be a significant cause of haemorrhage

1.3.6 Peripheral vascular injuries
and death. It is essential to return the pelvis to its origi-
nal configuration as swiftly as possible. As an emergency
Peripheral vascular injuries are not in themselves life-
procedure, a compressing sheet or commercially available
threatening providing that the bleeding is controlled.
pelvic binders can be used. There are also external fixa-
However, it is critical to assess whether ischaemia and
tion devices, such as the C-clamp and the external fixa-
vascular continuity are present, since this will influence
tor, which can be placed in the resuscitation suite, which
the overall planning.
immediately return the pelvis to its normal anatomy.
Every ED should have access to a simple flow Doppler
However, their fixation may be time-consuming, requires
monitor to assess pressures and flow. If there is any doubt
skill and may not present advantages over the non-
over whether the vessel is patent, the anklebrachial index
invasive binders for initial management. As the pelvis
should be measured; if it is less than 0.9, an arteriogram
is realigned, it helps to compress the haematoma in the
is mandatory. Time and availability decide whether the
pelvis. Since approximately 85 per cent of pelvic bleeding
patient can be transported to an angiography suite or
is venous, compressing the haematoma usually stops the
should have an angiogram performed in the operating
majority of bleeding from the pelvis.
room or ED. Although it is desirable to do this in the
If the patient continues to be hypotensive, resuscitation
angiography suite, that is not always possible, and the
should continue, and an angiogram should be consid-
necessary equipment may not be available. If there is any
ered. This will identify the presence of significant arterial
doubt, consideration should be given to the use of the ED
bleeding in the pelvis, which then can be embolized imme-
angiogram.18
diately. In the absence of bleeding from the pelvis, an arte-
riogram of the solid organs in the abdomen also can be
performed for diagnostic purposes as well as to assess the
potential for embolization. If the patient is exsanguinat-
1.4Summary
ing from the pelvic injury or is haemodynamically unsta-
The decision of whether to operate in the ED or in the
ble, damage control surgery should be performed with
operating room should be made based on an overview of
extraperitoneal packing of the pelvis combined with a
the urgency and the predicted outcome.
laparotomy before angiography.
It is useful to have a well-thought-out plan for dealing
with the potentially dying trauma patient so that both
1.3.5 Long bone fractures clinical diagnosis and relevant investigations can be per-
formed immediately and an operative or non-operative
Lone bone fractures, particularly of the femur, can bleed therapeutic approach implemented. There is no future in
significantly. The damage control approach to fractures altering only the geographical site of death.
Overview | 11
1.5 References 12 Olsen WR, Hildreth DH. Abdominal paracentesis and

peritoneal lavage in blunt abdominal trauma. J Trauma
1 American College of Surgeons Committee on Trauma. 1971;11:8249.
Resources for Optimal Care of the Injured Patient 2006. 13 Bivens BA, Sachatello CR, Daugherty ME, Ernst CB,
Chicago: Committee on Trauma American College of Griffen WD. Diagnostic peritoneal lavage is superior to
Surgeons, 2006. clinical evaluation in blunt abdominal trauma. Am Surg
2 Hoyt D, Coimbra R, Potenza B. Trauma systems, triage 1978;44:63741.
and transport. In: Moore EE, Feliciano DV, Mattox KL, eds. 14 Loong ED, Law PR, Healey JN. Fresh blood by direct
Trauma, 6th edn. New York: McGraw-Hill, 2008: 5785. transfusion for haemostatic failure in massive haemorrhage.
3 Baker SP, ONeill B, Haddon W, Long WB. The Injury Anaesth Intensive Care 1981;9:3715.
Severity Score: a method for describing patients with 15 Shapiro M. Blood transfusion practice: facts and fallacies.
multiple injuries and evaluating emergency care. J Trauma SAfr Med J 1976;50:1059.
1974;14:18796. 16 Bickell WH. Immediate versus delayed fluid resuscitation for
4 American Association for the Advancement of Automotive hypotensive patients with penetrating torso injuries. N Engl
Medicine. The Abbreviated Injury Scale: 2005 Revision. J Med 1994;331:11058.
Barrington, IL: American Association for the Advancement of 17 Brooks A, Bowley DMG, Boffard KD. Bullet markers
Automotive Medicine, 2005. Available from: www.AAAM.org asimple technique to assist in the evaluation of penetrating
5 Trunkey DD. Trauma. Sci Am 1983;249:2835. trauma. J R Army Med Corps 2002;148:25961.
6 American College of Surgeons. Advanced Trauma Life 18 MacFarlane C, Saadia R, Boffard K. Emergency room
Support Course for Doctors: Student Course Manual, 8th arteriography: a useful technique in the assessment
edn. Chicago: American College of Surgeons, 2008. of peripheral vascular injuries. J Roy Coll Surg Edin
7 Jacobs LM, Berrizbeitia LD, Bennett B, Madigan C. 1989;34:31013.
Endotracheal intubation in the prehospital phase of
emergency medical care. JAMA 1983;250:21757.
8 Taryle DA, Chandler JE, Good JT, Potts DE, Sahn SA. 1.6 Recommended reading
Emergency room intubations complications and survival.
Chest 1979;75:5413. American College of Surgeons. Advanced Trauma Life Support
9 Baker CC, Thomas AN, Trunkey DD. The role of emergency Course for Doctors: Student Course Manual, 8th edn.
room thoracotomy in trauma. J Trauma 1980;20:84855. Chicago: American College of Surgeons, 2008.
10 Thomas AN, Stephens BG. Air embolism: a cause of Jacobs LM, ed. Advanced Trauma Operative Management.
morbidity and death after penetrating chest trauma. Chicago/Woodbury, CT: American College of Surgeons/
JTrauma 1974;14:6338. Cin-Med Publishing, 2010.
11 Yee ES, Verrier ED, Thomas AN. Management of air American College of Surgeons Committee on Trauma.
embolism in blunt and penetrating trauma. J Thor Resources for Optimal Care of the Injured Patient 2006.
Cardiovasc Surg 1983;85:6618. Chicago: American College of Surgeons, 2006.
Part 2
Physiology and metabolism

Resuscitation physiology 2
2.1Metabolic response to Increased cardiac output

trauma Elevated core temperature.
These responses are marked by hyperdynamic circula-

2.1.1 Definition of trauma tory changes, signs of inflammation, glucose intolerance
and muscle wasting.
Bodily injury is accompanied by systemic as well as local
effects. Stress will initiate the metabolic response to
trauma. Following trauma, the body responds locally by 2.1.2Initiating factors
inflammation and by a general response that is protective,
and that conserves fluid and provides energy for repair. The magnitude of the metabolic response depends on the
Proper resuscitation may attenuate the response, but will degree of trauma and concomitant contributory factors,
not abolish it. such as infection, tissue necrosis and pre-existing sys-
The response is characterized by an acute catabolic reac- temic disease. The response will also depend on the age
tion, which precedes the metabolic process of recovery and and sex of the patient, the underlying nutritional state,
repair. This metabolic response to trauma traditionally the timing of treatment and its effectiveness. In general,
was divided into an ebb and flow phase by Cuthbertson the more severe the injury (i.e. the greater the degree of
in 1932.1 The ebb phase is relatively short lived, and cor- tissue damage), the greater the metabolic response.
responds to the period of severe shock characterized by a The metabolic response seems to be less aggressive
depression of enzymatic activity and oxygen consumption. in children and the elderly, and in the premenopausal
After effective resuscitation has been accomplished with female. Starvation and nutritional depletion also modify
restoration of adequate oxygen transport, the flow phase the response. Patients with poor nutritional or immuno-
comes into play. The flow phase can be divided into: logical status (e.g. those with human immunodeficiency
virus) have a reduced metabolic response to trauma com-
A catabolic phase with fat and protein mobilization pared with well-nourished patients, while burns cause a
associated with increased urinary nitrogen excretion relatively greater response than other injuries.
and weight loss Wherever possible, efforts should be made to reduce
An anabolic phase with restoration of fat and protein the magnitude of the initial insult, since by doing so it
stores, and weight gain. may be possible to reduce the nature of the metabolic
The flow phase is characterized by: changes. Thus, aggressive resuscitation, control of pain
and temperature, adequate tissue debridement, avoidance
A normal or slightly elevated blood glucose level of unnecessary blood component administration, and
Increased glucose production nutritional provision are critical.
Normal or slightly elevated free fatty acid levels, with The precipitating factors can be broadly divided into
flux increased the following categories.
A normal or elevated insulin concentration
High-normal or elevated levels of catecholamine and
2.1.2.1 Hypovolaemia
an elevated glucagon level
A normal blood lactate level Decrease in circulating volume of blood
Elevated oxygen consumption Increase in alimentary loss of fluid
Loss of interstitial volume be accompanied by autonomic blockade, in order to mini-

Extracellular fluid shift. mize or abolish the metabolic response.
2.1.2.2Afferent impulses 2.1.2.8 Wound factors
Somatic Endogenous factors may prolong or even exacerbate the

Autonomic trauma insult, despite the fact that the primary cause can
Increased sympathetic impulses be treated well. Tissue injury activates a diverse response
Decreased cholinergic impulses. via Toll-like receptors (TLRs), along two pathways:
Inflammatory (humoral) pathway

2.1.2.3 Wound factors: inflammatory and cellular Cellular pathway.
Neutrophils superoxide, elastase Uncontrolled activation of endogenous inflammatory

Platelets mediators and cells may contribute to this syndrome.
Macrophages Both humoral and cell-derived activation products play
Endothelial cells a role in the pathophysiology of organ dysfunction.2 It is
Cytokines interleukins (ILs) IL-2, IL-6, IL-8, tumour important, therefore, to monitor post-traumatic biochem-
necrosis factor (TNF), prostaglandin E2 (PGE2) ical and immunological abnormalities whenever possible.
Eicosanoids leukotriene (LT) B4 and C4,
thromboxane A2 (TXA2)
Damage-associated molecular patterns (DAMPs). 2.1.3Immune response
The immune response is complex and initially consists

2.1.2.4Toxins/sepsis of an enhanced innate system and a suppressed adaptive
Endotoxins system. The magnitude of these responses is modified by
Exotoxins. the depth and duration of the insult.
2.1.2.5Free radicals 2.1.3.1Inflammatory pathway
Superoxide and derivatives. The inflammatory mediators of injury have been impli-
cated in the induction of membrane dysfunction.
Neutrophils have been invoked in inflammatory proc-
2.1.2.6 Hypovolaemia esses for more than 100 years, but now we recognize
Hypovolaemia, specifically tissue hypoperfusion, is the that the initial response involves platelets, macrophages,
most potent precipitator of the metabolic response. endothelium and epithelium.
Hypovolaemia also can be due to external losses, internal
shifts of extracellular fluids and changes in plasma osmo- Cytokines
lality. However, the most common cause is blood loss (see The term cytokine refers to a diverse group of polypep-
Section 2.2, Shock). tides and glycoproteins that are important mediators of
The hypovolaemia will stimulate catecholamines, inflammation. They are produced by a variety of cell types,
which in turn trigger the neuroendocrine response. This but predominantly by leukocytes. Cytokines are generally
plays an important role in volume and electrolyte conser- divided into pro-inflammatory cytokines and anti-inflam-
vation and protein, fat and carbohydrate catabolism. matory cytokines, but some, for example IL-6, have both
properties. Discussion of cytokines is further complicated
by confusing nomenclature. Many cytokines were found
2.1.2.7Afferent impulses
in different settings such as tumour necrosis factor
Hormonal responses are initiated by pain and anxiety. (TNF), originally termed cachectin. Current nomenclature
The metabolic response may be modified by the admin- follows a more consistent system. The term interleukin
istration of adequate analgesia, which may be parenteral, refers to a substance that acts between leukocytes, and is
enteral, regional or local. Somatic blockade may need to used in conjunction with a number, for example IL-6.
Resuscitation physiology | 17
Pro-inflammatory cytokines fundamental phenomenon, in which systemic inflam-

Certain cytokines, particularly TNF, IL-1 and IL-8, pro- matory response syndrome (SIRS) occurs in response to
mote the inflammatory response by up-regulating the a stimulus, and the whole-body inflammatory response
expression of genes that generate the pro-inflammatory can ultimately lead to multiple organ dysfunction syn-
mediators. Pro-inflammatory cytokines also mediate drome, which is associated with a mortality higher than
inflammation by activating neutrophils, endothelium 50 per cent. It was initially suggested that SIRS and sep-
and epithelium all of which lead to tissue damage. sis were initially attributable to an overwhelming pro-
Tumour necrosis factor and IL-1 act synergistically to inflammatory immune response, moderated by TNF and
produce the acute innate immune response to ischae- other cytokines. Another view suggests that the body also
mia/reperfusion in many organs. Tumour necrosis factor mounts a countering anti-inflammatory reaction that can
causes neutrophils to be attracted to injured epithelium, then lead to compensatory anti-inflammatory response
thereby helping to regulate the inflammatory response. syndrome (CARS). It may be that when the pro-inflam-
It also stimulates endothelial cells to produce a cytokine matory response predominates, SIRS and shock result,
subset known as chemokines (e.g. IL-8), which produce and when the anti-inflammatory response predominates,
leukocyte migration into the tissues and IL-1 production. CARS, immunosuppression and increased susceptibility
Like TNF, IL-1 is a primary responder in the inflamma- to infection result.
tory cascade, and its actions are similar to those of TNF, It is clear that the role of cytokines in sepsis is very com-
but it cannot induce apoptosis. plex, with both pro-inflammatory and anti-inflammatory
Interferon-gamma is produced in response to antigen, factors playing a role and determining clinical outcome.
an event enhanced by IL-12. It activates macrophages.
Interleukin-12 is produced by mononuclear phagocytes Activated protein C (Xigris)
and dendritic cells in response to intracellular microbes. Pro-inflammatory factors have a role in triggering
Interleukin-6 is produced by mononuclear phagocytes, the clotting cascade by stimulating the release of
endothelial cells and fibroblasts, and acts in a pro-inflam- tissue factor from monocytes and the vascular endo
matory manner by providing a potent stimulus for hepa- thelium, leading to thrombin formation and a fibrin
tocyte synthesis of acute-phase proteins. clot. At the same time, thrombin stimulates many
Unlike the above cytokines, which exert most of their inflammatory pathways and suppresses the natural
influence via the innate immune system, IL-2 mediates anticoagulant response by activating thrombin-
acquired immunity and has an immunomodulatory func- activatable fibrinolysis inhibitor. This procoagulant
tion as well. response leads to microvascular thrombosis and is
implicated in the multiple organ failure associated
Anti-inflammatory cytokines with sepsis. On the other hand, thrombin binding to
endothelial thrombomodulin generates protein C, which
The anti-inflammatory cytokines exert their effects by
is an endogenous anticoagulant.
inhibiting the production of pre-inflammatory cytokines
or by countering their action. They reduce gene expres-
sion and mitigate or prevent inflammatory effects. Eicosanoids
Interleukin-10 is important in the control of innate These compounds are derived from eicosapolyenoic fatty
immunity. It can prevent fever, pro-inflammatory acids. They may be subdivided into prostanoids (the pre-
cytokine release and clotting cascade activation during cursors of the PGs) and LTs. Eicosanoids are synthesized
endotoxin challenge. Other potent anti-inflammatory from arachidonic acid (AA), which has been synthesized
modulators include IL-4, IL-13 and transforming growth from the phospholipids of cell walls, by the action of
factor-beta. phospholipase A2. Cyclo-oxygenase converts AA to pros-
tanoids, prostacyclins (PGIs) and TXs. The term pros-
Modulation of cytokine activity in sepsis, systemic taglandins is used loosely to include all prostanoids.
The LTs are produced by the action of 5-lipoxygenase on
inflammatory response syndrome and compensatory
AA with subsequent byproducts produced by LTA4 and
inflammatory response syndrome LTC4 synthase. Eicosanoids modulate the blood flow
Systemic inflammatory activity, which may occur in to organs and tissues by altering local balances between
response to infectious or non-infectious stimuli, is the the production of vasodilators and the production of
vasoconstricting components, and directly stimulate cer- 2.1.3.3Toxins

tain immune cells.
Endotoxin is a lipopolysaccharide component of bacte-
The prostanoids (PGs of the E and F series), PGI2 and TX
rial cell walls. Endotoxin causes the vascular margina-
not only cause vasoconstriction (TXA2 and PGF1), but also
tion and sequestration of leukocytes, particularly in the
vasodilatation (PGI2, PGE1 and PGE2). TXA2 activates and
capillary bed. At high doses, granulocyte destruction is
aggregates platelets and white cells, and PGI2 and PGE1
seen. Endotoxin is known to activate many immune cells,
inhibit white cells and platelets. The leukotriene LTB4 is a
particularly via the TLR4 receptors and particularly at the
very potent polymorphonuclear cell chemoattractant and
level of the hepatocyte, and may act to liberate TNF in the
activator, while LTC4 causes vasoconstriction, increased
macrophages.
capillary permeability and bronchoconstriction.
2.1.3.4Pathogen-associated molecular patterns and

2.1.3.2Cellular pathway damage-associated molecular patterns
The classical pathway of complement activation involves Injury causes a SIRS clinically much like sepsis.
an interaction between the initial antibody and the initial Multicellular animals detect pathogens via a set of pattern
trimer of complement components C1, C4 and C2. In the recognition receptors that recognize pathogen-associated
classical pathway, this interaction then cleaves the com- molecular patterns (PAMPs), which in turn activate innate
plement products C3 and C5, via proteolysis, to produce immunocytes. Evidence is accumulating that trauma and
the very powerful chemotactic factors C3a and C5a. its associated tissue damage are recognized at the cell level
The so-called alternative pathway seems to be the via the receptor-mediated detection of intracellular pro-
main route following trauma. It is activated by proper- teins released by dead cells. The term alarmin has been
din and proteins D or B, to activate C3 convertase, which proposed to categorize such endogenous molecules that
generates the anaphylatoxins C3a and C5a. Its activa- signal tissue and cell damage.4
tion appears to be the earliest trigger for activating the Endogenous alarmins and exogenous PAMPs there-
cellular system, and is responsible for the aggregation fore convey a similar message and elicit similar responses.
of neutrophils and activation of basophils, mast cells They can be considered to be subgroups of a larger set of
and platelets to secrete histamine and serotonin, which molecules that cause damage from the damage or death
alter vascular permeability and are vasoactive. In trauma of host cells (DAMPs).
patients, the serum C3 level is inversely correlated with The release of such mitochondrial enemies within by
the Injury Severity Score.3 Measurement of C3a is the cellular injury is a key link between trauma, inflammation
most useful because the other products are more rapidly and SIRS.5
cleared from the circulation.
The short-lived fragments of the complement cas-
2.1.3.5Free radicals
cade, C3a and C5a, stimulate macrophages to secrete
IL-1 and its active circulating cleavage product proteo Oxygen radical (O2) formation by white cells is a normal
lysis-inducing factor. These cause proteolysis and lipoly- host defence mechanism. Changes after injury may lead to
sis with fever. Interleukin-1 activates T4 helper cells to an excessive production of oxygen free radicals, released
produce IL-2, which enhances cell-mediated immunity. by neutrophils and macrophages, with deleterious effects
Interleukin-1 and proteolysis-inducing factor are potent on organ function. Nitric oxide (NO) is also released by
mediators stimulating cells of the liver, bone marrow, macrophages, causing vasodilatation and decreased sys-
spleen and lymph nodes to produce acute-phase pro- temic vascular resistance. NO combines with O2 to form
teins, which include complement, fibrinogen, alpha2- a potent oxidizing agent that can oxidize the catecho-
macroglobulin and other proteins required for defence lamine ring. Hydroxyl ion (OH) and hydrogen peroxide
mechanisms. are also increased following sepsis or stress.
There is considerable cross-talk between the clot-
ting cascade and inflammation. Activation of factor XII
(Hageman factor A) stimulates kallikrein to produce 2.1.4 Hormonal mediators
bradykinin from bradykininogen, which also affects capil-
lary permeability and vasoactivity. A combination of these In response to trauma, many circulatory hormones
reactions causes the inflammatory response. are altered. Levels of adrenaline (epinephrine),
noradrenaline (norepinephrine), cortisol and glucagon 2.1.4.2Adrenal hormones

are increased, while certain others are decreased. The
Plasma cortisol and glucagon levels rise following trauma.
sympathetic-adrenal axis is probably the major system by
The degree of this is related to the severity of injury. The
which the bodys response to injury is activated.
function of glucocorticoid secretion in the initial meta-
bolic response is uncertain, since the hormones have lit-
2.1.4.1The pituitary tle direct action, and primarily they seem to augment the
effects of other hormones such as the catecholamines.
The hypothalamus is the highest level of integration of
With passage into the later phases after injury, a number
the stress response. The major efferent pathways of the
of metabolic effects occur. Glucocorticoids exert catabolic
hypothalamus are endocrine via the pituitary and the
effects such as gluconeogenesis, lipolysis and amino acid
efferent sympathetic and parasympathetic systems. The
breakdown from muscle. Catecholamines also participate
cholinergic system is now recognized to have a variety of
in these effects by mediating insulin and glucose release
anti-inflammatory effects.
and the mobilization of fat.
The pituitary gland responds to trauma with two secre-
tory patterns. Adrenocorticotropic hormone (ACTH), pro-
lactin and growth hormone levels increase. The remainder 2.1.4.3 Pancreatic hormones
are relatively unchanged.
Pain receptors, osmoreceptors, baroreceptors and There is a rise in the blood sugar level following trauma.
chemoreceptors stimulate or inhibit ganglia in the The insulin response to glucose is reduced substantially
hypothalamus to induce sympathetic nerve activity. The with alpha-adrenergic stimulation, and enhanced with
neural end-plates and adrenal medulla secrete catecho- beta-adrenergic stimulation.6
lamines. Pain stimuli via the pain receptors also stimu-
late the secretion of endogenous opiates, beta-endorphin 2.1.4.4Renal hormones
and pro-opiomelanocortin (the precursor of the ACTH
molecule), which modifies the response to pain and rein- Aldosterone secretion is increased by several mechanisms.
forces the catecholamine effects. The beta-endorphin has The reninangiotensin mechanism is the most important.
little effect but serves as a marker for anterior pituitary When the glomerular arteriolar inflow pressure falls, the
secretion. juxtaglomerular apparatus of the kidney secretes renin,
Hypotension, hypovolaemia in the form of a decrease which acts with angiotensinogen to form angiotensin I.
in left ventricular pressure, and hyponatraemia stimulate This is converted to angiotensin II, a substance that stim-
the secretion of vasopressin, antidiuretic hormone (ADH) ulates the production of aldosterone by the adrenal cor-
from the supraoptic nuclei in the anterior hypothalamus, tex. A reduction in sodium concentration stimulates the
aldosterone from the adrenal cortex, and renin from the macula densa, a specialized area in the tubular epithelium
juxtaglomerular apparatus of the kidney. The increase in adjacent to the juxtaglomerular apparatus, to activate
aldosterone secretion results in a conservation of sodium renin release. An increase in plasma potassium concentra-
and thereby water. As osmolality increases, the secretion tion also stimulates aldosterone release. Volume decrease
of ADH increases and more water is reabsorbed, thereby and a fall in arterial pressure stimulates the release of
decreasing the osmolality (via a negative feedback control ACTH via receptors in the right atrium and the carotid
system). artery.
Hypovolaemia stimulates receptors in the right atrium,
and hypotension stimulates receptors in the carotid artery.
2.1.4.5Other hormones
This results in activation of the paraventricular hypotha-
lamic nuclei, which secrete pituitary-releasing hormone Atrial natriuretic factor or atriopeptin is a hormone pro-
from the median eminence into the capillary blood; this duced by the atria, predominantly the right atrium of
in turn stimulates the anterior pituitary to secrete ACTH. the heart, in response to an increase in vascular volume.7
Adrenocorticotropic hormone stimulates the adrenal cor- Atrial natriuretic factor produces an increase in glomeru-
tex to secrete cortisol and aldosterone. Changes in glucose lar filtration and pronounced natriuresis and diuresis.
concentration influence the release of insulin from the It also produces an inhibition of aldosterone secretion,
beta cells of the pancreas, and high amino acid levels, the which minimizes kaliuresis and causes suppression of
release of glucagon from the alpha cells. ADH release.
Prior to the discovery of atrial natriuretic factor, it was Accompanying the above changes is an increase in oxy-
suggested that a hormone, a third factor, was secreted fol- gen delivery to the microcirculation. Total body oxygen
lowing distension of the atria, which complemented the consumption (Vo2) is increased. These reactions produce
activity of two known regulators of blood pressure and heat, which is also a reflection of the hyperdynamic state.
blood volume: the hormone aldosterone and filtration
of blood by the kidney. Atrial natriuretic factor has also
emphasized the hearts function as an endocrine organ. 2.1.5.2 Water and salt retention
Secretion of ADH from the supraoptic nuclei in the ante-

rior hypothalamus is stimulated by volume reduction
2.1.5Effects of the various mediators and increased osmolality of the circulation. The latter is
due mainly to the increased sodium content of the extra-
2.1.5.1 Hyperdynamic state cellular fluid. Volume receptors are located in the atria
and pulmonary arteries, and osmoreceptors are located
Following illness or injury, the systemic inflammatory near ADH neurones in the hypothalamus. Antidiuretic
response occurs, in which there is an increase in activity hormone acts mainly on the connecting tubules of the
of the cardiovascular system, reflected as tachycardia, wid- kidney, as well as on the distal tubules to promote the
ened pulse pressure and a greater cardiac output. There reabsorption of water.
is an increase in the metabolic rate, with an increase in Aldosterone acts mainly on the distal renal tubules to
oxygen consumption, increased protein catabolism and promote reabsorption of sodium and bicarbonate, and
hyperglycaemia. increased excretion of potassium and hydrogen ions.
The cardiac index may exceed 4.5L/m2 per minute after Aldosterone also modifies the effects of catecholamines
severe trauma in those patients who are able to respond on cells, thus affecting the exchange of sodium and
adequately. Decreases in vascular resistance accompany potassium across all cell membranes. The release of large
this increased cardiac output. This hyperdynamic state quantities of intracellular potassium into the extracellu-
elevates the resting energy expenditure to more than 20 lar fluid may cause a significant rise in serum potassium,
per cent above normal. In an inadequate response, with especially if renal function is impaired. Retention of
a cardiac index of less than 2.5L/m2 per minute, oxygen sodium and bicarbonate may produce metabolic alkalosis
consumption may fall to values of less than 100mL/m2 with impairment of the delivery of oxygen to the tissues.
per minute (normal = 120160 mL/m2 per minute). After injury, urinary sodium excretion may fall to 1025
Endotoxins and anoxia may injure cells and limit their mmol per 24 hours, and potassium excretion may rise to
ability to utilize oxygen for oxidative phosphorylation. 100200mmol per 24 hours.
The amount of ATP synthesized by an adult is consid-
erable. However, there is no reservoir of ATP or creatinine
phosphate, and therefore cellular injury and lack of oxy- 2.1.5.3Effects on substrate metabolism
gen results in a rapid deterioration of processes requiring
energy, and lactate is produced. Because of anaerobic gly- Carbohydrates
colysis, only two ATP equivalents instead of 34 are pro- Critically ill patients develop a glucose intolerance which
duced from one mole of glucose in the Krebs cycle. resembles that found in patients with diabetes. This is a
Lactate is formed from pyruvate, which is the end prod- result of both an increased mobilization and a decreased
uct of glycolysis. It is normally reconverted to glucose in uptake of glucose by the tissues. The turnover of glucose
the Cori cycle in the liver. However, in shock, the oxida- is increased, and the serum glucose is higher than normal.
tionreduction (redox) potential declines, and the conver- Glucose is mobilized from stored glycogen in the
sion of pyruvate to acetyl co-enzyme A for entry into the liver by catecholamines, glucocorticoids and glucagon.
Krebs cycle is inhibited. Lactate therefore accumulates Glycogen reserves are limited, and glucose can be derived
because of impaired hepatic gluconeogenesis, causing from glycogen for only 1218 hours. Early on, the insu-
a metabolic acidosis. Lactic acidosis after injury corre- lin blood levels are suppressed (usually being lower by 8
lates with the Injury Severity Score and acute blood loss. units/mL) by the effect of adrenergic activity of shock on
Persistent lactic acidosis is predictive of the development degranulation of the beta cells in the pancreas. Thereafter,
of multiple organ failure and subsequent adult respira- gluconeogenesis is stimulated by corticosteroids and
tory distress syndrome (ARDS).8 glucagon. The suppressed insulin favours the release of
amino acids from muscle, which are then available for Amino acids
gluconeogenesis. Growth hormone inhibits the effect of
The intake of protein by a healthy adult is between 80 and
insulin on glucose metabolism.
120g of protein: 12g protein/kg per day. This is equiva-
As blood glucose rises during the phase of hepatic glu-
lent to 1320g of nitrogen per day. In the absence of an
coneogenesis, blood insulin concentration rises, some-
exogenous source of protein, amino acids are principally
times to very high levels. Provided that the liver circulation
derived from the breakdown of skeletal muscle protein.
is maintained, gluconeogenesis will not be suppressed by
Following trauma or sepsis, the release rate of amino
hyperinsulinaemia or hyperglycaemia, because the accel-
acids increases by three to four times. The process mani-
erated rate of glucose production in the liver is required
fests as marked muscle wasting.
for the clearance of lactate and amino acids, which are
Cortisol, glucagon and catecholamines play a role in
not used for protein synthesis. This period of breakdown
this reaction. The mobilized amino acids are utilized for
of muscle protein for gluconeogenesis and the resultant
gluconeogenesis or oxidation in the liver and other tis-
hyperglycaemia characterizes the catabolic phase of the
sues, but also for the synthesis of acute-phase proteins
metabolic response to trauma.
required for immunocompetence, clotting, wound heal-
The glucose level following trauma should be moni-
ing and maintenance of cellular function.
tored carefully in the intensive care unit. The optimum
Certain amino acids like glutamic acid, asparagine and
blood glucose level remains controversial, but the maxi-
aspartate can be oxidized to pyruvate, producing alanine,
mum level should be 10mmol/L. Control of blood glu-
or to alpha-ketoglutarate, producing glutamine. The oth-
cose is best achieved by titration with intravenous insulin,
ers must first be deaminated before they can be utilized.
based on a sliding scale. However, because of the degree of
In the muscle, deamination is accomplished by transami-
insulin resistance associated with trauma, the quantities
nation from branched chain amino acids. In the liver,
required may be considerably higher than normal.
amino acids are deaminated by urea that is excreted in
Parenteral nutrition may be required, and this will exac-
the urine. After severe trauma or sepsis, as much as 20g
erbate the problem. However, glucose remains the safest
per day of urea nitrogen is excreted in the urine. Since 1g
energy substrate following major trauma: 6075 per cent
of urea nitrogen is derived from 6.25g degraded amino
of the caloric requirements should be supplied by glucose,
acids, this protein wastage is up to 125g per day.
with the remainder being supplied using a fat emulsion.
One gram of muscle protein represents 5g of wet mus-
cle mass. The patient in this example would be losing
Fat 625g of muscle mass per day. A loss of 40 per cent of body
A major source of energy following trauma is adipose protein is usually fatal, because failing immunocompe-
tissue. Lipids stored as triglycerides in adipose tissue are tence leads to overwhelming infection. Nitrogen excre-
mobilized when insulin falls below 25units/mL. Because tion usually peaks several days after injury, returning to
of the suppression of insulin release by the catecholamine normal after several weeks. This is a characteristic feature
response after trauma, as much as 200500g of fat may be of the metabolic response to illness. The most profound
broken down daily after severe trauma.9 Tumour necrosis alterations in metabolic rate and nitrogen loss occur after
factor and possibly IL-1 play a role in the mobilization of burns, and may persist for months.
fat stores. To measure the rates of transfer and utilization of amino
Catecholamines and glucagon activate adenyl cyclase acids mobilized from muscle or infused into the circula-
in the fat cells to produce cyclic adenosine monophos- tion, the measurement of central plasma clearance rate
phate (cyclic AMP). This activates lipase, which promptly of amino acids has been developed. Using this method,
hydrolyses triglycerides to release glycerol and fatty a large increase in the peripheral production and central
acids. Growth hormone and cortisol play a minor role uptake of amino acids into the liver has been demonstrated
in this process as well. Glycerol provides substrate for in injured patients, especially if sepsis is also present. The
gluconeogenesis in the liver, which derives energy by protein-depleted patient can be improved dramatically by
the beta-oxidation of fatty acids, a process inhibited by parenteral or enteral alimentation provided adequate liver
hyperinsulinaemia. function is present. Amino acid infusions in patients who
Free fatty acids provide energy for all tissues and for ultimately die cause plasma amino acid concentration to
hepatic gluconeogenesis. Carnitine, synthesized in the liver, rise to high levels with only a modest increase in the cen-
is required for the transport of fatty acids into thecells. tral plasma clearance rate of amino acids.
The gut 2.2Shock

The intestinal mucosa demonstrates a rapid synthesis of
amino acids. Depletion of amino acids results in atrophy 2.2.1 Definition of shock
of the mucosa, causing failure of the mucosal barrier.
This may lead to bacterial translocation from the gut to Shock is defined as an inadequate circulation of oxygen-
the portal system. The extent of bacterial translocation ated blood to the tissues, resulting in cellular hypoxia.
in trauma has not been defined.10 The presence of food This at first leads to reversible ischaemically induced
in the gut lumen is a major stimulus for mucosal cell cellular injury. If the process is sufficiently severe or pro-
growth. Food intake is invariably interrupted after major tracted, it ultimately results in irreversible cellular and
trauma, and the supply of glutamine may be insufficient organ injury and dysfunction. The precise mechanisms
for mucosal cell growth. Early nutrition (within 2448 responsible for the transition from reversible to irrevers-
hours), and early enteral rather than parenteral feeding, ible injury and the death of cells are not clearly under-
may prevent or reduce these events. stood, although the biochemical/morphological sequence
in the progression of ischaemic cellular injury has been
fairly well elucidated.11 By understanding the events lead-
2.1.6The anabolic phase ing to cell injury and death, we may be able to intervene
therapeutically in shock by protecting sublethally injured
During this phase, the patient is in positive nitrogen cells from irreversible injury and death.
balance, regains weight and restores fat deposits. The
hormones that contribute to anabolism are growth hor-
mones, androgens and 17-beta-ketosteroids. The utility of 2.2.2Classification of shock
growth hormone, and also more recently of insulin-like
growth factor-1, in reversing catabolism following injury The classification of shock is of practical importance if
is critically dependent on adequate caloric intake. the pathophysiology is understood in terms that make a
fundamental difference in treatment. Although the basic
definition of shock insufficient nutrient flow remains
2.1.7Clinical and therapeutic relevance inviolate, six types of shock, based on a distinction not
only in the pathophysiology but also in the management
Survival after injury depends on a balance between the of the patients, are recognized:
extent of cellular damage, the efficacy of the metabolic
response and the effectiveness of treatment. Hypovolaemic
Tissue injury, hypoxia, pain and toxins from invasive Cardiogenic
infection add to the initiating factor of hypovolaemia. Cardiac compressive (cardiac tamponade)
The degree to which the body is able to compensate for Inflammatory (previously called septic shock)
injury is astonishing, although the compensatory mecha- Neurogenic
nisms may sometimes work to the patients disadvantage. Obstructive (mediastinal compression).
Adequate resuscitation to shut off the hypovolaemic In principle, the physiological basis of shock is based
stimulus is important. Once hormonal changes have on the following relationships:
been initiated, the effects of the hormones will not cease
merely because hormonal secretion has been turned off Cardiac output = Stroke volume Heart rate
byreplacement of blood volume. Blood pressure = Cardiac output Total peripheral
Mobilization and storage of the energy fuel substrates, resistance.
carbohydrate, fats and protein is regulated by insulin,
balanced against catecholamines, cortisol and glucagon. Stroke volume is determined by the preload, the con-
However, infusion of hormones has failed to cause more tractility of the myocardium and the afterload.
than a modest response.
Rapid resuscitation, maintenance of oxygen delivery to
2.2.2.1 Hypovolaemic shock
the tissues, removal of devitalized tissue or pus, and con-
trol of infection are the cornerstones. The best metabolic Hypovolaemic shock is caused by a decrease in the intra-
therapy is excellent surgical care. vascular volume. This results in a significant degeneration
of both pressure and flow. It is characterized by significant Renal function is also critically dependent on renal per-
decreases in filling pressures, with a consequent decrease fusion. Oliguria is an inevitable feature of hypovolaemia.
in stroke volume. Cardiac output is temporarily main- During volume loss, renal blood flow falls correspond-
tained by a compensatory tachycardia. With continuing ingly with the blood pressure. Anuria sets in when the
hypovolaemia, the blood pressure is maintained by reflex systolic blood falls to 50mmHg. Urine output is a good
increases in peripheral vascular resistance and myocardial indicator of peripheral perfusion.
contractility mediated by neurohumoral mechanisms.
Hypovolaemic shock is divided into four classes 2.2.2.2Cardiogenic shock
(Table2.1).
Initially, the body compensates for shock, and classI When the heart fails to produce an adequate cardiac out-
and class II shock is compensated shock. When the blood put, even though the end-diastolic volume is normal, car-
volume loss exceeds 30 per cent (class III and class IV diogenic shock is said to be present.
shock), the compensatory mechanisms are no longer Cardiac function is impaired in such shocked patients
effective, and the decrease in cardiac output causes even if myocardial damage is not the primary cause.
decreased oxygen transport to the peripheral tissues. Reduced myocardial function in shock includes dysrhyth-
These tissues attempt to maintain their oxygen consump- mias, myocardial ischaemia from systemic hypertension
tion by increasing their oxygen extraction. Eventually, this and variations in blood flow, and myocardial lesions from
compensatory mechanism also fails, and tissue hypoxia high circulatory levels of catecholamines, angiotensin and
leads to lactic acidosis, hyperglycaemia and failure of the possibly a myocardial depressant factor.
sodium pump, with swelling of the cells from water influx. The reduced cardiac output can be a result of:
Reduced stroke volume

Clinical presentation Impaired myocardial contractility due to ischaemia,
infarction, cardiomyopathy or trauma
The classic features of hypovolaemic shock are hypoten-
Altered ejection volume
sion, tachycardia, pallor secondary to vasoconstriction,
Coronary air embolism
sweating, cyanosis, hyperventilation, confusion and olig-
Mechanical complications of acute myocardial
uria. Cardiac function can be depressed without gross
infarction acute mitral valvular regurgitation,
clinical haemodynamic manifestations. The heart shares
ventricular septal rupture or trauma
in the total-body ischaemic insult. Systemic arterial hypo-
Arrhythmias
tension increases coronary ischaemia, causing rhythm
Conduction system disturbances (bradydysrhythmias
disturbances and decreased myocardial performance. As
and tachydysrhythmias).
the heart fails, left ventricular end-diastolic pressure rises,
ultimately causing pulmonary oedema. Other forms of cardiogenic shock include those clinical
Hyperventilation may maintain the arterial partial examples in which the patient may have a nearly normal
pressure of oxygen (Pao2) at near-normal levels, but the resting cardiac output but cannot raise the cardiac out-
arterial partial pressure of carbon dioxide (Paco2) falls put in circumstances of stress because of poor myocar-
to 2030 mmHg (2.74.0 kPa). Later, pulmonary insuf- dial reserves or an inability to mobilize those myocardial
ficiency may supervene from alveolar collapse and pul- reserves due to pharmacological beta-adrenergic blockade,
monary oedema, resulting from damaged pulmonary for example propanolol for hypertension. Heart failure and
capillaries, cardiac failure or inappropriate fluid therapy. dysrhythmias are discussed in depth elsewhere in this book.
Table 2.1 Classes of hypovolaemic shock
Class Percentage Volume (mL) Pulse rate Blood pressure Pulse pressure Respiratory rate
blood loss (beats/min) (per min)
Class I 15 <750 <100 Normal Normal 1420

Class II 30 7501500 >100 Normal Increased 2030
Class III 40 2000 >120 Decreased Narrowed 3040
Class IV >40 >2000 >140 Decreased Narrowed >35
Clinical presentation Clinical presentation

The clinical picture will depend on the underlying cause. Cardiac tamponade follows blunt or penetrating trauma,
Clinical signs of peripheral vasoconstriction are promi- and as a result of the presence of blood in the pericardial
nent, pulmonary congestion is frequent, and oliguria is sac, the atria are compressed and cannot fill adequately.
almost always present. Pulmonary oedema may cause The systolic blood pressure is less than 90 mmHg, and
severe dyspnoea, central cyanosis and crepitations, audi- there is a narrowed pulse pressure and a pulsus para-
ble over the lung fields, and lung oedema visible on doxus exceeding 10 mmHg. Distended neck veins may
X-rays. be present, unless the patient is hypovolaemic as well.
Signs on cardiac examination depend on the under- Heart sounds are muffled. The limited compliance of the
lying cause. A systolic murmur appearing after myocar- pericardial sac means that a very small amount (<25mL
dial infarction suggests mitral regurgitation or septal blood) may be sufficient to cause decompensation.
perforation.
Haemodynamic findings consist of a systolic arte- 2.2.2.4Inflammatory (distributive) shock
rial pressure less than 90 mmHg, decreased cardiac
output, usually to less than 1.8 L/m2 per minute, and Dilatation of the capacitance reservoirs in the body occurs
a pulmonary artery wedge pressure (PAWP) of greater with endotoxic shock or prolonged hypovolaemic shock.
than 20mmHg. Sometimes, cardiogenic shock occurs Endotoxin can have a major effect on this form of periph-
without the PAWP being elevated. This may be a result eral pooling, and even though the blood volume is nor-
of diuretic therapy or plasma volume depletion by fluid mal, the distribution of that volume is changed so that
lost into the lungs. Patients with relative hypovolae- there is insufficient nutrient flow where aerobic metabo-
mia below the levels where there is a risk of pulmonary lism is needed.
oedema and, finally, patients with significant right In the ultimate analysis, all shock leads to cellular
ventricular infarction and right heart failure will also defect shock. Aerobic metabolism takes place in the
not have an elevated PAWP. These patients, although cytochrome system in the cristae of the mitochondria.
their shock is cardiogenic, will respond dramatically to Oxidative phosphorylation in the cytochrome system
plasma volume expansion and will deteriorate if diuret- produces high-energy phosphate bonds by coupling oxy-
ics are given. gen and glucose, forming the freely diffusable byproducts
carbon dioxide and water. Several poisons uncouple oxi-
dative phosphorylation, but the most common in clinical
2.2.2.3Cardiac compressive shock
practice is endotoxin. Sepsis is frequent in hospitalized
The pathophysiology of cardiac compressive shock is patients, and endotoxic shock is distressingly common.
very different from that of cardiogenic shock. External There is fever, tachycardia may or may not be present, the
forces compress the thin-walled chambers of the heart mean blood pressure is usually below 60mmHg, yet the
(the atria and the right ventricle), the great veins (sys- cardiac output varies between 3 and 6 L/m2 per minute.
temic or pulmonary), the great arteries (systemic or This haemodynamic state is indicative of low peripheral
pulmonary) or any combination of these. Impaired vascular resistance.
diastolic filling occurs. Clinical conditions capable of In addition to low peripheral resistance as a cause of
causing compressive shock include pericardial tampon- hypotension in septic shock, other causes of the inability
ade, tension pneumothoraces, positive-pressure ventila- of the cardiovascular system to maintain the cardiac out-
tion with large tidal volumes or high airway pressures put at a level sufficient to maintain normal blood pres-
(especially in a hypovolaemic patient), an elevated dia- sure may include:
phragm (as in pregnancy), displacement of abdominal
Hypovolaemia due to fluid translocation from the
viscera through a ruptured diaphragm, and the abdomi-
blood into the interstitial spaces
nal compartment syndrome (e.g. from ascites, abdomi-
Elevated pulmonary vascular resistance due to ARDS
nal distension, abdominal or retroperitoneal bleeding
Bioventricular myocardial depression manifested
or a stiff abdominal wall, as in a patient with deep burns
by reduced contractility and an inability to increase
to the torso).
stroke-work.
The consequence of this compression is an increase
in right atrial pressure without an increase in volume, The ultimate cause of death in septic shock is a failure
impeding venous return and provoking hypotension. of energy production at the cellular level, as reflected by
a decline in oxygen consumption. It is not only the circu- return, the atrial filling is reduced, with consequent hypo-
latory insufficiency that is responsible for this, but also tension. The obstruction to flow can be on either the right
the impairment of cellular oxidative phosphorylation by or the left side of the heart. Causes include pulmonary
endotoxin or endogenously produced superoxides. There embolism, air embolism, ARDS, aortic stenosis, calcifi-
is a narrowing of arterialmixed venous oxygen difference cation of the systemic arteries, thickening or stiffening
as an indication of reduced oxygen extraction, which often of the arterial walls as a result of the loss of elastin and
precedes the fall of cardiac output. Anaerobic glycogenol- its replacement with collagen (as occurs in old age), and
ysis and a severe metabolic acidosis due to lactacidaemia obstruction of the systemic microcirculation as a result of
result. The mechanisms responsible for the phenomena chronic hypertension or the arteriolar disease of diabetes.
observed in sepsis and endotoxic shock are discussed in The blood pressure in the pulmonary artery or the aorta
detail above. will be high; the cardiac output will be low.
2.2.2.5Neurogenic shock Clinical presentation

In the patient with hypotension, the problem usually can
Neurogenic shock is a hypotensive syndrome in which
be identified immediately from decreased breath sounds,
there is loss of alpha-adrenergic tone and dilatation of the
hyperresonance of the affected side and displacement of
arterial and venous vessels. The cardiac output is normal,
the trachea to the opposite side. The neck veins may be
or may even be elevated, but because the total peripheral
distended.
resistance is reduced, the patient is hypotensive. The con-
sequence may be reduced perfusion pressure.
A simple example of this type of shock is syncope (vas-
ovagal syncope). It is caused by a strong vagal discharge 2.2.3 Measurements in shock
resulting in dilatation of the small vessels of the splanch-
nic bed. The next cycle of the heart has less venous return In physics, flow is directly related to pressure and inversely
so that the ventricle will not fill and the next stroke vol- related to resistance. This universal flow formula is not
ume will not adequately perfuse the cerebrum, causing a dependent on the type of fluid and is applied to the flow
faint. No blood is lost, but there is a sudden increase in of electrons. In electricity, it is expressed as Ohms law.
the amount of blood trapped in one part of the circula- This law applies just as appropriately to blood flow:
tion where it is no longer available for perfusion to the Pressure
obligate aerobic glycolytic metabolic bed the central Flow =
Peripheral resistance
nervous system.
From this law, it can be deduced that shock is just as
much a state of elevated resistance as it is a state of low
Clinical presentation blood pressure. However, the focus should remain on
The patient usually has weakly palpable peripheral pulses, flow rather than simply on pressure since most drugs that
warm extremities and brisk capillary filling, and may be result in a rise in pressure do so by raising the resistance,
anxious. The pulse pressure is wide, with both systolic which in turn decreases flow.
and diastolic blood pressure being low. Heart rate is below
100 beats per minute, and there may even be bradycardia.
The diagnosis of neurogenic shock should only be made 2.2.3.1Cardiac output
once other causes of shock have been ruled out, since the Blood flow is dependent on cardiac output. Three factors
common cause is injury, and there may be other injuries determine cardiac output:
present causing a hypovolaemic shock in parallel.
Preload, or the volume entering the heart
The contractility of the heart
2.2.2.6Obstructive shock Afterload, or the resistance against which the heart
must function to deliver the nutrient flow.
Intravascular obstructive shock results when intravascu-
lar obstruction, excessive stiffness of the arterial walls or These three factors are interrelated to produce the
obstruction of the microvasculature imposes an undue systolic ejection from the heart. Up to a point, the
burden on the heart. Because of the decreased venous greater the preload, the greater the cardiac output. As
myocardial fibres are stretched by the preload, the con- additional amino acids to produce the octapeptide angi-
tractility increases according to the FrankStarling prin- otensin II, one of the most potent vasopressors known.
ciple. However, an excessive increase in preload leads to The third step is that the same octapeptide stimulates the
symptoms of pulmonary/systemic venous congestion zona glomerulosa of the adrenal cortex to secrete aldos-
without further improvement in cardiac performance. terone, which causes sodium retention and results in
The preload is a positive factor in cardiac performance up volume expansion.
the slope of the FrankStarling curve but not beyond the The kidney thus has three methods of protecting its
point of cardiac decompensation. perfusion: autoregulation, pressor secretion and volume
Contractility of the heart is improved by inotropic expansion. When all three compensatory mechanisms
agents. The product of the stroke volume and the heart have failed, there is a decrease in the quality and quantity
rate equals the cardiac output. Cardiac output acting of urine as a function of nutrient flow to this organ. Urine
against the peripheral resistance generates the blood pres- flow is such an important measurement of flow in the
sure. Diminished cardiac output in patients with pump patient in shock that we can use this to define the pres-
failure is associated with a fall in blood pressure. To ence or absence of shock. For practical purposes, if the
maintain coronary and cranial blood flow, there is a reflex patient is producing a normal quantity of normal quality
increase in systemic vascular resistance to raise the blood urine, he is not in shock.
pressure. An exaggerated rise in systemic vascular resist- Another vital perfusion bed that reflects the adequacy
ance can lead to a further depression of cardiac function of nutrient flow is the brain itself. Since adequate nutri-
by increasing ventricular afterload. Afterload is defined ent flow is a necessary, but not the only, requirement for
as the wall tension during left ventricular ejection and is cerebration, consciousness also can be used to evaluate
determined by systolic pressure and the radius of the left the adequacy of nutrient flow in the patient with shock.
ventricle. Left ventricular radius is related to end-diastolic
volume, and systolic pressure to the impedance to blood 2.2.3.3 Direct measurements
flow in the aorta, or total peripheral vascular resistance.
As the emphasis in the definition of shock is on flow, Central venous pressure
we should be looking for ways to measure flow. Between the groin or axillae and the heart, the veins do
not have any valves, so measurement of the pressure in
this system at the level of the heart will reflect the pres-
2.2.3.2Indirect measurement of flow
sure in the right atrium, and therefore the filling pressure
In many patients in shock, simply laying a hand upon of the heart.
their extremities will help to determine flow by the cold Placement of a central venous line that will allow accu-
clammy appearance of hypoperfusion. However, prob- rate measurement of the hydrostatic pressure of the right
ably the most important clinical observation to indirectly atrium following fluid boluses can help to differentiate
determine adequate nutrient flow to a visceral organ will between the different shock states. The actual measure-
be the urine output. ment is less important than the change in value, espe-
The kidney responds to decreased nutrient flow with cially in the acute resuscitation of a patient. The normal
several compensatory changes to protect its own per- value is 412cmH2O. A value below 4cmH2O indicates
fusion. Over a range of blood pressure, the kidneys that the venous system is empty, and thus the preload is
maintain a nearly constant blood flow. If the blood pres- reduced, usually as a result of dehydration or hypovolae-
sure decreases, the kidneys autoregulation of resistance mia. Conversely, a high value indicates that the preload is
results in dilatation of the vascular bed. It keeps nutrient increased, either as the result of a full circulation or due
flow constant by lowering the resistance even though the to pump failure (e.g. cardiogenic shock due to aetiologies
pressure has decreased. This allows selective shunting of such as tension pneumothorax, cardiac tamponade or
blood to the renal bed. myocardial contusion).
If the blood pressure falls further and a true decrease in As a general rule, if a patient in shock has both systemic
flow across the glomeruli occurs, the reninangiotensin arterial hypotension and central venous hypotension, the
mechanism is triggered. Renin from the juxtaglomeru- shock is due to volume depletion. On the other hand, if
lar apparatus acts upon angiotensin from the liver. The central venous pressure is high although arterial pressure
peptide is cleaved by renin, and a decapeptide results, is low, shock is not due to volume depletion and is more
which in the presence of converting enzyme clips off two likely to be due to pump failure.
Cannulation of the central venous system is generally 10 Introduce the guidewire while monitoring the ECG
achieved using the subclavian, jugular or femoral route. for abnormalities.
The subclavian route is the preferred one in the trauma 11 Insert the catheter over the guidewire to a
patient, particularly when the status of the cervical spine predetermined length. The tip of the catheter should
is unclear. It is ideal for the intensive care setting, where be at the entrance to the right atrium. In an adult,
occlusion of the access site against infection is required. this distance is approximately 18cm.
The safest technique is that recommended by the 12 Connect the catheter to intravenous tubing.
Advanced Trauma Life Support (ATLS) programme.12 13 Affix it securely to the skin and cover it with an
The internal jugular route, or occasionally the exter- occlusive dressing.
nal jugular route, is the one most commonly utilized by 14 Obtain a chest X-ray to confirm its position.
anaesthesiologists, often under ultrasonic guidance. It
Technique of femoral line insertion14
provides ease of access, especially under operative con-
The femoral route is easy to access, especially when the line
ditions. However, there are significant dangers in the
also will be used for venous transfusion. However, the inci-
trauma patient, especially where the cervical spine has
dence of femoral vein thrombosis is high, and the line should
not yet been cleared, and other routes may be preferable.
not be left beyond 48 hours because of the risk of infection.
The ability to occlude the jugular site, especially in the
Pitfalls include placing the cannula inside the abdominal
awake patient in the intensive care unit, is however, more
cavity. This can be particularly misleading if blood is present
limited, and there is greater discomfort for the patient.
inside the abdominal cavity, since aspiration of the cannula
The subclavian route is reliable, easy to maintain and
will yield blood and a false sense of security!
relatively safe. Pitfalls include arterial puncture and
pneumothorax. 1 Place the patient in a supine position.
2 Cleanse the skin.
Technique of subclavian line insertion13 3 Locate the femoral vein by locating the femoral
1 Place the patient in a supine position, at least 15 artery. The vein lies immediately medial to the artery.
degrees head down to distend the neck veins and 4 If the patient is awake, infiltrate the puncture site
prevent an air embolism. Do not move the patients with lignocaine 1 per cent.
head. 5 Introduce a large-calibre needle, attached to a 10mL
2 Cleanse the skin, and drape the area. syringe containing 1mL saline. The needle, directed
3 Use lignocaine (lidocaine) 1 per cent at the injection towards the patients head, should enter the skin
site to effect local anaesthesia. directly over the femoral vein.
4 Introduce a large-calibre needle, attached to a 6 Hold the needle and syringe parallel to the frontal
10mL syringe with 1mL saline in it, 1cm below plane.
the junction of the middle and medial thirds of the 7 Direct the needle cephalad and posteriorly at
clavicle. 45degrees to the skin, and slowly advance the needle
5 After the needle has been introduced, with the bevel while withdrawing the plunger of the syringe.
of the needle upwards, expel the skin plug that may 8 When a free flow of blood appears in the syringe,
occlude the needle. remove the syringe. Occlude the needle to avoid any
6 Hold the needle and syringe parallel to the frontal chance of air embolism.
plane. 9 Insert the catheter over the guidewire to a
7 Direct the needle medially, slightly cephalad predetermined length. The tip of the catheter should
and posteriorly, behind the clavicle, towards the be at the entrance to the right atrium. In an adult,
posterior superior angle of the clavicle to the sternal this distance is approximately 30cm.
end of the clavicle. (Aim at a finger placed in the 10 Connect the catheter to intravenous tubing.
suprasternal notch.) 11 Affix it securely to the skin and cover it with an
8 Advance the needle while gently withdrawing the occlusive dressing.
plunger of the syringe. 12 Obtain a chest X-ray to confirm its position.
9 When a free flow of blood appears in the syringe,
rotate the bevel so that it faces caudally and remove Systemic arterial pressure
the syringe. Occlude the needle to avoid any chance Systemic arterial pressure reflects the product of the
of air embolism. peripheral resistance and the cardiac output. Measurement
can be indirect or direct. Indirect measurement involves has the effect of occluding the lumen. As a result, the
the use of a blood pressure cuff with auscultation of the pressure transmitted via the catheter represents pulmo-
artery to determine systolic and diastolic blood pressure. nary venous pressure, and thus left atrial pressure. The
Direct measurement involves placement of a catheter into wedged pulmonary atrial pressure is a useful approxima-
the lumen of the artery, with direct measurement of the tion of left ventricular end-diastolic pressure, the latter
pressure. usually correlating with left ventricular end-diastolic
In patients in shock, with an elevated systemic vascular volume.
resistance, there is often a significant difference obtained In addition to direct measurement of pressures, a pul-
between the two measurements. In patients with increased monary artery catheter allows the following:
vascular resistance, low cuff pressure does not necessarily
Measurement of cardiac output by thermodilution
indicate hypotension. Failure to recognize this may lead
Sampling of pulmonary arterial (mixed venous) blood.
to dangerous errors in therapy.
An arterial Doppler scan can be used for measuring Technique of insertion of a pulmonary artery catheter using
arterial blood pressure. Only measurement of the systolic the internal jugular route15
blood pressure is possible. However, the Doppler result Equipment
correlates well with the direct measurement pressure. Lignocaine
The radial artery is the most common site for arterial SwanGanz catheter set: commercial pack
cannulation. It is usually safe to use, provided adequate Calibrated pressure transducer with a continuous
ulnar collateral flow is present. It is important both medi- heparin flush and connecting tubing
cally and legally to do an Allen test, compressing both the Visible oscilloscope screen showing both ECG and
radial and ulnar arteries, and releasing the ulnar artery to pressure tracings
check for collateral flow. Thrombosis of the radial artery A dedicated assistant (e.g. a nurse).
is quite common, although ischaemia of the hand is rare
due to collaterals from the ulnar artery. Technique
The femoral artery is generally quite safe to use in an 1 Prepare all supplies at the bedside.
emergency situation, but the cannula should be removed 2 Calibrate the transducer for a pressure range of
as soon as possible. 050mmHg.
Cannulation of the brachial artery is not recommended 3 Remove all pillows from behind the patient, and
because of the potential for thrombosis and for ischaemia turn the patients head to the left.
of the lower arm and hand. 4 Make sure the patients airway and breathing are
acceptable. The patient should be on oxygen, and
preferably also monitored on pulse oximetry.
Pulmonary arterial pressure 5 Tilt the bed head down to distend the jugular vein.
The right-sided circulation is a valveless system through 6 Prepare and drape the skin, allowing access from
which flows the entire cardiac output from the right side below the clavicle to the mastoid process.
of the heart. 7 Locate the right carotid pulse, and infiltrate over the
Catheterization can be performed easily and rapidly at area with local anaesthetic at the apex of the triangle
the bedside, using a balloon-tipped, flow-directed ther- between the sternal and clavicular heads of the
modilution catheter. In its passage from the superior vena sternomastoid muscle.
cava through the right atrium, from which it migrates 8 Insert a 16G needle beneath the anterior border of
into the right ventricle on a myocardial contraction, the sternomastoid, aiming towards the right nipple,
the balloon tip enters the pulmonary valve exactly like to place the needle behind the medial end of the
a pulmonary embolus, until the balloon-tipped catheter clavicle, and to enter the right internal jugular vein.
wedges in the pulmonary artery. Additional side holes are 9 Pass the J-wire through the needle and advance the
provided in the catheter, allowing measurement of pres- wire until it has passed well into the vein.
sure in each right-sided chamber, including right arterial 10 Remove the needle, and enlarge the skin site with
pressure, right ventricular pressure, pulmonary pressure a no. 11 scalpel blade, followed with the dilator
and pulmonary wedge pressure. provided in the set.
The tip of the catheter is placed in the pulmonary 11 Attach an intravenous solution to the introducer,
artery, and then the occlusive balloon is inflated. This and suture the introducer to the skin.
12 Connect and flush the catheter to clear all air and Paco2, pH and arterial lactate will supply information on
to test all balloons, ports, etc. Move the catheter to oxygen delivery and utilization of energy substrates. Both
confirm that the trace is being recorded. Pao2 and Paco2 are concentrations partial pressures of
13 Insert the catheter into the introducer. If it has a oxygen and carbon dioxide, respectively, in arterial blood.
curve, ensure that this is directed anteriorly and to If the Paco2 is normal, there is adequate alveolar ventila-
the left. Insert it to the 20cm mark. This should tion. Carbon dioxide is one of the most freely diffusable
place the tip in the right atrium. gases in the body and is not overproduced or underdif-
14 Inflate the balloon. fused. Consequently, its partial pressure in the blood is
15 Advance the catheter through the right ventricle to a measure of its excretion through the lung, which is a
the occlusion pressure position. In most adults, this direct result of alveolar ventilation. The Pao2 is a similar
is at the 4555cm mark. concentration but is the partial pressure of oxygen in the
16 Deflate the balloon. The pulmonary artery waveform blood and not the oxygen content. A concentration meas-
should appear, and with slow inflation the occlusion ure in the blood does not tell us the delivery rate of oxygen
waveform should return (Figure 2.1). If this does to the tissues per unit of time without knowing some-
not occur, advance and then withdraw the catheter thing of the blood flow that carried this concentration.
slightly. For evaluation of oxygen utilization, however, data are
17 Attach the sheath to the introducer. obtainable from arterial blood gases that can indicate what
18 Apply a sterile dressing. the cells are doing metabolically, which is the most impor-
19 Confirm correct placement with a chest X-ray. tant reflection of the adequacy of their nutrient flow. The
pH is the hydrogen ion concentration, which can be deter-
Cardiac output mined easily and quickly. The lactate and pyruvate concen-
trations can be measured, but this is more time-consuming.
Cardiac output can be measured with the thermodilution
The pH and the two carbon fragment metabolites are very
technique.16 A thermodilution pulmonary artery catheter
important indicators of cellular function in shock.
has a thermistor at the distal tip. When a given volume
In shock, there is a fundamental shift in metabolism.
of a solution that is cooler than the body temperature is
When there is adequate nutrient flow, glucose and oxy-
injected into the right atrium, it is carried by the blood past
gen are coupled to produce, in glycolysis, the high-energy
the thermistor, resulting in a transient fall in temperature.
phosphate bonds necessary for energy exchange. This
The temperature curve so created is analysed, and the rate
process of aerobic metabolism also produces two freely
of blood flow past the thermistor (i.e. cardiac output) can
diffusable byproducts carbon dioxide and water both
be calculated. By estimating oxygen saturation in the pul-
of which leave the body by excretion through the lung
monary artery, blood oxygen extraction can be determined.
and the kidney. Aerobic metabolism is efficient; therefore,
there is no accumulation of any products of this catabo-
2.2.4End points in shock resuscitation17 lism, and a high yield of ATP is obtained from this com-
plete combustion of metabolites.
The ultimate measurement of the impact of shock must be When there is inadequate delivery of nutrients and
at the cellular level. The most convenient measurement is oxygen, as occurs in shock, the cells shift to anaerobic
a determination of the blood gases. Measurement of Pao2, metabolism within 35 minutes. There are immediate
Right ventricle Pulmonary

25 artery
20
Wedge pressure
mmHg
15
v
a
10 Right atrium
5 v
a
0
Figure 2.1 A recording of pressures showing the passage of the pulmonary artery catheter through the right side of the heart until it is wedged in
the pulmonary artery. Note that the wedge pressure is less than the diastolic pulmonary artery pressure. a, atrial activity; v, ventricular activity.
consequences of anaerobic metabolism in addition to In shock, whether hypovolaemic or septic, energy pro-
its inefficient yield of energy. In the absence of aerobic duction is insufficient to satisfy requirements. In the
metabolism, energy extraction takes place at the expense presence of oxygen deprivation and cellular injury, the
of accumulating hydrogen ions, lactate and pyruvate, conversion of pyruvate to acetyl-CoA for entry into the
which have toxic effects on normal physiology. These Krebs cycle is inhibited. Lactic acid accumulates, and the
products of anaerobic metabolism can be seen as the oxidationreduction potential falls, although lactate is
oxygen debt. There is some buffer capacity in the body normally used by the liver via the Cori cycle to synthe-
that allows this debt to accumulate within limits, but it size glucose. Hepatic gluconeogenesis may fail in hypo-
must ultimately be paid off. volaemic or septic shock because of hepatocyte injury
Acidosis has significant consequences in compensatory and inadequate circulation. The lactacidaemia cannot be
physiology. In the first instance, oxyhaemoglobin dissoci- corrected by an improvement in circulation and oxygen
ates more readily as the concentration of hydrogen ions delivery once the cells have been irreparably damaged.
increases. However, there is a significant toxicity of hydro- In the low-output shock-state, plasma concentrations
gen ions as well. Despite the salutary effect on oxyhaemo- of free fatty acids and triglycerides rise to high levels
globin dissociation, the hydrogen ion has a negative effect because ketone production by beta-oxidation of fatty
on oxygen delivery. Catecholamines speed up the hearts acids in the liver is reduced, suppressing the acetoacetate:
rate and increase its contractile force, and the product of betahydroxybutarate ratio in the plasma.
this inotropic and chronotropic effect is an increase in The post-shock sequel of inadequate nutrient flow,
cardiac output. Catecholamines, however, are physiologi- therefore, is progressive loss of function. The rate at
cally effective at alkaline or neutral pH. Therefore, an acid which this loss occurs depends upon the cells ability to
pH inactivates this catecholamine method of compensa- switch metabolism to convert alternate fuels to energy,
tion for decreased nutrient flow. on the increased extraction of oxygen from haemoglobin
For example, if a catecholamine such as isoproterenol and on the compensatory collaboration of failing cells
is administered to a patient in shock, it increases myo- and organs whereby nutrients may be shunted selectively
cardial contractility and heart rate and also dilates the to more critical systems.
periphery to increase nutrient flow to these ischaemic cir- Not all cells are equally sensitive to shock or similarly
culation areas. However, the ischaemic areas have shifted refractory to restoration of function when adequate nutri-
to anaerobic metabolism, accumulating hydrogen ions, ent flow is restored. As cells lose function, the reserves of the
lactate and pyruvate. When the circulation dilates, this organ composed of those cells are depleted until impaired
sequestered oxygen debt is dumped into the central circu- function of the organ results. These organs function in sys-
lation, and the drop in pH inactivates the catecholamines tems and a system failure results. Multiple systems failure
circulatory improvement as effectively as if infusion of the occurring in sequence leads to the collapse of the organism.
agent had been interrupted.
2.2.6 Management of the shocked patient

2.2.5Post-shock and multiple organ failure
syndromes The primary goal of shock resuscitation is the early estab-
lishment of adequate oxygen delivery (Do2). The calcu-
Although the consequences of sepsis following trauma lated variable of Do2 is the product of cardiac output and
and shock, the development of multiple organ failure, are arterial oxygen content (Cao2).
discussed elsewhere in this book, it is important to briefly By convention, cardiac output is indexed to body sur-
reiterate the usual sequence of events following shock to face area and expressed as a cardiac index (CI), and when
enable a logical discussion of its management. multiplied by Cao2, yields an oxygen delivery index (Do2I).
The ultimate cause of death in shock is failure of energy Normal Do2I is roughly 450L/m2 per minute. Cao2 and
production, as reflected by a decline in oxygen consump- Do2I are calculated as follows:
tion (Vo2) to less than 100mL/m2 per minute. Circulatory
Cao2 (mL O2/dL = [Hb](g/dL) 1.38 mL O2/g Hb
insufficiency is responsible for this fall in energy, com-
Sao2 (%) + [Pao2 (mmHg) 0.003 mL O2 /mmHg]
pounded by an impairment of cellular oxidative phos-
phorylation by endotoxin and endogenously produced Do2I (L/m2 per minute) = CI (L/m2 per minute)
substances known as superoxides. Cao2 (mL/dL) 10 dL/L
where Hb = haemoglobin concentration, Sao2 = haemo- Breathing indications for intubation

globin oxygen saturation, Pao2 = arterial oxygen tension, Inability to breathe (e.g. paralysis, either spinal or
and 0.003 = solubility of oxygen in blood. drug-induced)
Early work demonstrated that the survivor response to Tidal volume less than 5mL/kg.
traumatic stress is to become hyperdynamic. Supranormal
resuscitation based on the Do2I was therefore proposed.
Subsequent randomized controlled trials have failed Breathing indications for ventilation
to demonstrate improved outcomes with goal-directed
Inability to oxygenate adequately
supranormal therapy, and this strategy may even be
Pao2 less than 60mmHg (7.9kPa) on 40 per cent
harmful. The Glue Grant study for shock resuscitation18
oxygen or
suggests using a CI of over 3.8 L/m2 per minute as the
Oxygen saturation (Spo2) of less than 90 per cent on
resuscitation goal.
oxygen
The purpose of distinguishing the different pathophysi-
A respiratory rate of 30 breaths or more per minute and
ological mechanisms of shock becomes important when
Excessive ventilatory effort
treatment has to be initiated. The final aim of treatment is
A Paco2 of greater than 45mmHg (6kPa) with
to restore aerobic cellular metabolism. This requires resto-
metabolic acidosis, or greater than 50mmHg
ration of an adequate flow of oxygenated blood (which is
(6.6kPa) with normal bicarbonate levels.
dependent on optimal oxygenation and adequate cardiac
output) and restoration of aerobic cellular metabolism.
These aims can be achieved by securing a patent airway and Circulation indication for intubation
controlling ventilation if alveolar ventilation is inadequate.
Systolic blood pressure less than 75mmHg despite
Restoration of optimal circulating blood volume,
resuscitation.
enhancing cardiac output through the use of inotropic
agents or increasing systemic vascular resistance through
the use of vasopressors, the correction of acidbase distur- Disability indications for intubation
bances and metabolic deficits, and the combating of sep-
High spinal injury with inability to breathe
sis are all vital in the management of the shocked patient.
Coma (Glasgow Coma Scale score <8/15).
Best practice guidelines for shock resuscitation are sum-
marized in a large-scale collaborative project to provide
standard operating procedure for clinical care the so-called Environmental indication for intubation
Glue Grant study (see Recommended reading below).
Core temperature of less than 32C.
If ventilatory support is instituted, the goals are rela-

2.2.6.1Oxygenation tively specific.
The traumatized, hypovolaemic or septic patient has an The respiratory rate should be adjusted to ensure a
oxygen demand that often exceeds twice the normal. The Paco2 of between 35 and 40mmHg (4.65.3kPa). This
traumatized, shocked patient usually cannot exert the will avoid respiratory alkalosis and a consequential
additional respiratory effort required, and therefore often shift of the oxyhaemoglobin dissociation curve to the
develops respiratory failure followed by a lactic acidosis left, which results in an increased affinity of haemo-
due to tissue hypoxaemia. globin for oxygen and significantly decreases oxygen
In some patients, an oxygen mask may be enough to availability to the tissues, which will require increased
maintain efficient oxygen delivery to the lungs. In more cardiac output to maintain tissue oxygenation. The
severe cases, endotracheal intubation and ventilatory arterial Pao2 should be maintained at between 80 and
assistance may be necessary. It is important to distinguish 100 mmHg (10.613.2 kPa) with the lowest possible
between the need for intubation and the need for ventilation. oxygen concentration.
It has been shown that respiratory muscles require a
disproportionate share of the total cardiac output, and
Airway indications for intubation therefore other organs are deprived of necessary blood
Obstructed airway flow, and lactic acidosis is potentiated. Mechanical venti-
Inadequate gag reflex. lation tends to reverse this lactic acidosis.
2.2.6.2Fluid therapy for volume expansion comparing crystalloids and colloids for resuscitation after
trauma showed no improvement in survival with colloids,
Considerable controversy exists regarding the type of
and therefore their use cannot be supported at present.19
fluid to be administered for volume expansion in hypo-
Lactated Ringers is the currently preferred crystalloid.
volaemic shock. Despite many studies, minimal convinc-
As yet, no advantages have been shown for the use of
ing evidence exists that favours any specific fluid regimen.
newer formulations utilizing pyruvate or acetate. Normal
Balanced salt solutions (BSSs) are effective volume
saline results in an increase of hyperchloraemic metabolic
expanders for the initial resuscitation of patients with
alkalosis.
shock. For most patients, Ringers lactate solution is the
preferred crystalloid solution. The lactate acts as a buffer
and is eventually metabolized to carbon dioxide and Hypotensive resuscitation
water. However, septic patients with significant hepatic In 1994, Bickell et al.20 concluded that patients with pen-
dysfunction do not metabolize lactate well, and for these etrating trauma in hypovolaemic shock who were not
patients other BSSs are preferred. given intravenous fluids during transport and emer-
In hypovolaemic shock, a volume of solution in excess gency department evaluation had a better chance of sur-
of measured losses is generally required. In principle, vival than those who received conventional treatment.
three times the volume of BSS is given per unit of blood However, the only difference in survival was in the sub-
lost. A bolus dose of 2000mL BSS (e.g. Ringers lactate) group with pericardial tamponade. In animal studies,
is given in adults, and the response of pulse rate, blood intravenous fluids have been shown to inhibit platelet
pressure and urinary output is monitored. If this fails to aggregation, dilute clotting factors, modulate the physi-
correct haemodynamic abnormalities, additional crystal- cal properties of thrombus and cause increases in blood
loid solution and blood is indicated, because crystalloids pressure that can mechanically disrupt clot.21 This was
in large quantities will ultimately cause a dilutional effect possibly because the reduced blood pressure reduced the
that can decrease the bloods oxygen-carrying capacity. amount of bleeding that took place.
It is true that the restored vascular volume will increase The optimum systolic blood pressure for a patient with
the cardiac output and thus maintain tissue oxygenation. uncontrolled haemorrhage would appear to be between
This increased cardiac output can be sustained by the nor- 90 and 100mmHg for the military environment, but this
mal heart, but in the diseased heart or the elderly patient, issue remains controversial in the civilian environment.
it is safer to give blood earlier to obviate the possibility
of cardiac failure. In many countries, packed red blood Hypertonic saline22,23
cells with crystalloid solutions are given instead of whole
Hypertonic saline solutions containing up to 7.5 per cent
blood because the blood-banking industry in those coun-
sodium chloride (compared with 0.9 per cent for normal
tries has changed to component therapy to the extent that
saline) show promise for resuscitating patients in situa-
whole-blood replacement is not readily available for large-
tions where large-volume resuscitation with isotonic solu-
volume transfusion.
tions is impossible (e.g. combat, events involving mass
casualties and pre-hospital trauma care). Hypertonic
Crystalloids or colloids? solutions provide far more blood volume expansion than
Crystalloids are cheaper, with fewer side effects. Colloids isotonic solutions and result in less cellular oedema.
are more expensive and have more side effects. However, Several randomized controlled trials have evaluated the
their rate of excretion is much slower than that of crystal- use of hypertonic saline in the resuscitation of hypovol-
loids, so that the volume remains in the circulation for aemia. In all the trials, patients resuscitated with saline
longer. Balanced salt solutions are said to have a half-life survived longer than those resuscitated in the conven-
in the circulation of 20 minutes, while colloids, such as tional fashion. In all the trials, the patients did best when
Gelofusine, have a half-life of 46 hours. However, addi- the hypertonic saline was given as the initial therapy, and
tional considerations relate to the rate of infusion, and the those patients most likely to benefit were those with head
problem with most cases of hypovolaemic shock is that injuries. Hypertonic saline may be more effective when
inadequate volumes of resuscitation fluid are infused in the mixed with a small amount of an oncotically active mol-
time available. Thus, there are advantages to using a fluid ecule such as dextran. However, no adequately powered
that does not leave the circulation as quickly. However, trial to date has demonstrated any benefits, and in view of
a recent Cochrane Review of the available trial data the costs, these solutions cannot be recommended.
Blood substitutes contractility can be enhanced by pharmacological agents.

Blood substitutes, including haemoglobin-based prepa- Reducing the systemic vascular resistance with vasodila-
rations and perfluorocarbons, have several potential tors can be a very effective means of improving cardiac
advantages. No crossmatching is necessary, disease trans- output when systemic pressures or cardiac filling pres-
mission is not an issue, and shelf-life is extended. Several sures are normal or elevated, but this is not currently
haemoglobin substitutes are being evaluated, but at recommended for acute trauma.
present these remain experimental and are not generally
approved for human use in trauma. Noradrenaline
The preferred inotropic agent for acute trauma is
2.2.6.3Route of administration noradrenaline. It is a sympathetic neurotransmitter
with potent inotropic effects. It activates myocardial
In principle, with all intravenous lines, the shorter the beta-adrenergic and vascular alpha-adrenergic receptors.
line and the wider the diameter of the cannula, the faster It is used in the treatment of shock and hypotension
will be the flow. For the same bore of line, flow rates are characterized by low systemic vascular resistance that is
reduced (Table 2.2): unresponsive to fluid resuscitation.
14G via a peripheral cannula full flow
14G via a 30cm central line 33 per cent reduction Adrenaline
in flow
Adrenaline is a natural catecholamine with both alpha-
14G via a 70cm central line 50 per cent reduction
and beta-adrenergic agonist activity. The pharmacologi-
in flow.
cal actions are complex, and it can produce the following
cardiovascular responses:
Table 2.2 Flow rates for different cannulas and fluids
Increased systemic vascular resistance
Flow rates (mL/min) Increased systolic and diastolic blood pressure
Cannula size Crystalloid Colloid Increased electrical activity in the myocardium
Increased coronary and cerebral blood flow
8.5FG 1000 600
Increased strength of myocardial contraction
14G 125 90
Increased myocardial oxygen requirement.
16G 85 65
18G 60 35
The primary beneficial effect of adrenaline is periph-
eral vasoconstriction, with improved coronary and cere-
20G 40 17
bral blood flow. It works as a chronotropic and inotropic
agent. The initial dose is 0.03g/kg per minute, titrated
A minimum of two lines is required. In all cases of upwards until the desired effect is achieved. In trauma
hypovolaemic shock, two large-bore peripheral lines are patients, it is often used in conjunction with dobutamine.
essential. A central line is most useful for monitoring, but
can be used for transfusion as well. The monitoring line
should be a central venous line, inserted via the subcla- Dopamine
vian, jugular or femoral route. In blunt polytrauma, the Dopamine hydrochloride is a chemical precursor of
subclavian route is preferable, since this avoids any move- noradrenaline that stimulates dopaminergic, beta1-adren-
ment of the head in a patient whose neck has not yet been ergic and alpha-adrenergic receptors in a dose-dependent
cleared. The jugular route is less preferable because of the fashion. Low doses of dopamine (<3g/kg per minute)
longer term issues of securing the lines and because of produce cerebral, renal and mesenteric vasodilatation,
earlier sepsis at the insertion site due to movement. and venous tone is increased. Urine output is increased,
but there is no evidence to show that this is in any way
protective to the kidneys.
2.2.6.4 Pharmacological support of blood pressure
At doses above 10 g/kg per minute, however, the
Stroke volume is controlled by ventricular preload, alpha-adrenergic effects predominate. This results in
afterload and contractility. Preload is mainly influenced marked increases in systemic vascular resistance and pul-
by the volume of circulating blood, but afterload and monary resistance and increases in preload due to marked
arterial, splanchnic and venous constriction. It increases Cortisol

systolic blood pressure without increasing diastolic blood The role of relative adrenal insufficiency in the manage-
pressure or heart rate. ment of the critically injured patient remains controversial.
Dopamine is used for haemodynamically significant
hypotension in the absence of hypovolaemia.
2.2.6.5 Metabolic manipulations23
Dobutamine The endogenous opiate beta-endorphin appears to be
Dobutamine is a synthetic sympathomimetic amine that involved in the hypotension and impaired tissue per-
has potent inotropic effects by stimulating beta1- and fusion that occur in both hypovolaemic and septic shock
alpha1-adrenergic receptors in the myocardium. There is states, as elevations in this substance can be demonstrated
only a mild vasodilatory response. Dobutamine-mediated at the time that these physiological changes take place.
increases in cardiac output also lead to a decrease in Naloxone, an opiate antagonist, has been shown to
peripheral vascular resistance. At a dose of 10g/kg per elevate blood pressure and cardiac output, and to signifi-
minute, dobutamine is less likely to induce tachycardia cantly improve survival in septic and haemorrhagic shock
than either adrenaline or isoproterenol. Higher doses may models. Early results in shock patients have supported
produce a tachycardia. Dobutamine in low doses has also these findings. Prostaglandins also have been implicated
been used as a renal-protective agent. There is little evi- in shock. They may play a role in the pathophysiology
dence to support its use on its own, but it may be helpful of shock by vasodilatation or vasoconstriction of the
in improving renal perfusion as an adjunct to the admin- microcirculation with shunting of blood. Experimental
istration of high-dose adrenaline. evidence exists that cyclo-oxygenase inhibitors, such as
Dobutamine increases cardiac output, and its lack of indomethacin (indometacin) and ibuprofen, can improve
induction of noradrenaline release means that there is a the haemodynamic state in experimental shock.
minimal effect on myocardial oxygen demand. There is
also increased coronary blood flow.
Dobutamine and dopamine have been used together. 2.2.7 Prognosis in shock
The combination of moderate doses of both (7.5g/kg per
minute) maintains arterial pressure with less increase in The prognosis of the shocked patient depends on the
pulmonary wedge pressure than the use of dopamine alone. duration of the shock, the underlying cause and the pre-
existing vital organ function. The prognosis is best when
Isoproterenol the duration is kept short by early recognition and aggres-
sive correction of the circulatory disturbance, and when
Isoproterenol hydrochloride is a synthetic sympatho-
the underlying cause is known and corrected.
mimetic amine with a particularly strong chronotropic
Occasionally, shock does not respond to standard
effect. Newer inotropic drugs, such as dobutamine, have
therapeutic measures. Unresponsive shock requires an
largely superseded isoproterenol in most settings.
understanding of the potential occult causes of persist-
ent physiological disturbances. These correctable causes
Nitroprusside include:
Sodium nitroprusside is a potent peripheral vasodilator
Underappreciated volume need with inadequate fluid
with effects on both venous and arterial smooth muscle,
resuscitation and a failure to assess the response to a
and has balanced vasodilating effects on both circula-
fluid challenge
tions, thus minimizing adverse effects on arterial blood
Erroneous presumption of overload when cardiac
pressure. It has a very short half-life.
disease is also present
Hypoxia caused by inadequate ventilation, barotrauma
Digoxin to the lung, pneumothorax or cardiac tamponade
Digoxin enhances cardiac contractility, but its use in Undiagnosed or inadequately treated sepsis
shock is limited because it takes considerable time to act. Uncorrected acidbase or electrolyte abnormalities
In the intensive care situation, digoxin is usually reserved Endocrine failure, such as adrenal insufficiency or
for the treatment of atrial flutter and supraventricular hypothyroidisim
tachycardias. Drug toxicity.
2.2.8Recommended protocol for shock Intubation should be considered if it has not already
been performed.
If the CI is over 3.8L/m2 per minute, the patient
2.2.8.1 Military experience
should be monitored appropriately.
Recent military experience from the Iraq war has shown the Haemoglobin level should be maintained at between
value of damage control resuscitation.24,25 This implies that 8 and 10g/dL.
damage control techniques are used from the time of injury, Pulmonary capillary wedge pressure greater than
minimizing the time between injury and care, controlling the 15mmHg may enhance cardiac performance.
bleeding and the contamination, through the use of minimal After obtaining an optimal pulmonary capillary wedge
clear fluids, early fresh whole blood, early resuscitation and pressure, if the CI is below 3.8L/m2 per minute, infusion
early damage control surgery. The military use of whole of a vasodilating inotropic agent should be considered.
blood has minimized some of the risks of component Dobutamine is recommended as the preferred agent,
therapy, and has also shown that survival is improved. commencing at a dose of 5g/kg per minute. If the
From this philosophy has come the change in protocol in patient does not tolerate the vasodilatation, an agent
civilian practice towards minimizing crystalloid or fluid such as dopamine should be considered.
resuscitation (hypotensive resuscitation), and towards the Occasionally, an inotropic agent with vasoconstrictive
early use of blood and blood products to maintain the effects, such as noradrenaline or adrenaline, may be
normal coagulation profile as much as possible. required.
2.2.8.2Initial resuscitation
Major trauma patients arriving in shock (systolic 2.3References

blood pressure <90mmHg and/or heart rate >130
beats per minute) are managed using ATLS protocols. 1 Cuthbertson D. Observations on disturbance of metabolism
Major torso trauma patients requiring ongoing produced by injury of the limbs. Q J Med 1932;25:2336.
resuscitation should have a central venous line placed 2 Lilly MP, Gann DS. The hypothalamic-pituitary-adrenal
in the emergency department. immune axis. Arch Surg 1992;127:146374.
Early central venous pressure of greater than 3 Kapur MM, Jain P, Gidh M. The effect of trauma on serum
15mmHg (before extensive volume loading) suggests C3 activation, and its correlation with Injury Severity Score
cardiogenic or cardiac compressive shock. in man. J Trauma 1986;26:4646.
Central venous pressure less than 10mmHg despite 4 Bianchi ME. DAMPs, PAMPs and alarmins: all we need to
volume loading suggests ongoing bleeding. End know about danger. J Leukoc Biol 2007;81:15.
points are currently vague. At present, the rational 5 Zhang Q, Raoof M, Chen Y et al. Circulating mitochondrial
compromise is hypotensive resuscitation (systolic DAMPs cause inflammatory responses to injury. Nature
blood pressure >90mmHg and heart rate <130 beats 2010;464:1047.
per minute) with moderate volume loading until 6 Porte D, Robertson RP. Control of insulin by catecholamines,
haemorrhage has been controlled. stress, and the sympathetic nervous system. Fed Proc
Boluses of Ringers lactate should be continued, and 1973;32:179296.
when the amount exceeds 30mL/kg, blood should be 7 Needleman P, Greenwald JF. Atriopeptin: a cardiac
administered. hormone intimately involved in fluid, electrolyte and blood
Protocols for massive transfusion should be pressure homeostasis. N Engl J Med 1986;314:82834.
established (see below). 8 Roumen RMH, Redl H, Schlag G et al. Scoring systems
and blood lactate concentrations in relationship to the
development of adult respiratory distress syndrome and
2.2.8.3Intensive care unit resuscitation
multiple organ failure in severely traumatized patients.
On arrival, a decision is made on continuing JTrauma 1993;35:34955.
resuscitation using serial vital signs. 9 Shaw JHF, Wolfe RR. An integrated analysis of glucose, fat
For patients not responding to ongoing volume and protein metabolism in severely traumatized patients:
loading or transfusion, cardiac output monitoring or studies in the basal state and the response to total
pulmonary artery catheterization is warranted. parenteral nutrition. Ann Surg 1989;209:6372.
10 Moore FA, Moore EE, Poggetti R et al. Gut bacterial 21 Roberts I, Evans P, Bunn F, Kwan I, Crowhurst E. Is the
translocation via the portal vein: a clinical perspective with normalisation of blood pressure in bleeding trauma patients
major torso trauma. J Trauma 1991;31:62938. harmful? Lancet 2001;357:3857.
11 Teplitz C. The pathology and ultrastructure of cellular 22 Younes RN, Aun F, Accioly CQ. Hypertonic saline in the
injury and inflammation in the progression and outcome treatment of hypovolaemic shock: a prospective controlled
of trauma, sepsis and shock. In: Clowes GHA, ed. Trauma randomized trial in patients admitted to the emergency
Sepsis and Shock. New York: Marcel Dekker, 1988: 71120. room. Surgery 1992;111:3805.
12 American College of Surgeons. Central venipuncture. In: 23 Wisner DH, Schuster L, Quinn C. Hypertonic saline
Advanced Trauma Life Support Course. Chicago: American resuscitation of head injury: effects on cerebral water
College of Surgeons, 2008: 7381. content. J Trauma 1990;30:758.
13 American College of Surgeons, Subclavian venipuncture. In: 24 Holcomb JB, Jenkins D, Rhee P et al. Damage control
Advanced Trauma Life Support Course. Chicago: American resuscitation: directly addressing the early coagulopathy of
College of Surgeons, 2008: 76. trauma. J Trauma 2007;62:30710.
14 American College of Surgeons. Femoral venipuncture. In: 25 Hess JR, Holcomb JB, Hoyt DB. Damage control
Advanced Trauma Life Support Course. Chicago: American resuscitation: the need for specific blood products to treat
College of Surgeons, 2008: 76. the coagulopathy of trauma. Transfusion 2006;46:6856.
15 Ramsay JG, Bevan DR. Cardiac emergencies. In Ellis BW, ed.
Hamilton Baileys Emergency Surgery, 13th edn. London:
Arnold, 2000: 4857. 2.4Recommended reading
16 Elkayam U, Berkley R, Asen S et al. Cardiac output by
thermodilution technique. Chest 1983;84:41822. American Heart Association. Advanced Cardiovascular
17 Gump FE. Whole body metabolism. In: Altura BM, Lefer Life Support Provider Manual. Dallas: American Heart
AM, Shumer W, eds. Handbook of Shock and Trauma, Vol. Association, 2010.
I: Basic Sciences. New York: Raven Press, 1983: 89113. Holcroft JT, Anderson JT, Sena MJ. Shock. Surgery: Principles
18 Moore FA, McKinley BA, Moore EE et al. Inflammation and Practice. Section 8, Chapter 3. New York: Web MD
and the Host Response to Injury Large Scale Collaborative Publishing, 2007.
Research Program III. Guidelines for shock resuscitation. International Surviving Sepsis Campaign Guidelines Committee.
JTrauma 2006;61:829. Surviving Sepsis Campaign: international guidelines for the
19 Alderson P, Schierhout G, Roberts I, Bunn F. Colloids versus management of severe sepsis and septic shock: 2008. Crit
crystalloids for fluid resuscitation in critically ill patients. Care Med 2008;36:296327.
Cochrane Database Syst Rev 2000;(2):CD000567. Moore FA, McKinley BA, Moore EE et al. Inflammation and the
20 Bickell WH, Wall MJ, Pepe PE. Immediate versus delayed Host Response to Injury Large Scale Collaborative Research
resuscitation for hypotensive patients with penetrating Program III. Guidelines for shock resuscitation. J Trauma
torso injuries. N Engl J Med 1994;331:11057. 2006;61:829.
Part 3
Transfusion in trauma
Transfusion in trauma 3
Transfusion of blood and blood components is a fun- patient more coagulopathic from both factor depletion
damental part of our treatment of injured patients. and dilutional coagulopathy.
Approximately 40 per cent of 11 million units of blood
transfused in the United States each year are used in emer-
gency resuscitation. Despite this, there is little level I evi- 3.2Transfusion fluids
dence to provide a rationale for administration of packed
red blood cells (pRBCs) to trauma patients. 3.2.1Fresh whole blood
The human being is an O2-dependent organism, and O2

3.1 Indications for transfusion depletion causes major damage within minutes. Thus, in
the exsanguinating patient, blood is transfused in order
3.1.1Oxygen-carrying capacity to improve O2 transport. Evidence from the Iraqi war
and recent studies in civilian trauma have highlighted
Anaemia is a decrease in the O2-carrying capacity of the advantage of fresh whole blood (FWB) in the resus-
blood, and is defined by a decrease in circulating red citation and survival of the exsanguinating patient.1 The
cell mass (to below 24mL/kg in females and 26mL/kg rationale is that blood has more function than purely
in males). Anaemia will result in an increase in car- that of an O2 carrier, providing:
diac output at a haemoglobin (Hb) level of 4.57 g/dL
(2.74.0 mmol/L). Oxygen extraction increases as O2 Oncotic pressure (from plasma and stored fresh
delivery falls, ensuring a constant O2 uptake by the frozen plasma [FFP])
tissues. The threshold for O2 delivery is at a haematocrit Coagulation function (clotting factors in FFP and
of 10 per cent and an Hb level of 3g/dL (1.8mmol/L) platelets)
when breathing 100 per cent O2 and with a normal Temperature homeostasis (from warm circulating
metabolicrate. fluid).
Previous haemorrhage management transfused exces-

sive amounts of crystalloids and pRBCs, which diluted
3.1.2 Volume expansion native clotting factors, causing hypocoagulation.2 This
aggravated the coagulopathy initiated from the moment
Normal humans can survive an 80 per cent loss of red of injury due to:
cell mass if they are normovolaemic. Volume-dependent
markers, such as packed cell volume and Hb, are poor The injury itself, and in proportion to its extent
indicators of anaemia because of the effect of dilution on (hypoperfusion resulted in increased activated
their values, i.e. they are relative values. proteinC levels, leading to increased tissue
plasminogen activator and increased fibrinolysis)
Loss of warm blood and replacement with cooler
3.1.2.1Starches
fluid, resulting in decreased body temperature
The use of starches is contraindicated in the actively bleed- Hypoperfusion, resulting in anaerobic metabolism,
ing patient, since all starches deplete the von Willebrand/ increased lactic acid production and a decrease
factor VIII complex, and may make the actively bleeding inpH.
Biochemical reactions within the body require a spe- Prophylaxis: if the platelet count is <15000/mm3
cific and narrow temperature and pH range to proceed. Pre-surgery: if the platelet count is <50000/mm3
The coagulation cascade does not proceed, even in the Active bleeding: with a platelet count of <100000/mm3
presence of all the clotting factors, when the tissue pH 1 unit increases the platelet count by 10000/mm3
is below 7.2 and the temperature below 34C. This is 1 mega-unit (5 units) of apheresis platelets increases
defined as acute coagulopathy of traumashock (ACoTS)3 the platelet count by 50000/mm3.
and differs from disseminated intravascular coagulo
pathy, which may develop after hours or days, when the
septic component adds its consequences to trauma. 3.2.2.2Fresh frozen plasma
Fresh whole blood offers blood at close to 37C, RBCs, Most trauma patients will need FFP early. This is differ-
plasma and platelets in natural proportions, to cover the ent from most recommendations, which are based on
need of the exsanguinating patient for O2 and oncotic more controlled circumstances, and is founded on com-
pressure, and to minimize ACoTS. A 500mL unit of FWB puter simulation of the amount of FFP required to avoid
has a haematocrit of 3850 per cent, 150000400000 excessive plasma dilution compromising haemostasis.
fully functional platelets/mm3 and 100 per cent activity Most patients will require 1 unit of FFP for every unit
of clotting factors diluted only by the 70mL of anticoagu- of blood transfused. A unit of FFP also contains most
lant. In addition, the viability and flow characteristics of of the citrate anticoagulant from the unit of blood from
fresh RBCs are better than their stored counterparts that which it was originally derived. It contains about 0.5g
have metabolic depletion and membrane dysfunction.1 fibrinogen, and normal levels of pro- and anticoagulants.
However, FWB, unless in a military environment with a Solvent-detergent-related/freeze-dried plasma carries
large number of healthy, screened, young blood carriers, about 20percent less of the above per unit given:
is generally not available.
Fresh whole blood can, if warmed, be transfused within 24 It contains all coagulation factors, but not all in equal
hours. It is, however, considered still fresh if stored at 4oC for concentration.
48 hours.1 If it is less than 8 hours old, it can be refrigerated It is preferred to cryoprecipitate, which contains
for 3 weeks,2 remaining transfusable but not fresh. 50 per cent of coagulation factors (especially of
The levels of clotting factors V and VIII decline quickly fibrinogen, factor VIII and von Willebrand factor).
for 24 hours after collection. The rate of decline then
slows until clinically subnormal levels are reached within 3.2.2.3Cryoprecipitate
714 days. It is because FWB contains these factors that
it is recommended for massive transfusion and is so effec- Cryoprecipitate contains fibrinogen, von Willebrand fac-
tive in the correction of coagulopathy. The other clotting tor/factor VIII complex and fibrin stabilizing factor/fac-
factors remain stable in stored blood. Fresh whole blood tor XIII. Cryoprecipitate may not be required in all cases
has lost most of its platelets after 3 days of storage. of trauma. One unit (250mL) of FFP contains 0.5g fibrin-
ogen; 1 unit of cryoprecipitate contains 0.25g fibrinogen,
but in 10mL (rather than 250mL). Therefore, in most
3.2.2Component therapy (platelets, FFP, cases, FFP will meet the needs required. However, if a
cryoprecipitate) rapid increase in the amount of fibrinogen is required,
cryoprecipitate is a useful adjunct.
3.2.2.1 Platelets
A fall in platelet count occurs somewhat later than the 3.3Effects of transfusing blood
loss of clotting factors. Unfortunately, a platelet count and blood products2
is not simple since it gives no indication of the function
of the remaining platelets. Hypothermia affects platelet Stored pRBCs (stored for a maximum of 42 days with cur-
adhesion more than enzymes, above 33C, while hypo- rent US Food and Drug Administration approved storage
thermia affects all aspects of coagulation below 33C. solutions) develop defects proportionate to the duration
There is some evidence in which there appears to be a of storage that assume greater clinical significance when
survival advantage of receiving approximately 0.8 units of transfused rapidly, or in large quantities, such as in criti-
platelets per unit of RBCs: 4 cally ill patients.
Transfusion in trauma | 41
3.3.1Metabolic effects Packed red cells do not contain platelets as these are
generally spun off, and whole blood has lost most
There is decreased ATP. of its platelets after 3 days of storage. Spontaneous
Degradation of 2,3-diphosphoglycerate (2,3- bleeding rarely occurs if the platelet count is greater
DPG) has occurred after 710 days in storage. than 30000/mm. Levels as low as this are seen after
2,3-Diphosphoglycerate is an enzyme affecting the the replacement of one to two times the total blood
affinity of Hb for O2. After 7 days of storage, the volume, and may result from dilution. Despite this,
O2-transporting ability of Hb drops by two-thirds. the body has large reserves of platelets, sequestrated
Adenine added to pRBCs may restore levels of 2,3- in the spleen, liver and endothelium.
DPG in vivo after transfusion, although there is
Ideally, the use of blood components should be guided
limited level I evidence in this respect.
by laboratory tests of clotting function. This may be
Increased ammonia release occurs due to the release
appropriate where surgical bleeding is controlled and
of intracellular protein.
the operating field appears dry. However, in the face of
continued oozing, when obvious surgical bleeding has
3.3.2Effects of microaggregates been controlled, blood products may need to be given
empirically.
Red cell membrane instability leading to cell rupture Traditional laboratory tests (prothrombin time
Increased amounts of microaggregates (platelets/ and partial thromboplastin time), however, correlate
leukocytes/fibrin debris) in the buffy coat poorly with clinical bleeding in the injured patient.
Impaired pulmonary gas exchange and adult Thromboelastography (TEG) may offer a better assess-
respiratory distress syndrome (ARDS) and ment of the need for blood component therapy.
transfusion-related lung injury (TRALI) can occur
Reticulo-endothelial system depression
Activation of complement and coagulation cascades 3.3.5Other risks of transfusion
Production of vasoactive substances
Antigenic stimulation
3.3.5.1Transfusion-transmitted infections
Acute-phase response.
Hepatitis A, B, C and D
Human immunodeficiency virus window period
3.3.3Hyperkalaemia Cytomegalovirus
Atypical mononucleosis and a swinging temperature
Serum potassium levels rise in stored blood as the effi- that can be present for 710 days post-transfusion
ciency of the Na+/K+ pump decreases. Transfused blood Malaria
may have a potassium concentration of 4070mmol/L. Brucellosis
Transient hyperkalaemia may occur as a result. Yersinia
Syphilis.
3.3.4Coagulation abnormalities
3.3.5.2Haemolytic transfusion reactions
Thrombocytopenia and a loss of factors V and VIII
in stored blood may contribute to problems with Incompatibility: ABO, rhesus (type the blood) and 26
coagulation. others (screen for these)
Levels of clotting factors V and VIII decline quickly To frozen blood, overheated blood or pressurized
for 24 hours after collection. The rate of decline slows blood
until clinically subnormal levels are reached at 714 Immediate generalized reaction (plasma).
days. It is because FWB contains these factors that it
is recommended for massive transfusion, frequently
3.3.5.3 Immunological complications
for cost and legal reasons, although it is generally
not available outside the military. The other clotting Major incompatibility reaction (usually caused by
factors remain stable in stored blood. wrong blood due to administrative errors).
3.3.5.4 Post-transfusion purpura There is a relationship between transfusion and

TRALI and ARDS.
3.3.5.5Graft-versus-host disease So blood is bad, but there is as yet no alternative.
TRALI. The less bad blood may be FWB, and this is a surrogate
for the transfusion of components (which amounts to a
reconstitution of whole blood).
3.3.5.6 Immunomodulation
Reports on transplant and oncology patients have pro-
vided evidence that transfusion induces a regulatory 3.4Action
immune response in the recipient that increases the ratio
of suppressor to helper T cells. These changes may render 3.4.1Current best standards of practice
the trauma patient more susceptible to infection.
1 Aggressively pursue the diagnosis and treatment of
haemorrhage.
3.3.5.7Factors implicated in haemostatic failure 2 Titrate administered fluids to maintain a lower than
normal blood pressure.
Hypothermia blood is stored at 4C but body
3 Measure and closely follow serum lactate and arterial
temperature is 37C, so the body needs to provide
pH as indicators of the state of systemic perfusion.
1255kJ of energy to heat each unit of blood to body
If normal, attempt to maintain perfusion.
temperature
If abnormal, attempt a gradual improvement
Acidosis (from citrate and lactate)
without elevating the blood pressure and
Dilution, depletion and decreased production of red
aggravating the haemorrhage.
cells and platelets
4 Maintain normothermia.
Diffuse intravascular coagulation: there is a
5 Control ventilation to achieve O2 saturation of
consumption of clotting factors and platelets within
99100 per cent and a normal end-tidal carbon
the circulation, causing microvascular obstruction due
dioxide level.
to fibrin deposition via two pathways of coagulation
6 Aim for a target Hb of 79g/dL (45.5mmol/L)
Extrinsic: tissue thromboplastins, for example blunt
and a normal prothrombin time at the time that
trauma and surgery
haemorrhage is controlled. Consider maintaining
Intrinsic: endothelial injury, endotoxin, burns,
a higher Hb concentration in older patients and in
hypothermia, hypoxia, acidosis and platelet activation
those with known ischaemic disease.
Fibrinolysis
7 If massive transfusion is likely, attempt from the
Consumption of red cells and platelets
outset to maintain intravascular composition. Use
Protein C activation.
early RBC, plasma and platelet transfusion.
Despite the extensive list quoted above, there is no level
Blood pressure and heart rate are the current standard-
I evidence regarding the risks of pRBC transfusion. There
of-care monitors of shock resuscitation in the field, and
is level II evidence that pRBC transfusion is an independ-
in the emergency department when associated with serum
ent risk factor for:
lactate or base excess (base deficit). Both, however, are
Increased nosocomial infections (wound infection, insensitive markers of early compensated shock; alterna-
pneumonia, sepsis) tive monitors are badly needed for assessing the adequacy
Multiple organ failure and systemic inflammatory of tissue perfusion, with a view to avoiding both under-
response syndrome resuscitation and overresuscitation. The challenge is to
Longer intensive care unit (ICU) and hospital length of identify as early as possible those patients who are not
stay, increased complications and increased mortality. responding to early interventions. Blind and aggressive
volume loading in the hope of normalizing blood pres-
Additionally, there is level II evidence that:
sure and heart rate, without appropriate emphasis on the
Pre-storage leukocyte depletion of RBC transfusion control of haemorrhage, sets the stage for the so-called
reduces complication rates, some studies showing a bloody vicious cycle or the abdominal compartment
reduction in infectious complications. syndrome.
3.4.2Reduction in the need for transfusion2 Consider using a mixture of 1 pRBC unit (335mL) with
a haematocrit of 55 per cent, 1 unit of platelets (50mL)
Blood is a scarce (and expensive) resource and is also not with 5.5 1010 platelets, and 1 unit of FFP (275mL) with
universally safe. Reducing the need for transfusion is the 80 per cent coagulation factor activity. This combination
best way to limit the complications: results in 660mL of fluid with a haematocrit of 29 per
cent, 88000 platelets/mL and 65 per cent coagulation
Treat the cause, i.e. undertake urgent surgery to stop
factor activity.7 While principle largely favours FWB, blood
bleeding, and avoid hypothermia and acidosis.
component transfusion is the best feasible alternative in
Treat deficiencies and complications as they arise.
most civilian situations.
There is no evidence to support prophylactic therapy
The optimal ratio of RBCs to FFP remains, however,
with FFP, platelets, etc.
controversial. Currently, an initial 2 units of pRBCs fol-
Follow a restrictive transfusion policy in ICU. One
lowed by a 1:1:1 ratio of RBC:FFP:platelets appears to
large multicentre trial documented a significantly
be reasonable. If apheresis platelets (usually containing
lower mortality rate for critically ill patients
5units of platelets) are supplied, this ratio will become
managed with a restrictive transfusion strategy and
5:5:1.
a transfusion threshold of 7g/dL (5mmol/L) Hb.5
However, this assumes normovolaemia, absence of
ongoing bleeding and an absence of pre-existing
cardiovascular disease.
3.4.5Adjuncts to enhance clotting
Develop a capacity for cell salvage.
3.4.5.1Recombinant activated factor VII
3.4.3Transfusion thresholds There has been extensive interest in the provision of

adjuncts to enhance clotting as part of the resuscitation of
There is no level I evidence indicating the ideal trigger for the trauma patient. Interest has focused on recombinant
transfusion in trauma patients. In general, the following activated factor VIIa (NovoSeven). This was initially devel-
guidelines apply: oped as an adjunct for the treatment of haemophilia.
However, following its successful use in controlling the
1 Identify the critically ill patient with an Hb less than
bleeding in a trauma patient, there has been consider-
7g/dL (5mmol/L) or a haematocrit below 21percent.
able interest in its use. A large multicentre trial in 20058
2 If the Hb is less than 7g/dL, transfuse with pRBCs as
showed a reduction in red cell transfusion requirements
appropriate. For patients with severe cardiovascular
in blunt trauma patients, and the drug has been used
disease, and trauma patients with ongoing bleeding
extensively off-label. A further large multicentre trial in
or haemodynamic instability, a higher threshold of
2008 showed a reduction in blood product usage of 3.6
810g/dL (67mmol/L) is appropriate.
units in blunt injury, but there was no significant effect
3 If the Hb is less than 7g/dL, assess the patient for
on mortality or for penetrating injury.9 (A suitable proto-
hypovolaemia. If this is found, administer intravenous
col appears in Table 3.4 below).
fluids to achieve normovolaemia, and reassess the
Hblevel.
4 If the patient is not hypovolaemic, determine whether 3.4.5.2Tranexamic acid
there is evidence of impaired O2 delivery.
Tranexamic acid is indicated for prolonged bleeding
5 If impaired O2 delivery is present, consider cardiac
(empirically) or when there is evidence of hyperfibrinoly-
output monitoring.
sis (measured using TEG; see below). It is given at a dose
6 If impaired O2 delivery is not present, monitor Hb as
of 10mg/kg every 6 hours.
appropriate.
The CRASH-2 trial showed a significant reduction
in mortality with the use of tranexamic acid;10 however,
3.4.4Transfusion ratios although the trial involved very large numbers of subjects,
the two arms utilized the same amount of blood, and the
Military clinical research1 and newer studies on civil mortality rate for either arm did not correlate with that in
trauma6 suggest transfusing pRBC:FFP:platelets in a other studies. In addition, no injury severity comparisons
proportion of 1:1:1. were included. Therefore, further studies are needed.
3.4.5.3Desmopressin K time (kinetic time)

MA (maximum amplitude) the maximal clot strength
Desmopressin potentiates the function of platelets and is
Lysis at 30 or 60 minutes.
indicated only for functional platelet disorders, secondary
to aspirin, renal or hepatic failure, haemophilia-A and von It is possible to decide whether the bleeding is surgical
Willebrands disease. or pathological, which clotting factors are missing, the
function of platelets and whether fibrinolysis is evolving
normally (Figure 3.2). Transfusion of blood components,
3.4.5.4Aprotinin
coagulation factors and additional medication can be
Aprotinin has no indication in trauma, and was with- administered rationally, based on the results (Table 3.2).
drawn from the market in 2008.
Table 3.1 Interpretation of the parameters of the thromboelastogram
Parameter Measurement Normal value

3.4.6Monitoring the coagulation status3
R (reaction) time Clotting factor activity 48 minutes
Alpha angle Rate of increase in clot strength 6575
Fibrinogen degradation products
International normalized ratio extrinsic K (kinetic) time Kinetics to maximum clot strength <4 minutes
Partial thromboplastin time intrinsic Maximum Maximum strength of the clot >50mm
d-dimer values (fibrin deposition) amplitude
TEG or rotational thromboelastometry (RoTEM).11 A60, Ly30 Fibrinolysis <8%, <7.5%
A60, amplitude at 60 minutes; Ly30, lysis time at 30 minutes.

3.4.6.1TEG/RoTEM
Table 3.2 Administration of medication based on thromboelastography
This is a portable bedside device that gives qualitative
results for coagulation function, based on clotting, kinet- Primary action Secondary action
ics, strength and lysis. It accepts one specimen at a time and
Reaction time prolonged FFP rFVIIa
processes it immediately at room temperature, before the
Kinetic time prolonged Cryoprecipitate rFVIIa
natural temperature of the specimen changes. The result is
available within 310 minutes, in the form of a curve (Figure Alpha angle <65 Cryoprecipitate/platelets FFP/rFVIIa
3.1). A number of parameters can be measured (Table 3.1): Maximum amplitude Platelets Desmopressin
<50mm
R time (reaction time)/clotting time the latency
Lysis at 30 minutes Tranexamic acid
from the time at which the blood is placed in the cup
>7.5%
until the clot begins to form
The alpha angle the progressive increase in clot FFP, fresh frozen plasma; rFVIIa, recombinant activated factor VIIa
strength
Clotting Kinetics Strength Lysis
Alpha
angle
MA A60
2 mm 20 mm
60 mm
R time
K time
Coagulation Fibrinolysis
Time
Figure 3.1 Thromboelastogram. A60, amplitude at 60 minutes (now being replaced by lysis time at 30 minutes, the normal of value of which is
<7.5%). K time, kinetic time; MA, maximum amplitude; R time, reaction time.
Normal Fibrinolysis (UK SK or TPA)

R/K/MA/angle = normal R = normal, MA = continuous decrease
Heparin Hypercoagulation
R/K = prolonged; MA/angle = decreased R/K = decreased, MA/angle = increased
Thrombocytopenia No platelet function (DIC)

R = normal, K = prolonged, MA = decreased R = prolonged, MA/angle = decreased
Figure 3.2 Abnormal appearances of the thromboelastogram. DIC, disseminated intravascular coagulation; K, kinetic time; MA, maximum amplitude;
R, reaction time; SK, streptokinase; TPA, tissue plasminogen activator; UK, urokinase.
3.5Autotransfusion Cell washing and centrifugation techniques require a

machine and (usually) a technician to be the sole opera-
Intraoperative and postoperative blood salvage and alter- tor. This latter requirement can limit the utility of the
native methods for decreasing transfusion may lead to a devices in everyday practice. The cell washing cycle pro-
significant reduction in allogenic blood usage. duces red cells suspended in saline with a haematocrit
Autotransfusion eliminates the risk of incompat- of 5560 per cent. This solution is relatively free of free
ibility and the need for crossmatching; the risk of trans- Hb, procoagulants and bacteria. However, bacteria have
mission of disease from the donor is also eliminated. been shown to adhere to the iron in the Hb molecule, and
Autotransfusion is a safe and cost-effective method of sus- washing therefore does not eliminate the risk of infection.
taining RBC mass while decreasing demands on the blood To a degree, the simpler the system, the less likely it
bank. However, cell salvage in trauma patients is fraught is that problems will occur. In elective situations, nurses,
with difficulty as, in the trauma patient, autotransfu- technicians or anaesthesia personnel can participate in
sion typically involves the collection of blood shed into the autotransfusion process. In emergency situations
wounds, body cavities and drains. without additional personnel, such participation may not
Modern autotransfusion devices are basically of be possible. Systems that process reclaimed RBCs may
twotypes: require trained technicians, particularly if the procedure
is used infrequently.
Collection of blood that is mixed with an
anticoagulant, typically citrate, filtered and returned. In practical terms, bleeding from the chest seems ideal
The blood is collected, anticoagulated with heparin, for immediate autotransfusion as the contents of thoracic
and then run through a system in which it is washed cavity are sterile, in contrast with abdominal bleeding,
and centrifuged, before being retransfused. where visceral injury and contamination may coexist. The
Reinfusion after filtration, which is less labour intensive simplest effective method is to use the sterile chest drain
and provides blood for transfusion quickly. Whole container. Use saline to create the fluid valve at the end of
blood is returned to the patient with platelets and a chest drainage tube, to which is added 1 IU of fraction-
proteins intact, but free Hb and procoagulants are also ated heparin. The contents of the bottle may be hung and
reinfused. A high proportion of the salvaged blood is (using a microfilter to collect microaggregates) immedi-
returned to the patient, and the most recent devices do ately reintroduced intravenously.
not require mixing of the blood with an anticoagulant Autotransfusion is generally contraindicated in the
solution. In-line filters are absolutely essential when presence of bacterial or malignant cell contamination
autotransfusion devices are used. These filters remove (e.g. an open bowel, infected vascular prostheses, etc.)
gross particles and macroaggregates during collection unless no other RBC source is available and the patient is
and reinfusion, thus minimizing microembolization.12 in a life-threatening situation. However, there are several
studies showing the practice may not be as unreasonable Problems associated with Hb-based O2 carriers (HBOCs)
as previously thought.13 relate to effects on vasomotor tone, which appears to be
Cell salvage techniques have been shown to be cost- modulated by the carriers interaction with nitric oxide,
effective and useful in some trauma patients (e.g. in causing significant vasoconstriction.
splenic trauma with significant blood loss), but further
studies are indicated to clarify the indications further.
3.6.2.2Polymerized haemoglobin solutions (human-
outdated/bovine RBCs)
3.6Red blood cell substitutes These are known as haemoglobin-based O2 carriers

(HBOCs). (Although free Hb can transport O2 outside
The ideal blood substitute is cheap, has a long shelf-life, its cell membrane, it is too toxic to be clinically useful.)
is universally compatible and well tolerated and has an Techniques have been developed for removing the red cell
O2 delivery profile identical to that of blood. Significant membrane products, and cross-linking the Hbs, initially
effort has been made to find a suitable substitute that with a di-aspirin link and recently as a Hb polymer. Both
could, essentially, be treated as an artificial O2 carrier. human and bovine Hb have been used.
Artificial O2 carriers can be grouped into perfluoro- Considerable research has taken place in the past dec-
carbon (PFC) emulsions and modified Hb solutions. ade with regard to the development of synthesized Hb
The native Hb molecule needs to be modified in order to solutions. Bovine-derived Hb (Hemopure) is approved for
decrease its O2 affinity and to prevent rapid dissociation of clinical use in South Africa. Currently, the products have
the native alpha2beta2 tetramer into alpha2beta2 dimers. not been licensed for use in the trauma patient. No level
I evidence has yet appeared to support the use of Hb sub-
stitutes instead of blood.
3.6.1 Perfluorocarbons The O2 transport characteristics of modified Hb solu-
tions and PFC solutions are fundamentally different
Perfluorocarbons are carbonfluorine compounds that (Table 3.3). The Hb solutions exhibit a sigmoid O2 dis-
are completely inert and have low viscosity, but dissolve sociation curve similar to that of blood, while PFC emul-
large amounts of gas. They do not mix with water and sions are characterized by a linear relationship between
therefore need to be produced as emulsions. Unlike the the partial pressure and the content of O2. Haemoglobin
sigmoid relationship of Hb, they exhibit a linear relation- solutions therefore provide O2 transport and unloading
ship with O2, therefore their efficacy relies on maintain- characteristics similar to blood. This means that at a rela-
ing a high arterial partial pressure of oxygen; however, tively low arterial O2 pressure, substantial amounts of O2
PFCs unload O2 well. They do not expand the intravascu- are being transported. In contrast, relatively high arterial
lar volume and can only be given in small volumes as they O2 partial pressures are necessary to maximize the O2
overload the reticulo-endothelial system. Once thought transport of PFC emulsions (Figure 3.3).
to hold potential, they have so far not been found to Note that 5 per cent O2 can be offloaded by both blood
confer additional benefit compared with crystalloid solu- and PFCs, PFC O2 being more completely offloaded than
tions, especially as there is a significant incidence of side blood-transported O2.
effects.
Table 3.3 Advantages and disadvantages of haemoglobin-based

3.6.2Haemoglobin solutions
solutions compared with perfluorocarbons (PFCs)
3.6.2.1Liposomal haemoglobin solutions Haemoglobin-based solutions PFC-based emulsions
Advantages Advantages
These are based on the encapsulation of Hb in liposomes.
Carries and unloads O2 Carries and unloads O2
The mixing of phospholipid and cholesterol in the pres-
Sigmoidal O2 dissociation curve Few and mild side effects
ence of Hb yields a sphere with Hb at its centre. These
100% Fio2 not mandatory for No known organ toxicity
liposomes have O2 dissociation curves similar to those of
maximum potency
red cells, with low viscosity, and their administration can
Easy to measure
transiently produce high circulating levels of Hb.
hypothermia and hypocalcaemia. Hypothermia (<34C)

Haemoglobin-based solutions PFC-based emulsions
causes platelet sequestration and inhibits the release of
Disadvantages Disadvantages platelet factors that are important in the intrinsic clotting
Side effects 100% Fio2 is mandatory for pathway. In addition, it has consistently been associated
Vasoconstriction maximal efficacy with a poor outcome in trauma patients. Core tempera-
Interference with laboratory Additional colloid is often ture often falls insidiously because of exposure at the
methods (colorimetric) necessary, with potential side scene and in the emergency department, and because of
effects the administration of resuscitation fluids stored at ambi-
ent temperature.
Fio2, fraction of inspired oxygen.
The use of bicarbonate in the treatment of systemic
20
acidosis remains controversial. Moderate acidosis (pH
Blood
5 Vol% <7.20) impairs coagulation, myocardial contractil-
O2-Ex.~25% ity and oxidative metabolism. Acidosis in the trauma
patient is caused primarily by a rise in lactic acid pro-
15 duction secondary to tissue hypoxia and hypothermia,
and usually resolves when the volume deficit has been
CO2 [mL dL-1]
PFC corrected and the efficiency of the circulation restored.

10 Administration of sodium bicarbonate may cause a left-
ward shift of the oxyhaemoglobin dissociation curve,
reducing tissue O2 extraction, and may worsen intrac-
ellular acidosis caused by carbon dioxide production.
5
5 Vol%
On the other hand, adrenergic receptors may become
O2-Ex.~90% desensitized with protracted acidosis. Bicarbonate infu-
sion, therefore, should be limited to patients with pro-
0 tracted shock.
0 20 40 60 80 Hypocalcaemia caused by citrate binding of ion-
P O2 [kPa]
ized calcium does not occur until the blood transfu-
Figure 3.3 Oxygen transport characteristics of haemoglobin and sion rate exceeds 100 mL per minute (equivalent to
perfluorocarbons (PFCs). 1 unit every 5 minutes). Decreased serum levels of
ionized calcium depress myocardial function before
impairing coagulation. Calcium gluconate or calcium
3.7Massive haemorrhage/ chloride should be reserved for cases in which there is
massive transfusion ECG evidence of QT interval prolongation or, in rare
instances, for cases of unexplained hypotension during
3.7.1Definition massive transfusion.
Blood volume is approximately 70mL/kg. Massive trans-

fusion is defined as: 3.7.2 Protocol
The replacement of 100 per cent of the patients
An algorithm of coordinated action coordinating many
blood volume in less than 24 hours
hospital departments (surgery, blood bank, ICU, anaes-
The administration of 50 per cent of the patients
thesiology) is activated upon the arrival of a trauma
blood volume in 1 hour.
patient with massive haemorrhage. The protocol pro-
There is a danger of death when the blood loss is more vides roles for the personnel, actions to be taken, medi-
than 150mL per minute or 50 per cent of blood volume cations and blood products to be transfused. The target
in 20 minutes. Each trauma unit should have a policy for is the increase of survival of these patients. The basis
massive transfusion, which should be activated as soon as of these protocols has been the knowledge recently
a potential candidate is admitted. acquired from modern battlefields, which has dramati-
Also germane to the initial period of massive blood cally changed the way we manage these patients (Tables
transfusion are the potential complications of acidosis, 3.4 and 3.5).
Table 3.4 Guidelines for massive transfusion
Definition
Replacement of the whole blood volume within 24 hours, or 50% of the blood volume in 3 hours
Activation
The protocol will be activated automatically by the blood bank after 2 units of packed red blood cells (pRBCs) have been issued to a patient, and
a request for a further 4 units of blood or more is subsequently requested within any 24 hour period
Blood specimens
Group and crossmatch:
Leukodepleted blood should be used wherever it is available
Crossmatched blood if available
Uncrossmatched group O blood
The following baseline blood specimens are required:
Full blood count including platelets
Prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, International Normalized Ratio (INR), fibrinogen, d-dimer,
thromboelastogram (TEG) or RoTEM
The following are required after every six (6) units of transfused blood:
Repeat baseline blood samples
Full TEG or RoTEM
Avoid hypothermia (patient and transfused fluid)

Use an appropriate blood warmer
Keep the patient warm using an appropriate patient-warming device
Maintain a warm environment
Blood and blood products

The blood bank will issue the following products (as part of a 2 or 6 unit massive transfusion pack):
(NB: Multiple 2-unit packs are preferable as they can be returned if the cold chain is intact)
Two (2) units or six (6) units of pRBC s using the freshest blood available
Two (2) units or six (6) units of thawed fresh frozen plasma (FFP)
Two (2) units or six (6) units of platelets
or
For every six (6) units of blood issued,
One (1) apheresis unit of platelets (platelet mega-unit)
Administration
Microaggregate filters are not advised
Once administration of the massive transfusion pack blood is begun, administer all the above in a 1:1:1 ratio, (blood:FFP:platelets) or 6:6:1
(blood:FFP:apheresis mega-platelet unit). After every 6 units of red cells, if ongoing bleeding or need for transfusion is present:
Give a further 4 units of FFP if PT or APTT is >1.5 times mid-normal
Give 10 units of cryoprecipitate if fibrinogen <1g/L
Give 10mL 10% calcium chloride only if the above additional doses are given
Give at least 1 unit of pooled platelets if the platelet count is <75000 /mm3
Return all unused massive transfusion packs to the blood bank as soon as possible
End points of transfusion

Any active surgical bleeding has been controlled
No further need for red cells
Temperature > 35C
pH > 7.3
Fibrinogen > 1.5g/L
INR better than 1.5, PT less than 16 seconds, aPTT less than 42 seconds
Haemoglobin 810g/dL
Table 3.5 Guidelines for the use of recombinant activated factor VII (rFVIIa) in trauma
Definition
This guideline describes the use of rFVIIa as an adjunct in the management of coagulopathy following trauma with massive bleeding or the need to
enter the massive transfusion protocol
Issue
The blood bank will issue the required rFVIIa for administration immediately after completion of the 6th and 12th units of transfused blood
Limitation
rFVIIa should only be used:
If all surgical bleeding has been controlled
In the presence of active bleeding
Where possible, its use should be backed up with a thromboelastogram (TEG)
Increased R (reaction) time despite fresh frozen plasma
After transfusion of >6 units of blood
If the platelet count is >50000/mm3
If the pH is >7.2
If the temperature is >34C
Blood specimens
Disseminated intravascular coagulopathy screen:
Full blood count and platelets
Prothrombin time, activated partial thromboplastin time, thrombin time, International Normalized Ratio, d-dimer
Fibrinogen
TEG or rotary thromboelastomer (RoTEM)
Dose
The dose of rFVIIa should be 90mg/kg:
Round UP to the nearest 1.2mg
(Example: a 75kg male receives 75 90mg/kg = 6.75mg rFVIIa. Round UP to 7.2mg)
If the patient continues to bleed:

Repeat the dose after 1 hour and after 3 hours from first dose
Repeat the dose after completion of the 12th unit of transfused blood
End points of administration

The first of:
Cessation of bleeding
or
Three doses
3.8References 3 Hess JR, Brohi K, Dutton RP et al. The coagulopathy of

trauma: a review of mechanisms. J Trauma 2008;65:74854.
1 Kauvar DS, Holcomb JB, Norris GC, Hess JR. Fresh whole 4 British Committee for Standards in Haematology, Blood
blood transfusion: a controversial military practice. JTrauma Transfusion Task Force. Guidelines for the use of fresh
2006;61:1814. frozen plasma, cryoprecipitate, and cryosupernatant. Br J
2 Spinella PC, Holcomb JB. Resuscitation and transfusion Haematol 2004;126:1128.
principles for traumatic hemorrhagic shock. Blood Rev 5 Dutton RP, Carson JL. Indications for early red blood cell
2009;23:23140. transfusion. J Trauma 2006;60(6 Suppl.):S3540.
6 Napolitano LM, Kurek S, Luchette FA et al. Clinical practice 13 Bowley DM, Barker P, Boffard KD. Intraoperative blood
guideline: red blood cell transfusion in adult trauma and salvage in penetrating abdominal trauma: a randomised
critical care. Crit Care Med 2009;37:312457. controlled trial. World J Surg 2006;30:107480.
7 Nunez TC, Young PP, Holcomb JB, Cotton BA. Creation,
implementation, and maturation of a massive transfusion
protocol for the exsanguinating trauma patient. J Trauma 3.9Recommended Reading
2010;68:1498505.
8 Boffard KD, Riou B, Warren B et al.; NovoSeven Trauma Johansson PI, Ostrowsky SR, Secher NH. Management of
Study Group. Recombinant factor VIIa as adjunctive therapy major blood loss: an update. Acta Anaesthesiol Scand
for bleeding control in severely injured trauma patients: 2010;54:103949.
two parallel randomized, placebo-controlled, double-blind Journal of Trauma-Injury Infection and Critical Care. Early
clinical trials. J Trauma. 2005;59(1):815; discussion 1518. massive trauma transfusion: current state of the art.
9 Hauser CJ, Boffard KD, Dutton R et al., for the CONTROL JTrauma 2006;60(6, Suppl.).
Study Group. Results of the CONTROL Trial: efficacy Malone DL, Hess JR, Fingerhut A. Massive transfusion practices
and safety of recombinant activated factor VII in the around the globe and a suggestion for a common massive
management of refractory traumatic hemorrhage. J Trauma transfusion protocol. J Trauma 2006; 60(6, Suppl.):S916.
2010;69:489500. Marino PC. Transfusion practices in critical care. In The ICU
10 CRASH-2 Trial Collaborators. Effects of tranexamic acid on Book, 3rd edn. Baltimore, MD: Williams & Wilkins, 2007:
death, vascular occlusive events, and blood transfusion in 65986.
trauma patients with significant haemorrhage (CRASH-2): a Petersen R, Weinberg JA. Transfusion, autotransfusion, and
randomised, placebo-controlled trial. Lancet 2010;376:2732. blood substitutes. In: Moore EE, Feliciano DV, Mattox KL,
11 Nylund CM, Borgman MA, Holcomb JB, Jenkins D, Spinella eds. Trauma, 6th edn. New York: McGraw-Hill, 2008:
PC. Thromboelastography to direct the administration of Chapter 13.
recombinant activated factor VII in a child with traumatic Society of Critical Care Medicine. Clinical Practice Guideline:
injury requiring massive transfusion. Pediatr Crit Care Med Red blood cell transfusion in adult trauma and critical care.
2009;10:e226. J Trauma 2009;67:143942.
12 Hughes LG, Thomas DW, Wareham K, Jones JE, John West MA, Shapiro MB, Nathens AB et al. Inflammation and the
A, Rees M. Intra-operative blood salvage in abdominal host response to injury. Large Scale Collaborative Research
trauma: a review of 5 years experience. Anaesthesia Program Investigators. IV: Guidelines for transfusion in the
2001;56:21720. trauma patient. J Trauma 2006;61:4369.
Part 4
Damage control surgery

Damage control surgery 4
4.1 Damage control Systolic blood pressure <90mmHg for more than
60 minutes
The concept of damage control (also known as staged Temperature <34C
laparotomy or abbreviated laparotomy) has as its objec- Metabolic instability
tive the delay in imposition of additional surgical stress at pH <7.2
a moment of physiological frailty. Base excess >5 and worsening
Briefly stated, this is a technique whereby the surgeon Serum lactate >5mmol/L
minimizes operative time and intervention in the grossly Coagulopathy
unstable patient. The primary reason for this is to mini- Prothrombin time >16 seconds
mize hypothermia, metabolic acidosis and coagulopathy, Partial thromboplastin time >60 seconds
and to return the patient to the operating room in a few Surgical anatomy
hours after stability has been achieved in an intensive Inaccessible major venous injury, such as
care setting. Although the principles are sound, extreme retrohepatic vena cava, pelvis, etc.
care has to be exercised in overutilization of the concept Anticipated need for a time-consuming surgical
so that we do not cause secondary insults to the viscera. procedure in a patient with a suboptimal response
Furthermore, enough appropriate surgery has to be carried to resuscitation
out in order to minimize activation of the inflammatory Inability to perform the definitive repair
cascade and the consequences of systemic inflammatory Demand for non-operative control of other
response syndrome (SIRS) and organ dysfunction. injuries, for example a fractured pelvis
The concept is not new, and livers were packed as Inability to approximate the abdominal incision
long as 90 years ago, but with a failure to understand Environment
the underlying rationale, the results were disastrous. The Blood requirement >10 units of blood
concept was reviewed, and the technique of initial abor- Operating time greater than 60 minutes.
tion of laparotomy, establishment of intra-abdominal Irrespective of the setting, a coagulopathy is the single
pack tamponade and then completion of the procedure most common reason for abortion of a planned proce-
once coagulation had returned to an acceptable level dure or curtailment of definitive surgery. It is important
proved to be life-saving. The concept of staging applies to abort the surgery before the coagulopathy becomes
to both routine and emergency procedures, and can obvious.
apply equally as well in the chest, pelvis and neck as in Damage control surgery may be performed in smaller
the abdomen. hospitals before transfer to a larger centre. Damage con-
trol surgery procedures, on properly selected patients, can
be life-saving, and may have to be performed in any hos-
4.1.1 Stage 1: Patient selection
pital admitting trauma cases. Damage control concepts
are not restricted to trauma, and may be applied to other
The indications for damage control generally can be
aspects of emergency surgery.
divided into the following:
The technical aspects of the surgery are dictated by the
Haemodynamic instability injury pattern.
4.1.2Stage 2:Operative haemorrhage and Quick to do

contamination control Cheap
Keeps the abdominal contents inside the abdominal
The primary objectives of the technique are as follows. cavity
(See also Section 7.1, The trauma laparotomy.) Allows drainage of fluid
Minimizes sepsis
Facilitates delayed primary fascial closure.
4.1.2.1 Haemorrhage and contamination control
The sandwich technique was first described by Schein
Arrest bleeding:
in 19861 and was popularized by Rotondo and Schwab.2
Tamponade using wraps or packs
A sheet of self-adhesive incise drape (Opsite [Smith &
Occlusion of inflow into the bleeding organ (e.g.
Nephew, London, UK], Steri-Drape [3M Corporation, St
Pringles manoeuvre for bleeding liver)
Paul, MN, USA] or Ioban [3M Corporation]) is placed flat,
Temporary intravascular shunting
sticky side up, and an abdominal swab is placed upon it.
Intraoperative or postoperative embolization
The size should be large enough that, when inserted, the
Repair or ligation of accessible blood vessels
sheet will extend laterally to the paracolic gutters and
Control of contamination
10cm cranial and caudal to the incision. The edges are
Ligation or stapling of bowel
folded over to produce a composite sheet with a mem-
Resection of damaged segments with clips, clamps
brane (i.e. the drape) on one side, and an abdominal swab
or staples
on the other. The membrane is utilized as an on-lay with
Copious wash-out
the margins tucked in under the edges of the open sheath
Adequate drainage (preferably suction drainage).
as far as the paracolic gutters, with only the membrane in
In the operating room, efforts must be started to reverse contact with the bowel.
all the associated adjuncts, such as acidosis, hypothermia
and hypoxia, and it may be possible to improve the coagu- Pitfalls
lation status through these methods alone. Adequate time
should still be allowed for this, following which reassess- Cover only one side of the swab. Covering both sides
ment of the abdominal injuries should take place, as it is not impedes drainage by preventing capillary wicking
infrequent to discover further injuries or ongoing bleeding. through the weave of the swab.
Do not make any holes in the membrane. Holes would
allow the suction to be transmitted directly to the serosa
4.1.2.2Temporary abdominal closure
of the bowel, with possible risk of fistula formation.
The abdominal cavity should be closed to prevent heat
and moisture loss, and to protect the viscera. Outer layer
Delayed closure is required when any combination of (Opsite/loban)
the factors listed above under damage control, or re-look Swab/drape
surgery, exists. In particular, multiply injured cases who
have undergone protracted surgery with massive volume
resuscitation to maintain haemodynamic stability will
develop tissue interstitial oedema. This may predispose to Inner layer
the development of abdominal compartment syndrome (Opsite/loban)
(ACS) or may simply make primary closure of the sheath
impracticable. In addition, significant enteric or other
contamination will raise the risk of intra-abdominal sep-
sis, or the extent of tissue damage may raise doubt over Abdominal
the viability of any repair; these conditions usually man- contents
date planned re-laparotomy and thus a temporary closure.
In these circumstances, a temporary abdominal closure
is required. The needs of such a closure can be summa- Suction drains
rized as:
Figure 4.1 Diagrammatic representation of the sandwich technique (VacPac).
Damage control surgery | 55
The appreciable drainage of serosanguinous fluid that The timing of transfer of the patient from the oper-
occurs is best dealt with by placing a pair of drainage ating theatre to the intensive care unit (ICU) is critical.
tubes (e.g. sump-type nasogastric tubes or closed-system Prompt transfer is cost-effective; premature transfer is
suction drains) through separate stab incisions, with the counterproductive. Control of bleeding and contamina-
tips placed caudally, onto the membrane, and utilizing tion must be achieved. On the other hand, once haemos-
continuous low-vacuum suction. tasis has been properly achieved, it may not be necessary
This arrangement is covered by an occlusive incise to abort the procedure in the same fashion.
drape applied to the skin, thus providing a closed system Conversely, there are some patients with severe head
(the Sandwich; Figures 4.1 and 4.2). injuries in whom the coagulopathy is induced secondary
The Bogota bag and towel clips, etc. are no longer to severe irreversible cerebral damage, and further surgical
used, and for temporary abdominal closure, no sutures energy is futile.
should be placed in the sheath.
Gauze swab laid on top
Sticky side up
Sheet trimmed
NB: Plastic on one side only
Tuck in all round
Insertion plastic side inside
Second sheet on top

Suction drains
cranially
Figure 4.2 Technique of insertion of the membrane sandwich.

4.1.3Stage 3: Physiological restoration in Patients with persistent bleeding despite correction

the ICU of the other parameters require immediate return to the
operating theatre. A transfusion requirement of greater
Priorities in the ICU are as follows. than 4 units of blood in the normothermic patient is an
indicator of ongoing bleeding and mandates re-operation.
Patients who develop major ACS must undergo re-look
4.1.3.1Restoration of body temperature
surgery early, and any further underlying causes must be
Passive rewarming using warming blankets, warmed corrected.
fluids, etc. Every effort must be made to return all patients to
Active rewarming with lavage of the chest or abdomen. the operating theatre within 24 hours of their initial
surgery. By leaving matters longer, other problems, such
as acute respiratory distress syndrome, SIRS and sepsis,
4.1.3.2Correction of clotting profiles
may intervene (cause or effect) and may preclude further
Blood component repletion. surgery.
The re-look operation should be carried out thoroughly,
suspecting further, previously undiagnosed abdominal
4.1.3.3Optimization of oxygen delivery
injury. If the patients physiological parameters deterio-
Volume loading rate again, further damage control should take place.
Haemoglobin optimization to a haemoglobin level of
810g/dL (46mmol/L)
Monitoring of cardiac output 4.1.5Stage 5:Abdominal wall reconstruction
Ultrasonic cardiac output devices if required
SwanGanz pulmonary artery wedge pressure
monitoring Once the patient has completed definitive surgery and no
SwanGanz pulmonary capillary wedge pressure further operations are contemplated, the abdominal wall
monitoring can be closed. Methods involved include:
Correction of acidosis to a pH >7.3
Primary closure of the sheath, with or without skin
Measurement and correction of lactic acidosis to less
closure
than 2.5mmol/L
Vacuum-assisted closure
Inotropic support as required.
Skin-only closure
Grafts with Vicryl mesh (3M Corporation), Gore-Tex
4.1.3.4Avoidance of ACS (W.L. Gore & Associates, Flagstaff, AZ, USA) sheets or
other synthetic sheets
Measurement of intra-abdominal pressure (IAP) Biologic meshes human dermal matrix (AlloDerm;
Foley (bladder) catheter Life Cell Corporation, Branchburg, NJ, USA) or
Intragastric catheter porcine dermal matrix (Permacol; Covidien, Norwalk,
Assessment and normalization of any coagulopathy CT, USA)
Coagulation studies Split-thickness skin grafts directly on granulated
Thromboelastography (TEG) or rotational bowel or mesh.
thromboelastometry (RoTEM).
4.1.6RE-LAPAROTOMY
4.1.4 Stage 4:Operative definitive surgery
The re-look may be:
The patient is returned to the operating theatre as soon as
Planned, that is decided upon at the time of the initial
stage 3 has been achieved. The time for this is determined by:
procedure and usually for reasons of contamination,
The indication for damage control in the first place with doubtful tissue viability, for retrieval of intra-
The injury pattern abdominal packs or for further definitive surgery after
The physiological response. a damage control exercise
On demand, which is when evidence of intra- Should a mesh be used and left in situ, however, the
abdominal complication develops. In these cases, resulting defect will require skin coverage by split-grafting
the principle applies of re-operation when the or flap transfer.
patient fails to progress according to expectation.
Failure to act in these circumstances may have dire
4.1.7.1 Planned hernia
consequences in terms of morbidity and mortality.
A planned hernia approach aims at skin coverage with
subsequent delayed abdominal wall reconstruction. It is
4.1.7 Delayed closure most often achieved with autologous split-thickness skin
grafting over the exposed bowel. Conditions favouring a
Delayed closure will be required once the reasons for the planned hernia strategy include the inability to reapproxi-
temporary surgery have been removed or treated. This is mate the retracted abdominal wall edges, sizeable tissue
usually undertaken by secondary suturing after an inter- loss, risk of tertiary ACS, inadequate infection source con-
val of 2448 hours (or longer). trol, anterior enteric fistula and poor nutritional status of
It is expected that virtually all cases in which such the patient. Maturation of the skin graft requires about
temporary closures are used will undergo re-exploration 912 months, after which the grafted skin can be easily
with subsequent definitive sheath closure. Gradual clo- removed from the bowel surface. Large abdominal wall
sure can be achieved until a later stage than previously defects can be reconstructed with pedicular or microvas-
believed, using a vacuum-assisted technique. Delayed cular flaps. The most commonly used is the tensor fascia
primary fascial closure is usually possible at the second lata flap.
operation. It is advisable to continue measuring IAP
postoperatively to recognize the possible development
of ACS. 4.1.8Outcomes
If delayed primary closure is not possible, there are sev-
eral options: In a recent study of 88 damage control patients with a
mean Injury Severity Score of 34, Brenner et al. reported,
Closure of skin only, allowing the formation of a hernia
of the 63 survivors, 81 per cent had gone back to work and
Biologic material such as human (AlloDerm) or
resumed normal daily activities.4
porcine (Permacol) dermal matrix used as mesh early
to prevent hernia formation, providing skin coverage
Continued vacuum-assisted temporary abdominal
closure until granulation on bowel for subsequent
4.2Abdominal compartment
split-thickness skin grafting
syndrome
If a synthetic mesh is left in situ, skin coverage of the
Raised IAP has far-reaching consequences for the physiol-
resulting defect by split-grafting or flap transfer
ogy of the patient. There have been major developments
For large hernias, often the need for later
in our understanding of IAP and intra-abdominal hyper-
reconstruction using different techniques such as
tension (IAH). The syndrome that results when organs
component separation and flap
fail as a result is known as abdominal compartment
Mesh-assisted V.A.C. (Kinetic Concepts Inc., San
syndrome. Increasingly, it is being recognized that ACS
Antonio, TX, USA) closure3
is not uncommon in trauma patients, and failure to con-
A Wittmann patch.
sider its prevention, detect it in a timely fashion and treat
An absorbable mesh of polyglycolic (e.g. Vicryl) acid it aggressively results in a high mortality.
and membranes (polytetrafluoroethylene [PTFE] or Gore-
Tex), eliciting minimal tissue reaction and ingrowth, and
thus minimal risk of infection or fistula formation, can be 4.2.1 Definition of ACS
used, but it is considerably more costly. Recently, compos-
ite meshes have shown promise. The mesh can then have a The first World Congress on ACS was held in 2004 and
skin graft placed upon it (or even directly on bowel), and an internal consensus agreement relating to defini-
definitive abdominal wall reconstruction can take place tions, updated in 2009, is shown in Table 4.1. Various
at a later stage. aspects were defined, including IAP (Definition 1),
abdominal perfusion pressure (APP; Definition 2) and 4.2.2 Pathophysiology

IAH (Definitions 7 and 8).
Specifically, ACS is defined as a sustained IAP of The incidence of IAH in postoperative trauma patients
20mmHg or more (with or without an APP <60mmHg) ranges from 20 to 50 per cent. It is common after many
that is associated with new organ dysfunction/failure forms of emergency surgery. The causes of acutely
(Definition 9). ACS is also classified as follows: increased IAP are usually multifactorial and are shown
in Table 4.2. Raised IAP occurs commonly with over-
Primary ACS (Definition 10) ACS that develops due
enthusiastic fluid resuscitation.5 In addition to the
to conditions associated with injury or illness in the
direct causes shown in Table 4.2, hypothermia, acidosis
abdominopelvic region. This includes conditions
and overall injury severity will further exacerbate the
requiring emergency surgical or angioradiological
problem.
intervention (including damage control laparotomy,
bleeding pelvic fractures, massive retroperitoneal
haematomas and failed non-operative management of
4.2.3Causes of raised IAP
solid organ injuries), and following disease processes
such as severe acute pancreatitis.
See Table 4.2.
Secondary ACS (Definition 11) ACS that develops
from causes originating outside the abdomen, Table 4.2 Causes of raised intra-abdominal pressure
such as sepsis, capillary leak, major burns and
overenthusiastic fluid resuscitation. Massive resuscitation
Recurrent ACS (Definition 12) ACS that develops Major intra-abdominal and retroperitoneal haemorrhage
following initially successful surgical or medical Tissue oedema secondary to insults such as ischaemia and sepsis
treatment of either primary or secondary ACS, or Paralytic ileus
following the closure of a previously performed Ascites
decompressive laparotomy.
Table 4.1 Consensus definitions relation to intra-abdominal pressure (IAP), intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS)
Definition 1 Intra-abdominal pressure (IAP) is the pressure concealed within the abdominal cavity
Definition 2 Abdominal perfusion pressure (APP) = Mean arterial pressure (MAP) IAP
Definition 3 Filtration gradient (FG) = Glomerular filtration pressure (GFP) Proximal tubular pressure (PTP) = MAP 2 IAP
Definition 4 IAP should be expressed in mmHg and measured at end-expiration in the complete supine position after ensuring that abdominal
muscle contractions are absent and with the transducer zeroed at the level of the mid-axillary line
Definition 5 The reference standard for intermittent IAP measurement is via the bladder with a maximal instillation volume of 25mL of sterile saline
Definition 6 Normal IAP is approximately 57mmHg in critically ill adults
Definition 7 IAH is defined by a sustained or repeated pathological elevation of IAP >12mmHg
Definition 8 IAH is graded as follows:
Grade I: IAP 1215 mmHg
Grade II: IAP 1620 mmHg
Grade III: IAP 2125 mmHg
Grade IV: IAP >25 mmHg
Definition 9 ACS is defined as a sustained IAP 20mmHg (with or without an APP <60mmHg) that is associated with new organ dysfunction/failure
Definition 10 Primary ACS is a condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or
interventional radiological intervention
Definition 11 Secondary ACS refers to conditions that do not originate from the abdominopelvic region
Definition 12 Recurrent ACS refers to the condition in which ACS redevelops following previous surgical or medical treatment of primary or
secondary ACS
4.2.4Effect of raised IAP on individual organ a reduction in ventilation, decreased lung compliance,
function an increase in airway pressures and a reduction in tidal
volumes.
In critically ill ventilated patients, the effect on the res-
4.2.4.1Renal
piratory system can be significant, resulting in reduced
In 1945, Bradley and Bradley,6 in a study of 17 volunteers, lung volumes, impaired gas exchange and high ventilatory
demonstrated that there was a reduction in renal plasma pressures. Hypercarbia can occur, and the resulting aci-
flow and glomerular filtration rate in association with dosis can be exacerbated by simultaneous cardiovascular
increased IAP. In 1982, Harman et al.7 showed that as IAP depression as a result of raised IAP. The effects of raised
increased from 0 to 20mmHg in dogs, the glomerular fil- IAP on the respiratory system in ICU can sometimes be
tration rate decreased by 25 per cent. At 40 mmHg, the life-threatening, requiring urgent abdominal decom-
dogs were resuscitated and their cardiac output returned pression. Patients with true ACS undergoing abdominal
to normal. However, their glomerular filtration rate and decompression demonstrate a remarkable change in their
renal blood flow did not improve, indicating a local effect intraoperative vital signs.
on renal blood flow. The situation in seriously ill patients
may, however, be different, and the exact cause of renal
4.2.4.4Visceral perfusion
dysfunction in the ICU is not clear owing to the complex-
ity of critically ill patients. Interest in visceral perfusion has increased with the popu-
The most likely direct effect of increased IAP is an increase larization of gastric tonometry, and there is an association
in the renal vascular resistance, coupled with a moderate between IAP and visceral perfusion as measured by gas-
reduction in cardiac output. Pressure on the ureter has tric pH. This has recently been confirmed in 18 patients
been ruled out as a cause, as investigators have placed uret- undergoing laparoscopy, in whom a reduction of between
eric stents with no improvement in function. Other factors 11 and 54 per cent in blood flow was seen in the duode-
that may contribute to renal dysfunction include humeral num and stomach, respectively, at an IAP of 15mmHg.
factors and intraparenchymal renal pressures. Animal studies suggest that the reduction in visceral per-
The absolute value of IAP that is required to cause fusion is selective, affecting intestinal blood flow before,
renal impairment is probably in the region of 15mmHg. for example, adrenal blood flow. We have demonstrated,
Maintaining adequate cardiovascular filling pressures in in a study of 73 post-laparotomy patients, that IAP and
the presence of increased IAP also seems to be important. pH are strongly associated, suggesting that early decreases
in visceral perfusion are related to levels of IAP as low as
15 mmHg.
4.2.4.2Cardiovascular
Increased IAP reduces cardiac output as well as increas-

4.2.4.5Intracranial pressure
ing central venous pressure, systemic vascular resistance,
pulmonary artery pressure and pulmonary artery wedge Raised IAP can have a marked effect on intracranial patho-
pressure. Cardiac output is affected mainly by a reduc- physiology and cause severe rises in intracranial pressure.
tion in stroke volume, secondary to a reduction in preload
and an increase in afterload. This is further aggravated by
hypovolaemia. Paradoxically, in the presence of hypovolae- 4.2.5Measurement of IAP
mia, an increase in IAP can be temporarily associated with
an increase in cardiac output. It has been identified that The gold standard for IAP measurement involves using a
venous stasis occurs in the legs of patients with abdominal urinary catheter. The patient is positioned flat on the bed. A
pressures above 12mmHg. In addition, recent studies of standard Foley catheter is used, with a T-piece bladder pres-
patients undergoing laparoscopic cholecystectomy show sure device attached between the urinary catheter and the
up to a fourfold increase in renin and aldosterone levels. drainage tubing. This piece is then connected to a pressure
transducer on-line to the monitoring system. The pressure
transducer is placed in the mid-axillary line and the urinary
4.2.4.3Respiratory
tubing is clamped. Approximately 50mL isotonic saline is
In association with increased IAP, there is diaphragmatic inserted into the bladder via a three-way stopcock. After
stenting, exerting a restrictive effect on the lungs, with zeroing, the pressure on the monitor is recorded.
Increasingly, it is recognized that IAP is not a static con- of IAP is effective and shows trends as well as actual
dition and should be measured continuously. In addition, pressures.
whether IAP is measured intermittently or continuously,
consideration should be given to abdominal perfusion
measurement. 4.2.6Treatment
4.2.5.1Measurement of APP 4.2.6.1 Prevention
As with the concept of cerebral perfusion pressure, cal- To avoid ACS developing in the first place, in the emer-
culation of the abdominal perfusion pressure, which is gency department, concepts of damage control coupled
defined as mean arterial pressure minus IAP, assesses not with adequate pre-hospital information will help to
only the severity of IAP present, but also the adequacy of identify patients at high risk even before they arrive in
the patients abdominal blood flow. the emergency room. Avoiding excessive fluid resuscita-
APP has been studied as a resuscitation end point in tion (damage control resuscitation) is an important fac-
four clinical trials. These demonstrated statistically signif- tor in reducing the risk of developing subsequent ACS.
icant differences in APP between survivors and non-sur- In patients undergoing damage control laparotomy, it is
vivors with IAH/ACS. Cheatham et al.,8 in a retrospective mandatory to leave the abdomen open to prevent ACS
trial of surgical and trauma patients with IAH (mean IAP and in anticipation of a second operation.
22, range 8mmHg) , concluded that an APP of greater
than 50 mmHg optimized survival based upon receiver
4.2.7.2Treatment
operating characteristic curve analysis. Abdominal per-
fusion pressure was also superior to global resuscitation There are a number of key principles in the management
end points, such as arterial pH, base deficit, arterial lac- of patients with potential ACS:
tate and hourly urinary output, in its ability to predict
Regular appropriate monitoring of IAP in the ICU
patient outcome.
Optimization of systemic perfusion, circulating
Malbrain et al.,911 in three subsequent trials in mixed
volume and organ function in the patient with IAH
medical-surgical patients (mean IAP 10, range 4 mmHg),
grade I and grade II (i.e. 20mmHg)
suggested that 60mmHg represented an appropriate
Institution of specific medical procedures to reduce
resuscitation goal. A persistence of IAH and a failure to
IAP and the end-organ consequences of IAH/ACS,
maintain an APP of 60mmHg or more by day 3 follow-
including diuretics, and removing excess ascites if
ing the development of IAH-induced acute renal fail-
present by percutaneous puncture
ure was found to discriminate between survivors and
In patients with grade IIIIV IAH (IAP >20mmHg)
non-survivors.
with evidence of new-onset organ failure not
responding to non-operative management, a
4.2.5.2Tips for IAP measurement decompressive laparostomy performed as soon
aspossible.
A strict protocol and staff education on the technique and
interpretation of IAP is essential. The decompressed abdomen should be closed using a
Very high pressures (especially unexpected ones) are low-vacuum sandwich technique.
usually caused by a blocked urinary catheter, and should
be repeated.
4.2.6.3Reversible factors
The volume of saline instilled into the bladder is not
critical but should be less than 50mL and the same every The second aspect of management is to correct any
time. A central venous pressure manometer system can reversible cause of ACS, such as intra-abdominal bleed-
be used, but it is more cumbersome than on-line moni- ing. Massive retroperitoneal haemorrhage is often asso-
toring. The size of the urinary catheter does not matter. ciated with a fractured pelvis, and consideration should
Elevation of the catheter and measuring the urine col- be given to measures that would control haemor-
umn provides a rough guide and is simple to perform. rhage, such as pelvic fixation or vessel embolization. In
If the patient is not lying flat, IAP can be measured from some cases, severe gaseous distension or acute colonic
the pubic symphysis. Real-time continuous monitoring pseudo-obstruction can occur in ICU patients. This may
respond to drugs such as neostigmine, but if it is severe, 4.2.7.1Tips for surgical decompression for raised IAP
surgical decompression may be necessary. A common
There should be early investigation and correction of
cause of a raised IAP in ICU is related to the ileus. There
the cause of raised IAP.
is little that can be actively done in these circumstances
Ongoing abdominal bleeding with raised IAP requires
apart from optimizing the patients cardiorespiratory
urgent operative intervention.
status and serum electrolytes, and inserting a nasogas-
Reduction in urinary output is a late sign of renal
tric tube.
impairment. Gastric tonometry may provide earlier
Remember that ACS is often only a symptom of an
information on visceral perfusion.
underlying problem. In a prospective review of 88 post-
Abdominal decompression requires a full-length
laparotomy patients, Sugrue et al. found that those with
abdominal incision.
an IAP of 18mmHg had an increased odds ratio for intra-
The surgical dressing should be closed using a
abdominal sepsis of 3.9 (95 per cent confidence interval
sandwich technique using two suction drains placed
0.722.7).12,13 Abdominal evaluation for sepsis is a pri-
laterally to facilitate fluid removal from the wound.
ority, and this should obviously include a rectal exami-
If the abdomen is very tight, pre-closure with a silo
nation as well as investigations such as ultrasound and
should be considered.
computed tomography scanning. Surgery is the obvious
mainstay of treatment in patients whose rise in IAP is due Unfortunately, clinical infection is common in the
to postoperative bleeding. open abdomen, and the infection is usually polymicro-
bial. Particular care needs to be taken in patients under-
going post-aortic surgery as the aortic graft may become
4.2.7 Surgery for raised IAP colonized. The mesh in this situation should be removed,
and the abdomen left open. It is desirable to close the
As yet, there are few guidelines for exactly when surgical abdominal defect as soon as possible. This is often not
decompression is required in the presence of raised IAP. possible due to persistent tissue oedema.
Some studies have stated that abdominal decompression
is the only treatment and that it should be performed
early in order to prevent ACS. This is an overstatement 4.2.8Management algorithm
and not supported by level I evidence. The indications
for abdominal decompression are related to correcting Figure 4.3 outlines an algorithm for the management of
pathophysiological abnormalities as much as achieving a IAH and ACS.
precise and optimum IAP.
In general, temporary abdominal closure is superior to
conventional techniques for dealing with intra-abdomi- 4.2.9World Society of the Abdominal
nal sepsis. Indications for performing temporary abdomi- Compartment Syndrome
nal closure include:
The concept of IAP measurement and its significance is
Abdominal decompression
increasingly important in the ICU and is rapidly becom-
When re-exploration is planned
ing part of routine care. Patients with raised IAP require
To facilitate re-exploration in abdominal sepsis
close and careful monitoring, aggressive resuscitation and
Inability to close the abdomen
a low index of suspicion for the requirement of surgical
Prevention of ACS.
abdominal decompression.
A large number of different techniques have been used The formation of the World Society of the Abdominal
to facilitate a temporary abdominal closure, including Compartment Syndrome (www.wsacs.org) has been a
intravenous bags, Velcro, silicone and zips. Whatever major advance, with the production of consensus defini-
technique is used, it is important that effective decom- tions, the formation of a research policy, multicentre trials
pression be achieved with adequate incisions. and the publication of the consensus guidelines on ACS.
Medical treatment options to reduce IAP

Patient has IAH
NO 1. Improve abdominal wall compliance
(IAP 12 mmHg)
Sedation and analgesia
Neuromuscular blockage
Avoid head of bed > 30 degrees
Initiate treatment to reduce IAP 2. Evacuate intraluminal contents
Avoid excessive fluid Nasogastric decompression
resuscitation Rectal decompression
Intra-abdominal hypertension (IAH)
Optimze organ perfusion Gastro-/colo-prokinetic agents

3. Evacuate abdominal fluid collections
Paracentesis
Percutaneous drainage
Monitor IAP with 4. Correct positive fluid balance
IAP >
serial measurements Avoid excessive fluid resuscitation
20 mmHg IAP < 12 mmHg
NO at least every 4 hours Diuretics
with new organ consistently?
while patient is Colloids/hypertonic fluids
failure?
critically ill Hemodialysis/ultrafiltration
5. Organ support
YES Maintain APP 60 mmHg with vasopressors
YES Optimize ventilation, alveolar recruitment
Use transmural (tm) airway pressures
IAH has resolved Pplattm = Pplat IAP
Discontinue IAP measurements Consider using volumetric preload indices
Patient has ACS and monitor patient for If using PAOP/CVP, use transmural pressures
clinical deterioration PAOPtm = PAOP 0.5 * IAP
CVPtm = CVP 0.5 * IAP
IDENTIFY AND TREAT

UNDERLYING ETIOLOGY
FOR PATIENTS ACS Definitions
IAH intra-abdominal hypertension
ACS abdominal compartment syndrome
IAP intra-abdominal perfusion pressure (MAP IAP)
Does
Patient has secondary or Primary ACS a condition associated with injury
patient have NO recurrent ACS or disease in the abdominopelvic region that
primary ACS?
frequently requires early surgical or
interventional radiological intervention
Secondary ACS ACS due to conditions that do
Abdominal compartment syndrome (ACS)
YES
not originate from the abdominopelvic region
Recurrent ACS the condition in which ACS
Perform/revise abdominal Is IAP redevelops following previous surgical or
decompression with > 25 mmHg with medical treatment of primary or secondary ACS
temporary abdominal closure YES progressive organ
as needed to reduce IAP failure?
NO
Continue medical treatment options to reduce IAP
Measure IAP/APP at least every 4 hours while patient is critically ill NO

IAH has resolved
Decrease frequency of IAP
Perform balanced resuscitation of patient preload, contractility and measurements and observe
afterload using crystalloid/colloid/vasoactive medications patient for deterioration
AVOID EXCESSIVE FLUID RESUSCITATION
NO
Can APP be IAP < 12 mmHg
maintained YES consistently? YES
60 mmHg?
Figure 4.3 Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) management algorithm. Adapted from Intensive Care
Medicine 2006;32(11):17221732 and 2007;33(6):951962. World Society of the Abdominal Compartment Syndrome. All rights reserved. PAOP,
pulmonary artery occlusion pressure; Pplat, plateau pressure.
4.3References 4.4Recommended reading

1 Schein M, Saadia R. Jamieson JR, Decker GA. The sandwich 4.4.1 Damage control
technique in the management of the open abdomen. Br J
Surg 1986;73:36970. Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I,
2 Rotondo MF, Schwab CW, McGonigal MD et al. Damage Tagliabue L, Sciannameo F. Damage control surgery
control: an approach for improved survival in exsanguinating for abdominal trauma. Cochrane Database Syst Rev
penetrating abdominal injury. J Trauma 1993;35:37583. 2010;(1):CD007438.
3 Petersson U, Acosta S, Bjrck M. Vacuum-assisted wound Hoey BA, Schwab CW. Damage control surgery. Scand J Surg
closure and mesh-mediated fascial traction a novel 2002;91:92103.
technique for late closure of the open abdomen. World J Lee JC, Peitzman AB. Damage-control laparotomy. Curr Opin
Surg 2007;31:21337. Crit Care 2006;12:34650.
4 Brenner M, Bochicchio G, Bocchicchio K et al. Long term Leppniemi AK. Laparostomy: why and when? Crit Care
impact of damage control laparotomy: a prospective study. 2010;14:216.
Arch Surg 2011;146:3959. Loveland JA, Boffard KD. Damage control in the abdomen and
5 Balogh Z, McKinley BA, Cocanour CS et al. Supranormal beyond. Br J Surg 2004;91;1095101.
trauma resuscitation causes more cases of abdominal Moore EE, Burch JM, Franciose RJ et al. Staged physiologic
compartment syndrome. Arch Surg 2003;138:63742. restoration and damage control surgery. World J Surg
6 Bradley SE, Bradley GP. The effect of increased intra- 1998;22:118491.
abdominal pressure on renal function in man. J Clin Invest Rotondo MF, Schwab CW, McGonigal MD et al. Damage
1947;26:101022. control: an approach for improved survival in exsanguinating
7 Harman PK, Kron IL, McLachlan HD, Freedlender AE, Nolan penetrating abdominal injury. J Trauma 1993;35:37583.
SP. Elevated intra-abdominal pressure and renal function.
Ann Surg 1982;196:5947.
8 Cheatham ML, White MW, Sagraves SG, Johnson JL, Block 4.4.2Abdominal compartment syndrome
EF. Abdominal perfusion pressure: a superior parameter in
the assessment of intra-abdominal hypertension. J Trauma Burch J, Moore E, Moore F, Franciose R. The abdominal
2000;49:6216. compartment syndrome. Surg Clin North Am 1996;76:833
9 Malbrain ML, Cheatham ML, Kirkpatrick A et al. Results from 42.
the International Conference of Experts on Intra-abdominal Cheatham ML. Abdominal compartment syndrome:
Hypertension and Abdominal Compartment Syndrome. pathophysiology and definitions. Scand J Trauma Resusc
I.Definitions. Intensive Care Med 2006;32:172232. Emerg Med 2009;17:10.
10 Malbrain ML, Chiumello D, Pelosi P et al. Prevalence of Gaarder C, Naess PA, Frischknecht Christensen E et al.
intra-abdominal hypertension in critically ill patients: a Scandinavian Guidelines The massively bleeding
multicentre epidemiological study. Intensive Care Med patient. Scand J Surg 2008;97:1536.
2004;30:8229. Ivatury RR, Porter JM, Simon RJ, Islam S, John R, Stahl
11 Malbrain ML, Chiumello D, Pelosi P et al. Incidence and WM. Intra-abdominal hypertension after life-
prognosis of intraabdominal hypertension in a mixed threatening penetrating abdominal trauma: prophylaxis,
population of critically ill patients: a multiple-centre incidence, and clinical relevance to gastric mucosal
epidemiological study. Crit Care Med 2005;33:31522. pH and abdominal compartment syndrome. J Trauma
12 Sugrue M, Buist MD, Hourihan F, Deane S, Bauman A, 1998;44:101621.
Hillman K. Prospective study of intra-abdominal hyper Ivatury RR, Cheatham ML, Malbrain MLNG, Sugrue M.
tension and renal function after laparotomy. Br J Surg Abdominal Compartment Syndrome. Georgetown, TX:
1995;82:2358. Landes Biosciences, 2006.
13 Sugrue M, Jones F, Deane SA, Bishop G, Bauman A, Schein M, Wittman DH, Aprahamian CC, Condon RE. The
Hillman K. Intra-abdominal hypertension is an independent abdominal compartment syndrome: the physiological and
cause of postoperative renal impairment. Arch Surg clinical consequences of elevated intra-abdominal pressure.
1999;134:10825. J Am Coll Surg 1995;180:74550.
Sugrue M. Intra-abdominal pressure: time for clinical practice Sugrue M, Bauman A, Jones F et al. Clinical examination is an
guidelines? Intensive Care Med 2002;28:38991. inaccurate predictor of intraabdominal pressure. World J
Sugrue M, Jones F, Janjua J et al. Temporary abdominal closure. Surg 2002;26:142831.
J Trauma 1998;45:91421. World Society for the Abdominal Compartment Syndrome.
wwww.wsacs.org.
Part 5
Specific organ injury

The neck 5
5.1 Overview may have a role. It may be possible to pass the broncho-
scope through an endotracheal tube, enter the trachea
The high density of critical vascular, aerodigestive and under direct vision and then slide the endotracheal tube
neurological structures within the neck makes the man- into place.
agement of penetrating injuries difficult and contributes Laryngeal masks do not provide a definitive airway and
to the morbidity and mortality seen in these patients. may be hazardous in the presence of penetrating neck
Before the Second World War, non-operative manage- injury.
ment of penetrating neck trauma resulted in mortality NB: The use of paralysing agents in these patients is contrain-
rates of up to 15 per cent. Therefore, the exploration of dicated, since the airway may be held open only by the patients
all neck wounds penetrating the platysma muscle became use of muscles.
mandatory. However, in recent years, numerous centres Abolishing the use of muscles in such patients may
have challenged this principle of mandatory exploration, result in the immediate and total obstruction of the air-
since up to 50 per cent of neck explorations may be nega- way and, with no visibility due to the presence of blood,
tive for significant injury. may result in catastrophe. Ideally, local anaesthetic spray
should be used with sedation, and a cricothyroidotomy
below the injury should be considered when necessary.
5.2 Management principles Control of haemorrhage should be done by direct pres-
sure where possible. If the neck wound is not bleeding, do
The current management of penetrating cervical injuries not probe or finger the wound as a clot may be dislodged. If
depends on several factors. the wound is actively bleeding, the bleeding should be con-
trolled by digital pressure or, as a last resort, a Foley catheter.
Patients with signs of significant neck injury, and those
5.2.1Initial assessment whose condition is unstable, should be explored urgently
once rapid initial assessment has been completed and the
Patients with signs of significant neck injury will require airway has been secured. There should be no hesitation
prompt exploration. However, initial assessment and in performing an emergency cricothyroidotomy should
management of the patient should be carried out accord- circumstances warrant it. Tracheostomy should be con-
ing to Advanced Trauma Life Support principles. sidered as a planned procedure in the operating theatre.
The major initial concern in any patient with a pen- Cricothyroidotomies should be converted to formal
etrating neck wound is early control of the airway. tracheostomies within about 48 hours.
Intubation in these patients is complicated by the possi-
bility of associated cervical spine injury, laryngeal trauma 5.2.1.1Injury location
and large haematomas in the neck. Appropriate protective
Division of the neck into anatomical zones (Figure5.1)
measures for possible cervical spine injury must be imple-
helps the categorization and management of neck
mented. The route of intubation must be carefully con-
wounds:
sidered in these patients since it may be complicated by
distortion of anatomy, haematoma, dislodging of clots, Zone I extends from the bottom of the cricoid
laryngeal trauma and a significant number of cervical spi- cartilage to the clavicles and thoracic outlet.
nal injuries. Fibreoptic bronchoscopy and laryngoscopy Within zone I lie the great vessels, the trachea,
the oesophagus, the thoracic duct and the upper position, the vertebral artery is less frequently involved.
mediastinum and lung apices. The larynx and trachea, and pharynx and oesophagus are
Zone II includes the area between the cricoid cartilage frequently injured, whereas the spinal cord is involved less
and the angle of the mandible. Enclosed within its often.
region are the carotid and vertebral arteries, jugular
veins, pharynx, larynx, oesophagus and trachea.
Zone III includes the area above the angle of the 5.2.2Use of diagnostic studies
mandible to the base of the skull and the distal
extracranial carotid and vertebral arteries, as well as In the stable patient without indications for immediate
segments of the jugular veins. neck exploration, additional studies are often obtained,
including angiography, endoscopy, contrast radiogra-
Injuries in zone II are readily evaluated and easily
phy and bronchoscopy. (A few recent studies have even
exposed operatively. Adequate exposure of zone I or
suggested that asymptomatic patients can be observed
zoneIII injuries can be difficult; therefore, the diagnostic
safely by serial examination, but this is a highly selective
work-up may be more extensive than for zone II injuries.
approach.)
III
5.2.2.1Computed tomography scanning with

contrast/computed tomography angiography
II
Modern 1664-slice computed tomography (CT) scanners
have provided a means of creating a three-dimensional
Cricoid image of high quality. Use of contrast has allowed CT
angiography. Computed tomography scanning is now
I
the investigation of choice for penetrating injury in the
(a) stable patient.
5.2.2.2Angiography
Especially in zone I or zone III injuries, where surgical

exposure can be difficult, angiography is invaluable to
plan the conduct of operation. Angiography should vis-
ualize both the internal and external carotid arteries on
both sides (four-vessel angiography), as well as the verte-
bral arteries on both sides.
Anterior Posterior
Using a selective approach to the management of zone
triangle triangle
(b) II wounds, angiography is useful in excluding carotid
(b) injuries, especially with soft signs of injury, including sta-
Figure 5.1 Zones of the neck.
ble haematoma and a history of significant bleeding, or
when the wound is in close proximity to the major vessels.
5.2.1.2 Mechanism
5.2.2.3 Other diagnostic studies
Gunshot wounds carry a higher risk of major injury than
stab wounds because of their tendency to penetrate more The selective management of penetrating neck wounds
deeply and their ability to damage tissue outside the tract involves evaluation of the oesophagus, larynx and trachea.
of the missile due to cavitation. Either contrast oesophagography or oesophagoscopy
alone will detect 60 per cent of oesophageal injuries. The
two tests used together increase the diagnostic accuracy
5.2.1.3 Frequency of injury
to nearly 90 per cent. Laryngoscopy and bronchoscopy
The carotid artery and internal jugular vein are the most are useful adjuncts in localizing or excluding injury to the
frequently injured vessels. Due to its relatively protected hypopharynx or trachea.
The neck | 69
5.3Treatment zone II may require angiography if the vertebral vessels

are thought to be injured. However, angiography will not
5.3.1Mandatory versus selective neck rule out significant injury to the venous system, trachea
exploration or oesophagus.
The patient is placed in the supine position on the
Recommendations for the management of patients operating table with the arms tucked at the sides. Active
with penetrating cervical trauma depend on the zone of bleeding from a penetrating wound should be controlled
injury and the patients clinical status. If the platysma is digitally. However, penetrating wounds to the neck should
not penetrated, the patient may be observed. Mandatory not be probed, cannulated or locally explored because
exploration for penetrating neck injury in patients with these procedures may dislodge a clot and cause uncontrol-
hard signs of vascular or aerodigestive tract injury is still lable bleeding or air embolism. Skin preparation should
appropriate. include the entire chest and shoulder, extending above
The mandatory exploration of all stable patients is the angle of the mandible. If possible, the head should be
controversial. Significant morbidity and mortality due to extended and rotated to the contralateral side. A sandbag
missed visceral injuries, as well as the negligible morbidity may be placed between the shoulder blades.
caused by negative exploration, are reasons to operate on Zone III injuries, at the very base of the skull, are com-
all patients with penetrating wounds. However, explora- plex and should be explored with great care. Access is
tion of all stab wounds of the neck may yield a high rate often extremely difficult. On rare occasions, it may not
of negative findings. Thus, the selective management of be possible to control the distal stump of a high inter-
penetrating neck wounds with thorough non-operative nal carotid artery injury. While techniques for mandibu-
evaluation has been recommended. It is clear that missed lar dislocation may be helpful, bleeding from this injury
injuries are associated with high morbidity and mortality. can be controlled both temporarily and permanently by
In the stable patient with a wound that penetrates the inserting a Fogarty catheter into the distal segment. The
platysma, either mandatory exploration or non-operative catheter is secured, transected and left in place. It may
evaluation (angiography, oesophagography, bronchos- be necessary to control the internal carotid artery from
copy and thorough endoscopy) is appropriate. within the cranial cavity.
Zone II injuries are explored by an incision made along
the anterior border of the sternocleidomastoid muscle, as
for carotid endarterectomy. An extended collar incision or
5.3.2Treatment based on anatomical zones
bilateral incisions along the anterior edge of the sternoclei-
domastoid muscles may be used for wounds that traverse
5.3.2.1Vascular injuries both sides of the neck. Proximal and distal control of the
blood vessel is obtained. If the vessel is actively bleeding,
If associated injuries allow, a 500010000 unit bolus
direct pressure is applied to the bleeding site while control
of heparin should be given before any of the arteries in
is obtained. Use of anticoagulation is optional. If there are
the neck are occluded. Because they have no branches,
no injuries that preclude its use, heparin may be given in
the common and internal carotid arteries can be safely
the management of carotid injuries. Vascular shunts are
mobilized for some distance from the injury to ensure a
rarely needed in patients with carotid injuries, especially
tension-free repair.
if the distal clamp is applied proximal to the bifurcation
All patients with zone I and III neck injuries should
of the internal and external carotid arteries. Repair tech-
undergo angiography as soon as their vital signs are sta-
niques for cervical trauma do not differ significantly from
ble. Zone I injuries require angiography because of the
those used for other vascular injuries.
increased association of vascular injuries with penetrat-
ing trauma to the thoracic outlet. Angiography helps The intraoperative decisions are influenced by the
the surgeon plan the surgical approach. Zone III inju- patients preoperative neurological status. If the patient
ries require angiography because of the relationship of has no neurological deficit preoperatively, the injured
the blood vessels to the base of the skull. Often these vessel should be repaired. (The one exception may be
injuries can be best managed by either non-operative if a complete obstruction of blood flow is found at the
techniques or manoeuvres remote from the injury site, time of surgery, because restoration of flow may cause
such as balloon tamponade or embolization. Injuries in distal remobilization or haemorrhagic infarction.)
Operative management of the patient with a carotid As with all vascular injuries of the neck, a useful adjunct
injury and a preoperative neurological deficit is is to have a size 3 or 4 Fogarty catheter available. This can
controversial. Vascular reconstruction should be be passed up into the vessel to obtain temporary occlusive
performed in patients with mild-to-moderate deficits control.
in whom retrograde flow is present. Ligation is There is increasing support for the treatment of carotid
recommended for patients with severe preoperative artery injuries with intraluminal stenting. This approach is
neurological deficits greater than 48 hours old, and now commonly used for central as well as for more distal
without evidence of retrograde flow at the time of peripheral vascular lesions. It has also been applied to the
operation. management of traumatic injuries to the thoracic aorta
and selected injuries of the peripheral and visceral vascula-
Zone I vascular injuries at the base of the neck require
ture. Not surprisingly, stenting has also been used for the
aggressive management. Frequently, uncontrollable
management of carotid artery injuries, particularly inju-
haemorrhage will require immediate thoracotomy for ini-
ries to the distal internal carotid artery that are not easily
tial proximal control. In an unstable patient, quick expo-
approached surgically. Overall, stents are most frequently
sure often may be achieved via a median sternotomy and
used in situations where arterial lesions are not surgically
a supraclavicular extension.
accessible or when anticoagulation is contraindicated.
The location of the vascular injury will dictate the
definitive exposure. For right-sided great vessel injuries,
a median sternotomy with a supraclavicular extension 5.3.2.2Tracheal injuries
allows optimal access. On the left side, a left anterolateral
Injuries to the trachea should be closed in a single layer
thoracotomy may provide initial proximal control.
with absorbable sutures. Larger defects may require a fas-
Further operation for definitive repair may require a ster-
cia flap. These injuries should be drained.
notomy, or extension into the right side of the chest or up
into the neck. Trapdoor incisions are not recommended, as
they are often difficult to perform and do not significantly 5.3.2.3 Pharyngeal and oesophageal injuries
improve the exposure, but significantly increase the post-
Oesophageal injuries are often missed at neck explora-
operative disability. Care must be taken to avoid injury to
tion. Injuries to the hypopharynx and cervical oesopha-
the phrenic and vagus nerves as they enter the thorax. In
gus may also be difficult to diagnose preoperatively.
the stable patient in whom the vascular injury has been
Perforations of the hypopharynx or oesophagus should
confirmed by angiography, the right subclavian artery or
be closed in two layers and widely drained. For devastat-
the distal two-thirds of the left subclavian artery can be
ing oesophageal injuries requiring extensive resection and
exposed through an incision immediately superior to the
debridement, a cutaneous oesophagostomy for feeding,
clavicle. The clavicle can be divided at its mid-point, or
and pharyngostomy for diversion, may be necessary.
occasionally it may be necessary to resect the medial half
of the clavicle, although this is rarely necessary.
5.3.3Rules
Injuries to the internal jugular vein should be
repaired if possible. In severe injuries that require
The first concern in the patient with a penetrating injury
extensive debridement, ligation is preferred. Venous
of the neck is early control of the airway.
interposition grafts should not be performed.
The next concern is to stop bleeding, either by digital
Vertebral artery injuries are generally found to have
pressure or by the use of a Foley catheter.
been injured only on angiographic study. These rarely
The stability of the patient decides the appropriate
require surgical repair, as they are best dealt with by
diagnostic and treatment priorities. Never make the oper-
angioembolization. Operative exposure may be difficult
ation more difficult than necessary by inadequate expo-
and may require removal of the vertebral lamina in
sure. Adequate exposure of the area involved is critical.
order to access the vertebral artery for ligation. If a
vertebral artery injury is found at operation, the area
around the injury should be packed. If this tamponades 5.4Access to the neck
the bleeding, the patient should be transferred from the
operating room to the radiology suite for angiography The operative approach selected to explore neck injuries
and embolization of the vertebral artery. is determined by the structures known or suspected to be
The neck | 71
injured. Surgical exploration should be done formally and served. The occipital artery and inferior branches of the
systematically in a fully equipped operating room under ansa cervicalis may be divided.
general anaesthesia with endotracheal intubation. Blind To expose the carotid bifurcation, the dissection is car-
probing of wounds or mini-explorations in the emergency ried upwards to the posterior belly of the digastric muscle,
department should never be attempted. which is divided behind the angle of the jaw. Access to the
internal carotid can be improved by dividing the sterno-
cleidomastoid muscle near its origin at the mastoid. Care
5.4.1Incision
must be taken not to injure the accessory nerve where it
enters the sternomastoid muscle 3cm below the mastoid,
Always expect the worst, and plan the incision to pro-
or the glossopharyngeus nerve crossing anteriorly over
vide optimal access for early proximal vascular control
the internal carotid artery.
or immediate access to the airway. The most universally
More distal exploration of the internal carotid artery
applicable approach is via an anterior sternomastoid inci-
may require unilateral mandibular subluxation or divi-
sion, which can be lengthened proximally and distally,
sion of the ascending ramus. The styloid process may be
extended to a median sternotomy or augmented with lat-
excised after division of the stylohyoid ligament and sty-
eral extensions. The patient is positioned supine with a
loglossus and stylopharyngeus muscles. The facial nerve
bolster between the shoulders, and the neck extended and
lies superficial to these muscles and must be preserved.
rotated away provided that the cervical spine has been
To reach the internal carotid artery where it enters the
cleared preoperatively. The face, neck and anterior chest
carotid canal, part of the mastoid bone can be removed.
should be prepped and widely draped.
Fortunately, this is rarely required. Figures 5.2 and 5.3
The incision is made along the anterior border of the ster-
show the surgical approach to the neck.
nocleidomastoid muscle and carried through the platysma
into the investing fascia. The muscle is freed and retracted
laterally to expose the fascial sheath covering the internal
Divided posterior belly
jugular vein. Lateral retraction of the jugular vein and under- of the digastric muscle
Divided
lying carotid artery allows access to the trachea, oesophagus sternocleidomastoid
and thyroid, and medial retraction of the carotid sheath and muscle
its contents will allow the dissection to proceed posteriorly Internal
carotid
to the prevertebral fascia and vertebral arteries. artery
External Hypoglossal
carotid nerve
5.4.2Carotid artery artery
Accessory nerve
Exposure of the carotid artery is obtained by ligating the

Vagus nerve
middle thyroid and common facial veins and retracting
the internal jugular laterally together with the sterno- Internal jugular vein
cleidomastoid. The vagus nerve posteriorly in the carotid

sheath, and the hypoglossal nerve anteriorly, must be pre-
Figure 5.2 Approach to the left side of the neck with divided
sternomastoid and digastric muscles.
Platysma muscle
Sternocleidomastoid
muscle
Thyroid gland
Cricoid cartilage
Internal jugular vein
Carotid sheath Carotid artery Oesophagus
Vagus nerve
Cervical sympathetic nerve Figure 5.3 Approach to the left side of the
Prevertebral fascia neck showing retraction of the platysma and
sternomastoid muscles.
The proximal carotid artery is exposed by division of the the fascia covering the thyroid. The thyroid isthmus can
omohyoid muscle between the superior and inferior bellies. be divided to expose the trachea. A high collar incision,
More proximal control may require a midline sternotomy. placed over the larynx, is useful for repairing isolated
laryngeal injuries.
5.4.3 Midline visceral structures

5.4.6Vertebral arteries
The trachea, oesophagus and thyroid are approached by
retracting the carotid sheath laterally. The inferior thyroid The proximal part of the vertebral artery is approached
artery should be divided laterally near the carotid artery, via the anterior sternomastoid incision, with division of
and the thyroid lobe is lifted anteriorly to expose the tra- the clavicular head of the sternomastoid. The internal
chea and oesophagus posteriorly. Oesophageal identifi- jugular vein and common carotid artery are mobilized,
cation is aided by passing a large dilator or nasogastric the vein is retracted medially, and the artery and nerve
tube. The recurrent laryngeal nerves should be carefully are retracted laterally. The proximal vertebral artery lies
preserved: the left nerve runs vertically in the tracheo- deeply between these structures. The vertebral artery is
oesophageal groove, but the right nerve runs obliquely crossed by branches of the cervical sympathetic chain and
across the oesophagus and trachea from inferolateral to on the left side by the thoracic duct. The inferior thyroid
superomedial. Both nerves are at risk of injury with cir- artery crosses in a more superficial plane just before the
cumferential mobilization of the oesophagus. Bilateral vertebral artery enters its bony canal.
exposure of the midline structures may require transverse Access to the distal vertebral artery is challenging and
extension of the standard incision. rarely needed. The contents of the carotid sheath are
retracted anteromedially, and the prevertebral muscles
5.4.4Root of the neck are longitudinally split over a transverse process above
the level of the injury. The anterior surface of the trans-
The structures at the root of the neck can be approached verse process can be removed with a small rongeur, or a
by extending the incision laterally above the clavicle. The J-shaped needle may be used to snare the artery in the
clavicular head of the sternocleidomastoid is divided, space between the transverse processes.
and the supraclavicular fat pad is cleared by blunt dissec- The most distal portion of the vertebral artery can be
tion. This reveals the scalenus anterior muscle, with the approached between the atlas and the axis after division
phrenic nerve crossing it from the lateral side. Division of the sternocleidomastoid near its origin at the mas-
of the scalenus anterior, with preservation of the phrenic toid process. The prevertebral fascia is divided over the
nerve, allows access to the second part of the subclavian transverse process of the atlas. With preservation of the
artery. The distal subclavian artery can be exposed by C2 nerve root, the levator scapulae and splenius cervicus
dividing the clavicle at its mid-point, and dissecting away muscles are divided close to the transverse process of the
the subclavius muscle and fascia. The clavicle should not atlas. The vertebral artery can now be visualized between
be resected as this leads to considerable morbidity. To fix the two vertebrae, and may be ligated with a J-shaped
the divided bone, the periosteum should be approximated needle.
with strong polyfilament absorbable sutures. Neck exploration wounds are closed in layers after
acquiring homeostasis. Drainage is usually indicated,
mainly to prevent haematomas and sepsis.
5.4.5Collar incisions
Horizontal or collar incisions placed either over the thy- 5.5Recommended reading
roid or higher up over the thyroid cartilage are useful to
expose bilateral injuries or injuries limited to the larynx Demetriades D, Asensio JA, Velmahos G, Thal E. Complex
or trachea. The transverse incision is carried through the problems in penetrating neck trauma. Surg Clin North Am
platysma, and subplatysmal flaps are then developed: 1996;76:66183.
superiorly up to the thyroid cartilage notch, and inferi- Fabian TC, George SM Jr, Croce MA, Mangiante EC, Voeller GR,
orly to the sternal notch. The strap muscles are divided Kusdk KA. Carotid artery trauma: management based on
vertically in the midline and retracted laterally to expose mechanism of injury. J Trauma 1990;30:95361.
The chest 6
6.1 Overview Injuries to the chest wall and thoracic viscera can
directly impair oxygen transport mechanisms. Hypoxia
and hypovolaemia resulting as a consequence of thoracic
6.1.1Introduction: the scope of the problem injuries may cause secondary injury to patients with brain
injury, or may directly cause cerebral oedema.
Thoracic injury constitutes a significant problem in terms Conversely, shock and/or brain injury can secondarily
of mortality and morbidity. In the United States during aggravate thoracic injuries and hypoxaemia by disrupting
the early 1990s, there were approximately 180000 deaths normal ventilatory patterns or by causing loss of protec-
per annum from injury. Several investigators have shown tive airway reflexes and aspiration.
that 50 per cent of fatal injuries are due to primary brain The lung is a target organ for secondary injury follow-
injury, 25 per cent of fatal accidents are due to chest ing shock and remote tissue injury. Microemboli formed
trauma, and in another 25 per cent (including brain in the peripheral microcirculation embolize to the lung,
injury) thoracic injury contributes to the primary cause of causing ventilationperfusion mismatch and right heart
mortality.1 Approximately 15 per cent of thoracic injuries failure. Tissue injury and shock can activate the inflam-
will require definitive surgery. matory cascade, which can contribute to pulmonary
Somewhat less clearly defined is the extent of appreci- injury (reperfusion).
able morbidity following chest injury, most usually the
long-term consequences of hypoxic brain damage. There
are a number of important points to be taken into account. 6.1.2The spectrum of thoracic injury
A significant proportion of these deaths occur virtu-
ally immediately (i.e. at the time of injury), for example, Thoracic injuries are grouped into two types, as described
rapid exsanguination following traumatic rupture of the below.
aorta in blunt injury or major vascular disruption after
penetrating injury.
6.1.2.1Immediately life-threatening injuries
Of survivors with thoracic injury who reach hospital, a
significant proportion die in hospital as the result of mis- Airway obstruction due to any cause, including
assessment or delay in the institution of treatment. These laryngeal or tracheal disruption with obstruction or
deaths occur early as a consequence of shock, or late as extensive facial bony and soft tissue injuries
the result of adult respiratory distress syndrome, multiple Impaired ventilation due to tension pneumothorax,
organ failure and sepsis. Most life-threatening thoracic inju- major bronchial disruptions, open pneumothorax or
ries can be simply and promptly treated after identification flail chest
by tube placement for drainage. These are simple and effec- Impaired circulation due to massive haemothorax or
tive techniques that can be performed by any physician. pericardial tamponade
Emergency department thoracotomy (EDT) has spe- Air embolism.
cific indications; these virtually always relate to patients
in extremis with penetrating injury. Indiscriminate use of
6.1.2.2 Potentially life-threatening injuries
EDT, however, especially in blunt trauma, will not alter
patient outcome, but will increase the risk of communi- Blunt cardiac injury
cable disease transmission to health workers. Pulmonary contusion
Traumatic rupture of the aorta occurred, laparotomy is indicated. Other options include
Traumatic diaphragmatic herniation laparoscopy or thoracoscopy to determine whether the
Tracheobronchial tree disruption diaphragm has been injured (see Chapter 13, Minimally
Oesophageal disruption invasive surgery in trauma).2
Haemothorax Patients arrive in one of two general physiological
Pneumothorax. states:
Penetrating wounds traversing the mediastinum war- Haemodynamically stable
rant specific mention. Injuries of this type frequently Haemodynamically unstable.
damage a number of mediastinal structures, and are thus
In the patient with penetrating injury to the upper
more complex in their evaluation and management.
torso who is haemodynamically unstable, and whose
bleeding is occurring into the chest cavity, it is important
6.1.3 Pathophysiology of thoracic injuries to insert a chest tube as soon as possible during the ini-
tial assessment and resuscitation. In the patient in extremis
The well-recognized pathophysiological changes occur- who has chest injuries or in whom there may be suspicion
ring in patients with thoracic injuries are essentially the of a transmediastinal injury, bilateral chest tubes may
result of: be indicated. X-ray is not required to insert a chest tube,
but it is useful after the chest tubes have been inserted to
Impairment of ventilation
confirm proper placement.
Impairment of gas exchange at the alveolar level
In patients who are haemodynamically stable, X-ray
Impairment of circulation due to haemodynamic
remains the gold standard for diagnosis of a pneumo
changes
thorax or haemothorax. In these patients, it is prefer-
Impairment of cardiac function due to tamponade or
able to have the X-ray completed before placement of a
air embolus.
chest tube. The decrease in air entry may not be due to a
The approach to the patient with thoracic injury must pneumothorax, and especially following blunt injury may
therefore take all these elements into account. be due to a ruptured diaphragm with bowel or stomach
Specifically, hypoxia at a cellular or tissue level results occupying the thoracic cavity.
from inadequate delivery of oxygen to the tissues, with
the development of acidosis and associated hypercapnia.
The late complications resulting from misassessment 6.1.4Applied surgical anatomy of the chest
of thoracic injuries are directly attributable to these
processes. It is useful to broadly view the thorax as a container with
Penetrating chest injuries should be obvious. Exceptions an inlet, walls, a floor and contents.
include small puncture wounds such as those caused by
ice picks. Bleeding is generally minimal secondary to the
6.1.4.1The chest wall
low pressure within the pulmonary system. Exceptions
to these management principles include wounds to the This is the bony cage constituted by the ribs, thoracic
great vessels as they exit over the apex of the chest wall vertebral column and sternum with the clavicles anteri-
to the upper extremities, or injury to any systemic vessel orly and the scapula posteriorly. The associated muscle
that may be injured in the chest wall, such as the internal groups and vascular structures (specifically the intercos-
mammary or intercostal vessel. tal vessels and the internal thoracic vessels) are further
Penetrating injuries to the mid-torso generate more components.
controversy. These will require a fairly aggressive Remember the safe area of the chest. This triangular
approach, particularly with anterior wounds. If the wound area is the thinnest region of the chest wall in terms of
is between one posterior axillary line and the other and musculature. This is the area of choice for tube thora-
obviously penetrates the abdominal wall, laparotomy is costomy insertion. In this area, there are no significant
indicated. If the wound does not obviously penetrate, an structures within the walls that may be damaged; how-
option is to explore the wound under local anaesthesia to ever, note that there is a need to avoid the intercostal
determine whether or not it has penetrated the peritoneal vascular and nerve bundle on the undersurface of the rib
lining or the diaphragm. If peritoneal penetration has (Figure6.1).
The chest | 75
The triangle of safety

The mediastinum
Superior
Border of pectoral muscle

Anterior axillary line
Anterior
Nipple line
Middle
Posterior
Figure 6.1 Anatomy of the chest wall.
6.1.4.2The chest floor Figure 6.2 Chest contents.
This is formed by the diaphragm with its various open-

ings. This broad sheet of muscle with its large, trefoil- bifurcates. The right main bronchus is shorter, straighter
shaped central tendon has hiatuses through which pass and at less of an angle compared with that on the left side. It
the aorta, the oesophagus and the inferior vena cava, and lies just below the junction between the azygos vein and the
it is innervated by the phrenic nerves. The oesophageal superior vena cava, and behind the right pulmonary artery.
hiatus also contains both vagus nerves. The aortic hiatus
contains the azygos vein and the thoracic duct. Lungs and pleurae
During normal breathing, the diaphragm moves about
The right lung constitutes about 55 per cent of the total
2 cm, but it can move up to 10 cm in deep breathing.
lung mass, and has oblique and transverse fissures that
During maximum expiration, the diaphragm may rise as
divide it into three lobes. The left lung is divided into
high as the fifth intercostal space. Thus, any injury below
upper and lower lobes by the oblique fissure. Both lungs
the fifth intercostal space may involve the abdominal
are divided into bronchopulmonary segments corre-
cavity.
sponding to the branches of the lesser bronchi, and are
supplied by branches of the pulmonary arteries. The right
6.1.4.3The chest contents and left pulmonary arteries pass superiorly in the hilum,
anterior to each respective bronchus. There are superior
These are:
and inferior pulmonary veins on each side, the middle
The left and right pleural spaces containing the lungs, lobe usually being drained by the superior vein.
lined by the parietal and visceral pleurae, respectively The pleural cavities are lined by parietal and visceral
The mediastinum and its viscera, located in the centre pleura. The parietal pleura lines the inner wall of the tho-
of the chest. The mediastinum itself has anterior, racic cage. The visceral pleura is intimately applied to the
middle, posterior and superior divisions. The superior surface of the lungs, and is reflected onto the mediasti-
mediastinum is contiguous with the thoracic inlet num to join the parietal pleura at the hilum.
and zone I of the neck (Figure 6.2).
Heart and pericardium
Tracheobronchial tree The heart lies in the middle mediastinum, extending from
The trachea extends from the cricoid cartilage at the level the level of the third costal cartilage to the xiphisternal
of the fifth cervical vertebra, to the carina at the level of junction. The majority of the anterior surface of the
the upper border of the sixth thoracic vertebra, where it heart is represented by the right atrium and its auricular
appendage superiorly, and the right ventricle inferiorly. Thoracic duct

The aorta emerges from the cranial aspect and crosses to The duct arises from the cysterna chyli overlying the first
the left as the arch. The pulmonary artery extends crani- and second lumbar vertebrae. It lies posteriorly and to the
ally, and bifurcates in the concavity of the aortic arch. The right of the aorta. It ascends through the oesophageal hia
left pulmonary artery is attached to the concavity of the tus of the diaphragm between the aorta and the azygos
arch of the aorta, just distal to the origin of the left sub- vein, anterior to the right intercostal branches from the
clavian artery, by the ligamentum arteriosum. The peri- aorta. It overlies the right side of the vertebral bodies, and
cardium is a strong fibrous sac that completely invests injury can result in a right-sided chylothorax. It drains
the heart and is attached to the diaphragm inferiorly. into the venous system at the junction of the left sub
Pericardial tamponade can be created by less than 50mL clavian and internal jugular veins.
or up to more than 200mL of blood. From a functional and practical point of view, it is use-
ful to regard the chest in terms of a hemithorax and its
The aorta and great vessels
content, both in evaluation of the injury and in choos-
The thoracic aorta is divided into three parts: the ascending the option for access. Figures 6.3 and 6.4 illustrate the
ing aorta, arch and descending aorta. The innominate hemithoraces and their respective contents.
artery is the first branch from the arch, passing upwards
and to the right, posterior to the innominate vein. The
left common carotid artery and left subclavian artery arise 6.1.5 Paediatric considerations
from the left side of the arch.
In children, the thymus may be very large, and care
Oesophagus should be taken to avoid damage to it.
The oesophagus, approximately 25cm long, extends from The sternum is relatively soft and can be divided
the pharynx to the stomach. It starts at the level of the using a pair of heavy scissors.
sixth cervical vertebra, and passes through the diaphragm Intercostal drains should be tunnelled subcutaneously
about 2.5cm to the left of the midline at the level of the over at least one rib space to facilitate later removal
11th thoracic vertebra. The entire intrathoracic oesopha- without air leaks. The child may not cooperate with
gus is surrounded by loose areolar tissue, which allows for a Valsalva manoeuvre, and pressure on the tract may
a rapid spread of infection if the oesophagus is breached. prevent iatrogenic pneumothorax.
Brachiocephalic veins
Superior vena cava Thoracic duct

Aortic arch
Right hilum
Left hilum
Right phrenic nerve

Left phrenic nerve
Inferior vena cava

Inferior vena cava
Oesophagus
Oesophagus
Aorta
Right hemithorax
Left hemithorax
Figure 6.3 Right hemithorax and mediastinum. Figure 6.4 Left hemithorax and mediastinum.
The chest | 79
Pitfalls
Do not use a purse-string closure as this is both
painful in the long term and less effective.
Do not weave the drain tie as, if it becomes loose,
the entire securing suture will be loose. The securing
suture should be wound around the drain in one
plane, as shown (Figure 6.10).
All connectors are taped to prevent inadvertent discon-

nection or removal of the chest tube.
After the chest tube has been placed, it is prudent to
obtain an immediate chest film to assess the adequate
removal of air and blood, and the position of the tube.
If, for any reason, blood accumulates and cannot be Figure 6.12 End result after drain removal.
removed, another chest tube is inserted. Persistent air leak
or bleeding should alert the surgeon that there is signifi-
cant visceral injury that may require operative interven- techniques, the incidence of both of these should be well
tion. The surgeon should be aware that the blood may be under 1 per cent.
entering the chest via a hole in the diaphragm. Routine antibiotics are not a substitute for good surgi-
The tube is removed once the lung has expanded. The cal technique.3
suture is cut at the halfway knot. The remaining suture
is unwound, and the skin can then be pinched, or sealed
with petroleum gauze, as the tube is withdrawn (Figure 6.1.7.2 nOn-OPerative ManageMent
6.11); the pre-placed suture, now unwound, is then pulled As noted above, non-operative management can be used
tight and secured. The wound should thus be closed as a in the majority of penetrating injuries. These patients
linear incision (Figure 6.12). should be observed in a monitored setting to ensure
Complications of tube thoracostomy include wound haemodynamic stability, monitoring of ventilatory status
tract infection and empyema. With meticulous aseptic and output of blood from the pleural cavity.
Non-operative management of mid-torso injuries is
problematic until injury to the diaphragm or abdominal
viscera has been ruled out. Thoracoscopy and laparoscopy
have been successful in diagnosing diaphragm penetra-
tion.4 Laparoscopy may have a small advantage in that,
if the diaphragm has been penetrated, it also allows some
assessment of the intraperitoneal viscera. It should be
noted, however, that in some studies up to 25 per cent of
penetrating injuries to hollow viscous organs have been
missed at laparoscopy. In many ways, thoracoscopy is bet-
ter for assessment of the diaphragm, particularly in the
right hemithorax. The disadvantage is that once an injury
has been detected, this does not rule out associated intra-
peritoneal injuries.
Title: Manual of Definitive Surgical Trauma Care 3E Failures of non-operative
Author: Boffardmanagement
ISBN:include patients
9781444102826 Proof Stage:
who continue to bleed from the pleural cavity and those
www.cactusdesign.co.uk patients who go on to develop a clotted thorax. If place-
ment of additional chest tubes does not remove the tho-
racic clots, thoracoscopy is indicated to aid in the removal
of these clots. Optimally, this should be done within 72
hours of injury, before the clot becomes too adherent to
Figure 6.11 Removal of drain showing pinching of the skin. be safely removed by thoracoscopy.
6.1.7.3 Operative management thoracic outlet. The sternotomy can be extended up the
sternocleidomastoid muscle or laterally along the top of
In general, patients who have penetrating injuries to the the clavicle. Resection of the medial half of the clavicle
torso should be left in the supine position in the operat- exposes most of the vessels, except possibly the proximal
ing room. The importance of this cannot be overempha- left subclavian vein. When this diagnosis is known, it is
sized. The surgeon must be prepared to extend incisions best approached by a left posterior lateral thoracotomy.
up into the neck or along the supraclavicular area if there In an emergency, it may be necessary to go through a
are thoracic outlet injuries. Similarly, once it has been fourth or fifth intercostal space for a left anterolateral
determined that the diaphragm has been penetrated or thoracotomy. Care should be taken in female patients not
there are associated injuries to the lower torso, it is impor- to transect the breast.
tant the patient not be in a lateral decubitus position that An adjunctive measure to exploratory thoracotomy,
would compromise exploration of the peritoneal cavity or after injuries have been dealt with, is the pleural toilet. It
pelvis. The posterolateral approach is not appropriate in is extremely important to evacuate all clots and foreign
this situation. The surgeon must be comfortable in deal- objects. Foreign objects can include clothing, wadding
ing with injuries on both sides of the diaphragm. from shotgun blasts and any spillage from hollow viscous
The trauma patient must be prepared and the drapes injury. In general, it is best to place a right-angle chest
positioned over a large area so that the surgeon can expe- tube to drain the diaphragmatic sulcus and a straight tube
ditiously gain access to any body cavity and can properly to drain the posterior gutter up towards the apex. These
place drains and chest tubes. The entire anterior portion chest tubes should be placed so that they do not exit the
and both lateral aspects of the torso should be prepared chest wall at the bed line. All chest tubes are sutured to the
with antiseptic solution and draped so that the surgeon skin with a size 0 monofilament suture. Another useful
can work in a sterile field from the neck and clavicle above adjunct is to inject 0.25 per cent bupivacaine (Marcaine)
to the groins below, and from table top to table top later- into the intercostal nerve posteriorly in the inner space
ally. Prepping should not involve more than a few min- of the thoracotomy and intercostal nerves just above and
utes, and is preferably carried out before induction of below the thoracotomy; this provides excellent analgesia
anaesthesia so that if deterioration should occur, imme- in the immediate postoperative period. This can then be
diate laparotomy or thoracotomy can be carried out. supplemented with a thoracic epidural if necessary after
For emergency thoracotomy, an anterior lateral tho the initial 12 hours of the postoperative period.
racotomy in the fifth intercostal space is preferred. Most Emergency department thoracotomy is indicated in the
often, this is done on the left chest, particularly if it is agonal or dying patient with thoracic injuries.5,6 The best
a resuscitative thoracotomy. The rationale for this left results have been obtained with penetrating injuries to the
thoracotomy is that posterior myocardial wounds will torso, but some authors report up to 5 per cent salvage in
necessitate traction of the heart. If this is done through patients with blunt injuries. Specific indications include
a median sternotomy and the heart is lifted, decreased resuscitative thoracotomy from hypovolaemic shock, sus-
venous return and fatal dysrhythmia may occur. In pected pericardial tamponade and air embolism. Patients
patients who are in extremis, and a left thoracotomy who have signs of life in the pre-hospital setting and arrive
hasbeen performed that turns out to be inadequate for with an electrical complex are also candidates. Exceptions
the extensive injuries, there should be no hesitation in include those patients who have associated head injuries
extending this into the right chest in a clamshell fashion, with exposure or extrusion of brain tissue from the injury.
which gives excellent exposure to all the intrathoracic The intent of the emergency thoracotomy is to either
viscera. Occasionally, a right anterolateral thoracotomy is aid in resuscitation or to control bleeding and broncho
indicated in emergencies if air embolism is suspected (see pulmonary vein fistulas (air embolism).
below).
In patients who are haemodynamically stable, a median
6.1.7.4 Management of specific injuries
sternotomy is often the best incision when the visceral
injury is undetermined or if there may be multiple inju- The incidence of open pneumothorax or significant chest
ries. An alternative is the butterfly or clamshell incision, wall injuries following civilian trauma is quite low, cer-
which gives superb exposure to the entire thoracic viscera. tainly less than 1 per cent of all major thoracic injuries.7
Sternotomy is generally preferred for upper mediastinal Although all penetrating wounds are technically open
injuries or injuries to the great vessels as they exit the pneumothoraces, the tissue of the chest wall serves as
The chest | 81
an effective seal. True open pneumothorax is most often pneumothorax, which is not quite as dramatic, occurs in
associated with close-range shotgun blasts and high- approximately 20 per cent of all penetrating chest inju-
energy missiles. There is usually a large gaping wound ries. Haemothorax, in contrast, is present in about 30 per
commonly associated with frothy blood at its entrance. cent of penetrating injuries, and haemopneumothorax is
Respiratory sounds can be heard with to-and-fro move- found in 4050 per cent of penetrating injuries.
ment of air. The patient often has air hunger and may be The diagnosis of tension pneumothorax can be diffi-
in shock from associated visceral injuries. cult in a noisy emergency department. The classic signs
The wound should be immediately sealed with an occlu- are decreased breath sounds and percussion tympany on
sive clean or sterile dressing, such as petroleum-soaked the ipsilateral side, and tracheal shift to the contralateral
gauze, thin plastic sheets, sealed on three sides to create side. The diagnosis is clinical. In the patient who is dying,
a valve, or even aluminium foil as a temporary dressing. there should be no hesitation in performing a tube thora-
Once the chest wound has been sealed, it is important costomy. Massive haemothorax is equally life-threatening.
to realize that a tube thoracostomy may be immediately Approximately 50 per cent of patients with hilar, great
necessary because of the risk of converting the open vessel or cardiac wounds expire immediately after injury.
pneumothorax into a tension pneumothorax, if there is Another 25 per cent live for periods of 56 minutes and,
associated parenchymal injury to the lung. Large gaping in urban centres, some of these patients may arrive alive
wounds will invariably require debridement, including in the emergency department after rapid transport. The
resection of devitalized tissue back to bleeding tissue, remaining 25 per cent live for periods of up to 30 minutes,
and removal of all foreign bodies including clothing, and it is this group of patients that may arrive alive in the
wadding from shotgun shells or debris from the object emergency department and require immediate diagnosis
that penetrated the chest. The majority of these patients and treatment.
will require thoracotomy to treat visceral injuries and to The diagnosis of massive haemothorax is invariably
control bleeding from the lung or chest wall. made by the presence of shock, ventilatory embarrassment
After the wounds have been thoroughly debrided and and a shift in the mediastinum. Chest X-ray will confirm
irrigated, the size of the defect may necessitate recon- the extent of blood loss, but most of the time tube tho-
struction. The use of synthetic material such as Marlex racostomy is done immediately to relieve the threat of
to repair large defects in the chest wall has mostly been ventilatory embarrassment. If a gush of blood is obtained
abandoned. Instead, myocutaneous flaps such as latis- when the chest tube is placed, autotransfusion should be
simus dorsi or pectoralis major have proven efficacy, considered. There are simple devices for this that should
particularly when cartilage or ribs must be debrided. The be available in all major trauma resuscitation centres. The
flap provides prompt healing and minimizes infection to only contraindication to autotransfusion is a high suspi-
the ribs or costal cartilages. If potential muscle flaps have cion of hollow viscus injury. Lesser forms of haemothorax
been destroyed by the injury, a temporary dressing can are usually diagnosed by routine chest X-ray.
be placed, and the patient stabilized in the intensive care The treatment of massive haemothorax is to restore
unit and then returned to the operating room in 2448 blood volume. Essentially, all such patients will require
hours for a free myocutaneous graft or alternative recon- thoracotomy. In approximately 85 per cent of patients
struction. Complications include wound infection and with massive haemothorax, a systemic vessel has been
respiratory insufficiency, the latter usually due to asso- injured, such as the intercostal artery or internal mam-
ciated parenchymal injury. Ventilatory embarrassment mary artery. In a few patients, there may be injury to the
can persist secondary to the large defect. If the chest wall hilum of the lung or the myocardium. In about 15 per
becomes infected, debridement, wound care and myo cent of instances, the bleeding is from deep pulmonary
cutaneous flaps should be considered. lacerations. These injuries are treated by oversewing the
lesion, making sure that bleeding is controlled to the
depth of the lesion, or, in some instances, tractotomy or
Tension pneumothorax (pneumo-haemothorax)
resection of a segment or lobe.
Tension pneumothorax is a common threat to life. The Complications of haemothorax or massive haemotho-
patient may present to the emergency department either rax are almost invariably related to the visceral injuries.
dead or dying. The importance of making the diagnosis is Occasionally, there is a persistence of undrained blood
that it is the most easily treatable life-threatening surgical that may lead to a cortical peel necessitating thoracoscopy
emergency in the emergency department. Simple closed or thoracotomy and removal of this peel. The aggressive
use of two chest tubes should minimize the incidence of combination of techniques such as tractotomy, wedge
this complication. resection and segmentectomy, reserving lobectomy or
pneumonectomy for only the most critical patients.
Tracheobronchial injuries Currently available stapling devices are invaluable.
Penetrating injuries to the tracheobronchial tree are

uncommon and constitute less than 2 per cent of all Air embolism
major thoracic injuries. Disruption of the tracheobron- Air embolism is an infrequent event following penetrat-
chial tree is suggested by massive haemoptysis, airway ing trauma.9 It occurs in 4 per cent of all major thoracic
obstruction, progressive mediastinal air, subcutaneous trauma. Sixty-five per cent of the cases are due to pen-
emphysema, tension pneumothorax and significant per- etrating injuries. The key to diagnosis is to be aware of
sistent air leak after placement of a chest tube. Fibreoptic the possibility. The pathophysiology is a fistula between
bronchoscopy is a useful diagnostic adjunct in diagnosis, a bronchus and the pulmonary vein. Those patients who
tube placement, postoperative tracheobronchial toilet are breathing spontaneously will have a pressure differ-
and postoperative follow-up of tracheobronchial repairs. ential from the pulmonary vein to the bronchus that will
Treatment for tracheobronchial injuries is straightfor- cause approximately 22 per cent of these patients to have
ward.8 If it is a distal bronchus, there may be persistent haemoptysis on presentation. If, however, the patient has
air leak for a few days, but it will usually close with chest a Valsalva-type respiration or grunts, or is intubated with
tube drainage alone. If, however, there is persistent air positive pressure in the bronchus, the pressure differen-
leak or the patient has significant loss of minute volume tial is from the bronchus to the pulmonary vein, causing
through the chest tube, bronchoscopy is used to detect systemic air embolism.
whether or not this is a proximal bronchus injury, and These patients present in one of three ways: focal or
the involved haemothorax is explored, usually through a lateralizing neurological signs, sudden cardiovascular col-
posterior lateral thoracotomy. If possible, the bronchus is lapse, and froth when the initial arterial blood specimen is
repaired with monofilament suture. In some instances, a obtained. Any patient who has obvious chest injury, does
segmentectomy or lobectomy may be required. not have obvious head injury and yet has focal or later-
alizing neurological findings should be assumed to have
Pulmonary contusion air embolism. Confirmation can occasionally be obtained
by fundoscopic examination, which shows air in the reti-
Pulmonary contusions represent bruising of the lung
nal vessels. Patients who are intubated and have a sudden
and are usually associated with direct chest trauma, high-
unexplained cardiovascular collapse with an absence of
velocity missiles and shotgun blasts. The pathophysiology
vital signs should be immediately assumed to have an air
is the result of ventilationperfusion defects and shunts.
embolism to the coronary vessels. Finally, those patients
The bruise also serves as a source of sepsis.
who have a frothy blood sample drawn for initial blood
The treatment of significant pulmonary contusion is
gas determination will have air embolism.
straightforward and consists primarily of cardiovascular
When a patient comes into the emergency department
and ventilatory support as necessary. Adjunctive measures
in extremis and an EDT is carried out, air should always
such as steroids and diuretics are no longer used, since it
be looked for in the coronary vessels. If air is found, the
is impossible to dry out a bruise selectively.
hilum of the offending lung should be clamped immedi-
Antibiotics are not generally used, as this will simply
ately to reduce the ingress of air into the vessels.
select out nosocomial, opportunistic and resistant organ-
The treatment of air embolism is immediate thoracot-
isms. It is preferable to obtain a daily Gram stain of the
omy, preferably in the operating room. In the majority of
sputum and chest X-rays when necessary. If the Gram
patients, the left or right chest is opened depending on
stain shows the presence of a predominant organism with
the side of penetration. If a resuscitative thoracotomy has
an associated increase in polymorphonuclear cells, anti
been carried out, it may be necessary to extend this across
biotics are indicated.
the sternum into the opposite chest if there is no paren-
chymal injury to the lung on the left. Definitive treat-
Pulmonary laceration
ment is to oversew the lacerations to the lung, in some
Lung preservation wherever possible is critically impor- instances perform a lobectomy, and only rarely perform
tant, with conservative resections if required, using a a pneumonectomy.
The chest | 83
Other resuscitative measures in patients who have If the coronary arteries have been transected, two
arrested from air embolism include internal cardiac mas options exist. Closure can be accomplished in the beating
sage and reaching up and holding the ascending aorta heart using a fine 6/0 or 7/0 Prolene suture, under mag-
with the thumb and index finger for one or two beats this nification if necessary. The second option is to temporar-
will tend to push air out of the coronary vessels and thus ily initiate inflow occlusion and fibrillation. However,
establish perfusion. Adrenaline (epinephrine); (1:1000) both of these measures have a high risk associated with
can be injected intravenously or down the endotracheal them. Heparinization is optimally avoided in the trauma
tube to provide an alpha effect, driving air out of the sys- patient, and fibrillation in the presence of shock and aci-
temic microcirculation. It is prudent to vent the left atrium dosis may be difficult to reverse. Bypass is usually reserved
and ventricle as well as the ascending aorta to remove all for patients who have injury to the valves, chordae tend-
residual air once the lung hilum has been clamped. This ineae or septum. In most instances, these injuries are not
prevents further air embolism when the patient is moved. immediately life-threatening, but become evident over a
Using aggressive diagnosis and treatment, it is possible few hours or days following the injury.
to achieve up to a 55 per cent salvage rate in patients with Complications from myocardial injuries include recur-
air embolism secondary to penetrating trauma. rent tamponade, mediastinitis and post-cardiotomy
syndrome. The former can be avoided by placing a medi-
Cardiac injuries astinal chest tube or leaving the pericardium partially
open following repair. Most cardiac injuries are treated
In urban trauma centres, cardiac injuries are most com- through a left anterolateral thoracotomy, and only occa-
mon after penetrating trauma, and constitute about 5 per sionally via a median sternotomy. If mediastinitis does
cent of all thoracic injuries.10,11 The diagnosis of cardiac develop, the wound should be opened (including the ster-
injury is usually fairly obvious. The patient presents with num), and debridement carried out with secondary clo-
exsanguination, cardiac tamponade and, rarely, acute sure in 45 days. If this is impossible, myocutaneous flaps
heart failure. Patients with tamponade due to penetrating should be considered. Another complication is herniation
injuries usually have a wound in proximity, decreased car- of the heart through the pericardium, which may occlude
diac output, increased central venous pressure, decreased venous return and cause sudden death. This is avoided by
blood pressure, decreased heart sounds, narrow pulse loosely approximating the pericardium after the cardiac
pressure and occasionally paradoxical pulse. injury has been repaired.
Many of these patients do not have the classic Beck triad.
Patients presenting with acute failure usually have injuries
Injuries to the great vessels
of the valves or chordae tendineae, or have sustained inter-
ventricular septal defects, but represent less than 2 per Injuries to the great vessels from penetrating forces are
cent of the total number of patients with cardiac injuries. infrequently reported. According to Rich, before the
Pericardiocentesis is not a very useful diagnostic technique Vietnam War there were fewer than 10 cases in the sur-
but may be temporarily therapeutic. In cases where the gical literature.12,13 The reason for this is that extensive
diagnosis of pericardial tamponade cannot be confirmed injury to the great vessels results in immediate exsanguin-
on clinical signs, an echocardiogram is useful. ation into the chest, and most of these patients die at the
The treatment of all cardiac injuries is immediate thora- scene of injury.
cotomy, ideally in the operating room. In the patient who The diagnosis of penetrating great vessel injury is usu-
is in extremis, thoracotomy in the emergency department ally obvious. The patient is in shock, and there is an injury
can be life-saving. The great majority of wounds can be in proximity to the thoracic outlet or posterior medi-
closed with simple sutures or horizontal mattress sutures astinum. If the patient stabilizes with resuscitation, an
of a 3/0 or 4/0 monofilament. Bolstering the suture with arteriogram should be performed to localize the injury.
Teflon pledgets may occasionally be required, particularly Approximately 8 per cent of patients with major vascular
if there is surrounding contusion, or there is proximity injuries do not have clinical signs, stressing the need for
of the wound to a coronary artery. If the stab wound or arteriograms when there is a wound in proximity. These
gunshot wound is in proximity to the coronary artery, patients usually have a false aneurysm or arteriovenous
care must be taken not to suture the vessels. This can be fistula. Treatment of penetrating injuries to the great
achieved by passing horizontal mattress sutures beneath vessels can almost always be accomplished using lateral
the coronary vessels, avoiding ligation of the vessel. repair, since larger injuries that might necessitate grafts
are usually incompatible with survival long enough to Flail chest

permit the patient to reach the emergency department Traditionally, flail chest has been managed by internal
alive.14,15 splinting (internal pneumatic stabilization). While this
Complications of injuries to the great vessels include is undoubtedly the method of choice in most instances,
rebleeding, false aneurysm formation and thrombosis. there has been increasing interest in the open reduction
A devastating complication is paraplegia, which usually and fixation of multiple rib fractures.16 In uncontrolled
occurs following blunt injuries but rarely after penetrat- trials, there have been considerable benefits shown, with a
ing injuries, either because of associated injury to the shortening of hospital time and improved mobility.
spinal cord, or because at the time of surgery important A flail chest may be stabilized using pins, plates, wires,
intercostal arteries are ligated. The spinal cord has a seg- rods or, more recently, absorbable plates. Exposure for the
mental blood supply to the anterior spinal artery, and insertion of these can be via a conventional posterolateral
every effort should be made to preserve the intercostal thoracotomy, or via incisions made over the ribs.
vessels, particularly those which appear to be larger than
normal. Diaphragmatic injuries
Diaphragmatic injuries occur in approximately 6 per cent of
Oesophageal injuries
patients with mid-torso injuries from penetrating trauma.
Penetrating injuries to the thoracic oesophagus are quite The left diaphragm is injured more commonly than the
uncommon. Injuries to the cervical oesophagus are some- right. The diaphragm usually rises to the fifth intercostal
what more frequent and are usually detected at the time of space during normal expiration, so that any patient with a
exploration of zone I and II injuries of the neck. In those mid-torso injury is at risk of a diaphragmatic injury.
centres where selective management of neck injuries is The diagnosis of penetrating injury to the diaphragm
practised, the symptoms found are usually related to pain is less problematic than injury from blunt trauma.
on swallowing and dysphagia. Occasionally, patients may Typically, the patient has a wound in proximity, and the
present late with signs of posterior mediastinitis. Injuries surgeons decision is how best to assess the diaphragm.
to the thoracic oesophagus may present with pain, fever, Thoracoscopy is a good method because it is so easy to vis-
pneumomediastinum, persistent pneumothorax in spite ualize the diaphragm from above. However, thoracoscopy
of tube thoracostomy, and pleural effusion with extra does not allow the assessment or repair of intra-abdom-
vasation of contrast on a Gastrografin swallow. inal organs. Laparoscopy has an additional advantage
Treatment of cervical oesophageal injuries is relatively in that it is possible to assess intraperitoneal organs as
straightforward. As noted above, the injury is usually well as the diaphragm for injury. However, laparoscopy
found during routine exploration of penetrating wounds has not withstood the degree of specificity and sensitivity
beneath the platysma. Once found, a routine closure is necessary for it to be the method of choice (see Chapter
performed. In more devitalizing injuries, it may be neces- 13, Minimally invasive surgery in trauma).
sary to debride and close using drainage to protect the Optimally, all diaphragmatic injuries should be
anastomosis. Injuries to the thoracic oesophagus should repaired, even small penetrating puncture wounds of no
be repaired if the injury is less than 6 hours old and there apparent importance. Those injuries that are not repaired
is minimal inflammation and devitalized tissue present. A will present late, usually with incarceration of the small
two-layer closure is all that is necessary. Postoperatively, bowel, colon or omentum into the hernia defect. The
the patient is kept on intravenous support and supple- preferred closure of diaphragmatic injuries is with an
mental nutrition. Antibiotics may be indicated during the interrupted non-absorbable suture. The use of synthetic
24-hour perioperative period. material to close large defects from high-velocity missile
If the wound is between 6 and 24 hours old, a decision injuries or shotgun blasts is only rarely indicated.
will be necessary to determine whether primary closure The complications of injuries to the diaphragm are
can be attempted or whether drainage and nutritional primarily related to late diagnosis with hernia formation
support is the optimal management. Almost all injuries and incarceration. Phrenic nerve palsy is another compli-
older than 24 hours will not heal primarily when repaired. cation, but this is uncommon after penetrating trauma.
Open drainage, antibiotics, nutritional support and con-
sideration of diversion are the optimal management. Complications
Complications following oesophageal injuries include As noted in the Preface, the lung is a target organ for reper-
wound infection, mediastinitis and empyema. fusion injury, and any injury to the viscera within the thorax
The chest | 85
can result in impaired oxygen transport. The lungs are at It is also important to differentiate between:
high risk from aspiration, which can accompany shock or
Patients with no signs of life
substance abuse, and is often associated with penetrating
injuries. Finally, pulmonary sepsis is one of the more com- Patients with no vital signs in whom pupillary
mon sequelae following major injuries of any kind. activity and/or respiratory effort is still evident.
Obviously, the results of EDT in these two circumstances

will differ. This section concentrates on the thoracoto-
6.1.8Emergency department thoracotomy mies performed by the surgeon in those patients who
present in extremis in the resuscitation area.
Rapid emergency medical response times and advances
in pre-hospital care have led to increasing numbers of
6.1.8.1 Objectives
patients arriving in resuscitation in extremis. Salvage of
these patients often demands immediate control of haem- The primary objectives of EDT in this set of circum-
orrhage and desperate measures to resuscitate them. This stances are to:
has often been attempted in hopeless situations, following
Release cardiac tamponade
both blunt and penetrating injury, and failure to under-
stand the indications and sequelae will almost inevitably Control intrathoracic bleeding
result in the death of the patient. With the increasing Control air embolism or bronchopleural fistula
financial demands on medical care, and the increasing risk Permit open cardiac massage
of transmission of communicable diseases, a differentia- Allow for temporary occlusion of the descending
tion must be made between the true EDT and futile care. aorta to redistribute blood to the upper body and
In 1874, Schiff described open cardiac massage, and in possibly limit subdiaphragmatic haemorrhage.
1901, Rehn sutured a right ventricle in a patient present- Emergency department thoracotomy has been shown
ing with cardiac tamponade. The limited success of EDT to be most productive in life-threatening penetrating
in most circumstances, however, prohibited the use of the cardiac wounds, especially when cardiac tamponade is
technique for the next six or seven decades. A revival of present. Patients requiring EDT for anything other than
interest occurred in the 1970s, when the procedure was isolated penetrating cardiac injury rarely survive, even in
initially revived by Ben Taub General Hospital in Houston established trauma centres. The outcome in the field is
for the treatment of cardiac injuries. It has subsequently even worse. Indications for the procedure in military prac-
been applied as a means of temporary aortic occlusion in tice are essentially the same as in civilian practice.
exsanguinating abdominal trauma. More recently, there
Emergency department thoracotomy (EDT) and the
has been decreased enthusiasm and a more selective
necessary rapid use of sharp surgical instruments, as well
approach, particularly with respect to blunt trauma.
as exposure to the patients blood, poses certain risks to
It must be noted that there is an extremely high mor- the resuscitating surgeon. Contact rates of patients blood
tality rate associated with all thoracotomies performed to the surgeons skin approximate to 20 per cent. Human
anywhere outside the operating theatre, especially when immunodeficiency virus rates among the patient popula-
performed by non-surgeons. tion at the Johannesburg Hospital Trauma Unit in South
It is also important early on to differentiate between the Africa have risen from 6 per cent in 1993 to 50 per cent in
definitions of thoracotomy: 2000. There are additional risks from other blood-borne
Thoracotomy performed in the emergency pathogens, such as hepatitis C. The use of universal pre-
department (EDT) for patients in extremis cautions and the selective use of EDT is essential to mini-
To control haemorrhage mize this risk.
To control the aortic outflow (aortic cross-
clamping) 6.1.8.2Indications and contraindications
To perform internal cardiac massage
There are instances where EDT has been shown to have
Planned resuscitative thoracotomy, i.e. in the
clear benefit. These indications include:
operating theatre or intensive care unit minutes to
hours after injury in acutely deteriorating patients for Those patients in whom there is a witnessed arrest
control of haemorrhage. and a high likelihood of isolated intrathoracic injury,
especially penetrating cardiac injury (salvageable on admission. A decision-making algorithm has been
post-injury cardiac arrest) formulated based on these findings, and the four factors
Those with severe post-injury hypotension (blood found to be most predictive of outcome following EDT
pressure <60mmHg) due to cardiac tamponade, air are reported to be:
embolism or thoracic haemorrhage.
Absence of signs of life at the scene
Less clear benefit occurs for: Absence of signs of life in the emergency department
Patients presenting with moderate post-injury Absence of cardiac activity at EDT
hypotension (blood pressure <80mmHg) potentially Systolic blood pressure less than 70mmHg after
due to intra-abdominal aortic injury (e.g. an epigastric aortic occlusion.
gunshot wound)
At the scene, patients in extremis and without cardiac
Major pelvic fractures
electrical activity are declared dead. Those with electrical
Active intra-abdominal haemorrhage.
activity are intubated, supported with CPR and trans-
The first group of patients constitutes those in whom ferred to the emergency department. If blunt injury is
EDT is relatively indicated. One must consider the present, EDT is embarked on only if pulsatile electrical
patients age, pre-existing disease, signs of life and injury activity is present. (In penetrating trauma, all patients
mechanism, as well as the proximity of the emergency undergo EDT.) If no blood is present in the pericar-
department to the operating theatre and the personnel dial cavity and there is no cardiac activity, the patient is
available, when applying the principles related to EDT. declared dead. All others are treated according to the type
Although optimal benefit from the procedure will be of injury, as above. Those with intra-abdominal injury
obtained with an experienced surgeon, in cases where who respond to aortic occlusion with a systolic blood
a moribund patient presents with a penetrating chest pressure of more than 70mmHg and all other surviving
wound, the emergency physician should not hesitate to patients are rapidly transported to the operating theatre
perform the procedure. for definitive treatment.
EDT is contraindicated:
When there has been cardiopulmonary resuscitation 6.1.8.4When to stop EDT

(CPR) in the absence of endotracheal tube intubation
in excess of 5 minutes Emergency department thoracotomy is a team event. It
When there has been CPR for more than 10 minutes should not be prolonged unduly but should have spe-
with or without endotracheal tube intubation cific end points. If an injury is repaired and the patient
In cases of blunt trauma, when there have been no responds, he or she should be moved to the operating
signs of life at the scene or only pulseless electrical room for definitive repair or closure.
activity is present in the emergency department. EDT should be terminated if:
Irreparable cardiac damage has occurred

6.1.8.3Results The patient is identified as having massive head
injuries
The results of EDT vary according to the injury mechanism
Pulseless electrical activity is established
and location and to the presence of vital and life signs.
Emergency department thoracotomy has been shown Systolic blood pressure is less than 70mmHg after 20
to be beneficial in around 50 per cent of patients present- minutes
ing with signs of life after isolated penetrating cardiac Asystolic arrest has occurred.
injury, and only rarely in those patients presenting with-
out signs of life (<2 per cent). With non-cardiac penetrat-
6.1.8.5Conclusion
ing wounds, 25 per cent of patients benefit when signs of
life and detectable vital signs are present, compared with Success in the management of thoracic injury in those
8 per cent of those with signs of life only and 3 per cent of cases requiring operation lies in rapid access to the tho-
those without signs of life. racic cavity with good exposure. Thus, good lighting,
Only 12 per cent of patients requiring EDT are sal- appropriate instrumentation, functioning suctioning
vaged after blunt trauma regardless of their clinical status apparatus and a controlled, aggressive but calm frame of
The chest | 87
mind on the part of the surgeon will result in acceptable, after proper evaluation and work-up has clearly identified
uncomplicated survival figures. the nature of the injury.
If time permits in the more stable patient, intubation (or
reintubation) with a double-lumen endotracheal tube, to
6.1.9Surgical approaches to the thorax allow selective deflation or ventilation of each lung, can be
very helpful and occasionally life-saving.
The choice of approach to the injured thorax should be It is seldom necessary to resort to the remaining
determined by three factors: approaches in the acute situation. The bilateral trans-
sternal thoracotomy (the clamshell incision) is some-
The hemithorax and its contents
what mutilating, with significant postoperative morbidity
The stability of the patient
and difficulty in terms of access and closure. The trap-
Whether the indication for surgery is acute or chronic
door incision is obsolete.
(non-acute).
A useful distinction can be made with respect to indi-

cations (Table 6.1). It will be noted that the acute indica- 6.2Access TO THE THORAX
tions include all acutely life-threatening situations, while
the chronic or non-acute indications are essentially late 6.2.1Anterolateral thoracotomy
presentations.
This is the approach of choice in most unstable patients
Table 6.1 Indications for surgery in the thorax and is utilized for EDT (Figure 6.13):
Acute indications Chronic indications This approach allows rapid access to the injured
hemithorax and its contents.
Cardiac tamponade Unevacuated clotted haemothorax
It is made with the patient in the supine position with
Acute deterioration Chronic traumatic diaphragmatic
no special positioning requirements or instruments.
hernia
It has the advantages that it:
Vascular injury at the thoracic Traumatic atrioventricular fistula
May be extended across the sternum into the
outlet
contralateral hemithorax (the clamshell incision
Loss of chest wall substance Traumatic cardiac septal or valvular or bilateral thoracotomy)
lesions
May be extended downwards to create a
Endoscopic or radiological Missed tracheobronchial injury or thoracoabdominal incision.
evidence of tracheal, oesophagus tracheo-oesophageal fistula
or great vessel injury This is the approach of choice in injury to any part of
Massive or continuing Infected intrapulmonary
the left thorax or an injury above the nipple line in the
haemothorax haematoma Anterolateral thoracotomy
Bullet embolism to the heart/
pulmonary artery
Penetrating mediastinal injury
The surgical approaches in current use include:
Anterolateral thoracotomy
Median sternotomy Mid-axillary line
Bilateral thoracotomy (clamshell incision)
The trapdoor incision Internal thoracic
Posterolateral thoracotomy. artery
In the unstable patient, the choice of approach usually will

be an anterolateral thoracotomy or median sternotomy,
depending upon the suspected injury. In the case of the
stable patient, the choice of approach must be planned Figure 6.13 Anterolateral thoracotomy.
right thorax. It should be noted that right lower thoracic 6.2.2 Median sternotomy
injuries (i.e. below the nipple line) usually involve bleed-
ing from the liver; the approach in these cases should This incision is the approach of choice in patients with a
initially be a midline laparotomy, the chest being entered penetrating injury at the base of the neck (zone I) and the
only if no source of intra-abdominal bleeding is found. thoracic outlet, as well as to the heart itself. It allows access
to the pericardium and heart, the arch of the aorta and the
6.2.1.1Technique origins of the great vessels. It has the attraction of allow-
ing upwards extension into the neck (as a Henrys inci-
A slight tilt of the patient to the right is advisable; this is sion), extension downwards into a midline laparotomy, or
achieved by use of either a sandbag or other support, or lateral extension into a supraclavicular approach (Figure
by tilting the table. 6.14). It has the relative disadvantage of requiring a sternal
The incision is made through the fourth or fifth inter- saw or chisel (of the Lebsche type). In addition, the infre-
costal space from the costochondral junction anteriorly quent but significant complication of sternal sepsis may
to the mid-axillary line posteriorly, following the upper occur postoperatively, especially in the emergency setting.
border of the lower rib in order to avoid damage to the
intercostal neurovascular bundle.
6.2.2.1Technique
The muscle groups are divided down to the periosteum
of the lower rib. The muscle groups of the serratus ante- The incision is made with the patient fully supine, in the
rior posteriorly and the intercostals medially and anteri- midline from the suprasternal notch to below the xiphoid
orly are divided. The trapezius and the pectoralis major cartilage. A finger-sweep is used to open spaces behind the
are avoided. Care should be taken at the anterior end of sternum, above and below. Excision of the xiphoid carti-
the incision, where the internal mammary artery runs and lage may be necessary if this is large and intrusive, and can
may be transected. be done with heavy scissors.
The periosteum is opened, leaving a cuff of approxi- Split section (bisection) of the sternum is carried out
mately 5mm for later closure. The parietal pleura is then with a saw (either oscillating or a braided-wire Gigli saw)
opened, taking care to avoid the internal mammary artery or a Lebsche knife, commencing from above and moving
adjacent to the sternal border. These vessels are ligated if downwards. This is an important point to avoid inadvert-
necessary. ent damage to vascular structures in the mediastinum. In
A Finochietto retractor is placed with the handle away addition, be aware of the possible presence of the large
from the sternum (i.e. laterally placed), the ribs are spread, transverse communicating vein, which may be found in
and intrathoracic inspection for identification of injuries the areolar tissue of the suprasternal space of Burns, and
is carried out after suctioning. In cases of ongoing bleed- must be controlled.
ing, an autotransfusion suction device is advisable.
Median sternotomy
Note that it is important to identify the phrenic nerve
in its course across the pericardium if this structure is to
be opened the pericardiotomy is made 1cm anterior and
vertical to the nerve trunk in order to avoid damage and Extension into the neck
subsequent morbidity.
6.2.1.2Closure
Following definitive manoeuvres, the anterolateral tho-

racotomy is closed in layers over one or two large-bore
intercostal tube drains and after careful haemostasis and
copious lavage.
The ribs and intercostal muscles should be closed Extension for

with synthetic absorbable sutures. laparotomy
Closure of discrete muscle layers reduces both pain
and long-term disability.
The skin is routinely closed. Figure 6.14 Median sternotomy.
The chest | 89
6.2.2.2Closure
The pericardium is usually left open or only partially

closed. It is advisable to close the pericardium with an
absorbable suture to avoid adhesion formation.
Two mediastinal tube drains are brought out through Medial third of clavicle
epigastric incisions.
Closure of the sternotomy is made with horizontal
sternal wires or encircling heavy non-absorbable
suture (braided, non-absorbable).
Closure of the linea alba should be by non-absorbable
suture.
6.2.3The clamshell thoracotomy
The clamshell is essentially a bilateral fourth or fifth

interspace thoracotomy, linked by division of the sternum,
which allows the chest to be opened very widely anteriorly.
Care should be taken to ligate the internal mammary Figure 6.15 Trapdoor incision.
arteries, and to ensure haemostasis prior to closure.
The incision is particularly effective in those situations
where it is important to achieve rapid access to the oppo- Closure too is time-consuming. A median sternotomy
site side of the chest, especially posteriorly, such as for: with extension of the incision into the neck will provide
more rapid and efficient exposure of injury in this region.
Transmediastinal injury
Lung injury
Injury on the right, where aortic control may be
6.3Emergency department
necessary.
thoracotomy
6.3.1Requirements
6.2.4 Posterolateral thoracotomy
The numbers of instruments and types of equipment
This approach requires appropriate positioning of the
necessary to perform EDT do not even begin to approach
patient and is usually used in the elective setting for
those used for formal thoracotomy in the operating thea-
definitive lung and oesophageal surgery. It is not usually
tre and really include only the following:
employed in the acute setting. It is more time-consuming
in approach and closure, since the bulkier muscle groups A scalpel, with a #20 or #21 blade
of the posterolateral thorax are traversed, and scapular Forceps
retraction is necessary. A suitable retractor such as Finochiettos chest
retractor or a Balfour abdominal retractor
A Lebsche knife and mallet or Gigli saw for the sternum
6.2.5 Trapdoor thoracotomy Large vascular clamps such as Satinski vascular
clamps (large and small)
The incision is considered obsolete. This is a combination of Mayo scissors
an anterolateral thoracotomy, a partial sternotomy and an Metzenbaum scissors
infra- or supraclavicular incision with resection or disloca- Long needle-holders
tion of the clavicle (Figure 6.15). It has the disadvantages Internal defibillator paddles
of being relatively more time-consuming, and retraction of Sutures, swabs and Teflon pledgets
the bony trapdoor created is often difficult, resulting in Sterile skin preparation and drapes
multiple fractures of the ribs laterally or posteriorly. Good light.
6.3.2Approach Cardiac bleeding points on the ventricle are initially

managed with digital pressure, and those on the atria and
Two basic incisions are used in EDT. These are applied great vessels by partially occluding vascular clamps. If
according to the best incision for the particular injury the heart is beating, repair should be delayed until initial
suspected (based on the entrance and exit wounds, resuscitation measures have been completed. If it is not
the trajectory and the most likely diagnosis from clini- beating, suturing precedes resuscitation.
cal examination), and may be extended in various ways Foley catheters may be used to temporarily control
according to need. haemorrhage prior to definitive repair in the emergency
Routine immediate resuscitation protocols as per the department or operating theatre. A Foley catheter with a
ATLS are instituted, and once indications for EDT have 30mL balloon is preferable. Once it has been placed, great
been fulfilled, EDT should follow without delay. care should be taken not to exert too much traction on the catheter
Pitfall: If the conditions are not fulfilled, you are embarking as it will easily tear out, making the hole dramatically bigger.
upon futile care. Suturing of the right ventricle requires the placement
The left anterolateral thoracotomy is the most common of Teflon pledgets, which are utilized selectively on the
site for urgent access. The incision is placed in the fifth left ventricle using a horizontal mattress suture under the
intercostal space through muscle, periosteum and pari- coronary vessels to avoid trauma to or occlusion of the
etal pleura from the costochondral junction anteriorly to coronary vessels. Low-pressure venous and atrial wounds
the mid-axillary line laterally following the upper border can be repaired with simple continuous sutures. Posterior
of rib, and care is taken to avoid the internal mammary wounds are more difficult as they necessitate elevation of
artery. This incision can be extended as a bilateral incision the heart before their closure, which can lead to further
requiring horizontal division of the sternum and ligation haemodynamic compromise. With large wounds of the
of the internal mammary vessels bilaterally. It affords ventricle or inaccessible posterior wounds, temporary dig-
excellent access to both pleural cavities, pericardial cavity ital inflow occlusion might be necessary to facilitate repair.
and even the abdominal cavity if required. The incision After initial repair, fluids are best slowed down to limit
also may be extended cranially in the midline by dividing further bleeding (the concept of hypotensive resuscita-
the sternum for penetrating wounds involving the medi- tion), aiming for critical organ perfusion while minimiz-
astinal structures. The same incision may be employed ing additional haemorrhage (i.e. a blood pressure of about
on the right side in hypotensive patients with penetrat- 85mmHg). The patient is best transferred to the operat-
ing right chest trauma in whom massive blood loss or air ing theatre, where repair of the injury and closure of the
embolism is suspected. This, too, may be extended trans- access procedure is carried out under controlled circum-
sternally if a cardiac wound is discovered. stances with adequate resources.
The median sternotomy affords the best exposure to the
anterior and middle mediastinum, including the heart and
6.3.3.2 Pulmonary haemorrhage
great vessels, and is typically advocated for penetrating
wounds, particularly of the upper chest between the nip- Access is best achieved by anterolateral thoracotomy on
ples. This can be extended supraclavicularly for access to the appropriate side. With localized bleeding sites, con-
control subclavian and brachiocephalic vascular injuries. trol can be achieved with vascular clamps placed across
the affected segment. The affected segment is then dealt
with, preferably in controlled circumstances in the oper-
6.3.3Emergency procedures ating theatre by local oversewing, segmental resection or
pulmonary tractotomy.
Pulmonary tractotomy is a means of controlling tracts
6.3.3.1Suspected cardiac injury and cardiac tamponade
that pass through multiple lung segments where the extent
Access is achieved via either lateral or midline sternotomy, of injury precludes pulmonary resection. It is a means of
the former allowing more rapid access, the latter approach non-anatomical lung preservation in which linear staplers
ensuring better exposure. It is important to identify the are passed along both sides of the tract formed, and the
phrenic nerve prior to opening the pericardium at least lung is divided to allow blood vessels and airways in the
1cm anterior to this structure. The pericardial incision is bases to be repaired; the divided edges are then oversewn.
initiated using either a knife or the sharp point of a pair With massive haemorrhage from multiple or indetermi-
of scissors, and blood and clots are evacuated. nate sites, or widespread destruction of lung parenchyma
The chest | 91
leaving large areas of non-viable tissue, hilar clamping It is important to examine the whole heart to localize
with a large soft vascular clamp across the hilar struc- the source of bleeding.
tures occluding the pulmonary artery, pulmonary vein Deal with the source of bleeding.
and main-stem bronchus is employed until a definitive It is not essential to close the pericardium after the
surgical procedure can be performed. procedure.
Air embolism is controlled by placing a clamp across If the pericardium is closed, it should be drained to
the hilar structures, and air is evacuated by needle aspira- avoid a recurrent tamponade.
tion of the elevated left ventricular apex.
6.3.4.2 Myocardial laceration
6.3.3.3Thoracotomy with aortic cross-clamping
Wherever possible, initial control of a myocardial
This technique is employed to optimize oxygen transport laceration should be digital, while the damage is assessed.
to vital proximal structures (the heart and brain), maximize Use 3/0 or 4/0 non-absorbable braided sutures tied
coronary perfusion and possibly limit infradiaphragmatic gently to effect the repair. Pledgets may be helpful.
haemorrhage in both blunt and penetrating trauma. Care should be exercised near coronary arteries.
The thoracic aorta is cross-clamped inferior to the left Whereas a vertical mattress suture is normally
pulmonary hilum, and the area is exposed by elevating acceptable, it may be necessary to use a horizontal
the left lung anteriorly and superiorly. The mediastinal mattress suture under the vessel to avoid occluding it.
pleura is dissected under direct vision, the aorta being In inexperienced hands, and as a temporizing measure,
separated by blunt dissection from the oesophagus ante- a skin stapler will allow control of the bleeding, with
riorly and the prevertebral fascia posteriorly. When prop- minimal manipulation of the heart. Pitfall: Staples often
erly exposed, the aorta is occluded using a large vascular eventually tear out, so the repair should not be regarded as
clamp. It is important that the aortic cross-clamp time definitive.
be kept to the absolute minimum, i.e. that the clamp is
removed once effective cardiac function and systemic arte-
rial pressure have been achieved, as the metabolic penalty 6.3.4.3Hilar clamping
rapidly becomes exponential once beyond 30 minutes. Wide anterolateral thoracotomy is the exposure of choice.
A vascular clamp can be placed across the hilum,
6.3.3.4Bilateral trans-sternal (CLAMSHELL) occluding the pulmonary artery, vein and main-stem
thoracotomy bronchus.
This is the thoracic equivalent of the chevron or bucket
handle upper abdominal incision, providing wide expo- 6.3.4.4Lobectomy or pneumonectomy
sure to both hemithoraces. It is relatively time-consuming
in terms of both access and closure. It may be argued that This is rarely performed, and usually done to control
median sternotomy will provide the same degree of expo- massive haemorrhage from the pulmonary hilum.
sure with greater ease of access and closure. It is usually Lung preservation should be attempted wherever possible.
necessary to use this incision only when it becomes neces- A double-lumen endotracheal tube should be used
sary to gain access to both hemithoraces. whenever possible.
The incision usually extends as a fifth intercostal space For segmental pneumonectomy, use of the GIA stapler
anterolateral thoracotomy, across the sternum. The ster- is helpful. The staple line can then be oversewn.
num is divided using a Gigli saw, chisel or bone-cutting for-
ceps. Care is taken to ligate the internal mammary arteries. 6.3.4.5 Pulmonary tractotomy
This is used where the injury crosses more than one

6.3.4Definitive procedures segment, commonly caused by a penetrating injury.
Anatomical resection may not be possible.
Linear staplers can be introduced along both sides of
6.3.4.1 Pericardial tamponade the tract, the tract being divided and then oversewn.
Open the pericardium in a cranial to caudal direction, This procedure is also helpful in damage control of
anterior to the phrenic nerve. the chest.
6.3.4.6Aortic injury 5 Moreno C, Moore EE, Majure JA et al. Pericardial

tamponade: a critical determinant for survival following
Most patients with these injuries do not survive to
penetrating cardiac wounds. J Trauma 1986;26:8216.
reach hospital.
6 Millham FH, Grindlinger GA. Survival determinants in
Cardiopulmonary bypass is preferable in order to
patients undergoing emergency room thoracotomy for
avoid paraplegia.
penetrating chest injury. J Trauma 1993;34:3327.
7 Pate JW. Chest wall injuries. Surg Clin North Am
6.3.4.7 Oesophageal injury 1989;69:5968.
8 Symbas PN, Hatcher CR Jr, Vlasis SE. Bullet wounds of the
Surgical repair is mandatory.
trachea. J Thorac Cardiovasc Surg 1982;83:23540.
Two-layer repair (mucosal and muscular) is preferable.
9 Yee ES, Verrier ED, Thomas AN. Management of air
If possible, the repair should be wrapped in
embolism in blunt and penetrating thoracic trauma.
autogenous tissue.
JThorac Cardiovasc Surg 1983;85:6617.
A feeding gastrostomy is preferable to a nasogastric
10 Mattox KL, Feliciano DV, Beall AC et al. 5,760 cardiovascular
tube through the area of repair, and the stomach
injuries in 4,459 patients: epidemiologic evolution 1958
should be drained.
1988. Ann Surg 1989;209:698706.
A cervical oesophagostomy may be required.
11 Ivatury RR, Rohman M, Steichen FM et al. Penetrating cardiac
injuries: 20 year experience. Am Surg 1987;53:31017.
6.3.4.8Tracheobronchial injury 12 Rich NM, Spencer FC. Injuries of the intrathoracic branches
of the aortic arch. In: Rich NM, Spencer FC, eds. Vascular
Flexible bronchoscopy is very helpful in assessment.
Trauma. Philadelphia: WB Saunders, 1978: 287306.
Formal repair should be undertaken under ideal
13 Rich NM, Baugh JH , Hughes CW. Acute arterial injuries in
conditions, with removal of devitalized tissue.
Vietnam: 1,000 cases. J Trauma 1970;10:35967.
14 Pate JW, Cole FH, Walker WA, Fabian TC. Penetrating
injuries of the aortic arch and its branches. Ann Thor Surg
6.4Summary 1993;55:58691.
15 Mattox KL. Approaches to trauma involving the major
The success in the management of thoracic injury in those vessels of the thorax. Surg Clin North Am 1989;69:7787.
cases requiring operation lies in the team approach, with 16 Blaisdell W, Trunkey D. Cervical thoracic trauma. In: Chest
good anaesthesia and rapid access to the thoracic cavity with Wall Injuries. New York: Thieme, 1994:190214.
good exposure. Thus, good lighting, appropriate instrumen-
tation, functioning suction apparatus and a controlled, 6.6Recommended reading
aggressive but calm frame of mind on the part of the team
will result in acceptable, uncomplicated survival figures. Asensio JA, Garcia Nunez LM, Petrone P. Trauma to the heart.
In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma, 6th
edn. New York: McGraw-Hill, 2008: 56988.
6.5References Livingston DH, Hauser CJ. Trauma to the chest wall and lung. In:
Moore EE, Feliciano DV, Mattox KL, eds. Trauma, 6th edn.
1 Baker CC, Oppenheimer L, Stephens B et al. Epidemiology New York: McGraw-Hill, 2004: 52552.
of trauma deaths. Am J Surg 1980;140:14450. Mattox KL. Thoracic injury requiring surgery. World J Surg
2 Mancini M, Smith LM, Nein A, Buechler KJ. Early evacuation 1982;7:4752.
of clotted blood and haemothorax using thoracoscopy: Mattox KL. Indications for thoracotomy: deciding to operate.
case reports. J Trauma 1993;34:1449. Surg Clin North Am 1989;69:4756.
3 Fallon WF, Wears RL. Prophylactic antibiotics for the Mattox KL, Wall MJ, LeMaire SA. Thoracic great vessel injury. In:
prevention of infectious complications including empyema Feliciano DV, Mattox KL, Moore EE, eds. Trauma, 6th edn.
following tube thoracotomy for trauma: results of meta- New York: McGraw-Hill, 2008: 589606.
analysis. J Trauma 1991;33:11017. Wall MJ, Huh J, Mattox KL. Thoracotomy. In: Feliciano DV,
4 Graeber GM, Jones DR. The role of thoracoscopy in thoracic Mattox KL, Moore EE, eds. Trauma, 6th edn. New York:
trauma. Ann Thorac Surg 1993;56:64651. McGraw-Hill, 2008: 51324.
The abdomen 7
7.1The trauma laparotomy and the definitive surgical treatment for abdominal
trauma:
Surgical resuscitation includes the technique of

7.1.1 Overview
damage control, and implies only that the surgical
procedure is necessary to save life by stopping
Delay in the diagnosis and treatment of abdominal inju-
bleeding and preventing further contamination
ries is one of the most common causes of preventable
or injury, but is restricted due to the patients
death from blunt or penetrating trauma. Approximately
physiological derangement.
20 per cent of abdominal injuries will require surgery. In
Definitive surgical treatment implies that the
the UK, Europe and Australia, the trauma is predomi-
physiological state of the patient allows the definitive
nantly blunt in nature, while in the military context, and
surgical repair to take place.
in civilian trauma in South Africa, South America and the
larger US cities, it is predominantly penetrating. During resuscitation, standard Advanced Trauma Life
The diagnosis of injury following blunt trauma can be Support (ATLS) guidelines should be followed. These
difficult, and knowledge of the injury mechanism can be should include:
helpful. Passenger restraints can themselves cause blunt
Nasogastric tube or orogastric tube
trauma to the liver and duodenum or pancreas, and rib frac-
Urinary catheter.
tures can cause direct damage to the liver or spleen. Virtually
all penetrating injury to the abdomen should be addressed
promptly, especially in the presence of hypotension: 7.1.1.1Difficult abdominal injury complexes
Blood is not initially a peritoneal irritant, and There are at least four complex abdominal injuries:
therefore it may be difficult to assess the presence or
Major liver injuries. Management of hepatic injuries
quantity of blood present in the abdomen.
is difficult, and experience in dealing with these
Bowel sounds may remain present for several hours
injuries can obviously lead to a better outcome. With
after abdominal injury, or may disappear soon after
improvements in CT scanning, there has been a recent
trivial trauma. This sign is therefore particularly
increase in the confidence of surgeons to treat adult
unreliable.
solid organ injury conservatively. Laparotomy for major
Diagnostic modalities depend on the nature of the injury: liver injury is technically demanding for the general
surgeon, and the principles of appropriate mobilization
Physical examination
and packing are the mainstay of treatment.
Ultrasound focused abdominal sonography for
Pancreaticoduodenal injuries. These are challenging
trauma (FAST)
because of the difficulties in diagnosis, and because of
Computed tomography (CT) scanning (stable patients
associated retropancreatic vascular injuries, which are
only)
difficult to access. Missed injuries lead to a significant
Diagnostic peritoneal lavage
morbidity and mortality.
Diagnostic laparoscopy.
Aortic and vena caval injuries. These are difficult,
It is important to appreciate the difference between because access to these injuries and control of
abdominal surgery as part of the resuscitation process, haemorrhage from them are especially problematic.
Complex pelvic injuries with associated open pelvic injury. Upper midline central retroperitoneal haematomas
These are particularly difficult to treat, and are must be explored to rule out underlying duodenal, pancre-
associated with a high mortality. atic or vascular injuries. It is wise to ensure that proximal
and distal control of the aorta and distal control of the
Damage control approaches to these injuries may dramatically
inferior vena cava (IVC) can be rapidly achieved, before the
improve survival.
haematoma is explored.
7.1.1.2The retroperitoneum
7.1.1.3Non-operative management of penetrating
Injuries to retroperitoneal structures are associated with abdominal injury
a high mortality and are often underestimated or missed.
Rapid and efficient access techniques are required to deal Although there is universal agreement that patients with
with exsanguinating vascular injuries, where large retro- peritonitis or haemodynamic instability should undergo
peritoneal haematomas often obscure the exact position urgent laparotomy after penetrating injury to the abdo-
and extent of the injury. men, it is also clear that certain stable patients without
The retroperitoneum is explored when major abdomi- peritonitis may be managed without operation.
nal vascular injury is suspected, or there is injury to the A recent review has concluded that routine laparotomy
kidneys, ureters and renal vessels, pancreas, duodenum is not indicated in haemodynamically stable patients
and colon. Because of the high incidence of intraperito- with abdominal stab wounds without signs of peritonitis
neal and retroperitoneal injuries occurring simultane- or diffuse abdominal tenderness. Likewise, laparotomy
ously, the retroperitoneum is always approached via a is also not routinely indicated in stable patients with
transperitoneal incision. abdominal gunshot wounds if the wounds are tangential
The decision to explore a retroperitoneal haematoma and there are no peritoneal signs. Computed tomography
is based on its location and the mechanism of injury, and of the abdomen and pelvis may be helpful in deciding on
whether the haematoma is pulsating or rapidly enlarging. a non-operative trial of management. (See Sections 7.3,
The retroperitoneum is divided into: The liver and biliary system, and 7.4, The spleen, for the
non-operative management of solid organ injury.)
A central zone (zone 1) It is imperative that serial examination of these patients is
Two lateral zones (zone 2) undertaken in a meticulous fashion, and that the patient is sub-
A pelvic zone (zone 3). jected to laparotomy if there is any concern about the reliability of
If the haematoma is not expanding, other abdominal a non-operative approach.
injuries take priority. If the haematoma is expanding, it The majority of patients with penetrating abdominal
must be explored. Before the haematoma is opened, it trauma managed non-operatively may be discharged
is important to try to gain proximal and distal control after 24 hours of observation in the presence of a reliable
of vessels supplying the area. Direct compression with abdominal examination and minimal to no abdominal
abdominal swabs and digital pressure may help to buy tenderness. In addition, diagnostic laparoscopy may be
time while vascular control is being obtained. considered as a tool to evaluate diaphragmatic lacerations
Lateral haematomas need not be explored routinely, and peritoneal penetration in an effort to avoid unneces-
unless perforation of the colon is thought to have sary laparotomy (see Chapter 13, Minimally invasive sur-
occurred. The source of bleeding is usually the kidney, gery in trauma).
and unless expanding, the haematoma will probably not Eastern Association for the Surgery of Trauma Practice
require surgery. Management Guidelines submit the following evidence-
Pelvic haematomas should not be explored if it can based guidelines for the management of penetrating
be avoided. It is preferable to perform a combination of abdominal trauma (Table 7.1).1
external fixation on the pelvis and angiographic emboli-
zation. Attempts at tying the internal iliac vessels are usu-
7.1.2The trauma laparotomy
ally unsuccessful. Expanding pelvic haematomas should
be packed. Extraperitoneal packing is more effective than
The trauma laparotomy contains several essential parts:
intraperitoneal pelvic packing, and is advocated in unstable
patients with pelvic fractures who have had to undergo sur- Rapid entry
gical exploration for reasons of haemodynamic instability. Adequate (large) incision
The abdomen | 95
Table 7.1 Evidence-based guidelines for the management of penetrating injury of the abdomen
Level I There are no level I evidence-based guidelines

Level II Patients who are haemodynamically unstable or who have diffuse abdominal tenderness after penetrating abdominal trauma should be
taken emergently for laparotomy
Patients with an unreliable clinical examination (i.e. severe head injury, spinal cord injury, severe intoxication or need for sedation or
intubation) should be explored or further investigation carried out to determine whether there is intraperitoneal injury
Others may be selected for initial observation. In these patients:
1.Triple-contrast (oral, intravenous and rectal contrast) abdominopelvic computed tomography should be strongly considered as a
diagnostic tool to facilitate initial management decisions as this test can accurately predict the need for laparotomy
2.Serial examinations should be performed, as physical examination is reliable in detecting significant injuries after penetrating trauma
to the abdomen. Patients requiring delayed laparotomy will develop abdominal signs
3.If signs of peritonitis develop, laparotomy should be performed
4.If there is an unexplained drop in blood pressure or haematocrit, further investigation is warranted
Level III The vast majority of patients with penetrating abdominal trauma managed non-operatively may be discharged after 24 hours of
observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness
Patients with penetrating injury to the right upper quadrant of the abdomen with injury to the right lung, right diaphragm and liver may
be safely observed in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness
Angiography and investigation for and treatment of diaphragm injury may be necessary as adjuncts to the initial non-operative
management of penetrating abdominal trauma
Mandatory exploration for all penetrating renal trauma is not necessary
Control of massive haemorrhage by: The antibiotics commonly recommended include a

Packing second-generation cephalosporin, or amoxycillin (amoxi-
Direct control cillin)/clavulanate. There is some evidence that aminogly-
Proximal + distal control (= source control) cosides should not be used in acute trauma, partly because
Identification of injuries of the shifts in fluids, which requires substantially higher
Control of contamination doses of aminoglycoside to reach the appropriate mini-
Reconstruction (if possible). mum inhibitory concentration, and partly because they
work best in an alkaline environment (traumatized tissue
being acidotic).
7.1.2.1Adjuncts
The administered dose should be increased twofold
Antibiotics2 to threefold, and repeated after every 10 units of blood
transfusion until there is no further blood loss. If intra-
Routine single-dose intravenous antibiotic prophylaxis
abdominal bleeding is significant, it may be necessary to
should be employed. Subsequent antibiotic policy will
give a further dose of antibiotic therapy intraoperatively,
depend on the intraoperative findings (Table 7.2).
due to dilution of the preoperative dose.
Table 7.2 Antibiotic prophylaxis in major abdominal injury

Temperature control
No pathology found No further antibiotics Temperature control is fundamental. Minimizing patient
Blood only No further antibiotics hypothermia by raising the operating room temperature
Small bowel or gastric Copious peritoneal wash-out to a higher than normal level, and warming the patient
contamination Continuation for 24 hours only with warm air blankets, warmed intravenous fluids and
Large bowel, minimal Copious peritoneal wash-out warmed anaesthetic gases, is very important.
contamination Continuation for 24 hours only Preparatory measures should be taken prior to com-
Large bowel, gross Copious peritoneal wash-out mencement of the procedure. These include warming
contamination 2472 hours of antibiotics of the operating theatre, warming of all fluids infused,
warming of anaesthetic gases and external warming
devices such as a Bair Hugger (Arizant International left of, the umbilicus, to avoid the falciform ligament.
Corporation, Eden Prairie, MN, USA). The incision is made from the xiphisternum to the pubis.
If necessary, this can be extended into a sternotomy, or
Blood collection and autotransfusion extended right or left as a thoracotomy for access to the
liver, diaphragm, etc. (Figure 7.1).
Preparations must be made for collection of blood and
In patients who have had significant previous surgery,
possible autotransfusion if indicated.
and in those with gross haemodynamic instability, a bilat-
eral subcostal (clamshell or chevron) incision can be
7.1.2.2Draping used; this extends from the anterior axillary line on each
side transversely across the midline just superior to the
In trauma, it is essential to be able to extend the access of
umbilicus.
the incision if required. All patients should therefore have
both thorax and abdomen prepared and draped to allow
access to the thorax, abdomen and groins if required
7.1.2.4 Procedure
(Figure 7.1).
A quick exploratory trauma laparotomy is performed to
identify any other associated injuries:
7.1.2.3Incision
1 As soon as the abdomen has been opened, scoop out
All patients undergoing a laparotomy for abdominal
as much blood as possible into a receiver. Do not use
trauma should be explored through a long midline inci-
a sucker at this time.
sion. The incision is generally placed through, or to the
2 Eviscerate the small bowel. Perform a rapid
exploration to ascertain whether there is an obvious
site of large-volume (audible!) bleeding. Assess the
midline structures where packing is inefficient the
aorta, IVC and mesentery, and if necessary control
with direct pressure or proximal control, e.g. on the
aorta. Massive haemoperitoneum must be controlled
before proceeding further with a laparotomy.
3 Perform absorptive packing using large dry
abdominal swabs, left unfolded initially:
3.1 Under the left diaphragm
3.2 In the left paracolic gutter
3.3 In the pelvis
3.4 In the right paracolic gutter
3.5 Into the subhepatic pouch
3.6 Above and lateral to the liver
3.7 Directly on any other bleeding area
Use dry swabs
Preferably keep the swabs folded as it is easier
to layer them into a cavity
Packing does not control arterial bleeding.
4 Allow the anaesthetist to achieve an adequate blood
pressure and to establish any lines required.
5 If the pelvis seems to be a major source of bleeding,
extraperitoneal pelvic packing should be performed.
6 Remove the abdominal packs, one at a time, starting
in the area least likely to be the site of the bleeding.
6.1 When the packs in the left upper quadrant are
Figure 7.1 Exploration of abdomen. Diagram showing the extent of removed, and if there is associated bleeding from
tissue preparation and draping prior to surgery. the spleen, a decision should be made on whether
The abdomen | 97
the spleen should be preserved or removed. 8 Replace the small intestine in the abdominal cavity
Avascular clamp placed across the hilum will with great care at the conclusion of the operation, and
allow temporary haemorrhage control. perform temporary abdominal closure as required.
6.2 When the packs are removed from the
Convert to a damage control procedure as appropriate.
right upper quadrant, injury to the liver is
assessed. It is prudent at this time to dissect
the gastrohepatic ligament using blunt and 7.1.2.5Retroperitoneum
sharp dissection so that a vessel loop (Rumel
tourniquet) or vascular clamp can be placed Lesser sac
across the portal triad. The stomach is grasped and pulled inferiorly, allowing the
6.2.1 If manual compression controls the operator to identify the lesser curvature and the superior
bleeding, the bleeding is probably venous aspect of the pancreas through the lesser sac. Frequently,
in nature, and can be arrested with the coeliac artery and the body of the pancreas can be well
therapeutic liver packing, If not, the identified through this approach.
Pringle manoeuvre should be performed.
6.2.2 If a Pringle manoeuvre controls the Greater sac
bleeding, the surgeon should be suspicious
of hepatic arterial or portal injury. The omentum is then grasped and drawn upwards. A
Hepatorrhaphy is then performed to window is made in the omentum (via the gastrocolic liga-
control intrahepatic vessels (See Section ment), and the operators hand is passed into the lesser
7.3, The liver and biliary system), alone or sac posterior to the stomach. This allows excellent expo-
in combination with packing. sure of the entire body and tail of the pancreas, as well
6.2.3 If a Pringle manoeuvre fails to control
as the posterior aspect of the proximal part of the first
bleeding, the likely source is the hepatic portion of the duodenum and the medial aspect of the
veins or IVC. Compression against the second part. Any injuries to the pancreas can be easily
posterior abdominal wall and diaphragm identified. If there is a possibility of an injury to the head
can be successful, and packing should be of the pancreas, a Kocher manoeuvre is performed. Better
performed. exposure can be achieved using the right medial visceral
6.2.4 Dissection of the porta hepatis should
rotation.
then be carried out, and selective clamping
of vessels performed to determine the Mobilization of the ascending colon (right hemicolon)
source of the haemorrhage. The hepatic flexure is retracted medially, dividing
6.2.5 The liver is mobilized if needed. adhesions along its lateral border down to the caecum
6.3 Use definitive packing as required: (Figure7.2).
6.3.1 Use dry folded swabs, packed in layers.
6.3.2 Do not cover them in plastic they will slip
and will be too rigid. Kocher manoeuvre
6.3.3 Place the packs flat against the organ. The Kocher manoeuvre is performed by initially dividing
6.3.4 Packs only work in venous injury (arteries the lateral peritoneal attachment of the duodenum. The
must be controlled directly). adhesions on the outer border of the duodenum are
6.3.5 Packs must exert sufficient force on the divided, allowing medial rotation of the duodenum
organ to tamponade the bleeding. (Figure 7.3).
6.3.6 Only use sufficient packs to achieve the The loose areolar tissue around the duodenum is bluntly
desired result. dissected, and the entire second and third portions of the
7 Deal with lesions in order of their lethality: duodenum are identified and mobilized medially with a
7.1 Injuries to major blood vessels combination of sharp and blunt dissection. This dissec-
7.2 Major haemorrhage from solid abdominal viscera tion is carried all the way medially to expose the IVC and
7.3 Haemorrhage from mesentery and hollow organs a portion of the aorta.
7.4 Retroperitoneal haemorrhage The posterior wall of the duodenum can be inspected,
7.5 Contamination. together with the right kidney, porta hepatis and IVC. By
Figure 7.2 Mobilization of the right hemicolon.
reflecting the duodenum and pancreas toward the anterior

Figure 7.3 Kocher manoeuvre.
midline, the posterior surface of the head of the pancreas
can be completely inspected (Figure 7.4). Better inspection
of the third part, and inspection of the fourth part, of the
duodenum can be achieved by mobilizing the ligament of
Treitz and performing a right medial visceral rotation.
Right medial visceral rotation3

The was previously known as the CattelBraasch manoeuvre.
The small bowel mesentery is mobilized, and a Kocher
manoeuvre is performed. The right retroperitoneum is also
exposed (Figure 7.5). The small bowel mobilization is under-
taken by sharply incising its retroperitoneal attachments
from the right lower quadrant to the ligament of Treitz. The
entire ascending colon and the caecum are then reflected
superiorly towards the left upper quadrant of the abdomen.
As the dissection is carried further, the inferior border of
the entire pancreas can then be identified and any injuries
inspected. Severe oedema, crepitation or bile staining of the
periduodenal tissues implies a duodenal injury until proven
otherwise. If the exploration of the duodenum is negative
but there is still strong suspicion of duodenal injury, meth- Figure 7.4 Reflection of the duodenum and right hemicolon to show
ylene blue can be instilled through the nasogastric tube. the right kidney and inferior vena cava.
7.1.3Closure of the abdomen desirable goal, and may be achieved when the conditions
outlined above are optimal, that is, a stable patient with
minimal blood loss and volume replacement, no or mini-
7.1.3.1 Principles of abdominal closure
mal contamination, no significant intercurrent problems
On completion of the intra-abdominal procedures, it is and a patient in whom surgical procedures are deemed to
important to adequately prepare for closure. This prepa- be completed with no anticipated subsequent operation.
ration includes: Should any reasonable doubt exist regarding these condi-
tions at the conclusion of operation, it would be prudent
Careful evaluation of the adequacy of haemostasis
to consider a technique of delayed closure.
and/or packing
Whichever method is used, the most important techni-
Copious lavage and removal of debris within the
cal point is that of avoiding excessive tension on the tis-
peritoneum and wound
sues of the closure. Remember the one centimetreone
Placement of adequate and appropriate drains if
centimetre rule as described by Leaper et al.6 (the so-called
indicated
Guildford technique; Figure 7.7). This uses 4 cm of
Ensuring that the instrument and swab counts are
material for every 1 cm advance. This spacing seems to
completed and correct.
minimize tension in the tissues, and thus also minimize
It is important to replace the small intestine in the compromise of the circulation in the area, as well as using
abdominal cavity with great care at the conclusion of the the minimum acceptable amount of suture. The use of a
operation. size 0 or 1 looped polydioxanone suture as a continuous
suture is recommended.
Retention sutures should be avoided at all costs, and
7.1.3.2Choosing the optimal method of closure
a wound that seems to require these is not suitable for
Thal and OKeefe5 state that the optimal closure tech- primary closure. Closure of such a wound may result in
nique is chosen on the basis of five principal considera- abdominal compartment syndrome; the wound should be
tions and list these as follows: left open, with a vacuum dressing.
Skin closure as a primary manoeuvre may be done in
The stability of the patient (and therefore the need for
a case with no or minimal contamination, using mono-
speed of closure)
filament sutures or staples. The latter have the advantage
The amount of blood loss both prior to and during
of speed and, while being less haemostatic, nevertheless
operation
allow for a greater degree of drainage past the skin edges
The volume of intravenous fluid administered
and less tissue reaction.
The degree of intraperitoneal and wound
contamination
The nutritional status of the patient and possible
intercurrent disease.
These factors will also dictate the decision to plan for a

re-laparotomy, which will naturally influence the method
chosen for closure.
The most commonly used technique at present is that
of mass closure of the peritoneum and sheath using a mono-
filament absorbable suture (e.g. size 1 polydioxanone loop
suture) with a continuous (preferable, since relatively
1 cm wide
quick) or an interrupted (discontinuous) application.
Either absorbable material or non-absorbable material (e.g. 1 cm deep
nylon) is used. Chromic catgut is not a suitable material. bite
7.1.3.3 Primary closure
Primary closure of the abdominal sheath (or fascia),

the subcutaneous tissue and the skin is obviously the Figure 7.7 Illustration of the Guildford technique.
The abdomen | 101
7.1.4Haemostatic adjuncts in trauma organs or to seal air leaks from lung injuries. It is available
in most countries in Europe.
Even after surgical haemostasis, deep parenchymal
7.1.4.1 Overview
injuries can require a resorbable tamponade; here, col-
Haemostatic substances can be used after surgical hae- lagen fleece (e.g. TissoFleece; Baxter, Vienna) is suitable.
mostasis in trauma surgery to secure the surface of the Collagen fleece is composed of heterologous collagen
wound. Tissue adhesives are used alone or in combination fibrils obtained from devitalized connective tissue and is
with other haemostatic measures. The main indications fully resorbable. Collagen fleece promotes the aggrega-
for using adhesives are: tion of thrombocytes when in contact with blood. The
platelets degenerate and liberate clotting factors, which
To arrest minor oozing of blood
in turn activate haemostasis. The spongy structure of
To secure the wound area to prevent subsequent
the collagen stabilizes and strengthens the coagulate.
bleeding
Another alternative for deep parenchymal injuries is
To act as a sealant for air leaks.
FloSeal (Baxter).
Various forms of fibrin sealing are available and are Fibrin glue and collagen fleece are used preferentially to
suitable for treating injuries, especially of the parenchy- treat slight oozing of blood. Before application, the bleed-
matous organs. The different presentations make some ing surface should be tamponaded and compressed with a
suitable for superficial bleeding surfaces, and others eas- warm pad for a few minutes. Immediately after removal of
ier to apply in deep lacerations. Some are readily avail- the pad, air is first sprayed alone, followed by short bursts
able, while preparation is time-consuming in others. It of fibrin. This creates a surface that is free from blood and
is important that the surgeon knows what haemostatic nearly dry when the fibrin glue is sprayed onto it. A dry
agents are available and how and where they can be used. field is essential for most fibrin sprays in order to secure
Of the adhesives currently available, fibrin glue is the adequate haemostasis.
most suitable for treating injuries to the parenchyma- If collagen fleece is to be applied, a thin layer of fibrin is
tous organs and retroperitoneum. It is also possible to sprayed onto the fleece, which, in turn, is pressed onto the
make autologous fibrin from the patients own blood wound. After a few moments of compression, the fleece is
(Vivostat system; Vivolution A/S, Birkeroed, Denmark); sprayed with fibrin glue. The thickness of the fibrin layer
the fibrin is applied with a sprayer. The necessary vol- will depend on the size and depth of the injury.
ume of blood (125 mL) can already be drawn in the
emergency room, and the autologous adhesive is ready
7.1.4.2 Other haemostatic adjuncts
within 30 minutes.
Fibrin sealing is based on the transformation of fibrin- Chitosan
ogen to fibrin. Fibrin promotes clotting, tissue adhesion
Chitosan (Celox [Medtrade Products, Crewe, Cheshire,
and wound healing through interaction with the fibro
UK], HemCon [Hemcon Medical Technologies, Portland,
blasts. The reaction is the same as in the last phase of blood
OR, USA]) is a granular product made from a natu-
clotting. One such heterologous fibrin is Tisseel/Tissucol
ral polysaccharide derived from chitin from shellfish.
(Baxter Hyland Immuno, Vienna, Austria). Heterologous
Chitosan is the deacetylated form of chitin. In the form of
fibrin is a biological two-component adhesive and has
an acid salt, chitosan demonstrates mucoadhesive activ-
high concentrations of fibrinogen and factor XIII, which,
ity. Chitosan stops bleeding by bonding with red blood
together with thrombin and calcium, result in clotting.
cells and gelling with fluids to produce a sticky pseudo-
Resorption time and resistance to tearing depend on the
clot. This reaction is not exothermic and has been used
size and thickness of the glue layer, and on the propor-
successfully within body cavities. Chitosan is broken
tion by volume of the two components. The fibrin sealant
down by enzymatic action within the body to produce
is best applied with a sprayer or syringe injection system
glucosamine. The dressing is sold as pads or bandages.
such as the Tissomat sprayer (Baxter Hyland Immuno).
TachoSil (Nycomed Austria GmbH, Linz, Austria) is
a fixed, ready-to-use combination of a collagen sponge Mineral zeolyte
coated with a dry layer of the human coagulation factors Mineral zeolyte (QuikClot; Z-Medical Corporation,
fibrinogen and thrombin, making it easy to employ. It is Wallingford, CT, USA), when made moist, produces an
most suitable for oozing from the raw surfaces of solid exothermic reaction that seals blood vessels and results
in haemostasis. The initial preparation was in the form of Retroperitoneal haematoma

granules and was very exothermic, resulting in significant Injuries to the retroperitoneal vessels can cause haemato-
tissue damage. The current preparation is presented in mas of varying size, depending on the calibre of the ves-
bags (tea-bags) that are packed into the wound and may sels injured and the severity of the injury. Retroperitoneal
cause less damage. haematomas can be treated by packing after surgical
control of injured vessels, and be followed by catheter
7.1.4.3Specific applications embolization.
When the patient is stable, the packs can be removed
Hepatic injury after 2448 hours. Rebleeding after removal of the packs
In severe liver injury, after successful surgical treatment can necessitate repacking. Slight bleeding can, however,
including the removal of devascularized necrotic tissue be stopped effectively by spraying on adhesives.
and resectional debridement, the liver is packed, and the
injured area compressed with warm pads. After complete
exploration of the abdomen and treatment of other inju- 7.1.5Briefing for operating room scrub
ries and sources of bleeding, the liver packs are removed nurses
and any slight oozing on the surface of the liver can be
arrested by sealing with fibrin and collagen fleece as A separate briefing for operating room scrub nurses forms
described above. Fibrin glue cannot, however, compensate Appendix E of this manual.
for inadequate surgical technique.
7.1.6Summary
Splenic injury
When possible, in the stable patient, the surgeon should The laparotomy in trauma needs to be performed in a
try to achieve splenic repair that preserves as much of systematic fashion. The ease with which injuries can be
the damaged spleen as possible. For splenic preservation, missed, and the potentially catastrophic consequences
the choice of procedure depends not only on the clinical that might result, mandate that extreme care is take to
findings, but also on the surgeons experience of splenic exclude injuries, based on the injury complexes that occur
surgery and the equipment available. In trauma cases, and the way in which the laparotomy is approached.
conservation of the spleen should not take significantly Careful examination of each organ is essential.
more time than would a splenectomy. The trauma laparotomy is a team event, and the anaes-
After using one of the surgical techniques described thesiologist must be fully involved and informed of all
above, definitive treatment can be completed by the decision-making.
application of adhesives to secure the resected edge or the
mesh-covered splenic tissue. Fibrin is sprayed on, and the
collagen fleece is pressed on it for a few minutes. After 7.2The bowel
removal of the compressing pad, a new layer of fibrin glue
can help to ensure the prevention of rebleeding. In case In all injuries, the entire length of bowel, from the stom-
of use of mesh, the collagen fleece and fibrin are placed ach, small bowel from the ligament of Treitz to the ile-
directly on the injured splenic surface and then covered ocaecal valve, and large bowel from the caecum to the
with the mesh. Additional fibrin spray may then be added. rectum, and their mesenteries should be inspected. This
is best achieved with the help of an assistant.
Pancreatic injury Starting at the ligament of Treitz, each segment of small
bowel is inspected, and then flipped over to examine the
When pancreatic injury is suspected, extended exploration
opposite side. The mesentery is carefully inspected as well. If
of the whole organ is imperative. Parenchymal lacerations
the bowel is dropped, start again at the ligament of Treitz!
that do not involve the pancreatic duct can be sutured
when the tissue is not too soft and vulnerable. With or
without sutures, a worthwhile option in the treatment of Pitfalls
such lacerations is fibrin sealing and collagen tamponade, Both the surgeon and the assistant inspect the same
for which adequate drainage is essential. segment at the same time, but ideally only one operator
The abdomen | 103
handles the bowel at any time, as otherwise each procedures. The first priority is to treat the haemorrhage,
operator thinks that the other is doing the inspection. and then to control contamination.
Both the antimesenteric border and the mesenteric Small wounds can be closed rapidly, using a skin sta-
border of the bowel must be inspected. pler or with mass closure. In severely injured patients,
with more extensive injuries requiring damage control,
simple proximal and distal closure of the injured bowel
7.2.1Stomach using a GIA-type stapler is the best way to prevent
ongoing soiling. The bowel should be transected and
The stomach is lifted up using two Babcock forceps, and closed for later repair. Umbilical tape can also be used.
the anterior surface inspected. It is helpful if there is a Neither any anastomosis nor any stoma should be
nasogastric tube in place place the forceps around the performed at this stage, as these can be time-consum-
tube, forming a useful gastric retractor. The posterior sur- ing, the tissue viability is uncertain, and the leak rate is
face of the stomach can be inspected in a similar way. much higher, especially in the presence of concomitant
contamination. The non-viable or damaged areas can
The stomach is highly vascular, and in all injuries,
be removed at a later time, and the need for colostomy
life-threatening bleeding can result. All holes should be
assessed. Additionally, the bowel may be oedematous
repaired using a continuous 3/0 polydioxanone suture.
secondary to trauma or overenthusiastic fluid resus-
citation, and suturing or stapling is then technically
Pitfall difficult.
In all penetrating injuries in which a hole is found on the In wounds caused by small penetrating missiles, for
anterior surface of the stomach, it is important to seek example with a shotgun, it is easy to miss multiple holes,
the corresponding hole on the posterior wall of the stom- which are often less than 2mm in diameter. It is recom-
ach. If this cannot be found, enlarge the anterior hole and mended that, in these cases, the bowel be passed through
inspect the stomach from within: penetrating holes gen- a bowl of water, so that any air leak will show itself as
erally go in pairs one in, one out. bubbles. All such injuries should be reinspected at 3648
The duodenum must be carefully inspected from the hours, and the procedure repeated.
pylorus to the ligament of Treitz. If there is a haematoma
on the duodenum, it is necessary to perform a Kocher
manoeuvre and inspect the posterior surface of the 7.2.3Large bowel
duodenum.
An odd number of bowel enterotomies should prompt 7.2.3.1The stable patient
a second look for missed injury.
For colonic injuries, indications for colostomy are still
debated. Time from injury, haemodynamic status, co-
morbid conditions and degree of contamination will
7.2.2Small bowel
influence the decision. More primary repairs/primary
anastomoses are being performed, with fewer colosto-
7.2.2.1The stable patient mies. When there are multiple small and large bowel lac-
erations, a protective ileostomy can be helpful.
Small bowel injuries should be closed, with primary With rectal injuries, primary repair should be con-
repair or resection and primary anastomosis as appropri- sidered for intraperitoneal injuries and extraperitoneal
ate. Consider one resection and anastomosis when several injuries that can be mobilized. A proximal diverting colos-
wounds are localized close to each other. Be mindful, how- tomy (often a loop sigmoidostomy) is indicated in more
ever, that bowel should be preserved wherever possible. extensive rectal injuries and when repair is impossible.
There is no indication for routine presacral drains or
distal wash-out.
7.2.2.2The unstable patient
In patients with complex abdominal injuries, peritoneal
The first priority is haemorrhage control. If the patient is soiling is of secondary importance to haemorrhage con-
haemodynamically unstable, damage control is likely, and trol. Once haemorrhage has been controlled, devascular-
bowel injuries should be treated using damage control ized areas accompanying deep injuries should be resected.
7.2.3.2The unstable patient (Table 7.3) 7.2.4 Mesentery

In the unstable patient undergoing a damage control
Arterial bleeders should be tied off. Do not extend
procedure, small wounds can simply be sutured using 3/0
mesenteric lacerations, and if necessary, oversew bleeding
polydioxanone. The wounds can be reinspected at the re-
wounds.
look procedure.
Larger wounds should be excluded in the same manner
as small bowel. All macroscopic contamination should
be washed out using copious amounts of warmed saline 7.2.5Adjuncts
before (temporary) closure.
Pitfall 7.2.5.1Antibiotics2
No stomas should be performed in the unstable patient Practice management guidelines for prophylactic anti-
as this prolongs the surgical time and may make things biotic use in penetrating abdominal trauma are given in
more complex in the presence of competing injury. Table 7.4.
Table 7.3 Evidence-based recommendations for the management of penetrating injuries of the colon7
Level I There are sufficient class I and class II data to support a standard of primary repair for non-destructive (involvement of <50% of the
bowel wall without devascularization) colon wounds in the absence of peritonitis
Patients with penetrating intraperitoneal colon wounds that are destructive (involvement of >50% of the bowel wall or devascularization
of a bowel segment) can undergo resection and primary anastomosis if they:
Are haemodynamically stable without evidence of shock (sustained pre- or intraoperative hypotension as defined by a systolic blood
pressure <90mmHg)
Have no significant underlying disease
Have minimal associated injuries (Penetrating Abdominal Trauma Index <25, Injury Severity Score <25, Flint grade <11)
Have no peritonitis
Level II Patients with shock, underlying disease, significant associated injuries or peritonitis should have destructive colon wounds managed by
resection and colostomy
Colostomies performed following colon and rectal trauma can be closed within 2 weeks if a contrast enema examination is performed to
confirm distal colon healing. This recommendation pertains to patients who do not have non-healing bowel injury or unresolved wound
sepsis, and are not unstable
A barium enema should not be performed to rule out colon cancer or polyps prior to colostomy closure for trauma in patients who
otherwise have no indications for being at risk of colon cancer and/or polyps
Table 7.4 Practice management guidelines for prophylactic antibiotic use in penetrating abdominal trauma
Level I There are sufficient class I and II data to recommend a single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic
and anaerobic coverage as a standard of care for trauma patients sustaining penetrating abdominal wounds. Absence of a hollow viscus
injury requires no further administration
Level II There are sufficient class I and class II data to recommend continuation of prophylactic antibiotics for only 24 hours in the presence of
injury to any hollow viscus
Level III There are insufficient clinical data to provide meaningful guidelines for reducing infectious risks in trauma patients with hemorrhagic
shock. Vasoconstriction alters the normal distribution of antibiotics, resulting in reduced tissue penetration. To circumvent this problem,
the administered dose may be increased two- or threefold and repeated after every 10th unit of blood product transfusion until there is
no further blood loss. Once haemodynamic stability has been achieved, antibiotics with excellent activity against obligate and facultative
anaerobic bacteria should be continued for periods that depend on the degree of wound contamination. Aminoglycosides have been
demonstrated to exhibit suboptimal activity in patients with serious injury, probably due to altered pharmacokinetics of drug distribution
The abdomen | 105
7.3The liver and biliary system Consider damage control and packing early before the coagu-
lopathy becomes established.
7.3.1 Overview
7.3.2Resuscitation
Although most injuries to the liver do not require surgical
intervention, management of severe hepatic lesions can be Haemodynamically stable patients without signs of peri-
a devastating experience. tonitis or other indication for operation are generally
Management of hepatic trauma demands a working managed non-operatively.
knowledge of the anatomy of the liver, including the Haemodynamically unstable patients with liver injuries
arterial supply, portal venous supply and hepatic venous require surgical exploration to achieve haemostasis and
drainage. Knowledge of the hepatic anatomy is important, exclude other sources of bleeding. The patient in whom
as its understanding helps to explain some of the patterns a surgical approach is decided upon or is mandated by
of injury following blunt trauma. In addition, there are haemodynamic instability should be transferred to the
differences in tissue elasticity that also determine injury operating room as rapidly as possible after the following
patterns. Segmental anatomical resection has been well have been completed:
documented but is usually not applicable to trauma.
Emergency airway or ventilatory management if
The forces from blunt injury are usually direct compres-
necessary
sive forces or shear forces. The elastic tissue within arterial
Establishment of adequate upper limb large-
blood vessels makes them less susceptible to tearing than
bore vascular access and initiation of crystalloid
any other structures within the liver. Venous and biliary
resuscitation
ductal tissue is moderately resistant to shear forces, whereas
Initiation of the massive haemorrhage (massive
the liver parenchyma is the least resistant of all. Thus, frac-
transfusion) protocol if appropriate.
tures within the liver parenchyma tend to occur along seg-
mental fissures or directly in the parenchyma. This causes Appropriate decision-making is critical to a good outcome. As a
shearing of branches lateral to the major hepatic and por- general rule, the simplest, quickest technique that can restore hae-
tal veins. With severe deceleration injury, the origin of the mostasis is the most appropriate. Once the patient is cold, coagu-
short retrohepatic veins may be ripped from the vena cava, lopathic and in irreversible shock, the battle has usually been lost.
causing devastating haemorrhage. Similarly, the small Consider early damage control surgery if appropriate.
branches from the caudate lobe entering directly into the
vena cava are at high risk for shearing with linear tears on
the caval surface. 7.3.3Diagnosis
Direct compressive forces usually cause tearing between
segmental fissures in an anteroposterior orientation. Surgery should not be delayed by multiple emergency
Horizontal fracture lines into the parenchyma give the department procedures, such as limb X-rays, unneces-
characteristic burst pattern to such liver injuries. If the sary ultrasonography and vascular access procedures.
fracture lines are parallel, these have been dubbed bear Computed tomography (CT) scanning of the brain should
claw-type injuries and probably represent where the ribs be delayed until the patient is stable. The anaesthesio
have been compressed directly into the parenchyma. This logist can continue resuscitation in the operating room.
can cause massive haemorrhage if there is direct extension In patients with blunt trauma, there may be an absence
or continuity with the peritoneal cavity. of clear clinical signs, such as rigidity, distension or unsta-
The diagnosis of hepatic trauma preoperatively may be ble vital signs. Up to 40 per cent of patients with signifi-
difficult (as blood itself is not an irritant). The liver is at risk cant haemoperitoneum have no obvious signs. Focused
of damage in any penetrating trauma to the upper abdomen abdominal sonography for trauma (FAST) may be par-
and lower thorax, especially of the right upper quadrant. ticularly useful in the setting of blunt injury and haemo-
Appropriate decision-making is critical to a good out- dynamic instability, since the presence of free fluid in the
come. As a general rule, the simplest, quickest technique abdominal cavity will influence the need for operation.
that can restore haemostasis is the most appropriate. With a haemodynamically stable patient, CT scanning is
Once the patient is cold, coagulopathic and in irreversible an invaluable diagnostic aid and allows the surgeon to
shock, the battle has usually been lost. make decisions on the need for embolization or operative
management. Diagnostic peritoneal lavage in the blunt haematomas, and VI representing avulsion of the liver
trauma setting may also be quite useful, particularly when from the vena cava. Isolated injuries that are not extensive
CT support services are inadequate or unavailable. (grades IIII) are usually managed non-operatively; how-
The purpose of diagnostic investigation in the stable ever, extensive parenchymal injuries and those involving
patient is to help identify those patients who can be safely the juxtahepatic veins (grades IV and V) may require com-
managed non-operatively, to assist decision-making in plex manoeuvres for successful treatment. Hepatic avul-
non-operative management, and to act as a baseline for sion (grade VI) is usually lethal.
comparison in future imaging studies. Accurate, good-
quality, contrast-enhanced CT scanning has enhanced
our ability to make an accurate diagnosis of liver injuries. 7.3.5 Management
Penetrating wounds of the liver usually do not present
a diagnostic problem, as most surgeons would advo- Traditionally, discussion of liver injuries differentiates
cate exploration of any wound in the unstable patient. between those arising from blunt and those arising from
Peritoneal lavage as a diagnostic tool in penetrating penetrating trauma. Most stab wounds cause relatively
trauma has been misleading. Computed tomography minor liver injury unless a critical structure, such as the
scans using contrast are not routinely advocated for pen- hepatic vein, the intrahepatic cava or the portal struc-
etrating injuries but can be useful, especially to deline- tures, are injured. In contrast, gunshot wounds, particu-
ate vascular viability, and to assist with the decision of larly high-energy injuries, can be quite devastating, as can
whether to treat the injury non-operatively, with or with- shotgun blasts. Twenty five per cent of penetrating inju-
out embolization, or by conservation or resection. ries to the liver can be managed non-operatively. Injuries
Penetrating wounds of the liver in the stable patient from severe blunt trauma continue to be the most chal-
can be managed non-operatively, but should be followed lenging for the surgeon.
closely because of the risk of bile leakage. Richardson and co-workers managed approximately
1200 blunt hepatic injuries over a 25-year period.9 Non-
operative management was used in up to 80 per cent of
7.3.4Liver injury scale cases. The rate of death secondary to injury dropped from
8 per cent to 2 per cent.
The American Association for the Surgery of Traumas
Committee on Organ Injury Scaling has developed a grad-
7.3.5.1Non-operative management10,11
ing system for classifying injuries to the liver (Table 7.5).
Hepatic injuries are graded on a scale of I to VI, with I Nearly all children and 5080 per cent of adults with blunt
representing superficial lacerations and small subcapsular hepatic injuries can be treated without a laparotomy. This
Table 7.5 Liver injury scale (see also Appendix B, Trauma scores and scoring systems)
Grade* Type of injury Description of injury
I Haematoma Subcapsular, <10% surface area

Laceration Capsular tear, <1cm parenchymal depth
II Haematoma Subcapsular, 1050% surface area: intraparenchymal <10cm in diameter

Laceration Capsular tear 13cm parenchymal depth, <10cm in length
III Haematoma Subcapsular, >50% surface area of ruptured subcapsular or parenchymal haematoma; intraparenchymal haematoma
>10cm or expanding 3cm parenchymal depth
Laceration Parenchymal disruption involving 2575% hepatic lobe or 13 Couinauds segments
IV Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Couinauds segments within a single lobe
V Vascular Juxtahepatic venous injuries; i.e. retrohepatic vena cava/central major hepatic veins
VI Vascular Hepatic avulsion
*Advance one grade for multiple injuries up to grade IV.

Reproduced from Moore et al. (1995).8
The abdomen | 107
change in approach has been occasioned by the increasing and even if the liver is not the highest priority, temporary
availability of rapid ultrasound, helical CT scanning and control of hepatic bleeding allows repair of other injuries
the development of interventional radiology. without unnecessary blood loss. This can be done by:
The primary requirement for non-operative therapy is
Perihepatic packing
haemodynamic stability. To confirm stability, frequent
Pringle manoeuvre
assessment of vital signs and monitoring of the hae-
Tourniquet or liver clamp application
matocrit are necessary, in association with CT scans as
Electrocautery or argon beam coagulator
required. Continued haemorrhage occurs in 14 per cent
Haemostatic agents and glues
of patients. Hypotension may develop, usually within the
Hepatic suture.
first 24 hours after hepatic injury, but sometimes several
days later.
The presence of extravasation of contrast on CT denotes 7.3.6.1Incision
arterial haemorrhage. There should be a low threshold for
The patient is placed in the supine position.
the performance of diagnostic and/or therapeutic angiog-
raphy with embolization. Otherwise, operative interven- Warming devices are placed around the upper body
tion will become necessary in these patients. and lower limbs.
A persistently falling haematocrit should be treated The chest and abdomen are surgically prepared and
with packed red blood cell transfusions. If the haema- draped.
tocrit continues to fall after 2 or 3 units of packed red The instruments necessary to extend the incision into
blood cells, embolization in the interventional radiology a sternotomy or thoracotomy must be available.
suite should be considered. A generous midline incision from pubis to
xiphisternum is the minimum incision required.
For the patient in extremis, a combined sternotomy
7.3.5.2 Operative (surgical) management
and midline laparotomy approach is recommended
Most injuries requiring surgical intervention are managed from the outset in order to allow access for internal
simply by evacuating the free intraperitoneal blood and cardiac massage and vena caval vascular control.
washing out the peritoneal cavity; some will require drain- Supradiaphragmatic intrapericardial inferior vena
age of the injury because of a possible bile leak. However, caval control is often easier than abdominal control
25 per cent of liver injuries requiring surgical intervention adjacent to a severe injury.
require direct control of more major hepatic bleeding. An Omni-Tract- or Bookwalter-type automatic
Most bleeding from hepatic injury is venous in nature, retractor greatly facilitates access.
and therefore can be controlled by direct compression
and liver packs. Tissue sealants may be a useful adjunct.12
7.3.6.2Initial actions
Caution must be exercised since bile within the peritoneal
cavity is not always well tolerated, and suction drainage Once the abdomen has been opened, intraperitoneal
should be routine in these patients. blood is evacuated, bleeding is controlled, and if there is
evidence of hepatic bleeding, the liver should be initially
packed and the abdomen rapidly examined to exclude ext-
7.3.6Surgical approach rahepatic sites of blood loss. Autotransfusion should be
considered. Once the anaesthetist has had an opportunity
During treatment of a major hepatic injury, ongo- to restore intravascular volume and haemostasis has been
ing haemorrhage may pose an immediate threat to the achieved for any extrahepatic injury, the liver injury then
patients life, and temporary control will give the anaes- can be approached.
thesiologist time to restore the circulating volume before If the lesion has ceased bleeding, nothing more needs
further blood loss occurs. This is best achieved in the first to done in most cases, and above all the non-bleeding
instance by direct manual compression of the liver. The lesion should not be explored further. If further surgery
goal is to try to restore the normal anatomy by manual is required, adequate exposure and mobilization of the
compression and then maintain it with packing. liver are necessary. Most injuries do not require formal
Additionally, multiple bleeding sites beyond the liver mobilization of the injured lobe to permit repair or
are common with both blunt and penetrating trauma, packing.
7.3.6.3Techniques for temporary control of haemorrhage from the left lobe can be controlled by
haemorrhage dividing the left triangular and coronary ligaments, and
Perihepatic packing compressing the lobe between the hands.
Tract tamponade balloons There are several key factors for success:
Tractotomy and direct suture ligation Use dry abdominal swabs. Wet swabs are less
Mesh wrap absorbent, and exacerbate hypothermia.
Hepatic artery ligation Use the swabs folded as it is easier to layer them for
Hepatic vascular isolation even pressure.
Techniques to control retrohepatic caval bleeding: Ensure that they have radio-opaque markers included
Atriocaval shunt in their manufacture.
MoorePilcher balloon Do not cover them with plastic as they will not hold
Venovenous bypass. their position.
Ongoing bleeding despite initial packing mandates
Perihepatic packing repacking or other haemostatic procedure, and
consideration of embolization.
The philosophy of packing has altered, and packs are used
primarily to restore the anatomical relationship of the During the period of time that the packs are placed, it is
components, and secondarily to act as compressive agent. important to establish more intravenous access lines and
Packs for a liver wound should not be placed within the other monitoring devices as needed. Hypothermia should
wound itself. be anticipated, and corrective measures taken. After
Liver packing can also be a definitive treatment, partic- haemodynamic stability has been achieved, the packs
ularly when there is bilobar injury, or can simply buy time are removed, and the injury to the liver rapidly assessed.
if the patient develops a coagulopathy or hypothermia, or Control of haemorrhage is the first consideration, fol-
there are no blood resources. Liver packing is the method lowed by control of contamination. If the bleeding has
of choice where expertise in more sophisticated tech- stopped, nothing further may be required.
niques is not available. If packing is successful, and the If in doubt, apply damage control techniques, with
bleeding is controlled, no further action may be required. definitive packing of the liver:
Packing is initially performed using large flat abdomi-
Consider angiography and embolization with damage
nal packs, placed laterally, inferiorly, medially and around
control surgery.
the liver. Perihepatic packing, with careful placement of
Packs should preferably be removed within
packs, is capable of controlling haemorrhage from almost
2472hours.
all hepatic venous injuries. If necessary, the liver can be
The packs should be carefully removed to avoid
mobilized by division of the hepatic ligaments (see below).
precipitating further bleeding.
Packs must not be forced into any splits or fractures as this
If there is no bleeding, the packs can be left out, and
increases the damage and encourages haemorrhage.
adequate drainage established.
Additional packs may be placed between the liver and
Necrotic tissue should be resected where possible.
the diaphragm, posteriorly and laterally, and between the
liver and the anterior chest wall, until the bleeding has Two complications may be encountered with the pack-
been controlled. There is no benefit in placing multiple ing of hepatic injuries. First, tight packing compresses the
packs between the dome of the liver and the diaphragm, inferior vena cava, decreases venous return and reduces
which will only have the effect of raising the diaphragm. right ventricular filling; hypovolaemic patients may not
The liver should not be packed backwards as compres- tolerate the resultant decrease in cardiac output. Second,
sion of the vena cava will reduce venous return. Several perihepatic packing forces the right diaphragm to move
packs may be required to control the haemorrhage from superiorly and impairs its motion; this may lead to
an extensive right lobar injury. The minimum number of increased airway pressures and decreased tidal volume.
packs to achieve haemostasis should be used. If compression and packing is unsuccessful, it will be
Packing is not as effective for injuries of the left lobe necessary to achieve direct access to the bleeding vessel and
because, with the abdomen open, there is insufficient direct suture ligation. This will often necessitate extension
abdominal and thoracic wall anterior to the left lobe of the wound to gain access and view the bleeding point.
to provide adequate countercompression. Fortunately, During this direct access, bleeding can be temporarily
The abdomen | 109
controlled by direct compression, which requires a capa- Finger fracture

ble assistant. Temporary clamping of the porta hepatis It may be necessary to perform finger fracture through
(Pringles manoeuvre) is also a useful adjunctive measure. normal liver tissue to get to the injured vessels deep in
Other adjunctive measures include interruption of the the parenchyma. The normal capsule is scored using
venous or arterial inflow to a segment or lobe (less than diathermy or scalpel. Then the normal liver tissue is
1 per cent of all liver injuries), haemostatic agents such gently compressed between thumb and forefinger, rub-
as crystallized bovine collagen, fibrin adhesives, gel foam bing the normal parenchymal tissue away, and leaving
and use of the argon laser or harmonic scalpel. just the intact vessels for ligation or clipping. Avoid
Pringles manoeuvre forceful pinching or crushing of the liver tissue, as this
Pringles manoeuvre is often used as an adjunct to pack- may disrupt the hepatic vasculature, increasing the
ing for the temporary control of haemorrhage. When haemorrhage.
encountering life-threatening haemorrhage from the
liver, the hepatic pedicle should be compressed manually. Tract tamponade balloons13
The compression of the hepatic pedicle via the foramen of
Winslow is known as Pringles manoeuvre. The liver then These can be very useful in haemostasis of a tract after
should be packed as above. The hepatic pedicle is best stab or gunshot wounds. The balloon is threaded down
clamped from the left side of the patient, by digitally dis- the tract and inflated, to tamponade the bleeding from
secting a small hole in the lesser omentum, near the pedi- inside out. The balloon can be manufactured by the sur-
cle, and then placing a soft clamp over the pedicle from geon using Penrose rubber tubing, or even a condom and
the left-hand side, through the foramen of Winslow. The a nasogastric tube. A SengstakenBlakemore tube for
advantage of this approach is the avoidance of injury to tamponade of oesophageal varices is ideal.
the structures within the hepatic pedicle, and the assur-
ance that the clamp will be properly placed the first time. Hepatic suture
The pedicle can theoretically be left clamped for up to
Suturing of the hepatic parenchyma is not routinely rec-
an hour. However, this is probably true only in the haemo-
ommended to control more superficial lacerations that
dynamically stable patient. In the shocked patient, Pringles
continue to bleed, but may be used if other methods are
manoeuvre should only be performed for about 15 minutes at
ineffective. If, however, the capsule of the liver has been
a time, for fear of decreasing liver fibrinogen production and
stripped away by the injury, sutures that are tied over the
other consequences of hepatic ischaemia. The clamp should
capsule are far less effective.
be replaced as soon as possible with a Rumel vascular sling.
The liver is usually sutured using a large curved, blunt-
In theory, Pringles manoeuvre also allows the surgeon
nosed needle with 0 or 2/0 resorbable sutures. The large
to distinguish between haemorrhage from branches of
diameter prevents the suture from pulling through
the hepatic artery or portal vein, which ceases when the
Glissons capsule. For shallow lacerations, a simple con-
clamp is applied, and haemorrhage from the hepatic veins
tinuous suture may be used to approximate the edges
or retrohepatic vena cava, or aberrant extrapedicular arte-
of the laceration. For deeper lacerations, interrupted
rial supply to the left or right lobes, which does not.
horizontal mattress sutures may be placed parallel to the
edges, and tied over the capsule. The danger of suturing is
Hepatic tourniquet that sutures tied too tightly may cut off the blood supply
When faced with bleeding from the left lobe of the liver, to viable liver parenchyma, resulting in necrosis.
Penrose tubing can be wrapped around the liver near Most sources of venous haemorrhage can be managed
the anatomical division between the left and right lobes with intraparenchymal sutures. An adjunct to parenchy-
once the bleeding lobe has been mobilized. The tubing mal suturing or hepatotomy is the use of the omentum
is stretched until haemorrhage ceases, and tension is to fill large defects in the liver and to buttress hepatic
maintained by clamping the drain. Unfortunately, tour- sutures. The rationale for this use of the omentum is that
niquets are difficult to use, and they tend to slip off or tear it provides an excellent source for macrophages and fills
through the parenchyma if placed over an injured area. a potential dead space with viable tissue. In addition, the
An alternative is the use of a liver clamp; however, the omentum can provide a little extra support for parenchy-
application of such devices is hindered by the variability mal sutures, often enough to prevent them from cutting
in the size and shape of the liver. through Glissons capsule.
Mesh wrap positioned and inflated, it occludes the hepatic veins and
A technique that may be attempted if packing fails is to the vena cava, thus achieving vascular isolation. The cath-
wrap the injured portion of the liver with a fine porous eter itself is hollow, and appropriately placed holes below
material (e.g. polyglycolic acid mesh) after the injured the balloon permit blood to flow into the right atrium,
lobe has been mobilized. Using a continuous suture or a in much the same way as with the atriocaval shunt. At
linear stapler, the surgeon constructs a tight-fitting stock- present, the survival rate for patients with juxtahepatic
ing that encloses the injured lobe. Blood clots beneath the venous injuries who are treated with this device is similar
mesh, which results in tamponade of the hepatic injury. It to that for patients treated with the atriocaval shunt i.e.
is best to secure this mesh to the falciform ligament once only occasional survivors have been reported.
full mobilization has been completed, in order to keep the
mesh wrap from stripping off the liver. Hepatic isolation
Hepatic vascular isolation is accomplished by execut-
Hepatic resection ing a Pringle manoeuvre, clamping the aorta at the dia-
phragm and clamping the inferior vena cava above the right
In elective circumstances, anatomical resection produces
kidney (suprarenal) and above the liver (suprahepatic). The
good results, but in the uncontrolled circumstances of
technique is not straightforward, and is best achieved
trauma, mortality has been recorded in excess of 50 per
by those experienced in its use. In patients scheduled for
cent. Resection should be reserved for patients with:
elective procedures, this technique has enjoyed nearly
Extensive injuries of the lateral segments of the left uniform success, but in trauma patients, the results have
lobe where bimanual compression is possible been disappointing. The time limit for isolation is about
Delayed lobectomy in patients in whom packing 30 minutes.
initially controls the haemorrhage, but there is a
segment of the liver that is non-viable Haemostatic agents and glues
Almost free segments of liver
Fibrin adhesive has been used in treating both superficial
Devitalized liver at the time of pack removal.
and deep lacerations, and appears to be the most effective
topical agent (see also Section 7.1.4.3, Specific applica-
Hepatic shunts14 tions). Some adhesives are suitable for injection deep into
The atriocaval shunt was designed to achieve hepatic vas- bleeding gunshot and stab wound tracts to prevent exten-
cular isolation while still permitting some venous blood sive dissection and blood loss. Others are more suitable for
from below the diaphragm to flow through the shunt into surface application. Fibrin adhesives are made by mixing
the right atrium. concentrated human fibrinogen (cryoprecipitate) with a
A 9mm endotracheal tube with an additional side hole solution containing bovine thrombin and calcium.
cut into it (for return of blood into the right atrium) is
introduced into the auricular appendage via a hole sur-
7.3.6.4 Mobilization of the liver
rounded by a purse-string suture. The tube is passed into
the inferior vena cava, and passed caudally so that the end In general, and for most injuries, it is not necessary to
of the tube lies infrahepatically, below the intrahepatic mobilize the liver; injuries can be dealt with without
liver damage. The cuff is then inflated. Blood passes into resorting to full mobilization. However, in some situa-
the tube from below, and exits into the right atrium. The tions, particularly with injury to the superior or posterior
top of the tube is kept clamped (or can be used for addi- aspects, mobilization is a useful adjunct.
tional blood transfusion). The suprahepatic inferior vena Access to the right lobe of the liver is restricted due
cava should be looped in order to prevent back-bleeding to the right subcostal margin and the posterior attach-
down the inferior vena cava. Hepatic isolation is then ments. The costal margin should be elevated, initially
completed with a Pringles manoeuvre. with a Morris retractor, and then with a Kelly or Deaver
Care must be taken to avoid damage to the integral retractor. The right triangular and coronary ligaments
inflation channel for the balloon. An alternative to the are divided with scissors. This can usually be done under
atriocaval shunt is the MoorePilcher balloon. This device vision, but in the larger subject it can be accomplished
is inserted through the femoral vein and advanced into blindly from the patients left side. The superior coronary
the retrohepatic vena cava. When the balloon is properly ligament is divided, avoiding the lateral wall of the right
The abdomen | 111
hepatic vein. The inferior coronary ligament is divided, Regardless of how the lesion is diagnosed, subsequent
taking care not to injure the right adrenal gland (which is decision-making is often difficult. If a grade I or II subcap-
vulnerable because it lies directly beneath the peritoneal sular haematoma (i.e. a haematoma involving less than 50
reflection) or the retrohepatic vena cava. When the liga- per cent of the surface of the liver that is not expanding
ments have been divided, the right lobe of the liver can be and is not ruptured) is discovered during an exploratory
rotated medially into the surgical field. A sudden onset or laparotomy, it should be left alone. If the haematoma
aggravation of bleeding during mobilization of the right is explored, hepatotomy with selective ligation may be
liver attests to hepatic vein or retrohepatic caval injury required to control bleeding vessels. Even if hepatotomy
and mandates immediate replacement of the mobilized with ligation is effective, one must still contend with dif-
liver and damage control packing. fuse haemorrhage from the large denuded surface, and
The left lobe can be easily mobilized by dividing the left packing may also be required.
triangular ligament under vision, avoiding injury to the A haematoma that is expanding during operation
left inferior phrenic vein and the left hepatic vein. (grade III) may have to be explored. Such lesions are often
In the event of a retrohepatic haematoma being evident, the result of uncontrolled arterial haemorrhage, and pack-
rotation of the right lobe of the liver should be avoided ing alone may not be successful. An alternative strategy is
unless strong indications are present and adequate exper- to pack the liver to control venous haemorrhage, close the
tise is available. Packing and transport to a higher level abdomen and transport the patient to the interventional
centre may be a safer option. radiology suite for hepatic arteriography and emboliza-
If exposure of the junction of the hepatic veins and the tion of the bleeding vessels. Ruptured grades III and IV
retrohepatic vena cava is necessary, the midline abdomi- haematomas are treated with exploration and selective
nal incision can be extended by means of a median ster- ligation, with or without packing.
notomy or a lateral subcostal extension. The pericardium
and the diaphragm then can be divided in the direction of
the inferior vena cava. 7.3.7Complications
Overall mortality for patients with hepatic injuries is

7.3.6.5 Perihepatic drainage
approximately 10 per cent. The most common cause of
Several prospective and retrospective studies have dem- death is exsanguination, followed by multiple organ dys-
onstrated that the use of either Penrose or sump drains function syndrome and intracranial injury:
carries a higher risk of intra-abdominal infection than
Morbidity and mortality increase in proportion to the
the use of either closed suction drains or no drains at all.
injury grade and to the complexity of the repair.
It is clear that, if drains are to be used, closed suction
Hepatic injuries caused by blunt trauma carry a
devices are preferred. Patients who are initially treated
higher mortality than those caused by penetrating
with perihepatic packing may also require drainage;
trauma.
however, drainage is not indicated at the initial damage
Infectious complications occur more often with
control procedure, given that the patient will be returned
penetrating trauma.
to the operating room within the next 3648 hours. The
primary function of the drain is to drain for bile leak, Postoperative haemorrhage occurs in a small per
not blood. centage of patients with hepatic injuries. The source
may be either a coagulopathy or a missed vascular
injury (usually to an artery). In most instances of per-
7.3.6.6Subcapsular haematoma
sistent postoperative haemorrhage, the patient is
An uncommon but troublesome hepatic injury is sub- best served by being returned to the operating room.
capsular haematoma, which arises when the parenchyma Arteriography with embolization may be considered in
of the liver is disrupted by blunt trauma but Glissons selected patients. If coagulation studies indicate that a
capsule remains intact. Subcapsular haematomas range coagulopathy is the likely cause of postoperative haem-
in severity from minor blisters on the surface of the liver orrhage, correction of the coagulopathy must be a criti-
to ruptured central haematomas accompanied by severe cal part of the strategy.
haemorrhage. They may be recognized either at the time Perihepatic infections occur in fewer than 5 per
of the operation or in the course of CT scanning. cent of patients with significant hepatic injuries. They
develop more often in patients with penetrating inju- 7.3.8Injury to the retrohepatic vena cava
ries than in patients with blunt injuries, presumably
because of the greater frequency of enteric contamina- Approximately 2 per cent of all liver injuries are complex
tion. An elevated temperature and a rising white blood and represent injuries to major hepatic venous structures,
cell count should prompt a search for intra-abdominal the portal triad or the intrahepatic cava, injuries that are
infection. In the absence of pneumonia, an infected line bilobar, or injuries that are difficult to control because of
or urinary tract infection, an abdominal CT scan with hypothermia and coagulopathy. Injuries to the hepatic
intravenous and upper gastrointestinal contrast should vein or retrohepatic cava can be approached in the follow-
be obtained. ing ways:
Many perihepatic infections (but not necrotic liver) can
Direct compression and definitive repair
be treated with CT- or ultrasound-guided drainage. In
Intracaval shunting
refractory cases, especially for posterior infections, right
Temporary clamping of the porta hepatis, suprarenal
12th rib resection remains an excellent approach.
cava and suprahepatic cava (vascular isolation)
Bilomas are loculated collections of bile that may
Venovenous bypass
become infected. They are best drained percutaneously
Packing.
under radiological guidance. If a biloma is infected, it
should be treated as an abscess; if it is sterile, it will even- Direct compression and control of hepatic venous
tually be resorbed. injuries can be accomplished in some patients. Major
Biliary ascites is caused by disruption of a major bile liver injury requires manual compression and simultane-
duct, and requires reoperation and the establishment of ous medial rotation and retraction a difficult manoeu-
appropriate drainage. Even if the source of the leaking bile vre. In such a situation, the most senior surgeon should
can be identified, primary repair of the injured duct can be the one doing the direct compression, and the assist-
be difficult to achieve. It is best to wait until a firm fistu- ant should do the actual suturing of the hepatic vein or
lous communication is established with adequate drain- cava.
age. Adjunctive, transduodenal drainage by endoscopic The intracaval shunt has been maligned because only
retrograde cholangiopancreatography and papillotomy 2535 per cent of these patients survive their injury, and
(ductotomy), or stent placement, has recently been shown the subsequent surgery. Usually this is due to using the
to be of benefit in selected cases. device late in the course of treatment when the patient
Biliary fistulas occur in up to 15 per cent of patients has already developed coagulopathy and is premorbid.
with major hepatic injuries. They are usually of little Any decision to use a shunt should be made early, ide-
consequence and generally close without specific treat- ally prior to massive transfusion. However, in many cases,
ment. In rare instances, a fistulous communication with especially with blunt injury, packing the liver against the
intrathoracic structures forms in patients with associated cava secures haemostasis as part of damage control, and
diaphragmatic injuries, resulting in a bronchobiliary or the definitive care can take place later.
pleurobiliary fistula. Because of the pressure differential Hepatic vascular isolation, by clamping of the porta
between the biliary tract and the thoracic cavity, most of hepatis, suprarenal cava and suprahepatic cava, can be
these fistulas must be closed operatively. done on a temporary basis. This requires considerable
Haemorrhage from hepatic injuries is often treated experience on the part of the anaesthesiologist, and a sur-
without identifying and controlling each bleeding vessel geon capable of dealing with the problems rapidly.
individually, and arterial pseudoaneurysms may develop Venovenous bypass has been used successfully in liver
as a consequence. As the pseudoaneurysm enlarges, it may transplant surgery and, with new heparin-free pumps and
rupture into the parenchyma of the liver, into a bile duct tubing, it is possible to use this in the trauma patient.
or into an adjacent branch of the portal vein. Rupture into In some patients who have bilobar injuries with exten-
a bile duct results in haemobilia, which is characterized by sive bleeding, or in patients who have developed coagulop-
intermittent episodes of right upper quadrant pain, upper athy secondary to massive transfusions and hypothermia,
gastrointestinal haemorrhage and jaundice; rupture into it may be prudent to institute damage control procedures
a portal vein may result in portal vein hypertension with and return to surgery when physiological stability has
bleeding varices. Both of these complications are exceed- been obtained. Packing may often be used as definitive
ingly rare and are best managed with hepatic arteriogra- treatment. Vicryl mesh and omental pedicles also have
phy and embolization. been advocated in controlling severe lacerations.
The abdomen | 113
Injuries to the porta hepatis also can be exsanguinat- is recommended. An adjunctive measure is to bring the
ing. Right and left hepatic arteries can usually be man- roux-en-Y end to the subcutaneous tissue so that access
aged by simple ligation, as can injuries to the common can be gained later if a stricture develops. Percutaneous
hepatic artery. intubation of the roux-en-Y limb is then possible, with
Injuries to the left or right portal vein can be ligated. dilatation of the anastomosis.
Ligation of the portal vein has been reported to be suc- Treatment of injuries to the left or right hepatic duct is
cessful, but repair is recommended whenever possible. even more difficult. If only one hepatic duct is injured, a
The options for retrohepatic vein and vena cava injuries reasonable approach is to ligate it and deal with any infec-
include direct compression and extension of the lacerations or atrophy of the lobe rather than to attempt repair.
tion as mentioned above, atrial caval shunt, non-shunt If both ducts are injured, each should be intubated with
isolation (Heaney technique) and venovenous bypass. a small catheter brought through the abdominal wall.
Liver packing also can be definitive treatment, particu- Once the patient has recovered sufficiently, delayed repair
larly when there is bilobar injury, or it can simply buy is performed under elective conditions with a roux-en-Y
time if the patient develops a coagulopathy or hypother- hepatojejunostomy.
mia, or there are no blood resources. Liver packing is the
method of choice where expertise in more sophisticated
techniques is not available, or when it is therapeutic in 7.4The spleen
controlling the bleeding.
Packing should be removed in the standard damage 7.4.1 Overview
control sequence (when the patient is warm and appro-
priately transfused, and haemodynamic and respiratory The conventional management of splenic injury used to
parameters have been normalized). It is recommended be splenectomy. However, stimulated by the success of
that lateral and medial suction drains be placed after non-operative management (NOM) in children and the
packs have been removed, as biliary leak is relatively recognition of the importance of splenic function, there
common. has been a shift in strategy. Today, the management of
splenic injury should rely primarily on the haemodynamic
status of the patient on presentation, although splenic
7.3.9Injury to the bile ducts and gallbladder injury grade, patient age, associated injuries and institu-
tional specific resources must be taken into consideration.
Injuries to the extrahepatic bile ducts, although rare, can
be caused by either penetrating or blunt trauma. The
diagnosis is usually made by noting the accumulation of 7.4.2Anatomy
bile in the upper quadrant during laparotomy for treat-
ment of associated injuries. The splenic artery, a branch of the coeliac axis, provides
Bile duct injuries can be divided into those below the the principal blood supply to the spleen. The artery gives
confluence of the cystic duct and common duct and those rise to a superior polar artery, from which the short gas-
above the cystic duct. Treatment of common bile duct tric arteries arise. The splenic artery also gives rise to supe-
injuries after external trauma is complicated by the small rior and inferior terminal branches that enter the splenic
size and thin wall of the normal duct. hilum. The artery and the splenic vein are embedded in
For lower ductal injuries (those injuries below the cystic the superior border of the pancreas.
duct), when the tissue loss is minimal, the lesion can be Three avascular splenic suspensory ligaments maintain
closed over a T-tube (as with exploration of the common the intimate association between the spleen and the dia-
bile duct for stones). A choledochoduodenostomy can be phragm (splenophrenic ligament), left kidney (lienorenal/
performed if the duodenum has not been injured. If the splenorenal ligament) and splenic flexure of the colon
duodenum has been injured or there is tissue loss, since (splenocolic ligament). The gastrosplenic ligament con-
the common duct is invariably small, a modification of tains the short gastric arteries.
the Carrel patch can be utilized. These attachments place the spleen at risk of avulsion
In higher ductal injuries, between the confluence of the during rapid deceleration. The spleen is also relatively
cystic duct and the common duct and the hepatic paren- delicate and can be damaged by impact from the over
chyma, a hepaticojejunostomy with an internal splint lying ribs.
7.4.3Diagnosis assessment of injury, whether it is by radiological study,

laparotomy, laparoscopy or autopsy evaluation (Table7.6).
7.4.3.1Clinical
The patient may complain of left upper quadrant pain or 7.4.5 Management
referred pain to the left shoulder, and there may be local
tenderness. Signs of hypovolaemia (tachycardia or hypo-
7.4.5.1Non-operative management10
tension) might be present. Pain may radiate to the left
shoulder, and there may be a palpable mass. The approach of NOM for blunt splenic injuries in the
paediatric population is well described, with a splenic
7.4.3.2Computed tomography scan preservation rate of more than 90 per cent. Stimulated by
the success of NOM in children, there has been a simi-
In the haemodynamically stable patient with blunt
lar trend in haemodynamically stable adults with splenic
abdominal trauma, CT scanning is the preferred diag-
injury. The advantages of NOM include the avoidance of
nostic modality to identify and grade splenic injury.
non-therapeutic laparotomies with their associated cost
Computed tomography will show the parenchymal
and morbidity, a lower rate of intra-abdominal compli-
lesions and any blood collection. Contrast blush on the
cations and reduced transfusion risk. The risk of delayed
CT scan will indicate whether there is still active bleeding.
rebleeding of the spleen after NOM is acceptably low,
If so, angiography with embolization should be consid-
reportedly in the range of 18 per cent. Rebleeding is con-
ered if available.
sidered more likely if a higher grade injury (grade IV) has
been managed non-operatively.
7.4.3.3Ultrasound
After resuscitation and completion of the trauma work-
Ultrasonic diagnosis has the great advantage that it can up, haemodynamically stable patients with grade I, II or
be performed in the emergency room during resuscita- III splenic injuries who have no associated intra-abdomi-
tion. Focused abdominal sonography for trauma can nal injuries requiring surgical intervention, and who have
detect free fluid around the spleen and in the paracolic no co-morbidities to preclude close observation, are obvi-
gutter, indicating splenic injury. It will not show whether ous candidates for NOM. Even haemodynamically stable
active bleeding is taking place. Serial ultrasound examina- patients with grade IV or V injury can be treated success-
tions may be necessary. fully with NOM, often with routine angiographic emboli-
zation as part of the treatment protocol. However, the
7.4.4Splenic injury scale8 failure rate of NOM for splenic injuries in adults increases
with the grade of splenic injury. Patients with high-grade
The Organ Injury Scale of the American Association for splenic injuries treated non-operatively should be moni-
the Surgery of Trauma is based on the most accurate tored closely to detect any signs that indicate the need
Table 7.6 Splenic injury scale (see also Appendix B, Trauma scores and scoring systems)
Grade* Injury type Description of injury
I Haematoma Subcapsular <10% surface area

Laceration Capsular tear <1cm parenchymal depth
II Haematoma Subcapsular 1050% surface area; intraparenchymal <5cm in diameter
Laceration Capsular tear 13cm parenchymal depth that does not involve a trabecular vessel
III Haematoma Subcapsular >50% surface area or expanding; ruptured subcapsular or parenchymal haematoma; intraparenchymal
haematoma 5cm or expanding
Laceration >3cm parenchymal depth or involving trabecular vessels
IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)
V Laceration Completely shattered spleen
Vascular Hilar vascular injury with devascularized spleen
*Advance one grade for multiple injuries up to grade III.

The abdomen | 115
for intervention. Associated injuries must be excluded on The spleen is gently pulled upwards and medially, and
admission.15 However, there is less evidence to support the lienorenal and lienocolic ligaments are divided.
the use of serial CT scans, without clinical indications, to The spleen is then gently pulled downwards, and the
monitor progress.16 lienophrenic ligaments are divided with scissors, close
Angiography with embolization, if available, is a useful to the spleen, between the spleen and the diaphragm.
adjunct to NOM.17,18 The indications include evidence of The short gastric vessels between the greater curvature
ongoing bleeding with a significant drop in haemoglobin of the stomach and the spleen must be divided
level and tachycardia, or contrast extravasation outside between ligatures. These vessels must be divided away
or within the spleen on CT as well as formation of a from the greater curvature, as there is a danger of
pseudoaneurysm. avascular necrosis of the stomach if they are divided
There is no evidence that bed rest or restricted activity too close to the stomach itself.
is beneficial. The spleen is pulled forward, and several packs can be
placed in the splenic bed to hold it forward so that it
7.4.5.2 Operative management can be inspected.
If a patient with splenic injury is haemodynamically unsta- In the presence of other competing major injuries, if
ble, operative treatment is necessary. Although splenic there is haemodynamic instability or if the spleen has sus-
preservation is desirable, most patients who require an tained damage at the hilum, a routine splenectomy should
operation due to splenic bleeding will have a splenectomy be carried out. In the stable patient and in the absence
performed. of other life-threatening injuries, a partial splenectomy
Non-operative management is generally contraindi- or the use of local haemostatic agents should be consid-
cated and open surgical intervention is indicated19 when ered. In the stable patient and in the absence of other
there is: life-threatening injuries, splenic preservation should be
considered.
Haemodynamic instability
Risk of concurrent abdominal hollow organ injury, or
associated intra-abdominal injury requiring surgery 7.4.6.1Spleen not actively bleeding
Evidence of continued splenic haemorrhage If not actively bleeding, the spleen can be left alone.
Replacement of greater than 50 per cent of the
patients blood volume
Age over 55 years. 7.4.6.2Splenic surface bleed only
These bleeds will usually stop with a combination of
7.4.6Surgical approach manual compression, packing, diathermy, argon beam or
fibrin adhesives in combination with collagen fleece.
Access to the spleen in trauma is best performed via
a long midline incision. When indicated, the spleen is
7.4.6.3 Minor lacerations
mobilized under direct vision. In paediatric patients, a
midline incision should also be used, rather than a sub- These may be sutured using absorbable sutures, with or
costal incision, since there is better access to the entire without Teflon pledgets. Suturing is time-consuming and
abdominal cavity if there is injury to other intra-abdom- mostly not helpful in trauma patients. The superficial lac-
inal structures. erations are best treated with fibrin adhesive and collagen
The spleen is best approached by a surgeon standing tamponade. These measures are best taken at the begin-
on the patients right-hand side. The spleen is mobilized ning of the operation and the spleen packed; upon com-
under direct vision. Great care and gentle handling are pletion of the operation, the pack can be removed without
necessary to avoid pulling on the spleen, avulsing the cap- displacing the collagen fleece.
sule, and making a minor injury worse and stripping the
capsule off the lower pole.
7.4.6.4Splenic tears
Medial traction by the operators non-dominant hand
will give access to the lienophrenic, lienorenal and lieno- If the lacerations are deep and involve both the concave
colic ligaments. and convex surfaces, the spleen is best and most effectively
preserved with a mesh splenorrhaphy. If the lacerations of avascular necrosis of the wall of greater curvature of the
involve only one pole or one half of the organ, the respec- stomach. The posterior approach, more expedient, entails
tive vessels should be ligated, and a partial splenectomy manual mobilization and rotation of the spleen medially,
performed. after opening the peritoneum lateral to the convex surface
of the spleen. Care must be taken to avoid injuring the
tail of the pancreas, which lies very close to the hilum of
7.4.6.5 Mesh wrap
the spleen.
If the spleen is viable, it can be wrapped in an absorbable
mesh to tamponade the bleeding.
7.4.6.8Drainage
The prerequisite for mesh splenorrhaphy is complete
mobilization and elevation of the spleen. An absorbable The splenic bed is not routinely drained after splenectomy.
mesh should be chosen (e.g. Vicryl). There are meshes that If the tail of the pancreas has been damaged, a closed suc-
already include two or three purse-string sutures and can tion drain should be placed in the area affected.
be used according to the size of the spleen. If one wants
to make ones own purse-string pouch, it is advantageous
to make an impression of the spleen and then to stitch 7.4.7Complications
in a circle exactly on the edges, using absorbable suture
material. It is extremely important that the pouch should Delayed splenic rupture:20 this is probably not
be slightly smaller than the spleen, so that the suture lies delayed but contained
on the acute and obtuse margin when it has been pulled Left upper quadrant haematoma
taut. The mesh is pulled laterally over the spleen like a Pancreatitis
headscarf; the suture is tied on the hilar side but with- Pleural effusion
out compressing the hilum. Mild bleeding through the Pulmonary atelectasis
holes in the mesh can be stopped with collagen tampons Pseudoaneurysm of the splenic artery
together with fibrin glue or, if possible, autologous fibrin. Splenic arteriovenous fistula
Subphrenic abscess
7.4.6.6 Partial splenectomy Overwhelming post-splenectomy sepsis
Pancreatic injury/fistula/ascites.
This is rarely used in the trauma patient. Injuries involv-
ing only one pole of the spleen can be treated with partial
resection. Prior to resection, the spleen should be mobi-
7.4.8 Outcome
lized. Stapler resection makes organ conservation possible
in many cases, and it represents a valuable alternative to
A large number of publications support NOM in the
sutured partial splenectomy or splenorrhaphy. Its great-
haemodynamically stable patient.
est advantages are simplicity of use, the practicality of the
instrument itself and the reduction in time and blood NOM is becoming more routine, with a high success
transfusion. rate in haemodynamically stable patients.
The risk of delayed rebleeding of the spleen after
NOM is acceptably low, reportedly in the range of 18
7.4.6.7Splenectomy
per cent.
In the presence of other major injuries, with haemody- Pleural effusion, pulmonary atelectasis and
namic instability or if the spleen has sustained damage at pneumonia are not uncommon in patients treated
the hilum, a routine splenectomy should be carried out. either non-operatively or operatively.
Following careful mobilization of the spleen, the splenic Pseudoaneurysm development can be successfully
vessels (artery and vein) should be isolated and tied sepa- treated with embolization.
rately, as there is a small risk of subsequent arteriovenous Subphrenic abscess can be seen in patients treated
fistula formation. operatively, but may be treated by percutaneous
Access to the splenic pedicle can be anterior or poste- drainage.
rior. In the anterior approach, the short gastric vessels After splenectomy, there is a small but lifelong
must be ligated away from the stomach to avoid the risk risk of overwhelming post-splenectomy sepsis.
The abdomen | 117
Patients should be informed of the defect in their The surgeon must always be critically aware of the patients
immune system and be encouraged to keep their changing physiological state, and be prepared to forsake the techni-
pneumococcus and influenza immunizations current. cal challenge of definitive repair for life-saving damage control.
These patients are more susceptible to malaria than
the rest of the population.
7.5.2Anatomy
7.5THE Pancreas The pancreas lies at the level of the pylorus and crosses
the first and second lumbar vertebrae. It is about 15cm
7.5.1 Overview long from the duodenum to the hilum of the spleen, 3cm
wide and up to 1.5cm thick. The head lies within the con-
Pancreatic and combined pancreaticoduodenal inju- cavity formed by the duodenum, with which it shares its
ries remain a dilemma for most surgeons and, despite blood supply through the pancreaticoduodenal arcades.
advances and complex technical solutions, they still carry The pancreas has an intimate anatomical relationship
a high morbidity and mortality. The increase particularly with the upper abdominal vessels. It overlies the inferior
in penetrating injuries, and the increase in wounding vena cava, the right renal vessels and the left renal vein.
energy from gunshots, has made the incidence of pancre- The uncinate process encircles the superior mesenteric
atic injury more common. Pancreatic injury must be sus- artery and vein, while the body covers the suprarenal
pected in all patients with abdominal injuries, even those aorta and left renal vessels. The tail is closely related to
who initially have few signs. Since the pancreas is retro- the splenic hilum and left kidney, and overlies the splenic
peritoneal, it usually does not present with peritonitis. It artery and vein, with the artery marking a tortuous path
requires a high level of suspicion and significant clinical at the superior border of the pancreas.
acumen, as well as aggressive radiographic imaging, to There are a number of named arterial branches to the
identify an injury early. head, body and tail that must be ligated in spleen-sparing
The pancreas and duodenum are difficult areas for procedures. Studies have shown that between seven and
surgical exposure and represent a major challenge for 10 branches of the splenic artery, and 13 to 22 branches of
the operating surgeon when these organs are substan- the splenic vein, run into the pancreas.
tially injured. Although the retroperitoneal location of
the pancreas means that it is commonly injured, it also
contributes to the difficulty in diagnosis as the organ is 7.5.3 Mechanisms of injury
concealed, and this often results in delay, with an attend-
ant increase in morbidity.
7.5.3.1Blunt trauma
Management varies from simple drainage to highly
challenging procedures depending on the severity, the The relatively protected location of the pancreas means
site of the injury and the integrity of the duct. Accurate that a high-energy force is required to damage it. Most
intraoperative investigation of the pancreatic duct will injuries result from motor vehicle accidents in which the
reduce the incidence of complications and dictate the energy of the impact is directed to the upper abdomen
correct operation. The position of the pancreas makes its epigastrium or hypochondrium commonly through
access and all procedures on it challenging. To compound the steering wheel of an automobile. This force results
this, pancreatic trauma is associated with a high incidence in crushing of the retroperitoneal structures against the
of injury to adjoining organs and major vascular struc- vertebral column, which can lead to a spectrum of injury
tures, which adds to the high morbidity and mortality.21 from contusion to complete transection of the body of
A review of the English language literature on pancreatic the pancreas.
trauma from 1970 to 2006 states, among other things,
that limited injuries affecting the head of the pancreas are
7.5.3.2 Penetrating trauma
best managed by simple external drainage, even if there
is suspected pancreatic duct injury. Appropriate intraop- The rising incidence of penetrating trauma has increased
erative investigation of the pancreatic duct will reduce the risk of injury to the pancreas. A stab wound damages
the incidence of complications and dictate the correct tissue only along the track of the knife, but in gunshot
operation.22 wounds the passage of the missile and its pressure wave
will result in injury to a wider region. Consequently, the 7.5.4.4Diagnostic peritoneal lavage
pancreas and its duct must be fully assessed for damage
The retroperitoneal location of the pancreas renders diag-
in any penetrating wound that approaches the substance
nostic peritoneal lavage inaccurate in the prediction of
of the gland. Injuries to the pancreatic duct occur in 15
isolated pancreatic injury. However, the numerous associ-
per cent of cases of pancreatic trauma, and are usually a
ated injuries that may occur with pancreatic injury may
consequence of penetrating trauma.23
make the lavage diagnostic, and the pancreatic injury is
often found intraoperatively.
7.5.4Diagnosis
7.5.4.5Computed tomography
The central retroperitoneal location of the pancreas
makes the investigation of pancreatic trauma a diagnos- Computed tomography scan has been advocated as the
tic challenge: the specific diagnosis is often not clear until best investigation for evaluation of the retroperitoneum.
laparotomy, especially if there are other life-threatening In a haemodynamically stable patient, CT scanning with
vascular and other intra-abdominal organ injuries. In contrast enhancement has a sensitivity and specificity as
recent years, there has been debate about the need to high as 80 per cent.29 However, particularly in the initial
accurately assess the integrity of the main pancreatic duct. phase, CT scanning may miss or underestimate the sever-
Bradley et al.24 showed that mortality and morbidity were ity of a pancreatic injury,30 so normal findings on the ini-
increased when recognition of ductal injury was delayed. tial scan do not exclude appreciable pancreatic injury, and
When these results are reviewed in conjunction with ear- a repeated scan in the light of continuing symptoms may
lier work25,26 that showed an increase in late complications improve its diagnostic ability.
if ductal injuries were missed, the importance of evaluat-
ing the duct is evident. 7.5.4.6Endoscopic retrograde cholangiopancreatography
There are two phases in the investigation of pancreatic

7.5.4.1Clinical evaluation injury in which endoscopic retrograde cholangiopancrea-
In a patient with an isolated pancreatic injury, even duc- tography (ERCP) may have a role.
tal transection may be initially asymptomatic or have only
minor signs; the possibility must be kept in mind. Acute phase
Patients with isolated pancreatic trauma occasionally
7.5.4.2Serum amylase have benign clinical findings initially. It must be stressed
that these patients are few, as most patients will not be
The level of the serum amylase is not related to pancreatic stable enough, and their injuries will not allow position-
injury in either blunt or penetrating trauma. A summary ing for ERCP. However, where appropriate, ERCP will give
of recent work on serum amylase in blunt abdominal detailed information about the ductal system.
trauma by Jurkovich and Bulger27 showed a positive pre-
dictive value of 10 per cent and a negative predictive value
Post-traumatic or delayed presentation
of 95 per cent for pancreatic injury, although more recent
work has suggested that accuracy may be improved when A small number of patients present with symptoms
the activity is measured more than 3 hours after injury.28 months to years after the initial injury. Applying ERCP
At present, serum amylase has little value in the initial is effective in these patients and, in association with CT
evaluation of pancreatic injury. scanning, will allow a reasoned decision to be made about
the need for operative intervention.
7.5.4.3Ultrasound
7.5.4.7 Magnetic resonance cholangiopancreatography
The posterior position of the pancreas almost completely
masks it from diagnostic ultrasound. In conjunction with New software has opened up investigation of the pan-
its location, a post-traumatic ileus with loops of gas-filled creas and biliary system to magnetic resonance imaging
bowel will mask it even further, and assessment of the (MRI).31 However, to date, there has been little work done
pancreas is particularly difficult in obese patients. in pancreatic injuries.
The abdomen | 119
7.5.4.8Intraoperative pancreatography 7.5.5 Pancreas injury scale

Intraoperative visualization of the pancreatic duct has
The organ injury scale developed by the American
been advocated in the investigation of the duct, particu-
Association for the Surgery of Trauma (AAST)35 has been
larly when it is not possible to assess its integrity by exam-
accepted by most institutions that regularly deal with
ination. Nevertheless, in the opinion of Subramanian et
pancreatic trauma (Table 7.7).
al., simple examination of the area of injury for several
minutes with loupe magnification reveals a leakage of Table 7.7 Pancreas injury scale (see also Appendix B, Trauma scores
clear pancreatic fluid in most injuries that involve the and scoring systems)
pancreatic duct.32 An accurate assessment of the degree
of injury to the duct will reduce the complication rate,33 Grade* Type of injury Description of injury
indicate the most appropriate operation and, when no I Haematoma Minor contusion without duct injury
involvement is found, allow a less aggressive procedure Laceration Superficial laceration without duct injury
to be undertaken. The ductal system can be examined at
II Haematoma Major contusion without duct injury or
operation by transduodenal pancreatic duct catheteriza-
tissue loss
tion, distal cannulation of the duct in the tail, or needle
Laceration Major laceration without duct injury or
cholecystocholangiography.
tissue loss
The major drawback of surgical duodenotomy is the
III Laceration Distal transection or parenchymal injury
need for formal biliary sphincteroplasty for cannulation
with duct injury
of the duct, which can be lengthy and challenging, and
IV Laceration Proximal** transection or parenchymal
is rarely indicated. The main disadvantage of retrograde
injury involving the ampulla
pancreatography is that, at this level, the duct is small and
difficult to cannulate in the young patient with trauma.32 V Laceration Massive disruption of the pancreatic
Intraoperative ultrasound can be used to help diagnose head
a parenchymal or ductal laceration.34 *Advance one grade for multiple injuries up to grade III.
**The proximal pancreas is to the patients right of the superior mesenteric vein.
7.5.4.9 Operative evaluation
Operative evaluation of the pancreas necessitates com- 7.5.6 Management

plete exposure of the gland. A central retroperitoneal
haematoma must be thoroughly investigated, and intra-
7.5.6.1Non-operative management
abdominal bile staining makes a complete evaluation
essential to find the pancreatic or duodenal injury. In this In isolated blunt pancreatic injuries, exclusion of a major
case, a ductal injury must be assumed until excluded. pancreatic duct injury with ERCP followed by expectant
If the sphincter of Oddi and the distal biliary tract are NOM is gaining popularity. Recent reports utilizing early
intact, it is wise to attempt to preserve the head and neck ERCP to identify and sometimes treat blunt pancreatic
of the pancreas. A person can survive quite well with 10 injuries by transpapillary stent insertion are showing
per cent of the pancreas without pancreatic insufficiency promising results.36,37 A pancreatic duct stent appears
or diabetes. Major injuries to the body of the pancreas are useful for a proximal pancreatic fistula but may be com-
usually treated by a distal pancreatectomy with splenec- plicated by a long-term stricture, whereas ductal stenting
tomy. If the injury is to the head of the pancreas, involv- in the acute phase is potentially dangerous in that it may
ing the duct and sphincter, a Whipple procedure must be lead to a delay in necessary laparotomy and definitive
contemplated. Increasingly, there is a move toward lesser repair of the pancreatic injury.38 Because of the small size
procedures since the mortality of a Whipple procedure of the pancreatic duct distal to the ampulla, stenting is
continues to be significant in the severely injured trauma ordinarily not used in this location.39
patient. These injuries continue to be a major challenge Non-operative management of low-grade (grades I
for the trauma surgeon. It is essential to understand the and II) blunt pancreatoduodenal injuries is safe despite
manoeuvres necessary for gaining complete control of the occasional failures. Missed diagnosis continues to occur
duodenum and pancreas in order to completely explore despite advances in CT scanning, but does not seem to
and identify any injuries. cause an adverse outcome in most patients.40
7.5.6.2 Operative management explored, including irrigation of the haematoma, to

exclude possible injury of the duct.
Many pancreatic injuries will only be confirmed following
a CT scan, or actually at the time of surgery. The surgi-
cal approach is often for that of the presenting sign (e.g. Access via the lesser sac
peritonitis), and the pancreatic injury will be found at The stomach is then grasped and pulled inferiorly, allow-
laparotomy. There are commonly associated injuries of ing the operator to identify the lesser curvature and the
the duodenum, bowel mesentery, etc. pancreas through the lesser sac. Frequently, the coeliac
artery and the body of the pancreas can be identified
through this approach. The omentum is then grasped
7.5.7Surgical approach and drawn upwards. An otomy is made in the omentum,
and the operators hand is passed into the lesser sac poste-
7.5.7.1Incision and exploration rior to the stomach. This allows excellent exposure of the
entire body and tail of the pancreas. Any injuries to the
Access to the pancreas in trauma is gained via a long mid-
pancreas can be easily identified.
line incision.
Penetrating pancreatic trauma should be obvious
since the patient will almost invariably have been Duodenal rotation (Kochers manoeuvre)
explored for an obvious injury. Once the retroperito- If there is the possibility of an injury to the head of the
neum has been violated in penetrating trauma, it is pancreas, a Kocher manoeuvre is performed. The loose
imperative for the surgeon to do a thorough exploration areolar tissue around the duodenum is bluntly dissected,
of the central region. and the entire second and third portions of the duode-
Diagnosis of blunt pancreatic trauma is much more num are identified and mobilized medially. This dissec-
problematic. As the pancreas is a retroperitoneal organ, tion is carried all the way medially to expose the inferior
there may be no anterior peritoneal signs. The history vena cava and a portion of the aorta. By reflecting the
can be helpful if information from the paramedics indi- duodenum and pancreas toward the anterior midline,
cates that the vehicles steering column was bent, or if the posterior surface of the head of the pancreas can be
the patient can give a history of epigastric trauma. The completely inspected.
physical examination, as stated above, is often mislead-
ing. However, a doughy abdomen should make the cli- Right medial visceral rotation
nician suspicious. Amylase level and full blood count are
The inferior border of the proximal portion of the pan-
non-specific. Diagnostic peritoneal lavage and FAST are
creas can be identified by performing a right medial
unhelpful. Gastrografin swallow has fair sensitivity; CT
visceral rotation. This is performed by taking down the
scanning is at least 85 per cent accurate and remains the
ascending colon and then mobilizing the caecum, the
non-operative diagnostic modality of choice for blunt
terminal ileum and the mesentery toward the midline.
pancreatic injury. Endoscopic retrograde cholangiopan-
The entire ascending colon and caecum are then reflected
creatography can be helpful in selected patients.
superiorly towards the left upper quadrant of the abdo-
For complete evaluation of the gland, it is essential to
men. This gives excellent exposure of the entire vena
see the pancreas from both the anterior and posterior
cava, the aorta and the third and fourth portions of the
aspects. To examine the anterior surface of the gland, it
duodenum.
is necessary to divide the gastrocolic ligament and open
the lesser sac. An extended Kocher manoeuvre is required
so that the duodenum can be mobilized and an adequate Left medial visceral rotation
view gained of the pancreatic head, uncinate process and The descending colon on the left is mobilized, together
posterior aspect. Injury to the tail requires mobilization with the spleen and the tail of the pancreas. These are
of the spleen and left colon to allow medial reflection of rotated medially, allowing inspection of the tail and
the pancreas and access to the splenic vessels. Division of posterior and inferior aspects of the pancreas.
the ligament of Treitz and reflection of the fourth part
of the duodenum and duodenojejunal flexure gives access These manoeuvres allow for complete exposure of the
to the inferior aspect of the pancreas. Any parenchy- first, second, third and fourth portions of the duodenum
mal haematoma of the pancreas should be thoroughly along with the head, neck, body and tail of the pancreas.
The abdomen | 121
When pancreatic injury is suspected, extended explora- place a tube drain directly into the duct, both for drainage
tion of the whole organ is imperative. Parenchymal lac- and to allow easier isolation of the duct at the subsequent
erations that do not involve the pancreatic duct can be operation. The damage control laparotomy is followed
sutured when the tissue is not too soft and vulnerable. by a period of intensive care and continued aggressive
With or without the use of sutures, a worthwhile option resuscitation to correct physiological abnormalities and
in the treatment of such lacerations is fibrin sealing and restore reserve before the definitive procedure.
collagen tamponade, and adequate drainage is essential.
Contusion and parenchymal injuries
7.5.7.2 Pancreatic injury: surgical decision-making Relatively minor pancreatic lacerations and contusions
(AAST grades I and II) comprise most injuries to the
When ductal injury to the body and/or the tail of the pan- pancreas. Nowak et al.42 showed that these require simple
creas is suspected, the best and safest treatment is resec- drainage and haemostasis, and this has become standard
tion. In the case of severe injuries, therapeutic options practice.43 There is, however, debate about whether the
range from drainage alone to Whipples procedure. The ideal drainage system is a closed suction system or an
latter is a rarely used option with a high incidence of mor- open pencil drain. Those in favour of suction drainage
bidity and mortality. A good, effective and safe option is claim that fewer intra-abdominal abscesses develop and
pyloric exclusion with drainage of the injured area. With that there is less skin excoriation44 with a closed suction
concomitant duodenal injuries, an additional duode- system.
nal tube is necessary. The results of all these treatment Suturing of parenchymal lesions (AAST grades I and II)
options can be improved by using fibrin adhesives and in an attempt to gain haemostasis simply leads to necrosis
collagen fleece. of the pancreatic tissue. Bleeding vessels should be ligated
If there is obvious disruption to the pancreatic duct, it individually, and a viable omental plug sutured into the
should be ligated with distal pancreatic resection. defect to act as a haemostatic agent.
Injuries to the tail and body of the pancreas can usu-
ally be either drained or, if a strong suspicion for major Ductal injuries: tail and distal pancreas
ductal injury is present, resection can be carried out with
good results. The injuries that vex the surgeon most, Distal pancreatectomy
however, are those to the head of the gland, particularly In most cases in which there is a major parenchymal injury
those juxtaposed with or also involving the duodenum. of the pancreas to the left of the superior mesenteric ves-
Resection (Whipples procedure) is usually reserved for sels (AAST grades II or III), a distal pancreatectomy is the
those patients who have destructive injuries, or those in procedure of choice, independent of the degree of ductal
whom the blood supply to the duodenum and pancreatic involvement. Where there is concern over the involvement
head has been embarrassed. The remainder are usually of the duct, an intraoperative pancreatogram can be car-
treated with variations of drainage and pyloric exclusion. ried out. After mobilization of the pancreas and ligation
This includes extensive closed (suction) drainage around of the vessels, the pancreatic stump can be closed with
the injury site. Common duct drainage is not indicated. sutures and the duct ligated separately, or it can be closed
with a stapling device.45 An external drain should be
Damage control placed at the site of transection as there is a postoperative
fistula rate of 14 per cent.46 Suction drains are preferable.
The origin of the concept of damage control was described
Procedures associated with resection of greater than 80
by Halsted in the packing of liver injuries as reported and
per cent of the pancreatic tissue are associated with a risk
repopularized by Stone in 1908,41 who advocated early
of adult-onset diabetes mellitus. Most authors agree that
packing and termination of the operation in patients who
a pancreatectomy to the left of the superior mesenteric
showed signs of intraoperative coagulopathy.
vessels usually leaves enough pancreatic tissue to result
Patients with severe pancreatic or pancreaticoduode-
in an acceptably low rate of insulin-dependent diabetes.47
nal injury (AAST grades IV and V) are not stable enough
to undergo complex reconstruction at the time of initial Internal drainage of the distal pancreas
laparotomy. Damage control with the rapid arrest of Drainage of the distal pancreas with a roux-en-Y pan-
haemorrhage and bacterial contamination, and placement creaticojejunostomy has been suggested in cases in
of drains and packing, is preferable. It may be helpful to which there is not enough proximal tissue for endocrine
or exocrine function. Its popularity has greatly declined gastrojejunostomy. Contrast studies have shown that the
because of the high reported morbidity and mortality.48 pylorus reopens within 23 weeks in 9095 per cent of
patients, allowing flow through the anatomical channel.
Splenic salvage in distal pancreatectomy
Feliciano et al.50 reported on this technique in 68 of 129
Splenic salvage has been advocated in elective distal pan-
patients with combined injuries. Their results showed
createctomy, and is possible in some cases of pancreatic
a 26 per cent rate of pancreatic fistula formation and a
trauma. However, this should be saved for the rare occa-
6.5 per cent rate of duodenal fistula, but a reduced over-
sions when the patient is haemodynamically stable and
all mortality compared with patients who did not have
normothermic, and the injury is limited to the pancreas.
pyloric exclusion. The procedure has been adopted in
The technical problems of dissecting the pancreas free
many institutions for the treatment of grade III and IV
from the splenic vessels and ligating the numerous tribu-
combined pancreaticoduodenal injuries.
taries make the procedure contraindicated in an unstable
patient with multiple associated injuries.49 When this T-tube drainage
operation is considered, the surgeon must clearly balance Some surgeons advocate closing the injury over a T-tube
the extra time that it takes and the problems associated in combined injuries where the second part of the duo-
with lengthy operations in injured patients against the denum is involved. This ensures adequate drainage and
small risk of the development of overwhelming post- allows the formation of a controlled fistula once the track
splenectomy infection postoperatively. has matured. Our preference in these injuries, however, is
primary closure, pyloric exclusion and gastroenterostomy.
Suture and drainage
In most trauma units, simple suture and drainage is Internal and external drainage
reserved for minor injuries in which the pancreatic duct Although there is little controversy over the importance of
is not involved and injuries to both organs are slight.42 external, periduodenal drainage of complex duodenal or
pancreaticoduodenal injuries, the role of internal decom-
Ductal injuries: combined injuries of the head of the pression via a nasogastroduodenal or retrograde jejunodu-
pancreas and duodenum odenal tube, or tube duodenostomy, is more controversial.
Delay in repairing a duodenal injury often results in duo-
Severe combined pancreaticoduodenal injuries account
denal leaks, emphasizing the importance of adequate
for less than 10 per cent of injuries to these organs, and
external drainage that allows the formation of a controlled
are commonly associated with multiple intra-abdominal
fistula once the track has matured. The preferred method
injuries, particularly of the vena cava.50 They are usually
of managing complex duodenal injuries, however, is pri-
the result of penetrating trauma. The integrity of the dis-
mary closure, pyloric exclusion and gastroenterostomy.
tal common bile duct and ampulla on cholangiography,
and the severity of the duodenal injury, will dictate the Pancreaticoduodenectomy (Whipples procedure)
operative procedure. If the duct and ampulla are intact, In only 10 per cent of combined injuries will a pancrea-
simple repair and drainage or repair and pyloric exclusion ticoduodenectomy, or Whipples procedure, be required.
will suffice. Indications for considering a pancreaticoduodenectomy
are massive disruption of the pancreaticoduodenal com-
Duodenal diversion
plex, devascularization of the duodenum and sometimes
See Section 7.6.6, The duodenum, especially Sections
extensive duodenal injuries of the second part of the
7.6.6.5 (Duodenal diversion), 7.6.6.6 (Duodenal diverticu-
duodenum involving the ampulla or distal common bile
lation) and 7.6.6.7 (Triple tube decompression).
duct.51 This is a major procedure to be practised in trauma
Pyloric exclusion (see also Section 7.6.6.8) only if no alternative is available.52
Pyloric exclusion has been widely reported for the man- The Whipple procedure, as first described for carci-
agement of severe combined pancreaticoduodenal inju- noma of the ampulla,53 is indicated only in the rare stable
ries without major damage to the ampulla or the common patient with this type of injury. The nature and sever-
bile duct. The technique involves the temporary diversion ity of the injury and the coexisting damage to vessels is
of enteric flow away from the injured duodenum by clo- often accompanied by haemodynamic instability, and the
sure of the pylorus. This is best achieved with access from surgeon must therefore control the initial damage and
the stomach through a gastrotomy and the use of a slowly delay formal reconstruction until the patient has been
absorbable suture. The stomach is decompressed with a stabilized.54 The results of this operation vary, and when
The abdomen | 123
patients with major retroperitoneal vascular injuries are flexure, providing a non-invasive alternative. We prefer
included, mortality can approach 50 per cent. Oreskovich elemental diets that are less stimulating to the pancreas
and Carrico, however, reported a series of 10 Whipples and have no greater fistula output than total parenteral
procedures for trauma with no deaths.55 nutrition.60 Total parenteral nutrition is far more expen-
The role of pancreaticoduodenectomy in trauma is best sive, but may be used if enteral access distal to the duode-
summarized by Walt:56 nojejunal flexure is impossible.
Finally, to Whipple or not to Whipple, that is the

question. In the massively destructive lesions involv- 7.5.9 Pancreatic injury in children
ing the pancreas, duodenum and common bile duct,
the decision to do a pancreaticoduodenectomy is The pancreas is injured in up to 10 per cent of cases of
unavoidable; and, in fact, much of the dissection blunt abdominal trauma in children, usually as a result
may have been done by the wounding force. In a of a handlebar injury. Whether these children should be
few patients, when the call is of necessity close, the operated upon or managed conservatively (the current
overall physiologic status of the patient and the vogue for the management of solid organ injuries in chil-
extent of damage become the determining factors dren) is controversial. Shilyansky et al.61 reported that non-
in the decision. Though few in gross numbers, more operative management of pancreatic injuries in children
patients are eventually salvaged by drainage, TPN was safe for both contusion and pancreatic transection,
[total parenteral nutrition] and meticulous overall and Keller et al. recommended conservative management
care than by a desperate pancreaticoduodenectomy if there were no signs of clinical deterioration or major
in a marginal patient. ductal injury.62 A recent retrospective review of 31 cases
initially treated conservatively found that only 10 per cent
needed secondary surgery.63
7.5.8Adjuncts
Although pseudocysts are more likely to develop with
transection injuries, they tend to respond to percutane-
7.5.8.1Somatostatin and its analogues ous drainage.63
Somatostatin and its analogue octreotide have been used
to reduce pancreatic exocrine secretion in patients with
7.5.10Complications
acute pancreatitis. Despite meta-analysis, its role has
not been clearly defined. Bchler et al.57 reported a slight
Pancreatic trauma is associated with up to 19 per cent
but not significant reduction in the complication rate in
mortality. Early deaths result from the associated intra-
patients with moderate-to-severe pancreatitis, but this
abdominal vascular and other organ injuries, and later
was not verified by Imries group in Glasgow,58 who found
deaths from sepsis and the systemic inflammatory
that somatostatin gave no benefit.
response syndrome. Pancreatic injuries have postop-
After pancreatic surgery, somatostatin can reduce the
erative complication rates of up to 42 per cent, and the
output from a pancreatic fistula.59 Retrospective work on
number rises with increasing severity of injury; with com-
the role of octreotide in pancreatic trauma, however, dif-
bined injuries and associated injuries, the complication
fers. Somatostatin cannot be recommended in trauma on
rate approaches 62 per cent.64
the current evidence, and a level I study is required.
Most complications are treatable or self-limiting, how-
ever, and could be avoided by an accurate assessment of
7.5.8.2Nutritional support whether the pancreatic duct was damaged.65 Pancreatic
complications can be divided into those occurring early
Whether nutritional support is required should be con-
and those occurring late in the postoperative period.
sidered at the definitive operation. Major injuries that
precipitate prolonged gastric ileus and pancreatic com-
plications may preclude gastric feeding. The creation 7.5.10.1Early complications
of a feeding jejunostomy, ideally 1530cm distal to the
duodenojejunal flexure, should be routine and will allow Pancreatitis
early enteral feeding. Sometimes a long nasojejunal feed- Postoperative pancreatitis may develop in about 7 per
ing catheter can be negotiated past the duodenojejunal cent of patients. It may vary from a transient biochemical
leak of amylase to a fulminant haemorrhagic pancreatitis. Exocrine and endocrine deficiency

Fortunately, most cases run a benign course and respond Pancreatic resection distal to the mesenteric vessels will usu-
to bowel rest and nutritional support. ally leave enough tissue for adequate exocrine and endocrine
function, as work has shown that a residual 1020 per cent
Fistula of pancreatic tissue is usually enough. Patients who have
The development of a postoperative pancreatic fistula is procedures that leave less functioning tissue will require
the most common complication; this increases when the exogenous endocrine and exocrine enzyme replacement.
duct is involved, and the rate may be as high as 37 per cent
in combined injuries.66 Most fistulas are minor (less than
7.5.11Summary of evidence-based
200mL of fluid per day), and self-limiting when there is
guidelines 70
adequate external drainage. However, high-output fis-
tulas (>7000mL per day) may require surgical interven-
Table 7.8 gives a summary of the evidence-based guide-
tion for closure or prolonged periods of drainage with
lines for pancreatic trauma.
nutritional support. Management is directed locally at
adequate drainage, reduction of pancreatic output with Table 7.8 Summary of evidence-based guidelines for pancreatic trauma
octreotide and (recently) transpapillary pancreatic stent-
ing of confirmed ductal injuries.67 Systemic treatment Level of Recommendation
includes treatment of the underlying cause (such as sep- evidence
sis) and early adequate nutrition, preferably with distal I There are insufficient data to support a level I
enteral feeds through a feeding jejunostomy. If the fistula recommendation
persists, the underlying cause should be investigated with II There are insufficient data to support a level II
ERCP, CT scanning and operation as necessary. recommendation
III Delay in recognition of main pancreatic duct injury causes
Abscess formation increased morbidity
Most abscesses are peripancreatic and associated with Computed tomography scanning is suggestive, but not
injuries to other organs, specifically the liver and intes- diagnostic, of pancreatic injury
tine. A true pancreatic abscess is uncommon and usually Amylase/lipase levels are suggestive, but not diagnostic,
results from inadequate debridement of necrotic tissue. of pancreatic injury
For this reason, simple percutaneous drainage is generally Grade I and II injuries can be managed by drainage alone
not enough, and further debridement is required. Grade III injuries should be managed with resection and
drainage
7.5.10.2Late complications Closed suction is preferred to sump suction
Pseudocyst
Accurate diagnosis and surgical treatment of pancreatic
injuries should result in a rate of pseudocyst formation of 7.6The duodenum
about 23 per cent,68 but Kudsk et al.69 reported pseudocysts
in half their patients who were treated non-operatively for 7.6.1 Overview
blunt pancreatic trauma. Investigation entails imaging of
the ductal system with either ERCP or MRI. Accurate evalu- Duodenal injuries can pose a formidable challenge to the
ation of the state of the duct will dictate management, and surgeon, and failure to manage them properly can have
if the duct is intact, percutaneous drainage is likely to be devastating results. The total amount of fluid passing
successful. However, a pseudocyst together with a major through the duodenum exceeds 6L per day, and a fistula
ductal disruption will not be cured by percutaneous drain- in this area can cause serious fluid and electrolyte imbal-
age, which will convert the pseudocyst into a chronic fistula. ance. A large amount of activated enzymes liberated into
Current options include cystogastrostomy (open or endo- a combination of the retroperitoneal space and the peri-
scopic), endoscopic stenting of the duct or resection. toneal cavity can be life-threatening.
The abdomen | 125
Both the pancreas and the duodenum are well pro- tears at the junction of the third and fourth parts of the
tected in the superior retroperitoneum deep within the duodenum (and less commonly, the first and second parts
abdomen. Since these organs are in the retroperitoneum, are reported). These injuries occur at the junction of free
they usually do not present with peritonitis, and are (intraperitoneal) parts of the duodenum with fixed (retro-
delayed in their presentation. Therefore, in order to sus- peritoneal) parts. A high index of suspicion based on the
tain an injury to either one of them, there must be other mechanism of injury and physical examination findings
associated injuries. If there is an anterior penetrating may lead to further diagnostic studies.
injury, the stomach, small bowel, transverse colon, liver,
spleen or kidneys are frequently also involved. If there is
a blunt traumatic injury, there are frequently fractures of 7.6.3Diagnosis
the lower thoracic or upper lumbar vertebrae. It requires
a high level of suspicion and significant clinical acumen
7.6.3.1Clinical presentation
as well as aggressive radiographic imaging to identify an
injury to these organs this early in the presentation. The clinical changes in isolated duodenal injuries may be
Preoperative diagnosis of isolated duodenal injury can extremely subtle until severe, life-threatening peritonitis
be very difficult to make, and there is no single method develops. In the vast majority of the retroperitoneal per-
of duodenal repair that completely eliminates dehiscence forations, there is initially only mild upper abdominal
of the duodenal suture line. As a result, the surgeon is tenderness with a progressive rise in temperature, tachy-
frequently confronted with the dilemma of choosing cardia and occasionally vomiting. After several hours, the
between several preoperative investigations and many duodenal contents extravasate into the peritoneal cavity,
surgical procedures. A detailed knowledge of the available with the development of peritonitis. If the duodenal con-
operative choices and when each one of them is preferably tents spill into the lesser sac, they are usually walled off
applied is important for the patients benefit.71 and localized, although they can occasionally leak into
the general peritoneal cavity via the foramen of Winslow,
with resultant generalized peritonitis.72 Diagnostic diffi-
7.6.2 Mechanism of injury culties do not arise in the cases in which the blunt injury
causes intraperitoneal perforations.

7.6.3.2Serum amylase
Penetrating trauma is the leading cause of duodenal inju-
ries in countries with a high incidence of civilian violence. Theoretically, duodenal perforations are associated with
Because of the retroperitoneal location of the duodenum, a leak of amylase and other digestive enzymes, and it has
and its close proximity to a number of other viscera and been suggested that determination of the serum amylase
major vascular structures, isolated penetrating injuries of concentration might be helpful in the diagnosis of blunt
the duodenum are rare. The need for abdominal exploration duodenal injury.73,74 However, the test lacks sensitivity.75,76
is usually dictated by associated injuries, and the diagnosis The duodenum is retroperitoneal, the concentration of
of duodenal injury is usually made in the operating room. amylase in the fluid that leaks is variable, and amylase
concentrations often take hours to days to increase after
injury. Although serial determinations of serum amylase
7.6.2.2Blunt trauma
are better than a single, isolated determination on admis-
Blunt injuries to the duodenum are both less common sion, sensitivity is still poor, and necessary delays are
and more difficult to diagnose than penetrating inju- inherent in serial determinations. If the serum amylase
ries, and they can occur in isolation or with pancreatic level is elevated on admission, a diligent search for duode-
injury. These usually occur when crushing the duodenum nal rupture is warranted. The presence of a normal amy-
between the spine and a steering wheel or handlebar, lase level, however, does not exclude duodenal injury.77
or when some other force is applied to the duodenum.
These injuries can be associated with flexion/distraction
7.6.3.3Diagnostic peritoneal lavage/ultrasound
fractures of the L1L2 vertebrae the Chance fracture.
Stomping and striking the mid-epigastrium are com- The duodenum, like the pancreas, lies in the retro-
mon. Less common in deceleration injury patterns are peritoneum, so that neither ultrasound nor diagnostic
peritoneal lavage (DPL) will be reliable. Although virtually anatomical position, diagnostic laparoscopy is a poor
all patients with blunt duodenal injury will eventually have modality to determine organ injury in these cases.83
increased white blood cell and amylase levels in DPL fluid,
DPL has a low sensitivity for duodenal perforations.78
7.6.3.6Exploratory laparotomy
Exploratory laparotomy remains the ultimate diagnos-

7.6.3.4Radiological investigation
tic test if a high degree of suspicion of duodenal injury
Radiological studies may be helpful in diagnosis. Plain continues in the face of absent or equivocal radiographic
X-rays of the abdomen are useful when gas bubbles are signs.84
present in the retroperitoneum adjacent to the right psoas
muscle, around the right kidney or anterior to the upper
lumbar spine. They can also show free intraperitoneal air, 7.6.4Duodenal injury scale
and, although rarely seen, air in the biliary tree also has
been described.79 Obliteration of the right psoas muscle Grading systems have been devised to characterize duode-
shadow or fractures of the transverse processes in the nal injuries (Table 7.9).
lumbar vertebrae are indicative of forceful retroperitoneal
Table 7.9 Duodenum injury scale (see also Appendix B, Trauma scores
trauma and serve as a predictor of duodenal trauma.
and scoring systems)
An upper gastrointestinal series using water-soluble
contrast material can provide positive results in 50 per Grade* Type of injury Description of injury
cent of patients with duodenal perforations. Meglumine
I Haematoma Involving a single portion of duodenum
(gastrografin) should be infused via the nasogastric tube
and then swallowed, and the study should be done under Laceration Partial thickness, no perforation
fluoroscopic control with the patient in the right lateral II Haematoma Involving more than one portion
position. If no leak is observed, the investigation continues Laceration Disruption <50% of circumference
with the patient in the supine and left lateral positions. If III Laceration Disruption 5075% of circumference of D2
the Gastrografin study is negative, it should be followed Disruption 50100% of circumference of
by administration of barium to allow the detection of D1, D3 or D4
small perforations more readily. Upper gastrointestinal IV Laceration Disruption >75% of circumference of D2
studies with contrast are also indicated in patients with Involving the ampulla or distal common bile
a suspected intramural haematoma of the duodenum, duct
because they may demonstrate the classic coiled-spring V Laceration Massive disruption of the duodenopancreatic
appearance of complete obstruction by the haematoma.80 complex
Computed tomography scanning has been added to Vascular Devascularization of duodenum
the diagnostic tests used for investigation for subtle
duodenal injuries. It is very sensitive to the presence of *Advance one grade for multiple injuries up to grade III.
D1, first portion of duodenum; D2, second portion of duodenum; D3, third portion
small amounts of retroperitoneal air, blood or extrava-
of duodenum; D4, fourth portion of duodenum.
sated contrast from the injured duodenum, especially
in children.81,82 Its reliability in adults is more contro-
versial. The presence of periduodenal wall thickening or
haematoma without extravasation of contrast material 7.6.5 Management
should be investigated with a gastrointestinal study with
Gastrografin. If the result is normal, it should be followed While upper gastrointestinal radiological studies and CT
by a barium study contrast, if the patients condition scanning can lead to the diagnosis of blunt duodenal
allows this. trauma, exploratory laparotomy remains the ultimate
diagnostic test if a high suspicion of duodenal injury con-
tinues in the face of absent or equivocal radiographic signs.
7.6.3.5Diagnostic laparoscopy
The majority of duodenal injuries can be managed by
Unfortunately, diagnostic laparoscopy does not confer simple repair. More complicated injuries require more
any improvement over more traditional methods in the sophisticated techniques. High-risk duodenal injuries
investigation of the duodenum. In fact, because of its are followed by a high incidence of suture line dehiscence,
The abdomen | 127
and their treatment should include duodenal diversion. and management of any injury is complex, and resection,
The management of all full-thickness duodenal lac- unless involving the entire C loop and pancreatic head,
erations should include adequate external periduodenal is impossible. The lower portion involving the third and
drainage. Pancreaticoduodenectomy is practised only if fourth part of the duodenum can generally be treated like
no alternative is available. Damage control should pre- the small bowel, and the diagnosis and management of
cede the definitive reconstruction. The detailed knowl- injury is relatively simple, including debridement, closure,
edge of available operative choices and the situation for resection and reanastomosis.
which each one of them is preferably applied is important
for the patients benefit.
7.6.6.1Intramural haematoma
This is a rare injury of the duodenum specific to patients

7.6.6Surgical approach with blunt trauma. It is most common in children with
isolated force to the upper abdomen, possibly because
Although useful for research purposes, the specifics of the of the relatively flexible and pliable musculature of the
grading systems are less important than several simple childs abdominal wall, and half of the cases can be attrib-
aspects of the duodenal injuries: uted to child abuse.
The haematoma develops in the submucosal or subse-
The anatomical relation to the ampulla of Vater
rosal layers of the duodenum. The duodenum is not per-
The characteristics of the injury (simple laceration
forated. Such haematomas can lead to obstruction. The
versus destruction of duodenal wall)
symptoms of gastric outlet obstruction can take up to 48
The circumference of the duodenum involved
hours to present. This is due to the gradual increase of
Associated injuries to the biliary tract or pancreas, or
the size of a haematoma as the breakdown of the haemo-
major vascular injuries.
globin makes it hyperosmotic, with resultant fluid shifts
Timing of the operation is also very important as mor- into it. The diagnosis can be made by double-contrast CT
tality rises from 11 per cent to 40 per cent if the time inter- scan or upper gastrointestinal contrast studies that show
val between injury and operation is more than 24 hours.83 the coiled spring or stacked coin sign.80
(See also Section 7.5.7, on the surgical approach to the Management of the injury is usually considered non-
pancreas.) surgical, and best results are obtained by conservative
In addition to the Kocher manoeuvre to visualize the treatment, if associated injuries can be ruled out.85 After
second part of the duodenum, a medial visceral rotation 3 weeks of conservative management with nasogastric
can be used to expose the entire transverse part of the aspiration and total parenteral nutrition, the patient
duodenum. Alternatively, the fourth part of the duode- is re-evaluated. If there is no improvement, the patient
num can be mobilized by dividing the ligament of Treitz undergoes laparotomy to rule out the presence of duo-
and gently dissecting with right index finger in the avas- denal perforation or injury of the head of the pan-
cular plane behind the transverse duodenum. Combining creas, which may be an alternative cause of duodenal
this with the Kocher manoeuvre allows the index fingers obstruction.
to be brought together from both sides and thereby to The treatment of an intramural haematoma that is
exclude a posterior perforation of the transverse part of found at early laparotomy is controversial. One option
the duodenum. is to open the serosa, evacuate the haematoma without
From a practical point of view, the duodenum can violation of the mucosa, and carefully repair the wall of
be divided into one upper portion that includes the the bowel. The concern is that this may convert a partial
first and second parts, and another lower portion that tear to a full-thickness tear of the duodenal wall. Another
includes the third and fourth parts. The upper portion option is to carefully explore the duodenum to exclude
has complex anatomical structures within it (the common a perforation, leaving the intramural haematoma intact
bile duct and the sphincter) and the pylorus. It requires and planning nasogastric decompression postoperatively.
distinct manoeuvres to diagnose injury (cholangiogram
and direct visual inspection), and complex techniques to
7.6.6.2Duodenal laceration
repair them. The first and second parts of the duodenum
are densely adherent and dependent for their blood sup- The great majority of duodenal perforations and lacera-
ply on the head of the pancreas; therefore, the diagnosis tions can be managed with simple surgical procedures.
This is particularly true with penetrating injuries, when of the duodenum may not be possible without produc-
the time interval between injury and operation is nor- ing undue tension on the suture line. If this is the case
mally short. On the other hand, a minority are high risk, and complete transection occurs in the first part of the
for example with increased risk of dehiscence of the duo- duodenum, it is advisable to perform an antrectomy with
denal repair, with increased morbidity and sometimes closure of the duodenal stump and a Billroth II gastroje-
mortality. These injuries are related to associated pancre- junostomy. When such injury occurs distal to the ampulla
atic injury, blunt or missile injury, involvement of more of Vater, closure of the distal duodenum and roux-en-Y
than 75 per cent of the duodenal wall, injury of the first duodenojejunal anastomosis is appropriate.90
or second part of the duodenum, a time interval of more Mobilization of the second part of the duodenum
than 24 hours between injury and repair, and associated is limited by its shared blood supply with the head of
common bile duct injury. In these high-risk injuries, sev- the pancreas. A direct anastomosis to a roux-en-Y loop
eral adjunctive operative procedures have been proposed sutured over the duodenal defect in an end-to-side fash-
in an attempt to reduce the incidence of dehiscence of the ion is the procedure of choice. This also can be applied as
duodenal suture line. The methods of repair of the duode- an alternative method of operative management of exten-
nal trauma as well as the supportive procedures against sive defects to the other parts of the duodenum when pri-
dehiscence are described. mary anastomosis is not feasible.
External drainage should be provided in all duodenal
injuries because it affords early detection and control of
7.6.6.3Repair of the perforation
the duodenal fistula. The drain is preferably a simple,
Most injuries of the duodenum can be repaired by pri- soft silicone rubber, closed system placed adjacent to the
mary closure in one or two layers. The closure should be repair.
oriented transversely, if possible, to avoid luminal com-
promise. Excessive inversion should be avoided.
7.6.6.5Duodenal diversion
Longitudinal duodenotomies can usually be closed
transversely if the length of the duodenal injury is less In high-risk duodenal injuries, duodenal repair is followed
than 50 per cent of the circumference of the duodenum. by a high incidence of suture line dehiscence. In order to
If primary closure would compromise the lumen of the protect the duodenal repair, the gastrointestinal contents
duodenum, several alternatives have been recommended. with their proteolytic enzymes can be diverted, a prac-
A pedicled mucosal graft, as a method of closing large tice that would also make the management of a potential
duodenal defects, has been suggested, using a segment duodenal fistula easier.
of jejunum or a gastric island flap from the body of the
stomach. An alternative to that is the use of a jejunal
7.6.6.6Duodenal diverticulation
serosal patch to close the duodenal defect.86 The serosa
of the loop of the jejunum is sutured to the edges of the This includes a distal Billroth II gastrectomy, closure
duodenal defect. Although encouraging in experimental of the duodenal wound, placement of a decompressive
studies, the clinical application of both methods has been catheter into the duodenum, and generous drainage
limited, and suture line leaks have been reported.87 Laying of the duodenal repair.91 Truncal vagotomy and biliary
a loop of jejunum onto the area of the injury so that the drainage could be added. The disadvantage of duodenal
serosa of the jejunum buttresses the duodenal repair has diverticulation is that it is an extensive procedure totally
also been suggested,88 although no beneficial results have inappropriate for the haemodynamically unstable trauma
been reported from this technique.89 patient, or the patient with multiple injuries. Resection
of a normal distal stomach cannot be beneficial to the
patient, and should not be considered unless there is a
7.6.6.4Complete transection of the duodenum
large amount of destruction and tissue loss and no other
The preferred method of repair is usually primary anasto- course is possible.
mosis of the two ends after appropriate debridement and
mobilization of the duodenum. This is frequently the case
7.6.6.7Triple tube decompression
with injuries of the first, third or fourth part of the duo-
denum, where mobilization is technically not difficult. Tube decompression was the first technique used for
However, if a large amount of tissue is lost, approximation decompression of the duodenum and diversion of its
The abdomen | 129
contents in an attempt to preserve the integrity of the The closure of the pylorus breaks down after several
duodenorrhaphy. It was first described in 1954 as a weeks, and the gastrointestinal continuity is re-estab-
method of management of a precarious closure of the lished. This occurs regardless of whether the pylorus was
duodenal stump after a gastrectomy.92 To protect a duo- closed with absorbable sutures, non-absorbable sutures or
denal repair, a tube duodenostomy can be used by insert- staples.95
ing a tube through a separate incision through the lateral Major concern has been expressed at the ulcerogenic
duodenal wall using the Witzel technique to ensure seal- potential of the pyloric exclusion, as marginal ulceration
ing of the hole after removing the tube. In trauma, the has been reported in up to 10 per cent of patients.94,96 The
technique was introduced by Stone and Garoni as a triple long-term incidence of marginal ulceration in patients
ostomy.93 This consists of a gastrostomy tube to decom- who have undergone pyloric exclusion is probably under-
press the stomach, a retrograde jejunostomy to decom- estimated as it is notoriously difficult to obtain long-term
press the duodenum, and an antegrade jejunostomy to follow-up in the trauma population. We do not practise
feed the patient. vagotomy in our patients with pyloric exclusion.
The initial favourable reports on the efficacy of this Ginzburg et al. question the need to perform routine
technique to decrease the incidence of dehiscence of the gastrojejunostomy after pyloric exclusion, taking into
duodenorrhaphy have, however, not been supported by consideration that the continuity of the gastrointestinal
more recent reports.94 The drawbacks of this technique are tract will be re-established within 3 weeks in 90 per cent of
the formation of several new perforations in the gastroin- patients. 97,98 A duodenal fistula can still occur with pyloric
testinal tract, the inefficiency of the jejunostomy tube to exclusion, and there is concern that spontaneous opening
properly decompress the duodenum, and the common of the pyloric sphincter will negatively influence the clo-
scenario of finding that the drains have fallen out or been sure of the fistula. This has been shown not to be a clini-
removed by the patient. The fashioning of a feeding jeju- cally relevant problem. Pyloric exclusion is a technically
nostomy at the initial laparotomy in patients with duode- easier, less radical and quicker operation than diverticula-
nal injury and extensive abdominal trauma (Abdominal tion of the duodenum, and appears to be equally effective
Trauma Index score >25) is highly recommended. in the protection of the duodenal repair.99,100 Recent ret-
rospective studies show, however, that pyloric exclusion
does not decrease duodenal leak rates or improve out-
7.6.6.8 Pyloric exclusion
come when compared with simple primary repair, even
Pyloric exclusion was devised as an alternative to this after severe duodenal injuries.101
extensive procedure in order to shorten the operative time The use of octreotide to protect the suture line in pan-
and make the procedure reversible. After primary repair creaticojejunostomy after pancreaticoduodenectomy has
of the duodenum, a gastrotomy is made at the antrum been shown to be beneficial.57,102 The principle is attrac-
along the greater curvature. The pyloric ring is grasped tive, but further experience is required before sound con-
and invaginated outside the stomach through the gastrot- clusions can be drawn.
omy and is closed with a large running suture or stapled.
The closed pyloric ring is returned into the stomach, and
7.6.6.9 Pancreaticoduodenectomy (Whipples procedure)
the gastrojejunostomy is fashioned at the gastrotomy site
(Figure 7.8). This is a major procedure to be practised in trauma only
if no alternative is available. Damage control with con-
trol of bleeding and of bowel contamination, and ligation
of the common bile and pancreatic ducts, should be the
rule.51 Reconstruction should take place within the next
48 hours when the patient is stable.
7.6.6.10Specific injuries
Simple combined injuries of the pancreas and duodenum

should be managed separately. More severe injuries require
Figure 7.8 Pyloric exclusion and gastric bypass. more complex procedures. Feliciano et al. reported by far
the largest experience of combined pancreaticoduodenal 7.7.2Injuries of the aorta and vena cava
injuries,50 and suggested the following:
Aorta and caval injuries are primarily a problem of access
Simple duodenal injuries with no ductal pancreatic
(rapid) and control of haemorrhage. If the surgeon opens
injury (grades I and II) should be managed with
the abdomen and there is extensive retroperitoneal bleed-
primary repair and drainage.
ing centrally, there are two options:
Grade III duodenal and pancreatic injuries are best
treated with repair or resection of both organs as If the bleeding is primarily venous in nature, the right
indicated, pyloric exclusion, gastrojejunostomy and colon should be mobilized to the midline, including
closure. the duodenum and head of the pancreas. This will
Grades IV and V duodenal and pancreatic injuries are expose the infrarenal cava and infrarenal aorta. It will
best treated by pancreaticoduodenectomy. also facilitate access to the portal vein.
If the bleeding is primarily arterial in nature, it
Extensive local damage of the intraduodenal or intra-
is best to approach the injury from the left. This
pancreatic bile duct injuries frequently necessitates a
includes taking down the left colon and mobilizing
staged pancreaticoduodenectomy. Less extensive local
the pancreas and spleen to the midline. Access to the
injuries can be managed by intraluminal stenting,
posterior aorta includes mobilizing the left kidney. By
sphincteroplasty or reimplantation of the ampulla of
approaching the aorta from the left lateral position,
Vater.103,104
it is possible to identify the plane of Leriche more
rapidly than it is by approaching it through the
lesser sac. The problem is the coeliac and superior
7.7Abdominal vascular injury
mesenteric ganglion, which can be quite dense and
hinder dissection around the origins of the coeliac
7.7.1 Overview
and superior mesenteric artery. Additional exposure
can be obtained simply by dividing the left crus of
Abdominal vascular injury presents a serious threat to life
the diaphragm. This will allow proximal control of
where preparedness and anticipation are vital to a success-
the abdominal aorta until complete dissection of the
ful outcome. Consideration of both the possible injuries
visceral vessels can be accomplished. The exception is
and the surgical approach to manage them is crucial.
in the area of the coeliac ganglion, which can contain
Adequate preparation is essential, an adequate incision
aortic haemorrhage from significant injuries, and
will be required.
which may require short segmental graft replacement.
It is helpful to have available all the apparatus for massive
transfusion, with adequate warming of all intravenous fluids. Treatment of aortic or caval injuries is usually straight-
Autotransfusion should be considered in all cases. forward. Extensive lacerations are not compatible with
Major vessel injuries within the abdominal cavity prima- survival, and it is uncommon to require graft material
rily present as haemorrhagic shock that does not respond to repair the aorta. Caval injuries below the renal veins,
to resuscitation; thus, immediate surgery becomes a part if extensive, can be ligated, although lateral repair is pre-
of the resuscitative effort. In penetrating injury, this may ferred. Injuries above the renal veins in the cava should be
necessitate an emergency department thoracotomy and repaired if at all possible, including onlay graft of autog-
aortic cross-clamping. enous tissue.
However, the emergency department thoracotomy is not
indicated in the severely shocked patient with blunt abdominal
trauma, as the survival rate is close to zero. 7.7.3Retroperitoneal haematoma in the
Direct or proximal control of the vessel is mandatory for abdomen
success. Injuries above the pelvic brim can be approached
from the right side if the injury is thought to be below the
7.7.3.1Central haematoma
renal artery, and from the left side for injuries between
the renal artery and the hiatus. Vascular injuries in the To expose the potential sites of arterial bleeding in the
pelvis following blunt trauma are best managed with an upper midline region of the retroperitoneum, medial vis-
arteriogram. This will determine whether a direct opera- ceral rotation is performed by mobilizing not only the
tive approach or interventional radiology is appropriate. left colon, but also the spleen, pancreas and stomach. The
The abdomen | 131
lienorenal and lienophrenic ligaments are divided, followed leave pelvic haematomas undisturbed if they are not rap-
by an incision down the left paracolic gutter, and a blunt idly expanding or pulsatile, as they are most likely due to
dissection to free the organs from the retroperitoneum pelvic venous damage. These veins are notoriously fragile
towards the centre of the abdomen. An extended reflection and unforgiving to any attempt at repair.
of the abdominal structures from the left to the right will There is recent literature to support extraperitoneal
reflect the spleen, colon, tail of pancreas and fundus of the pelvic packing as the most efficient damage control tech-
stomach towards the midline. This provides access to the nique to control this type of bleeding.105 After packing,
aorta, the coeliac axis, the superior mesenteric artery, the the patient should be sent directly to the angiographic
splenic artery and vein, and the left renal artery and vein. suite from the operating theatre, for embolization, with-
In order to reach the posterior wall of the aorta, the kid- out further exploration.
ney should be mobilized as well and rotated medially on its
pedicle, taking great care not to cause further injury.
7.7.4Surgical approach
7.7.3.2Lateral haematoma
7.7.4.1Incision
If a lateral haematoma is not expanding or pulsatile, blunt
The patient must be prepared from sternal notch to
injuries are best left alone, as the damage is usually renal.
knee. It is critical to gain proximal and distal control, and
Renal injuries can generally be managed non-operatively
patient preparation should include the need to extend to
including the use of selective embolization. However, with
a left lateral thoracotomy to gain access to the thoracic
penetrating injury, because of the risk of damage to adja-
aorta, a median sternotomy to control the intracardiac
cent structures such as the ureter, it is safer to explore
IVC, and groin incisions to gain control of the iliac vessels.
lateral haematomas, even if they are not expanding. The
surgeon must also be confident that there is no perfora-
tion of the posterior part of the colon in the paracolic 7.7.4.2Aorta
gutters on either side.
Control of the aorta can be achieved at several different lev-
els depending on the site of injury. The supracoeliac aorta
7.7.3.3 Pelvic haematoma can be exposed by incising the gastrohepatic ligament,
If the patient is stable, contrast-enhanced CT in the and retracting the left lobe of the liver superiorly and the
emergency situation may demonstrate a large pelvic hae- stomach inferiorly. A window is then made in the lesser
matoma with a vascular blush indicating ongoing arte- omentum, and the peritoneum overlying the crura of the
rial bleeding. In this case, it may be more appropriate to diaphragm is divided. The fibres of the crura are separated
transfer the patient for immediate embolization. by sharp or blunt dissection. This is often difficult, but is
This surgery is fraught with hazard, and exploration of such essential for proper exposure in this area. The oesophagus
haematomas should be a last resort. Wherever possible, angi- is then mobilized to the left in order to reach the abdomi-
ographic visualization and embolization of any arterial bleeding nal aorta at the diaphragmatic hiatus. The aorta can be
must be tried before surgery is commenced, if the patient is suffi- clamped or compressed at this point (Figure 7.9).
ciently stable. However, rapidly expanding or pulsating haemato- Exposure of the suprarenal aorta is not ideal with this
mas in this region may need exploration. anterior approach, and better exposure can be obtained by
The first concern should be to apply a binder to reduce performing a left medial visceral rotation procedure. This
pelvic volume. Stabilization of the pelvis using external entails mobilization of the splenorenal ligament and inci-
fixators or a C-clamp in the emergency situation can be sion of the peritoneal reflection in the left paracolic gutter,
considered, but this does not always provide adequate down to the level of the sigmoid colon. The left-sided vis-
posterior fixation, and may interfere with subsequent viscera are then bluntly dissected free of the retroperitoneum,
ualization of vessels for embolization. If the patient is too and mobilized to the right. Care should be taken to remain
unstable for angiography, damage control surgery with in a plane anterior to Gerotas fascia. The entire abdomi-
packing of the pelvis should provide initial control. The nal aorta and the origins of its branches are exposed by
peritoneum is incised over the distal aorta or the iliac ves- this technique. This includes the coeliac axis, the origin of
sels, in order to control the arterial inflow, before atten- the superior mesenteric artery, the iliac vessels and the left
tion is directed to the actual injury. However, it is best to renal pedicle. The dense and fibrous superior mesenteric
Figure 6:8 Control of aorta by cross clamping
The left gastric and splenic arteries can be tied. The

common hepatic artery can be safely tied provided that
the injury is proximal to the gastroduodenal artery.
7.7.4.4Superior mesenteric artery
The superior mesenteric artery is a vital artery for the via-

bility of the small bowel, and should always be repaired,
using conventional techniques (Figure 7.10). Proximally,
the artery is accessible from the aorta at the level of the
renal arteries, and is best approached with a left medial
visceral rotation. More distally, the artery is accessed at
the root of the small bowel mesentery.
If a period of ischaemia has elapsed, or the surgery is
part of a damage control procedure, the artery should be
shunted, using a plastic vascular shunt (e.g. Javid shunt),
until repair can be effected.106
Figure 7.9 Control of the aorta by cross-clamping at the crura of the If repair is not possible, and replacement of the artery
diaphragm. with a graft is required, it is best to place the graft on
the infrarenal aorta, away from the pancreas and areas
and coeliac nerve plexuses, however, overlie the proximal of potential leak.107 Placement of the proximal end of
aorta and need to be sharply dissected in order to identify the graft too high can result in kinking and subsequent
the renal and superior mesenteric arteries. occlusion of the graft when the bowel is returned to the
The distal aorta can be approached transperitoneally abdominal cavity. The graft must be tailored so that there
by retracting the small bowel to the right, the transverse is no tension, and the aortic suture line must be covered
colon superiorly, and the descending colon to the left. The to prevent an aortoenteric fistula.
aorta below the left renal vein can be accessed by incising The survival rate with penetrating injuries of the supe-
the peritoneum over it and mobilizing the third and fourth rior mesenteric artery is approximately 58 per cent, falling
parts of the duodenum superiorly. Both iliac vessels can be to 22 per cent if a complex repair is required.107,108
exposed by distal continuation of the dissection. The ure- The superior mesenteric vein can be either shunted or
ters should be identified and carefully preserved, especially simply ligated.109
in the region of the bifurcation of the iliac vessels.
7.7.4.5Inferior mesenteric artery
7.7.4.3Coeliac axis
Injuries to the inferior mesenteric artery are uncommon,
The left colon is reflected to the right, together with the and the artery can generally be tied off. The viability of
spleen and the tail of pancreas, to display the aorta and its
branches. The coeliac trunk lies behind and inferior to the
gastro-oesophageal junction. Injuries to this area are com- Superior mesenteric
monly missed, particularly in patients with stab wounds. artery
Major vascular injury is particularly likely if there is a cen-
Left renal artery
tral retroperitoneal haematoma. In this situation, proxi- Coeliac artery
mal vascular control prior to entering the haematoma is
essential, either locally or via a left lateral thoracotomy.
Division of the left triangular ligament and mobilization
of the lateral segment of the left lobe of the liver is also
helpful.
It is difficult to repair the coeliac axis. The artery can Aorta
be tied off, provided that the tie is proximal to its main

branches and the superior mesenteric artery is intact. Figure 7.10 Anatomy of the superior mesenteric artery.
The abdomen | 133
the colon should be checked before closure, with planned

reoperation to evaluate viability of the colon.
7.7.4.6Renal arteries
Preliminary vascular control is best obtained by accessing

the renal arteries on the aorta using a standard infrarenal
aortic approach. Access can also be obtained by mobiliz-
ing the viscera medially.
Repair is done using standard vascular techniques.
However, the kidney tolerates warm ischaemia poorly,
and its viability after 45 minutes is in doubt. Therefore, if
there has been complete transection of the artery, and the
kidney is of doubtful viability, preservation may not be in
the best interest of the patient.
7.7.4.7Iliac vessels
Proximal and distal control may be required, and distal

control via a separate groin incision should be considered.
The iliac vessels are exposed by lifting the small bowel
upwards, out of the pelvis. On the left, the sigmoid colon
and its mesentery can be mobilized, and on the right, divi-
sion of the peritoneal attachments over the caecum and
mobilization of the caecum to the midline will aid expo-
Figure 7.11 Right medial visceral rotation to expose the inferior vena cava.
sure of the vessels.
The ureters must be formally identified as they cross
the iliac bifurcation.
The common iliac veins are often adherent to the back reflected medially in a plane anterior to Gerotas fascia.
wall of the common iliac artery, and attempts to mobilize If more exposure is required, the root of the mesentery
the veins for control may result in torrential bleeding. A vas- can be mobilized by dividing the inferior mesenteric vein.
cular clamp, applied proximally from above to the hypogas- Performance of a Kocher manoeuvre and medial mobiliza-
tric and iliac veins, may be preferable to direct control. tion of the duodenum and head of the pancreas will reveal
the segment of vena cava immediately below the liver, and
also provide excellent exposure of the right renovascular
7.7.4.8Inferior vena cava110 pedicle.
Control is best achieved by direct pressure on the IVC
Suprahepatic IVC
above and below the injury, utilizing swabs (Figure 7.12).
Access to the suprahepatic IVC can be obtained by incis- If more definitive control is required, a combination of
ing the central tendon of the diaphragm, or by perform- vascular clamps to the renal arteries and Rumel tourni-
ing a median sternotomy and opening the pericardium. quets placed above the renal vessels (suprarenal), or above
and below the injury, should be used (Figure 7.13).
Infrahepatic IVC Injuries to the posterior part of the IVC should always
The infrahepatic vena cava can be exposed by means of be expected with penetrating injury to the anterior part
Title: Manual of Definitive Surgical Trauma
of Care
the Author:
3E Not all
IVC. bleedingBoffard ISBN: 9781444102826
posterior wounds need to be Proof Stage: 1
a right medial visceral rotation procedure (Figure 7.11;
see also right medial visceral rotation in Section 7.1.2.5, repaired.
www.cactusdesign.co.uk
Retroperitoneum). It is very difficult to roll the IVC to approach it poste-
The right colon is mobilized by taking down the hepatic riorly, due to multiple lumbar veins, so all injuries should
flexure and incising the peritoneal reflection down the be approached transcavally. Not all non-bleeding poste-
length of the right paracolic gutter. The colon is then rior wounds require repair.
Figure 7.12 Control of the inferior vena cava using swab pressure.
Figure 7.13 Control of the inferior vena cava with clamps and two
Rumel tourniquets.
Provided it is infrarenal, ligation of the IVC is acceptable.
7.7.4.9 POrtal vein111
The portal vein lies in the free edge of lesser omentum,

together with the common bile duct and the hepatic
artery (Figure 7.14).
The portal vein can generally be controlled with a
Pringles manoeuvre. If the injury is more proximal, it may Hepatic
artery
be necessary to reflect the duodenum medially, or divide
the pancreas.
The portal vein should be shunted early to avoid Common
venous hypertension of the bowel, which will make access bile duct
to the area increasingly difficult. The stent can be left in
place as part of a damage control procedure, or repaired. Portal vein
Portocaval shunting is a possibility, and ligation as a last
resort; ligation, however, carries a high mortality.
nitive Surgical Trauma Care 3E Author: Boffard ISBN: 9781444102826 Proof Stage: 1 Fig No: 7.12
Figure 7.14 Access to the portal vein.
co.uk 7.7.5 shunting

fashioned from a suitable size of plastic tube, for example
If repair is not possible, or the procedure is being abbrevi-
nasogastric tube, endotracheal tube, chest tube, etc.:
ated, vascular shunting will restore circulation. It can be
performed atraumatically, and rapidly. The length required is three times the length of the defect.
If Javid or other proprietary shunts are available, these The diameter should be two-thirds of the diameter of
can be used. However, if they are not, a shunt can be the vessel to be shunted.
The abdomen | 135
The shunt is fashioned as follows (Figure 7.15): 7.8 the urOgenital systeM
Choose a plastic tube with the correct diameter.
Cut the tube to length, as described above, bevelling 7.8.1 Overview
the edges so that they can be passed into the vessel.
Tie a length of silk around the tube, dividing it into a Urogenital trauma refers to injuries to the kidneys, ure-
one third to two-thirds ratio. ters, bladder and urethra, the female reproductive organs
in the pregnant and non-pregnant state, and the penis,
Once the vessel has been controlled, using either clamps scrotum and testes.
or Rumel tourniquets: Death from penetrating bladder trauma was men-
Clamp one end of the shunt to prevent leakage. tioned in Homers Iliad, as well as by Hippocrates and
Pass the long (two-thirds) end of the shunt up the Galen, while Evans and Fowler in 1905 demonstrated
vessel until the shunt is lying inside the vessel lumen that the mortality from penetrating intraperitoneal blad-
or proximally, releasing the tourniquet to allow it to der injuries could be reduced from 100 per cent to 28 per
pass through. cent with laparotomy and bladder repair. Ambroise Par
Using the silk as a handle, pull the shunt distally observed death following a gunshot wound of the kidney,
into the other end of the vessel. with haematuria and sepsis, and it was only in 1884 that
Secure it with ties. nephrectomy became the recommended treatment for
renal injury.
There is no need for anticoagulation as the patients Haematuria is the hallmark of urological injury, but
are often coagulopathic, and the rate of flow itself should may be absent even in severe trauma, and a high index
prevent clot formation. The shunt can be left in place for of suspicion is then needed, based on the mechanism of
4872 hours. injury and the presence of abdominal and pelvic injury.
7.8.2 renal injuries
Injury to the kidney is seen in up to 10 per cent of patients

with blunt or penetrating abdominal injuries; however,
most cases involve blunt rather than penetrating injury.
Serious renal injuries are frequently associated with inju-
ries to other organs, with multiorgan involvement in 80
per cent of patients with penetrating trauma and in 75 per
cent of those with blunt trauma.
Haematuria, defined as more than five red blood
cells per high-power field, is present in over 95 per cent
of patients who sustain renal trauma; however, the
absence of haematuria does not preclude significant
renal injury.
7.8.2.1 diagnOsis
The first investigation is to look for gross haematu-

ria, followed by urinalysis to check for microscopic
haematuria.
Up to 30 per cent of patients with serious renal trauma will
have no haematuria whatsoever, while the majority of patients
with significant abdominal trauma will have microscopic haema-
turia, often in the absence of relevant renal injury.
Figure 7.15 Diagrammatic representation of manufacture and
placement of a vascular shunt.
The haemodynamic status of the patient will then pyelogram (IVP)/tomogram, followed by angiography if
determine the subsequent steps, for both blunt and pen- suspicious, or multiphase contrast-enhanced CT scan-
etrating trauma. ning of the abdomen as a stand-alone investigation.
Unstable patient Blunt trauma

The investigation of choice in unstable patients is imme- Investigations, as above, are reserved for children irrespec-
diate surgery. tive of urinalysis, and adults with frank haematuria or a
systolic blood pressure below 90mmHg.
Stable patient
Computed tomography has replaced intravenous urogra- 7.8.2.2Renal injury scale
phy as the primary modality for the assessment of sus-
pected renal injuries. The investigation of choice is the Table 7.10 outlines the renal injury scale.
multiphase, double- or triple-contrast CT scan, but this
can misgrade the renal injury. More commonly, however,
7.8.2.3 Management
it does allow grading of renal injuries, and forms the basis
for non-operative treatment, possibly up to, and inclusive Unstable patient
of, non-vascular grade IV injuries and blunt renal artery
At laparotomy, it will become apparent whether or not
thrombosis.
the kidneys are the source of the shock. Should a large
It has been shown that the size of the haematoma can
retroperitoneal haematoma be present in the region of
be related to the grade of renal injury, which is a use-
the kidney, the options are to leave the kidney alone at
ful correlation in suboptimal studies and where older
first and perform a single shot on-table IVP, to assess the
machines are used.
functionality of both kidneys, explore the injured kidney
Contrast-enhanced ultrasound can also allow the visu-
immediately, or pack the area around the kidney and get
alization of active intrarenal bleeds.
out, if in a damage control situation.
In addition, duplex Doppler ultrasound can allow visu-
alization of arteriovenous fistulas and active intrarenal
bleeds. Stable patient
Non-operative management
Penetrating trauma In recent years, it has been recognized that many renal
The individual trauma centres accepted method of injuries can be managed without operation, and angioem-
evaluation of penetrating torso trauma must be used, bolization is a worthwhile option, if the skills are readily
the renal visualization being provided by an intravenous available.
Table 7.10 Kidney injury scale (see also Appendix B, Trauma scores and scoring systems)
Grade* Type of injury Description of injury
I Contusion Microscopic or gross haematuria, urological studies normal

Haematoma Subcapsular, non-expanding without parenchymal laceration
II Haematoma Non-expanding perirenal haematoma confined to the renal retroperitoneum
Laceration <1.0cm parenchymal depth of renal cortex without urinary extravasation
III Laceration >1.0cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
IV Laceration Parenchymal laceration extending through the renal cortex, medulla and collecting system
Vascular Main renal artery or vein injury with contained haemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilum that devascularizes the kidney
*Advance one grade for bilateral injuries up to grade III.

Reproduced from Moore et al. (1989).112
The abdomen | 137
In a recent review, 97 patients sustained a kidney injury, 7.8.2.4Surgical approach

72 from blunt force trauma and 25 from penetrating
Access should be by midline laparotomy, even if isolated
injury. Of the 72 blunt trauma patients, only 5 patients (7
renal injury is suspected, since the likelihood of other
per cent) underwent urgent nephrectomy, 3 (4 per cent)
injuries is always present.
had repair and/or stenting, and 89 per cent were observed
The kidneys are usually explored after dealing with the
despite a 29 per cent laparotomy rate for associated intra-
intra-abdominal emergencies. Ideally, control of the renal
abdominal injuries. Of the 25 patients with penetrating
pedicle should be obtained before opening Gerotas fascia.
trauma, 8 (31 per cent) underwent a nephrectomy, 1 had
A direct approach to suspected peripheral penetrating
a partial nephrectomy, and 2 underwent renal repairs.
injuries is advocated by some as being faster and equally
Nephrectomy was more likely to be required after pen-
safe. A left medial visceral rotation on the left, including
etrating injury, and was most likely in severely injured
division of Gerotas fascia and medial rotation of the left
patients with ongoing haemorrhage.
kidney, or an extended Kochers manoeuvre on the right
An on-table IVP should be obtained even in the absence
can also afford good control of the aorta, IVC and renal
of a large haematoma to exclude renal artery thrombosis,
vessels, if required.
followed by exploration with repair or nephrectomy in the
The right renal artery can be found by dissecting pos-
persistently unstable patient.
teriorly between the aorta and the IVC (Figure 7.16).
Up to half of renal stab injuries, and up to one-third
Dissection lateral to the IVC may lead to inadvertent iso-
of gunshot in one series, can be treated non-operatively,
lation of a segmental branch of the right renal artery. The
as long as excellent diagnostic methods can visualize the
vessels are then controlled by loops to allow rapid occlu-
injuries.
sion should bleeding occur on opening Gerotas fascia.
In principle, management can be guided by the
The right renal vein is easily controllable after reflection
severity of injury, and many patients can be treated
of theFigure
right colon
6:13:and duodenum,
Access to theand has to
Right be mobi-
Kidney
non-operatively.113,114
lized to expose the artery. It always should be repaired if
Grades I and II possible, because of the lack of collateral venous drainage.
These comprise the majority of renal injuries and can usu-
ally be treated conservatively.
Grade III
These comprise major lacerations through the cortex
extending to the medulla or collecting system with or
without urinary extravasation. Drainage may be necessary.
Grade IV
These are catastrophic injuries, and include multiple
renal lacerations and vascular injuries involving the renal
pedicle. These injuries often require surgery, and may
need nephrectomy. The most significant vascular injury
following blunt trauma is thrombosis of the main renal
artery, caused by deceleration with intimal tear and prop-
agation of thrombus in the renal artery.
Grade V
Pelviureteric junction injuries are a rare consequence of
Figure 7.16 Access to the right kidney.
blunt trauma, and are caused by sudden deceleration,
which creates tension on the renal pedicle. The diag-
nosis may be delayed because haematuria is absent in The peritoneum over the aorta is opened, and the
one-third of patients. Pelviureteric junction injuries are anterior wall of the aorta followed up to the left renal
classified into two groups: avulsion (complete transec- vein. After exposing the retroperitoneum from the right
tion) and laceration (incomplete tear). Nephrectomy is or the left, the left renal artery is identified by dissect-
often required. ing upwards on the lateral aspect of the aorta above the
Fig 6: 14 138 Access
| Manual
to of
theDefinitive Surgical Trauma Care
left kidney
inferior mesenteric vein. The left renal vein crosses the collateral drainage via the lumbar gonadal and
aorta just below the level of the origin of the renal arteries adrenal vessels will be sufficient to deal with the
(Figures 7.17 and 7.18). venous drainage on the left (Figure 7.19).
After control of the renal pedicle has been obtained,

Gerotas fascia can be opened or debrided as necessary.
Care must be taken not to strip the renal capsule from
the underlying parenchyma, as this may bleed profusely.
The mobilized kidney now can be examined, debrided,
trimmed and sutured with drainage (Figure 7.20).
The kidney tolerates a single ischaemic event much
better than repeated ischaemic times. However, the maxi-
mum warm ischaemic time that the kidney will tolerate
is less than 1 hour, although this can be prolonged by ice
packing.
With complete vascular isolation for up to 30 minutes,
Gerotas fascia is then opened, and the injured kidney
debrided by sharp dissection, and sutured or partially
amputated. The renal pelvis collecting system should
Figure 7.17 Access to the left kidney. be closed with a running absorbable suture to provide a
watertight seal. Nephrectomy will be required in less than
10 per cent of stable patients.
Cover can then be effected using the renal capsule,
omentum, meshes, etc., replacing the kidney within
Gerotas fascia, and draining the area with a suction drain
until it is draining minimally and urine collections have
been excluded.
Nephrostomy tubes or ureteric stents can be used either
immediately or at some later time in cases of major renal
trauma with extravasation.
7.8.2.5 POstOPerative care
Urinomas, infected urinomas, perinephric abscesses and

delayed bleeding are the most common complications
of conservative management, and are often amenable to
imaging and percutaneous, transureteric or angiographic
management. Even when the kidney appears to be shat-
tered into several pieces, drainage of the surrounding uri-
Figure 7.18 Access to the left renal vessels.
nomas seems to encourage healing and avoid sepsis.
Hypertension is a rare late complication.115
Access to the left renal artery may also
be improved by one of two manoeuvres:
Ligation of the adrenal, gonadal and

lumbar tributaries of the left renal vein
will enhance the mobilization of the
vein to expose the renal artery.
Ligation of the distal renal vein at
the IVC can improve exposure of
the origin of the renal artery. The
Figure 7.19 Division of the left renal vein.
The abdomen | 139
7.8.3 ureteric injuries
Significant ureteric injuries are often missed or not picked

up until late, after the onset of complications or deterio-
ration in renal function.
7.8.3.1 diagnOsis
Patients with ureteric injury present without even micro-

scopic haematuria in up to 50 per cent of cases, and the
injuries are mostly associated with penetrating trauma,
although ureteric avulsion and rupture can happen in
blunt trauma, especially in the paediatric population.
Ureteric injuries may even be missed by high-dose IVP,
and a high index of suspicion is essential. Intraoperative
recognition may be facilitated by the intravenous or
intraureteral injection of indigo carmine or methylene
blue.
7.8.3.2 surgical aPPrOach
The procedures described for access to the retroperito-

neal great vessels allow also perfect exposure to both ure-
ters. Ureteric injuries are rare, usually due to penetrating
trauma, so that local exploration and mobilization of part
of the ascending or descending colon alone may be suf-
ficient, depending on the site of injury. Minimal dissec-
tion of the periureteric tissues should take place, except
at the precise level of injury, in order to preserve the deli-
cate blood supply. Ureteric injuries close to the kidney
are accessed by left or right medial visceral rotation as
described above. Ureteric injuries near the bladder may be
accessed by opening the peritoneal layer in the region and
mobilizing the bladder.
Unstable patients
Unstable patients require immediate surgery and explora-
tion of the ureter after life-threatening injuries have been
dealt with, ideally preceded by one-shot on-table IVP.
If the patient requires an abbreviated laparotomy, the
ureteric injury can be safely left alone, stented or ligated
until the patient returns to the operating theatre for
definitive procedures; indeed, successful repair has fre-
quently been effected after delayed or missed presentation.
Percutaneous nephrostomy can be used as a postoperative
adjunct for the ligated ureter.
In unstable patients with associated colonic injuries,
especially those requiring colectomy, even nephrectomy
itive Surgical Trauma Care 3E Author: Boffard ISBN: 9781444102826 Proof Stage: 1 Fig No: 7.20
Figure 7.20 Techniques of renal repair. can be justified.
o.uk
The abdomen | 141
7.8.4.2 Management 7.8.5Urethral injuries

Urgent operative treatment is indicated in all intraperi-
Urethral injuries can have the most disastrous conse-
toneal, and some types of extraperitoneal, injuries, while
quences of all genitourinary trauma, such as inconti-
others require delayed surgery upon failure of non-oper-
nence, long-lasting impotence and strictures.
ative methods. The greatest majority of penetrating inju-
ries require immediate surgery.
7.8.5.1Diagnosis
Non-operative management The mechanism of injury, a pelvic fracture and blood at
Urethral or suprapubic catheter drainage with a large- the meatus must alert the surgeon to the possibility of
bore catheter, for up to 2 weeks, will allow most extraperi- a urethral rupture, mainly of the posterior urethra from
toneal injuries from blunt trauma to heal; surgery will be blunt trauma.
needed only if a cystogram at that stage shows ongoing Rectal examination is mandatory before urethral cath-
leakage. Contraindications to non-operative management eter insertion, and a high-riding prostate will suggest that
are bladder neck injury, the presence of bony fragments the urethra is disrupted. Rupture of the female urethra is,
through the bladder wall, infected urine and associated fortunately, very uncommon.
female genital injuries. Once rupture is suspected, two completely different
Extraperitoneal bladder repair during a laparotomy approaches are practised and acceptable:
for other trauma is often easily accomplished, but may
Retrograde urethrography is performed by placing a
be dangerous if it requires opening into a tamponaded
small Foley catheter in the fossa navicularis, with the
pelvic haematoma, and is inappropriate in the context of
patient in the oblique position.
damage control.
The preferable approach, however, is not to
intervene with an emergency procedure at all. This
7.8.4.3Surgical approach is particularly important if a pelvic haematoma
is present, due to the risk of effectively causing
Bladders can be repaired easily and with few complica- a compound injury. It is preferable to place a
tions with absorbable sutures. suprapubic catheter (it will be necessary to allow the
All repairs should be carried out through an intraperi- bladder to fill until it is palpable prior to insertion
toneal approach, from within the lumen of the bladder, of the catheter). A cystogram and, if necessary,
after performing an adequate longitudinal incision on the cystoscopy can then be done under controlled
anterior surface in order to avoid entering lateral pelvic circumstances at a later stage.
haematomas.
The presence and patency of both ureteric orifices must
be confirmed in all cases. If suturing in the vicinity, these 7.8.5.2 Management
should be cannulated with a size 5 feeding tube or ureteric
catheter. Suprapubic cystostomy
In cases of gunshot wound, both wounds to the blad- The mainstay of immediate treatment is the placement
der must be sought and identified. In some situations, it of a suprapubic catheter for urinary drainage. This can
will be necessary to open the bladder widely, explore and be done as an isolated open procedure, as an open pro-
repair from within. cedure during a laparotomy, or using a percutaneous
Single-layer mass suturing is indicated in extraperito- method. The isolated open method requires a lower mid-
neal ruptures, but for intraperitoneal ruptures closure line laparotomy incision, and an intraperitoneal approach
should be in separate layers. to the bladder to avoid entering a pelvic haematoma.
A large-bore transurethral or suprapubic catheter, Suprapubic placement during a laparotomy done for
or both, can be used, the latter being fed extraperito- other reasons follows the same principles.
neally into the bladder, and a drain left in the Retzius Percutaneous placement is done using specifically
space. A cystogram will be done in most cases after 10 designed trochar and catheter kits.
days to 2 weeks, followed by removal of the suprapubic The procedure requires a full bladder, as identified
catheter. clinically or on ultrasound. If this is not the case, and the
patient is not in a condition to produce a lot of urine, a sufficient. This can be achieved by an open lower midline
small intravenous catheter can be placed under ultrasonic laparotomy and passage of Foley catheters from above
guidance using the Seldinger technique, and the bladder and below, with ultimate passage into the bladder, or via
can then be distended with saline until a standard percu- flexible cystoscopy and manipulation.
taneous method can be used. Patients managed with a suprapubic catheter alone
should have their definitive urethral repair after about 3
months from the injury.
7.8.5.3Ruptured urethra Primary realignment may have better results than delayed
Urethral injuries are most often associated with pelvic frac- repair, but delayed primary repair (day 810) is recommended
tures, especially anterior arch fractures with displacement. when there is a large haematoma.
Although blood at the urethral meatus, gross haematuria
and displacement of the prostate are signs of urethral dis-
ruption, their absence does not exclude urethral injury. 7.8.6Scrotal injury
The male urethra is divided into two portions:
The posterior urethra is made up of the prostatic 7.8.6.1Diagnosis

urethra and the membranous urethra, which Ultrasound of the scrotum is indicated in evaluation of
courses between the prostatic apex and the perineal blunt trauma to the testicle, and can differentiate between
membrane. The membranous urethra is prone to torsion, disruption and haematoma.
injury from pelvic fracture because the puboprostatic
ligaments fix the apex of the prostate gland to the
bony pelvis, and shearing forces are applied to the 7.8.6.2 Management
urethra when the pelvis is disrupted. The blood supply to the scrotum is so good that pene-
The anterior urethra is distal to that point. It is susceptible trating trauma usually can be treated by debridement and
to blunt force injuries along its path in the perineum suturing.
(such as from direct blows or fall astride injuries). If the tunica vaginalis of the testis is disrupted, the
The conventional treatment for urethral injury is to extruding seminiferous tubules should be trimmed off
divert the urinary stream with a suprapubic catheter and and the capsule closed as soon as possible, in order to
refer to a specialist centre for delayed reconstruction of minimize host reaction against the testis.
the urethral injury. Early endoscopic realignment (within 1 Loss of scrotal skin with exposed testicle, a well-
week of injury) using a combined transurethral and percu- described occurrence after burns and other trauma, often
taneous transvesical approach is advocated by some experts. can be remedied by the creation of pouches in the proxi-
Anterior urethral trauma may present late, with symp- mal thigh skin and subsequent approximation, with little
toms of urethral stricture. effect on the testicles.
Urethral repair 7.8.7Gynaecological injury and sexual

Immediate surgical intervention is recommended for the assault
following conditions:
Any evidence of gynaecological injury requires external
All penetrating injuries of the posterior urethra and
and internal examination using a speculum, and exclu-
most of the anterior urethra
sion of associated urethral and anorectal injuries. If rape
Posterior urethral injuries associated with rectal
is suspected or reported, the official sexual assault evi-
injuries and bladder neck injuries
dence collection kit should be used, and detailed clinical
Where there is wide separation of the ends of the urethra
notes should be made. The patient must be counselled,
Penile fracture.
and informed consent must, where possible, be obtained
Accurate approximation and end-to-end anastomo- for examinations.
sis is recommended for injuries to the anterior urethra, Reporting of all cases of sexual assault should be car-
while for membranous urethra injuries, realignment and ried out by the treating physician, in order to minimize
stenting over a Foley catheter for 3 or 4 weeks may be underreporting by the already traumatized patient.
The abdomen | 143
7.8.7.1 Management 6 Leaper DJ, Pollock AV, Evans M. Abdominal wound

closure: a trial of nylon, polyglycolic acid and steel sutures.
Lacerations of the external genitalia and vagina can be
Br J Surg 1977;64:6036.
sutured under local or general anaesthesia, and a vaginal
7 Cayten CG, Fabian TC, Garcia VF, Ivatury RR, Morris
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Additional supportive care for the psychological effects
Malangoni MA, Champion HR. Organ injury scaling:
of sexual assault should be made available.
spleen and liver (1994 revision). J Trauma 1995;38:3234.
Antiretroviral treatment is more effective if instituted
9 Richardson JD, Franklin GA, Lukan JK et al. Evolution in
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and pregnancy prophylaxis should be given according to
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standard protocols. Baseline blood tests required include
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the duodenum: a comparison of 1 closure and the jejunal representative cases and a description of technique.
patch. J Trauma 1975;15:84753. JTrauma 2005;59:151014.
89 Ivatury RR, Gaudino J, Ascer E et al. Treatment of 106 Reilly PM, Rotondo MF, Carpenter JP, Sherr SA, Schwab
penetrating duodenal injuries. J Trauma 1985;25:33741. CW. Temporary vascular continuity during damage
90 Purtill M-A, Stabile BE. Duodenal and pancreatic trauma. control: intraluminal shunting for proximal superior
In: Naude GP, Bongard FS, Demetriades D, eds. Trauma mesenteric artery injury. J Trauma 1995;39:75760.
Secrets. Philadelphia: Hanley & Belfus, 1999: 12330. 107 Accola KD, Feliciano DV, Mattox KL, Burch JM, Beall AC
91 Berne CJ, Donovan AJ, White EJ et al. Duodenal Jr, Jordan GL Jr. Management of injuries to the superior
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Surg 1974;127:5037. 108 Asensio JA, Britt LD, Borzotta A et al. Multi-institutional
92 Welch CE, Rodkey CV. Methods of management of the experience with the management of superior mesenteric
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1954;98:37680. 3656.
93 Stone HH, Garoni WJ. Experiences in the management of 109 Donahue TK, Strauch GO. Ligation as definitive
duodenal wounds. South Med J 1966;59:8648. management of injury to the superior mesenteric vein.
94 Cogbill TH, Moore EE, Feliciano DV et al. Conservative JTrauma 1988;28:5413.
management of duodenal trauma: a multicentre 110 Feliciano DV, Burch JM, Mattox K, Edelman M. Injuries of
perspective. J Trauma 1990;30:146975. the inferior vena cava. Am J Surg 1988;156:54852.
95 Martin TD, Felicano DV, Mattox KL et al. Severe 111 Stone HH, Fabian TC, Turkleson ML. Wounds of the portal
duodenal injuries: treatment with pyloric exclusion and venous system. World J Surg 1982;6:33541.
gastrojejunostomy. Arch Surg 1983;118:6315. 112 Moore EE, Shackford SR, Pachter HL et al. Organ
96 Buck JR, Sorensen VJ, Fath JJ et al. Severe Injury Scaling: Spleen, liver and kidney. J Trauma
pancreaticoduodenal injuries with vagotomy. Am Surg 1989;29:16646.
1992;58:55761. 113 Armenakas NA. Duckett CP, McAninch JW. Indications for
97 Degiannis E, Krawczykowski D, Velmahos GC et al. Pyloric nonoperative management of renal stab wounds. J Urol
exclusion in severe penetrating injuries of the duodenum. 1999;16:76871.
World J Surg 1993;17:7514. 114 Velmahos GC, Demetriades D, Cornwell EE 3rd et al.
98 Ginzburg E, Carillo EH, Sosa JL et al. Pyloric exclusion in Selective management of renal gunshot wounds. Br J Surg
the management of duodenal trauma: is concomitant 1998;85:11214.
gastrojejunostomy necessary? Am Surg 1997;63:9646. 115 Montgomery RC, Richardson JD, Harty JI. Posttraumatic
99 Asensio JA, Feliciano DV, Britt LD et al. Management of renovascular hypertension after occult renal injury.
duodenal injuries. Curr Probl Surg 1993;30:102392. JTrauma 1998;45:10610.
100 Asensio JA, Demetriades D, Berne JD. A unified approach
to surgical exposure of pancreatic and duodenal injuries.
Am J Surg 1997;174:5460.
101 DuBose JJ, Inaba K, Teixeira PG et al. Pyloric exclusion
in the treatment of severe duodenal injuries: results 7.10Recommended reading
from the National Trauma Data Bank. Am Surg
2008;74:92529. 7.10.1The trauma laparotomy
102 Sikora SS, Posner MC. Management of the pancreatic
stump following pancreaticoduodenectomy. Br J Surg Demetriades D, Velmahos GC. Indications for laparotomy. In:
1995;82:159097. Moore EE, Feliciano DV, Mattox KL, eds. Trauma, 6th edn.
103 Jurkovich GJ, Hoyt DB, Moore FA et al. Portal triad injuries. New York: McGraw-Hill, 2008: 60722.
J Trauma 1995;39:42634. Hoff WS, Holevar M, Nagy KK et al. Practice management
104 Obeid FN, Kralovich KA, Gaspatti MG et al. Sphincteroplasty guidelines for the evaluation of blunt abdominal trauma.
as an adjunct in penetrating duodenal trauma. J Trauma J Trauma 2002;53:60215. Also in: Eastern Association
1999;47:224. for the Surgery of Trauma, Trauma Practice Management
105 Smith WR, Moore EE, Osborn P et al. Retroperitoneal Guidelines. Available from: www.east.org (accessed
packing as a resuscitation technique for haemodynamically December 2010).
The abdomen | 147
7.10.2The liver 7.10.7The Urogenital system
Bade PG, Thomson SR, Hirshberg A et al. Surgical options in Santucci RA, Bartley JM. Urologic trauma guidelines: a 21st
traumatic injury to the extrahepatic biliary tract. Br J Surg century update. Nat Rev Urol 2010;7:51019.
1989;76:2568. Santucci RA, Wessels H, Bartsch G et al. Evaluation and
Feliciano DV, Bitondo CG, Burch JM et al. Management of management of renal injuries: consensus statement of the
traumatic injuries to the extrahepatic biliary ducts. Am J Renal Trauma Subcommittee. Br J Urol Int 2004;93:93754.
Surg 1985;150:7059.
Moore EE. Critical decisions in the management of hepatic 7.10.7.1Renal injuries
trauma. Am J Surg 1984;148:71216.
Posner MC, Moore EE. Extrahepatic biliary tract injury: operative Coburn M. Genitourinary trauma. In: Feliciano DV, Moore EE,
management plan. J Trauma 1985;25:8337. Mattox KL, eds. Trauma, 6th edn. New York: McGraw-Hill,
Sheldon GF, Lim RC, Yee ES et al. Management of injuries to 2008: 789826.
the porta hepatis. Ann Surg 1985;202:53945. El Khader K, Bouchot O, Mhidia A, Guille F, Lobel B, Buzelin
JM. Injuries of the renal pedicle: is renal revascularization
justified? Prog Urol 1998;8:9951000.
7.10.3The spleen Gonzales RP, Falimirski M, Holevar MR, Evankovich C. Surgical
management of renal trauma: is vascular control necessary?
Peizman AB, Heil B, Rivera L et al. Blunt splenic injury in adults: J Trauma 1999;47:103944.
multi-institutional study of the Eastern Association for the Meng MV, Brandes SB, McAnich JW. Renal trauma: indications
Surgery of Trauma. J Trauma 2000;49:17787. and techniques for surgical exploration. World J Urol
Savage SA, Zarzaur BL, Magnotti LJ et al. The evolution of 1999;17:717.
blunt splenic injury: resolution and progression. J Trauma Velmahos GC, Degiannis E. The management of urinary tract
2008;64:108592. injuries after gunshot wounds of the anterior and posterior
Smith J, Armen S, Cook CH, Martin LC. Blunt splenic injuries: abdomen. Injury 1997;28:5358.
have we watched long enough? J Trauma 2008;64:65665.
7.10.7.2Ureteric injuries
7.10.4The pancreas Armenakas NA. Current methods of diagnosis and management
of ureteral injuries. World J Urol 1999;17:7883.
Eastern Association for the Surgery of Trauma Guidelines for
Velmahos GC, Degiannis E, Wells M, Souter I. Penetrating
the Diagnosis and Management of Pancreatic Trauma.
ureteral injuries: the impact of associated injuries on
Available from www.east.org.
management. Am Surg 1996;62:4618.
7.10.5The duodenum 7.10.7.3Bladder
Seamon MJ, Pieri PG, Fisher CA et al. A ten-year retrospective Haas CA, Brown SL, Spirnak JP. Limitations of routine spiral
review: does pyloric exclusion improve clinical outcome after computerized tomography in the evaluation of bladder
penetrating duodenal and combined pancreaticoduodenal trauma. J Urol 1999;162:502.
injuries? J Trauma 2007;62:82933. Volpe MA, Pachter EM, Scalea TM, Macchia RJ, Mydlo JH. Is
Velmahos GC, Constantinou C, Kasotakis G. Safety of repair there a difference in outcome when treating traumatic
for severe duodenal injuries. World J Surg 2008;32:712. intraperitoneal bladder rupture with or without a
suprapubic tube? J Urol 1999;161:11035.
7.10.6Abdominal vascular injury

7.10.7.4Scrotum
Moore EE, Cogbill TH, Jurkovich GJ. Organ injury scaling. Cline KJ, Mata JA, Venable DD, Eastham JA. Penetrating trauma
III: Chest wall, abdominal vascular, ureter, bladder and to the male external genitalia. J Trauma 1998;44:4924.
urethra. J Trauma 1992;33:3378. Munter DW, Faleski EJ. Blunt scrotal trauma: emergency
Welling DR, Rich NM, Burris DG, Boffard KD, Devries WC. Who department evaluation and management. Am J Emerg Med
was William Ray Rumel? World J Surg 2008;32:21225. 1989;7:22734.
The pelvis 8
8.1Introduction 8.2Anatomy
Fractured pelvis is a surgical problem, since 65 per cent of The surgical anatomy of the pelvis is a key to the patho-
patients with a fractured pelvis suffer associated injuries, genesis of pelvic injuries:
and mortality is largely due to haemorrhage and infec-
The pelvic inlet is circular, a structure that is
tions in the pelvic soft tissues. Both can lead to multiple
immensely strong, but routinely gives way at more
organ failure.
than one point should sufficient force be applied to it.
Although mortality following severe pelvic fractures
The forces required to fracture the pelvic ring do not
has decreased dramatically with better methods of con-
respect the surrounding organ systems.
trolling haemorrhage, these patients still represent a sig-
The pelvis has a rich collateral blood supply, especially
nificant challenge to every link of the treatment chain.
across the sacrum and posterior part of the ileum.
Mortality rates exceeding 40 per cent have recently been
The cancellous bone of the pelvis also has an excellent
reported. Extreme force is required to disrupt the pel-
blood supply. Most pelvic haemorrhage emanates
vic ring, and associated injuries and extrapelvic bleeding
from venous injury and fracture sites. However, in the
sources are common. The haemodynamically unstable
haemodynamically unstable patient with severe pelvic
patient with a severe pelvic fracture has a 90 per cent risk
injury, arterial bleeding is frequent (5080 per cent).
of associated injuries, a 50 per cent risk of extrapelvic
Post-mortem examination has shown that the
bleeding sources, and a 30 per cent risk of intra-abdom-
pelvic peritoneum that should tamponade pelvic
inal bleeding.
haematomas can accommodate more than 3000mL.
To save these patients, three questions need to be
All iliac vessels, the sciatic nerve roots, including
addressed:
the lumbosacral nerve, and the ureters cross the
Whether the patient is at high risk of massive sacroiliac joint, and disruption of this joint may
bleeding cause severe haemorrhage, and sometimes causes
What the sources of bleeding are arterial obstruction of the iliac artery and nerve palsy.
How to stop the bleeding. Fortunately, injuries to the ureters are rare.
The pelvic viscera are suspended from the bony pelvis
All sources of bleeding need to be identified and con- by condensations of the endopelvic fascia. Shear
trolled. The decisions are made on an individual basis, forces acting on the pelvis will transmit these to pelvic
taking into account the patients status, the injury viscera, leading to avulsion and shearing injuries.
pattern and the surgeons experience in dealing with The pelvis also features the acetabulum, a major
these complex injuries. Severe pelvic injuries require a structure in weight transfer to the leg. Inappropriate
multidisciplinary team involving trauma-trained gen- treatment will lead to severe disability.
eral surgeons and interventional radiologists, as well
as orthopaedic surgeons. If adequate orthopaedic expe-
rience is unavailable, consideration should be given 8.3Classification
towards early transfer of this patient to an institution
with the necessary expertise, as soon as the patients The different classification systems are all based on grade
condition allows. of fracture stability, and close correlation with risk of
The pelvis | 149
bleeding has been shown. However, no fracture pattern

can exclude significant haemorrhage. Pelvic ring fractures
can be classified into three types, using the Tile classifica-
tion,1,2 based on their severity.
8.3.1Type A
Figure 8.2 Tile classification: type B fracture.
This involves isolated fracture of the iliac wing or pubic
rami, mostly caused by direct compression (Figure 8.1).
These are stable fractures, to be treated conservatively. 8.3.3Type C
In this type (Figure 8.3), there is complete horizontal and

vertical instability, due to anterior and posterior fractures
and/or disruptions (complete sacroiliac disruption or dis-
placed vertical sacral fracture). A fall from height, and also
anteroposterior shearing forces in a dashboard impact in
a motor vehicle accident result in this type of fracture.
Type C fracture is the result of major mechanical forces,
and is associated with major blood loss and related inju-
Figure 8.1 Tile classification: type A fracture.
ries within the pelvis (bladder, urethra, rectum, vagina,
sciatic and femoral nerve, and iliac vein and artery).
8.3.2Type B
These fractures (Figure 8.2) are subdivided into:
Type B1. This occurs less commonly, and is a

lateral compression-type injury, which results in
an intrinsically stable fracture of the pelvic ring,
with an impression of the posterior complex in the
sacral bone and mostly a fracture of the pubic arch.
Figure 8.3 Tile classification: type C fracture.
Perforation of the bladder can be caused by the
anterior fracture, as can hypovolaemic shock due
In both type B and type C pelvic injuries, there is a high
to severe disruption of the soft tissues of the pelvic
risk of associated abdominal injuries, (bowel perforation
diaphragm; organ injury to the lower urogenital tract
or mesenteric laceration) and laceration of the diaphragm.
and rectum can be seen in these cases.
Type B2. This is the most common type of fracture,
also known as anTitle:
openManual of Definitive
book fracture. Surgical
There is Trauma Care 3E Author: Boffard ISBN: 9781444102826 Proof Stage: 1 F
8.4Clinical examination and
horizontal (rotational) instability due to an anterior
www.cactusdesign.co.uk diagnosis
lesion (disruption of the symphysis and/or fracture of
the superior and inferior pubic rami) combined with
Pelvic fractures should be easily identified if Advanced
a posterior disruption of the anterior or posterior
Trauma Life Support (ATLS) guidelines are followed (i.e.
ligaments of the sacroiliac joint. It can result in
routine chest X-ray and pelvic X-rays for any blunt injury
bleeding in an enlarged lesser pelvic cavity. Injury of
in a patient unable to walk). In the absence of X-ray facili-
the lower urogenital tract, rectum and vagina and
ties, a clinical examination can be performed with gentle
severe soft tissue damage due to the rotation are
e Surgical Trauma Care 3E Author: Boffard ISBN: 9781444102826 bimanual
Proof Stage: lateral1 and anteroposterior
Fig No: 8.1 compression (not
frequently seen in these cases.
distraction!) of the pelvis. Any instability felt indicates the
k Internal or external stabilization is required for both presence of major pelvic instability, associated with life-
types. threatening blood loss, requiring appropriate measures.
The absence of clinical instability does not, however, unstable exsanguinating patient and when angiography
preclude an unstable pelvic fracture. One-third of such is unavailable.
trauma victims with pelvic ring fractures sustain circula-
tory instability on arrival. Focused abdominal sonogra-
phy for trauma (FAST) may be unreliable as it does not 8.5.1Haemodynamically normal patients
exclude intra-abdominal bleeding in these patients.
Inspection of the skin may reveal lacerations in the There is usually an isolated injury possibly requiring
groin, perineum or sacral area, indicating a compound external or internal (open) reduction and fixation to limit
pelvic fracture, the result of gross deformation. Evidence future instability and disability. The management is not
of perineal injury or haematuria mandates radiologi- critically urgent.
cal evaluation of the urinary tract from below upwards
(retrograde urethrogram followed by cystogram or com-
puted tomography [CT] cystogram, followed by an excre- 8.5.2Haemodynamically stable patients
tory urogram as appropriate) when the physiology allows.
Inspection of the urethral meatus may reveal a drop of In this situation, traditional external fixation cannot pro-
blood, indicating urethral rupture. There seems to be lit- vide complete stability or compression. A force applied
tle evidence to support the fear of converting partial ure- to a segment of a circle cannot stabilize defects outside
thral rupture into a complete rupture by gently trying to that segment; it can do so only in one dimension, and will
insert a Foley catheter. If there is resistance, the patient aggravate disruption outside the segment across which it
should have a suprapubic catheter inserted. is applied. Pelvic C-clamps are applied close to the maxi-
Inspection of the anus may reveal lacerations of the mum diameter of the pelvis at the level of the sacroiliac
sphincter mechanism. Diligent rectal examination may joint and should be more effective in providing pelvic
reveal blood in the rectum, and/or discontinuity of the compression. Their application may be more difficult.
rectal wall, indicating a rectal laceration. In male patients, Apply an external fixator with anterior compression if
the prostate is palpated; a high-riding prostate indicates a there is a type B injury. However, if facilities allow and
complete urethral avulsion. A full neurological examina- time permits, performing angiographic embolization
tion is performed of the perineal area, sphincter mecha- provides a better control of haemorrhage than external
nism and femoral and sciatic nerves. fixation.
The CT scanner is the diagnostic modality of choice in
the haemodynamically stable patient, and CT angiogra-
phy is particularly helpful. 8.5.3Haemodynamically unstable patients
Because of the capacity of the pelvis to bleed, these patients

8.5Resuscitation require urgent control of haemorrhage. These patients
tend to exsanguinate rapidly, and immediate measures
The priorities for resuscitating patients with pelvic frac- are required to control bleeding. Applying a sheet at the
tures are no different from the standard. These injuries level of the greater trochanters is often effective and less
produce a real threat to the circulation, and management time-consuming than using the external fixator or the
is geared toward controlling this threat. C-clamp, immediately followed by bleeding control. In a
Management is based on haemodynamic status. The type C fracture, any vertical dislocation should be reduced
patient is either haemodynamically normal, haemody- by applying traction to the leg on the side of the cranially
namically stable (maintaining output due to ongoing dislocated hemipelvis before binding the pelvis together.
resuscitation) or haemodynamically unstable. Because If facilities allow and the patients haemodynamics per-
of the capacity of the pelvis to continue to bleed, these mit, angiographic embolization should be considered.
patients require urgent control of haemorrhage. These
patients tend to exsanguinate rapidly, and immedi-
ate measures are required to control bleeding. Most 8.5.4Laparotomy
contemporary treatment protocols rely on stabiliza-
tion and interventional radiology, alone or in combina- If the patient is exsanguinating or requires surgery for
tion. Other (damage control) options are needed for the other injuries, or angiography is delayed or unavailable,
The pelvis | 151
it is prudent to perform a laparotomy to treat or exclude 8.6 Pelvic packing

intra-abdominal bleeding. If a major source of bleeding
is the pelvis, consider extraperitoneal pelvic packing, A total of 85 per cent of pelvic bleeding is venous, arising
which should preferably be performed first (i.e. before the from the multiple venous plexuses around the pelvis. This
laparotomy). If pelvic bleeding persists, direct exploration bleeding is usually not controllable by embolization.
with suturing or ligature of lacerations of major blood Extraperitoneal packing was first described in 1985 by
vessels may be required. Pohleman,2 and the technique was further described by
In the exsanguinating patient, immediate control of Ertel in 2001,3 and Smith in 2005.4 The original technique
haemorrhage can be achieved by aortic clamping. In the was more aggressive, but the current technique stops
unstable patient, consider damage control surgery (DCS), below or medial to the external iliac vessels at the pelvic
followed by extraperitoneal packing of the pelvis. Other brim.
sources of intra-abdominal bleeding must be excluded. If the source of the bleeding is in doubt, or FAST or
Repair of anatomical structures (bladder, rectum and diagnostic peritoneal lavage (DPL) results are positive, it
vagina), cystostomy and/or colostomy with rectal wash- is wise to perform an exploratory laparotomy to treat or
out as required are not critical, as most can wait until the rule out intra-abdominal bleeding first. In the presence of
patient has been physiologically corrected. a large or expanding pelvic haematoma, extraperitoneal
Temporary closure of the abdominal wall is preferable, pelvic packing should be performed by grabbing the edges
ideally using a vacuum-assisted (sandwich) technique. of the peritoneum and entering the preperitoneal space
Angiography should be performed after DCS from the midline.
for control of any remaining pelvic bleeding by If other sources of bleeding have been ruled out with CT
embolization of the bleeding vessels. Extraperitoneal scan, the extraperitoneal pelvic packing can be done with-
pelvic packing should be considered. out entering the abdomen via a lower midline suprapubic
incision.
In the more stable patient, if bleeding persists, explore
the pelvis and tamponade the area, with suturing or liga-
ture of lacerations of the major blood vessels, repair of 8.6.1Technique of extraperitoneal packing
anatomical structures (bladder and rectum) where possi-
ble, and cystostomy and/or colostomy with rectal wash- The patient is positioned supine, and, if necessary, an
out as required. If it is required and possible at this stage, external fixator or C-clamp is applied. An 8cm midline
undertake internal fixation of the pelvic ring. suprapubic incision is made, and the fascia anterior to
After the initial haemorrhage has been controlled, gen- the rectus muscle is exposed. The fascia is divided until
eral DCS principles apply, and the patient is returned to the symphysis can be palpated directly (the pre-peritoneal
the operating room for definitive surgery when physiol- plane has been reached). The fascia is divided in the mid-
ogy has been restored (3648 hours). Making a plan for line, protecting against urinary bladder damage. From the
definitive surgery and further wound management is a symphysis, the pelvic brim is followed laterally and pos-
multidisciplinary task. A caveat of pack removal is that terior to the sacroiliac joint (first bony irregularity felt),
the longer the packs are left in, the greater the risk of pel- first on the side of major bleeding (most often the side of
vic sepsis. Definitive internal fixation of the pelvis is ide- sacroiliac joint disruption).
ally performed early, but timing will obviously depend on The fascia is then dissected away from the pelvic brim
the physiology. as far posteriorly as possible at the level of the pelvic brim.
Formal treatment protocols for pelvic injuries have The bladder and rectum are then held to the opposite side
been shown to decrease mortality and should be devel- while the plane is opened bluntly down to the pelvic floor,
oped in every hospital treating pelvic injuries. avoiding injury to vascular and nerve structures in the
Requirements for blood average 15 units for com- area. The space is then packed with vascular or abdomi-
pound pelvic fractures. To avoid dilutional coagulopathy, nal swabs, starting posteriorly and distal to the tip of the
protocols for massive transfusion should be instituted. sacrum, and building the packs cranially and anteriorly.
Volume replacement is ultimately only an adjunct to the The procedure is then repeated on the opposite side.
treatment of haemorrhagic shock stopping the bleed- Packing a pelvis efficiently implies also addressing arte-
ing. Thromboelastography is invaluable in monitoring rial bleeding. This requires applying force while packing.
and correcting any coagulopathies that may arise. In an unbroken pelvis with an intact pelvic floor, one
should be able accommodate three large abdominal swabs perineum and perianal area should have a diverting colos-
on each side. In severe pelvic fractures, efficient packing tomy. However, in the damage control situation, estab-
might require many more (over 10 packs not being unu- lishment of a colostomy should be postponed until the
sual). The number of packs needed is defined by the avail- patients physiology has returned to normal.
able space and the appropriate force applied. All vaginal injuries should be explored under a general
The skin is closed. If laparotomy is required, it should anaesthetic. Vaginal lacerations should be managed as
precede the packing procedure. follows:
After a DCS laparotomy with extraperitoneal pelvic
High lesions should be repaired and closed.
packing, a temporary abdominal closure is appropriate.
Lower lesions should be packed.
As in the abdomen, the packs should be removed after
2448 hours.
8.8Associated conditions
8.7Complex pelvic injuries
Associated injuries can only be managed once the patient
Complex pelvic fractures with open pelvic injury can be is haemodynamically stable. Procedures for damage con-
the most difficult of all injuries to treat. Initially, they can trol may be the only available option.
cause devastating haemorrhage and may later be associ-
ated with overwhelming pelvic sepsis and distant multiple
organ failure. 8.8.1Head injuries
These are the most commonly associated major injuries.

8.7.1Diagnosis It is worthwhile remembering that C precedes D during
resuscitation and management: the CT scan and neuro-
For those patients who present with compound pelvic surgical procedures have to wait for haemodynamic sta-
fractures and are haemodynamically stable, diagnostic bility, and haemodynamic stability may be achieved only
studies such as plain films of the pelvis, three-dimen- after DCS.
sional CT scans and occasionally arteriograms should be
rapidly carried out, particularly if the patient was initially
unstable and has been resuscitated, and there is a margin 8.8.2Intra-abdominal injuries
of time to do the arteriogram safely.
These are frequently masked by pelvic pain. Retro
peritoneal haematomas may break through into the
8.7.2Surgery peritoneal cavity, causing a false-positive result on DPL.
In the presence of a pelvic fracture, CT scanning is the
All patients with an open (compound) pelvic fracture diagnostic modality of choice in the stable patient. In all
should be taken to the operating room as soon as the neces- other patients, diagnostic ultrasound is preferred. Open
sary diagnostic studies have been carried out. Stabilization DPL is preferred to exclude intraperitoneal haemor-
of pelvic bleeding can be temporarily achieved by packing rhage. If open DPL is performed, the entry point should
the open wound and then making the decision of whether be above the umbilicus to avoid entering extraperitoneal
or not to obtain a pelvic arteriogram (which will be posi- haematomas tracking up the anterior abdominal wall.
tive in 15 per cent of cases), or to move rapidly to external A low threshold should be maintained for laparotomy
fixation of the anterior pelvis and consideration for poste- because of associated intraperitoneal injury.
rior stabilization as well. These decisions are made on an
individual basis, taking into account the patients status,
the injury pattern and the surgeons experience in dealing 8.8.3Urethral injuries
with these complex injuries.
Based on location of the injury, colostomy may be Urethral injuries should be managed conservatively.
required in order to prevent soilage of the wound in the Primary urethral repair by cystoperineal traction sutures
post-injury period. In general, all injuries involving the results in minimal disability in the hands of experts when
The pelvis | 153
performed immediately in stable patients. For the major- Procedures for damage control may be the only
ity, suprapubic cystostomy and delayed urethral repair is available option.
required. Extraperitoneal packing should, where possible, be
performed prior to opening the abdomen.
8.8.4Anorectal injuries
8.10References
Injuries of the anus and rectum are managed according
to the degree of damage to the sphincters and anorectal 1 Tile M. Acute pelvic fractures: causation and classification.
mucosa. Injuries superficial to these require only debri- J Am Acad Orthop Surg 1996;4:14351.
dement and dressings. Deep injuries require colostomy 2 Pohleman T, Gnsslen A, Bosch U, Tscherne H. The
and drainage (presacral drainage is not required and may technique of packing for control of haemorrhage in
disrupt the nervous plexuses). There is doubt about the complex pelvic fractures. Tech Orthop 1995;9:26770.
benefit of prograde wash-out of the rectum due to the risk 3 Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe
of pelvic infection introduced by washing faeces into the haemorrhage using C-clamp and pelvic packing in multiply
pelvic cavity. Careful mechanical cleansing of the rectum, injured patients with pelvic ring disruption. J Orthop
wash-out via a wide-bore tube after gentle anal dilatation- Trauma 2001;15:46874.
and adequate debridement performed in a stable patient 4 Smith WR, Moore EE, Osborn P et al. Retroperitoneal
makes common sense. Sphincter repair is best left for the packing as a resuscitation technique for haemodynamically
experts, but repeated debridement and early approxima- unstable patients with pelvic fractures: report of two
tion of mucosa to skin should limit infection and scarring. representative cases and a description of technique. J
Trauma 2005;59:151014.
8.9Summary
8.11Recommended reading
In summary, a haemodynamically normal patient can be
safely transferred for stabilization of unstable fractures
Fry RD. Anorectal trauma and foreign bodies. Surg Clin North
within hours after injury and following control of the
Am 1994;74:1491506.
associated damage.
Scalea TM, Stein D, OToole RV. Pelvic fractures. In: Feliciano
Associated injuries can only be managed once the DV, Mattox KL, Moore EE. Trauma, 6th edn. New York:
patient is haemodynamically stable. McGraw-Hill, 2008: 75988.
Extremity trauma 9
9.1overview 9.3Key issues

9.3.1 Management of open fractures
A fracture is a soft tissue injury in which
broken bone is present. (Unknown)
Sepsis is a constant threat to the healing of open frac-
Extremity injuries often look dramatic and occur in 85 tures. Risk factors for infection are:
per cent of patients who sustain blunt trauma, but they
Severity of injury (especially the injury to the soft
rarely cause a threat to life or limb. However, in some cir-
tissue envelope of a limb)
cumstances, the relevance of such injuries assumes major
Delay from injury to surgical care (>6 hours)
importance.
Failure to use prophylactic antibiotics
Fractures of the bony skeleton may occur in isolation
Inappropriate wound closure.
or as part of multiple injuries. Although these are not usu-
ally life-threatening in isolation, poorly managed extrem-
ity trauma can lead to significant disability. 9.3.2Severity of injury (Gustilo
Injuries of the limbs rarely threaten life but it happens classification)
and the possibility must be borne in mind when there
are multiple long bone fractures associated with vascular Table 9.1 outlines the Gustilo classification of injury.1
damage and ongoing bleeding. Where this is the case, a
timely and appropriately applied tourniquet may buy
time to stabilize the patient and treat other life-threaten- 9.3.3Sepsis and antibiotics
ing injuries.
Sepsis is a constant threat to the healing of open frac-
tures, and the main risk factors include the severity of the
injury, the delay from injury to surgical care, failure to use
9.2Management of severe prophylactic antibiotics and inappropriate wound clo-
injury to the extremity sure. In fractures classified by the Gustilo grading, grade
I and II patients may be given agents effective against
The primary survey and resuscitation must take priority.
Staphylococcus aureus, but for grade III injuries, broader
Rapidly assess limb injuries, making careful note of Gram-negative cover is advisable.
distal perfusion. The early use of prophylactic antibiotics is impor-
Involve the orthopaedic and plastic surgeons early. tant, but it must be recognized that antibiotics are an
Restore impaired circulation. adjunct to appropriate wound care. The introduction of
Cover open wounds with a sterile dressing, and give the Thomas splint and improved understanding of the
tetanus toxoid and antibiotic prophylaxis. need for surgical wound care is credited with reducing
Debride non-viable tissue. the mortality rate for open fractures of the femur from
Restore skeletal stability. 80 per cent to 16 per cent during the First World War.2
Achieve wound closure and commence During the Spanish Civil War, Truetta reported a septic
rehabilitation. mortality rate of 0.6 per cent in 1069 open fractures with
Extremity trauma | 155
Table 9.1 Gustilo classification of injury1
Fracture grade Description
Grade I Wound less than 1cm with minimal soft tissue injury
Wound bed is clean
Bone injury is simple with minimal comminution
With intramedullary nailing, average time to union is 2128 weeks
Grade II Wound is greater than 1cm with moderate soft tissue injury
Wound bed is moderately contaminated
Fracture contains moderate comminution
Grade III Following fracture, automatically results in classification as type III:
Segmental fracture with displacement
Fracture with diaphyseal segmental loss
Fracture with associated vascular injury requiring repair
Farmyard injuries or highly contaminated wounds
High-velocity gunshot wound
Fracture caused by a crushing force from a fast-moving vehicle
Grade IIIA Wound greater than 10cm with crushed tissue and contamination
Soft tissue coverage of bone is usually possible
Wound sepsis rate is 4%
Grade IIIB Wound greater than 10cm with crushed tissue and contamination; there is periosteal stripping and bone exposure, usually
associated with contamination
Soft tissue injury is extensive cover is inadequate and requires a regional or free flap
Wound sepsis rate is 52%
Grade IIIC A fracture in which there is a major vascular injury requiring repair for limb salvage; major soft tissue injury is not necessarily
significant
Wound sepsis rate 42%
Fractures can be classified using the Mangled Extremity Severity Score
In some cases, it will be necessary to consider below-knee amputation
a policy of wound excision and debridement, reduction 9.3.4Venous thromboembolism

of the fracture, stabilization with plaster and leaving the
traumatic wound open.3 Deep venous thrombosis prophylaxis remains an inte-
Recent consensus guidelines (Eastern Association for gral part of management of patients with severe limb
the Surgery of Trauma Guidelines) recommend that anti- injury. Ideally, both mechanical and chemical prophylaxis
biotics be discontinued 24 hours after wound closure for should be used.6
grade I and II fractures. For grade III wounds, the antibi-
otics should be continued for only 72 hours after the time
of injury, or for not more than 24 hours after soft tissue
coverage of the wound is achieved, whichever occurs first. 9.3.5Timing of skeletal fixation in
Agents effective against Staphylococcus aureus appear to be polytrauma patients
adequate for grade I and II fractures; however, the addi-
tion of broader Gram-negative coverage may be beneficial The advantages of early fixation of fractures in patients
for grade III injuries.4,5 with multiple injuries have been challenged. However,
early external fixation as part of damage control orthopae- who present with mangled limbs, produced by mecha-
dics may obviate some of the risks:7,8 nisms of high-energy transfer or crush in which there is
Specific areas of risk are described here. vascular disruption in combination with severe open com-
minuted fractures and moderate loss of soft tissue. These
injuries most frequently affect healthy individuals during
9.3.5.1Respiratory insufficiency9
their prime years of gainful employment and can result in
Episodes of respiratory insufficiency often occur after varying degrees of functional and emotional disability.
orthopaedic injury. Extremity injury may occur as part There are many ways to classify major limb injuries
of a multisystem insult, with associated head, chest and and their complications, and these scoring systems can be
other injuries. Hypoxia, hypotension and tissue injury found towards the end of this chapter.
provide an initial hit to prime the patients inflamma- During the past two decades, a better understanding
tory response; operative treatment of fractures constitutes of the individual injuries, and technical advances in diag-
a modifiable secondary insult. In addition, post-traumatic nostic evaluation and surgery (allowing revascularization
fat embolism has been implicated in the respiratory com- of the extremity, stabilization of the complex fracture and
promise that appears after orthopaedic injury. reconstruction of the soft tissues), medicine and rehabili-
Nevertheless, most comparative studies have shown a tation have led to an increased frequency of attempts at
reduction in risk of post-traumatic respiratory compro- limb salvage. In some of these patients, however, limb sal-
mise after early, definitive fixation of fractures (i.e. within vage may have subsequent deleterious results, being asso-
48 hours), for both isolated injuries and multisystem ciated with a high morbidity and a poor prognosis and
trauma. There is also evidence of reduction in mortal- often requiring late amputation (2770 per cent) despite
ity, duration of mechanical ventilation, thromboembolic initial success. In these, early or primary ablation might
events and cost in favour of early fixation. even be beneficial.
Thus, the management of the mangled limb remains a
vexing problem, and should thus be multidisciplinary and
9.3.5.2Head injury
involve the combined skills of the orthopaedic, vascular
In approximately 5 per cent of long bone fractures of the and plastic and reconstructive surgeons. Poorly coordi-
leg, the patient is physiologically unstable after initial nated management often results in more complications,
resuscitation due to haemodynamic instability, raised increased duration of treatment and a less favourable out-
intracranial pressure or other problems. Temporary meth- come for the patient. Ultimately, the decision to amputate
ods of fixation are attractive in this setting. Although or repair is often a difficult one, and best shared, if pos-
some studies have suggested that early nailing of a femoral sible, with a senior colleague. The cost of rehabilitation
fracture may be harmful in patients with a concomitant is often less and the time shorter if a primary ampu-
head injury, there is no compelling evidence that early long tation is performed than if lengthy and repeated opera-
bone stabilization in mildly, moderately or severely brain- tions are undertaken, and persistent painful debility or an
injured patients either enhances or worsens the outcome.10 insensate or flail limb is still the outcome. A successful
limb salvage is defined by the overall function and satis-
faction of the patient.
9.4Massive limb trauma: life
versus limb
9.4.1 Management
Certain skeletal injuries by their nature indicate significant
forces sustained by the body, and should prompt the treat- It is important to remember that a fracture is not a separate
ing surgeon to look for other associated injuries. Other limb entity from the soft tissue damage that accompanies it it
injuries, presenting with crush injury with extensive soft is simply an extension of the soft tissue injury that involves
tissue damage, concomitant vascular or nerve injury and bone, and the principles of management are the same.
major bony disruption pose other threats to either life or
limb, and it is on these that this topic concentrates.
9.4.1.1Vascular injury
Despite huge advances in the management of these inju-
ries, and the resultant decrease in amputation rates associ- Vascular injuries are present in 2535 per cent of all pen-
ated with them, there remains a small group of patients etrating trauma to the extremities. More recently, duplex
scanning has been found to play a useful screening role. distortion or compartment syndromes that interfere with
Except for inconsequential intimal injuries and distal arterial flow.
artery injuries, most extremity vascular injuries should be In principle, it is wise to fix the bony skeleton before
repaired. embarking on vascular repair. However, this can be cata-
Signs of vascular injury include an expanding or pulsat- strophic if ischaemia is present. The following protocol
ing haematoma, to-and-fro murmurs, a false aneurysm, should be used:
continuous murmurs from arteriovenous fistulas, loss of
Initial assessment for ischaemia
pulses, progressive swelling of an extremity, unexplained
Exploration of the vessels
ischaemia or dysfunction, and unilateral cool or pale
Fasciotomy if required
extremities. A significant percentage of these patients
Temporary stenting of the vein and artery
have no physical findings suggesting vascular trauma;
Orthopaedic fixation of the skeletal damage
thus, routine further investigation has been advocated.
Definitive repair of the vascular damage.
The most common cause of peripheral vascular injury
is penetrating trauma, which includes a spectrum from Damage control of the extremity injury should take place in
simple puncture wounds to wounds resulting from high- the same fashion as in the abdomen. If there is doubt regarding
energy missiles. Normal pulses do not rule out vascular viability, the wound should not be closed.
injuries: 10 per cent of significant and major vascular There are five options open to the surgeon when vas-
injuries have no physical findings. Penetrating trauma cular damage is encountered: vessels may be repaired,
also includes iatrogenic injuries, such as those following replaced (grafted), ligated (and bypassed), stented or
percutaneous catheterization of the peripheral arteries for shunted.
diagnostic procedures or access for monitoring. When a Intraluminal shunts may be manufactured out of intra-
needle or catheter dislodges an arteriosclerotic plaque or venous tubing, nasogastric tubing, biliary T-tubes or even
elevates the intima, a vessel may thrombose, leading to chest drain tubing, depending on the size of the vessel to
acute ischaemia in a limb. The key, therefore, is to main- be shunted. Commercially made shunts (as used routinely
tain a high index of suspicion based on the mechanism of in carotid surgery) are on the market, and others are now
injury and the proximity of vascular structures. being made specifically for trauma. Essentially, the shunt
Recently, duplex scanning of blood vessels has been is tied into the damaged vessel and ligated securely proxi-
shown to be a useful adjunct in determining whether an mally and distally there is no need for heparinization
arteriogram is indicated. A positive duplex scan is valu- and this allows time for other damage control proce-
able, but a negative one does not exclude vascular injury. dures to take precedence while maintaining perfusion
A positive duplex scan, or an anklebrachial index of less of the limb. Where possible, both artery and vein should
than 0.9 in a distal pulse, is a mandatory indication for be shunted if both are damaged. If not possible, the vein
arteriogram and possible operation. should be tied off. The shunts may safely be left in place
The gold standard for confirming a suspected vascular for 24 hours and probably longer; there are no controlled
injury remains the arteriogram. However, arteriography trials reporting on this.
should not be performed in the patient who is unstable Some injury complexes should raise a specific suspicion
and needs emergency laparotomy or thoracotomy. The of vascular damage, for example a supracondylar fracture
arteriogram should be delayed until after resuscitation of the humerus or femur, and posterior dislocation of the
and treatment of the life-threatening emergency. knee. The presence of palpable pulses does not exclude
If doubt exists, an angiogram should be obtained. arterial injury, and a difference of 10 per cent in the meas-
Blunt trauma also may cause peripheral vascular ured Doppler pressure compared with the opposite unin-
injuries, with shear injuries as the most common cause. jured limb mandates urgent angiography. This is not hard
Contusions or crushing injuries may produce transmural to do, and the technique is well described elsewhere. An
or partial disruption of arteries, resulting in elevation of absent pulse mandates exploration if the level of injury is
the intima and the formation of intramural haemato- known, and angiography if it is not.
mas. Blunt trauma, such as posterior dislocation of the Repairs, particularly graft replacements of injured ves-
knee, may cause total disruption of a major vessel. Blunt sels, should only be attempted by those competent to do
trauma may also indirectly contribute to vascular occlu- them, and only in limbs where the viability of the soft tis-
sion by creating large haematomas in proximity to the sues is not in doubt (i.e. after fasciotomy). Ligation may
vessel. These haematomas may lead to arterial spasm, be done as a measure of desperation in the exsanguinating
patient, and limb survival is often surprising. Claudication sounded a note of caution about relying exclusively on a
pain may be dealt with at a later date. Extra-anatomical scoring system to make these important decisions.
bypass has no place in the setting of damage control and
trauma surgery. Endovascular stenting is rapidly becom-
ing a procedure of choice in some areas (e.g. traumatic 9.4.2Scoring systems
aortic rupture), but requires facilities and expertise that
may not always be available.
9.4.2.1 Mangled Extremity Syndrome Index
Gregory et al.13 retrospectively reviewed 17 patients with

9.4.1.2Chemical vascular injuries
severe injuries (12 of the lower extremity) and proposed
The frequency of chemical injury to blood vessels has a Mangled Extremity Syndrome Index (Table 9.2). The
increased secondary to iatrogenic injury and the intra- injury was categorized according to the integument,
arterial injection of illicit drugs. These agents may cause nerve, vessel and bone injury. A point system quanti-
intense vasospasm or direct damage to the vessel wall, fied injury severity, delay in revascularization, ischaemia,
often associated with intense pain and distal ischaemia. age of the patient, pre-existing disease and whether the
Chemical vascular injuries may be treated with intra- patient was in shock.
arterial or intravenous administration of 10000 units
heparin to prevent distal thrombosis. Reserpine (0.5mg)
9.4.2.2 Predictive Salvage Index System
also has been recommended, although its only effect
experimentally has been to protect against the release of Howe et al.14 reviewed 21 patients with pelvic or lower
catecholamines from the vessel walls. Other vasodilators extremity trauma with vascular injuries and proposed
and thrombolytic enzymes have been tried, with variable a predictive index incorporating the level of the arterial
results. A reliable combination is 5000 units heparin in injury, degree of bony injury, degree of muscle injury and
500mL Hartmanns solution (Ringers lactate) to which is interval for warm ischaemia time (Table 9.3). Variables
added 80mg papaverine to combat arterial spasm. This is such as additional injuries and the presence of shock were
administered in boluses of 2030mL intra-arterially every not felt to be predictive of amputation. Of the patients,
30 minutes, or intravenously at the rate of 1000 units 43 per cent underwent amputation, infrapopliteal inju-
heparin per hour. ries being associated with the highest amputation rate
(80percent).
The MESS, which characterizes the skeletal and soft tissue
9.4.1.3Crush syndrome
injury, warm ischaemia time, shock and age of the patient,
Badly injured limbs will all have an element of crush syn- has also been proposed as a means of solving this dilemma.
drome associated with them unless one is dealing with a
traumatic amputation by a sharp instrument such as a chain
9.4.2.3 Mangled Extremity Severity Score
saw or machete. As such, a watch must be kept for the devel-
opment of a compartment syndrome and/or myoglobinuria. Johansen et al.11 described the MESS (Table 9.4), which char-
The salvage of severe lower extremity fractures can be acterizes the skeletal and soft tissue injury, warm ischaemia
extremely challenging. Even if the surgical team is suc- time, presence of shock and age of the patient, as a means
cessful in preserving the limb, the functional result may of solving the dilemma of which patient needs amputation.
be unsatisfactory because of residual effects of injuries to A MESS value greater than 7 predicted amputation.
muscle and nerve, bone loss and the presence of chronic
infection. Failed efforts at limb salvage consume resources
9.4.2.4NISSSA Scoring System
and are associated with increased patient mortality and
high hospital costs. McNamara et al.15 and others have, subsequently, retro-
Many lower extremity injury severity scoring systems spectively evaluated the MESS in 24 patients with severely
have been developed to assist the surgical team with the injured tibias. Attempts have been made to address criti-
initial decision to amputate or salvage a limb. Scores such cisms of the MESS by including nerve injury in the scor-
as the Mangled Extremity Severity Score (MESS)11,12 can be ing systems and by separating the soft tissue and skeletal
used to facilitate identification of the irretrievably injured injury components of the MESS. The result is the NISSSA
lower extremity. Recent prospective studies have, however, (nerve injury, ischaemia, soft tissue injury/contamination,
Table 9.2 Mangled Extremity Syndrome Index Table 9.3 Predicted Salvage Index System
Criterion Score Criterion Score
Injury severity score Level of arterial injury

<25 1 Suprapopliteal 1
2550 2 Popliteal 2
>50 3 Infrapopliteal 3
Integument injury Degree of bone injury
Guillotine 1 Mild 1
Crush/burn 2 Moderate 2
Avulsion/degloving 3 Severe 3
Nerve injury Degree of muscle injury
Contusion 1 Mild 1
Transection 2 Moderate 2
Avulsion 3 Severe 3
Vascular injury Interval from injury to operating room (hours)
Vein transected 1 <6 0
Artery transected 1 612 2
Artery thrombosed 2 >12 4
Artery avulsed 3
Salvage: score <7. Amputation: score >8.
Bone injury
Reproduced from Howe et al. (1987).14
Simple 1
Segmental 2
Table 9.4 Mangled Extremity Severity Score
Segmental comminuted 3
Bone loss <6cm 4 Factor Score
Articular 5
Skeletal/soft tissue injury
Articular with bone loss >6cm 6
Low energy (stab, fracture, civilian gunshot wound) 1
Delay in time to operation 1 point per hour > 6 hours
Medium energy (open or multiple fracture) 2
Age (years)
High energy (shotgun or military gunshot wound) 3
<40 0
Very high energy (above plus gross contamination) 4
4050 1
Limb ischaemia
5060 2
Pulse reduced or absent but perfusion normal 1*
>60 3
Pulseless, diminished capillary refill 2*
Pre-existing disease 1
Patient is cool, paralysed, insensate, numb 3*
Shock 2
Shock
Score <20: functional limb salvage can be expected. Score >20: limb salvage is Systolic blood pressure always >90mmHg 0
improbable. Systolic blood pressure transiently <90mmHg 1
Reproduced from Gregory et al. (1985).13
Systolic blood pressure persistently <90mmHg 2
Age (years)
skeletal injury, shock/blood pressure, age) scoring system <30 0
(Table 9.5), which is thus more sensitive and more specific 3050 1
than the MESS. >50 2
Scoring systems clearly have their limitations when the *Double the value if the duration of ischaemia is over 6 hours.
resuscitating surgeon is faced with an unstable polytrauma Score >7 predicted amputation.
patient. Thus, these scoring systems are not universally Reproduced from Johansen et al. (1990).11
accepted. They have shortcomings with respect to repro- dations derived from them must be judged in terms of
ducibility, prognostic value and treatment-planning available technology and expertise.
in this context. These factors can lead to inappropriate In summary, the decision of whether to amputate prima-
attempts at limb salvage when associated life- and limb- rily or to embark on limb salvage and continue with planned
threatening injuries might be overlooked if attention is repetitive surgeries is complex. Prolonged salvage attempts
focused mainly on salvage of the mangled limb, or to an that are unlikely to be successful should be avoided, espe-
amputation when salvage may have been possible. While cially in patients with insensate limbs and predictable
experience with these scoring systems is generally limited, functional failures. Scoring systems should be used only
they may provide some objective parameters on which cli- as a guide for decision-making. The relative importance of
nicians can base difficult decisions regarding salvage of each of the associated trauma parameters (with the excep-
life or limb, but it must be stressed that any recommen- tion of prolonged, warm ischaemia time or risking the life
of a patient with severe, multiple organ trauma) is still of
questionable predictive value. A good understanding of
Table 9.5 NISSSA scoring system
the potential complications facilitates the decision-making
Factor Score process in limb salvage versus amputation.
Nerve injury
Sensate 0
Loss of dorsal 1 9.5Compartment syndrome16,17
Partial plantar 2
Compartment syndrome may occur after extremity
Complete plantar 3
injury, with or without vascular trauma. Increasing
Ischaemia
pressure within the closed fascial space of a limb com-
None 0
promises the blood supply of muscle. Early clinical diag-
Mild 1* nosis and treatment is important to prevent significant
Moderate 2* morbidity.
Severe 3* Compartment syndrome occurs relatively commonly,
Soft tissue injury/contamination following trauma or ischaemia to an extremity, with or
Low 0 without vascular injury. It is important to emphasize
Medium 1 that reperfusion probably plays a major role. As such, the
High 2
classical clinical findings may be absent prior to vascular
repair. Once the diagnosis of compartment syndrome is
Severe 3
made, urgent fasciotomy is indicated.
Skeletal injury
The measurement of intracompartment pressure is
Low energy 0
invaluable when doubt exists about the diagnosis. It
Medium energy 1 must be emphasized that a pulse still may be palpable, or
High energy 2 recordable on the Doppler, even though a compartment
Very high energy 3 syndrome exists.
Shock/blood pressure
Normotensive 0
Transient hypotension 1 9.6fasciotomy
Persistent hypotension 2
Age (years) Two techniques have been described:
<30 0
Two-incision, four-compartment fasciotomy
3050 1 Fibulectomy.
>50 2
The skin must be opened widely, in order to allow a
*Double the value if the duration of ischaemia exceeds 6 hours. good view of the underlying fascia. It is critical that the
Score >11 predicted amputation. fascia is split over its entire length, and this can only
Reproduced from McNamara et al. (1994).15 be done under direct vision. Care must be taken not to
damage the saphenous veins, which may constitute the Table 9.6 Complications of fractures
major system of venous return in such an injured leg.
Skin and soft Skin and tissue loss, wound slough, coverage
In trauma, there is no place for subcutaneous fasciotomy.
tissue failure
Bone and Compartment syndrome with necrosis of muscle/nerve

9.6.1 Four-compartment fasciotomy18 fracture site injury
Deep infection acute/chronic
Two long incisions are made: Bone loss, delayed union, malunion/loss of alignment,
non-union Fixation problems failure of hardware
A long incision is made, anterolaterally, 2cm anterior
Bone refracture
to the shaft of the fibula. The anterior and lateral
Nerves Direct injury or ischaemic damage
fascial compartments are opened separately.
Reflex sympathetic dystrophy
A long posteromedial incision is made 2cm posterior
Vascular Arterial occlusion, venous insufficiency
to the medial border of the tibia. The subcutaneous
Deep vein thrombosis, compartment syndrome
tissue is pushed away by blunt dissection, and the
superficial and deep posterior compartments are Joint motion Associated joint surface fracture
opened separately. Contracture, late arthritis

Secondary Ototoxicity, nephrotoxicity, myonecrosis from
Fasciotomy must be performed before arterial explora-
antibiotics
tion when an obvious arterial injury exists, or where there
Secondary spread of infection, sepsis/multiple organ
is a suspicion of high intracompartmental pressures.
failure/death
Should there be doubt over whether or not the compartment
Psychosocial Depression, loss of self-worth
syndrome is significant, a fasciotomy should be performed.
Economic hardship, questionable employment status,
marital problems
Functional Chronic pain
9.6.2 Fibulectomy
Disability muscle strength/endurance
Decrease in activities of daily function
This is a difficult procedure, leading to extensive blood
Loss of ability to return to work, inability to participate
oozing, and may well result in damage to the peroneal
in recreational activities
artery.
It should not be practised in the trauma situation. Cosmesis Scars, bulky flaps
9.7Complications of major limb

injury
also noted. The cost of initial hospitalization was lower
Table 9.6 outlines fracture complications. with early amputation.
In a review of 53 mangled lower extremities, Bondurant The decision to amputate primarily is difficult. At the
et al. compared primary with delayed amputation in terms initial examination, the extent of the eventual loss of soft
of morbidity and cost. Patients undergoing delayed abla- tissue can never be fully appreciated, distal perfusion is
tion had longer periods of hospitalization (22.3 versus also difficult to assess (many patients are shocked), and
53.4 days) and more surgical procedures (1.6 versus 6.9) at the neurological evaluation is often unreliable (as a result
greater cost ($28964 versus $53462).19 Six patients with of associated head injury or ischaemia and soft tissue
delayed amputation developed sepsis from the injured disruption). Any thoughts of limb salvage should take
lower extremity and died, while no patient with a pri- cognisance of Advanced Trauma Life Support protocols,
mary amputation developed sepsis or died. Georgiadis et always maintaining the priority of life over limb, and thus
al. indicated that patients with limb salvage at an aver- minimizing systemic complications and missed injuries.
age of 3 years follow-up had more complications, more In an attempt to facilitate this early decision-making, a
procedures and a longer hospital stay than patients with number of systems have been devised providing objective
early below-knee amputation.20 Slow recuperation and criteria using a grading score to predict which injuries
decreased motivation toward gainful employment were might eventually require amputation.
9.8Summary Practice Management Guidelines Work Group. J Trauma

2001;50:95867.
It seems preferable to perform early, definitive long bone 9 Robinson CM. Current concepts of respiratory insufficiency
stabilization in polytrauma patients. Recent consensus syndromes after fracture. J Bone Joint Surg 2001;83B:78191.
guidelines suggest that, for patients with dominant head 10 Scalea TM, Scott JD, Brumback RJ et al. Early fracture
or chest injuries, the timing of long bone stabilization fixation may be just fine after head injury: no
should be individualized according to the patients clini- difference in central nervous system outcomes. J Trauma
cal condition. 1999;46:83946.
11 Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr.
Objective criteria accurately predict amputation following
9.9References lower extremity trauma. J Trauma 1990;30:56872.
12 Bosse MJ, MacKenzie EJ, Kellam JF et al. A prospective
1 Gustilo RB, Mendoza RM, Williams DN. Problems in evaluation of the clinical utility of the lower-extremity
the management of type III (severe) open fractures: a injury-severity scores. J Bone Joint Surg 2001;83A:314.
new classification of type III open fractures. J Trauma 13 Gregory RT, Gould RJ Peclet M et al. The Mangled Extremity
1984;24:7426. Syndrome (MES): a severity grading system for multisystem
2 Gustilo RB, Anderson JT. Prevention of infection in the injuries of the extremities. J Trauma 1985;25:114750.
treatment of one thousand and twenty-five open fractures 14 Howe HR Jr, Poole GV Jr, Hansen KJ et al. Salvage of
of long bones: retrospective and prospective analyses. J lower extremities following combined orthopedic and
Bone Joint Surg 1976;58A:45358. vascular trauma: a predictive salvage index. Am Surg
3 Truetta J. War surgery of extremities: treatment of war 1987;53:20528.
wounds and fractures. Br Med J 1942;1:616. 15 McNamara MG, Heckman JD, Corley FG. Severe open
4 Luchette FA, Bone LB, Born CT et al. Practice Management fractures of the lower extremity: a retrospective evaluation
Guidelines for prophylactic antibiotic use in open fractures. of the Mangled Extremity Severity Score (MESS). J Orthop
In: Eastern Association for the Surgery of Trauma. Practice Trauma 1994;8:817.
Management Guidelines. Available from www.east.org 16 Perron AD, Brady WJ, Keats TE. Orthopedic pitfalls in
(accessed December 2010). the ED: acute compartment syndrome. Am J Emerg Med
5 Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. EAST 2001;19:41316.
Practice Management Guidelines Work Group: update 17 Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment
to Practice Management Guidelines for prophylactic syndromes. Br J Surg 2002;89:397412.
antibiotic use in open fractures. In: Eastern Association for 18 Mubarak SJ, Owen CA. Double incision fasciotomy of
the Surgery of Trauma. Practice Management Guidelines. the leg for decompression in compartment syndromes.
Available from www.east.org (accessed December 2010). JTrauma 1977;59A:1847.
6 Rogers FB, Cipolle MD, Velmahos G, Rozycki G. Practice 19 Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P,
management guidelines for the management of venous Browner BD. The medical and economic impact of severely
thromboembolism (VTE) in trauma patients. J Trauma injured lower extremities. J Trauma 1988;28:12703.
2002;53:14264. In: Eastern Association for the Surgery of 20 Georgiadis GM, Behrens FF, Joyce MJ, Earle AS,
Trauma. Practice Management Guidelines. Available from Simmons AL. Open tibial fractures with severe soft-
www.east.org (accessed December 2010). tissue loss. Limb salvage compared with below-the-knee
7 Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, amputation. JBone Joint Surg Am 1993;75:143141.
Pollak AN. External fixation as a bridge to intramedullary
nailing for patients with multiple injuries and with
femur fractures: damage control orthopedics. J Trauma 9.10Recommended reading
2000;48:61321.
8 Dunham CM, Bosse MJ, Clancy TV et al.; The EAST Arrillaga A, Bynoe R, Frykberg R, Practice Management
Practice Management Guidelines Work Group. Practice Guidelines for penetrating trauma to the lower extremity.
management guidelines for the optimal timing of long- In: Eastern Association for the Surgery of Trauma. Practice
bone fracture stabilization in polytrauma patients: the EAST Management Guidelines. Available from www.east.org.
Part 6
Additional (optional modules)

Critical care of the trauma patient 10
10.1 Introduction After major trauma, some patients experience con-

siderable delay before organ perfusion is fully restored,
Most trauma mortality in the intensive care unit (ICU) despite apparently adequate systolic blood pressure and
occurs during the first few days of admission, primarily apparently normal urine output. This phenomenon has
as a result of closed head injury, respiratory failure or been called occult hypoperfusion.1 A clear association
refractory haemorrhagic shock, all of which are largely has been identified between occult hypoperfusion after
non-preventable deaths. The remainder, many of which major trauma and increased rates of infections, length of
may be preventable, occur late and are caused by multiple stay, days in the surgical/trauma ICU, hospital charges
organ failure, infection or both. and mortality. Equally, early identification and aggressive
resuscitation aimed at correcting occult hypoperfusion
has been shown to improve survival and reduce complica-
10.2 Goals of trauma ICU care tions in severely injured trauma patients.2
Several studies have shown that patients who have the
The fundamental goals of trauma ICU care are early res- ability to achieve supranormal (or optimal) haemody-
toration and maintenance of tissue oxygenation, diag- namic values after resuscitation are more likely to survive
nosis and treatment of occult injuries, and prevention than those who do not.3 However, the practice of supranor-
and treatment of infection and multiple organ failure. mal resuscitation itself was associated with more infusion
Trauma ICU care is best provided by a multidisciplinary of lactated Ringers solution, decreased intestinal perfusion
team focused on resuscitation, monitoring and life sup- (a higher value for gastric partial carbon dioxide minus
port. In the ICU, those who take care of a patient admit- end-tidal carbon dioxide [GAPco2]), and an increased inci-
ted with lethal brain injury play a vital role in the support dence of intra-abdominal hypertension, abdominal com-
and maintenance of potential organ donors. partment syndrome, multiple organ failure and death.4,5
An elevated fluid balance in itself is a separate risk factor
for adult respiratory distress syndrome (ARDS).
10.3 Phases of ICU care
10.3.1Resuscitative phase (first 24 hours 10.3.1.1 Traditional end points of resuscitation
post-injury)
These generally include the following:
During this phase, management is focused on fluid resus- Clinical examination: cold and clammy, blood
citation, and the goal of treatment is the maintenance of pressure, central venous pressure, heart rate, arterial
adequate tissue oxygenation. At the same time, occult life- partial pressure of oxygen (Pao2), etc., but may not
threatening or limb-threatening injuries are sought. identify occult hypoperfusion
Inadequate tissue oxygenation must be recognized and Base deficit and lactic acidosis
treated immediately. Deficient tissue oxygen delivery in the Pulmonary artery catheter measurements, which
acutely traumatized patient is usually caused by impaired may be used to derive measures of cardiac index and
perfusion or severe hypoxaemia. Although several differ- oxygen delivery
ent types of shock can be present, inadequate resuscitation Gastric tonometry
from hypovolaemia and blood loss is most common. Tissue oximetry.
10.3.1.2 Post-traumatic respiratory failure 10.3.2.1 Priorities
The aetiology includes: Gas exchange and ventilatory support

Monitoring and control of ICP
Chest trauma
Fluid and electrolyte balance
Fluid overload
Haematological parameters
Shock
Occult injuries
Aspiration
Delayed intracranial haematoma formation
Post-traumatic ARDS
follow-up computed tomography scan of the head
Spinal cord injury
Intra-abdominal injuries follow-up computed
Fat embolism syndrome
tomography scan or ultrasound of the abdomen
Pre-existing respiratory disease.
Cervical spine injury completion of the radiographic
survey and clinical examination if possible
10.3.1.3Respiratory assessment and monitoring Thoracic and lumbar spine injury
Assess work of breathing: Extremity injury: hands and feet
Nerve injuries.
Respiratory rate
Arterial blood gases
Oxygen delivery and consumption
10.3.3Prolonged life support (>72 hours
Bronchoscopy.
post-injury)
Ventilatory support should be instituted earlier rather
than later; select a mode of ventilation tailored to the The duration of the prolonged life support phase depends
patients needs using appropriate volumes and amounts on the severity of the injury and its associated complica-
of positive end-expiratory pressure (PEEP), i.e.: tions. Many of those who are critically injured can be
successfully weaned from life support, while the more seri-
Volume-cycled
ously injured enter a phase in which ongoing life support
Pressure support ventilation
is necessary to prevent organ system failure. Predominant
Non-invasive ventilatory support.
clinical concerns that arise include infectious complica-
tions that may lead to the development of late multiple
10.3.2Early life support phase (2472 hours organ failure or death.
post-injury) The main objective of the management of patients
developing MODS is to provide support for failing organ
During this phase, treatment is focused on the manage- systems while attempts are made to isolate and eliminate
ment of post-traumatic respiratory failure and progres- inflammatory foci that could be perpetuating the organ
sive intracranial hypertension in patients suffering from system failure. In addition, prolonged immobility can
severe head injury. Usually, the diagnostic evaluation for cause problems with muscle wasting, joint contractures
occult injuries is now complete. Evidence of early multiple and skin compromise in pressure areas. Physiotherapy
organ failure may become apparent during this time. should be commenced early, with the proper use of
Problems that may develop at this time include intra splints, early exercise and ambulation when possible.
cranial hypertension, systemic inflammatory response
syndrome (SIRS), early multiple organ dysfunction syn-
10.3.3.1Respiratory failure
drome (MODS) and continued respiratory insufficiency.
The main priorities of the early life support phase are Unexplained respiratory failure look for occult
the maintenance of tissue oxygenation, the control of infection or necrotic tissue
intracranial pressure (ICP), an ongoing search for occult Tracheostomy early.
injuries, and the institution of nutritional support and
withdrawal or replacement of trauma resuscitation lines
10.3.3.2 Infectious complications6
or devices that may have been placed in less than ideal
conditions. Further establishment of the medical history Nosocomial pneumonia Gram stain of sputum and
or events of the injury is also completed. microbiological culture
Critical care of the trauma patient | 167
Lung abscess and empyema 10.3.3.6Extubation criteria (SOA2P)

Surgical site infection
S Secretions minimal
Superficial incisional surgical site, e.g. wound
O Oxygenation good
infection
A Alert
Deep incisional surgical site infection
A Airway: without injury or compromise
Organ/space surgical site infection, e.g. intra-
P Pressures or parameters: measurements of tidal
abdominal abscess
volume, vital capacity, negative inspiratory force, etc.
Intravenous catheter-related sepsis
Bloodstream infections
Urinary tract infection
10.3.4Recovery phase (separation from the ICU)
Acalculous cholecystitis
Sinusitis and otitis media
During the recovery phase, the patient is weaned from full
Ventriculitis and meningitis.
ventilatory support until he or she is breathing spontane-
Antibiotic therapy should ideally be of limited spec- ously and invasive monitoring devices can be removed. The
trum and directed toward cultures. Remember the risk of patient and family are prepared for the transition from the
antibiotic-associated colitis. ICU to general patient or intermediate care unit, and plans
for further convalescence and rehabilitation are developed.
10.3.3.3Non-infectious causes of fever
Drugs 10.4Hypothermia
Pulmonary embolus (PE)
Deep venous thrombosis (DVT). Hypothermia is a potential complication of trauma.
While hypothermia may itself cause cardiac arrest, it is
10.3.3.4 Percutaneous tracheostomy7 also protective to the brain through a reduction in meta-
bolic rate and thus reduced oxygen requirements. Oxygen
Percutaneous tracheostomy has been shown to have fewer consumption is reduced by 50 per cent at a core tempera-
perioperative and postoperative complications compared ture of 30C. The American Heart Association guidelines
with conventional tracheostomy, and is now the tech- recommend that the hypothermic patient who appears
nique of choice in critically ill patients. dead should not be considered so until a near-normal
Various techniques are described, with dilation by for- body temperature is reached. However, hypothermia is on
ceps or multiple or single dilators. Patient selection is balance extremely harmful to trauma patients, especially
important, and percutaneous tracheostomy should not by virtue of the way it alters oxygen delivery. Therefore,
be attempted if the procedure is non-elective, the land- the patient must be warmed as soon as possible, and heat
marks are obscure in the neck or the patient has a coagu- loss minimized at all costs.
lopathy. Confirmation of correct placement by fibreoptic
bronchoscopy is valuable. Ultrasound scanning of the
neck and routine endoscopy during the procedure appear 10.4.1Rewarming
to reduce early complications. Percutaneous tracheos-
tomy is not suitable for children. Hypothermia is common after immersion injury.
Rewarming must take place with intensive monitor-
ing. Patients who have spontaneous respiratory effort
10.3.3.5 Weaning from ventilatory support
and whose hearts are beating, no matter how severe the
During the recovery phase, the most important transition bradycardia, should not receive unnecessary resuscita-
made is that from mechanical ventilation to unassisted tion procedures. The hypothermic heart is very irritable
breathing, known as weaning. Weaning begins when the and fibrillates easily. Patients with a core temperature of
causes of respiratory failure have resolved. less than 29.5C are at high risk of ventricular arrhyth-
When signs of infection, respiratory failure or multisys- mias, and should be rewarmed as rapidly as possible.
tem failure abate, recovery from critical illness requiring Recent studies have not shown any increase in ventricular
prolonged ICU care is imminent. arrhythmias with rapid rewarming.
A hypothermic heart is resistant to both electrical and the aetiology in these abacteraemic patients may be
pharmacological cardioversion, especially if the core tem- burns, pancreatitis, significant soft tissue and destruc-
perature is below 29.5C, and cardiopulmonary resusci- tive injuries to tissue, particularly when associated with
tation should be continued if necessary. shock. The common theme through all of these vari-
If the core temperature is greater than 29.5 C and ous injuries and types of sepsis is that the inflamma-
fibrillation is present, one attempt at electrical cardiover- tory cascade has been initiated and runs amok. Once
sion should be made. If this is ineffective, intravenous the inflammatory response has been initiated, it leads
bretylium may be helpful. to systemic symptoms that may or may not be benefi-
Patients with a core temperature of between 29.5 C cial or harmful. The primary symptoms associated with
and 32 C can generally be passively rewarmed, and if SIRS include:
haemodynamically stable may be rewarmed more slowly.
Temperature <36C or >38C.
However, active core rewarming is still generally required.
Heart rate >90 beats per minute
Patients with a core temperature of over 32C can gen-
Respiratory rate >20 breaths per minute
erally be rewarmed using external rewarming.
Deranged arterial gases: partial pressure of carbon
Methods of rewarming include:
dioxide (Pco2) <32mmHg (4.2kPa)
White blood count >12.0 109/L or <4.0 109/L or
External 0.1% immature neutrophils.
Removal of wet or cold clothing and drying of the
Patients who have one or more of these primary compo-
patient
nents are thought to have SIRS. A further classification
Infrared (radiant) heat
of SIRS is that sepsis is SIRS plus documented infection.
Electrical heating blankets
Severe sepsis is sepsis plus organ dysfunction, hypoper-
Warm air heating blankets.
fusion abnormalities or hypotension. Finally, septic shock
NB: In the presence of hypothermia, space blankets are is defined as sepsis-induced hypotension despite fluid
ineffective, since there is minimal intrinsic body heat to resuscitation.
reflect. It is now recognized that there are a number of mes-
sengers associated with SIRS, including cytokines,
Internal growth factors and cell surface adhesion molecules.
Equally important components of the expression of
Heated, humidified respiratory gases to 42C
SIRS are the genetic cellular events, including those
Intravenous fluids warmed to 37C
involving the transcriptases and other proteins asso-
Gastric lavage with warmed fluids (usually saline at 42C)
ciated with the up-regulation and down-regulation
Continuous bladder lavage with water at 42C
of gene expression. It is now appreciated that if these
Peritoneal lavage with potassium-free dialysate at
cytokines and cell adhesion molecules are in proper bal-
42C (20mL/kg every 15 minutes)
ance, beneficial effects occur during the inflammatory
Intrapleural lavage
response. Conversely, if there is a dysregulation or dys-
Extracorporeal rewarming via a femoral artery
homeostasis of these various cytokines and growth fac-
femoral vein bypass.
tors, harmful effects may take place, damaging organs
It is recommended that resuscitation should not be and may lead to patient death. This dysregulation
abandoned while the core temperature is subnormal, may effect vascular permeability, chemotaxis, vascular
since it may be difficult to distinguish between cerebro- adherence, coagulation, bacterial killing and all the
protective hypothermia and hypothermia resulting from components of tissue remodelling.
brainstem death. One of the corollary concepts that has grown out of our
understanding of SIRS is that the inflammatory cascade is
not to be interpreted as harmful. It is only when dysregu-
10.5Systemic inflammatory lation occurs that it is a problem in patient management.
response syndrome The second concept is that cytokines are messengers, and
that we must not kill the messenger. Whether or not we
Two large studies have shown that 50 per cent of patients can control them by either up-regulation or down-regula-
with sepsis are abacteraemic. It is also recognized that tion remains to be proven by careful human studies.
10.6Multisystem organ 10.7Coagulopathy of major

dysfunction syndrome trauma8
Multisystem organ dysfunction syndrome is a clini- (See also Chapter 3, Transfusion in trauma.)
cal syndrome characterized by the progressive failure of Trauma patients are susceptible to the early develop-
multiple and interdependent organs. The dysfunction ment of coagulopathy, and the most severely injured
identifies a phenomenon in which organ function is not patients are coagulopathic on hospital admission. The
capable of maintaining homeostasis, so it occurs along a coagulopathy is worsened by:9
continuum of progressive organ failure, rather than abso-
Haemodilution dilutional thrombocytopenia is the
lute failure. The lungs, liver and kidneys are the princi-
most common coagulation abnormality in trauma
pal target organs; however, failure of the cardiovascular
patients
and central nervous system may be prominent as well.
Consumption of clotting factors
The main inciting factors in trauma patients are haem-
Hypothermia which causes platelet dysfunction
orrhagic shock and infection. As life support and resus-
and a reduction in the rate of the enzymatic clotting
citation techniques have improved, so the incidence of
cascade
MODS has increased. The early development of MODS
Acidosis
(<3 days post-injury) is usually a consequence of shock
Metabolic derangements (especially acidosis), which
or inadequate resuscitation, while late onset is usually a
also interfere with the clotting mechanism.
result of severe infection.
Multisystem organ dysfunction syndrome develops More recently in trauma, the focus has shifted from
as a consequence of local inflammation with activation a disseminated intravascular coagulation (DIC) type
of the innate immune system and a subsequent uncon- coagulopathy without microthrombi, to extensive tissue
trolled or inappropriate systemic inflammatory response trauma in combination with reduced perfusion in which
to inciting factors such as severe tissue injury (e.g. brain, the endothelium shows an increased expression of throm-
lung or soft tissue), hypoperfusion or infection. Two bomodulin, thus binding thrombin.
basic models have emerged: the one-hit model involves With the reduced levels of thrombin, there is a reduced
a single insult that initiates a SIRS, which may result in production of fibrin. The thrombinthrombomodulin
progressive MODS, whereas the two-hit model involves complex activates protein C. The activated protein C
sequential insults that may lead to MODS. The initial inactivates co-factors V and VIII, causing anticoagulation.
insult may prime the inflammatory response such that Activated protein C also inactivates plasminogen activator
a second insult (even a modest one) results in an exag- inhibitor type 1, increasing fibrinolysis. The thrombin
gerated inflammatory response and subsequent organ thrombomodulin complex also binds thrombin-activated
dysfunction. fibrinolysis inhibitor (TAFI), reducing the inhibition of
Early factors that increase the risk for MODS include fibrinolysis. In trauma-induced coagulopathy, the shift-
persistent and refractory shock with lactic acidosis and ing balance between the binding of protein C and TAFI
elevated base deficit, a high ISS and the need for multiple may be the cause of the different clinical presentations.
blood transfusions. Advanced age or pre-existing disease Long-standing hypotension, acidosis and ischaemia give
may also increase a patients risk of developing MODS a release of a tissue plasminogen activator. Together with
because of co-morbid disease or decreased organ reserves reduced liver function, the consumption of coagulation
secondary to normal ageing. factors, activated plasmin and fibrin degradation prod-
Specific therapy for MODS is currently limited, apart ucts, haemostasis is compromised.
from providing adequate and full resuscitation, treatment Platelet survival is so short that severe thrombocyto-
of infection and general ICU supportive care. Strategies penia is common. There is a consumptive deficiency of
to prevent MODS include adequate fluid resuscitation to coagulation factors.
establish and maintain tissue oxygenation, debridement Excess plasmin generation is reflected by reduced
of devitalized tissue, early fracture fixation and stabiliza- plasma levels of fibrin and elevated levels of fibrin deg-
tion, early enteral nutritional support when possible, the radation products, with abnormal concentrations being
prevention and treatment of nosocomial infections, and found in 85 per cent of patients. Tranexamic acid may
early mobility and resumption of exercise. have a major role in clot stabilization.10
10.7.1Management The development of ARF complicates the ICU manage-

ment of a patient, increases the length of stay12 and is
The management of diffuse bleeding after trauma relies associated with a mortality of approximately 60 per cent.
on haemorrhage control, active rewarming and replace- Approximately one-third of acute post-traumatic renal
ment of blood products. The empirical transfusion of failure cases are caused by inadequate resuscitation, while
platelets, fresh frozen plasma and cryoprecipitate is rec- the remainder seem to develop as part of MODS.
ommended in patients with major injuries (i.e. the dam- The clinician should look for and manage these com-
age control group).11 mon causes:
Clinically, it is difficult to identify DIC as a separate
Hypovolaemia
entity from the coagulopathy of major trauma described
Rhabdomyolysis
above. The distinction is, however, largely academic; the
Abdominal compartment syndrome
key step in the management of DIC is resolution of the
Obstructive uropathy.
condition predisposing to the coagulopathy. The condi-
tion will not resolve until the underlying cause has been Avoid nephrotoxic dyes and drugs.
corrected; while this is being achieved, component ther-
apy is indicated.
10.10Evaluation of metabolic
disturbances
10.8Recognition and treatment
of raised ICP Disturbances in acidbase and electrolyte balance can be
anticipated in patients in shock, those who have received
Early mortality in blunt trauma patients in the ICU is often massive transfusions and the elderly with co-morbid
caused by head injury. The primary goal in the ICU man- conditions.
agement of the patient with a severe head injury is to pre- Typical abnormalities may include:
vent secondary neuronal injury. One important factor that Acidbase disorders
can contribute to secondary brain injury is increased ICP. Electrolyte disorders
Consequently, monitoring and controlling ICP and cerebral Hypokalaemia
perfusion pressure is a high priority in this phase of ICU Hyperkalaemia
care. Other conditions that worsen brain injury include: Hypocalcaemia
Hypotension Hypomagnesaemia.
Hypoxia In acidbase disorders, one must identify and correct
Hyperglycaemia the aetiology of the disturbance, for example metabolic
Hyperthermia acidosis caused by hypoperfusion secondary to occult
Hypercarbia. pericardial tamponade.
10.9Recognition of acute renal 10.11 Pain control

failure
A number of adverse consequences result when pain is
While the frequency of acute renal failure (ARF) is rela- inadequately treated. These include increased oxygen
tively low, injured patients are at high risk of its develop- consumption, increased minute volume demands, psy-
ment. Several indicators of the severity of physiological chic stress, sleep deprivation, and impaired lung mechan-
injury, including the lowest body temperature, the high- ics with associated pulmonary complications. Subjective
est lactate level and the need for packed red blood cell and pain assessment is best documented objectively and,
cryoprecipitate transfusions, were independently asso- after initiation of treatment, requires serial re-evaluation.
ciated with a higher risk of developing ARF. Other fac- Inadequate pain relief can be determined objectively by
tors included tissue damage and necrosis, hypotension, the failure of the patient to achieve adequate volumes on
rhabdomyolysis, the use of iodinated contrast for diag- incentive spirometry, persistently small radiographic lung
nostic tests, and pre-existing conditions such as diabetes. volumes, or a reluctance to cough and cooperate with
chest physiotherapy. If the patient can cooperate, visual High-priority occult injuries:
analogue pain scores may be helpful.
Brain, spinal cord and peripheral nerve injury
Early pain control in the ICU is primarily achieved
Thoracic aortic injury
through the use of intravenous opiates. Other techniques are
Intra-abdominal or pelvic injury
employed and tailored to the individual patient and injury:
Vascular injuries to the extremities
Bolus opiates morphine titrated intravenously Cerebrovascular injuries occult carotid/vertebral
Patient-controlled analgesia artery injury
Epidural analgesia (patient-controlled epidural Cardiac injuries
analgesia) Aerodigestive tract injuries ruptured bowel
Intrapleural anaesthesia Occult pneumothorax
Extrapleural analgesia Compartment syndrome foreleg, thigh, buttock or arm
Intercostal nerve blocks Eye injuries (remember to remove the patients
Catheter techniques for peripheral nerve blocks, e.g. contact lenses)
femoral nerve, brachial plexus, popliteal nerve and Other occult injuries hands, feet, digits or joint
paravertebral nerve blocks. dislocations
Vaginal tampons.
10.12Family contact and

support 10.13.2Assess co-morbid conditions
It is very important to establish early contact with fam- Medical history (including drugs and alcohol)
ily members to explain the injuries, clinical condition and Contact the patients personal physicians
prognosis of the patient. This provides family members Check pharmacy records.
with essential information, and establishes a relationship
between the ICU care team and the family. Administrative
facts, such as ICU procedures, visiting hours and available
services, should also be explained. With the elderly, iden-
10.14Nutritional support14,15
tifying the existence of living wills or other predetermina-
Trauma patients are hypermetabolic, and have increased
tion documents is important.
nutritional needs due to the immunological response to
trauma and the requirement for accelerated protein syn-
thesis for wound healing. Early enteral feeding has been
10.13 ICU tertiary survey13 shown to reduce postoperative septic morbidity after
trauma. A meta-analysis of a number of randomized trials
The tertiary survey is a complete re-examination of the
has demonstrated a twofold decrease in infectious com-
patient, plus a review of the history and all available
plications in patients treated with early enteral nutrition
results and imaging. Missed injuries are a potent cause of
compared with total parenteral nutrition.
morbidity, and the majority will be identified by a thor-
Traumatic brain injury (TBI) patients appear to have
ough tertiary survey. A tertiary trauma survey has much
similar outcomes whether fed enterally or parenter-
to recommend it in minimizing the delay in the ultimate
ally. A Cochrane Review has confirmed that early (either
diagnosis of missed injury. Nevertheless, it is not a com-
parenteral or enteral) feeding is associated with a trend
plete solution, and an ongoing analysis of errors should
towards better outcomes in terms of survival and dis-
be undertaken at any major trauma centre.
ability compared with later feeding.16 Patients with a TBI
exhibit protein wasting and gastrointestinal dysfunction,
which may be risk factors for a septic state. However,
10.13.1Evaluation for occult injuries
standard nutritional support may not allow restoration
of the nutritional state of TBI patients.17
Factors predisposing to missed injuries:
Enteral nutrition should be used when the gut is acces-
Mechanism of injury re-verify the events sible and functioning.18 Enteral nutrition is not invariably
surrounding the injury. safer and better than parenteral nutrition, but a mix of
the two modalities can be used safely. Immunonutrition acid-blocking and cytoprotective therapies has become
holds promise for the future.19 commonplace.
Patients at risk include those with: Those patients at greatest risk for stress ulcer develop-
ment are those with a previous history of ulcer disease,
Major trauma
those requiring mechanical ventilation and those with
Burns.
a coagulopathy, regardless of whether it is intrinsic or
It is critical to: chemically induced. Burn patients have also been labelled
as high risk in historical studies.
Determine energy and protein requirements
Cytoprotective agents (e.g. sucralfate) as a preventive
Determine and establish a route of administration
measure have been shown to be the most cost-effective by
Set a time to begin nutrition support.
statistical analysis in several trials, although there are fewer
cases of stress ulcer bleeding in the H2-receptor blockade
arm of these trials. However, the marked decrease in the
10.14.1Access for enteral nutrition
rate of development of ventilator-associated pneumonia
seen in the sucralfate population does make this thera-
10.14.1.1Simple peutic option quite attractive.14
Intravenous H2-receptor blockade therapy (e.g. raniti-
Naso/orogastric tube
dine) to some degree blocks the production of stomach
Naso/oroduodenal tube
acid. Most studies demonstrating its efficacy in stress
Naso/orojejunal tube.
ulcer prevention do not attempt to neutralize gastric pH.
Most critically ill trauma patients should be started on Newer intravenous proton pump inhibitors may well
early enteral nutrition. The majority do not require pro- replace H2 blockade as the mainstay of therapy.
longed feeding (beyond 1014 days), and simple nasoen- Perhaps the simplest and safest method of stress ulcer
teric tube feeding is then all that is required. For patients prevention is adequate resuscitation and early intragastric
who have prolonged tube-feeding requirements, nasoen- enteric nutrition. During the early resuscitative phase and
teric tubes are inconvenient, as they tend to dislodge, while vasoactive drugs to elevate blood pressure are in use,
worsen aspiration and are uncomfortable. it is not always prudent to provide nutrition enterally. It
is in these circumstances that the use of acid blockade,
cytoprotective agents or both is necessary.
10.14.1.2More complicated
Percutaneous endoscopic gastrostomy. This does not

interfere with swallowing, is easy to nurse and has 10.15.2Deep venous thrombosis and
target feeding rates that are more likely to be achieved pulmonary embolus22
compared with nasoenteric tubes. However, it is an
invasive procedure with some risk. Pulmonary embolus from DVT continues to be a lead-
Jejunostomy. Jejunostomy can be placed endoscopically ing preventable cause of death in the injured patient.
or during laparotomy. Rates of major complications Recognizing the risk factors for the development of DVT
should be less than 5 per cent.20 and instituting an aggressive management regimen can
reduce this risk from DVT in the ICU with little added
morbidity. The incidence of DVT in trauma patients
10.15Preventive measures in the is 1232 per cent, and those at highest risk of fatal PE
ICU include those with spinal cord injuries, weight-bearing
pelvic fracture and combined long bone fracture/TBI or
10.15.1Stress ulceration21 long bone fracture/pelvic fracture.
A high index of suspicion in these severely injured
Stress ulceration and associated upper gastrointestinal patients should result in preventative therapy and diag-
bleeding has been on the decline in most ICUs for the past nostic screening measures being taken in the ICU. Unless
decade. This is, in great part, due to the improved resusci- haemorrhagic TBI or spinal cord epidural haematoma
tation efforts in the pre-hospital environment, emergency precludes the use of subcutaneous heparin therapy, these
department and operating room. Additionally, the use of patients should all receive fractionated low molecular
weight subcutaneous heparin. Unfractionated heparin of administration of these vaccines in trauma patients,
does not appear to be nearly as effective in this severely but it is clear that adult patients do not benefit from
injured population.23 Similarly, unless extremity injury the antibacterial chemoprophylaxis needed in paediatric
precludes their use, graded pneumatic compression patients post-splenectomy. Due to the multiple strains
devices should be used on all such patients. Foot pumps of each organism, the immunizations are not foolproof
may also be of some benefit. in preventing overwhelming post-splenectomy infec-
Screening for the presence of DVT, which, if present, tion. Therefore, patients must be carefully counselled
would necessitate more aggressive anticoagulant therapy, to seek medical attention immediately for high fevers,
should also be implemented in these patients. The easiest and healthcare providers must be aggressive in the use
and safest screening tool is venous Doppler ultrasound of empirical antibiotics in patients who may have over-
or duplex scanning. This is a portable, readily available, whelming post-splenectomy infection upon presentation
repeatable and cost-effective procedure with no side effects in the outpatient setting. Currently, booster immuniza-
for the patient. These modalities are, however, operator- tion with Pneumovac is indicated each 5 years for these
dependent and can fail to diagnose DVT in the deep pel- splenectomized patients.
vic veins, but contrast ultrasound trials to overcome this Adequate wound debridement and irrigation are nec-
weakness are now being conducted. This screening should essary to eliminate non-viable tissue and debris from all
be performed whenever clinical suspicion of DVT arises, traumatic wounds, in order to limit infection of these
within 48 hours of admission, and each 57 days thereaf- wounds. Whenever possible, these wounds should be
ter as long as the patient remains in the ICU. thoroughly prepared as above and closed primarily. If
In the highest risk patients previously mentioned, every skin coverage is lacking, or more than 6 hours has elapsed
consideration of the prophylactic placement of an infe- since injury, moist dressings (to prevent tissue desiccation
rior vena cava filter should be made. The lifetime risk and further non-viable wound tissue) should be applied
of the filter appears to be quite low in several studies, and changed twice per day, further wound debridement
with an obvious significant benefit in the prevention of performed as indicated and skin grafts or flap coverage
death. An additional subgroup of patients to be consid- performed once the health of the wound can be assured.
ered for prophylactic inferior vena cava filter placement Special attention must be given to difficult wounds of the
are those with significant injuries who also have either a perineum (consider faecal diversion), complex fractures
contraindication to full anticoagulation (PE treatment) with soft tissue injury and contamination (osteomyelitis),
or severe lung disease (long-standing or acutely acquired, and wounds on the back and occiput (as pressure may
i.e. ARDS), which could result in death even from a small cause additional wound necrosis).
PE. The combination of aggressive prevention measures, Thrombophlebitis and sepsis from intravenous can-
screening by duplex and prophylactic inferior vena cava nulas are significant considerations as these intravenous
filters can result in a fatal PE rate of significantly less than lines are frequently placed under less than optimal circum-
1 per cent of the trauma ICU population. stances and technique in the field and in the resuscitation
areas. Removal and replacement of all such lines as early
as possible, but in every instance in less than 24 hours, is
10.15.3 Infection paramount to avoid these infectious complications.
In patients with any open wounds from trauma, it is imper-

ative that the tetanus immunization status of the patient is 10.16Antibiotics
addressed. For those patients immunized within the previ-
ous 5 years, no additional treatment is generally needed, The goal of antibiotic treatment is to improve survival;
while booster tetanus toxoid should be administered to however, preventing the emergence of antibiotic resist-
those who have previously received the initial tetanus series ance is also important.
but have not been reimmunized in the preceding 510 There is good evidence to support a limitation of use
years. Tetanus immune globulin should be administered of antibiotics in the critically ill trauma patient.24 Many
to those patients who lack any history of immunization. institutions will administer a single dose of a cepha-
Patients undergoing splenectomy require immuniza- losporin in the emergency area in all patients with open
tion for Haemophilus influenzae type B, meningococcus and injury, irrespective of its origin. There is no evidence to
pneumococcus. Debate continues regarding the timing support this unless surgical operation is required.25 There
is conflicting evidence regarding the need for routine anti- Short-therapy duration (8 days) if the patient is
biotics with tube thoracostomy. on an appropriate regimen and not infected by a
For thoracoabdominal injuries requiring operation, a multidrug-resistant pathogen.
single dose of broad-spectrum antibiotics is indicated.
Given the variations in antibiotic susceptibility profiles
Prolonged courses of antibiotics, extending beyond 24
of VAP pathogens, both in location and with respect to
hours, are not currently indicated in these patients.
changes over time, it is inappropriate to specify the use of
Patients with open fractures are frequently treated with
specific antibiotic regimens.
both Gram-negative and Gram-positive prophylaxis for
long periods. There is no evidence for this practice, or for
whether the correct management should be any different 10.17Respiration
from that for torso injury.26,27
Patients in the ICU on mechanical ventilation, with or Mechanical ventilation should be gentle as high tidal
without known aspiration, have no indication for anti volumes and pressures can damage the lungs.
biotics to prevent pneumonia. In fact, this practice has Prevent aspiration.
hastened the onset of antibiotic resistance worldwide. Undertake early tracheostomy.
According to the Centers for Disease Control, a diagno- Pulmonary toilet and pain control should be used in
sis of pneumonia must meet the following criteria: patients with rib fractures.
Rales or dullness to percussion Employ pressure control ventilation and high-PEEP
AND any of the following: for ARDS.
New purulent sputum or a change in sputum Prone ventilation may improve oxygenation in
Culture growth of an organism from blood or patients with ARDS or severe sepsis.
tracheal aspirate, bronchial brushing or biopsy VAP is the common hospital-acquired infection in ICU.16
Radiographic evidence of new or progressive infiltrate,
consolidation, cavitation or effusion, 10.18Organ donation
AND any of the following:
Isolation of virus or detection of viral antigen in Identification of potential organ donors from among
respiratory secretions brain-dead patients is an important role in every critical
Diagnostic antibody titres for pathogen care department. It is difficult to balance the require-
Histopathological evidence of pneumonia. ments of the organ transplant teams with a sympathetic
For ventilator-associated pneumonia (VAP) there are and understanding approach to grieving relatives. Specific
new guidelines:28 training is vital.
VAP diagnosis the VAP diagnosis interventions

considered most appropriate for inclusion in the care 10.19References
bundle were as follows:
Early chest X-ray with expert interpretation within 1 Claridge JA, Crabtree TD, Pelletier SJ, Butler K, Sawyer RG,
1 hour Young JS. Persistent occult hypoperfusion is associated
Immediate reporting of respiratory secretions with a significant increase in infection rate and mortality in
Gram-stain findings, including cells major trauma patients. J Trauma 2000;48:814.
VAP treatment the VAP treatment interventions 2 Blow O, Magliore L, Claridge JA, Butler K, Young JS. The
considered most appropriate for inclusion in the care golden hour and the silver day: detection and correction of
bundle were as follows: occult hypoperfusion within 24 hours improves outcome
Immediate treatment after microbiological from major trauma. J Trauma 1999;47:9649.
sampling 3 Velmahos GC, Demetriades D, Shoemaker WC et al.
Empirical therapy based on a knowledge of local Endpoints of resuscitation of critically injured patients:
pathogens and an assessment of risk factors normal or supranormal? A prospective randomized trial.
De-escalation of antibiotics in responding patients Ann Surg 2000;232:40918.
once culture results are available 4 Papadakos PJ, Karcz M, Lachmann B. Mechanical ventilation
Assessment of response to treatment within 72 hours in trauma. Curr Opin Anaesthesiol 2010;23:22832.
5 Balogh Z, McKinley BA, Cocanour CS et al. Supranormal 20 Holmes JH 4th, Brundage SI, Yuen P, Hall RA, Maier RV,
trauma resuscitation causes more cases of abdominal Jurkovich GJ. Complications of surgical feeding jejunostomy
compartment syndrome. Arch Surg 2003;138:63743. in trauma patients. J Trauma 1999;47:100912.
6 Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC 21 Guillamondegui OD, Gunter OL Jr, Bonadies JA et al.
definitions for nosocomial infections, 1988. Am J Infect Practice management guidelines for stress ulcer prophylaxis.
Control 1988;16:12840. In: Eastern Association for the Surgery of Trauma. Practice
7 Mallick A, Bodenham AR. Tracheostomy in critically ill Management Guidelines. Available from www.east.org
patients. Eur J Anaesthesiol 2010;27:67882. (accessed December 2010).
8 Ganter MT, Pittet JF. New insights into acute coagulopathy 22 Rogers FB, Cipolle MD, Velmahos G, Rozycki G. Practice
in trauma patients. Best Pract Res Clin Anaesthesiol management guidelines for the management of venous
2010;24:1525. thromboembolism (VTE) in trauma patients. J Trauma
9 Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy: its 2002;53:14264. In: Eastern Association for the Surgery of
pathophysiology and treatment in the injured patient. Trauma. Practice Management Guidelines. Available from
World J Surg 2007;31:105564. www.east.org (accessed December 2010).
10 Geeraedts LMG Jr, Kaasjager HAH, van Vugt AB, Frlke 23 Boddi M, Barbani F, Abbate R et al. Reduction in deep
JPM. Exsanguination in trauma: a review of diagnostics and vein thrombosis incidence in intensive care after a clinician
treatment options. Injury 2009;40:1120. education program. J Thromb Haemost 2010;8:1218.
11 CRASH-2 Trial Collaborators. Effects of tranexamic acid on 24 Hauser CJ, Adams CA Jr, Soumitra RE; Council of the Surgical
death, vascular occlusive events, and blood transfusion in Infection Society. Surgical Infection Society Guidelines:
trauma patients with significant haemorrhage (CRASH-2): a prophylactic antibiotic use in open fractures: an evidence-
randomised, placebo-controlled trial. Lancet 2010;376:2732. based guideline. Surg Infect (Larchmt) 2006;7:379405.
12 Bihorac A, Delano MJ, Schold JD et al. Incidence, clinical 25 Velmahos GC, Toutouzas KG, Sarkisyan G et al. Severe
predictors, genomics, and outcome of acute kidney injury trauma is not an excuse for prolonged antibiotic prophylaxis.
among trauma patients. Ann Surg 2010;252:15865. Arch Surg 2002;137:53741.
13 Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of 26 Luchette FA, Bone LB, Born CT et al. Practice management
early missed injuries and the role of the tertiary trauma guidelines for prophylactic antibiotic use in open fractures.
survey. J Trauma 1998;44:10006; discussion 10067. In: Eastern Association for the Surgery of Trauma. Practice
14 Jacobs DO, Kudsk KA, Oswanski MF, Sacks GS, Sinclair KE. Management Guidelines Workgroup. Available from http://
Practice management guidelines for nutritional support of www.east.org. (accessed December 2010).
the trauma patient. In: Eastern Association for the Surgery 27 Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. Eastern
of Trauma. Practice Management Guidelines. Available Association for the Surgery of Trauma. Eastern Association
from www.east.org. for the Surgery of Trauma. Practice Management Guidelines
15 Kreymann KG, Berger MM, Deutz NE et al. DGEM (German Workgroup: Update to practice management guidelines for
Society for Nutritional Medicine), Ebner C, Hartl W, Heymann prophylactic antibiotic use in open fractures. Available from
C, Spies C; ESPEN (European Society for Parenteral and www.east.org (accessed December 2010).
Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: 28 Rello J, Paiva JA, Baraibar J et al. International Conference for the
intensive care. Clin Nutr 2006;25:21023. Development of Consensus on the Diagnosis and Treatment of
16 Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional Ventilator-associated Pneumonia. Chest 2001;120:95570.
support for head-injured patients. Cochrane Database Syst
Rev 2000;(2):CD001530. 10.20Recommended reading
17 Cook AM, Peppard A, Magnuson A. Nutrition considerations
in traumatic brain injury. Nutr Clin Pract 2008;23:60820. Eastern Association for the Surgery of Trauma. Practice
18 Moore FA, Feliciano DV, Andrassy RJ et al. Early enteral Management Guidelines. Available from www.east.org.
feeding compared with parenteral reduces postoperative Marino PL, Sutin KM, eds. The ICU Book, 3rd edn. Philadelphia:
septic complications: the result of a meta-analysis. Ann Surg Lippincott Williams & Wilkins, 2007.
1992;216:17283. Orlinsky M, Shoemaker W, Reis ED, Kerstein MD. Current
19 Houdijk AP, Rijnsburger ER, Jansen J et al. Randomised trial of controversies in shock and resuscitation. Surg Clin North
glutamine-enriched enteral nutrition on infectious morbidity Am 2001;81:121762.
in patients with multiple trauma. Lancet 1998;352:7726. Schwab CW, Reilly PM, eds. Critical care of the trauma patient.
Surg Clin North Am 2000;80(3).
Austere conditions and
battlefield surgery 11
11.1introduction even the most advanced countries cannot always achieve.

Following a natural disaster, or in a conflict or post-
Austere: severely simple, morally strict, harsh. conflict environment, supply chains and systems will be
disrupted and vulnerable; in a conflict, they may be delib-
Harsh: unpleasantly rough or sharp, severe, cruel. erately targeted. No delivery can ever be guaranteed, and
the team may have only what they carried off the plane.
Multiple casualties: More than one patient, but
Psychologically, some doctors do not work well out
can be dealt with within existing resources.
of their normal hospital or workplace, and some cannot
Mass casualties: Many patients with demands adapt easily. In addition, the availability of a volunteer
beyond the resources available. does not imply the ability or even the affability required
to work in a small team. Also, individual health states
Before the surgeon picks up a scalpel, or the anaesthetist need to be high: a person with diabetes, for example, is
picks up a syringe, they must understand their environ- unlikely to do well without cold-chain controlled insulin.
ment. In the response to a natural disaster or a military So all members of a surgical team need to understand
environment, this also implies that they should not them- this and have a realistic expectation of what they can
selves become casualties. or cannot provide in the situation in which they find
Modern surgery and anaesthesia require infrastructure themselves.
and resources, not just sutures and drugs. However, a good
nights sleep and a mosquito net may be as important as
the availability of an intensive care bed in providing a 11.2 Injury patterns
high standard of care. Flexibility and capability beyond
ones conventional speciality are also required: surgeons In the nineteenth century, warfare was infantry-based. In
do not often service generators, and anaesthetists do not the twentieth century, it became mechanized and airborne,
often sterilize water, but they may have to. and in the twenty-first century, combat is asynchronous,
Infrastructure requirements include shelter, power for with possibly only one side in uniform. To quote General
lighting and temperature control, and water for hygiene Sir Rupert Smith, author of The Utility of Force,1 the mod-
and cooking purposes. Waste needs to be disposed of ern battlefield is amongst the people. Injuries sustained
properly, medical waste disposal (particularly sharps) in contemporary combat operations are inflicted on com-
always being problematic. batant and non-combatant alike: in a recent review of
Resources include medical gases, food, drugs, fluids activity at a coalition hospital in Afghanistan, 60 per cent
and other consumables such as gloves and gowns. Fluids of casualties were local nationals, including women and
include blood and blood products, and these in particular children.
need a reliable and documented cold chain. During a recent conflict in an urban setting in Somalia,2
In the civilian setting, these materials and resources casualty distribution in military personnel was similar to
are provided by a series of complex supply chains that that of the Vietnam War:3 11 per cent died on the bat-
are carefully controlled and tracked, guaranteeing deliv- tlefield, 3 per cent died after reaching a medical facility,
ery within 24 hours anywhere in the world. To provide 47 per cent were evacuated, and 39 per cent returned to
a similar standard of care in a deployed environment duty. In the first 6.5 years of Operation Iraqi Freedom,
requires similar supply chains, which, in times of conflict, US military casualties exceeded 3400 hostile deaths, 800
Austere conditions and battlefield surgery | 177
non-hostile deaths (due to disease, non-battle injury and Military medical practitioners have been described as
other causes) and over 31000 troops wounded in action. working at the interface of two dynamic technologies,
Casualty rates in Iraq have been considerably lower than warfare and trauma management. In addition to the
during the Vietnam conflict, and a greater proportion of problems of dispersed battlefields, highly mobile front
troops wounded in Iraq survive their wounds. Before the lines, extended lines of logistics and a delay in evacua-
surge in troop levels that began in early 2007, the survival tion, the modern military surgeon is likely to be called
rate was 90.4 per cent in Iraq compared with 86.5 per cent upon to treat civilians, including females (especially
in Vietnam. obstetric care) and children, as well as service personnel,
The leading causes of injury among casualties in with a requirement to offer immediate care well away
Afghanistan and the Iraq war were explosive devices, gun- from their speciality; problems in ophthalmology, maxil-
shot wounds, aircraft crashes and terrorist attacks. Of the lofacial surgery, ear, nose and throat medicine, paediat-
casualties, 55 per cent died in hostile action and 45 per rics, gynaecology, tropical medicine or even public health
cent in non-hostile incidents. Chest or abdominal inju- will fall under the remit of the military surgeon. These
ries (40 per cent) and brain injuries (35 per cent) were the challenges are magnified by the nature of modern sur-
main causes of death for soldiers killed in action. The case gical training, with its accent on early training in sub-
fatality rate in Iraq was approximately half as high as in specialities, combined with the decline in the popularity
the Vietnam War. In contrast, the amputation rate was of trauma surgery and surgical intensive care. Military
twice as high. Approximately 815 per cent of the deaths surgeons therefore have to be trained in a variety of spe-
appeared to be preventable. cialities and undergo multiple course training (including
Wounding patterns are modified by the presence or team training) before they deploy.
absence of modern ballistic protection (armour) and Modern all-arms battle presents a vast array of poten-
the pre-hospital timeline. Many fatal penetrating inju- tial wounding agents, from high-velocity military rifles,
ries are likely to be caused by missiles entering through shrapnel from mortars or mines, blast from any explosive,
areas not protected by body armour, such as the face and and chemical, biological and nuclear exposure (depleted
junctional areas in the neck, face, groin and buttocks. uranium in shells) to motor vehicle crashes. The latter
Injuries can be sustained by gunshot or the effect of con- are often the most common cause of injury. It is impera-
ventional explosive munitions (air-delivered bombs, artil- tive that military medical personnel become familiar with
lery shells, rocket-propelled grenades or hand grenades). the medical consequences of toxin exposure, the illnesses
The proportion of penetrating injuries due to bullets or caused by these agents and the measures required to
fragments will depend on the nature of the battle, with protect military healthcare providers.
blunt injury and burns likely to comprise a significant
component of the injuries in conventional manoeuvre
warfare. However, the defining injury pattern in recent 11.3Emergency medical services
counterinsurgency operations is that caused by impro- systems
vised explosive devices, which cause a combination of
blast and missile wounds. The patient presenting to the surgical team in a
One of the characteristics of military wounding is civilian hospital has already been part of a supply
early lethality, with a high proportion of deaths occur- chain. Consider the victim of a road traffic collision.
ring soon after injury. Of those who survive to reach Summoning help requires the existence of an intact
hospital, the majority will have injury to the extremities. telephone or radio system, appropriately trained indi-
Protocols for casualty assessment, tourniquet applica- viduals arriving in suitably equipped vehicles and an
tion, the use of haemostatic wound dressings, and the unimpeded journey, delivering an appropriately pack-
direct transfer of casualties from ambulance to operat- aged patient, to the hospital. In the deployed environ-
ing theatre are designed to recognize that exsanguination ment, this pre-hospital chain is particularly vulnerable.
remains the main cause of preventable battlefield death. Patients may experience delays of hours or days getting
In a recent review of deaths of servicemen after combat to care, which will in turn influence how they present to
injury, although 85 per cent of deaths were considered the surgical team.
non-preventable, half of those that were considered to Deployed military medical systems usually consist of a
be potentially survivable were the result of intracavity crescendo series of levels (roles) of care in military medi-
haemorrhage. cal treatment units, traditionally called roles 14. Close
to the point of injury, a casualty either applies self-aid or barrier preventing accidental or unauthorized access to
receives buddy aid (such as field dressing or tourniquet the site. An inner cordon may be set up around wreckage,
application). The next stage is care by a medic and then especially if hazards still exist.
by a doctor or nurse at an aid post (role 1 facility). By
the time a casualty reaches a surgical team at a role 2 Control
facility, they have usually received some treatment (anal-
Once cordons have been set up, the control of the cordons
gesia and antibiotics) and resuscitation (to various fluid
and scene is maintained by clear rendezvous and access
protocols).
points.
The situation becomes complicated when casualties
move between systems (e.g. military to host nation, or
Once the 4 Cs have been established, medical manage-
non-governmental organization to military) having
ment and support can begin:
received surgery in the first system. Because standards of
care can vary enormously between systems, these casu- Command and control
alties need a thorough examination and re-evaluation. Safety
Soldiers have been trained and issued their equipment Communication
before the disaster or injury occurs, in order to perform Assessment
immediate aid on themselves or each other; civilians, Triage
however, have not. It is critically important that full Treatment
documentation accompanies the patient in order to Transport.
prevent overtreatment.
11.3.1.1Command and control
11.3.1Incident management and multiple This is the paramount principle. If good command and
casualties control are not established, the initial chaos will continue,
and the injured will suffer regardless of how well some
At incidents in which bombs are involved or secondary individual casualties are treated. Command usually over-
devices are suspected, the 4 Cs must be adopted: rides control. Command implies the overall responsibility
for the mission, whereas control implies the authority to
Confirm
modify procedures or actions by services.
Clear
Cordon
Control. 11.3.1.2Safety
Healthcare workers must remember that their own safety

Confirm is paramount, and that they must not become casualties
Incident commanders must be clear about what is hap- themselves.
pening, and about the risk and position of further haz-
ards. Factors that must be considered are clearance
11.3.1.3Communication
priorities, cordon locations, safe areas, access and egress
routes and rendezvous points. Communication is the transmission between a sender and
a receiver, preferably such that the receiver is in no doubt
Clear about the intent and need of the sender. Every major inci-
dent inquiry has identified failings in communications.
The scene should be cleared to a safe distance. This dis-
Without good communication, command and control is
tance will vary depending on the terrain. The method and
impossible.
urgency of clearance will depend on the incident.
Cordon 11.3.1.4Assessment
Cordons establish the area in which the rescue effort is This is a constant process. Commanders should always
taking place, and define safe zones and tiers of command. consider the current situation, what resources are required
An outer cordon should be established as a physical and where these can be obtained.
11.3.1.5Triage limb-saving surgery in the forward locations, and taking

into account all the other factors, the key question will
In any situation when there is more than one casualty, a
be Do they need to go on the table at all? Overtriage is
system of triage must be used (see triage, below). There are
a feature of all mass casualty situations; however, a rate
many different systems in use (Table 11.1).
of overtriage is acceptable to avoid missing patients who
really did require an intervention. In a series of 1350
Table 11.1 Triage categories laparotomies from the Vietnam War, based on the clini-
cal assessment of wounded soldiers, the rate of negative
Priority Label colour Description
laparotomy was 19.2 per cent. In a modern military set-
T1 Red Immediate ting, an accurate screening tool (perhaps using computed
T2 Yellow Urgent tomography [CT] or focused abdominal sonography for
T3 Green Delayed trauma [FAST]) can be very useful.
Dead White or black Dead Effective triage is crucial in an efficient military health-
T4 Blue (not standard) Expectant
care system. It is dynamic, and must be applied at all
levels of medical care, from the point of wounding to
definitive surgical care. Triage must be repeated at every
point of care, or at any point of deterioration. Patients
11.3.1.6Treatment
compensate, change condition and deteriorate without
At the scene of any ballistic incident, treatment teams prior warning. The dead are dead nothing can be done
may be faced with casualties with multiple serious inju- for them. The needs of the dying, who will require 50 per
ries. Treatment must follow the <C>ABC paradigm (see cent of the resources of a surgical team to save them, need
below under Section 11.7.1, Overview). to be balanced against the needs of the next 10 patients
who arrive. The factors to be taken into account in triage
include:
11.3.1.7Transport
Patient load and severity
Not every patient needs to travel in an ambulance. Buses or
Medical capability and supply
other multipassenger vehicles should be used to move the
Local situation and safety
walking wounded. The judicious use of other resources,
Available evacuation assets and flight times
including armoured vehicles and aircraft, is essential.
Theatre medical assets.
Transfer time will also dictate who requires life-saving

11.4Triage interventions at that point, and who can wait until they
reach the next echelon of medical care. Equipment will
Effective triage is crucial in an efficient military health- always be in limited supply in these forward locations,
care system, and was first described by Napoleons sur- and must be used appropriately as resupply will take time.
geon, Dominique Jean Larrey, who introduced a system The flow of casualties in a fast-moving battle will also
of sorting casualties as they presented to field dressing influence how many and what type of casualties should
stations. His priority, and the aim of the system, was be operated on. The prospect of incoming serious casual-
to identify those soldiers who had minor wounds, and ties will change triage decisions for the wounded already
therefore could with minor treatment return to the bat- at the medical facility. If there is only one surgical table
tle. Although we might now call this reverse triage, he available forward, Who goes on first? and Do they need
had introduced a formal system of prioritizing casual- to go on at all? may be simple questions to ask, but the
ties. Triage remains a fundamental principle in modern answers are anything but straightforward.
military medicine. It is dynamic, and should be applied at The need for effective triage poses difficult questions.
all levels of medical care, from the point of wounding to A patient with extensive multiple injuries, who would get
definitive surgical care. maximum effort and resources in a civilian trauma cen-
The system for surgical triage may be slightly differ- tre, may need to be labelled expectant if several other
ent from the triage system used in resuscitation, but the patients face a better chance of survival given early access
same principles apply. Those requiring life-saving sur- to the limited equipment and expertise available. Thus, an
gical intervention take priority over patients requiring awareness of the overall tactical picture on the part of the
senior surgeon is paramount. It may be wise to remem- Human factors of physical and emotional fatigue will
ber that triage, including surgical triage, means doing the also affect how long the surgical team can endure the
best for the most, and expectant treatment for some may challenges of operating in austere and dangerous envi-
eventually benefit the most. ronments without reinforcement or resupply. The teams
will often have to function independently, but may also
deploy as augmentation of an existing medical facility
11.4.1Forward surgical teams and triage during a casualty surge. Even in wartime, the best surgical
teams could not operate for more than 18 hours at a time
Many military healthcare teams around the globe are now over a sustained period without breaking after 3 days.
incorporating far-forward resuscitative surgery capabili- There is a difference between a well-equipped, relatively
ties into doctrine and mission planning. Although these static field (or combat support) hospital and a forward
forward surgical teams provide only a limited trauma surgical team. The raison dtre of the team is the delivery
surgical capability, they aim to provide life- and limb-sav- of life- and limb-saving surgery as far forward as possible
ing surgery to the select group of potentially salvageable to a select group of potentially salvageable patients who
patients who would otherwise die or suffer permanent would otherwise suffer due to delays in evacuation from
disability due to delays in evacuation from the fast-mov- the battlefield. Without patient selection (by security
ing modern battlefield. However, such a surgical team perimeter or guard-force) a small team will not function.
will necessarily have a very limited scope of activity, and Triage is challenging, it requires difficult decisions to
requires the commitment of other military assets in order be made, but it remains crucial to the effective use and
to protect the medical workforce. efficiency of the forward surgical teams.
These teams should be capable of providing life-saving
thoracoabdominal haemorrhage control, control of con-
tamination within body cavities, temporary limb revas- 11.5Mass casualties
cularization, stabilization of fractures and evacuation of
major intracranial haematomas. Each nation has a slightly One of the fundamental planning parameters for medi-
different balance and skill mix within this forward surgical support is an estimate of the numbers and types of
cal capability, but most will normally provide the three casualty expected. An estimate of the numbers and types
main tenets of forward care: a resuscitation capability, of casualty, the resources required to deal with them per
one or more surgical tables and a critical care capability. phase of battle, and their evacuation is the cornerstone
Most nations mission-tailor their teams to the spe- of operational medical planning. Casualty estimates are
cific operational environment, and sizes range from as major resource-drivers and will determine what capabili-
few as six members to larger teams of more than 30. As ties are required, and at what level. The medical support
part of the casualty estimate, military planners need to for a specific operation will therefore be planned in light
decide on the number of surgical tables required and the of the perceived threat.
speed at which they can safely transfer patients to the next Mass casualties, however, may occur for many reasons,
echelon of care (emptying the back door). The size and and the cause of the major incident may not have been
sophistication of the attached critical care element will identified as one of the known threats. The term mass
be determined by the capability of tactical aeromedical casualty is of course, relative, and for a small team, this
evacuation. If there is no such facility, either in- or out- number may be as low as three casualties. Multiple motor
country, the first few patients may fill a facility and render vehicle crashes, downed helicopters, floods and even earth-
it completely ineffective. quakes have recently produced mass casualty situations
Forward surgical teams must be light, mobile and rap- or major incidents for military forces around the world.
idly deployable to allow them to respond in an uncertain All these incidents have produced an unexpected surge in
battlefield. Restrictions and constraints within these casualties, far greater than the casualty estimate that each
teams are many, and include limitations of space and operation had declared. The key in all these events was
equipment, poor lighting and the need to achieve some that the medical facilities were overwhelmed, and avail-
degree of climate control for the human resources and, able resources could not meet the required demand.
particularly, for blood and other products. Some resteri- When major incidents produce mass casualties in civil-
lization of surgical tools may be possible, but disposable ian situations, for example from rail crashes or as a result
equipment, water and especially oxygen will all be limited. of urban terrorism events, there are often a number of
receiving hospitals to choose from to spread the load of In Afghanistan, a successful international system of
casualties. This luxury is rarely available in the military evacuation assets provides cover to the whole theatre of
environment. In some situations, other nations medi- operations. The different evacuations provide different
cal facilities may be available, but often the only avail- levels of care ranging from a flight nurse to full-blown
able receiving hospital will be the forward surgical team. intensive care unit (ICU) capacity.
Triage remains the key to effective medical management
of a mass casualty event, especially when large numbers
of wounded arrive at the location in a short space of time. 11.7Resuscitation
Equipment, manpower and transport will be in short sup-
ply, so sound training and adherence to the principles of 11.7.1Overview
triage should ensure effective use of the limited resources
available. The treatment and resuscitation available will alter with
After triage and treatment, transport remains the third each echelon of care; resources and complexity of care
key element of medical support in a mass casualty event. generally increase as the casualty moves away from the
Unlike in a civilian environment, where there will be many battlefield.
options for both ground and air transport, transport is Hypovolaemia remains the most common cause of
likely to be very limited in the military mass casualty situ- death among those killed in action during military con-
ation. Regular and effective triage will determine who is flicts. Although the principles remain the same, resus-
transported first, and by what means, to ensure that the citation of wounded combatants remains a formidable
right patient arrives at the right time at the next level of challenge on the battlefield, and there are some crucial
medical care. differences to consider in this environment.
Unlike in the urban setting, the military must consider
the weight and therefore the quantity of supplies that can
11.6Evacuation4,5 be transported into austere locations. Large volumes of
fluids at any stage in the resuscitation process are there-
It is recognized that speed of evacuation from point of fore not a realistic option. The Advanced Trauma Life
wounding to first surgical intervention is a critical deter- Support standard of 2 L of infused crystalloid for the
minant of outcome. The Korean War saw the introduc- acutely injured hypotensive patient is not feasible in the
tion of helicopter evacuation of the wounded from the far-forward environment due to logistical constraints,
front line to mobile army surgical hospitals (MASH), with but is also likely to be detrimental to the survival of the
onward transport by fixed-wing aircraft to base hospitals. patient with uncontrolled haemorrhagic shock in whom
During the Vietnam conflict, the average pre-hospital surgical intervention is not immediately available. For
time for combat casualties treated at a US Navy hospital such patients, the goal of maintaining a systolic arterial
was 80 minutes. pressure of 7080mmHg (palpable radial pulse) is now
Limited provision of aircraft in a combat setting has generally accepted.
meant that medical evacuation has used assets earmarked The UK military are teaching the approach of <C>ABC
for other purposes; for example, during Operations Desert for ballistic injury, where <C> stands for catastrophic
Shield/Desert Storm in 1991, many patients were success- haemorrhage. This is because of the high incidence of
fully airlifted using converted cargo aircraft. This concept severe (but potentially survivable) injuries to limbs and
of using cargo aircraft was originally validated in the junctional areas in military casualties (Table 11.2).
Second World War, and is still in vogue today. Dedicated Approximately 90 per cent of casualties are in a stable
aeromedical capability in the military now exists with two condition on arrival at hospital. However, 710 per cent of
distinct models: the UK Medical Emergency Response combat casualties will require massive transfusion, and it
Team and the US Air Force helicopter rescue fleet known is in these maximally injured that major improvements in
as PEDROS (named after the call sign of the first US Air care have recently been achieved.
Force HH-43 rescue helicopters in the Vietnam conflict). Arguably, the most important change in military
A landmark study documented prohibitively long pre- trauma care in recent years has been the introduction
hospital times. Since the introduction of a dedicated air of the concept of damage control resuscitation. Damage
asset, pre-hospital times from wounding to point of care control resuscitation can begin in the pre-hospital medi-
have fallen to approximately 45 minutes. cal emergency response team phase; however, it more
Table 11.2 An aide-memoire for clinical considerations in ballistic casualties
Catastrophic haemorrhage
Penetrating wounds to the groins, axilla and neck. Consider haemostatic agents
Penetrating wounds to major limb vessels/traumatic amputations. Consider early use of a tourniquet
Airway and cervical spine

Simple first: jaw thrust, nasopharyngeal airway
Airway at risk from:

Burn injury
Disruption from fragments
Compression from a penetrating vascular injury in the neck
Consider early anaesthesia and intubation (aided by fibreoptic scopes and the use of small-diameter endotracheal tubes) or an early surgical airway
Cervical collars: play a limited role in pure penetrating injury, and may conceal developing haematoma in the neck. Are needed in mixed injuries, as
occur in bombings
Use of cervical collars is a balance of risk: protection of cervical spine versus concealment of injury
Breathing
Needle decompression for tension pneumothorax
Manage sucking chest wounds with Asherman seals, and then consider chest drainage
Circulation
Catastrophic bleeding should have been controlled early. Smaller external bleeds can be managed with simple first aid measures of compression and
elevation. Ongoing internal bleeding from penetrating cavity injury needs to be suspected or recognized from the history and clinical findings
Unlike urban settings, the military must consider the weight and therefore quantity of supplies that can be transported into austere locations. Large
volumes of fluid at any stage in the resuscitation process are therefore not a realistic option. Options available to resuscitation teams include isotonic
crystalloids, colloids, hypertonic saline, and hypertonic saline plus colloid. The choice of fluid remains unresolved, and may in fact be less important
than the quantity and rate of fluid infused in patients with uncontrolled haemorrhage
The goal of maintaining a systolic arterial pressure of 7080mmHg is now accepted by most practitioners treating the wounded forward of the first
surgical capability, although emerging research is that this may not be optimal for all blast victims
Difficulty in obtaining vascular access can be experienced in austere conditions, when hypotension, low ambient temperature and tactical
considerations, such as the presence of mass casualties or operating light restrictions, can conspire to frustrate attempts at vascular access;
intraosseous access is an attractive option in these scenarios
Deficit
The majority of casualties who sustain a high-energy penetrating brain injury do not survive to medical care. Casualties who survive to care from
penetrating injury are generally a preselected group, and in the absence of obvious devastating injury should be resuscitated as above to minimize
secondary injury. There is an obvious conflict between hypotensive resuscitation for cavity bleeding and the need to maintain cerebral perfusion, and
this becomes a judgement call at the time
Environment
Hypothermia needs to be treated and managed with warm air blankets and environmental control. The temperature of any fluid given to trauma
patients, particularly in a military or austere environment, is crucial. Any fluid used in resuscitation must be warmed to avoid further cooling of a
haemorrhagic casualty. The actual process of warming the fluids remains a considerable challenge, and in most cases requires improvisation on
behalf of the provider
typically begins after rapid initial assessment in the emer- and chitosan (HemCon), and regional haemostasis with
gency department and progresses through the operating the use of tourniquets.
room into the ICU. This is followed by rapid evacuation to a surgical
In the severely injured casualty, damage control resusci- facility where damage control surgery can take place.
tation consists of two parts. First, pre-surgical fluid ther- Resuscitation fluids are minimized where possible, and
apy is limited to keep the blood pressure at approximately the early transfusion of blood and blood products where
90 mmHg, preventing renewed bleeding from recently available is encouraged. An example of this is the UK
clotted vessels; in practice, this means limiting crystal- Damage Control Resuscitation protocol (Table 11.3).
loid fluid infusion and using the casualtys conscious
level and/or presence of a radial pulse as a guide. Second, Table 11.3 UK Damage Control Resuscitation Protocol
intravascular volume restoration is accomplished by
using thawed plasma as a primary resuscitation fluid in 1 For the first hour after injury, resuscitate to a palpable radial
at least a 1:1 or 1:2 ratio with packed red cells and empiric pulse, and after this (if not in surgery) resuscitate to a normal
transfusion with platelets. blood pressure (an approach known as novel hybrid resuscitation
Blood is the gold standard fluid of choice in such casu- and taught on the UK Battlefield Advanced Trauma Life Support
alties, particularly those in profound shock, and is now course (BATLSTM)
carried by a few military resuscitation teams forward 2 For severely injured casualties, recognize that they are likely to be
of the first surgical teams. However, in most military coagulopathic early and resuscitate with blood, thawed plasma
healthcare systems, blood will not be available forward and platelets (blood and plasma initially in a 1:1 ratio)
of the surgical teams, and other fluids need to be carried. 3 Balance the need for volume replacement against the risk of
Options available to resuscitation teams include isot- overtransfusion reassess constantly
onic crystalloids, colloids, hypertonic saline, and hyper- 4 Early use of tranexamic acid
tonic saline plus colloid. The choice of fluid remains 5 Monitoring of blood gases, lactate, calcium and potassium
unresolved, and may in fact be less important that the with active management of falling calcium or rising potassium
quantity and rate of fluid infused in patients with uncon- 6 With blast casualties anticipate lung injury and ventilate using
trolled haemorrhage. adult respiratory distress syndrome protocols
Difficulty in obtaining vascular access can be expe-
7 The anaesthesia team and surgical team work closely together to
rienced in austere conditions, when hypotension, low
ensure the correct sequencing of damage control procedures
ambient temperature and tactical considerations, such
as the presence of mass casualties or operating light
restrictions, can conspire to frustrate attempts at vascular
access. Intraosseous access is an attractive option, in these 11.7.3Damage control surgery in the
scenarios.6,7 military setting912
The temperature of any fluid given to trauma patients,
particularly in a military or austere environment, is cru- The typical civilian damage control patient is likely to
cial. Any fluid used in resuscitation must be warmed to require the direct attention of at least two surgeons and
avoid further cooling of a haemorrhagic casualty. The one nurse during the first 6 hours, full invasive monitor-
actual process of warming the fluids remains a considering, multiple operations, massive transfusion of blood
able challenge, and in most cases requires improvisation and products, and prolonged ICU stay, with a high mor-
on the part of the provider. Locally available rewarming/ tality. The utility of this philosophy was even recently
protective devices, such as plastic bags, the use of hot car labelled as impractical for common use in a forward
engines, etc., may have to do. military unit during times of war. However, experience
in the current counterinsurgency conflicts has led to a
widespread adoption of the philosophy of damage con-
11.7.2Damage control resuscitation8 trol surgery in the military context as minimally accepta-
ble care with rapid procedures and pragmatic objectives.
The concept of damage control resuscitation implies that Current military surgical efforts are framed within a
rather than treat haemorrhage per se, efforts are primarily damage control mindset, with temporary revasculariza-
directed at stopping any bleeding, using local methods tion of limbs and damage control laparotomy providing
such as pressure, topical agents such as zeolite (QuikClot) good control.
In the far-forward, highly mobile, austere military envi- the lung, tympanic membrane (the most common
ronment, it is quite likely that the surgeon will not have injury) and bowel are the most vulnerable.
the luxury of being able to perform definitive surgery on Secondary blast injury. These are penetrating injuries
every casualty. Short, focused operative interventions can caused by blast projectiles and debris. They are the
be used on peripheral vascular injuries, extensive bone and leading cause of death and injury in both military
soft tissue injuries and thoracoabdominal penetrations and civilian terrorist attacks, except in cases of major
in patients with favourable physiology, instead of defini- building collapse.
tive surgery being provided for every injured soldier. This Tertiary blast injury. Displacement injuries result from
may conserve precious resources such as time, operating persons or objects falling or being thrown because of
table space and blood. Instead of applying these tempo- the blast wave. Structural collapse or large airborne
rary abbreviated surgical control (TASC) manoeuvres to fragments lead to crush injury and extensive blunt
patients about to exhaust their physiological reserve, as in trauma.
classic damage control, TASC is applied when the limita- Quaternary blast injury. This includes asphyxia, burns
tions of reserve exist outside the patient. and inhalation injuries.
This philosophy relies heavily on the military medical
system, with postoperative care and evacuation to the
resource-replete environment a priority. In the military, 11.8.1Diagnosis and management of
the key would seem to be triage, i.e. patient selection. The primary blast injuries
philosophy for the military surgeon exposed to numbers
of casualties in the setting of limited resources remains to
do the best for the most, rather than expend resources on 11.8.1.1Blast lung injury
limited numbers of critically wounded. This may be immediately lethal or present a pattern simi-
lar to blunt trauma, with pulmonary contusion, often
without rib fractures or chest wall injury. The earliest sign
11.8Blast injury of blast lung injury is systemic arterial oxygen desatura-
tion, often in the absence of other symptoms.
Blast injury is the physiological and anatomical insult to Radiological features can range from a typical butterfly
the human body caused by the physical properties of an pattern bihilar shadowing on the chest X-ray to a white-
explosion. The shock wave that results from the explosion out. Management is principally supportive. Mechanical
is referred to as the blast wave, its leading edge is the blast ventilation and effective chest drainage form the mainstay
front, and the rush of air caused by the blast wave is the of treatment. High-peak inspiratory pressures should be
blast wind. avoided to decrease the chance of iatrogenic pulmonary
In open air, the force of a blast rapidly dissipates, but barotraumas.
within confined spaces the blast wave is actually magnified
by its reflection off walls, floors and ceilings, increasing 11.8.1.2Rupture of the tympanic membrane
its destructive potential. Because water is less compress-
ible than air, an underwater blast wave propagates at high All explosion victims should be evaluated with an oto-
speeds and loses energy less quickly over long distances, scopic examination. Small perforations typically heal
being approximately three times greater in strength than within a few weeks, and treatment should be expectant,
that which is detonated in the air. with topical antibiotics if the ear canal is full of debris.
Blast injury has been classified into four specific and Some authors suggest that early operative intervention
distinct categories that reflect the mechanism of tissue be considered in patients with large perforations that are
injury and physical tissue damage which occur as a result unlikely to heal. Some studies have reported a high (30
of blast phenomena: primary, secondary, tertiary and per cent) incidence of permanent high-frequency hearing
quaternary blast injury: loss 1 year after injury.
Primary blast injury. This refers to the effects

11.8.1.3 Intra-abdominal injuries
of direct pressure (barotrauma) due to either
underpressurization or overpressurization relative to Primary blast injury to the gastrointestinal tract is rare. The
atmospheric pressure. Gas-enclosing organs, such as characteristic bowel lesion is a mural haematoma, ranging
in severity from a minor submucosal haemorrhage to full- staff in the provision of safe and effective analgesia are
thickness disruption and perforation. The ileocaecal junc- available.
tion and colon are the most commonly affected sites, and Analgesia methods used in recent conflicts include:
delayed perforation can occur. Pneumoperitoneum alone
Simple non-pharmacological
may be a non-specific sign only associated with bowel per-
Reassurance
foration in less than 50 per cent of the patients.
Splinting of fractures
Rupture of solid organs has been observed in the
Cooling of burns
absence of other mechanisms of injury. Management
Oral analgesics
should be in accordance with the principles of damage
Non-steroidal anti-inflammatory drugs
control. Diagnostic peritoneal lavage can be difficult to
Paracetamol
interpret because of the high incidence of retroperitoneal
Nerve blocks and infiltration of local anaesthesia
and mesenteric haematoma. Patients can also develop
Intramuscular and intravenous opiates
haematemesis or melena without obvious intraperitoneal
Fentanyl suckers.
involvement due to mucosal and submucosal haemor-
rhage. Colonoscopy is not recommended because of the Methods under development include intranasal keta-
risk of perforation. mine, fentanyl and inhalational analgesics, such as meth-
oxyflurane inhalation.
11.8.1.4Other injuries
Transfer of kinetic energy from the blast wave to the

eye can result in rupture of the globe, serous retinitis, 11.10Battlefield anaesthesia
and hyphaema. Ophthalmology consultation should
be obtained. Battlefield anaesthesia presents many challenges, includ-
The most common blast-induced arrhythmias, in ing the need to maintain airway control, hypothermia
addition to bradycardia, are premature ventricular of the casualty, restricted drug availability, lack of sup-
contractions and asystole. The treating physician plementary oxygen and the possible requirement for
should be aware that haemorrhaging, explosion- prolonged postoperative mechanical ventilation. Mass
injured patients may not have the expected casualty situations are also a constant possibility in the
compensatory tachycardia and may become military arena.
hypotensive without rapid resuscitation. Surgery requires both adequate analgesia and anaes-
Traumatic amputations from primary blast injury are thesia. No single agent can provide both an appropriate
uncommon and controversial as to whether the blast level of anaesthesia and analgesia; hence a combination
wave alone is the cause. of drugs and techniques is required. The choices of anaes-
Primary blast injury can also result in cranial fractures thetic are narrowed in austere conditions, being limited to
around air-filled sinuses, and focal neurological general anaesthesia (either intravenous or inhalational),
deficits as a result of air embolism. There are data regional anaesthesia or none at all. For surgical explo-
supporting the concept of blast-induced brain injury, ration of body cavities, general anaesthesia is most fre-
with psychological as well as physical symptoms. quently chosen, while a regional anaesthetic may be more
appropriate for injuries of the extremities or perineum.
In the field, rapid sequence induction (RSI) is the norm,
using fast-acting hypnotic and neuromuscular blocking
11.9Battlefield analgesia13 agents to facilitate rapid airway control. In the absence or
limitation of supplemental oxygen supplies, RSI becomes
Relief of pain is an important consideration for both the even more crucial as preoxygenation of the patients lungs
wounded person and the military caregiver. Provision is often not possible. There are several RSI cocktails used
of effective analgesia is humane, but also attenuates the in the pre-hospital setting, most using a combination of an
adverse pathophysiological responses to pain, and is induction agent, a paralysing agent and analgesia. Sedation,
likely to aid evacuation from the battlefield and main- amnesia and analgesia can then be maintained with intra-
tain morale. Analgesia may be given at self- and buddy- venous agents such as ketamine, benzodiazepines and
aid levels; protocols to guide medical and paramedical opiates.
For long procedures or surgical sites involving the in these conditions. Therefore an active rewarming device
a bdomen or thorax, a combination anaesthetic that will be required, as well as warming all intravenous fluids
includes an inhalational agent such as isoflurane may and ventilator circuits. If a return to the operating theatre
be used. British surgical teams use a portable Triservice for more definitive surgery is not planned in the forward
apparatus that does not require a compressed gas source, location, critical care must be maintained throughout the
and have gained much experience with this technique aeromedical evacuation.
of field anaesthesia. This draw-over type of vaporizer is
currently also in use by US forces in austere settings.
Regional anaesthesia remains an important option in
battlefield anaesthesia, as it provides both patient com-
11.12Translating military
fort and surgical analgesia, while maintaining patient
experience to civilian
consciousness and spontaneous ventilation. With the
trauma care14
relatively large number of extremity wounds in modern
Six aspects of military trauma care have been identified
conflicts, and certainly in the mass casualty setting with
as contributing to recent good outcomes for patients
a limited anaesthesia capability, regional aesthetic tech-
wounded in combat.
niques should not be overlooked. Continuous infusion
nerve blocks provide excellent analgesia for postoperative
casualties during evacuation. Leadership
Current military trauma care systems are delivered by
consultants.
11.10.1Damage control anaesthesia in the
military setting
Front-end processes
Anaesthesia for damage control procedures and major The treatment of patients wounded by military weapons
cavity injury is really a fusion of continuing resuscitation is fundamentally geared towards the concept of damage
and critical care. This requires optimization of haemody- control. Correction of a patients deranged physiology is
namic status, rewarming of the casualty and pain relief. recognized as a greater priority than definitive anatomical
One of the biggest challenges will be reversing the hypo- repair. In addition, the key hospital infrastructure (emer-
thermia that is almost universal in haemorrhagic patients gency department, operating room, CT scanner and ICU)
in these conditions. As well as warming all intravenous is planned around the needs of the time-critical patient,
fluids and ventilator circuits, an active rewarming device ensuring that all key components are close to each other.
will be required. If a return to the operating theatre for
more definitive surgery is not planned in the forward Common training
location, critical care must be maintained throughout the
It is considered that the common military training model
aeromedical evacuation.
(from first aid to multidisciplinary field hospital simula-
tion) facilitates effective teamworking and the delivery of
11.11Critical care appropriate human and other resources at the right time
for wounded patients.
If temporary abbreviated surgical control is going to be the
norm for the far-forward surgeon, a critical care capabil- Governance
ity must be a part of the forward surgical team structure.
Military trauma systems operate a robust and diligent
The priorities will therefore be optimization of haemody-
framework that, through a vigorous review of injury data,
namic status, rewarming of the patient, control of coagu-
clinical processes and patients outcomes, provides feed-
lopathy, pain relief and preparation for return to theatre
back to improve the systems performance.
or evacuation depending on the situation. The health-
care providers looking after the critical care of a patient
in these surroundings face many of the problems already Rehabilitation services
identified for the anaesthetic provider. As stated above, Formal, dedicated rehabilitation specialists and facilities
one of the biggest challenges will be reversing the hypo- are recognized as being fundamental to favourable long-
thermia that is almost universal in haemorrhagic patients term outcomes.
Translational research 6 Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-
osseous access (EZ-IO) for resuscitation: UK military combat
Integrated basic and clinical research streams feed rapid
experience. J R Army Med Corps 2007;153:31416.
improvements in all aspects of care to clinicians, which
7 Dubick MA, Holcomb JB. A review of intraosseous vascular
can then be introduced into clinical care.
access: current status and military application. Mil Med
2000;165:5529.
11.13Summary 8 Holcomb JB, Champion HR. Military damage control. Arch
Surg 2001;136:9656.
These are exciting times in which to be a military medi- 9 Holcomb JB, Helling TS, Hirshberg A. Military, civilian, and
cal practitioner. Dramatic changes in the global world rural application of the damage control philosophy. Mil
order have shifted the priorities for military planners, Med 2001;166:4903.
and surgical doctrines also have to adapt to the likely 10 Rotondo MF, Zonies DH. The damage control sequence and
scenarios of future conflict. Low-density dispersed bat- underlying logic. Surg Clin North Am 1997;77:76177.
tlefields, highly mobile operations, extended lines of 11 Granchi TS, Liscum KR. The logistics of damage control.
evacuation and logistic supply, civilian wounded and the Surg Clin North Am 1997;77:9218.
possibility of chemical, biological and nuclear attack all 12 Eiseman B, Moore EE, Meldrum DR, Raeburn C. Feasibility
mean that military doctors will have to demonstrate their of damage control surgery in the management of military
adaptability and resourcefulness, as well as their surgi- combat casualties. Arch Surg 2000;135:13237.
cal skills. Whether labelled TASC or damage control, 13 Hocking G, De Mello WF. Battlefield analgesia: an advanced
limited initial surgery is likely to be part of the surgeons approach. J R Army Med Corps 1999;145:11618.
armamentarium. 14 Hettiaratchy S, Tai N, Mahoney P, Hodgetts T. UKs NHS
In summary, in the operational setting, resources are trauma systems: lessons from military experience. Lancet
more limited, and the word finite achieves a new mean- 2010;376:14951.
ing. Triage and intervention may be modified by an open
or closed back door, or by open skies. Environmental
protection is minimal when compared with civilian struc-
tures. Surgery has to be tailored taking into considera-
tion operational realities. Procedures such as simple burr 11.15.1Ballistics: history, mechanisms,
holes, evacuation of a retro-orbital haematoma (com- ballistic protection and casualty
pressing the optic nerve), damage control thoracotomy management
and laparotomy, shunting of vascular injuries, fascioto-
mies and, above all, the extent of debridement required Mahoney PF, Ryan JM, Brooks AJ, Schwab CW. Ballistic
are new skills to be learnt. Trauma: A Practical Guide, 2nd edn. London: Springer
Verlag, 2005.
Miller FP, Vandome AF, McBrewster J, eds. Ballistic Trauma:
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Ultrasound in trauma 12
12.1Focused abdominal penetrating injury is a strong predictor of significant

sonography for trauma injury, but if negative, additional diagnostic studies may
be required to rule out occult injury.
Four areas of the torso are scanned for the detection of
free fluid (blood):
12.2.1.2Blunt trauma
Perihepatic
Perisplenic In blunt abdominal trauma, FAST has a sensitiv-
Pericardial ity of approximately 86 per cent and a specificity of
Pelvic. approximately 98 per cent for the detection of intra-
abdominal injuries. The positive predictive value is
Focused abdominal sonography for trauma (FAST) is not approximately 87 per cent, and the negative predictive
organ-specific, but the detection of free fluid in any of the value 98percent.
four views is regarded as a positive examination. However, if An International Consensus Meeting concluded that
any of the views is not clearly seen, the examination is deemed a negative FAST examination should be followed up by
incomplete, and an alternative means of investigation is a period of observation of at least 6 hours and a follow-
required, or FAST must be repeated at frequent intervals. up FAST. The alternative is to use diagnostic peritoneal
FAST is non-invasive and repeatable. Repeated scans lavage (DPL) and computed tomography to confirm the
have been shown to increase sensitivity. ultrasound findings.
FAST is equally accurate when used by appropriately
trained surgeons as by radiologists.
FAST examination relies on the detection of free 12.2.2Ultrasound in thoracic trauma
intraperitoneal fluid. In the hands of most operators,
ultrasound will detect a minimum of 200mL of fluid. The evaluation of fluid in the pericardium is a standard
Therefore, false-negative examinations may occur (e.g. part of the FAST assessment after blunt trauma, although
hollow viscus injury). the presence of a left-sided pneumothorax may create
The retroperitoneum is not well visualized in FAST. technical difficulties in visualization of the pericardial
space.
A prospective, multicentre evaluation of 261 patients
12.2Applications of ultrasound with a penetrating precordial or transthoracic wound
in trauma suspicious for cardiac injury demonstrated an accuracy of
97.3 per cent.
12.2.1Ultrasound in abdominal trauma Ultrasound can be valuable in the detection of haemo
thorax, with a sensitivity and a specificity similar to those
for portable chest X-rays. However, the performance time
for ultrasound is significantly shorter.
False-negative rates have been high in FAST after pen- Ultrasound has been used to detect pneumothorax
etrating abdominal injury. A positive FAST result after with 95 per cent sensitivity.
12.2.3Other applications of ultrasound Haemodynamically unstable patients with a blunt

abdominal injury should be initially evaluated with
Ultrasound can be used in genitourinary trauma for eval- FAST or DPL.
uation of the kidney. Ultrasound is useful in detecting thoracic injuries,
Ultrasound is the examination of choice in testicular particularly cardiac tamponade.
injury.
12.3 Pitfalls
Bain IM KR, Tiwari P, McCaig J et al. Survey of abdominal
ultrasound and diagnostic peritoneal lavage for suspected
FAST is operator-dependent. Although the examination
intra-abdominal injury following blunt trauma. Injury
is aimed at the detection of fluid (blood) in the body cavi-
1998;29:6571.
ties, in most hands only 100mL of blood or more will be
Branney SW, Wolfe RE, Moore EE et al. Quantitative sensitivity
detected. This should be compared with DPL, for which a
of ultrasound in detecting free intraperitoneal fluid.
count of 100000 red blood cells/mm3 is deemed positive
JTrauma 1995;39:37580.
(which equates to 20mL of blood).
Buzzas GR, Kern SJ, Smith SR, Harrison PB, Helmer SD, Reed JA. A
Limitations include failure to diagnose damage to
comparison of sonographic examinations for trauma performed
a hollow viscus (e.g. bowel injury), failure to diagnose
by surgeons and radiologists. J Trauma 1998;44:6048.
injury to the diaphragm and failure to be able to assess
Dolich MO, McKenney MG, Varela JE, Compton RP, McKenney
the retroperitoneum.
KL, Cohn SM. 2,576 ultrasounds for blunt abdominal
trauma. J Trauma 2001;50:10812.
Dulchavsky SA SK, Kirkpatrick AW, Billica RD et al. Prospective
12.4 summary
evaluation of thoracic ultrasound in the detection of
pneumothorax. J Trauma 2001;50:2015.
In haemodynamically stable patients with a blunt abdom-
Rozycki GS, Feliciano DV, Ochsner MG et al. The role of
inal injury, clinical findings may be used to select those
ultrasound in patients with possible penetrating cardiac
who may be safely observed. This is safe only if the patient
wounds: a prospective multicentre study. J Trauma
is alert, is cooperative, is alcohol- and drug-free, and does
1999;46:54352.
not have significant distracting injuries.
Scalea TM, Chiu WC, Brenneman FD et al. Focused
In the absence of a reliable physical examination, assessment with sonography for trauma (FAST): results
FAST is a good initial screening tool for blunt from an International Consensus Conference. J Trauma
abdominal injury. 1999;46:44472.
Computed tomography can be used to delineate Stengel D, Bauwens K, Sehouli J et al. Systematic review and
injury patterns in stable patients with an equivocal meta-analysis of emergency ultrasonography for blunt
FAST result. abdominal trauma. Br J Surg 2001;88:90112.
A single negative FAST examination should be Udobi KF, Rodriguez A, Chiu WC, Scalea TM. Role of
supported by a period of observation, repeated FAST ultrasonography in penetrating abdominal trauma: a
or other diagnostic modalities. prospective clinical study. J Trauma 2001;50:4759.
Minimally invasive surgery
in trauma 13
Minimally invasive techniques have yet to be widely thoracoscope is discouraged as thoracoscopy cannot
adopted by trauma surgeons, unlike their general surgi- exclude intra-abdominal injury.
cal colleagues. However, selective indications for the use Suspected diaphragmatic injury due to both blunt and
of these techniques are emerging rapidly in both adult penetrating injury can be accurately evaluated by VATS.
and paediatric fields. Physiological instability and severe In the largest series of patients evaluated using VATS for
head injury are a contraindication to the creation of the suspected penetrating diaphragmatic injury, 171 stable
pneumoperitoneum that is often used in association with patients with penetrating chest injury and without a sepa-
minimally invasive techniques. rate indication for either thoracotomy or laparotomy were
investigated with VATS. Sixty patients (35 per cent) had a
diaphragmatic injury, and the majority of these (93 per
13.1Thoracic injury1 cent) were repaired using a laparotomy. Of the patients
with diaphragmatic injury, 47 of 60 (78 per cent) had an
Persistent, non-exsanguinating haemorrhage can be associated intra-abdominal injury. Other than to repair
investigated and occasionally treated by video-assisted the diaphragm, no therapeutic intervention was required
thoracoscopic surgery (VATS):2,3 at laparotomy in 36 per cent of cases.
Diaphragmatic injury can be repaired thoracoscopi-
VATS can be of great assistance in the evacuation of a cally, but there are dangers in that intraperitoneal injury
clotted haemothorax. may be missed.
VATS allows direct visualization and stapling of In a series of patients with suspected tamponade, tho-
persistent air leaks, with aspiration of associated racoscopic pericardial windows have been performed,
haemothorax. with no significant complications, and have been found
VATS has been used to perform a pericardial window to be accurate in 97 per cent of cases.
in penetrating cardiac trauma.4
Injuries to the thoracic duct are rare after chest
trauma. However, thoracoscopic ligation may be 13.3Abdominal injury
successful when conservative medical management
fails to reduce chyle leakage. 13.3.1Screening for intra-abdominal injury
Laparoscopy appears to be a poor screening tool after

13.2Diaphragmatic injury blunt trauma. In one series, a 16 per cent incidence of
missed intra-abdominal injuries was found in patients
In asymptomatic patients with anterior or flank stab evaluated laparoscopically after blunt trauma. In recent
wounds of the lower chest or upper abdomen, the risk studies, the sensitivity and specificity of laparoscopy
of an occult diaphragmatic injury is about 7 per cent. in detecting blunt small bowel injuries has consider-
Specifically, in patients with left-sided thoracoabdomi- able improved from that in earlier studies.6 However, in
nal stab wounds, the risk is 17 per cent.5 Laparoscopy abdominal stab wounds, diagnostic laparoscopy prevents
is adequate to exclude occult diaphragmatic injury after an unnecessary laparotomy in 5487 per cent of the cases.
penetrating abdominal trauma. A diaphragmatic injury It can also be used to assess whether or not an equivocal
can be repaired laparoscopically. Repair through the wound has breached the peritoneal cavity. However, its
sensitivity is poor for hollow viscus injury. Laparoscopy Missed injuries, mainly intestinal, with their
has also been advocated to rule out diaphragmatic injury attendant high morbidity (and mortality)
when the non-operative management of penetrating Gas embolism, supposedly more frequent when
thoracoabdominal injuries is envisaged.7 mesenteric and hepatic (venous) lesions have
While laparoscopy can be used to confirm the penetra- occurred, but apparently as rare as in any laparoscopic
tion of a wound into the peritoneal cavity, as well as the procedure today
presence of bile or blood, the localization of such injury, Impeded venous return (because of raised intra-
especially when the bowel is injured, is difficult, even in abdominal pressure)
the most experienced of hands. Increased intracranial pressure.
These last two points make physiological instability and

severe head injury absolute contraindications to the crea-
13.3.2Splenic injury
tion of the pneumoperitoneum necessary for minimally
invasive techniques.
Laparoscopic splenic preservation or partial splenectomy
Caution is also warranted in the presence of abdomi-
has been reported after trauma using fibrin glue, argon
nal compartment syndrome or diaphragmatic rents.11
beam coagulator or splenic wrapping with mesh. Successful
Whereas laparoscopy may rarely detect and treat the cause
autotransfusion of haemoperitoneum aspirated from the
of the former, the risk of tension pneumothorax if there is
peritoneum has also been reported. Laparoscopy is an
a coexisting diaphragmatic tear requires that a large-bore
excellent approach for the secondary treatment of post-
needle be inserted into the thorax during the exploratory
traumatic localized splenic infarcts or pseudocysts.
laparoscopy.
13.3.3Liver injury
13.5Summary
Patients failing a trial of non-operative management for
hepatic injury have been managed successfully using min- To date, minimally invasive surgery has played only a
imally invasive surgery, including the laparoscopic appli- small role in trauma surgery. Surgeons should be encour-
cation of fibrin glue as a haemostatic agent.8 aged to incorporate laparoscopy and VATS into their pro-
Haemoperitoneum may be drained, and biliary leaks, tocols, and gain familiarity and expertise with their use. It
with or without peritonitis, can be controlled via the should, in light of current knowledge, still be regarded as
laparoscope, usually combined with endoscopic retro- suitable for only a small group of stable patients.
grade cholangiopancreatography.9
Reports of successful laparoscopic treatment for injury
to intra-abdominal organs other than the liver or spleen 13.6References
are increasing.
1 Lowdermilk GA, Naunheim KS. Thoracoscopic evaluation
and treatment of thoracic trauma. Surg Clin North Am
13.3.4Bowel injury 2000;80:153542.
2 Lang-Lazdunski L, Mouroux J, Pons F et al. Role of
Laparoscopy has been used to repair small bowel injuries, videothoracoscopy in chest trauma. Ann Thorac Surg
and to raise a colostomy to defunction the lower intestinal 1997;63:32733.
tract in colorectal injuries.10 Laparoscopic examination for 3 Freeman RK, Al-Dossari G, Hutcheson KA et al. Indications
penetrating injury of the bowel is particularly unreliable. for using video-assisted thoracoscopic surgery to diagnose
diaphragmatic injuries after penetrating chest trauma. Ann
Thorac Surg 2001;72:3427.
13.4Risks of laparoscopy in 4 Morales CH, Salinas CM, Henao CA, Patino PA, Munoz
trauma CM. Thoracoscopic pericardial window and penetrating
cardiac trauma. J Trauma 1997;42:2735.
Laparoscopy in abdominal trauma entails four specific 5 Leppniemi A, Haapiainen R. Occult diaphragmatic injuries
risks: caused by stab wounds. J Trauma 2003;55:64650.
Minimally invasive surgery in trauma | 193
6 Leppniemi A, Haapiainen R. Diagnostic laparoscopy in 13.7Recommended reading

abdominal stab wounds: a prospective, randomized study.
J Trauma 2003;55:63645. Brooks AJ, Boffard KD. Current technology: laparoscopic
7 Friese RS, Coln E, Gentilello L. Laparoscopy is sufficient surgery in trauma. Trauma 1999;1:5360.
to exclude occult diaphragmatic injury after penetrating Demetriades D, Hadjizacharia P, Constantinou C et al. Selective
abdominal trauma. J Trauma 2005;58:78992. nonoperative management of penetrating abdominal solid
8 Chen RJ, Fang JF, Lin BC et al. Selective application of organ injuries. Ann Surg 2006;244:6208.
laparoscopy and fibrin glue in the failure of nonoperative Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of
management of blunt hepatic trauma. J Trauma laparoscopy in penetrating abdominal trauma. J Trauma
1998;44:6915. 1993;34:8227.
9 Griffen M, Ochoa J, Boulanger BR. A minimally invasive Sauerland S, Agresta, F. Bergamaschi, R et al. Laparoscopy for
approach to bile peritonitis after blunt liver injury. Am Surg abdominal emergencies Evidence-based guidelines of the
2000;66:30912. European Association for Endoscopic Surgery. Surg Endosc
10 Mathonnet M, Peyrou P, Gainant A, Bouvier S, 2005;20:1429.
CubertafondP. Role of laparoscopy in blunt perforations Villavicencio RT, Aucar JA. Analysis of laparoscopy in trauma.
of the small bowel. Surg Endosc 2003;17:6415. JAm Coll Surg 1999;189:1120.
11 Ivatury RR, Sugerman HJ, Peitzman AB. Abdominal
compartment syndrome: recognition and management.
Adv Surg 2001;35:25169.
Burns 14
14.1Overview Hair shaft
Globally, burns are a serious public health problem.

There are over 300000 deaths each year from fires alone,
Pore of
with more deaths from scalds, electrical burns and other sweat gland
forms of burns, for which global data are not available. Epidermis Stratum
Fire-related deaths alone rank among the 15 leading corneum
causes of death among children and young adults aged Sebaceous
529 years. Over 95 per cent of fatal fire-related burns gland
occur in low- and middle-income countries. South-East Hair bulb
Dermis
Asia alone accounts for just over one-half of the total
Eccrine
number of fire-related deaths worldwide, and females sweat gland
in this region have the highest fire-related burn mortal-
Outer root
ity rates globally. Among the various age groups, chil-
sheath
dren under 5 years and the elderly over 70 years have Inner root
the highest fire-related burn mortality rates. Along with sheath
those who die, millions more are left with lifelong disa-
bilities and disfigurements, often with resulting stigma Subcutaneous tissue Vein Artery
and rejection.
The suffering caused by burns is even more tragic as Figure 14.1 Layers and structures of the skin.
burns are so eminently preventable. High-income coun-
tries have made considerable progress in lowering rates of
burn-related death and disability, through combinations open for infection, as well as loss of heat by convection and
of proven prevention strategies and improvements in the conduction.
care of burn victims. Most of these advances in preven- In physiological terms, there is a significant loss of pro-
tion and care have been incompletely applied in low- and tein primarily albumin and electrolytes, and haemo-
middle-income countries.1 concentration, along with a massive increase in energy
requirements to heal the wound.
The burn wound is divided into three areas
14.2Anatomy (Figure14.2):
The zone of coagulation

Apart from simple erythema (sunburn), all other burns
The zone of stasis
constitute an open wound of greater or lesser severity. To
The zone of hyperaemia.
create a dramatic analogy, a burn is similar to an eviscera-
tion with exposed bowel. In the case of the burn, it is the Inadequate resuscitation or the inappropriate use of ice
dermis (Figure 14.1) that is exposed to a lesser or greater or iced water to cool the burn may lead to deepening the
extent, resulting in significant losses of fluid from the body, burn due to vasoconstriction in the zone of stasis, extend-
along with loss of the bacterial barrier, leaving the path ing the zone of coagulation.
Burns | 195
Zone of stasis
Zone of
Zone of coagulation
hyperaemia
Zone of necrosis
Epidermis (coagulation)
Dermis Oedema layer
Zone of injury (stasis)
Adequate Inadequate
resuscitation Zone of resuscitation
coagulation
Normal tissue
Zone of stasis preserved Zone of stasis lost
Figure 14.2 Zones of a burn.
Figure 14.3 Superficial partial thickness burn.

14.3 dePth of the burn
Burns have been traditionally divided into first, second and 14.3.3 deep partial thickness burn
third degree, but the terms partial thickness (superficial
and deep) and full thickness are more informative and Destruction of the epidermis occurs down to the base-
will be used here. There is also a group of indeterminate ment membrane plus the middle third of the dermis.
thickness burns, which represent a separate challenge. Re-epithelialization is much slower (24 weeks) due to
fewer remaining epidermal cells and a lesser blood sup-
ply. More collagen deposition will occur, especially if the
14.3.1 superficial burn (erythema)
wound has not closed by 3 weeks. The depth of wound
has a significant risk of conversion. The zone of stasis is
Sunburn is painful, dry, is not blistered and will fade
much larger than in the SPT injury because of the lower
on its own within 7 days. It requires no debridement and
blood flow and greater initial injury to the remaining
is not counted in the calculation of percentage of total
epidermal cells (Figure 14.4).
burn surface area (TBSA). Simple oral analgesics and anti-
A deep partial thickness (DPT) burn is often a mixture
inflammatories are all that are needed.
of wet and dry. The drier it is, the deeper. Sensation is
variable but is still present to touch, although often less
14.3.2 superficial partial thickness burn painful. The skin texture is thicker and more rubbery. Red
patches do not blanch on pressure but exhibit fixed skin
These involve the entire epidermis down to the base- staining due to capillary stasis. The hairs will come out
ment
Surgical Trauma Care 3E
membrane and no
Author: Boffard more than the upper third
ISBN:of9781444102826 of the readilyStage:
Proof when pulled.
1 If
Fignot
No:excised,
14.2 these burns take 46
Title: Manual Definitive Surgical Trauma Care 3E Author: Boffard ISBN: 9781444102826 Proof Stage: 1
dermis. Rapid re-epithelialization occurs in 12 weeks. weeks to heal and scar badly. The function of a re-epithe-
Because of the large number of remaining epidermis cells
www.cactusdesign.co.uk lialized DPT burn is poor due to fragility of the epidermis
and the good blood supply, there is a very small zone of and the rigidity of the scar-laden dermis.
injury or stasis beneath the burn eschar (Figure 14.3).
A superficial partial thickness (SPT) burn is wet, often
blistered, intensely painful and red or white (including 14.3.4 Indeterminate partial thickness burn
in coloured races), blanches on pressure, and will gener-
ally heal without split-skin grafting (SSG), usually within These are usually a mixture of SPT and DPT burns, and
1014 days. The hairs remain attached when they are may exhibit the clinical features of both. The history may
pulled. The skin still feels elastic and supple. These burns help in deciding which is the predominant element and
are often caused by hot water and steam. They do not scar. enable management decision-making.
include the use of a burns resuscitation chart that also

shows burn surface area (traditionally the rule of nines
in the adult, and the Lund and Browder chart in the child;
Figure 14.5). The patients palm, including the fingers, repre-
Zone of necrosis sents approximately 1 per cent TBSA and is useful when
(coagulation) calculating patchy burns.
Oedema layer
It must be emphasized that burn surface area calculation is
only a starting point for working out a plan of management.
Zone of injury (stasis)
Subsequent management is dictated by the patients response
not by calculated numbers!
14.5 manaGement
14.5.1 safe retrieval
As with all trauma, this will follow the usual Advanced

Figure 14.4 Deep partial thickness burn.
Trauma Life Support protocols of Airway, Breathing,
Circulation, etc. the ABCDEs.
However, it may, in addition, include removing the
14.3.5 full-thickness burn casualty from the source of burning without concomitant
risk to the rescuer. This may mean that electrical power sup-
Full-thickness burns involve the entire epidermis and at plies must be switched off, chemical and fuel spillages
least two-thirds of the dermis, leaving very few dermis contained, and fires extinguished to allow rescuers access
and epidermal cells to regenerate. Spontaneous healing is to the casualty. Burning clothing must be removed, and
very slow, over 4 weeks. Sharp debridement is needed to caustic substances washed off as much as possible, but
remove the eschar. Scarring is usually severe if the wound little time should be spent at the scene.
is not skin-grafted, and there is a high risk of infection.
Inflammation-induced conversion to a full-thickness
burn is common. 14.5.2 first aid
Full-thickness burns are thick, dry, insensate, leath-
ery and usually black or yellow. Thrombosis is often vis- Do: Cool the burn with cold, running water. If a tap is
ible in the surface vessels. The hairs have been burned not available, use a bucket and jug. Continue for at least
off. Escharotomies and fasciotomies may be indicated 2030 minutes up to 2 hours from the time of injury. This
for circumferential full-thickness burns. If left, these will reduce the depth of the burn.
burns will contract, become infected and scar badly. Dont: Use ice or iced water as these may extend the
They require early excision and grafting. All electrical depth of burn. Do not use butter, egg, oil, toothpaste
burns are full thickness, as are many flame and chemi- or any other kitchen or bathroom items. Do not let the
cal burns. patient get cold; removing burning clothing and leav-
e Surgical Trauma Care 3E Author: Boffard ISBN: 9781444102826 Proof
ing the Stage:
patient 1
exposed toFig
theNo: 14.4 will very quickly
elements
result in hypothermia.
uk
14.4 area of the burn The principle is to cool the burn but warm the patient.
Any burn produces inflammation and associated
For the purposes of calculating the TBSA as a percent- swelling and capillary leakage. The greater the percent-
age, only SPT and DPT burns, along with full-thickness age burn area, the greater the inflammatory response,
burns, are included in the calculation. Erythema simple so that any burn of over 25 per cent will produce a total
sunburn alone is ignored. body systemic reaction with resultant systemic inflamma-
All units involved in the management of burns should tory response syndrome (SIRS). This is unavoidable and
have a clearly established protocol, and this should should be anticipated.
Burns | 197
Head = 9%
(front and back) Back = 18%
Right arm Chest = 18% Left arm

= 9% = 9%
Head = 18%
(front and back)
Back = 18%
Right arm Left arm
= 9% Chest = 9%
= 18%
Perineum = 1%
Right leg Left leg Perineum = 1%

= 18% = 18%
Right leg Left leg

= 13.5% = 13.5%
Adult Child
Figure 14.5 Calculation of burn size from body surface area.
14.5.3Emergency department 14.5.3.2Analgesia
Partial thickness burns are intensely painful and require

repeated doses of intravenous opiates, titrated against the
14.5.3.1Airway
pain. Analgesia must always be given, even if the child or
A rapid assessment of the circumstances of the burn adult cannot communicate with you. However, the deeper
may well alert the medical team to the potential for an the burn gets, the fewer nerve endings survive, to the point
airway burn. Fires in an enclosed space (such as shack where full-thickness burns are insensate. Nevertheless,
fires) with much combustible material and a prolonged the emotional trauma of a major burn alone requires the
extrication time will clearly represent a significant risk. calming effect of opiate drugs. Providing early, adequate
Aspiration of caustic substances may produce a fierce pain relief will reduce stress to the patient and attending
chemical pneumonitis, and steam inhalation from boil- medical staff alike, and should be a priority in manage-
ing water may cause significant airway injury. Where ment after airway control.
obvious signs of airway injury exist (stridor, singed Intravenous access should be accomplished and, at the
facial hair, soot in the nares or mouth, or carbonaceous same time, blood samples taken for full blood count, elec-
sputum), not only should supplemental oxygen be trolytes, amylase, blood type and screen, and glucose. In
administered by 60 per cent reservoir mask, but early patients with a greater than 50 per cent burn, it is likely
Title: Manual intubation
of Definitive Surgical
shouldTrauma Care 3E
be accomplished Author: Boffard
before swelling ISBN:
that 9781444102826
a consumption coagulopathyProof
mayStage:
develop; Fig No: 14.5
1 there-
closes the upper airway. fore, a thromboelastogram should be performed or, if
It is easier to subsequently extubate a stable patient who has this is not available, a conventional coagulation screen
been intubated early, than to try a late intubation on a patient (International Normalized Ratio, activated partial throm-
whose airway is swollen, distorted and burnt. boplastin time, platelet estimation, etc.).
If possible, arterial blood gases with an assessment hour for adults, and 1.02mL/kg per hour for infants and
of carboxyhaemoglobin should be obtained, and a note children. If too much fluid is given, capillary leakage will
made of the fraction of inspired oxygen (Fio2) on the increase, producing fluid creep and increasing oedema
result so that the degree of pulmonary shunting can be as the fluid shifts into the third space, thus increasing
calculated. This may be helpful if subsequent ventilation the likelihood of SIRS and adult respiratory distress syn-
is required. drome (ARDS).1 The exception would be if there were
myoglobinuria, as in electrical burns, where an output
over 1.0mL/kg per hour would be required for an adult.
14.5.3.3Emergency management of the burn wound
Antibiotics are not indicated for early burns within 72 hours
Coverage of the burn wound in the emergency setting of injury, as the burn is still essentially sterile.
is best accomplished with large quantities of clingfilm,
which has been shown to be sterile and is available in
14.5.3.5Associated injuries
industrial quantities. Clingfilm reduces pain by covering
exposed nerve endings, and contains and reduces fluid It is easy to focus on the burn alone and miss any associ-
losses, while still allowing proper inspection of the burn ated injuries. A careful history will give clues to not only
wound. The old practice of mummifying the patient in the type and depth of the burn, but also the possibility of
swathes of gauze and crepe bandages (with or without the the associated injuries.
addition of underlying silver creams) is unhelpful, pain- A casualty trapped in an enclosed space filled with fur-
ful for the patient, messy, time-consuming, inefficient for niture, such as in a house fire, is likely to have an airway
nursing staff and obstructive to the clinician. burn and carbon monoxide poisoning, along with the
possibility of toxicity from many other poisonous inhaled
gases. Furthermore, if the patient had to be removed
14.5.3.4Fluid resuscitation
unconscious by rescuers, the length of exposure to heat
All burns over 15 per cent constitute major burns. All of and flames makes the likelihood of full-thickness burns
these will require intravenous fluid replacement, a urinary much greater than if he or she was able to escape by them-
catheter to monitor output, a nasogastric tube for early selves. The patient may have had to jump from a burn-
feeding, and at least high-care nursing. Lesser percent- ing building to escape the flames, and have fractures or
age burns may be treated by aggressive oral rehydration, ruptured soft tissues, such as liver or spleen.
but particularly in infants it is better to err on the side of If the patient is hypotensive on admission, it is wrong
caution, and some units still routinely resuscitate those to attribute signs of shock to the burn until all other
under 12 years who have a greater than 10 per cent TBSA sources of shock have been ruled out. Burn shock does
burn with intravenous fluids. not usually develop in the first 24 hours post-burn. A full
All fluid replacement formulae are only guidelines to examination is essential once analgesia is adequate, intra-
resuscitation. Adequacy of resuscitation is based on urine venous lines (which may have to transgress a burned area
output rather than slavishly following a formula such as of skin) are running, oxygen is being administered and the
the Parkland formula for fluid requirements. Fluid losses burn has been covered.
start at the time of burn, and fluid replacement is calcu- Any other injuries found during examination of the
lated from the time of burn, and not from the time of admis- patient must be dealt with according to clinical need.
sion to hospital. The Parkland formula is traditionally Injuries that are bleeding take priority, and the normal
used to work out requirements for the first 24 hours: principles of resuscitation, including damage control,
apply. Most orthopaedic injuries may be deferred for
% burnt body surface area (BSA) 4mL mass in
definitive treatment until the resuscitation phase of the
kg = requirement in first 24 hours
burn injury is over. This is usually within the first 48
(If BSA >60%, use 3mL/kg)
hours. However, if the patient requires early tangential
The first half of the total requirement is given in excision and SSG, it may be appropriate to attend to
the first 8 hours, and the other half over the following orthopaedic conditions at the same time, as long as the
16 hours; this is given as Ringers lactate. There is lim- patients physiology is not compromised.
ited evidence that changing to a colloid solution in the The clinician must be alert to the possibility of deliber-
next 24hours will reduce capillary leakage. Urine output ate abuse, especially in children, where the nature and dis-
should be maintained at no more than 0.51.0mL/kg per tribution of the burn is inconsistent with the story given
Burns | 199
by the parent or caregiver. The pattern of burn and an

unacceptably late presentation may be further clues to a
deliberate, punishment burn. Where suspicion exists, it
is important to document the burn injury meticulously,
with photographs if possible. Other signs of abuse should
be looked for, and social services contacted if appropriate.
14.5.3.6Escharotomy and fasciotomy
In any trauma resuscitation, the purpose is to combat

shock, defined as tissue hypoxia inadequate to the needs
of that tissues survival. Burns are no different, but they
present with some special challenges, particularly when
the airway is compromised, or when circumferential full-
thickness burns with a thick, unyielding eschar produce a
tourniquet effect. This can occur around the chest, neck
or limbs, producing a slow asphyxiation or critical limb
ischaemia. Recognition of the need for escharotomy is
vital and needs to be acted upon, usually within the emer-
gency department.
NB: An escharotomy is not necessarily a fasciotomy.
The technique is simple. Linear incisions are made deep
Figure 14.6 Escharotomy and fasciotomy sites.
enough to release the tension. The escharotomy wounds
then gape apart, relieving the tension. The escharotomy
the patients own skin or an effective biological alterna-
wounds have to be extensive enough to reach normal tis-
tive, the longer it remains a significant breech of the skins
sue. Although a scalpel is usually adequate to achieve this,
antibacterial barrier and a significant source of heat and
diathermy may be necessary.
fluid loss to the body, analogous to bowel evisceration.
Figure 14.6 shows the main incision lines for the release
From about 72 hours post-burn, surface bacteria
of eschar causing constriction. Escharotomy should be a
migrate into the remaining deep dermis and below, ren-
painless procedure as it is only transgressing devitalized
dering topical antiseptics and antibiotics ineffective, and
tissue, but at its limits it may encroach upon living tissues
increasing the chances of systemic septicaemia. For these
that are supremely sensitive. This will alert the clinician
reasons, there has been a move towards early excision of
to stop.
the wound and SSG where necessary.
Despite escharotomy release, some tissues especially
Clearly, not all burns require grafting. Hot water and
in limbs may remain ischaemic, particularly where there
scalds from steam will often heal on their own within 10
has been an electrical burn, which is always full thick-
days, despite their dramatic initial appearances. It is wise
ness and frequently produces significant myonecrosis. In
to wait for this time before deciding to operate. The SSG
these cases, it may be necessary to extend the escharotomy
rate for these burns has been almost halved by such an
into a fasciotomy to release the compartment syndrome.
approach. However, all burns should undergo an initial
Fasciotomy is usually accompanied by profuse bleeding
cleaning and debridement under anaesthesia as soon as
if the tissue within isTitle:
still Manual
viable, and it is as Surgical
of Definitive well toTrauma
be Care 3E after Author: Boffard ISBN: 9781444102826 Proof Stage: 1
possible admission, preferably within the first 48
prepared for this.
hours. The reasons for this are fourfold:
This cleans the wound thoroughly and enables an
14.5.4Definitive management appropriate choice of dressing, as clingfilm is difficult
to secure for more than 48 hours.
It allows a proper inspection of the burn and removal
14.5.4.1 Closing the burn wound
of blisters, because it is not unusual for the area of the
Burns are not static wounds: they are pathology-in-evo- burn to be underestimated in the emergency room,
lution. The longer the burn remains uncovered by either and a 9 per cent burn may turn out to be 16 per cent,
putting it into the major burn category, with all its Neck skin is good for the eyelids.
attendant requirements. Inner arm skin is good for the face.
It is often (wrongly) assumed that blistered burns are Wherever possible, match the colour, texture and hair
always SPT burns. Blistered skin should be removed, growth.
unless it is really slack, so that the clinician can be sure When skin substitutes are not an option, reharvesting
there is no deeper burn beneath. It is safer to excise the donor sites is usually possible within 1014 days.
blister and assess the depth of the burn beneath, as it
It is beyond the scope of this book to discuss the many
may turn out to be DPT or even full thickness.
skin substitutes currently available on the market. The
If it is seen that excision and SSG are required,
patients own skin is always the best. Substitutes are often
this may be accomplished at the same visit to the
difficult to obtain, culturally unacceptable or just too
operating room.
expensive. The issue of substitutes only arises where the
percentage TBSA is greater than the amount of harvest-
Technique of excision able skin from the patient.
Both these techniques can be accomplished by using
either the Humby knife (or a modification of it) or an
electric dermatome. The set of the blade (depth of cut) 14.5.4.2Assessing and managing airway burns
will need to be greater for excision than for the harvesting
Upper airway
of skin for SSG.
Suspicion is the watchword, with early intervention
before the opportunity to protect the airway by intuba-
Tumescent technique
tion has been lost. Listening to the respiration is vital, and
Blood loss can be significant in both procedures, but may dyspnoea with hoarse, coarse breathing or stridor should
be minimized by using tourniquets for the limbs, or the prompt immediate action.
tumescent technique on the torso: Upper airway burns to the larynx and trachea may be
1 The technique uses 2mL 1:1000 adrenaline suspected by the history (e.g. a steam valve blew into the
(epinephrine) + 40mL 0.5 per cent plain bupivacaine face) or by inspection of the mouth, tongue and orophar-
added to 1 L of warm normal saline. ynx, which may be red, injected and swollen. These burns
2 Take a 19-gauge 3.5 inch spinal needle, and attach a usually require intubation but generally resolve within
giving set to the bag, which is placed in a pressurized 36 hours. It is important to remember that the burn is
infusion device and the injection given subdermally. pathology-in-evolution and that the early signs will get
3 The raised skin should feel cold (and look white in worse in the next 24 hours.
Caucasian races).
4 Once the skin has been harvested or the burn excised, Lower airway
adrenaline-soaked abdominal packs (5mg in 1L
The deep, alveolar burn is much more difficult to detect or
normal saline) can be applied to the wound bed, with
predict. Its rate of onset is slower, and it may only manifest
a significant reduction in blood loss.
itself 35 days after the burn. Some indication that a lower
SSGs are secured by skin clips, tissue glue or sutures, airway burn is present may come from the history of pro-
depending on the site, and then covered with several lay- longed smoke exposure and raised carboxyhaemoglobin
ers of paraffin gauze to prevent movement, followed by levels. Blood gases should be taken whenever possible, and
dry gauze and bandaging. the ventilationperfusion shunt worked out by plotting the
If infection has been a problem, activated nanocrystal- Fio2 against the arterial partial pressure of oxygen (Pao2).
line silver (e.g. Acticoat; Smith & Nephew, London, UK) Although no clear guidelines exist in the literature at
may be applied and secured in place with water-soaked present, it is unusual to find a patient with a shunt of
gauze and bandages. The dressing will remain bacterially 1520 per cent or more who has not required prolonged
active for up to 4 days, and may also have anti-inflamma- ventilation over a week. The alveolitis produces exces-
tory properties. sive lung water, and the picture is one of ARDS. It may
The choice of site for harvesting skin depends on the become increasingly difficult to ventilate these patients,
site that is burned (e.g. back or eyelids), and what skin is and nebulized heparin or acetylcysteine can be used in an
available: attempt to reduce the stickiness of secretions. The issue of
Burns | 201
whether to perform bronchoscopy and bronchial lavage 14.6.2Hands

is still debated but has not been subjected to a controlled
clinical trial, so no conclusions can be drawn. Function is the priority for burned hands. Wrapping
up in boxing glove-type dressings will rapidly result in
Inhalational toxicity stiff, contracted hands, so wherever possible leave the
hands exposed or with minimal dressings. The prac-
This third component of airway burns may present first as
tice of smothering burned hands in silver sulphadiazine
the effects of carbon monoxide poisoning are immediate.
cream and then placing them in plastic bags is not recom-
Remember that the peak level of carbon monoxide is present at
mended as this macerates the remaining normal skin and
the scene, and not at first measurement in the hospital.
just produces a pool of foul liquid in the bag in a short
Any carbon monoxide level of over 10 per cent is regarded
time. Superficial partial thickness burns can be covered
as toxic, and 100 per cent oxygen should be given until the
with copious amounts of mupirocin ointment to combat
carbon monoxide level has fallen to below 5 per cent.
staphylococcal and streptococcal infection, keep the burn
Pulse oximetry may be unreliable if high levels of carbon mon-
supple and allow the occupational therapist the freedom
oxide are present, as the haemoglobin is saturated with carbon
to work without restriction.
monoxide and not oxygen.
It may be necessary to splint the hand at night to pre-
Other gases such as cyanide may also have an imme-
vent contracture. This must be done in the intrinsic-plus
diate toxic effect, but the effects of gases like ammonia,
or position of function, with the wrist slightly dorsi-
sulphur dioxide, chlorine, hydrogen chloride, phosgene
flexed, the metacarpophalangeal joints at a right angle
and the aldehydes may take a day or two to present.
and the fingers in full extension (Figure 14.7).
Treatment is supportive, although if cyanide is a strong
The splint is best applied from the palmar surface and
possibility, sodium nitrite may be given intravenously.
wrapped gently around the edges of the index and little
Methaemoglobin production is a side effect of such
fingers to stop them falling off the splint platform. It is
treatment.
important to place paraffin gauze between the fingers on
the splint to prevent adherence to each other, with the
Tracheostomy
potential for later syndactyly.
Early tracheostomy should be considered, especially if the Deeper burns to the hand may be covered with a bio-
area of the burn includes the neck. It is quite acceptable synthetic dressing such as Biobrane.
to place a tracheostomy through the site of a burn. Once
the oedema has occurred, placement of a tracheostomy
is far more difficult and hazardous. The tracheostomy 14.6.3 Perineum
should be well secured, as if it is displaced, replacement
may prove very difficult. Early catheterization is recommended, as is nursing by
exposure as much as possible. Nappies/diapers coated
14.6Special areas
HP joint flexion
The face, hands, perineum and feet are special areas that PIP joint extension
need special attention to obtain a good outcome.
90
14.6.1Face
Biobrane (Smith & Nephew, London, UK) is very useful for

SPT burns of the face. It needs to be held in place firmly Thumb
with compression for 48 hours to bond. This may be abduction
accomplished by crepe bandaging, which is then removed
after 2 days. Biobrane reduces pain and may be left in place
until it begins to separate by itself after about 10 days, Figure 14.7 Splinting in the functional position of the hand. MP,
leaving new epithelium that does not need to be grafted. metacarpophalangeal; PIP, proximal interphalangeal.
with silver sulphdiazine cream are comfortable and prac- Carbohydrates provide the majority of calorie intake
tical for both adults and children. A temporary colostomy under most conditions, including the stress of burns.
for faecal diversion should be considered. Providing adequate calories from carbohydrates spares
incoming protein from being used for fuel. The body
breaks down carbohydrates into glucose that the body
14.6.4Feet then uses for energy.
Fat is needed to meet essential fatty acid requirements
Apart from preventing syndactyly as mentioned previ- and provide needed calories. Common recommendations
ously, the importance of burns to the feet is the ability to include giving 30 per cent of calories as fat, although this
be able to weight bear, and to prevent foot-drop during can be higher if needed. Excess fat intake has been impli-
the recovery period. Splints will be needed to maintain the cated in decreased immune function, and intake levels
ankle joint at a right angle. should be monitored carefully. Vitamins and trace ele-
ments are also necessary.
14.7Adjuncts in burn care 14.7.1.1 Paediatric burn nutrition
14.7.1Nutrition in the burned patient2 Providing adequate calories and nutrients is a difficult
task when treating burn injuries. This task becomes even
A dietitian is an essential member of the burns team. All more difficult when the patient is a child. It is important
patients with a major burn (>15 per cent TBSA) should have to do an initial nutritional assessment early after admis-
a nasogastric tube or fine-bore feeding tube for early enteral sion as often it is children in the lower socio-economic
nutrition. This should ideally be started within 18 hours of group who get burned. This group is also more likely to
the burn. Not only does this help in the early replacement of be suffering from chronic malnutrition before their burn
calories, but it also protects against gut bacterial transloca- injury, giving them even less reserve with which to repair
tion and systemic sepsis. It may in addition protect against injured tissue.
the development of the rare Curlings ulcer.3
The aim should be, in paediatric patients at least, to 14.7.2Ulcer prophylaxis4
provide 100 per cent of their calorie requirements down
the tube, and any further food they can take orally is a See also Section 10.15.1, Stress ulceration.
bonus. Estimating the nutritional needs of burn patients In the presence of good nutritional policies, sucralfate
is essential to the healing process. The HarrisBenedict should be used for prophylaxis. H2-receptor blockers and
equation is designed to calculate the calorie needs of protein pump inhibitors should be reserved for therapy,
adults, and the Galveston formula is used for children. and not used for prophylaxis.
The Curreri formula addresses the needs of both. Some
studies suggest that these formulae may overestimate the
calorie needs of patients by up to 150 per cent. There is 14.7.3Venous thromboembolism
no one formula that can accurately determine how many prophylaxis5
calories a patient needs, so it is important to monitor a
patients nutritional condition closely. See also Section 10.15.2, Deep vein thrombosis and pul-
Protein requirements generally increase more than monary embolus.
energy requirements, and appear to be related to the Patients with major burns are at high risk of venous
amount of lean body mass. The body loses protein through thromboembolism. The nature of the burn is often such
the burn, and this will be reflected in a significant drop in that mechanical devices are excluded. Low molecular
serum albumin level over the first week, which will take weight heparins should be introduced early.
at least a month to recover despite assiduous nutritional
care. However, the majority of increased protein require-
ments come from muscle breakdown for use in extra 14.7.4Antibiotics
energy production. Providing an increased intake of pro-
tein does not stop this obligatory breakdown; it simply Antibiotic prophylaxis is not routinely used for burns.
provides the materials needed to replace lost tissue. There is no substitute for good wound care, hand-washing
Burns | 203
and infection control measures. Tissue excised during Burn care remains a team effort, and no amount of
tangential excision should be sent for culture, and when highly skilled grafting in the operating room will be
skin-grafting, cultures (sometimes obtained by local rewarded by a happy and functional outcome if the feed-
punch biopsy) should again be sent. Sepsis should be ing, nursing, intensive care, physiotherapy or occupa-
treated topically wherever possible, and systemic antibiot- tional therapy is lacking.
ics should be used only where there is evidence of systemic
sepsis.
14.10References
14.8Criteria for transfer 1 Rogers AD, Karpelowsky J, Millar AJW, Argent A, Rode H.
Fluid creep in major paediatric burns. Eur J Pediatr Surg
Special areas (as above), including those involving a 2010;20:1338.
major joint 2 Jacobs DO, Kudsk KA, Oswanski MF, Sacks GS, Sinclair KE.
Major burns (>15 per cent TBSA, although some Practice management guidelines for nutritional support of
centres recommend >10 per cent TBSA) the trauma patient. In: Eastern Association for the Surgery
Electrical burns and lightning injury of Trauma. Practice Management Guidelines. Available
All full-thickness burns of over 1 per cent in any age from www.east.org (accessed December 2010).
group 3 Muir IFK, Jones PF. Curlings ulcer: a rare condition. Br J
Chemical burns Surg 1976;63:606.
Inhalation injury 4 Guillamondegui OD, Gunter OL Jr, Bonadies JA et al. Practice
Burn injury in patients with pre-existing medical management guidelines for stress ulcer prophylaxis. EAST
disorders that could complicate management, Practice Management Guidelines Workgroup. Available
prolong recovery or affect mortality from www.east.org (accessed December 2010).
Any patients with burns and concomitant trauma 5 Rogers FB, Cipolle MD, Velmahos G, Rozycki G. Practice
(such as fractures) for whom the burn injury poses management guidelines for the management of venous
the greatest risk of morbidity or mortality. In such thromboembolism (VTE) in trauma patients. J Trauma
cases, if the trauma poses the greater immediate risk, 2002;53:14264. Available from Eastern Association for
the patients condition may be stabilized initially in a the Surgery of Trauma. Practice Management Guidelines
trauma centre before transfer to a burn centre Workgroup. Available from www.east.org (accessed
Clinical judgement and good communication will be December 2010).
necessary
Burned children in hospitals without adequate
qualified personnel or equipment. 14.11Recommended reading
Greenwood JE. Development of patient pathways for the surgical

14.9Summary management of burn injury. A NZ J Surg 2006;76:80511.
Herndon D, ed. Total Burn Care, 3rd edn. Philadelphia: Saunders
Burns are a huge problem worldwide, with the majority Elsevier, 2007.
occurring in countries that are ill-equipped to deal with
them as resources are few, transport is lacking and cul-
tural influences militate against early referral to modern 14.11.1 Websites
facilities. Education is the cornerstone of prevention, and
up to 95 per cent of burns in developing countries are pre- http://global.smith-nephew.com/us/BURN_MGMT_TRTMNT_
ventable. Education is also, sadly, often lacking. PRTL_THK_17134.htm
Nevertheless, for those who are lucky enough to reach http://wound.smith-nephew.com/uk/
a burns facility, modern techniques, including supportive www.burnsurgery.com
ventilation for inhalational burns, early tangential exci- www.burnsurvivor.com
sion and grafting, utilization of biosynthetic dressings www.metrohealth.org
and nanocrystalline silver technology have significantly www.who.int/violence_injury_prevention/other_injury/burns/
increased survival and quality of life for burns patients. en/index.html
Head trauma 15
In the Western world, the most common cause of death degeneration, with subsequent deafferentation of its tar-
after trauma is severe brain injury, which contributes sig- get structure. Profound deficits may result from this dif-
nificantly to half of all deaths from trauma. fuse axonal injury.
Head injury is a major cause of morbidity in survi- There may also be associated injuries: all patients sus-
vors, disability may occur whatever the initial severity of taining a major mechanism of injury should be suspected
the head injury, and surviving patients with brain injury of having a cervical spine injury.
are more impaired than patients with injuries to other
regions. Severely brain-injured individuals also have the
highest mean length of stay in hospital, and the highest 15.2Depressed skull fractures
mean hospital costs.
An understanding of the concept of secondary brain Traditional wisdom suggests that all open, depressed skull
injury, caused by hypotension and hypoxia, is fundamen- fractures should be surgically treated, and that closed,
tal, and the treatment of a head-injured patient should depressed fractures should be elevated when the depth of
emphasize early control of the airway (while immobilizing the depression meets or exceeds the thickness of the adjacent
the cervical spine), ensuring adequate ventilation and oxy- skull table to alleviate compression of the underlying cortex.
genation, correcting hypovolaemia and prompt imaging If the dura under the fracture is damaged, it must
by computed tomography (CT). Recent guidelines have always be repaired.
been produced in an attempt to improve outcome after
severe traumatic brain injury (TBI).
15.3 Penetrating injury
15.1 Injury patterns Patients with a penetrating craniocerebral injury require
emergency craniotomy if there is significant mass effect
There are two major categories of brain injury: focal inju- from a haematoma or bullet track.
ries and diffuse injuries. Removal of fragments of the projectile or in-driven
Focal brain injuries, which are usually caused by direct bone fragments should not be pursued at the expense of
blows to the head, comprise contusions, brain lacerations, damaging normal brain tissue.
and haemorrhage leading to the formation of haematoma Patients with penetrating craniocerebral gunshot inju-
in the extradural (epidural), subarachnoid, subdural or ries with a Glasgow Coma Scale (GCS) score of 5 or less
intracerebral compartments within the head. The availabil- after resuscitation, or a GCS score of 8 or less with CT
ity of CT scanning has been shown to reduce the mortality findings of transventricular or bihemispheric injury, have
of patients with an acute extradural (epidural) haematoma, a particularly poor outcome, and conservative treatment
as the time taken to diagnose and evacuate an intracer- may be indicated.1
ebral haematoma is critical in determining the outcome.
However, the majority of patients with a brain injury do
not have a lesion suitable for neurosurgical intervention. 15.4Adjuncts to care
Diffuse brain injuries, which are usually caused by a
sudden movement of the head, cause the failure of cer- While in the context of major cerebral injury, it may, after
tain axons. The distal segment of the axon undergoes admission to hospital, be difficult to alter the severity
Head trauma | 205
of the primary injury, the greatest challenge is to mini- Deep vein thrombosis prophylaxis
mize the secondary brain damage. The 2007 guidelines Graduated compression stockings or intermittent
suggested by the Brain Trauma Foundation form the pneumatic compression stockings are recommended,
best basis of evidence-based medicine in this regard (see unless lower extremity injuries prevent their use. Use
Recommended reading). should be continued until the patient is ambulatory
(level III).
Blood pressure and oxygenation Low molecular weight heparin or low-dose
Blood pressure should be monitored, and unfractionated heparin should be used in combination
hypotension (systolic blood pressure [SBP] with mechanical prophylaxis. However, there is an
<90mmHg should be avoided (level of evidence II). increased risk of intracranial haemorrhage (level III).
Oxygenation should be monitored, and hypoxia There is insufficient evidence to support
(arterial partial pressure of oxygen [Pao2] <60mmHg recommendations regarding the preferred agent, dose
[8.0kPa]) avoided (level III). or timing of pharmacological prophylaxis for the
prevention of deep vein thrombosis (level III).
Hyperosmolar therapy
Indications for ICP monitoring
Mannitol is effective for the control of raised
intracranial pressure (ICP) at doses of 0.251.0g/kg ICP should be monitored in all salvageable patients
body weight. Arterial hypotension (SBP <90mmHg) with severe TBI with a GCS score of 38 out of 15
should be avoided. after resuscitation, and an abnormal CT scan (an
abnormal CT scan of the head being defined as
Restrict mannitol use prior to ICP monitoring, only to one that reveals haematomas, contusions, swelling,
those patients with signs of transtentorial herniation or herniation or compressed basal cisterns) (level III).
progressive neurological deterioration not attributable to ICP monitoring is indicated in patients with severe
extracranial causes (level III). TBI with a normal CT scan and two or more of the
following features are noted at admission:
Prophylactic hypothermia Age over 40 years
There are insufficient data at either level I or level II to Unilateral or bilateral motor posturing
make any recommendations here. SBP <90mmHg.
Infection prophylaxis and the use of antibiotics ICP monitoring technology

In the current state of technology, the ventricular cath-
Broad-spectrum antibiotic prophylaxis is recommended
eter, connected to an external strain gauge, is the most
in both military and civilian medicine for penetrating
accurate, low-cost and reliable method of monitoring
craniocerebral injuries, including those due to sports or
ICP. It can also be recalibrated. In situ ICP transduction via
recreational injuries. Generally, a cephalosporin or amoxi-
fibreoptic or microstrain gauge devices placed in ventricu-
cillin/clavulanate is recommended.2
lar catheters provides similar benefit, but at a higher cost.
Periprocedural antibiotics for intubation should be Parenchymal ICP monitors cannot be recalibrated during
administered to reduce the incidence of pneumonia. monitoring. Parenchymal ICP monitors, using microstrain
However, it does not change the length of stay, or the pressure transducers, have negligible drift. The measure-
mortality (level II). ment drift is independent of the duration of the moni-
Routine ventricular catheter exchange or prophylactic toring. Subarachnoid, subdural and extradural (epidural)
antibiotic use for ventricular catheter placement is monitors (fluid-coupled or pneumatic) are less accurate.
not recommended to reduce infection (level III).
ICP thresholds
Tracheostomy Treatment should be initiated at ICP thresholds
Early tracheostomy should be performed to reduce the above 20mmHg (level II).
number of days on mechanical ventilation. However, it A combination of ICP values and brain CT findings
does not alter the mortality or the rate of nosocomial should be used to determine the need for treatment
pneumonia. (level III).
Cerebral perfusion thresholds first few days after injury; however, the exact duration and
Aggressive attempts to maintain the cerebral role of these drugs is unclear.
perfusion pressure (CPP) above 70mmHg with fluids Schierhout3 recently reviewed the available evidence
and pressors should be avoided because of the risks of and concluded that although prophylactic antiepileptics
adult respiratory distress syndrome (level II). are effective in reducing the number of early seizures,
A CPP of <50mmHg should be avoided (level III). there is no evidence that treatment with prophylactic
The CPP value to target lies within the range 5070 antepileptics reduces the occurrence of late seizures, or
mmHg. Patients with intact pressure autoregulation has any effect on death and neurological disability.
tolerate higher CPP values (level III). The prophylactic use of phenytoin or valproate is
Ancillary monitoring of cerebral parameters that not recommended for preventing late post-traumatic
include blood flow, oxygenation or metabolism seizures (level II).
facilitates CPP management. Anticonvulsants are indicated to decrease the
incidence of early post-traumatic seizures (within
Brain oxygen monitoring and thresholds 7 days of injury). However, such seizures are not
Jugular venous saturation and brain tissue oxygen moni- associated with a worse outcome.
toring measure cerebral oxygenation.
Hyperventilation
The treatment thresholds are a jugular venous
saturation of less than 50 per cent or a brain tissue Hyperventilation is recommended as a temporizing
oxygenation tension below 15mmHg. measure for the reduction of elevated ICP (level III).
Prophylactic hyperventilation is not recommended
(level II).
Anaesthetics, analgesics and sedatives
Hyperventilation should be avoided for the first 24
Prophylactic administration of barbiturates to induce hours after injury when cerebral blood flow is often
burst suppression is not recommended (level II). critically reduced (level III).
High-dose barbiturate administration is If hyperventilation is used, jugular venous
recommended to control elevated ICP that is oxygen saturation or brain tissue oxygen tension
refractory to maximum standard medical and surgical measurements are recommended to monitor oxygen
treatment. Haemodynamic stability is essential before delivery.
and during barbiturate therapy (level III).
Propofol is recommended for the control of ICP, Steroids
but no improvement is seen in mortality or 6-month
outcome. High-dose propofol can produce significant The use of steroids is not recommended for improving
morbidity (level III). outcome or reducing ICP. In patients with moderate
or severe TBI, high-dose methyl prednisolone is
associated with an increased mortality, and is
Nutrition
contraindicated (level I).
Patients should be fed full caloric nutrition by day 7
post-injury (level II).
15.5Burr holes
Antiseizure prophylaxis
Seizure activity in the early post-traumatic period follow- Patients with closed head injury and expanding extradural
ing head injury may cause secondary brain damage as a or subdural haematomas require urgent craniotomy for
result of increased metabolic demands, raised ICP and decompression and control of haemorrhage.
excess neurotransmitter release. In remote areas where neurosurgeons are not available,
For patients who have had a seizure after a head injury, non-neurosurgeons may occasionally need to intervene to
anticonvulsants are indicated and are usually continued avert progressive neurological injury and death. Surgeons
for 6 months to 1 year. in remote, rural hospitals in the United States have shown
Many neurosurgeons give prophylactic anticonvulsants that emergency craniotomy can be undertaken with good
to all patients with significant head injury for at least the results where clear indications exist.4
Head trauma | 207
15.6Summary 3 Schierhout G, Roberts I. Anti-epileptic drugs for preventing

seizures following acute traumatic brain injury. Cochrane
Efforts at prevention of primary head injuries revolve Database Syst Rev 2001;(4):CD000173.
around education and legislation. However, improve- 4 Rinker CF, McMurry FG, Groeneweg VR, Bahnson FF, Banks
ments in care related to minimizing secondary brain KL, Gannon DM. Emergency craniotomy in a rural level III
injury continue at a slow pace. trauma center. J Trauma 1998;44:9849.
15.7References 15.8Recommended reading
1 Semple PL, Domingo Z. Craniocerebral gunshot injuries in Brain Trauma Foundation Guidelines. www.tbiguidelines.org.
South Africa a suggested management strategy. S Afr Maas AI, Dearden M, Teasdale GM et al. EBIC-guidelines for
Med J 2001;91:1415. management of severe head injury in adults. European Brain
2 Bayston R, de Louvois J, Brown EM, Johnston RA, Lees P, Injury Consortium. Acta Neurochir (Wien) 1997;139:28694.
Pople IK. Use of antibiotics in penetrating craniocerebral
injuries. Infection in Neurosurgery Working Party of
British Society for Antimicrobial Chemotherapy. Lancet
2000;355:181317.
Special patient situations 16
16.1 Paediatrics 16.1.4Resuscitation room
16.1.1 Introduction 16.1.4.1Airway
An understanding of the different anatomy, physiology The indications for airway control are identical to those in
and injury patterns of the injured child is essential for a the adult patient. The routine administration of oxygen and
successful outcome of treatment. Many simple, familiar the stepwise system of management according to severity of
procedures that are taken for granted in the adult patient airway compromise are the cardinal features of paediatric air-
need to be practised in the paediatric patient before they way management. Orotracheal intubation is accomplished
can be safely performed in the stress of a resuscitation using a non-cuffed or micro-cuffed endotracheal tube. The
situation. If necessary, the need for referral should be con- placement of an endotracheal tube in a small child requires
sidered as soon as the patient will tolerate safe transfer to no force, otherwise bothersome or even dangerous postextu-
an appropriate facility. bation stridor can ensue from a traumatic intubation.
A surgical airway is seldom performed. If it is required,
a tracheostomy should be performed.
16.1.2 Injury patterns The greatest pitfalls are the danger of tube dislodge-
ment, commonly due to failure to secure the tube ade-
Certain injury patterns of paediatric trauma are becom- quately, or too small an endotracheal tube.
ing apparent. It is important to obtain an accurate history The airway of the obligate nasal breather (the neonate
of the mechanism of injury in order to detect associated or infant) must not be compromised with a nasogastric
injuries during the resuscitation stage: tube. The clinical assessment of the cervical spine injury
Lap belt complex is less reliable in the fearful, uncooperative child, and cer-
Pedestrianvehicle crash complex vical spine protection must be maintained until the neck
Forward-facing infant complex has been passed clear radiologically.
The common cycle scenarios: the fall astride and the
handlebars in the epigastrium 16.1.4.2Ventilation
Non-accidental injury complex.
Hypoventilation is a prominent cause of hypoxia in the
injured child. Because the child depends primarily on dia-
16.1.3 Pre-hospital phragmatic breathing, one must be particularly cautious
of conditions that impair diaphragmatic movement (ten-
Pre-hospital interventions should be limited to basic life sion pneumothoraces, diaphragmatic rupture and severe
support with airway and ventilatory support, securing gastric dilatation) and treat expeditiously.
haemostasis of external bleeding and basic attempts to Once a controlled and monitored situation has been
secure vascular access. Extensive unsuccessful roadside obtained, one should avoid both barotrauma and volume
resuscitative procedures are a common cause of morbidity trauma by providing about 6 mL/kg body weight tidal
and mortality. The younger the child and the more unsta- volume at the lowest pressure. It is usually safer to permit
ble his or her condition, the greater the tendency should mild-to-moderate hypercapnia (permissive hypercapnia)
be to scoop and run to the nearest appropriate facility. than to cause acute lung injury from hyperventilation.
Special patient situations | 209
16.1.4.3Circulation pulseless electrical activity or asystole. The primary objec-

tive of resuscitation should be to correct the underlying
Frequent assessment of circulatory status is important.
cause (such as tension pneumothorax, hypovolaemia,
Children have effective compensatory mechanisms for
hypothermia or hypoxia), and to provide cardiac massage
compensating for blood loss, dependent predominantly
and ventilatory support.
on an adequate heart rate. Tachycardia, peripheral vaso-
constriction and signs of inadequate central nervous sys-
tem perfusion predominate. Hypotension is a late sign of 16.1.4.6Resuscitative thoracotomy
blood loss, reflecting a class IV shock with greater than 40
Resuscitative thoracotomy is usually futile and not rec-
per cent blood volume loss.
ommended for blunt trauma, but should be considered
The practitioner must recognize and treat shock
for children with witnessed cardiac arrest and penetrating
aggressively. The primary management of bleeding is
thoracic injury.
surgical haemostasis. Rapid vascular access is obtained
tailored to the severity of the childs shock and the practi-
tioners experience: central lines are reserved for the larger
16.1.5Specific organ injury
child and the more experienced physician. Most children
respond rapidly to crystalloid resuscitation. Evaluate the
Certain injury patterns of pediatric trauma are becoming
effect of crystalloid fluid resuscitation (e.g. Ringers lac-
apparent, so detailed information of the mechanism of
tate 20mL/kg as a bolus, which can be repeated one or
injury is of utmost importance to detect any associated
two times). If the patient still remains haemodynamically
injuries.
unstable, suspect ongoing bleeding, and transfuse with
packed red blood cells.
Do not delay the transfer of the unstable child to the 16.1.5.1Head injury
operating room establish good access and resuscitate in
Most paediatric trauma deaths result from head injury.
theatre while the surgeon stops the bleeding. Hypothermia
Computed tomography is the most accurate modality to
is critical and must be avoided. The urinary output is an
evaluate paediatric patients with a suspected head injury.
invaluable aid to determine the adequacy of resuscitation.
Diffuse intracranial lesions are more common in children
than in adults. The short neck combined with a propor-
16.1.4.4Disability tionally heavy head, little muscle support and laxity of the
ligaments makes the child vulnerable to cervical injuries.
Make a quick neurological assessment, including the
Glasgow Coma Scale score, pupils and movements of all
extremities. In general, children have a lower incidence 16.1.5.2Thoracic injury
of intracranial mass lesions requiring surgical drainage Young children have a more flexible thoracic cage than
after blunt injury compared with adults. However, a child adults. Rib fractures in children are uncommon, and
with signs of transtentorial herniation a unilateral fixed, indicate major injury. Pulmonary contusion is the most
dilated pupil, contralateral muscle weakness in the lower common injury to the chest, and is commonly seen in the
extremity from anterior cerebral artery compression or absence of rib fractures. Contusions are typically delayed
a deteriorating level of consciousness will require an in appearance on chest X-ray. If pathological findings of
urgent computed tomography (CT) scan and prompt pulmonary contusion are visible on the admission chest
neurosurgical management that supersedes all other pri- X-ray, the contusion is severe, and hypoxia should be
orities except the management of the airway and the treat- expected to worsen over the next 12 days.
ment of hypovolaemic shock. It may be necessary for the
neurosurgeons and abdominal or orthopaedic surgeons
to operate in two teams. 16.1.5.3Abdominal injury
Abdominal injuries must be suspected after high-energy

trauma. The upper abdominal organs have little protec-
16.1.4.5Cardiac arrest
tion from the rib cage and musculature. Not surprisingly,
In children, cardiac arrest usually is not caused by ven- the spleen and the liver are the most frequently injured
tricular fibrillation, and is often heralded by bradycardia, intra-abdominal organs in children. Most children with
abdominal injuries from blunt trauma can be safely will rise to more than 20 per cent of the population. In
treated non-operatively. For the trauma surgeon, the sub-Saharan Africa, the rate of increase of the over-60s
challenge is to identify expeditiously those patients who between 2000 and 2025 is expected to reach 145 per cent
require surgical intervention, for example laparotomy. (in contrast, in Western Europe, this increase will be less
Hollow viscus injuries are relatively rare, and symptoms than 45 per cent). However, more older people means
can be vague in the early stage after trauma. Repeated more older trauma.
examination remains essential in the early diagnosis of The definition of elderly varies. While, convention-
these injuries. Free fluid in the absence of solid organ ally, the term may be used to describe an age of 6575
injury on a CT scan in a patient with an appropriate injury years depending on location, the break-point for the eld-
mechanism (e.g. lap belt injury) is highly indicative of an erly in trauma scoring systems is 55 years of age. In the
intestinal lesion. United States, the 12.5 per cent of the population over
Pancreatic injuries are rare, and diagnosis often is delayed. the age of 65 account for almost one-third of all deaths
Contusions can be treated non-operatively, whereas opera- from injury.
tive treatment is most often recommended in patients with The response of the older person to any medical insult
transection through the distal part of the gland. or trauma is typically modified or even masked, in part
Duodenal injuries are uncommon, diagnosis often due to the ageing process and in part due to co-morbidi-
being delayed and complicated by serious complications. ties and attendant medications. A high index of suspicion
In some countries, as many as 20 per cent of duodenal must prevail in assessing and managing these situations.
injuries are related to child abuse.
16.2.2 Physiology
16.1.5.4 Genitourinary injury
The hallmark of genitourinary tract injury is haematuria. The older persons response to bodily insult, whether
The degree of haematuria does not correlate with injury medical or traumatic, will often be atypical, and is likely
severity, and the absence of blood in the urine does not to be accompanied by vague and misleading signs. Careful
exclude substantial urological injury. The kidneys are and open-minded assessment is essential.
most commonly involved. Less than 5 per cent of chil-
dren with renal injuries will need operative treatment. A
16.2.2.1Respiratory system
CT scan of the abdomen is highly sensitive and specific.
Pelvic fracture is a rare cause for exsanguination in chil- Decreased lung elasticity with decreased pulmonary
dren, and most fractures are treated non-operatively. compliance
Coalescence of the alveoli
Decrease in surface area available for gas exchange
16.1.6Analgesia Atrophy of bronchial epithelium, leading to a
decrease in clearance of particulate foreign matter
Giving appropriate titrated doses of morphine 0.1 mg/kg Chronic bacterial colonization of the upper airway.
4-hourly or when required greatly facilitates resuscitation
and assessment, and does not mask important clini-
16.2.2.2Cardiovascular system
cal signs, but rather improves the patients cooperation.
However, the patients respiratory and haemodynamic Diminished pump function and lower cardiac output
status and level of consciousness must be followed closely. Inability to mount an appropriate response to
both intrinsic and extrinsic catecholamines, and a
consequent inability to augment cardiac output
16.2The elderly Reduced flow to vital organs
Co-existing commonly prescribed medication that can
16.2.1Definition and response to trauma blunt normal physiological responses.
Population ageing is a global phenomenon. In the United

16.2.2.3Nervous system
States in 1990, those over 65 accounted for 12.5 per cent
of the population, while in 2040 it is expected that this Progressive atrophy of the brain
Special patient situations | 211
Deterioration in cerebral and cognitive functions 16.2.5Analgesia

Deterioration in hearing
Deterioration in eyesight There is no reason to deny the older person adequate
Deterioration in proprioception. analgesia in any given situation. However, the following
guiding principles must be remembered:
16.2.2.4Renal Assess the prevailing medication context, and then
apply the most appropriate analgesic.
Decline in renal mass
Start with a low dose not uncommonly 30 per cent
Normal serum creatinine level no longer implies
of that for a healthy adult.
normal renal function
Avoid drug combinations where possible.
Increased vulnerability to nephrotoxic agents (e.g.
non-steroidal anti-inflammatory medication).
16.2.6Outcome
16.2.2.5Musculoskeletal
Mortality rates are higher for comparable injuries com-
Osteoporosis causing fractures in the presence of
pared with younger patients. The following guidelines
minimal energy transfer
have been recommended:
Diminution of vertebral body height
Decrease in muscle mass. Accept the potential for a decreased physiological
reserve.
Suspect co-morbid disease.
16.2.3 Influence of co-morbid conditions Suspect multiple medications and polypharmacy.
Suspect atypical manifestations for any given
situation with masked signs.
16.2.3.1Cardiac disease including hypertension Look for subtle signs of organ dysfunction by
In addition to the typical changes listed above, the devel- aggressive monitoring.
opment of disease states commonly associated with the Assume that any alteration in mental status is
elderly can have a significant impact on the response to associated with brain injury, and only accept age-
injury. These can include the following in isolation or any related deterioration after exclusion of injury.
combination: Be aware of poorer outcomes and sudden
physiological deterioration.
Metabolic disease Be aware of the distinction between aggressive care
Diabetes mellitus and futile care.
Obesity (body mass index >30)
Liver disease
Malignancy 16.3Futile care
Pulmonary disease
Renal disease In every environment, there are circumstances where the
Neurological or spinal disease. provision of adequate healthcare may not alter the out-
come. In providing this care, there may be a significant
drain on the resources available, and denial to others of
16.2.4Multiple medications polypharmacy adequate care as a result. This rationing of healthcare
may be the result of operating theatres being in use, and
All of the above must be considered within the likely consequently not available, inadequate numbers of inten-
context of treatments with multiple medications, which sive care unit beds or financial restrictions.
together may produce a misleading clinical picture or may It must be stressed, however, that all patients are enti-
even mask vital changes in clinical signs. tled to an aggressive initial resuscitation and careful com-
As ageing progresses, rates of drug metabolism are prehensive diagnosis. The magnitude of their injuries
diminished, and accumulations readily occur with should be assessed within their wider health context, and
unpleasant consequences when the physician is unwary. only then can the appropriateness and aggression required
in their care be determined. In addition, this must all be 16.4Recommended reading

fully discussed with the associated staff and family.
Basic ethical principles apply, and it is essential to be Kauder DR. Geriatric trauma. In: Peitzman AB, ed. The Trauma
humane, not to prolong life without definite therapeutic Manual, 3rd edn. Philadelphia: Wolter Kluwer/Lippincott
goals and realistic expectations of a positive outcome. Williams & Wilkins, 2008: 46976.
There should be full involvement, depending on the cir-
cumstances, of ethical and social support staff, the family
and the medical team.
Our primary aim as physicians is to relieve suffering.
Interventional radiology
in trauma 17
17.1 Introduction should be taken to assess the external iliac veins as these
are less amenable to packing.
In a large number of patients, interventional radiology, Arterial embolization is carried out after performing
with angio-embolization (AE), stent or stent-graft place- an abdominal aortography followed by selective cath-
ment, has become either the first line of treatment or an eterization of the internal iliac arteries. When contrast
important adjunct to open surgery. Clinical evaluation, extravasation is demonstrated, the bleeding vessels are
however, determines the course of treatment. catheterized superselectively, and embolized with coils or
Patients who are haemodynamically stable are evalu- a combination of coils and gelfoam particles. If this is not
ated with computed tomography (CT) for non-operative possible due to spasm or uncontrolled bleeding, a central
management (NOM) with or without interventional embolization of the internal iliac arteries is performed
radiology. Patients who are haemodynamically unstable using coils. If the patient deteriorates haemodynamically
despite resuscitation are diagnosed with chest and pelvic during angiography, an occlusion balloon may be placed
X-ray, focused abdominal sonography for trauma (FAST) in the infrarenal aorta to achieve haemodynamic control.
and/or diagnostic peritoneal lavage, aimed at determin-
ing the most compelling bleeding source, and are then
directed to the operating room for immediate operative 17.3Blunt splenic injuries
treatment without additional imaging.
Non-operative management of blunt splenic injuries has
become the treatment of choice in haemodynamically sta-
17.2 Pelvic fractures ble patients, regardless of injury grade and grade of hae-
moperitoneum, in the absence of other intra-abdominal
Severe pelvic fractures, particularly with disruption of injuries requiring laparotomy. Non-operative manage-
the sacroiliac joints, are associated with a high risk of ment has been strongly motivated by the wish to preserve
severe arterial and venous bleeding. The application the spleen in order to avoid overwhelming post-splenec-
of a sheet or external fixation may control the venous tomy infections and laparotomy-associated morbid-
bleeding. However, arterial bleeding often requires AE, ity. This can be achieved by using splenic AE in selected
which has become the first line of treatment in patients patients.
stable enough to reach angiography. Established indica- The indications for AE include CT evidence of ongo-
tions for AE are CT scan evidence of ongoing bleeding, ing bleeding with contrast extravasation outside or
such as visible extravasation of contrast on the CT, or within the spleen, a drop in haemoglobin level, tachycar-
CT evidence of bladder compression or distortion of dia and haemoperitoneum, as well as the formation of a
the bladder due to a haematoma, and ongoing transfu- pseudoaneurysm.
sion requirements without evidence of other extrapelvic Selective catheterization of the splenic artery is per-
bleeding sources. formed, followed by superselective catheterization of
There is also a possibility in this subgroup of patients the bleeding arteries or feeders to the pseudoaneurysm.
that there may be severe venous bleeding. The patient in Embolization is then performed using microcoils (which
shock refractory to resuscitation should therefore be con- can be combined with gelfoam particles or microspheres).
sidered for damage control surgery with (extraperitoneal) In this way, infarctions caused by embolization are lim-
pelvic packing (see Chapter 8, The pelvis) before AE. Care ited to small areas.
If there are multiple bleeding arteries or selective cath- patients, the use of stent-grafts has recently replaced open
eterization is impossible due to spasm, central emboli- surgery. This includes injuries to the common carotid
zation of the splenic artery may be performed using arteries, brachiocephalic trunk and subclavian arteries.
microcoils. Such an embolization often contributes to Acute aortic traumatic transections are also well suited
decreasing the perfusion pressure, and is often enough to to the use of stent-grafts. The heparinization needed for
stop the bleeding while at the same time preserving the open aortic surgery represents an additional risk factor in
circulation to the spleen through collaterals existing in these patients, who often suffer from multiple associated
this area. Applying such selection criteria and technique, injuries.
NOM of blunt splenic injuries may be successful in up to Currently, there are no long-term results to prove the
8595 per cent of patients. durability of the stent-graft repair. However, due to its
minimally traumatic nature, stent-graft treatment of
acute aortic transections is today considered to be the
17.4Liver injuries first line of treatment for these patients.
Non-operative management of blunt liver injuries in

haemodynamically stable or stabilized patients has 17.6Recommended reading
become standard practice. The introduction of AE has
been reported to increase the success rate of NOM to well Asensio JA, Roldan G, Petrone P et al. Operative management
above 80 per cent. and outcomes in 103 AAST-OIS grades IV and V complex
Operative treatment of liver injuries, even in experi- hepatic injuries: trauma surgeons still need to operate, but
enced hands, still carries a high mortality and morbidity angioembolization helps. J Trauma 2003;54:64753.
risk. Arterial embolization seems to be a valuable adjunct Dent D, Alsabrook G, Erickson BA et al. Blunt splenic injuries:
to operative management since most patients are haemo- high nonoperative management rate can be achieved with
dynamically abnormal at the end of a damage control selective embolization. J Trauma 2004;56:10637.
laparotomy, and ongoing arterial bleeding is difficult to Dondelinger RF, Trotteur G, Ghaye B, Szapiro D. Traumatic
rule out clinically. injuries: radiological hemostatic intervention at admission.
The indications for AE should include CT evidence of Eur Radiol 2002;12:97993.
ongoing bleeding with contrast extravasation outside or Haan JM, Biffi W, Knudson MM et al.; Western Trauma
within the liver, a drop in haemoglobin level, tachycardia Association Multi-institutional Trials Committee. Splenic
and haemoperitoneum, in addition to the formation of a embolization revisited: a multicenter review. J Trauma
pseudoaneurysm. The risk of bleeding with NOM in Organ 2004;56:5427.
Injury Scale grade 4 and 5 liver injuries (see Appendix B Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S.
Trauma scores and scoring systems) is significant, and The usefulness of transcatheter arterial embolization for
angiography in these patients should cause no contro- patients with blunt polytrauma showing transient response
versy. In addition, angiography should be performed after to fluid resuscitation. J Trauma 2004;57:2716; discussion
damage control surgery with packing of the liver. 2767.
Angiography is performed via femoral artery puncture. Johnson JW, Gracias VH, Gupta R et al. Hepatic angiography in
Embolization is performed as peripherally as possible by patients undergoing damage control laparotomy. J Trauma
the placement of microcoils alone or in combination with 2002;52:11026.
gelfoam particles. A completion angiogram should be per- Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL.
formed to confirm haemostasis of the embolized vessel. Management of blunt thoracic aortic injuries: endovascular
stents versus open repair. J Trauma 2004;56:56570.
Reed AB, Thompson JK, Crafton CJ, Delvecchio C, Giglia JS.
17.5Aortic rupture and injury Timing of endovascular repair of blunt traumatic thoracic
to middle-sized arteries aortic transections. J Vasc Surg 2006;43:6848.
Velmahos GC, Toutouzas KG, Vassiliu P et al. A prospective study
Traumatic injuries to the aortic arch vessels are uncom- on the safety and efficacy of angiographic embolization for
mon, and are often a result of deceleration accidents. pelvic and visceral injuries. J Trauma 2002;53:3038.
Physical findings are often non-specific, and diagnosis is Zealler IA, Chakraverty S. The role of interventional radiology in
often made on CT scanning. In haemodynamically stable trauma. Br Med J 2010;340:35660.
Appendices
Appendix A
Trauma systems
A.1 Introduction care. The extension of this concept to the management

of civilian trauma led to the evolution from the 1970s
Care of the injured patient has been fundamental to the onwards of todays trauma systems.
practice of medicine since recorded history. The word
trauma derives from the Greek meaning bodily injury.
The first trauma centres were used to care for wounded A.2 The inclusive trauma system
soldiers in Napoleons armies, and the first modern
trauma centre was the Birmingham Accident Hospital in In principle, a hospital that provides acute care for the
the United Kingdom, opened in 1944 in what was then severely injured patient (a trauma centre) should be a key
the Queens Hospital. component of a system that encompasses all aspects and
The lessons learned in successive military conflicts have phases of care, from prevention and education to pre-
advanced our knowledge of care of the injured patient. hospital care, to acute care, and through to rehabilitation
The Korean conflict and the Vietnam War established the (Figure A.1). The initial trauma systems did not consider
concept of minimizing the time from injury to definitive the non-trauma centre hospitals, even though they cared
Prevention
Training Sy
Evaluation
ste
ip m
sh de
er
ve
ad
lo
Le
All Major
pm
injured trauma
en
patients patients
t
Pre-hospital
Communication
Medical direction
Triage
Transport
Interfacility
transfer
Trauma centre
Acute care facility
most severely injured
within a
or
trauma system
Specialty care facility
other injured patients
paediatrics, burns, etc.
ce
Le
is
an
g
la n
ti o Rehabilitation Fi
n
Figure A.1 The inclusive trauma system.

for the majority of patients, those who were less severely Inclusive system
injured. Instead, these trauma systems were driven by the
major or severely injured trauma patient who required
immediate treatment, optimally at a trauma centre.
Number of patients
A system must be fully integrated into the emergency
medical services (EMS) system, and must meet the needs
Exclusive
of all the patients requiring acute care for injury, regard- system
less of severity of injury, geographical location and popu-
lation density. The trauma centre remains an essential
component, but the system recognizes the necessity for
other healthcare facilities. The goal is to match the facilitys Minor Moderate Severe
resources with the needs of the patient.
Injury severity risk
Figure A.2 The components of an inclusive trauma system.
A.3 Components of an inclusive

trauma system defined by the environment (urban or rural) or by special
segments of the population (the young or the elderly),
The structure of a trauma care system involves a number must be addressed by the system.
of components and providers, each of which must be
adapted to a specific environment. These components
and providers, graphically represented in Figure A.2, are: A.3.2 Prevention
Administrative components
Prevention reduces the actual incidence of injury, and is
Leadership
cost-efficient for the system and for society. Injury preven-
System development
tion is achieved through public education, legislation and
Legislation
environmental modification.
Finances
Operational and clinical components
Injury prevention and control
A.3.3 Public education
Human resources workforce resources
Education
Public education leads to a change in behaviour, and
Pre-hospital care EMS system
thus minimizes injury exposure. Education includes the
Ambulance and non-transporting guidelines
proper recognition of injury, and efficient access to the
Communications systems
EMS system. These components stimulate the necessary
Emergency disaster preparedness plan
political and legislative activity to establish legal author-
Definitive care facilities
ity, leadership and system changes.
Trauma care facilities
The development of a system is a major challenge for
Interfacility transfer
any community. The concept of centralizing trauma care
Medical rehabilitation
creates potential political and economic problems, since
Information systems
the normal flow of patients might be altered by trauma
Evaluation
triage protocols. Trauma systems, by their nature, will
Research.
direct the care of the most critically injured patients to
a limited number of designated trauma centres. The
A.3.1 Administration trauma system will only succeed if all parties are involved
in the initial planning, development and implementation.
The system requires administrative leadership, author- It is crucial that doctors, and especially surgeons, are
ity, planning and development, legislation and finances. involved in the system-planning process. They should
Together, these components form an outer sphere of sta- help to establish standards of care for all clinical compo-
bility that is vital for the continuation of activities directly nents, and participate in planning, verification, perform-
related to patient care. The diversity of the population, as ance improvement and system evaluation.
Trauma systems | 219
A.4 Management of the injured lead agency with a strong oversight, or an advisory body
patient within a system composed of healthcare, public and medical representa-
tives. This agency will develop the criteria for the system,
Once the injury has been identified, the system must regulate and direct pre-hospital care, establish pre-hospi-
ensure easy access and an appropriate response at the tal triage, ensure medical direction, designate the proper
scene of injury. The system must assign responsibility facilities to render care, establish a trauma registry and
and authority for care and triage decisions made prior to establish performance improvement programmes.
trauma centre access. Triage guidelines must be accepted
by all providers, and used to determine which patients
A.5.3 Establish criteria for optimal care
require access to trauma centre care. This coordination
requires direct communication between pre-hospital care These must be established by the lead authority in con-
providers, medical direction and the trauma facility. junction with health and medical professionals. The
The trauma centre, which serves as the definitive spe- adoption of system-wide standards is integral to the
cialized care facility, is a key component of the system, success of any system.
and is different from other hospitals within the system in
that it guarantees immediate availability of all the speci-
alities necessary for the assessment and management of A.5.4 Designation of trauma centres
the patient with multiple injuries. These centres need to
be integrated into the other components of the system to This takes place through a public process directed by
allow the best match of resources with the patients needs. the lead agency. Consideration must be given to the role
The system coordinates care between all levels of the facil- of all acute care facilities within the particular region.
ity, so that prompt and efficient integration of hospital Representatives from all these facilities must be involved
and resources can take place according to patient need. in the planning process.
Access to rehabilitation services, first in the acute care The number of trauma centres should be limited to the
hospital and then in more specialized rehabilitation facili- number required (based on the established need) for the
ties, is an integral part of the total management of the patient population at risk of major injury. Having too many
patient. It is important that the patients be returned to trauma centres may weaken the system by diluting the
their communities when appropriate. workload, thus reducing the experience for training, and will
unnecessarily consume resources that are not fully utilized.
Development of a system requires that all the principal
A.5 Steps in organizing a system players be involved from the beginning. There must be
agreement about the minimal data that will be contrib-
uted by all acute care facilities. Without the data from the
A.5.1 Public support
hospitals managing the less severely injured, the data will
be incomplete, and skewed towards major injury.
Public support is necessary for the enabling and necessary
legislation to take place. The process takes place as follows:
Identification of the need A.5.5 System evaluation

Establishment of a patient database to assist with
Trauma systems are complex organizational structures
need and resource assessment
with evolving methods and standards of care. It is neces-
Analysis to determine the resources available
sary to have a mechanism for ongoing evaluation, based on:
Resource assessment, formulated to identify the
current capabilities of the system Self-monitoring
Highlighting of deficiencies, and formulation of solutions. External evaluation.
A.5.2 Legal authority A.6 Results and studies

This is established once the need for a system has been The Skamania Conference was held in July 1998, with the
demonstrated. Legislation will be required to establish a purpose of evaluating the evidence regarding the efficacy
of trauma systems. During the conference, the evidence they cover all aspects of trauma care, including pre-hos-
was divided into three categories: that resulting from pital, hospital and rehabilitative. A critique of the popu-
panel studies, registry comparisons and population-based lation-based studies pointed out that there are a limited
research. number of clinical variables, and it is difficult to adjust
for severity of injury and physiological dysfunction. There
are other problems, although these probably apply to all
A.6.1 Panel review studies, including secular trends, observational issues and
problems with longitudinal population mortality studies.
An overview of panel studies was presented at the
Skamania Conference. The critique of panel reviews is
that they vary widely, and interrater reliability has been A.7 Summary
very low in some studies. Furthermore, autopsy results
alone are inadequate, and panel studies vary regarding Although there are difficulties with all three types of
the process of review and the rules used to come to a final study, each may also offer advantages to various com-
judgement. In general, all panel studies were classified as munities and regions. All three types may also influence
weak class III evidence. Nevertheless, MacKenzie came to health policy, and all can be used pre- and post-trauma
the conclusion that when all panel studies are considered system start-up. There was consensus at the Skamania
collectively, they do provide some face validity and sup- Conference that the evaluation of trauma systems should
port of the hypothesis that treatment at a trauma centre be extended to include an economic evaluation and
versus a non-trauma centre is associated with fewer inap- assessment of quality-adjusted lifeyears.
propriate deaths and possibly disabilities.
A.8 References
A.6.2 Registry study
Jurkovich GJ, Mock C. Systematic review of trauma system
Jurkovich and Mock1 reported on the evidence provided effectiveness based on registry comparisons. J Trauma
by trauma registries in assessing overall effectiveness. 1999;47(Suppl.):S4655.
They concluded fairly emphatically that this was not
class I evidence, but that it was probably better than a
panel study. Their critique of trauma registries included A.9 Recommended reading
the following six items: data are often missing, miscod-
ings occur, there may be interrater reliability factors, the American College of Surgeons. Guidelines for trauma care
national norms are not population-based, there is less systems. In: Committee on Trauma. Resources for Optimal
detail about the causes of death, and they do not take into Care of the Injured Patient 2006. Chicago: American
account pre-hospital deaths. A consensus of the partici- College of Surgeons, 2006.
pants at the Skamania Conference concluded that registry MacKenzie EJ. Review of evidence regarding trauma system
studies were better than panel studies but not as good as effectiveness resulting from panel studies. J Trauma
population studies. 1999;47(Suppl.):S3441.
Mullins RJ, Mann NC. Population-based research assessing
the effectiveness of trauma systems. J Trauma
A.6.3 Population-based studies 1999;47(Suppl.):S5966.
Peterson TD, Mello MJ, Broderick KB et al. Trauma Care
Populated-based studies probably also fall into class II Systems 2003 (Updated 2/10/2007). American College of
evidence. They are not prospective randomized trials, but, Emergency Physicians: Guidelines for Trauma Care Systems.
because of the nature of the population-based evidence, Available from www.acep.org (accessed December 2010).
Appendix B
Trauma scores and scoring systems
B.1 Introduction Table B.1 Glasgow Coma Scale
Parameter Response Score

Estimates of the severity of injury or illness are fun
damental to the practice of medicine. The earliest Eye-opening Nil 1
known medical text, the Smith Papyrus, classified To pain 2

injuries into three grades: treatable, contentious and To speech 3
untreatable. Spontaneously 4
Modern trauma scoring methodology uses a combi- Motor response Nil 1
nation of an assessment of the severity of anatomical Extensor 2
injury with a quantification of the degree of physiological
Flexor 3
derangement to arrive at scores that correlate with clinical
Withdrawal 4
outcomes.
Localizing 5
Trauma scoring systems are designed to facilitate
pre-hospital triage, identify trauma patients suitable for Obeys command 6
quality assurance audit, allow an accurate comparison of Verbal response Nil 1

different trauma populations, and organize and improve Groans 2
trauma systems. Words 3
In principle, scoring systems can be divided into: Confused 4
Physiological scoring systems, based on the bodys Orientated 5
response to injury
Anatomical scoring systems, based on the physical
injury that has occurred
Outcome analysis systems, based on the result after B.2.2 Revised Trauma Score
recovery.
Introduced by Champion et al., the Revised Trauma Score2
(RTS) evaluates blood pressure, the GCS and the respira-
B.2 Physiological scoring tory rate to provide a scored physiological assessment of
systems the patient.
The RTS can be used for field triage, and enables pre-
B.2.1 Glasgow Coma Scale hospital and emergency care personnel to decide which
patients should receive the specialized care of a trauma
The Glasgow Coma Scale1 (GCS), devised in 1974, was unit. An RTS score of 11 or less is suggested as the triage
one of the first numerical scoring systems (Table B.1). point for patients requiring at least level 2 trauma cen-
The GCS has been incorporated into many later scoring tre status (surgical facilities, 24 hour X-ray, etc.). An RTS
systems, emphasizing the importance of head injury as a of 10 or less carries a mortality of up to 30 per cent, and
triage and prognostic indicator. these patients should be moved to a level 1 institution.
The difference between RTS on arrival and best RTS Table B.3 Paediatric Trauma Score (PTS)
after resuscitation will give a reasonably clear picture of
Clinical parameter Category Score
the prognosis. By convention, the RTS on admission is
the one documented. Size (kg) >20 2
The RTS (non-triage) is designed for retrospec- 1020 1
tive outcome analysis. Weighted coefficients are used, <10 1
which are derived from trauma patient populations, Airway Normal 2
and provide a more accurate outcome prediction than
Maintainable 1
the raw RTS (Table B.2). Since a severe head injury car-
Unmaintainable 1
ries a poorer prognosis than a severe respiratory injury,
Systolic blood >90 2
the weighting is therefore heavier. The RTS thus varies
pressure (mmHg) 5090 1
from 0 (worst) to 7.8408 (best). The RTS is the most
widely used physiological scoring system in the trauma <50 1
literature. Central nervous Awake 2

system Obtunded/decreased LOC 1
Table B.2 Revised Trauma Score (RTS) Coma/decerebrate 1

Open wound None 2
Clinical parameter Category Score Weight Minor 1
Respiratory rate (breaths 1029 4 0.2908 Major/penetrating
per minute) >29 3 Skeletal None 2
69 2 Closed fracture 1
15 1 Open/multiple fractures 1
0 0
The values for the six parameters are summed to give the overall PTS.
Systolic blood pressure >89 4 0.7326 LOC, level of consciousness.
7689 3
5075 2
149 1
B.3 Anatomical Scoring Systems
0 0
Glasgow Coma Scale 1315 4 0.9368 B.3.1 Abbreviated Injury Scale
score 912 3
68 2 The Abbreviated Injury Scale4 (AIS) is an anatomically
45 1 based, consensus-derived, global severity-based scoring
3 0 system that classifies each injury by body region accord-
ing to its relative importance on a 6-point ordinal scale.
The values for the three parameters are summed to give the triage-RTS. Weighted The AIS was developed in 1971 as a system to describe
values are summed for the RTS.
the severity of injury throughout the body. The AIS has
been periodically upgraded, and AIS-2005 Update 2008
is currently in use.
B.2.3 Paediatric Trauma Score In AIS 2005, each injury is assigned a six-digit unique
numerical identifier, to the left of the decimal point. This
The Paediatric Trauma Score3 (PTS; Table B.3) has been in known as the pre-dot code. There is an additional
designed to facilitate triage of children. The PTS is the single digit to the right of the code (the post-dot code),
sum of six scores, and values range from 6 to +12, with a which is the AIS severity code The AIS grades each injury
PTS of 8 or less being recommended as the trigger to send by severity from 1 (least severe) to 5 (critical: survival
the child to a trauma centre. The PTS has been shown to uncertain). A score of 6 is given to certain injuries termed
accurately predict risk for severe injury or mortality, but maximal (currently untreatable/unsurvivable).
is not significantly more accurate than the RTS and is a The AIS manual4 is divided, for ease of reference, into nine
great deal more difficult to measure. different sections based on anatomy. All injuries therefore
Trauma scores and scoring systems | 223
carry a unique code that can be used for classification, for separation between patients with and without multiple
indexing in trauma registry databases and for severity. organ failure, and showed that the NISS is superior to the
ISS in the prediction of multiple organ failure.7 Although
the proponents of the NISS proclaim its superiority, it is
B.3.2 Injury Severity Score not yet in widespread use.
In 1974, Baker et al. created the Injury Severity Score (ISS)5

to relate AIS scores to patient outcomes. ISS body regions B.3.4 Anatomic Profile
are listed in Table B.4.
The Anatomic Profile8 (AP) was introduced in 1990 to
Table B.4 Injury Severity Score body regions overcome some of the limitations of the ISS. In contrast
to ISS, the AP allows the inclusion of more than one
Number Region
serious body injury per region, and takes into account
1 Head and neck the primacy of central nervous system and torso injury
2 Face over other injuries. AIS scoring is used, but four values
3 Thorax are used for injury characterization, roughly weighting
4 Abdomen/pelvic contents the body regions. Serious trauma to the brain and spinal
5 Extremities
cord, anterior neck and chest, and all remaining injuries
constitute three of the four values. The fourth value is a
6 External/skin/general
summary of all the remaining non-serious injuries. The
AP score is the square root of the sum of the squares of
The ISS is calculated by summing the square of the all the AIS scores in a region, thus enabling the impact
highest AIS scores in the three most severely injured of multiple injuries within that region to be recognized.
regions. ISS scores range from 1 to 75 (since the highest Component values for the four regions are summed to
AIS score for any region is 5). By convention, an AIS score constitute the AP score.
of 6 (defined as a non-survivable injury) for any region A modified AP (mAP) has recently been introduced,
becomes an ISS of 75. which is a four-number characterization of injury. The
The ISS only considers the single most serious injury in four component scores are the maximum AIS score
each region, ignoring the contribution of injury to other and the square root of the sum of the squares of all
organs within the same region. Diverse injuries may have AIS values for serious injury (AIS 3)in specified body
identical ISS scores but markedly different survival prob- regions (Table B.5). This leads to an Anatomic Profile
abilities (an ISS of 25 may be obtained with isolated severe Score, the weighted sum of the four mAP components.
head injury or by a combination of lesser injuries across The coefficients are derived from logistic regression
different regions). In addition, the ISS does not have the analysis of admissions to four level 1 trauma centres
power to discriminate between the impact of similarly (the controlled sites) in the Major Trauma Outcome
scored injuries to different organs, and therefore can- Study.
not identify, for example, the different impact of cerebral
injury over injury to other organ systems.
Table B.5 Component definitions of the modified Anatomic Profile
B.3.3 New Injury Severity Score Component Body region Abbreviated Injury
Scale severity
In response to these limitations, the ISS was modified in mA Head/brain 36
1997 to become the New Injury Severity Score (NISS).6 Spinal cord 36
NISS is calculated in the same way as ISS, but takes the
mB Thorax 36
three most severe injuries (i.e. the three highest AIS scores
Front of neck 36
regardless of body region). The NISS is then the simple
mC All other 36
sum of the squares of these three body regions.
The NISS is able to predict survival outcomes better mA, mB and mC scores are derived by taking the square root of the sum of the
than the ISS. In a separate study, the NISS yielded better squares for all injuries defined by each component.
A limitation of the use of AIS-derived scores is their whose only source of injury was penetrating abdomi-
cost. International Classification of Disease (ICD) tax- nal trauma. A complication risk factor was assigned
onomy is a standard used by most hospitals and other to each organ system involved, and then multiplied by
healthcare providers to classify clinical diagnoses. a severity of injury estimate. Each factor was given a
Computerized mapping of ICD-9CM rubrics into AIS value ranging from 1 to 5. The complication risk desig-
body regions and severity values has been used to com- nation for each organ was based on the reported inci-
pute ISS, AP and NISS scores. Despite limitations, ICD dence of postoperative morbidity associated with the
AIS conversion has been useful in population-based particular injury.
evaluation when AIS scoring from medical records is not The severity of injury was estimated by a simple modi-
possible. Outside North America, the ICD-10 is most fication to the AIS, ranging from 1 = minimal injury to 5
commonly used. = maximal injury. The sum of the individual organ score
times the risk factor comprised the final PATI score. If
the PATI score is 25 or less, the risk of complications is
B.3.5 ICD-based Injury Severity Score reduced (and where it is 10 or less, there are no complica-
tions), whereas if it is greater than 25, the risks are much
Severity scoring systems also have been directly derived higher.
from ICD-coded discharge diagnoses. Most recently, the In a group of 114 patients with gunshot wounds to the
ICD-9 Severity Score9 (ICISS) has been proposed, which is abdomen, Moore et al.11 showed that a PATI score of more
derived by multiplying survival risk ratios associated with than 25 dramatically increased the risk of postoperative
individual ICD diagnoses. Neural networking has been complications (46 per cent of patients with a PATI score
employed to further improve ICISS accuracy. ICISS has of over 25 developed serious postoperative complications,
been shown to be better than ISS and to outperform the compared with 7 per cent of patients with a PATI of less
Trauma and Injury Severity Score (TRISS) in identifying than 25). Further studies have validated the PATI scoring
outcomes and resource utilization. However, modifiedAP system.
scores, AP and NISS appear to outperform ICISS in
predicting hospital mortality.
There is some confusion over which anatomical scor-
B.4 Outcome analysis
ing system should be used; however, currently, NISS
probably should be the system of choice for AIS-based
scoring. B.4.1 Glasgow Outcome Scale
For head-injured patients, the level of coma on admission

B.3.6 Organ Injury Scaling System or within 24 hours expressed by the GCS was found to
correlate with outcome. The Glasgow Outcome Scale12
Organ Injury Scaling10 (OIS) is a scale of anatomical was an attempt to quantify the outcome parameters
injury within an organ system or body structure. The goal (TableB.6) for head-injured patients.
of OIS is to provide a common language between trauma
surgeons and to facilitate research and continuing quality Table B.6 Outcome parameters
improvement. It is not designed to correlate with patient
outcomes. The OIS tables can be found on the American GR Good recovery
Association for the Surgery of Trauma (AAST) web site9 or MD Moderate disability
at the end of this chapter. SD Severe disability
PVS Persistent vegetative state
D Death
B.3.7 Penetrating Abdominal Trauma Index
Moore and colleagues facilitated the identification The grading of depth of coma and neurological signs
of the patient at high risk of postoperative complica- was found to correlate strongly with outcome, but the low
tions when they developed the Penetrating Abdominal accuracy of individual signs limits their use in predicting
Trauma Index11 (PATI) scoring system for patients outcomes for individuals (Table B.7).
Table B.7 Outcome related to signs in the first 24 hours of coma after Table B.8 Coefficients from the Major Trauma Outcome Study database
injury: outcome scale as described by Glasgow group
Blunt Penetrating
Dead or vegetative (%) Moderate disability or b0 = 1.2470 0.6029
good recovery (%) b1 = 0.9544 1.1430
Pupils b2 = 0.0768 0.1516
Reacting 39 50 b3 = 1.9052 2.6676
Non-reacting 91 4
Eye movements The sloping line in Figure B.1 represents patients with
Intact 33 56
a probability of survival of 50 per cent; these PRE charts
Absent/bad 90 5
(from PREliminary) are provided for those with blunt ver-
Motor response sus penetrating injury, and for those above versus below
Normal 36 54 55 years of age. Survivors whose coordinates are above
Abnormal 74 16
the P(s)50 isobar and non-survivors below the P(s)50 iso-
bar are considered atypical (statistically unexpected), and
such cases are suitable for focused audit.
B.4.2 Major Trauma Outcome Study In addition to analysing individual patient outcomes,
TRISS allows a comparison of a study population with the
In 1982, the American College of Surgeons Committee huge MTOS database. The Z-statistic identifies whether
on Trauma began the ongoing Major Trauma Outcome study group outcomes are significantly different from
Study (MTOS), a retrospective, multicentre study of expected outcomes as predicted from the MTOS. Z is the
trauma epidemiology and outcomes. ratio (AE) / S, where A = actual number of survivors, E
The MTOS uses TRISS methodology13 to estimate the = expected number of survivors, and S = scale factor that
probability of survival, or P(s), for a given trauma patient. accounts for statistical variation. Z may be positive or neg-
P(s) is derived according to the formula: ative, depending on whether the survival rate is greater or
less than predicted by TRISS. Absolute values of Z above
P(s) = 1 / (1 + eb)
1.96 or below 0.96 are statistically significant (P<0.05).
where e is a constant (approximately 2.718282) and b = b0 + The so-called M-statistic is an injury severity match
b1(RTS) + b2(ISS) +b3(age factor). The b coefficients are derived allowing a comparison of the range of injury severity in
by regression analysis from the MTOS database (Table B.8). the sample population with that of the main database (i.e.
The P(s) values range from zero (survival not expected) the baseline group). The closer M is to 1, the better the
to 1.000 for a patient with a 100 per cent expectation of match; the greater the disparity, the more biased Z will
survival. Each patients values can be plotted on a graph be. This bias can be misleading; for example, an institu-
with ISS and RTS axes (Figure B.1). tion with a large number of patients with low-severity
0
D
1 D
D
2 L D
Revised Trauma Score
D
3
L
L
4
L L
D
5 LL L LL
L LL
D
6 LL
LLL
7 LL L L P(s)50 Isobar
LL L L LL L L L L L L L
8 LL
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Injury Severity Score
Figure B.1 PRE chart. D, dead; L, live.
injuries can falsely appear to provide a better standard of Trauma scoring systems are designed to facilitate pre-
care than another institution that treats a higher number hospital triage, identify trauma patients whose outcomes
of more severely injured patients. are statistically unexpected for quality assurance analysis,
The W-statistic calculates the actual numbers of sur- allow an accurate comparison of different trauma popu-
vivors greater (or fewer) than predicted by the MTOS, lations, and organize and improve trauma systems. They
per 100 trauma patients treated. The Relative Outcome are vital for the scientific study of the epidemiology and
Score can be used to compare W-values against a perfect the treatment of trauma, and may even be used to define
outcome of 100 per cent survival. The Relative Outcome resource allocation and reimbursement in the future.
Score may then be used to monitor improvements in Trauma scoring systems that measure outcome solely
trauma care delivery over time. in terms of death or survival are at best blunt instruments.
TRISS has been used in numerous studies. Its value as a Despite the existence of several scales (Quality of Well-
predictor of survival or death has been shown to be from being Scale, Sickness Impact Profile, etc.), further efforts
75 to 90 per cent as good as a perfect index, depending on are needed to develop outcome measures that are able to
the patient data set used. evaluate the multiplicity of outcomes across the full range
of diverse trauma populations.
Despite the profusion of acronyms, scoring systems
B.4.3 A Severity Characterization of Trauma are a vital component of trauma care-delivery systems.
The effectiveness of well-organized, centralized, multi-
A Severity Characterization of Trauma (ASCOT),14,15 disciplinary trauma centres in reducing the mortality
introduced by Champion et al. in 1990, is a scoring system and morbidity of injured patients is well documented.
that uses the AP to characterize injury in place of the ISS. Further improvement and expansion of trauma care can
Different coefficients are used for blunt and penetrating only occur if developments are subjected to scientifically
injury, and the ASCOT score is derived from the formula: rigorous evaluation. Thus, trauma scoring systems play a
P(s) = 1 / (1 + ek). The ASCOT model coefficients are central role in the provision of trauma care today and for
shown in Table B.9. ASCOT has been shown to outper- the future.
form TRISS, particularly for penetrating injury.
B.7 Scaling System for Organ-

Table B.9 Coefficients derived from Major Trauma Outcome Study data specific Injuries1624
for the ASCOT probability of survival, P(s)
Table 1 Cervical vascular organ injury scale
Type of injury Table 2 Chest wall injury scale
k-Coefficients Blunt Penetrating Table 3 Heart injury scale
K1 1.157 1.135 Table 4 Lung injury scale
K2 (RTS GCS value) 0.7705 1.0626 Table 5 Thoracic vascular injury scale
K3 (RTS SBP value) 0.6583 0.3638 Table 6 Diaphragm injury scale
K4 (RTS RR value) 0.281 0.3332 Table 7 Spleen injury scale
K5 (AP head region value) 0.3002 0.3702 Table 8 Liver injury scale
K6 (AP thoracic region value) 0.1961 0.2053 Table 9 Extrahepatic biliary tree injury scale
K7 (AP other serious injury value) 0.2086 0.3188 Table 10 Pancreas injury scale
K8 (age factor) 0.6355 0.8365 Table 11 Oesophagus injury scale
Table 12 Stomach injury scale
AP, Anatomic Profile; ASCOT, A Severity Characterization of Trauma; GCS, Glasgow
Coma Scale; RR, respiratory rate; RTS, Revised Trauma Score; SBP, systolic blood pressure.
Table 13 Duodenum injury scale
Table 14 Small bowel injury scale
Table 15 Colon injury scale
B.5 Summary Table 16 Rectum injury scale
Table 17 Abdominal vascular injury scale
Trauma scoring systems and allied methods of analys- Table 18 Adrenal organ injury scale
ing outcomes after trauma are steadily evolving and have Table 19 Kidney injury scale
become increasingly sophisticated over recent years. Table 20 Ureter injury scale
Table 21 Bladder injury scale Table 29 Testis injury scale

Table 22 Urethra injury scale Table 30 Scrotum injury scale
Table 23 Uterus (non-pregnant) injury scale Table 31 Penis injury scale
Table 24 Uterus (pregnant) injury scale Table 32 Peripheral vascular organ injury scale
Table 25 Fallopian tube injury scale
Table 26 Ovary injury scale In all the tables in this section, ICD refers to the
Table 27 Vagina injury scale International Classification of Diseases, and AIS to the
Table 28 Vulva injury scale Abbreviated Injury Scale.
Table 1 Cervical vascular organ injury scale
Grade* Description of injury ICD-9 ICD-10 AIS-2005
I Thyroid vein 900.8 S15.8 1

Common facial vein 900.8 S15.8 1
External jugular vein 900.81 S15.2 13
Non-named arterial/venous branches 900.9 S15.9 13
II External carotid arterial branches (ascending pharyngeal, superior 900.8 S15.0 13
thyroid, lingual, facial, maxillary, occipital, posterior auricular)
Thyrocervical trunk or primary branches 900.8 S15.8 13
Internal jugular vein 900.1 S15.3 13
III External carotid artery 900.02 S15.0 23
Subclavian vein 901.3 S25.3 34
Vertebral artery 900.8 S15.1 24
IV Common carotid artery 900.01 S15.0 35
Subclavian artery 901.1 S25.1 34
V Internal carotid artery (extracranial) 900.03 S15.0 35
* Increase one grade for multiple grade III or IV injuries involving more than 50 per cent of the vessel circumference. Decrease one grade for less than 25 per cent vessel
circumference disruption for grade IV or V.
From Moore et al.16
Table 2 Chest wall injury scale
Grade* Injury type Description of injury ICD-9 ICD-10 AIS-2005
I Contusion Any size 911.0/922.1 S20.2 1

Laceration Skin and subcutaneous 875.0 S20.4 1
Fracture <3 ribs, closed 807.01/807.02 S22.3 12
Non-displaced, clavicle closed 810.00/810.03 S42.0 2
II Laceration Skin, subcutaneous and muscle 875.1 S20.4 2
Fracture >3 adjacent ribs, closed 807.03/ 807.08 S22.4 1
Open or displaced clavicle 810.10/810.13 S42.0 23
Non-displaced sternum, closed 807.2 S22.2 2
Scapular body, open or closed 811.00/811.18 S42.1 2
III Laceration Full thickness including pleural penetration 862.29 S21.9 2
Fracture Open or displaced sternum 807.2 S22.2 2
Flail sternum 807.3 S22.2 2
Unilateral flail segment (<3 ribs) 807.4 S22.5 34
IV Laceration Avulsion of chest wall tissues with underlying rib fractures 807.10/807.18 S22.8 4
Fracture Unilateral flail chest (3 ribs) 807.4 S22.5 34
V Fracture Bilateral flail chest (3 ribs on both sides) 807.4 S22.5 5
This scale is confined to the chest wall alone and does not reflect associated internal or abdominal injuries. Therefore, further delineation of upper versus lower or anterior
versus posterior chest wall was not considered, and a grade VI was not warranted. Specifically, thoracic crush was not used as a descriptive term; instead, the geography and
extent of fractures and soft tissue injury were used to define the grade.
*Upgrade by one grade for bilateral injuries.
From Moore et al.17
Table 3 Heart injury scale
I Blunt cardiac injury with minor ECG abnormality (non-specific ST or T wave changes, 861.01 S26.0 3
premature arterial or ventricular contraction or persistent sinus tachycardia)
Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade or cardiac
herniation
II Blunt cardiac injury with heart block (right or left bundle branch, left anterior fascicular or 861.01 S26.0 3
atrioventricular) or ischaemic changes (ST depression or T wave inversion) without cardiac
failure
Penetrating tangential myocardial wound up to, but not extending through, endocardium, 861.12 S26.0 3
without tamponade
III Blunt cardiac injury with sustained (6 beats/min) or multifocal ventricular contractions 861.01 S26.0 34
Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid valvular 861.01 S26.0 34
incompetence, papillary muscle dysfunction or distal coronary arterial occlusion without
cardiacfailure
Blunt pericardial laceration with cardiac herniation 861.01 S26.0 34
Blunt cardiac injury with cardiac failure 861.01 S26.0 34
Penetrating tangential myocardial wound up to, but extending through, endocardium, with 861.12 S26.0 3
tamponade
IV Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid valvular 861.12 S26.0 3
incompetence, papillary muscle dysfunction or distal coronary arterial occlusion producing
cardiac failure
Blunt or penetrating cardiac injury with aortic mitral valve incompetence 861.03 S26.0 5
Blunt or penetrating cardiac injury of the right ventricle, right atrium or left atrium 861.03 S26.0 5
V Blunt or penetrating cardiac injury with proximal coronary arterial occlusion 861.03 S26.0 5
Blunt or penetrating left ventricular perforation 861.13 S26.0 5
Stellate wound with <50% tissue loss of the right ventricle, right atrium or left atrium 861.03 S26.0 5
VI Blunt avulsion of the heart; penetrating wound producing >50% tissue loss of a chamber 861.13 S26.0 6
With ICD-10, use supplementary character: 0 = without an open wound into the thoracic cavity; 1 = with an open wound into the thoracic cavity.
*Advance one grade for multiple wounds to a single chamber or multiple chamber involvement.
From Moore et al.18
Table 4 Lung injury scale
I Contusion Unilateral, <1 lobe 861.12/861.31 S27.3 3

II Contusion Unilateral, single lobe 861.20/861.30 S27.3 3
Laceration Simple pneumothorax 860.0/1/4/5 S27.0 3
III Contusion Unilateral, >1 lobe 861.20/861.30 S27.3 3
Laceration Persistent (>72-hour) air leak from distal airway 860.0/1/4/5 S27.3 34
Haematoma Non-expanding intraparenchymal 862.0/861.30 S27.3
IV Laceration Major (segmental or lobar) air leak 862.21/861.31 S25.4 45
Haematoma Expanding intraparenchymal S25.4
Vascular Primary branch intrapulmonary vessel disruption 901.40 S25.4 35
V Vascular Hilar vessel disruption 901.41/901.42 S25.4 4
VI Vascular Total uncontained transection of pulmonary hilum 901.41/901.42 S25.4 4
Haemothorax is scored under the thoracic vascular injury scale.

With ICD-10, use supplementary character: 0 = without an open wound into the thoracic cavity; 1 = with an open wound into the thoracic cavity.
From Moore et al.18
Table 5 Thoracic vascular injury scale
I Intercostal artery/vein 901.8 S25.5 23

Internal mammary artery/vein 901.82 S25.8 23
Bronchial artery/vein 901.89 S25.4 23
Oesophageal artery/vein 901.9 S25.8 23
Hemiazygos vein 901.89 S25.8 23
Unnamed artery/vein 901.9 S25.9 23
II Azygos vein 901.89 S25.8 23
Internal jugular vein 900.1 S15.3 23
Subclavian vein 901.3 S25.3 34
Innominate vein 901.3 S25.3 34
III Carotid artery 900.01 S15.0 35
Innominate artery 901.1 S25.1 34
Subclavian artery 901.1 S25.1 34
IV Thoracic aorta, descending 901.0 S25.0 45
Inferior vena cava (intrathoracic) 902.10 S35.1 34
Pulmonary artery, primary intraparenchymal branch 901.41 S25.4 3
Pulmonary vein, primary intraparenchymal branch 901.42 S25.4 3
V Thoracic aorta, ascending and arch 901.0 S25.0 5
Superior vena cava 901.2 S25.2 34
Pulmonary artery, main trunk 901.41 S25.4 4
Pulmonary vein, main trunk 901.42 S25.4 4
VI Uncontained total transection of thoracic aorta or pulmonary hilum 901.0 S25.0 5
Uncontained total transection of pulmonary hilum 901.41/901.42 S25.4 5
*Increase one grade for multiple grade III or IV injuries if more than 50 per cent of the circumference. Decrease one grade for grade IV injuries if less than 25 per cent of the
circumference.
From Moore et al.18
Table 6 Diaphragm injury scale
I Contusion 862.0 S27.8 2

II Laceration <2cm 862.1 S27.8 3
III Laceration 210cm 862.1 S27.8 3
IV Laceration >10cm with tissue loss 25cm2 862.1 S27.8 3
V Laceration with tissue loss >25cm 2
862.1 S27.8 3
From Moore et al.18

Table 7 Spleen injury scale (1994 revision)
I Haematoma Subcapsular, <10% surface area 865-01/865.11 S36.0 2

Laceration Capsular tear, <1cm parenchymal depth 865.02/865.12 S36.0 2
II Haematoma Subcapsular, 1050% surface area; intraparenchymal, <5 cm in 865.01/865.11 S36.0 2
diameter
Laceration Capsular tear, 13cm parenchymal depth that does not involve a 865.02/865.12 S36.0 2
trabecular vessel
III Haematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular 865.03 S36.0 3
or parenchymal haematoma; intraparenchymal haematoma >5cm or
expanding
Laceration >3 cm parenchymal depth or involving trabecular vessels 865.03 S36.0 3
IV Laceration Laceration involving segmental or hilar vessels producing major 865.13 S36.0 4
devascularization (>25% of spleen)
V Laceration Completely shattered spleen 865.04 S36.0 5
Vascular Hilar vascular injury with devascularized spleen 865.14 S36.0 5
With ICD-10, use supplementary character: 0 = without an open wound into the abdominal cavity; 1 = with an open wound into the abdominal cavity.
From Moore et al.19
Table 8 Liver injury scale (1994 revision)
Grade* Type of injury Description of injury ICD-9 ICD-10 AIS-2005
I Haematoma Subcapsular, <10% surface area 864.01/864.11 S36.1 2

Laceration Capsular tear, <1cm parenchymal depth 864.02/864.12 S36.1 2
II Haematoma Subcapsular, 1050% surface area: intraparenchymal <10cm in 864.01/864.11 S36.1 2
diameter
Laceration Capsular tear 13cm parenchymal depth, <10cm in length 864.03/864.13 S36.1 2
III Haematoma Subcapsular, >50% surface area or ruptured subcapsular or 864.04/864.14 S36.1 3
parenchymal haematoma; intraparenchymal haematoma >10cm or
expanding
Laceration 3cm parenchymal depth 864.04/864.14 S36.1 3
IV Laceration Parenchymal disruption involving 2575% hepatic lobe or 13 864.04/864.14 S36.1 4
Couinauds segmentswithin a single lobe
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 864.04/864.14 S36.1 5
Couinauds segments within a single lobe
Vascular Juxtahepatic venous injuries; i.e. retrohepatic vena cava/central major 864.04/864.14 S36.1 5
hepatic veins
VI Vascular Hepatic avulsion 864.04/864.14 S36.1 5
From Moore et al.19
Table 9 Extrahepatic biliary tree injury scale
I Gallbladder contusion/haematoma 868.02 S36.1 2

Portal triad contusion 868.02 S36.1 2
II Partial gallbladder avulsion from liver bed; cystic duct intact 868.02 S36.1 2
Laceration or perforation of the gallbladder 868.12 S36.1 2
III Complete gallbladder avulsion from liver bed 868.02 S36.1 3
Cystic duct laceration 868.12 S36.1 3
IV Partial or complete right hepatic duct laceration 868.12 S36.1 3
Partial or complete left hepatic duct laceration 868.12 S36.1 3
Partial common hepatic duct laceration (<50%) 868.12 S36.1 3
Partial common bile duct laceration (<50%) 868.12 S36.1 3
V >50% transection of common hepatic duct 868.12 S36.1 34
>50% transection of common bile duct 868.12 S36.1 34
Combined right and left hepatic duct injuries 868.12 S36.1 34
Intraduodenal or intrapancreatic bile duct injuries 868.12 S36.1 34
From Moore et al.20
Table 10 Pancreas injury scale
I Haematoma Minor contusion without duct injury 863.81/863.84 S36.2 2

Laceration Superficial laceration without duct injury S36.2 2
II Haematoma Major contusion without duct injury or tissue loss 863.81/863.84 S36.2 2
Laceration Major laceration without duct injury or tissue loss 863.81/863.84 S36.2 3
III Laceration Distal transection or parenchymal injury with duct injury 863.92/863.94 S36.2 3
IV Laceration Proximal transection or parenchymal injury involving ampulla 863.91 S36.2 4
V Laceration Massive disruption of pancreatic head 863.91 S36.2 5
863.51, 863.91: head; 863.99, 862.92: body; 863.83, 863.93: tail.
The proximal pancreas is to the patients right of the superior mesenteric vein.
From Moore et al.21
Table 11 Oesophagus injury scale
I Contusion Contusion/haematoma 862.22/826.32 S10.0/S27.8/S36.8 2

Laceration Partial thickness laceration 862.22/826.32 S10.0/S27.8/S36.8 3
II Laceration Laceration <50% circumference 862.22/826.32 S10.0/S27.8/S36.8 4
III Laceration Laceration >50% circumference 862.22/826.32 S10.0/S27.8/S36.8 4
IV Tissue loss Segmental loss or devascularization <2cm 862.22/826.32 S10.0/S27.8/S36.8 5
V Tissue loss Segmental loss or devascularization >2cm 862.22/826.32 S10.0/S27.8/S36.8 5
With ICD-10, use fifth character supplementary character: 0 = without an open wound into the abdominal or thoracic cavity; 1 = with an open wound into the abdominal or
thoracic cavity.
S10.0: cervical oesophagus; S27.8: thoracic oesophagus; S36.8: abdominal oesophagus.
*Advance one grade for multiple lesions up to grade III.
From Moore et al.20
Table 12 Stomach injury scale
I Contusion Contusion/haematoma 863.0/863.1 S36.3 2

Laceration Partial thickness laceration 863.0/863.1 S36.3 2
II Laceration <2cm in gastro-oesophageal junction or pylorus 863.0/863.1 S36.3 3
<5cm in proximal 1/3 stomach 863.0/863.1 S36.3 3
<10cm in distal 2/3 stomach 863.0/863.1 S36.3 3
III Laceration >2cm in gastro-oesophageal junction or pylorus 863.0/863.1 S36.3 3
>5cm in proximal 1/3 stomach 863.0/863.1 S36.3 3
>10cm in distal 2/3 stomach 863.0/863.1 S36.3 3
IV Tissue loss Tissue loss or devascularization <2/3 stomach 863.0/863.1 S36.3 4
V Tissue loss Tissue loss or devascularization >2/3 stomach 863.0/863.1 S36.3 4
From Moore et al.20
Table 13 Duodenum injury scale
I Haematoma Involving single portion of duodenum 863.21 S36.4 2

Laceration Partial thickness, no perforation 863.21 S36.4 3
II Haematoma Involving more than one portion 863.21 S36.4 2
Laceration Disruption <50% of circumference 863.31 S36.4 4
III Laceration Disruption 5075% of circumference of D2 863.31 S36.4 4
Disruption 50100% of circumference of D1, D3 or D4 863.31 S36.4 4
IV Laceration Disruption >75% of circumference of D2 863.31 S36.4 5
Involving ampulla or distal common bile duct 863.31 S36.4 5
V Laceration Massive disruption of duodenopancreatic complex 863.31 S36.4 5
Vascular Devascularization of duodenum 863.31 S36.4 5
D1, first portion of duodenum; D2, second portion of duodenum; D3, third portion of duodenum; D4, fourth portion of duodenum.
From Moore et al.21
Table 14 Small bowel injury scale
I Haematoma Contusion or haematoma without devascularization 863.20 S36.4 2

Laceration Partial thickness, no perforation 863.20 S36.4 2
II Laceration Laceration <50% of circumference 863.30 S36.4 3
III Laceration Laceration 50% of circumference without transection 863.30 S36.4 3
IV Laceration Transection of the small bowel 863.30 S36.4 4
V Laceration Transection of the small bowel with segmental tissue loss 863.30 S36.4 4
Vascular Devascularized segment 863.30 S36.4 4
From Moore et al.21
Table 15 Colon injury scale
I Haematoma Contusion or haematoma without devascularization 863.40863.44 S36.5 2

Laceration Partial thickness, no perforation 863.40863.44 S36.5 2
II Laceration Laceration <50% of circumference 863.50863.54 S36.5 3
III Laceration Laceration 50% of circumference without transection 863.50863.54 S36.5 3
IV Laceration Transection of the colon 863.50863.54 S36.5 4
V Laceration Transection of the colon with segmental tissue loss 863.50863.54 S36.5 4
With ICD-9, 863.40/863.50 = non-specific site in colon; 863.41/863.51 = ascending colon; 863.42/863.52 = transverse colon; 863.43/863.53 = descending colon;
863.44/863.54 = sigmoid colon.
From Moore et al.21
Table 16 Rectum injury scale
I Haematoma Contusion or haematoma without devascularization 863.45 S36.6 2

Laceration Partial-thickness laceration 863.45 S36.6 2
II Laceration Laceration <50% of circumference 863.55 S36.6 3
III Laceration Laceration 50% of circumference 863.55 S36.6 4
IV Laceration Full-thickness laceration with extension into the perineum 863.55 S36.6 5
V Vascular Devascularized segment 863.55 S36.6 5
From Moore et al.21
Table 17 Abdominal vascular injury scale
I Non-named superior mesenteric artery or superior mesenteric vein branches 902.20/.39 S35.2 NS
Non-named inferior mesenteric artery or inferior mesenteric vein branches 902.27/.32 S35.2 NS
Phrenic artery or vein 902.89 S35.8 NS
Lumbar artery or vein 902.89 S35.8 NS
Gonadal artery or vein 902.89 S35.8 NS
Ovarian artery or vein 902.81/902.82 S35.8 NS
Other non-named small arterial or venous structures requiring ligation 902.80 S35.9 NS
II Right, left or common hepatic artery 902.22 S35.2 3
Splenic artery or vein 902.23/902.34 S35.2 3
Right or left gastric arteries 902.21 S35.2 3
Gastroduodenal artery 902.24 S35.2 3
Inferior mesenteric artery/trunk or inferior mesenteric vein/trunk 902.27/902.32 S35.2 3
Primary named branches of mesenteric artery (e.g. ileocolic artery) or mesenteric vein 902.26/902.31 S35.2 3
Other named abdominal vessels requiring ligation or repair 902.89 S35.8 3
III Superior mesenteric vein, trunkand primary subdivisions 902.31 S35.3 3
Renal artery or vein 902.41/902.42 S35.4 3

Iliac artery or vein 902.53/902.54 S35.5 3
Hypogastric artery or vein 902.51/902.52 S35.5 3
Vena cava, infrarenal 902.10 S35.1 3
IV Superior mesenteric artery, trunk 902.25 S35.2 3
Coeliac axis proper 902.24 S35.2 3
Vena cava, suprarenal and infrahepatic 902.10 S35.1 3
Aorta, infrarenal 902.00 S35.0 4
V Portal vein 902.33 S35.3 3
Extraparenchymal hepatic veinonly 902.11 S35.1 3
Extraparenchymal hepatic veins + liver 902.11 S35.1 5
Vena cava, retrohepatic or suprahepatic 902.19 S35.1 5
Aorta suprarenal, subdiaphragmatic 902.00 S35.0 4
*This classification system is applicable to extraparenchymal vascular injuries. If the vessel injury is within 2cm of the organ parenchyma, refer to the specific organ
injury scale. Increase one grade for multiple grade III or IV injuries involving >50 per cent of the vessel circumference. Downgrade one grade if <25 per cent of the vessel
circumference laceration for grades IV or V.
NS, not scored.
From Moore et al.17
Table 18 Adrenal organ injury scale
I Contusion 868.01/.11 S37.9 1

II Laceration involving only cortex (<2cm) 868.01/.11 S37.8 1
III Laceration extending into medulla (2cm) 868.01/.11 S37.8 2
IV >50% parenchymal destruction 868.01/.11 S37.8 2
V Total parenchymal destruction (including massive intraparenchymal haemorrhage) 868.01/.11 S37.8 3
Avulsion from blood supply
*Advance one grade for bilateral lesions up to grade V.
From Moore et al.16
Table 19 Kidney injury scale
I Contusion Microscopic or gross haematuria, urological studies normal 866.01 S37.0 2

Haematoma Subcapsular, non-expanding without parenchymal laceration 866.01 S37.0 2
II Haematoma Non-expanding perirenal haematoma confined to renal 866.01 S37.0 2
retroperitoneum
Laceration <1.0cm parenchymal depth of renal cortex without urinary 866.11 S37.0 2
extravasation
III Laceration >1.0cm parenchymal depth of renal cortex without collecting system 866.11 S37.0 3
rupture or urinary extravasation
IV Laceration Parenchymal laceration extending through renal cortex, medulla and 866.02/866.12 S37.0 4
collecting system
Vascular Main renal artery or vein injury with contained haemorrhage 866.03/866.13 S37.0 4
V Laceration Completely shattered kidney 866.04/866.14 S37.0 5
Vascular Avulsion of renal hilum that devascularizes kidney 866.13 S37.0 5
From Moore et al.22
Table 20 Ureter injury scale
I Haematoma Contusion or haematoma without devascularization 867.2/867.3 S37.1 2

II Laceration <50% transection 867.2/867.3 S37.1 2
III Laceration 50% transection 867.2/867.3 S37.1 3
IV Laceration Complete transection with <2cm devascularization 867.2/867.3 S37.1 3
V Laceration Avulsion with >2cm devascularization 867.2/867.3 S37.1 3
*Advance one grade for bilateral up to grade III.
From Moore et al.17
Table 21 Bladder injury scale
I Haematoma Contusion, intramural haematoma 867.0/867.1 S37.2 2

Laceration Partial thickness 867.0/867.1 S37.2 3
II Laceration Extraperitoneal bladder wall laceration <2cm 867.0/867.1 S37.2 4
VIII Laceration Extraperitoneal (2cm) or intraperitoneal (<2cm) bladder wall 867.0/867.1 S37.2 4
laceration
IV Laceration Intraperitoneal bladder wall laceration 2cm 867.0/867.1 S37.2 4
V Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending 867.0/867.1 S37.2 4
into the bladder neck or ureteral orifice (trigone)
With ICD-10, use supplementary character: 0 = without an open wound into the pelvic cavity; 1 = with an open wound into the pelvic cavity.
From Moore et al.17
Table 22 Urethra injury scale
I Contusion Blood at urethral meatus; urethrography normal 867.0/867.1 S37.3 2

II Stretch injury Elongation of urethra without extravasation on urethrography 867.0/867.1 S37.3 2
III Partial disruption Extravasation of urethrography contrast at injury site with 867.0/867.1 S37.3 2
visualization in the bladder
IV Complete disruption Extravasation of urethrography contrast at injury site without 867.0/867.1 S37.3 3
visualization in the bladder; <2cm of urethra separation
V Complete disruption Complete transaction with 2cm urethral separation, or extension 867.0/867.1 S37.3 4
into the prostate or vagina
From Moore et al.17
Table 23 Uterus (non-pregnant) injury scale
I Contusion/haematoma 867.4/867.5 S37.6 2

II Superficial laceration (<1cm) 867.4/867.5 S37.6 2
III Deep laceration (1cm) 867.4/867.5 S37.6 3
IV Laceration involving the uterine artery 902.55 S37.6 3
V Avulsion/devascularization 867.4/867.5 S37.6 3
From Moore et al.20
Table 24 Uterus (pregnant) injury scale
I Contusion or haematoma (without placental abruption) 867.4/867.5 S37.6 2

II Superficial laceration (<1cm) or partial placental abruption <25% 867.4/867.5 S37.6 3
III Deep laceration (1cm) occurring in second trimester or placental abruption >25% but <50% 867.4/867.5 S37.6 3
Deep laceration (1cm) in third trimester 867.4/867.5 S37.6 4
IV Laceration involving uterine artery 902.55 S37.6 4
Deep laceration (1cm) with >50% placental abruption 867.4/867.5 S37.6 4
V Uterine rupture
Second trimester 867.4/867.5 S37.6 4
Third trimester 867.4/867.5 S37.6 5
Complete placental abruption 867.4/867.5 S37.6 45
From Moore et al.20
Table 25 Fallopian tube injury scale
I Haematoma or contusion 867.6/867.7 S37.5 2

II Laceration <50% circumference 867.6/867.7 S37.5 2
III Laceration 50% circumference 867.6/867.7 S37.5 2
IV Transection 867.6/867.7 S37.5 2
V Vascular injury; devascularized segment 902.89 S37.5 2
With ICD-10, use supplementary character: 0 = without an open wound into the abdominal or pelvic cavity; 1 = with an open wound into the abdominal or pelvic cavity.
From Moore et al.20
Table 26 Ovary injury scale
I Contusion or haematoma 867.6/867.7 S37.4 1

II Superficial laceration (depth <0.5cm) 867.6/867.7 S37.4 2
III Deep laceration (depth 0.5cm) 867.8/867.7 S37.4 3
IV Partial disruption or blood supply 902.81 S37.4 3
V Avulsion or complete parenchymal destruction 902.81 S37.4 3
From Moore et al.20
Table 27 Vagina injury scale
I Contusion or haematoma 922.4 S30.2 1

II Laceration, superficial (mucosa only) 878.6 S31.4 1
III Laceration, deep into fat or muscle 878.6 S31.4 2
IV Laceration, complex, into cervix or peritoneum 868.7 S31.4 3
V Injury into adjacent organs (anus, rectum, urethra, bladder) 878.7 S39.7 3
From Moore et al.20
Table 28 Vulva injury scale
I Contusion or haematoma 922.4 S30.2 1

II Laceration, superficial (skin only) 878.4 S31.4 1
III Laceration, deep (into fat or muscle) 878.4 S31.4 2
IV Avulsion; skin, fat or muscle 878.5 S38.2 3
V Injury into adjacent organs (anus, rectum, urethra, bladder) 878.5 S39.7 3

From Moore et al.20
Table 29 Testis injury scale
I Contusion/haematoma 911.0922.4 S30.2 1

II Subclinical laceration of tunica albuginea 922.4 S31.3 1
III Laceration of tunica albuginea with <50% parenchymal loss 878.2 S31.3 2
IV Major laceration of tunica albuginea with 50% parenchymal loss 878.3 S31.3 2
V Total testicular destruction or avulsion 878.3 S38.2 2
*Advance one grade for bilateral lesions up to grade V.

From Moore et al.16
Table 30 Scrotum injury scale
Grade Description of injury ICD-9 ICD-10 AIS-2005
I Contusion 922.4 S30.2 1

II Laceration <25% of scrotal diameter 878.2 S31.2 1
III Laceration 25% of scrotal diameter 878.3 S31.3 2
IV Avulsion <50% 878.3 S38.2 2
V Avulsion 50% 878.3 S38.2 2
From Moore et al.16
Table 31 Penis injury scale
I Cutaneous laceration/contusion 911.0/922.4 S30.2/31/2 1

II Bucks fascia (cavernosum) laceration without tissue loss 878.0 S37.8 1
III Cutaneous avulsion 878.1 S38.2 3
Laceration through glans/meatus
Cavernosal or urethral defect <2cm 3
IV Partial penectomy 878.1 S38.2
Cavernosal or urethral defect 2cm
V Total penectomy 876.1 S38.2 3

From Moore et al.16
Table 32 Peripheral vascular organ injury scale
I Digital artery/vein 903.5 S65.5 13

Palmar artery/vein 903.4 S65.3 13
Deep palmar artery/vein 904.6 S65.3 13
Dorsalis pedis artery 904.7 S95.0 13
Plantar artery/vein 904.5 S95.1 13
Non-named arterial/venous branches 903.8/904.7 S55.9/S85.9 13
II Basilic/cephalic vein 903.8 S45.8/S55.8 13

Saphenous vein 904.3 S75.2 13
Radial artery 903.2 S55.1 13
Ulnar artery 903.3 S55.0 13
III Axillary vein 903.02 S45.1 23
Superficial/deep femoral vein 903.02 S75.1 23
Popliteal vein 904.42 S85.5 23
Brachial artery 903.1 S45.1 23
Anterior tibial artery 904.51/904.52 S85.1 13
Posterior tibial artery 904.53/904.54 S85.1 13
Peroneal artery 904.7 S85.2 13
Tibioperoneal trunk 904.7 S85.2 23
IV Superficial/deep femoral artery 904.1/904.7 S75.0 34
Popliteal artery 904.41 S85.0 23
V Axillary artery 903.01 S45.0 23
Common femoral artery 904.0 S75.0 34
*Increase one grade for multiple grade III or IV injuries involving >50 per cent of the vessel circumference. Decrease one grade for <25 per cent disruption of the vessel
circumference for grades IV or V.
From Moore et al.16
B.7 References 8 Mayurer A, Morris JA. Injury severity scoring. In: Moore EE,
Feliciano DV, Mattox KL, eds. Trauma, 5th edn. New York:
1 Teasdale G, Jennet B. Assessment of coma and impaired McGraw-Hill, 2004: 8791.
consciousness: a practical scale. Lancet 1974;ii:814. 9 Osler T, Rutledge R, Deis J, Bedrick E. ICISS: an International
2 Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli Classification of Disease-9 based injury severity score.
TA, Flanagan ME. A revision of the Trauma Score. J Trauma JTrauma 1997;41:3808.
1989;29:6239. 10 Organ Injury Scale of the American Association for
3 Tepas JJ 3rd, Ramenofsky ML, Mollitt DL, Gans BM, the Surgery of Trauma (OIS-AAST). Available from
DiScala C. The Paediatric Trauma Score as a predictor www.aast.org (accessed December 2010).
of injury severity: an objective assessment. J Trauma 11 Moore EE, Dunn EL, Moore JB et al. Penetrating Abdominal
1988;28:4259. Trauma Index. J Trauma 1981;21:43945.
4 American Association for the Advancement of Automotive 12 Jennet B, Bond MR. Assessment of outcome: a practical
Medicine. The Abbreviated Injury Scale: 2005 Update scale. Lancet 1975;i:4807.
2008 Revision. Barrington, IL: AAAM, 2008. Available 13 Boyd CR, Tolson MA, Copes WS. Evaluating trauma care:
from: www.AAAM.org. the TRISS model. J Trauma 1987;27:3708.
5 Baker SP, ONeill B, Haddon W, Long WB. The Injury 14 Champion HR, Copes WS, Sacco WJ et al. A new
Severity Score: a method for describing patients with characterisation of injury severity. J Trauma 1990;30:53946.
multiple injuries and evaluating emergency care. J Trauma 15 Champion HR, Copes WS, Sacco WJ et al. Improved
1974;14:18796. predictions from A Severity Characterization of Trauma
6 Osler T, Baker SP, Long W. A modification of the Injury (ASCOT) over Trauma and Injury Severity Score (TRISS):results
Severity Score that both improves accuracy and simplifies of an independent evaluation. J Trauma 1996;40:428.
scoring. J Trauma 1997;43:9226. 16 Moore EE, Malangoni MA, Cogbill TH, Peterson NE,
7 Balogh Z, Offner PJ, Moore EE, Biffl WL. NISS predicts Champion HR, Shackford SR. Organ injury scaling VII:
postinjury Multiple Organ Failure better than the ISS. cervical vascular, peripheral vascular, adrenal, penis, testis
JTrauma 2000;48:6248. and scrotum. J Trauma 1996;41:5234.
240 | Manual of Definitive Surgical Trauma Care Second Edition
17 Moore EE, Cogbill TH, Jurkovich GJ. Organ injury scaling III: 21 Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ,
chest wall, abdominal vascular, ureter, bladder and urethra. Shackford SR, Champion HR. Organ injury scaling:
J Trauma 1992;33:3378. pancreas, duodenum, small bowel, colon and rectum.
18 Moore EE, Malangoni MA, Cogbill TH et al. Organ injury JTrauma 1990;30:14279.
scaling IV: thoracic, vascular, lung, cardiac and diaphragm. 22 Moore EE, Shackford SR, Pachter HL et al. Organ injury
J Trauma 1994;36:299300. scaling: spleen, liver and kidney. J Trauma 1989;29:16646.
19 Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, 23 World Health Organization. ICD-9CM. International
Malangoni MA, Champion HR. Organ injury scaling: spleen Classification of Diseases, Ninth Revision, Clinical
and liver (1994 Revision). J Trauma 1995;38:3234. Modification. Center for Diseases Control and Prevention,
20 Moore EE, Jurkovich GJ, Knudson MM et al. Organ Hyattsville MD. Available from www.cdc.gov/nchs/icd.htm
injury scaling VI: extrahepatic biliary, oesophagus, (accessed December 2010).
stomach, vulva, vagina, uterus (non-pregnant), uterus 24 World Health Organization. ICD-10 Codes. 2007 version
(pregnant), fallopian tube, and ovary. J Trauma online. Available from www.who.int/classifications/icd/en/
1995;39:106970. (accessed December 2010).
Appendix C
Definitive Surgical Trauma Care
course: course requirements and
syllabus
C.1 Background course participants, and reviews, strengthens and organ-

izes the performance of established and new procedures
Injury (trauma) remains a major healthcare problem specially required in trauma surgery. It is expected that the
throughout the world. In addition to improving aware- course will have special relevance for surgeons in countries
ness of trauma prevention and management, improved where major trauma rates are high, and for rapidly mobi-
application of surgical skills is expected to save further lized medical units in areas of conflict. It has proven par-
lives and contribute to minimizing disability. It is widely ticularly valuable in resource-challenged environments,
recognized that training of surgeons in the management where education and physical resources are limited.
of trauma is substantially deficient because of:
Limited exposure within individual training C.2 Course development and

programmes to the types of patient required to testing
develop the appropriate level of skills, and
Traditional trauma surgical training, which has been There have been many attempts to test the concept:
organ-specific.
Dr Fingerhuts laparoscopic trauma surgical training
Consequently, surgeons can finish their training with course, which he had run for two previous years at
suboptimal skills in this field, where there is often little the European Surgical Education Centre in Paris, was
time to contemplate an appropriate course of action. modified to incorporate these concepts. This two-day
Through the early 1990s, it became apparent to a course consisted of didactic sessions in the morning
number of surgeons familiar with trauma management and animal laboratory sessions in the afternoon.
around the world that there was a specific need for surgi- Evaluation responses were excellent.
cal training in the technical aspects of the operative care The Uniformed Services University of the Health
of the trauma patient, with particular emphasis on those Sciences, Bethesda, USA, started a similar course in
who were close to completing, or had recently completed, August 1994. Dr Don Jenkins has now put over 100
their training. This course had its origins during a meet- military surgeons through the course in the United
ing in October 1993 between Howard Champion (USA), States, and he is currently working on bringing the
David Mulder (Canada), Donald Trunkey (USA), Stephen course to Chile.
Deane (Australia) and Abe Fingerhut (France). There was a Swedish Trauma Surgery Course which
This postgraduate surgical course, developed in col- Drs Trunkey, Fingerhut and Champion attended
laboration with professional educators, assumes compe- in Sweden in November 1994. This was run by
tence with assessment and resuscitative measures that DrStenLennquist. The course was four days of
have become standardized through the Advanced Trauma didactic teaching and one day of practical work.
Life Support (ATLS) course of the American College of In Sydney in May 1996, a very successful pilot
Surgeons. It draws on the specialist surgical training of all course was organized at Prince Henry Hospital.
Theinternational faculty at that course included Don National organizations

Trunkey, Abe Fingerhut and Howard Champion. National organizations can present the course in their
The course was a tremendous success, and successful own country on behalf of IATSIC. A memorandum of
courses have since been held worldwide. understanding will be signed with IATSIC. Following
From 1999, following courses in Australia, Austria the presentation of the first two courses, the national
and South Africa, a standardized manual and slide set organization shall have the right to modify the course to
were developed. enhance its relevance to local conditions.
The course is revised every four years, with updated
material, in order to stay current and to recognize the
rapid improvements in trauma care globally.
C.3.5 Course materials and overview
C.3 Course details The course takes place over three days with the following
course materials:
C.3.1 Ownership The content of the course will, as a minimum, contain
the core curriculum, as laid down in the IATSIC
The Definitive Surgical Trauma CareTM (DSTC) course is DSTC manual (see Appendix D). Additional material
a registered trademark of the International Association and modules may be included at the discretion of
for Trauma Surgery and Intensive Care (IATSIC). IATSIC the local organizers, provided such material is not in
is an Integrated Society of the International Society of conflict with the core curriculum.
Surgery/Socit Internationale de Chirurgie (ISSSIC) Additional add-on modules may be presented at the
based in Lupsingen, Switzerland. Only courses recognized discretion of the local organizers.
by IATSIC may be called DSTC courses. The course will use a specific set of slides and the
DSTC course manual.
IATSIC is able to furnish the IATSIC DSTC course
C.3.2 Mission statement
manual, and course materials (including slides on
PowerPoint) if requested, at a substantial discount.
The DSTC course is designed to train participants in the
However, provided the minimum core syllabus is
techniques required for the surgical care of the trauma
adhered to, a local course manual and material can
patient. This is done by a combination of lectures, dem-
be used.
onstrations, case discussions and practical sessions, utiliz-
ing animal tissue and human (cadaver or prosected) tissue
if available.
C.3.6 Course director
C.3.3 Application to hold a course In addition to the requirements below, the course director
must be a full, current member of IATSIC. For an inaugu-
Application can be made to IATSIC for recognition of a ral course, the course director must be a member of the
course. Provided the minimum requirements for the course IATSIC Executive Committee.
have been met, as laid down below, IATSIC will recognize
the course, which will then be entitled to be called a DSTC
course, and carry the IATSIC logo. The course to be pre- C.3.7 Course faculty
sented will be the course prescribed by IATSIC, and no
changes may be made to the course material or syllabus. Course faculty will be divided into:
Local faculty
International faculty
C.3.4 Eligibility to present
Guest lecturers.
Course faculty members must have themselves
Local organizations attended a DSTC course.
The DSTC course can be presented by any tertiary aca- Course faculty members must have completed an
demic institution or recognized surgical organization. ATLS Instructor course, Royal College of Surgeons
Definitive Surgical Trauma Care course: course requirements and syllabus | 243
Train the Trainers course, or an equivalent instructor Additional modules, which may be added as required,
training course. at the discretion of the local organizing committee
Course international faculty must be members of and as required for local needs.
IATSIC.
Additional guest lecturers with particular expertise in
a subject are permitted. C.3.11 Course certification
Details of all faculty with confirmation of the above
must be lodged with IATSIC prior to commencement Participants are required to attend the entire course.
of the course. Certification of attendance and completion of the
The recommended student:instructor ratio should course can be issued.
ideally be 4:1, but may not be larger than 6:1 not The certificates of the courses will be numbered.
including the course director. Details of the course, final faculty and participants,
as well as a course evaluation, must be submitted to
IATSIC after the course.
C.3.8 Course participants
All course participants must be licensed medical

practitioners. C.4 iatsic recognition
Attendance at the entire course is mandatory.
The level of applicants can be decided locally, Application for recognition of individual courses should
provided that the participants are licensed medical be made to IATSIC. IATSIC-recognized courses may carry
practitioners, and are actively involved in the surgical the endorsement logos of IATSIC and the ISS-SIC, and
decision-making and surgery of the trauma patient. will be entitled to be called DSTC courses.
An entrance examination can be used if needed. An The DSTC course is the intellectual property and a reg-
exit examination is not mandatory. istered trademark of IATSIC, and IATSIC is an Integrated
Society of the ISSSIC based in Lupsingen, Switzerland.
Although it may carry the endorsement (support) of other
C.3.9 Practical skill stations bodies, this does not imply that other organizations may
operate or control the DSTC course in any way.
Practical skills may take place on different material, depend- The DSTC course is designed to train medical prac-
ing on the local constraints. The practical component of titioners in the techniques required for the definitive
the course must include an animal laboratory. However, the surgical care of the trauma patient. This is done by a com-
use of cadavers is optional and dependent on local condi- bination of lectures, demonstrations, case discussions
tions. Full local ethical committee certificates of approval and practical sessions.
for all animal and other tissue work, and any other legal The registration and control of the DSTC courses will
necessary approvals, must be obtained and must be submit- be controlled by the DSTC Sub-Committee on behalf of
ted to IATSIC before a course can be approved or held. IATSIC. While it is desirable that national courses be con-
trolled by a national organization, there will be no restric-
tion on local courses provided that international DSTC
C.3.10 Course syllabus criteria are met. Application to hold a course must be
made through IATSIC.
In order for IATSIC to recognize the course as a valid Only courses recognized by IATSIC may be called
DSTC course, the course must meet or exceed the mini- DSTC courses.
mum requirements of the core curriculum. The core cur-
riculum and modules are contained in this manual and
the course consists of:
C.5 Course information
Core knowledge
Surgical skills (see Appendix D) Course information is obtainable from IATSIC.
Appendix D
Definitive Surgical Trauma Care
course: core surgical skills
D.1 The neck D.2.3 Pericardiotomy

D.2.3.1 Preservation of the phrenic nerve
D.1.1 Standard neck (pre-sternomastoid) incision D.2.3.2 Access to the pulmonary veins
D.1.2 Control and repair of the carotid vessels D.2.4 Access to and repair of the thoracic aorta
D.1.2.1 Zone II D.2.5 Lung wounds
D.1.2.2 Extension into zone III D.2.5.1 Oversewing
D.1.2.3 Division of the digastric muscle and D.2.5.2 Stapling
subluxation or division of the mandible D.2.5.3 Partial lung resection
D.1.2.4 Extension into zone I D.2.5.4 Tractectomy
D.1.3 Extension by supraclavicular incision D.2.5.5 Lobectomy
D.1.3.1 Ligation of the proximal internal carotid D.2.6 Access to and repair of the thoracic oesophagus
artery D.2.7 Access to and repair of the diaphragm
D.1.3.2 Repair with a divided external carotid D.2.8 Compression of the left subclavian vessels from
artery below
D.1.4 Access to, control of and ligation of the internal D.2.9 Left anterior thoracotomy
jugular vein D.2.9.1 Visualization of the supra-aortic vessels
D.1.5 Access to and repair of the trachea D.2.10 Heart repair
D.1.6 Access to and repair of the cervical oesophagus D.2.10.1 Finger control
D.2.10.2 Involvement of the coronary vessels
D.2.11 Insertion of a shunt
D.2 The chest

D.3 The abdominal cavity
D.2.1 Incisions
D.2.1.1 Anterolateral thoracotomy D.3.1 Midline laparotomy
D.2.1.2 Sternotomy D.3.1.1 How to explore (priorities)
D.2.1.3 Clamshell bilateral thoracotomy incision D.3.1.2 Packing
D.2.2 Thoracotomy D.3.1.3 Localization of retroperitoneal
D.2.2.1 Exploration of the thorax haematomas when to explore?
D.2.2.2 Ligation of the intercostal and internal D.3.1.4 Damage control
mammary vessels D.3.1.4.1 Techniques
D.2.2.3 Emergency department (resuscitative) D.3.1.4.2 Abdominal closure
thoracotomy D.3.1.5 Extension of laparotomy incision
D.2.2.3.1 Supradiaphragmatic control of the D.3.1.5.1 Lateral extension
aorta D.3.1.5.2 Sternotomy
D.2.2.3.2 Control of the pulmonary hilum D.3.1.6 Cross-clamping of the aorta at the
D.2.2.3.3 Internal cardiac massage diaphragm (division at the left crus)
Definitive Surgical Trauma Care course: core surgical skills | 245
D.3.2 Left visceral medial rotation D.5 The spleen

D.3.2.1 Reflection of the left (descending) colon
medially D.5.1 Mobilization
D.3.2.2 Reflection of the pancreas and spleen D.5.2 Suture
towards the midline D.5.3 Mesh wrap
D.3.3 Right visceral medial rotation D.5.4 Use of tissue adhesives
D.3.3.1 Kochers manoeuvre D.5.5 Partial splenectomy
D.3.3.2 Reflection of the right (ascending) colon D.5.5.1 Sutures
medially D.5.5.2 Staples
D.3.4 Abdominal oesophagus D.5.6 Total splenectomy
D.3.4.1 Mobilization
D.3.4.2 Repair
D.3.4.2.1 Simple D.6 The pancreas
D.3.4.2.2 Mobilization of the fundus to
reinforce sutures D.6.1 Mobilization of the tail of the pancreas
D.3.5 Stomach D.6.2 Mobilization of the head of the pancreas
D.3.5.1 Mobilization D.6.3 Localization of the main duct and its repair
D.3.5.2 Access to vascular control D.6.4 Distal pancreatic resection
D.3.5.3 Repair of anterior and posterior wounds D.6.4.1 Stapler
D.3.5.4 Pyloric exclusion D.6.4.2 Oversewing
D.3.5.5 Distal gastrectomy D.6.5 Use of tissue adhesives
D.3.6 Bowel D.6.6 Diverticulization
D.3.6.1 Resection D.6.7 Access to the mesenteric vessels (division of the
D.3.6.2 Small and large bowel anastomosis pancreas)
D.3.6.3 Staple colostomy
D.3.6.4 Collagen fleece technique of anastomosis
protection D.7 The duodenum
D.3.6.5 Ileostomy technique
D.7.1 Mobilization of the duodenum
D.7.1.1 Kochers manoeuvre (rotation of the
D.4 The liver duodenum)
D.7.1.2 Division of the ligament of Treitz
D.4.1 Mobilization (falciform, suspensory, triangular D.7.1.3 Repair of the duodenum
and coronary ligaments)
D.4.2 Liver packing
D.4.3 Hepatic isolation D.8 The genitourinary system
D.4.3.1 Control of the infrahepatic inferior vena
cava D.8.1 Kidney
D.4.3.2 Control of the suprahepatic superior vena D.8.1.1 Mobilization
cava D.8.1.2 Vascular control
D.4.3.3 Pringles manoeuvre D.8.1.3 Repair
D.4.4 Repair of parenchymal laceration D.8.1.4 Partial nephrectomy
D.4.5 Technique of finger fracture D.8.1.5 Nephrectomy
D.4.6 Tractotomy D.8.2 Ureter
D.4.7 Packing for injury to hepatic veins D.8.2.1 Mobilization
D.4.8 Hepatic resection D.8.2.2 Stenting
D.4.9 Non-anatomical partial resection D.8.2.3 Repair
D.4.10 Use of tissue adhesives D.8.3 Bladder
D.4.11 Tamponade for penetrating injury (Foley/ D.8.3.1 Repair of intraperitoneal rupture
Penrose drains, Sengstaken tube) D.8.3.2 Repair of extraperitoneal rupture
D.9 Abdominal vascular injuries D.10 Peripheral vascular

injuries
D.9.1 Exposure and control
D.9.1.1 Aorta and its branches D.10.1 Extremities: vascular access
D.9.1.1.1 Exposure D.10.1.1 Axillary
D.9.1.1.2 Repair D.10.1.2 Brachial
D.9.1.1.3 Shunt D.10.1.3 Femoral
D.9.1.2 Inferior vena cava D.10.1.4 Popliteal
D.9.1.2.1 Suprahepatic inferior vena cava D.10.2 Fasciotomy
D.9.1.2.2 Infrahepatic inferior vena cava D.10.2.1 Upper limb
D.9.1.2.3 Control of haemorrhage with swabs D.10.2.2 Lower limb
D.9.1.2.4 Repair through an anterior wound
D.9.1.2.5 Shunting
D.9.2 Pelvis
D.9.2.1 Control of the pelvic vessels
D.9.2.1.1 Extraperitoneal packing
D.9.2.1.2 Suture of artery and vein
D.9.2.1.3 Ligation of artery and vein
D.9.2.1.4 Packing/anchor ligation of the sacral
vessels
Appendix E
Briefing for operating room
scrubnurses
E.1 Introduction E.2.1 Environment
Damage control techniques for the management of the Because of the underlying coagulopathy and hypother-
major trauma patient are fairly new, and the concepts mia, the patient needs to be prevented from further heat
include temporizing measures to prevent a cold, aci- loss at all costs to maximize haemostasis.
dotic and coagulopathic patient from further deteriora-
The internal temperature of the operating theatre
tion to eventual death. As a result of these strategies,
should be set at least 27C and maintained at this
some personnel working in the operating room (OR/
level.
theatre) environment may not have had previous expo-
Fluid and blood should be warmed before and
sure to these techniques, especially in countries where
during administration, using devices such as a
trauma volumes are limited and major trauma is a
Level 1 (Smiths Medical, St Paul, MN, USA) or
stressful rarity. This chapter is intended to help prepare
Ranger (Ranger Blood Warming System; Arizant
the team for the imminent arrival and intraoperative
International, Eden Prairie, MN, USA) device,
management of the major trauma patient. Good com-
which allows for rapid infusion without sacrificing
munication is the key to success. Anticipate and think
adequate heat transmission to the fluid. Ideally, the
laterally.
temperature should be set at 41C.
The aspects of care referred to in this section are as
Patient warming devices should be present and
follows:
readied for use. These can include a circulating warm
Preparation fluid underlay or warm air circulation device (e.g.
Cleaning and draping Bair Hugger [Arizant International]), which must be
Instruments and issues of technique directly in contact with the skin and not over a bed
Special tools and equipment including improvised sheet.
gadgets.
E.2.2 Blood loss

E.2 Preparing the operatinG
room Because of the propensity for massive blood loss, one
should consider activating and priming a cell-saving
As has been mentioned, patients with major trauma are device of some description.
complex in that they have deranged physiology and may
have complex injuries with competing priorities for treat-
ment. Optimizing the OR before the patient arrives and E.2.3 Instruments
planning ahead for every eventuality is what will make
the difference between a stressful, chaotic experience for Now is the time to request extra instrument packs
all concerned, and a planned environment where every and obtain packs of sponges/swabs as these will be
member of the team has a role, and acknowledges the rapidly required in large numbers.
strength of all the members of the team. A trolley with multiple drawers with pre-packed
equipment may be a useful option.1
E.2.4 Cleaning
With damage control surgery, there is less time than usual

to provide a truly sterile field, and alternate methods
should be used to achieve the same result. It is often said
that sterility is a luxury in trauma.
Typically, either an iodophore- or a chlorhexidine-

based skin preparation is utilized, and this applies
equally to the trauma patient. One should not
use both types as they may inactivate each other.
Chlorhexidine-based solutions are the current
solution of choice.2,3
The method of application may, however, vary. One
option, utilized in a number of prominent North
American centres, is the use of a spray bottle to apply
the preparation solution. This has been shown to be as
effective as traditional circular sponging techniques.4
Cleaning should be extended widely beyond the
expected bounds of the operative field, and the
recommendation is to clean from neck to knees, as
this allows for extension from abdomen to chest or
for vein harvest from the saphenous veins.
E.2.5 Draping
Draping is also along unconventional lines, and this Figure E.1 Draping required for a trauma laparotomy.
ensures that the surgeons can have ready access to more
than just the area of single focus, which is usual for when Although there is no good evidence that masks,
elective surgery is performed. overshoes and caps protect the patient from infection
during surgery, standard precautions should be
Drape widely using drapes that attach to the skin, or
maintained to protect the team members. The OR
fix them with skin staples, laterally from the neck,
nurse should ensure that all staff in the sterile area
lateral to the chest at the mid-axillary lines and along
are appropriately attired.
the same plane to the knees. The genitalia are covered
Place the scalpel in a receiver (kidney-bowl) for the
with a small drape or an opened swab (Figure E.1).
surgeon to take and replace. The body cavities should
Prevent further heat loss by covering the areas not
be opened primarily with a scalpel and heavy (Mayo)
initially needed for surgical access with sterile drapes.
scissors.
For example, if the abdomen is the default operation,
Have 2030 large dry swabs or sponges ready for the
cover the chest and legs with drapes that are easily
surgeon to perform rapid so-called packing. These
removed if access to those regions is required.
are best used unfolded initially, as the purpose is to
absorb blood rather than to stop bleeding. However,
E.2.6 Adjuncts note that for definitive packing, swabs should be used
folded in layers.
As far as pre-planning for the actual procedure is con- The suction devices should be ready and should
cerned, one can only recommend that the OR team antic- preferably be routed to the cell-saver device. It is
ipate all eventualities. Remember, too, that as there is useful for there to be two suction devices at the table.
little time to spare, the risk of injury to operative team An electrocautery machine should be available, but
members is high, and that all precautions should be taken there is no time for small vessel haemostasis at this
to ensure maximal protection. point, and this will most likely be used later.
Briefing for operating room scrubnurses | 249
E.3 Surgical procedure Umbilical tapes or the tapes on large sponges can be
used to ligate segments of bowel to control effluent.
Ligaclips can be useful for controlling bleeding vessels
E.3.1 Instruments on the liver or spleen or in the mesentery.
It is useful to keep handy a SengstakenBlakemore
The instrument sets one should have at the ready are as tube for placing in a bleeding hepatic tract to attempt
follows: to tamponade the deep bleeding. A Penrose drain can
A thoracotomy tray ready in the room, but not open achieve a similar effect.
unless the chest is the primary operative focus. A For suspected vascular injury or to control bleeding
sternal saw or Lebsche knife should also be available from non-ligatable vessels, various forms of
A standard laparotomy set open and ready, including temporary arterial shunt and similar devices are
a bowel resection set required.
Vascular instruments, including large aortic clamps The Rumel tourniquet is a useful device made by
(Crawford and Satinsky) open on the set-up trolley simply placing a cylindrical plastic tube over a
Extra small, medium and large crushing clamps (e.g. vascular loop and using this to compress a friable
Halstead, Crile, Roberts and mosquito) as there may vessel once it has been isolated and looped. It may
be many bleeding vessels to clamp also be used to hold a shunt in place proximally and
Several Babcock forceps for holding or marking a distally in an injured artery. The tourniquets can be
bowel injury kept in place with either Ligaclips or small artery
A right-angled dissecting forceps such as is used for clamps.
bile ducts (Lahey, Heiss, etc.) Proprietary shunts (such as Javid or Barker
A full selection of retractors (e.g. Morris, Army-Navy, shunts) should be available; alternatively, one
Langenbeck, Deaver and copper malleables), as well can manufacture them using intravenous tubing,
as some form of a self-retaining system, such as a nasogastric tubing or chest drain tubing, depending
Bookwalter, Omni-Tract or Gray system. on the vessel size.
A selection of vascular grafts should be close at hand.
E.3.2 Special instruments and improvised

gadgets E.4 Abdominal closure
The next aspect of the damage control procedure is to stop Closure of the abdomen may be final and definitive, but
the bleeding and the contamination, while maintaining more likely will involve some form of temporary closure
tissue perfusion. This may require the use of other specific device. The options include a vacuum-assisted closure
instruments and some improvised or home-made gadg- (VAC) sandwich (best), plastic silo bags sutured to the
ets to achieve the desired result. Again, a useful option is skin (Bogota bag) or towel-clip closures (neither of the
to have this equipment pre-selected and placed for use in latter being recommended). Equipment for the VAC-
a dedicated mobile, multiple-drawer trolley. sandwich is described below. The commercial VAC dress-
Since most major trauma (especially penetrating ing is not appropriate until definitive closure.
trauma) affects the abdomen, one must prepare for bowel
One sterile adhesive drape (Opsite or Ioban) is placed
and solid organ injury.
sticky side up, and one or two sterile towels or swabs
Skin staplers can temporize small holes from bullets are placed on the sticky surface. Note that only one
and lacerations in the stomach (and may be useful on side of the swab is covered in plastic membrane.
the heart). This is tucked under the fascia over the bowel, with
GIA-type cutting staplers are handy for the rapid the smooth plastic protecting the bowel, while the
closure of bowel ends during non-reconstructive sponges/swabs prevent evisceration by adhering to the
resection of small bowel or colon. parietal peritoneal surface.
TA-type non-cutting staplers can be used to fashion Two large drains or nasogastric tubes are laid inside
a pyloric exclusion, or for distal pancreas resection the gap between the sheath and the skin, and are
when the need for rapid resection is present. tunnelled cranially for about 58cm under the skin
to enable an adequate seal of the other adhesive drape E.7 Conclusion

over the entire abdomen.
A second large sterile adhesive drape is then used to The success of trauma surgery depends on a team per-
close the wound. forming at its peak with effective communication, will-
The drains are connected with a Y-connector and ing to work outside of the traditional norms and yet
may be placed on low-pressure wall suction (maximum with maximal concern for patient safety. This chapter
suction <50mmHg). This controls effluent and has hopefully provided some ideas to enable the team to
creates a good seal. It is also easiest to nurse in the prepare effectively for the major trauma patient.
ward or intensive care unit.
A commercial VAC device is available, but due to

expense it is not recommended for initial closure. It is, E.8 References
however, the device of choice for subsequent wound
management of the open abdomen. 1 Goslings JC, Haverlag R, Ponsen KJ, Luitse JSK. Facilitating
damage control surgery with a dedicated DCS equipment
trolley. Injury 2006;37:4667.
E.5 Instrument and swab count 2 Association of Anaesthetists of Great Britain and Ireland.
Infection Control in Anaesthesia. London: AAGBI, 2002.
As usual, counts are performed before closure. 3 Ritter MA , French ML, Eitzen HE, Gioe TJ. The antimicrobial
However, after damage control, a second count is per- effectiveness of operative-site preparative agents: a
formed after the abdominal vacuum dressing has been microbiological and clinical study. J Bone Joint Surg Am
completed. This allows a count of how many swabs have 1980;62:8268.
been left in the abdomen. (Dont forget to count the 4 Woodhead K, Taylor EW, Bannister G, Chesworth T,
swabs in the vacuum sandwich!) Hoffman P, Humphreys H. Behaviours and Rituals in the
An accurate record should be kept of any retained Operating Theatre: A report from the Hospital Infection
instruments and swabs, as there may be a different scrub Society Working Group on Infection Control in the
team at the time of the re-look laparotomy. Operating Theatres (published 2002). Available from
An abdominal X-ray before final closure is advisable, as an www.his.org.uk/_db/_documents/Rituals-02.doc (accessed
extra safeguard to avoid retained swabs or instruments. December 2010).
E.6 Critical incident stress issues

E.9 Recommended reading
The trauma environment is stressful for all concerned,
and time is of the essence tempers often flare, and one Emergency exploratory laparotomy. In Berry and Kohns
must not take the issues personally. Operating Room Technique, 11th edn. St Louis: Mosby,
Occasionally, the patient will not survive, and the risk 2007.
is that staff may develop post-traumatic stress disorder, Goldman MA. Pocket Guide to the Operating Room, 3rd edn.
especially if major trauma is a rare occurrence for them. Philadelphia: FA Davis, 2008.
The best method for dealing with this situation is via a Saullo DC. Trauma surgery. In: Rothrock JC, ed. Alexanders
debriefing session as soon as everyone has cleaned up or Care of the Patient in Surgery, 14th edn. St Louis: Mosby,
first thing the next morning. 2003: 1182223.
Index
Abbreviations: treatment 6061

DVT - deep venous thrombosis see also intra-abdominal pressure (IAP)
EDT - emergency department thoracotomy abdominal injury/trauma 93147
IAP - intra-abdominal pressure antibiotic prophylaxis 95, 104
MODS - multiple (multisystem) organ dysfunction syndrome blast injury 1845
SIRS - systemic inflammatory response syndrome blunt trauma 93
laparoscopy 19192
ultrasound for 189
Abbreviated Injury Scale (AIS) 22223 children 20910
abbreviated laparotomy see damage control complex injuries 9394
ABC, of resuscitation, ballistic wounds 181 delay in diagnosis/treatment 93
ABCDE of resuscitation 46 emergency department surgery 910
burns 196, 197 haemostatic adjuncts 1012
children 2089 laparotomy see laparotomy
intubation indications in shock and 31 minimally invasive surgery 19192
military casualties 181, 182 pelvic fractures and 152
abdomen (and abdominal cavity) pelvic fractures with 149, 152
decompression 6061 penetrating trauma 93
doughy 120 laparoscopy 192
DSTCcore surgical skills 24445 management guidelines 94, 95
packing 96, 97 non-operative management 94
see also individual organs ultrasound for 189
abdominal aortography 213 priority over thoracic aortic injury 9
abdominal closure 100, 24950 resuscitation 93
delayed 5455, 57, 100 screening for, laparoscopy 19192
mass, peritoneum and sheath 100 temperature control and 9596
optimal method 100 ultrasound use 189
primary 100 vascular see abdominal vascular injury
temporary 5455, 61, 151, 249 abdominal perfusion pressure 60
pitfalls 5455 measurement 60
vacuum-assisted (VAC) sandwich 24950 abdominal pressure see intra-abdominal pressure (IAP)
abdominal compartment syndrome (ACS) 42, 54, 5762 abdominal vascular injury 13035
avoidance/prevention 60 DSTCcore surgical skills 245
in ICU 56 penetrating 130
causes 57, 58, 60 retroperitoneal haematoma see retroperitoneal haematoma
definition 5758 scale 23334
management algorithm 61, 62 surgical approach 13134
pathophysiology 58 shunting 13435
primary, secondary and recurrent 58 see also specific vessels
abdominal wall, reconstruction 56 children 208

abscess indications for intubation in shock 31
pancreatic 124 military casualties 182
subphrenic 116 neck injury 67, 70
access, to neck see neck injuries airway obstruction 73
access, to circulation see vascular access alarmin 18
acetabulum 148 aldosterone 19, 20
acidbase disorders 170 Allen test 28
acidosis 20 alpha angle 44
in massive transfusions 47 alveolitis, airway burns 200
in shock 25, 30, 31 American Association for the Surgery of Trauma (AAST)
ACTH 19 224
activated protein C 17, 169 grading of injuries see Organ Injury Scaling
acute coagulopathy of traumashock (ACoTS) 40 amino acids
acute-phase proteins 21 infusions 21
acute renal failure (ARF) 170 metabolism 21, 22
adhesions, chest drainage 78 plasma clearance rate 21
adhesives, tissue 101, 110 amputation
administration, trauma systems 218 late, massive limb trauma 156, 161
adrenal hormones 19 primary, massive limb trauma 156, 160, 161
adrenaline (epinephrine) 1819 traumatic, blast injury 185
air embolism management 83 amylase (serum)
cardiovascular responses 33 duodenal injuries 125
shock management 33 pancreatic injuries 118
adrenal organ, injury scale 234 anabolic phase 15, 22
adrenocorticotropic hormone (ACTH) 19 anaemia 39
adult respiratory distress syndrome (ARDS) 20, 165 anaerobic metabolism 20, 25, 2930
after burns 198, 200 anaesthesia
head trauma 206 battlefield/military casualties 18586
Advanced Trauma Life Support Course/guidelines xxi, xxiii, damage control, military setting 186
3, 7, 241 head trauma 206
abdominal trauma 93 analgesia 171
chest tube placement 77 battlefield/military casualties 185
extremity injuries 161 burns 19798
military casualties 181 children 210
pelvic fractures 14950 elderly 211
Advanced Trauma Operative Management Course xxivxxv head trauma 206
aerobic metabolism 24, 29, 31 anaphylatoxins (C3a and C5a) 18
afferent impulses 16 anatomical scoring systems 22224
Afghanistan conflict 176, 177, 181 Anatomic Profile (AP) score 22324
afterload 26, 33 modified 223
ageing 210, 211 angio-embolization (AE) 213
air embolism 5, 8283, 91, 192 liver injuries 214
airway injuries pelvic fractures 213
burns 197, 198 splenic injury 21314
management 200201 see also embolization
lower airway, burns 200 angiography
upper airway, burns 200 chest trauma 77
airway management in resuscitation 4 four-vessel 68
burns 197, 200201 liver injuries 214
Index | 253
neck injury 68, 69 atrial filling pressure 6

pelvic fractures and 151 atrial natriuretic factor 1920
splenic injuries 115 atrial pressure, right 26
angiotensin I 19 increased 24
angiotensin II 19, 26 atriocaval shunt 110
anklebrachial index 157 atriopeptin (ANF) 1920
anorectal injuries, pelvic injuries with 153 austere conditions see military conflicts and austere
anterior sternomastoid incision 71, 72 conditions
anterolateral thoracotomy 8788, 90 autotransfusions 4546, 96, 130
closure 88 awareness 6
antibiotic prophylaxis axonal brain injury 204
abdominal injury 95, 104
burns 2023 bacteria, translocation from gut to portal system 22
head injury 205 balanced salt solutions (BSSs) 32
in ICU 17374 ballistic wounds see missile wounds
open fractures 15455, 174 barbiturates 206
anticonvulsants 206 barotrauma 184
antidiuretic hormone (ADH) 19 Battlefield Advanced Trauma Life Support course (BATLS)
antiretroviral therapy 143 183
antiseizure prophylaxis 206 battlefield anaesthesia 18586
antrectomy 128 battlefield analgesia 185
anuria 23 beta-endorphin 19
anus, inspection, pelvic fractures and 150 bicarbonate, massive transfusions and 47
aorta 76 bile ducts
anatomy 76 extrahepatic
injuries 92, 9394 injuries 113
abdominal 130, 13132 scale 231
rupture 214 intrapancreatic, injuries 130
surgical approach 13132 biliary ascites 112
thoracic, abdominal injury priority 9 biliary fistulas 112
transected 9, 214 biliary system 10513
occlusion 86 extrahepatic, injury scale 231
supracoeliac 131 biloma 112
suprarenal 131 Biobrane 201
thoracic, cross-clamping 91, 132 bladder injuries 14041
aortic cross-clamping 132, 151 diagnosis 140
thoracotomy with 91 DSTCcore surgical skills 245
aortography, abdominal 213 management 141
aprotinin 44 non-operative management 141
arachidonic acid 17 pelvic fractures with 149
arousal 6 penetrating 135
arterial Doppler scan 28 scale 235
arterial pressure, systemic, measurement 2728 surgical approach 141
arteriography blast injury 183, 18485
chest injuries 77 classification 184
see also angiography diagnosis and management 18485
ascites, biliary 112 bleeding
ASCOT (A Severity Characterization of Trauma) 226 cardiac 90
assessment (incident management) 178 from chest, autotransfusion 45
ATP 20 into chest cavity 74
bleeding (contd) effects and risks of 4042

control see haemorrhage control fresh whole blood 3940
pelvic 10 haemolytic reactions 41
persistent, damage control surgery 56 immunological complications 41
sites, secondary survey 7 indications 39, 43
splenic injuries 115 infections transmitted by 41
surgical vs pathological, thromboelastography 44 massive 42, 4749
upper gastrointestinal 172 abdominal vascular injury 130
see also blood loss; haemorrhage complications 47
blood definition 47
salvage, autotransfusion 45, 96, 247 military casualties 181
storage, defects associated 40, 41 protocol/guidelines 47, 48
volume 47 military casualties 181, 183
blood-borne infections 41, 85 pre-storage leukocyte depletion 42
blood component therapy 40, 41, 170 ratios 43
effects and risks of 4042 reduction in need for 43
blood flow 25 requirements, pelvic fractures 151
measurement in shock 35
direct 2629 thresholds 43
indirect 26 warming 186, 247
in shock 25 blunt, duodenal injuries 125
blood gases, measurement blunt trauma
burns 198 abdominal see abdominal injury/trauma
shock resuscitation 29 chest injuries 73
blood loss kidney injuries 136, 137
burn wound management 200 liver injuries 105, 1067
children 209 pancreatic injuries 117, 119, 120, 123
occult, sources 5 splenic injuries 114, 21314
operating room preparation 247 body temperature
resuscitation priority 5 control, trauma laparotomy 9596
transfusion indication 39 core 167, 168
volumes, in hypovolaemic shock 23 massive transfusions 47
see also bleeding reduced 6
blood pressure restoration, in ICU 56
head injury 205 Bogota bag 55
hypovolaemic shock 23 bowel see intestine
maintaining, military casualties 183 bowel sounds 93
measurement 2728 brachial artery, cannulation 28
pharmacological support 3334 bradycardia, blast injury 185
in shock 23, 26 brain, oxygen monitoring 206
systolic see systolic blood pressure brain injury xxiv, 171, 2045
blood substitutes 5, 4647 adjuncts to care 2046
comparisons 46, 47 diffuse 204
ideal 46 focal 204
shock management 33 patterns 204
blood transfusions 6, 3950 secondary 204, 205
autotransfusions 4546, 96, 130 see also head injuries
blood storage, effects 40 Brain Trauma Foundation 205
current best standards 42 breathing
in damage control surgery 56 diaphragm movement 75
Index | 255
indications for intubation in shock 31 as pathology-in-evolution 199, 200

indications for ventilation in shock 31 zones 194, 195
management in resuscitation 4 burr holes 206
children 208
military casualties 182
buddy aid 178 C3 levels 18
bullets 8 ABC, ballistic wounds 181
bupivacaine 80 calcium chloride 47
burns 21, 194203 calcium gluconate 47
adjuncts in care 2023 cannulas
anatomical aspects 194 flow rates 33
area 196, 197 thrombophlebitis/sepsis from 173
blisters 199, 200 carbohydrate metabolism 2021
children 19899, 202 after burns 202
criteria for patient transfer 203 carbon dioxide 29
deaths 194 end-tidal, monitoring 8
depth 19596 partial pressure (PaCO2) 23
electrical 196, 199 proxy for measuring 89
face 201 shock resuscitation 29, 31
feet 202 carbon monoxide poisoning 198, 201
fire-related 194 carboxyhaemoglobin 198, 200
full-thickness 196, 199 cardiac arrest, children 209
hands 201 cardiac arrhythmias, blast injury 185
hot water/scalds 195, 199 cardiac bleeding 90
major 198 cardiac compressive shock 24
management 196201, 203 cardiac disease, in elderly 211
airway burns 200201 cardiac index (CI) 20, 30
analgesia 19798 cardiac injuries see heart, injuries
associated injuries 19899 cardiac massage, internal 83
definitive 199201 cardiac output 22, 2526
emergency department 19799 factors determining 2526
escharotomy and fasciotomy 199 measurement 2526, 29
first aid dos and donts 194, 196 reduced, by raised IAP 59
fluid resuscitation 198 in shock 23, 24, 30
intravenous access 197 cardiogenic shock 23, 24
safe retrieval 196 drugs affecting 34
partial thickness 197 fluid therapy effect 32
deep 195, 196 hypovolaemic shock 23
indeterminate 195 cardiac tamponade 4, 76, 83
superficial 195, 201 cardiac compressive shock 24
perineum 2012 emergency management 9, 83, 90
resuscitation 196 management procedure 91
shock 198, 199 cardiogenic shock 2324
superficial 194, 195 clinical presentation 24
total burn surface area (TBSA) 195, 196 cardiopulmonary resuscitation (CPR) 86
wet and dry 195 cardiovascular collapse 5
wounds air embolism 82
closing 199200 cardiovascular system
debridement 199, 200 elderly 210
emergency management 198 raised IAP effects 59
carotid artery right, approach to 88

exposure/access 7172 safe area 74, 75
injuries 68, 69, 70 surgical approaches 87
treatment 69, 70 chest injuries 7392
internal blunt trauma 73
exploration/access 71 children 209
injuries 69 complications from misassessment 74
left common 76 diagnosis 77
carotid bifurcation, exposure/access 71 ultrasound 77, 189
catabolic phase 15, 21 DSTCcore surgical skills 244
catecholamines 21, 30 emergency room surgery 9
catheterization, pulmonary artery pressure measurement 2829 incidence 73
CattelBraasch manoeuvre 9899 life-threatening 7374
caval injuries see vena caval injuries management 7785
CCCC (four Cs) of incident management 178 drainage 7779
C-clamps, pelvic 150 non-operative 79
cell adhesion molecules 168 operative 80
cell salvage techniques, blood cells 45, 46 preparation for 80
cellular pathway, in metabolic response 16, 18 specific injuries 8085
Centers for Disease Control, pneumonia diagnosis 174 minimally invasive surgery 191
central venous hypotension 26 mortality 73, 81
central venous line 26, 27, 33 pathophysiology 74
central venous pressure 2627 penetrating injuries 73, 74, 77
measurement 2627 diagnosis 77
normal 26 large gaping wounds 81
in shock 2627, 35 operative management 80
central venous system, cannulation 27 pathophysiology 74
cephalosporins 17374 scale 227, 228, 229
cerebral perfusion pressure (CPP) 206 spectrum/types 7374
cerebral perfusion thresholds 206 surgical approaches 87
cervical spine, care during resuscitation 4, 67 chest tubes 74, 77
military casualties 182 complications 79
cervical spine injury insertion 78
children 209 massive haemothorax and 81
see also neck injuries pitfalls with 79
cervical vascular organ injury scale 227 removal 79
Chance fracture 125 securing 78, 80
chemical pneumonitis 197 site for/placement 74, 75, 77, 80
chemical vascular injuries 158 chest wall
chest anatomy 74, 75
access to 8789 injuries 73
applied surgical anatomy 7476 incidence 80
paediatric 76 management/repair 81
contents 7576 scale 227
drainage 7779 child abuse, burns 19899
see also chest tubes children 20810
flail 84 abdominal injuries 20910
floor, anatomy 75 analgesia 210
indications for surgery 87 burns 19899, 202
left, approach to 8788 nutrition 202
Index | 257
chest anatomy 76 colon

duodenal injuries 127 ascending, mobilization 97, 98
head injuries 209 injuries 1034
injury patterns 208 lacerations 233
Paediatric Trauma Score (PTS) 221 management recommendations 104
pancreatic injuries 123 scale/grading 233
pre-hospital management 208 colostomy 103, 152
resuscitation 2089 proximal diverting 103
shock management 209 coma 6
specific organ injury 20910 Glasgow Coma Scale 204, 221, 224
splenic injury management 115 command and control (incident management) 178
chitosan 101, 183 communication (incident management) 178
chlorhexidine-based solutions 248 co-morbid conditions
choledochoduodenostomy 113 assessment, in ICU 171
circulation elderly 211
access see vascular access compartment syndrome 160
indication for intubation in shock 31 compensatory inflammatory response syndrome (CARS) 17
management in resuscitation 46 compensatory mechanisms 22
children 209 complement, activation pathways 18
military casualties 182 complement components 18
clamshell incision 80, 87, 89 compression stockings 205
bilateral 91 computed tomography (CT)
claudication 158 abdominal trauma 10
cleaning, operating room 248 duodenal injuries 126, 127
clear (in 4 Cs of incident management) 178 liver injuries 105, 107
clingfilm, for burns 198, 199 pancreatic injuries 118, 120
clotting see coagulation splenic injury 114
clotting factors, loss in stored blood 40, 41 bladder injuries 140
clotting time 44 chest injuries 77
coagulation (clotting) 40 neck injury 68
abnormalities, blood transfusions associated 39, 41 pelvic fractures 150, 213
adjuncts to enhance 4344 renal injuries 136
cascade 18 computed tomography angiography, neck injury 68
correction in ICU 56 confirm (in 4 Cs of incident management) 178
monitoring status of 4445 consciousness 6
coagulation factors, loss in stored blood 40, 41 decreasing level 6
coagulopathy 39, 40 contamination control, damage control objective 54
consumption, in burns 197 control (in 4 Cs of incident management) 178
damage control indications 53 contusions
liver injuries 112 gastric 232
of major trauma 16970 myocardial 4
management 170 pancreatic 121
coeliac axis, repair 132 pulmonary 77, 82, 209, 228
collagen-based tissue adhesives 101 cordon (in 4 Cs of incident management) 178
collagen fleece 101, 102 coronary arteries
collagen sponge 101 air in 82
collar incisions (neck) 72 injuries 83
colloids cortisol 19, 34
cannula sizes and flow rates 33 cranial fractures 204
crystalloids vs 5, 32 blast injury 185
craniofacial injuries, emergency room surgery 89 damage control resuscitation 183

craniotomy, emergency 204, 206 military casualties 181, 183
CRASH-2 trial 43 UK protocol 183
critical care see intensive care/intensive care unit (ICU: critical damage (or death) of host cells (DAMPs) 18
care) death(s)
critical incidents, stress issues 250 burns 194
crush injuries 156, 157 causes xxiv, 3
crush syndrome 158 in shock 24, 30
cryoprecipitate 40 chest injuries 73, 81
crystalloids elderly after trauma 211
cannula sizes and flow rates 33 emergency department thoracotomy 85
children 209 in intensive care unit 165
colloids vs 5, 32 likelihood in major trauma 8
military casualties 183 liver injuries 106, 111
Curreri formula 202 open (extremity) fractures 154
cyanide 201 pancreatic injuries 123
cyclo-oxygenase 17 pelvic fractures 148
cystic duct injuries 113 death of host cells (DAMPs) 18
cystostomy, suprapubic 14142 deceleration injury
cytokines 1617 aortic rupture 214
anti-inflammatory 16, 17 duodenum 125
dysregulation, SIRS 168 kidney 137
modulation of activity 17 liver 105
nomenclature 16 spleen 113
pro-inflammatory 1617 decision-making, surgical xxi
in SIRS 168 pancreatic injuries 121
decompression (surgical)
damage control 5364, 247 abdominal 6061
abdominal trauma 93, 94 duodenum 12829
civilian vs military 18384 cranial 206
cleaning and sterility 248 deep venous thrombosis (DVT), prevention 17273
concept 53 after burns 202
delayed closure 54, 57 in head trauma 205
duodenal injuries 127 definitive surgery
extremity injury 157 military casualties and 184
indications 53 stage 4 damage control 56
liver injuries 105, 108, 112 Definitive Surgical Trauma Care (DSTC) course xxixxii, xxv,
military casualties 181, 18384 24143
objectives 54 application, eligibility 242
outcomes 57 certification 243
pancreatic injuries 117, 121 core surgical skills 24446
pelvic fractures 151 description and components xxv, 24243
stage 1 (patient selection) 53 development and testing 24142
stage 2 (haemorrhage/contamination control) 5554 materials and requirements 24243
stage 3 (physiological restoration) 56 need for xxv, 241
stage 4 (definitive surgery) 56 objectives xxv
stage 5 (abdominal wall reconstruction) 56 origin of course xxv, 241
surgery in military setting 18384 participants 243
ureteric injuries 139 practical skills 243
damage control anaesthesia, military setting 186 relevance for surgeons 241
Index | 259
source of information on 243 clinical presentation 125

syllabus 243 complete transection 128
delayed closure 57 damage control 127
abdominal 5455, 57, 100 diagnosis 12526
desmopressin 44 haematoma 126, 127, 232
developing countries, trauma management xxiii, xxiv intramural 127
diagnostic laparoscopy, duodenal injuries 126 high-risk 12627, 128
diagnostic peritoneal lavage (DPL) 7, 910 lacerations 126, 12728, 232
blast injury 185 lower portion 127
duodenal injuries 12526 management 12627
FAST comparison 190 mechanisms 125
liver injuries 106 pancreatic injuries with see pancreaticoduodenal injuries
pancreatic injuries 118 penetrating 125, 128
pelvic bleeding 151, 152 perforation, repair 128
diaphragm 75 scale/grading 126, 232
anatomy 75 surgical approach 12730
injuries 84 exposure 127
minimally invasive surgery 191 timing of surgery 127
scale 229 upper portion 127
movement during breathing 75 duodenorrhaphy 129
stenting, raised IAP effect 59 duodenotomy, surgical 119, 128
digoxin 34 duodenum 12430
2,3-diphosphoglycerate (2,3-DPG) 41 anastomosis 128
disability (D in resuscitation) see neurological status blood flow, raised IAP effect 59
(disability) complete transection 128
disseminated intravascular coagulation (DIC) 169, 170 diversion 122, 128
after transfusions 42 diverticulation 128
effect on thromboelastogram 45 DSTCcore surgical skills 245
dobutamine 34 exposure/inspection 9798, 99, 103
dopamine 3334 fistula 129
dobutamine with 34 injuries see duodenal injuries
Doppler monitor 10 obstruction 127
Doppler ultrasound rotation, Kocher manoeuvre 97, 98, 120
duplex see duplex Doppler ultrasound trauma laparotomy 97
DVT screening 173 triple tube decompression 12829
double-J stent 140 volume of fluid passing 124
drainage duplex Doppler ultrasound
chest 7779 peripheral vascular injuries 157
see also chest tubes renal injuries 136
pancreatic injuries 122
perihepatic 111 ebb phase 15
serosanguineous fluid, damage control 55 education, public, trauma systems 218
splenic bed 116 eicosanoids 1718
draping 96, 248 elderly 21011
drugs co-morbid conditions 211
blood pressure support 3334 definition 210
stress ulceration prevention 172 multiple medications 211
duodenal injuries 113, 12430 outcome of trauma 211
blunt 125 physiology 21011
children 127, 210 resuscitation in 6
electrocautery machine 248 enteral nutrition 17172

electrolyte disturbances 170 access routes 172
elemental diet 123 duodenal injuries 129
embolism in ICU 17172
air 5, 8283, 91, 192 pancreatic injuries 123
fat, post-traumatic 156 environment
pulmonary, prevention 17273 operating room preparation 247
embolization in resuscitation 67
liver injuries 214 indication for intubation in shock 31
pelvic fractures 213 military casualties 182
pelvic haematoma 131 epinephrine see adrenaline (epinephrine)
splenic injuries 115, 21314 equipment, operating room 247, 248, 249
see also angio-embolization (AE) erythema (superficial burn) 194, 195
emergency department escharotomy 199
burns management 19799 ethics 212
duration of stay 3 evacuation, casualties 181, 183
resuscitation see resuscitation extradural 8, 204
surgery in 810 extradural haematoma 8, 204
emergency department thoracotomy (EDT) 9, 73, 82, 8587, extrahepatic bile duct injuries 113
8992 scale 231
abdominal vascular injury 130 extremity trauma 15462
aortic cross-clamping and 91 classification 156
approach 8788, 90 damage control 157
cardiac injuries 83, 90 Gustilo classification of severity 154, 155
cardiac tamponade 90 head injuries with 156
contraindications 86 mangled limb, management 156, 158, 161
definitions 85 massive 15660
indications 73, 80, 8586, 9091 complications 161
mortality 85 management 15658
objectives 85 scoring systems 15860
patient types 85 open fractures, management 154
pulmonary haemorrhage 9091 primary survey 154
requirements (equipment) 89 respiratory insufficiency with 156
results/outcome 86 resuscitation 154
when to stop 86 severe, management 154
emergency medical service (EMS) systems 218 timing of skeletal fixation 15556
military 17779 vascular injuries 15658
endorphins 19, 34 venous thromboembolism 155
endoscopic retrograde cholangiopancreatography (ERCP) extubation criteria 167
118
endotoxin 18, 24 face, burns 201
endotracheal intubation 4 facial nerve 71
children 208 factor V, loss in stored blood 40, 41
extubation criteria 167 factor VII, recombinant activated (rFVIIa) 43
indications in shock 31 guidelines for use 49
tube dislodgement 208 factor VIII, loss in stored blood 40, 41
endovascular stenting, limb vascular injury 158 factor XII (Hageman factor A) 18
energy fallopian tube injury scale 237
production, failure, in shock 30 false aneurysm 83
resting expenditure, increased in trauma 20 family contact/support, ICU 171
Index | 261
fasciotomy 16061 choice of fluids 32, 33

burns 199 crystalloids vs colloids 5, 32
four-compartment 160, 161 delayed 5
FAST (focused abdominal sonography for trauma) 7, 18990 hypovolaemic shock therapy 32, 33
abdominal trauma 9, 189 military casualties 183, 186
liver injuries 105 rapid responders 5
pancreatic injuries 120 shock management 3233
applications 18990 transient responders 5
chest injuries 77, 189 warming 183, 186, 247
false-negative rates 189 focused abdominal sonography for trauma see FAST (focused
pelvic fractures 150 abdominal sonography for trauma)
pitfalls 190 Foley catheter 9, 59, 90, 150
repetition 189 forward surgical teams 180, 181, 184
fat embolism 156 four-compartment fasciotomy 160, 161
fat metabolism 21, 30 four Cs, of incident management 178
after burns 202 fraction of inspired oxygen (FiO2) 198, 200
feet, burns 202 fractures 154
femoral artery, cannulation 28 chest wall 227
femoral fractures complications 161
emergency room treatment 10 fixation see fixation of fractures
head injuries with 156 Gustilo classification of injuries 154, 155
femoral line insertion 27 long bone, emergency room surgery 10
fever, non-infectious causes 167 open (extremity)
fibrin 101 antibiotic prophylaxis 15455, 174
heterologous 101 management 154
fibrin glue 101, 102, 110 mortality 154
fibrinogen 40 sepsis and prevention 15455, 174
fibrinolysis, effect on thromboelastogram 45 skull, depressed 204
fibrin sealing 101 timing of fixation in polytrauma 15556
fibulectomy 160, 161 see also individual bones
field hospital 180 free fatty acids 21
finger fracture, liver injury management 109 free radicals 16, 18
firearm injuries xxiv fresh frozen plasma 40, 43, 170
see also gunshot wounds fresh whole blood (FWB) transfusions see blood transfusions
first aid, burns 196 front-end processes, military trauma care 186
fistula futile care 21112
biliary 112
duodenal 129 gallbladder injuries 113
pancreatic see pancreatic fistula Galveston formula 202
fixation of fractures gas, blood see blood gases
external, pelvic fractures 10, 131, 150, 213 gastric bypass 129
timing, in polytrauma 15556 Gastrografin swallow 120, 126
flail chest 84 gastrointestinal bleeding 172
flow phase, of trauma 15 gastrojejunostomy6 129
fluid losses, burns 194, 198 Gelofusine 32
fluid replacement 5 genitourinary injuries 13543
administration route 33 children 210
burns 198 DSTCcore surgical skills 245
cannula sizes and flow rates 33 Gerotas fascia 99, 138
children 209 GIA-type cutting staplers 249
Glasgow Coma Scale (GCS) 204, 221, 224 secondary survey 7

Glasgow Outcome Scale 22425 haemodynamically stable patients
glomerular filtration rate 59 chest injuries 74
glucagon 19 large bowel injuries 103
glucocorticoids 19 liver injuries 105, 107
gluconeogenesis 20, 30 non-operative management, abdominal injury 94
glucose, mobilization 20 pelvic fractures 150
glucose, blood levels 19, 21 secondary survey 7
intolerance 20 small bowel injuries 103
optimum level 21 haemodynamically unstable patients
Glue Grant study 31 bleeding sites 7
glycerol 21 chest injuries 74
glycogen 20 damage control indications 53
glycolysis 20, 29 large bowel injuries 104
governance, military trauma care 186 liver injuries 105
grading of injuries see scoring systems (trauma) pelvic fractures 150
graft replacement, limb vascular injury 157 secondary survey 7
graft-versus-host disease 42 small bowel injuries 103
greater sac, trauma laparotomy 97 splenic injuries 115
great vessels haemoglobin
anatomy 76 anaemia, transfusion indication 39, 43
injuries 8384 blood transfusion target 42
Guildford technique 100 liposomal solutions 46
gunshot wounds 68, 177 polymerized solutions 46
bladder 141 haemoglobin solutions, as blood substitute 4647
pancreatic 117 haemoperitoneum 192
trauma scoring 224 haemorrhage xxiv
Gustilo classification 154, 155 blood transfusions for 39
gynaecological injury 14243 catastrophic, military casualties 181, 182
intercostal vessels 9
H2-receptor blockade 172, 202 intra-abdominal 9
haematocrit 39, 40 pelvic fractures with 151
liver injuries 107 massive 47
haematoma protocol for management 6
duodenal see duodenal injuries pulmonary 9091
extremity/limb 157 transfusions 42, 4749
kidney 136, 234 pelvic 10
liver 111, 230 postoperative, liver injuries 111
oesophageal 231 pulmonary, emergency procedures 9091
pancreatic 120, 231 retroperitoneal 9
pelvic 94, 99, 131, 141 see also bleeding
retroperitoneal see retroperitoneal haematoma haemorrhage control xxv
splenic 114, 230 abdominal 95, 96, 97
subdural 8, 204 haemostatic adjuncts 1012
urogenital 235 damage control objective 54
haematuria 135, 142, 210 liver injuries 105, 107
haemobilia 112 techniques 10811
haemodilution 169 military casualties 183
haemodynamically normal patients neck injury 67
pelvic fractures 150 pelvic 150, 151
Index | 263
complex pelvic injuries 152 hepatic vein injury 111, 11213

pelvic fractures 213 hernia, planned 57
retrohepatic vena caval injuries 112 hilar clamping, management procedure 91
small bowel injuries 103 HIV infection 85, 143
splenic injuries 115, 116, 21314 hormones, in metabolic response 1820
vascular injuries of neck 69, 70 human immunodeficiency virus (HIV) 85, 143
haemorrhagic shock see hypovolaemic shock hydroxyl ion 18
haemostasis hypercapnia, permissive 208
abdominal trauma 1012 hypercoagulation, effect on thromboelastogram 45
failure, after transfusions 42 hyperdynamic state 20, 31
orthopaedic xxiv hyperkalaemia 20
haemostatic substances 1012 blood transfusions associated 41
liver injuries 110 hypermetabolic state 171
haemothorax 8182, 189 hyperosmolar therapy 205
hands, burns 201 hypertension
HarrisBenedict equation 202 in elderly 211
head injuries 166, 170, 2045 intra-abdominal see intra-abdominal hypertension (IAH)
adjuncts to care 2046 intracranial see intracranial hypertension (ICH)
children 209 hypertonic saline, fluid therapy in shock 32
contraindication to minimally invasive techniques 192 hyperventilation 23
extremity injury and early fixation 156 head trauma 206
pelvic fractures and 152 hypocalcaemia, massive transfusions and 47
penetrating 204 hypocoagulation 39
thoracic injury and 209 hypotension 23
see also brain injury abdominal trauma 93
Heaney technique 113 avoidance in head injury 205
heart central venous 26
acute failure 83 children 209
anatomy 7576 post-injury, EDT for 86
in hypothermia 167, 168 in shock 26
injuries 83, 85 septic shock 24
scale 228 hypotensive resuscitation 32, 35
suspected, emergency procedures 90 hypothalamus 19
see also cardiac tamponade hypothermia 6, 40, 16768
see also entries beginning cardiac avoidance, trauma laparotomy 9596
hemicolon, right 97, 98 blood transfusions and 40, 42
hemithorax 76 massive transfusions 47
left/right, anatomy 76 intensive care 16768
heparin 69, 173, 205 prophylactic, in head injury 205
effect on thromboelastogram 45 rewarming 16768
hepatectomy 110 hypoventilation 208
hepatic arteries, injuries 113 hypovolaemia 16, 19, 26
hepatic duct injuries 113 metabolic response precipitation 1516, 19, 22
hepatic injury see liver injuries military casualties 181
hepaticojejunostomy 113 raised intra-abdominal pressure and 59
hepatic resection 110 hypovolaemic shock 5, 2223
hepatic shunts 110 abdominal vascular injury 130
hepatic suture 109 classes 23
hepatic tourniquet 109 clinical presentation 23
hepatic vascular isolation 110, 112 compensated 23
hypovolaemic shock (contd) inhalational toxicity 201

fluid therapy 32, 33 injury prevention xxiii, xxiv
see also fluid replacement Injury Severity Score (ISS) 18, 223
military casualties 181 ICD-based 224
hypoxia 208 innominate artery 76
inotropic agents 33
iatrogenic injuries, peripheral vascular 157 instruments 249
IATSIC xxi, xxii, 242, 243 counts 250
ICD-9 and ICD-10 224 preparation 247
ICD-based Injury Severity Score (ICISS) 224 special and improvised 249
ileus, raised intra-abdominal pressure and 61 insulin
iliac arteries, embolization 213 increased levels 21
iliac vessels, repair 133 response in trauma 19, 2021
iliac wing, fracture 149 intensive care/intensive care unit (ICU: critical care) 16575
immune response 1618 acute renal failure in 170
innate, MODS and 169 coagulopathy in 16970
to transfused blood 41, 42 family contact/support 171
immunizations, post-splenectomy 173 goals 165
immunomodulation 42 hypothermia 16768
immunonutrition 172 metabolic disturbances 170
incident management, military 17879 military casualties 186
inclusive trauma system see under trauma systems mortality in 165
infants, airway control 208 nutritional support 17172
infections pain control 17071
blood transfusions transmitting 41 phases 165
burn wounds 199, 200 early life support 166
in intensive care 166 prolonged life support 16667
open (extremity) fractures 15455, 174 recovery 167
penetrating trauma and 7 resuscitative 35, 16566
perihepatic 11112 physiological restoration 56
prevention in head injury 205 preventive measures in 17273
prevention in ICU 173 priorities 166
surgical site 167 raised intracranial pressure 170
see also sepsis resuscitation 16566
inferior mesenteric artery 13233 in shock 35
inferior vena cava tertiary survey 171
bleeding control 107, 133, 134 transfer to, damage control surgery 55
infrahepatic 133 ventilation 174
laparotomy, exposure 98 intercostal drains, children 76
repair 133, 134 intercostal vessels, haemorrhage 9
suprahepatic 133 interferon-gamma 17
see also vena caval injuries interleukin-1 (IL-1) 17, 18
inferior vena cava filter 173 interleukin-6 (IL-6) 17
inflammation 16 interleukin-8 (IL-8) 17
inflammatory mediators 1618 interleukin-10 (IL-10) 17
inflammatory pathway 1618 interleukin-12 (IL-12) 17
inflammatory response interleukins 16
dysregulation 168 internal carotid artery see carotid artery, internal
systemic inflammatory response syndrome 168 International Association for Trauma Surgery and Intensive
inflammatory (distributive) shock 2425 Care (IATSIC) xxi, xxii, 242, 243
Index | 265
interventional radiology 21314 intramural haematoma, duodenum 127

intestine (bowel) 1024 intraoperative pancreatography, pancreatic injuries 119
injuries 1024 intravenous access 5
children 210 intravenous cannulas, thrombophlebitis/sepsis from 173
minimally invasive surgery 192 intubation
inspection 102 endotracheal see endotracheal intubation
ischaemia 132 orotracheal, children 208
large, injuries 1034 Iraq conflict 17677
antibiotic prophylaxis 104 ischaemia
management recommendations 104 extremity/limb 157
scale 233 kidney 138
see also colon isoproterenol 30, 34
in metabolic response 22
mural haematoma, blast injury 1845 jejunal serosal patch 128
penetrating wounds 103 jejunostomy, feeding 123, 129, 172
scale/grading 232, 233 jugular vein, internal
small, injuries 103, 232 injuries 68, 70
see also duodenal injuries line insertion 27
intra-abdominal bleeding, pelvic fractures with 151 pulmonary artery catheter insertion 2829
intra-abdominal hypertension (IAH) 57 jugular venous saturation 206
definitions 58
incidence 58 kallikrein 18
management algorithm 61, 62 ketones 30
see also intra-abdominal pressure (IAP) kidney
intra-abdominal injuries see abdominal injury/trauma access to 99
intra-abdominal pressure (IAP) autoregulation 26
definitions 58 DSTCcore surgical skills 245
measurement 5960 haematoma 234
tips 60 size 136
monitoring 57 ischaemia 138
raised 58 laparotomy, exposure 98, 99
causes 58, 61 perfusion 26
effects/consequences 57, 59 raised IAP effect 59
management algorithm 61, 62 in shock, compensatory changes 26
surgery for 61 see also entries beginning renal
intra-abdominal sepsis 54, 61 kidney injuries 13538
intracaval shunt 112 blunt trauma 136, 137
intracranial hypertension (ICH) 166 children 210
head injury 205 diagnosis 13536
recognition/treatment 170 lacerations 234, 235
intracranial mass lesions 8 left, access 138
intracranial pressure (ICP) management 13638
control 166, 206 non-operative management 13637
monitoring penetrating 136, 137
indications 205 postoperative care 138
technology for 205 right, access 137
raised see intracranial hypertension scale/grading 136, 23435
raised IAP effect 59 stable/unstable patients 136
thresholds 205 surgical approach 13738, 139
intraluminal shunts, limb vascular injury 157 kinetic energy (KE) 7, 185
knife wounds 7 laryngeal masks 67

Kocher manoeuvre 9798, 103, 120 leadership, military trauma care 186
duodenal injuries 127 left medial visceral rotation 99, 12021, 137
extended, pancreatic injuries 120 legislation, trauma systems 219
Korean conflict 181, 217 lesser sac
pancreatic injury access 120
lacerations trauma laparotomy 97
chest wall 227 leukotrienes (LTs) 17
colon 233 LTB4 18
duodenum 126, 12728, 232 life support phase in ICU
gastric 232 early 166
kidney 234, 235 prolonged 16667
liver 230 ligaclips 249
lung 5, 81, 82, 228 ligation, limb vascular injury 157
oesophagus 231 limb injury see extremity trauma
pancreas 121, 231 limb salvage 156, 158, 160, 161
spleen 114, 115, 230 lipids, metabolism 21, 30
urogenital 235 lipolysis 21
vagina 143, 152 liposomal haemoglobin solutions 46
lactate liver 10513
metabolic response to trauma 20 anatomy 105
in shock 25, 30 bleeding 105, 107, 112
lactic acidosis 20 DSTCcore surgical skills 245
management in massive transfusions 47 infections 11112
in shock 25, 30, 31 lobectomy 110
laparoscopy manual compression 107, 112
abdominal injuries 19192 mobilization 11011
bowel injuries 192 packing 102, 108, 112, 113
liver injuries 192 complications 1089
splenic injuries 192 portal vein injuries 113
chest injuries 79 postoperative haemorrhage 111
diagnostic, duodenal injuries 126 resection 110
diaphragmatic injuries 84, 191 suturing 109
risks in trauma 192 see also entries beginning hepatic
laparotomy liver injuries 93
exploratory, duodenal injuries 126 blunt injuries 105, 1067
midline 88, 96, 137, 143 children 20910
DSTCcore surgical skills 244 coagulopathy 112
re-laparotomy 5657 complications 11112
staged see damage control damage control 105, 108, 112
trauma 93, 9499 diagnosis 1056
adjuncts 9596 haematoma 230
closure after 100 haemorrhage 105, 107, 112
draping and incision 96, 248 haemostatic adjuncts for 102
pancreatic injuries 121 lacerations 230
pelvic fractures 15051 management 1067
procedure 9697 minimally invasive surgery 192
renal injuries 136 mortality 106, 111
retroperitoneum 9799 non-operative management 1067, 214
large bowel see colon; intestine (bowel) operative management 107
Index | 267
penetrating 105, 106, 110 metabolic instability, damage control indications 53

resuscitation 105 metabolic rate, increased in trauma 20
scale/grading 106, 230 metabolic response
subcapsular haematoma 111 to shock 24, 25, 29, 31, 34
surgical approach 10711 to transfusions 41
haemorrhage control 105, 107, 10811 to trauma 1522
incision 107 clinical and therapeutic relevance 22
initial actions 107 effects of mediators 2022
mobilization of liver 11011 factors modifying 15
types 105 hormonal mediators 1820
lobectomy immune response 1618
liver 110 initiating factors 1516, 22
lung 91 microaggregates, effects on blood transfusions 41
local anaesthesia, chest tube placement 77, 80 microemboli, lung 73
log-roll 6, 77 midline laparotomy see laparotomy
long bone fractures military conflicts and austere conditions xxiv, 17688
emergency room surgery 10 anaesthesia 18586
see also fractures analgesia 185
lung blast injury 18485
anatomy 75 casualty numbers 17677
infections 85 critical care 186
injuries 73 damage control resuscitation 181, 183
blast 184 emergency medical service systems 17779
laceration 5, 81, 82, 228 incident management (4 Cs) 17879
scale 228 evacuation 181, 183
lobectomy/pneumonectomy 91 forward surgical teams 180
microemboli 73 injury patterns 17677
raised IAP effect 59 mass casualties 17879, 18081
reperfusion injury 84 resources required 176
see also entries beginning pulmonary resuscitation 18184
shock resuscitation 35
magnetic resonance cholangiopancreatography 118 surgeon requirements 176, 177
major incidents 18081 translation to civilian care 18687
Major Trauma Outcome Study (MTOS) 225 trauma systems derived from 18687, 217
Mangled Extremity Severity Score (MESS) 158, 159 triage 17980, 181
Mangled Extremity Syndrome Index 158, 159 mineral zeolyte 1012, 183
mannitol 9, 205 minimally invasive surgery 19193
mass casualties 179, 18081 abdominal injuries 19192
mediastinitis 83 bowel injuries 192
mediastinum liver injuries 192
anatomy 75, 76 splenic injuries 192
penetrating wounds 74 diaphragmatic injuries 191
meglumine (gastrografin) 126 risks in trauma 192
mesentery, injury 104 thoracic injuries 191
mesh, composite 57 missile track 8, 77
mesh splenorrhaphy 116 pancreatic injuries 11718
mesh wrap missile wounds 8, 177
liver injuries 110 chest 77
splenic injuries 116 small bowel 103
metabolic disturbances, in intensive care 170 MIST handover 3
mobile army surgical hospitals (MASH) 181 in resuscitation 4

modified Anatomic Profile (mAP) score 223 nephrectomy 137, 138
MoorePilcher balloon 110 nervous system
morphine 210 afferent impulses 16
mortality see death(s) elderly 21011
motor vehicle trauma xxiv neurogenic shock 25
pancreatic blunt trauma 117 neurological deterioration 6
pelvic fractures 149 neurological evaluation 6
M-statistic 225 neurological status (disability) 6
multiple organ dysfunction syndrome (MODS) 166, 169, 170 carotid artery injuries 70
one-hit vs two-hit model 169 indication for intubation in shock 31
multiple organ failure syndromes 30 military casualties 182
muscle neck injuries 6970
mass lost 21 in resuscitation 6
protein breakdown 21, 202 children 209
wasting 21 neutrophils 16, 17
muscle flaps 81 New Injury Severity Score (NISS) 223
musculoskeletal system, elderly 211 Nissa Scoring System 15859, 160
myocardial contusion 4 nitric oxide (NO) 18
myocardial infarction 4 nitrogen, excretion 21
myocardial laceration, management procedure 91 nitroprusside 34
non-operative management (NOM) xxi
naloxone 34 abdominal trauma 10
natural disasters 176 penetrating 94
neck bladder injuries 141
anatomical zones 6768 chest injuries 79
DSTCcore surgical skills 244 evaluation for 213
root, access 72 kidney injuries 13637
neck injuries 6772 liver injuries 1067, 214
access approaches 7072 mid-torso injuries 79
collar incisions 72 pancreatic injuries 11920
incisions 71 splenic injuries 113, 11415, 116, 213
trapdoor incisions (obsolete) 70 see also angio-embolization (AE)
closure of wounds 72 noradrenaline 33
diagnostic studies 68 novel hybrid resuscitation 183
frequency 68 NovoSeven 43
haemorrhage control 67 nutritional support
initial assessment 67 burns patients 202
location/zones 6768 head trauma 206
treatment based on 6970 in ICU 17172
management principles 6768 pancreatic injuries 123
mandatory vs selective exploration 69
mechanism/types 68 obstructive shock 25
penetrating trauma 67, 69, 70 occult hypoperfusion 165
treatment 6970, 84 occult injuries, evaluation for 171
rules 70 octreotide 123, 124, 129
vascular injury scale 227 oesophageal injuries 84
vascular injury treatment 6970 access/approach to 72
neck veins cervical 70, 84
distended, causes 45 scale 231
Index | 269
thoracic 84, 92 oxygenation

treatment 70, 84 cerebral 206
oesophagus, anatomy 76 in head injury 205
oliguria 23 shock management 31
operating room oxygen debt 30
equipment/instruments 247, 248 oxygen radicals 18
preparation 247 oxyhaemoglobin 30, 47
operating room scrub nurses 102, 24750 oxytocin 143
operating room preparation 24748
surgical procedures 248 packed red blood cells (pRBCs), transfusions 39, 42, 43
operative team, protection 248 packing
opiates, intravenous 171 abdominal cavity 96, 97
optimal care, criteria, in trauma systems 219 extraperitoneal 94, 131, 151
oral rehydration, burns 198 technique 15152
organ donation 174 hepatic see liver, packing
Organ Injury Scaling (OIS) 224 pelvic see pelvic packing
duodenal injuries 126 perihepatic 108
liver injuries 106 spleen 115
pancreatic injuries 119 paediatrics see children
splenic injuries 114 Paediatric Trauma Score (PTS) 221
organ perfusion 165 pain control 17071
orotracheal intubation, children 208 battlefield/military casualties 185
orthopaedic haemostasis xxiv see also analgesia
osmolality 19, 20 pain receptors 19
outcome analysis, scoring systems 22426 pancreas 11724
outcome parameters 224 abscess 124
ovary injury scale 237 anatomy 117, 118
overtriage 179 distal, internal drainage 12122
oxidative phosphorylation 24 DSTCcore surgical skills 245
uncoupling 24 endocrine deficiency 124
oxygen evidence-based guidelines 124
artificial carriers 46 exocrine deficiency 124
brain tissue monitoring 206 haematoma 120
carrying capacity as transfusion indicator 39 injuries see pancreatic injuries
consumption, hypothermia and 167 pancreatectomy, distal 121, 122
delivery 20, 39 pancreatic duct 119
optimization in ICU 56 injuries 12122
in resuscitation 165 stent 119
in shock resuscitation 30 pancreatic fistula 123
depletion, effects 39 postoperative 123
Hb-based carriers 46 proximal 119
partial pressure (PaO2) 23 pancreatic hormones 19
shock resuscitation 29 pancreatic injuries 11724
saturation 42 acute, ERCP in 118
shock management 31 blunt trauma 117, 119, 120, 123
total body consumption (VO2) 20 children 123, 210
transport complications 12324
in modified Hb solutions 46, 47 contusions 121
in perfluorocarbons 46, 47 damage control 117, 121
utilization, evaluation 29 detection 97
pancreatic injuries (contd) arterial bleeding control 213

diagnosis 117, 11819, 120 associated injuries 148, 149
drainage 122 bleeding 148
duodenal injuries with see pancreaticoduodenal injuries children 210
grade/scaling 119, 231 classification 14849
haematoma 120 clinical examination 14950
haemostatic adjuncts 102 complex/severe 94, 152
head of pancreas 117, 119, 120, 121, 12223 interventional radiology 213
lacerations 121 damage control 151
management 117, 11920 diagnosis 14950, 213
mechanisms 11718 emergency room surgery 10
mortality 123 external fixation 10, 131, 150, 213
non-operative management 11920 haemodynamic status 150
nutritional support 123 mortality 148
operative evaluation 119 open book 149
operative management 120 resuscitation 150
penetrating 11718, 120 ruptured urethra with 142
post-traumatic/delayed presentation 118 stable/unstable 149
surgical approach 12023 venous bleeding control 213
adjuncts 123 pelvic haematoma 94, 99, 131, 141
head of pancreas and duodenum 12223 pelvic injuries
incision/exploration 12021 associated injuries 15253
tail/distal pancreas 12122 complex, with open pelvic injury 94, 152
surgical decision-making 121 emergency room surgery 10
suturing 121, 122 fractures see pelvic fractures
tail/body of pancreas 12122 vascular 130
pancreaticoduodenal injuries 93, 117, 121, 128, 12930 pelvic inlet 148
grading 130 pelvic instability 149
surgical management 12223 pelvic packing 15152
pancreaticoduodenectomy (Whipples procedure) 119, 121, complex pelvic injuries 152
12223, 127, 129 extraperitoneal 131
pancreaticojejunostomy 12122 technique 15152
pancreatic pseudocysts 123, 124 pelvic peritoneum 148
pancreatitis, postoperative 12324 pelvic ring
pancreatography, intraoperative, pancreatic injuries 119 fractures 148
panel reviews, trauma systems 220 stable fractures 149
paraplegia 84 pelvis 14853
parenchymal injuries, pancreas 121 anatomy 148
parenteral nutrition 21 blood supply 148
Parkland formula 198 stabilization 131
pathogen-associated molecular patterns (PAMPs) 18 vascular injuries 130
patient selection, damage control 53 pelviureteric junction injuries 137, 140
PEDROS 181 Penetrating Abdominal Trauma Index (PATI) 224
pelvic bleeding 10, 148, 149 penetrating trauma
complex pelvic injuries 152 abdominal see abdominal injury/trauma
control 150, 213 bladder 135
pelvic brim 151 blast injury 184
injuries 140 causes 7
pelvic C-clamps 150 chest see chest injuries
pelvic fractures 14853 diaphragm 84
Index | 271
duodenal 125, 128 planning of emergency response xxi

great vessels 83 plasma, thawed 183
head 204 plasmin 169
infections and 7 platelet(s)
intestine (bowel) 103 in coagulopathy of major trauma 169
kidney 136, 137 count 40
liver 105, 106, 110 spontaneous bleeding 41
management 78 transfusion 40, 43, 170
mediastinum 74 platysma 71
military conflicts 177 pleura and pleural cavity 75
neck 67, 69, 70 pleural toilet 80
oesophageal 84 pneumatic compression devices 173
pancreatic 11718, 120 pneumo-haemothorax 8182
peripheral vascular 157 pneumonectomy 91
wound description 8 pneumonia 166
penis injury scale 238 ventilator-associated 172, 174
percutaneous endoscopic gastrostomy 172 pneumoperitoneum, blast injury 185
percutaneous tracheostomy 167 pneumothorax 189
perfluorocarbons 46, 47 open, management 81
pericardial fluid 189 simple closed 81
pericardial tamponade see cardiac tamponade tension see tension pneumothorax
pericardiocentesis 4, 9, 83 Pneumovac 173
pericardium, anatomy 7576 polyglycolic acid mesh 57
perihepatic drainage 111 polypharmacy 211
perihepatic infections 11112 population-based studies, trauma systems 220
perihepatic packing 108 porta hepatis
perineal injuries 150 injuries 113
perineum, burns 2012 temporary clamping (Pringles manoeuvre) 97, 109, 110,
peripheral vascular injuries 15658 134
blunt 157 portal vein
DSTCcore surgical skills 245 access 134
emergency room treatment 10 injuries 113, 134
iatrogenic 157 positive end-expiratory pressure (PEEP) 166
penetrating 157 posterolateral thoracotomy 89
scale 23839 post-shock syndromes 30
peritoneal injury 74 post-traumatic respiratory failure 166
peritoneal lavage, diagnostic see diagnostic peritoneal lavage post-traumatic stress disorder (PTSD) 250
(DPL) potassium, excretion and serum levels 20
peritoneal soiling 103 Predictive Salvage Index System 158, 159
peritonitis pre-dot code 222
duodenal injuries 125 pregnancy, uterus injuries 143, 236
pancreatic injuries 117 pre-hospital care xxiv
pH, shock resuscitation 29 children 208
pharyngeal injuries, treatment 70 military casualties 181, 183
phenytoin 206 preload 25, 26, 33
physiological scoring systems 221 prevention of injury xxiii, xxiv
physiology trauma systems 218
elderly 21011 primary reflexes 6
of resuscitation 1536 primary survey 3, 47
pituitary gland 19 extremity trauma 154
primary survey (contd) rapid sequence induction (RSI) 185

neck injury 67 rationing of healthcare 211
priorities 4 recovery phase in ICU 167
Pringles manoeuvre 97, 109, 110, 134 rectal examination 141, 150
probability of survival (P(s)) 225 rectal injuries 103
procoagulant response 17 pelvic fractures with 153
prognosis, Revised Trauma Score for 222 scale 233
propofol 206 red blood cells
prostacyclins (PGIs) 17 packed, transfusions 39, 42, 43
prostaglandins 34 substitutes 4647
prostanoids 1718 regional anaesthesia, military casualties 186
prostate examination 150 registries, trauma 220
protein rehabilitation 219
intake 21 military trauma care 186
requirements, after burns 202 re-laparotomy 5657
protein C, activated 17, 169 re-look surgery 56
proton pump inhibitors 172, 202 renal arteries
pseudoaneurysms left, access 137, 138
arterial 112 repair 133
splenic 116 right, access 137
pseudocysts, pancreatic 123, 124 thrombosis 137
pubic rami, fractures 149 renal failure, acute 170
public education, trauma systems 218 renal hormones 19
public support, for trauma systems 219 renal impairment, raised intra-abdominal pressure effect 59
pulmonary artery 76 renal injuries see kidney injuries
pulmonary artery catheter renal plasma flow 59
insertion 2829 renal system, elderly 211
pressure recordings 29 renal vascular resistance 59
pulmonary artery pressure renal vein
measurement 2829 left
wedge pressure (PAWP) 24 access 138
pulmonary contusion 77, 82, 209, 228 division 138
pulmonary embolus, prevention 17273 right, access 137
pulmonary haemorrhage, emergency procedures 9091 renin 19, 26
pulmonary laceration 5, 81, 82, 228 reninangiotensin system 19, 26
pulmonary oedema 24 reserpine 158
pulmonary sepsis 85 respiration, in ICU 174
pulmonary tractotomy 90, 91 respiratory failure, post-traumatic 166
pulse, limb vascular injury and 157 respiratory insufficiency, extremity injury and early fixation 156
pulse oximetry 201 respiratory rate, in shock 31
pulse pressure, in hypovolaemic shock 23 hypovolaemic 23
pulse rate, in hypovolaemic shock 23 respiratory system
purse-string closure 79 assessment/monitoring 166
pyloric exclusion 122, 129 elderly 210
raised IAP effects 59
radial artery resuscitation 311
cannulation 28 ABCDE see ABCDE of resuscitation
thrombosis 28 abdominal trauma 93
radiography, plain see X-ray adequate, criteria for 6
rape, injuries 14243 all patients entitled to 21112
Index | 273
burns 196, 197 right medial visceral rotation 9899, 120, 133
children 2089 Ringers lactate 32, 35, 158, 165
damage control 35 burns, resuscitation 198
diagnostic studies in 67 rotational thromboelastometry (RoTEM) 44
drugs for blood pressure support 3334 Roux-en-Y loop 113, 128
emergency department 3 rule of nines 196
end points 165 Rumel tourniquet 133, 134, 135, 249
abdominal perfusion pressure 60
in shock 2930 sacroiliac joint 148
extremity trauma 154 safety (incident management) 178
hypotensive 32, 35 saline, hypertonic, fluid therapy in shock 32
in ICU 35, 16566 salt retention 20
liver injuries 105 sandwich technique 54, 55, 61
military casualties 18184 scars, from burns 196
novel hybrid 183 scoring systems (trauma) 22140
pelvic fractures 150 anatomical 22224
physiology 1536 organ-specific injuries 22639
primary survey see primary survey outcome analysis 22426
secondary survey 7 physiological 221
severe trauma 38 see also individual scoring systems
shock 3034, 35 scrotal injury 142
supranormal 31, 165 scale 238
surgical, abdominal trauma 93 scrub nurses see operating room scrub nurses
time factors 3 secondary survey 7
until core temperature normal 167, 168 sedatives, head trauma 206
resuscitation fluids see fluid replacement seizures, prevention, in head trauma 206
retrograde cystography, bladder injuries 140 SengstakenBlakemore tube 249
retrograde urethrography 141 sepsis 168
retrohepatic caval injury 111, 11213 cytokine activity 17
retrohepatic haematoma 111 major limb injuries 161
retroperitoneal haematoma 94, 119, 13031, 136 open fractures 15455
central 13031, 132 post-splenectomy 116, 173
haemostatic adjuncts 102 shock 2425
lateral 131 see also infections
pelvic 94, 99, 131, 141 septicaemia, burns 199
retroperitoneum 94, 125 septic shock 2425
injuries 94 severe trauma 3
radiology 126 death likelihood 8
see also pancreatic injuries extremities, management 154
in trauma laparotomy 9799 management/resuscitation 38
reverse triage 179 sexual assault, injuries 14243
Revised Trauma Score (RTS) 22122 shock 2235
field triage 221 burns 198, 199
non-triage 221 cardiac compressive 24
rewarming 16768, 247 cardiogenic see cardiogenic shock
ICU 56 cause of death in 24, 30
military casualties 183, 186 classification 2225
rib compensated 23
blunt dissection over, chest tubes 77 definition 22
fractures 209 duration 34
shock (contd) soft tissue injuries 156

end points in resuscitation 2930 somatostatin 123
haemorrhagic see hypovolaemic shock spinal cord injury, great vessel injury complication 84
hypovolaemic see hypovolaemic shock spleen 11317
inflammatory (distributive) 2425 anatomy 113
low-output states 23, 24, 30 DSTCcore surgical skills 245
management 3034 injuries see splenic injuries
blood pressure, drug support 3334 mobilization 115
children 209 packing 115
fluid therapy 3233 preservation, laparoscopy 192
metabolic manipulations 34 salvage, in distal pancreatectomy 122
oxygenation/intubation 31 splenectomy 115, 116
measurements 2529 immunizations 173
cardiac output 2526, 29 partial 116, 192
direct 2629 sepsis after 116, 173
indirect, of flow 26 splenic artery 113
mechanisms 22 catheterization 21314
metabolic response 24, 25, 29, 31, 34 central embolization 115, 214
multiple organ dysfunction syndrome and 169 splenic injuries
neurogenic 25 bleeding 115, 116
obstructive 25 surface 115
post-shock syndromes 30 blunt injuries 114
prognosis 34 interventional radiology 21314
recommended protocol 35 children 115, 20910
resuscitation 3034 complications 116
military experience 35 delayed rebleeding 114, 116
septic 2425 diagnosis 114
unresponsive 34 haematoma 114, 230
shock wave, blast injury 184 haemostatic adjuncts 102
shunting/shunts high-grade 114, 116
abdominal vascular injury 13435 lacerations 114, 115, 230
hepatic 110 management 11415
intracaval 112 non-operative 113, 11415, 116, 213
limb vascular injuries 157 operative 115
proprietary/improvised tubing 249 minimally invasive surgery 192
silver sulphadiazine 201 outcome 11617
Skamania Conference 21920 scale/grading 114, 230
skin surgical access/approach 115
layers/grafts 194 surgical approach 11516
substitutes 200 tears 11516
skin grafts 173 splenic suspensory ligaments 113, 115
split-skin, for burns 195, 199 splenorrhaphy, mesh 116
skin staplers 249 splints, hand, after burns 201
skull, burr holes 206 split-skin grafting (SSG) 195, 199
skull fractures stab wounds
blast injury 185 abdominal 191
depressed 204 describing 8
small bowel injuries 103 pancreas 117
scale 232 renal 137
sodium, reabsorption 19, 20 staged laparotomy see damage control
Index | 275
staging, of procedures 53 systemic vascular resistance 26

see also damage control elevated 28
Staphylococcus aureus 154, 155 systolic blood pressure
staplers 249 cardiac compressive shock 24
starches, contraindicated in haemorrhage 39 cardiogenic shock 24
stent-grafts 214 death likelihood 8
sterility 248 military casualties 181
sternomastoid incision, anterior 71, 72 optimum, in shock management 32
sternotomy 80 Paediatric Trauma Score 222
median 80, 8889, 90 Revised Trauma Score 222
closure 89 see also blood pressure
technique 88
sternum, children 76 TachoSil 101
steroids, head trauma and 206 tachycardia, compensatory 23
stomach tamponade balloons, tract, liver injury management 109
blood flow, raised IAP effect 59 TA-type non-cutting staplers 249
injuries 103 Teflon pledgets 83, 90, 115
scale 232 temperature
inspection 103 body/core see body temperature
pyloric exclusion 122, 129 operating theatre 247
stress, of critical incidents 250 temporary abbreviated surgical control (TASC) 184, 186
stress response 19 tension pneumothorax 5, 8182
stress ulceration 172 diagnosis 4, 81
stroke volume 22, 26, 33 emergency management 9, 8182
subcapsular haematoma, liver 111 minimally invasive surgery cautions 192
subclavian line insertion 27 tertiary survey, in ICU 171
subdural haematoma 8, 204 testis injury 142
subphrenic abscess 116 scale 238
substrate metabolism 2022 tetanus immunization 173
sucralfate 202 thermodilution technique 29
sunburn 195 Thomas splint 154
superior mesenteric artery 99 thoracic duct, anatomy 76
anatomy 132 thoracic injuries see chest injuries
repair 132 thoracic vascular injury scale 229
superior mesenteric vein 132 thoracic viscera injuries 73
superoxide 30 thoracoscopy 79, 84
suprapubic cystostomy 14142 thoracostomy, tube see chest tubes
surgical airway 4 thoracotomy
surgical triage 179 anterolateral see anterolateral thoracotomy
survival, after trauma 22 aortic cross-clamping with 91
suspensory ligaments, splenic 113, 115 bilateral trans-sternal 91
suturing, liver 109 clamshell 80, 87, 89
swab counts 250 bilateral 91
sympatheticadrenal axis 19 definitions 85
syncope 25 emergency 80, 82, 83
systemic inflammatory response syndrome (SIRS) 17, 18, 20, emergency department see emergency department
166, 168 thoracotomy (EDT)
after burns 196, 198 left posterior lateral 80
cytokine activity 17 planned resuscitative 85
symptoms 168 posterolateral 89
thoracotomy (contd) translational research 187

resuscitative, children 209 transoesophageal echocardiography 77
trapdoor 70, 87, 89 transperitoneal incision 94
thrombin 169 transport
thrombin-activated fibrinolysis inhibitor (TAFI) 169 after triage, mass casualties 181
thrombocytopenia 41, 169 military/austere conditions 179, 181
dilutional 169 transtentorial herniation 205, 209
effect on thromboelastogram 45 trapdoor incisions (obsolete) 70, 87, 89
thromboelastogram trauma 241
interpretation 44 definition 15
normal/abnormal 44, 45 ebb and flow phases 15
thromboelastography (TEG) 41, 4445, 151 origin of word 217
thromboembolism, venous see venous thromboembolism as public health problem xxiiixxiv
thrombomodulin 169 severe see severe trauma
thrombophlebitis 173 Trauma and Injury Severity Score (TRISS) 224, 225, 226
thromboxane A2 (TXA2) 18 trauma centres 217, 219
thymus 76 designation 219
thyroid, access/approach to 72 trauma laparotomy see laparotomy
tidal volume 208 trauma registries 220
Tisseel/Tissucol 101 trauma scores/scoring systems see scoring
tissue adhesives 101, 110 trauma systems 21720
tissue hypoperfusion 16 evaluation 219
Toll-like receptors (TLRs) 16 inclusive 21718
total burn surface area (TBSA) 195, 196 components 218
total parenteral nutrition 123 organizing, steps 219
tourniquet, hepatic 109 patient management in 219
toxins, as factors in metabolic response 16, 18 results and studies 21920
tracheal injuries traumatic brain injury (TBI) see brain injury
access/approach to 72 Treitz, ligament of 98, 102
treatment 70 triage 17980, 219
tracheobronchial tree categories (military) 179
anatomy 75 field, Revised Trauma Score for 221
injuries 82, 92 forward surgical teams 180, 181
tracheostomy incident management 179
airway burns 201 military/multiple casualties 17980
head trauma 205 repeating 179, 181
percutaneous 167 reverse 179
tractotomy, pulmonary 90, 91 triple osteomy 129
tract tamponade balloons, liver injury management 109 Triservice apparatus 186
training of surgeons 241 T-tube drainage, pancreatic injuries 122
deficiencies 241 tube decompression, duodenal 12829
military trauma care 186 tumescent technique 200
severe trauma management xxiiixxv tumor necrosis factor (TNF) 17
trauma surgical causes xxivxxv tympanic membrane rupture 184
see also Definitive Surgical Trauma Care (DSTC) course
tranexamic acid 43, 169, 183 UK Battlefield Advanced Trauma Life Support course (BATLS)
transfer, military casualties 178 183
transfer time 179 UK Medical Emergency Response Team 181
transfusions see blood transfusions ulcers
transfusion-transmitted infections 41 prophylaxis, after burns 202
Index | 277
stress 172 see also peripheral vascular injuries

ultrasound 18990 instruments required 249
applications 18990 neck, treatment 6970
bladder injuries 140 peripheral see peripheral vascular injuries
chest injuries 77 vascular isolation, hepatic 110, 112
duodenal injuries 12526 vasodilators 33, 158
pancreatic injuries 118, 119 vasopressin 19
splenic injury 114 vasovagal syncope 25
see also Doppler ultrasound; FAST velocity, penetrating trauma 8
umbilical tapes 249 vena caval injuries 9394, 130
urea nitrogen 21 repair 13334
ureteric injuries 13940 retrohepatic 111, 11213
complications 140 see also inferior vena cava
diagnosis 139 venous line/access 5
DSTCcore surgical skills 245 central 26, 27, 33
scale 235 venous thromboembolism
surgical approach 13940 DVT prevention 17273
uretero-neocystostomy 140 extremity trauma 155
urethral injuries 14142 prophylaxis, after burns 202
diagnosis 141 see also deep venous thrombosis (DVT)
male 142 venovenous bypass 112
management 14142 ventilation 166, 174
pelvic injuries with 15253 children 208
repair 142 in ICU 174
rupture 142, 150, 236 in shock management 31
scale 236 weaning from 167
urine flow ventilator-associated pneumonia 172, 174
burns resuscitation 198 ventricle, right, bleeding/suturing 90
in shock 26 vertebral arteries, access/approach 72
urinoma 138 vertebral artery injuries 70
urogenital system 13543, 150 video-assisted thoracoscopic surgery (VATS) 191
US, Air Force helicopter rescue (PEDROS) 181 Vietnam War 176, 179, 181, 217
uterus visceral perfusion, raised IAP effect 59
non-pregnant, injury scale 236 visceral rotation
pregnant, injury 143, 236 left medial 99, 12021, 137
right medial 9899, 120, 133
VacPac 54 visceral structures, neck, access to 72
vacuum-assisted closure (VAC) sandwich 24950 volume expansion 39
vagina, lacerations 143, 152 fluid therapy, in shock 3233
vagina injury scale 237 von Willebrand factor 40
valproate 206 vulva injury scale 237
vascular access 5
military casualties 183 war see military conflicts and austere conditions
to renal veins 137, 138 water retention 20
vascular injuries weapons, military 177
abdominal see abdominal vascular injury Whipples procedure 119, 121, 12223, 127, 129
cervical/neck, scaling 227 Witzel technique 129
chemical 158 World Congress on ACS 57
chest, scaling 229 World Society of the Abdominal Compartment Syndrome 61
extremity 15658 wounding energy (WE) 78
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wounds X-ray
burns see burns, wounds abdominal 126
debridement/care, in ICU 173 chest 74, 77, 79, 209
as factor in metabolic response 16 blast lung injury 184
wound track 8 duodenal injuries 126
W-statistic 226 pelvic 149
Xigris (activated protein C) 17 zeolyte 1012, 183

Z-statistic 225

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Manual of Definitive Surgical

Kenneth D Boffard BSc(Hons) FRCS FRCPS FCS(SA)

This third edition published in 2011 by

British Library Cataloguing in Publication Data

Library of Congress Cataloging-in-Publication Data

ISBN-13 978 1 444 102 826

Commissioning Editor: Francesca Naish

Typeset in 9pt ITC Legacy Serif by Phoenix Photosetting, Chatham, Kent

Text printed on FSC accredited material

Board of contributors xvii

Part 2: Physiology and metabolism 13

2.1.7 Clinical and therapeutic relevance 22

Part 3: transfusion in trauma 37

Part 4: damage control surgery 51

4 Damage control surgery 53

4.1.3 Stage 3: Physiological restoration in the ICU 56

Part 5: Specific Organ Injury 65

6.1.8 Emergency department thoracotomy 85

7.5 The pancreas 117

8.3.3 Type C 149

Part 6: ADDITIONal (OPtional) modules 163

10 Critical care of the trauma patient 165

10.3.3 Prolonged life support (>72 hours post-injury) 166

11.15 Recommended reading 187

14.7.2 Ulcer prophylaxis 202

Appendix A Trauma systems 217

A.2 The inclusive trauma system 217

C.3.5 Course material and overview 242

Philip Barker Peter Danne

Sascha Floh Lenworth M Jacobs

Jan Goris Ari Leppaniemi

Gareth Hide Peter F Mahoney

David Mulder Nigel Tai

Enhanced knowledge of the surgical physiology of the

Investigation and assessment of the abdomen can be 1.2.2Management of penetrating trauma

WE = M (VEN VEX)2 the diaphragm and/or mediastinum. It is recommended

Pelvic fractures can be a significant cause of haemorrhage

1.5 References 12 Olsen WR, Hildreth DH. Abdominal paracentesis and

Physiology and metabolism

2.1Metabolic response to Increased cardiac output

These responses are marked by hyperdynamic circula-

Loss of interstitial volume be accompanied by autonomic blockade, in order to mini-

2.1.2.2Afferent impulses 2.1.2.8 Wound factors

Somatic Endogenous factors may prolong or even exacerbate the

Inflammatory (humoral) pathway

Neutrophils superoxide, elastase Uncontrolled activation of endogenous inflammatory

The immune response is complex and initially consists

2.1.2.5Free radicals 2.1.3.1Inflammatory pathway

Pro-inflammatory cytokines fundamental phenomenon, in which systemic inflam-

vasoconstricting components, and directly stimulate cer- 2.1.3.3Toxins

2.1.3.4Pathogen-associated molecular patterns and

noradrenaline (norepinephrine), cortisol and glucagon 2.1.4.2Adrenal hormones

Secretion of ADH from the supraoptic nuclei in the ante-

The gut 2.2Shock

Reduced stroke volume

Table 2.1 Classes of hypovolaemic shock

Class I 15 <750 <100 Normal Normal 1420

Clinical presentation Clinical presentation

2.2.2.5Neurogenic shock Clinical presentation

Right ventricle Pulmonary

Board of contributors xvii

Part 2: Physiology and metabolism 13

2.1.7 Clinical and therapeutic relevance 22

Part 3: transfusion in trauma 37

Part 4: damage control surgery 51

4 Damage control surgery 53

4.1.3 Stage 3: Physiological restoration in the ICU 56

Part 5: Specific Organ Injury 65

6.1.8 Emergency department thoracotomy 85

7.5 The pancreas 117

8.3.3 Type C 149

Part 6: ADDITIONal (OPtional) modules 163

10 Critical care of the trauma patient 165

10.3.3 Prolonged life support (>72 hours post-injury) 166

11.15 Recommended reading 187

14.7.2 Ulcer prophylaxis 202

Appendix A Trauma systems 217

A.2 The inclusive trauma system 217

C.3.5 Course material and overview 242

2.1Metabolic response to Increased cardiac output

2.1.3.4Pathogen-associated molecular patterns and

4.1.2Stage 2:Operative haemorrhage and Quick to do

4.1.3Stage 3: Physiological restoration in Patients with persistent bleeding despite correction

5.2.2.1Computed tomography scanning with