Trauma Management

v a d e m e c u m
Trauma Management
Demetrios Demetriades, M.D., Ph.D., F.A.C.S.

University of Southern California
Juan A. Asensio, M.D., F.A.C.S.

LANDES
BIOSCIENCE
GEORGETOWN, TEXAS
U.S.A.
VADEMECUM
Trauma Management
LANDES BIOSCIENCE
Georgetown, Texas U.S.A.
Copyright 2000 Landes Bioscience
All rights reserved.
No part of this book may be reproduced or transmitted in any form or by any
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Printed in the U.S.A.
Please address all inquiries to the Publisher:
Landes Bioscience, 810 S. Church Street, Georgetown, Texas, U.S.A. 78626
Phone: 512/ 863 7762; FAX: 512/ 863 0081
ISBN: 1-57059-641-7
Library of Congress Cataloging-in-Publication Data

Trauma management / [edited by] Demetrios Demetriades, Juan A.
Asensio.
p. ; cm. -- (Vademecum)
Includes bibliographical references and index.
ISBN 1-57059-641-7 (spiral)
1. Wounds and injuries--Treatment. 2. Traumatology. 3. Surgical
emergencies. 4. Emergency medical services. I. Demetriades,
Demetrios, 1951- II. Asensio, Juan A. III. Series.
[DNLM: 1. Wounds and Injuries--diagnosis. 2. Wounds and
Injuries--therapy. 3. Critical care--methods. 4. Emergency Medical
Services--methods. 5. Emergency Treatment--methods.
WO 700 T77569 2000]
RD93.T6892 2000
617.1--dc21
00-031657
While the authors, editors, sponsor and publisher believe that drug selection and dosage and
the specifications and usage of equipment and devices, as set forth in this book, are in accord
with current recommendations and practice at the time of publication, they make no
warranty, expressed or implied, with respect to material described in this book. In view of the
ongoing research, equipment development, changes in governmental regulations and the
rapid accumulation of information relating to the biomedical sciences, the reader is urged to
carefully review and evaluate the information provided herein.
Dedication
To my parents, my wife Elizabeth, my daughters, Alexis and Stephanie,
and my son, Nicholas.
D. Demetriades
To my family, (E, JC, AA, JAA and HV) and to the memory of AOA, SG,
RP and SG, who were instrumental in my life.
J.A. Asensio
Contents
Prehospital Care
1. Prehospital Trauma Care .............................................................. 2
Samuel J. Stratton and Mark Eckstein
Emergency Room Care

2. Initial Evaluation and Management
in the Emergency Department .................................................... 16
Jack Sava and Juan A. Asensio
3. Ultrasound in Trauma ................................................................ 29

Diku Mandavia
4. Analgesia and Sedation in Trauma .............................................. 39

William K. Mallon, Grace Ting and Maria Rudis
5. Emergency Airway Management in the Trauma Patient ............. 54

Kirsten Robinson and Sean O. Henderson
6. Shock and Resuscitation ............................................................. 69

Fred Bongard
Head
7. Management of Head Injury ...................................................... 84
Peter Gruen
8. Maxillofacial Trauma .................................................................. 94

Dennis-Duke R. Yamashita and Mark M. Urata
Neck
9. Evaluation of the C-Spine ......................................................... 115
George C. Velmahos
10. Penetrating Injuries of the Neck ............................................... 127

Demetrios Demetriades
11. Carotid Artery Injuries ............................................................. 135

S. Ram Kumar and Fred A. Weaver
12. Subclavian and Axillary Vascular Injuries .................................. 141

13. Vertebral Artery Injuries .......................................................... 152

14. Laryngotracheal Injuries ........................................................... 157

Uttam K. Sinha and Dennis M. Crockett
15. Traumatic Brachial Plexus Injuries ............................................ 171

Milan Stevanovic and Frances Sharpe
Chest
16. Blunt Thoracic Trauma ............................................................ 186
George C. Velmahos
17. Penetrating Chest Injuries: Evaluation and Management .......... 195

Arthur Fleming
18. Cardiac Injuries ........................................................................ 200

19. Lung Injuries ............................................................................ 212

William C. Chiu and Aurelio Rodriguez
20. Blunt Aortic Trauma ................................................................ 221

Ismael Navarro Nuo, Juan A. Asensio
21. Penetrating Thoracic Vascular Injuries ...................................... 229

Matthew J. Wall, Jr. and Anthony Estrera
22. Diaphragm Injuries .................................................................. 237

James A. Murray
23. Esophageal Injury ..................................................................... 249

Juan A. Asensio and Esteban Gambaro
24. CT Scan in Chest Trauma ........................................................ 254

Alison Wilcox and Randall Radin
25. Emergency Department Thoracotomy ..................................... 271

Juan A. Asensio and Kuen-Jang Tsai
Abdomen
26. Evaluation of Blunt Abdominal Trauma ................................... 281
Michael Sugrue
27. Evaluation of Penetrating Abdominal Trauma .......................... 293

George C. Velmahos
28. Hepatic Injuries and Bile Duct Injuries .................................... 303

Thomas V. Berne
29. Splenic Injuries ......................................................................... 314

John A. Androulakis and Michael N. Stavropoulos
30. Pancreatic Injuries .................................................................... 326

Juan A. Asensio and Walter Forno
31. Duodenal Injuries ..................................................................... 333

32. Colon/Rectal Injuries ................................................................ 340

Claudia E. Goetter and William F. Fallon Jr.
33. Genitourinary Tract Trauma ..................................................... 348

Eila C. Skinner
34. Abdominal Vascular Injury ....................................................... 356

Juan A. Asensio and Matias Lejarraga
35. Abdominal Compartment Syndrome ........................................ 363

36. Damage Control Operations .................................................... 370

Richard J. Mullins and John C. Mayberry
37. CT Scan in Abdominal Trauma ................................................ 380

Sravanthi R. Keesara and Nabil A.Yassa
Orthopedic Injuries
38. Extremity Compartment Syndrome .......................................... 405
George C. Velmahos and Pantelis Vassiliu
39. Penetrating Extremity Injury .................................................... 413

Edward Newton
40. Popliteal Vessel Injuries ............................................................. 420

Michael S. Walsh and John P. Raj
41. Hand Trauma ........................................................................... 426

Christopher Shean and Stephen Schnall
42. Long Bone Fractures and the General Surgeon ......................... 437
Jackson Lee
43. Pelvic Fractures and the General Surgeon ................................. 450

Jackson Lee
44. Spinal Injuries .......................................................................... 458

Larry T. Khoo, Wei-Lee Liao and Gordon Engler
Miscellaneous Topics
45. Pediatric Trauma ...................................................................... 480
M. Margaret Knudson
46. Geriatric Trauma ...................................................................... 492

47. Trauma in Pregnancy ................................................................ 496

John Fildes and Timothy Browder
48. Interventional Radiology in the Care

of the Trauma Patient ............................................................... 501
Trevor D. Nelson and M. Victoria Marx
49. Minimally Invasive Surgery in Trauma ..................................... 527

James A. Murray
50. Ballistics of Gunshot Injuries .................................................... 532

Kenneth G. Swan and K.G. Swan, Jr.
51. Blast Injuries ............................................................................. 544

Avraham I. Rivkind and Tal Luria
52. Forensics for Trauma Care Givers ............................................. 553

Thomas T. Noguchi
53. Endocrine Problems in Trauma ................................................. 563

Elizabeth O. Beale
54. MOF Failure: MOF Syndrome ................................................. 577

H. Gill Cryer
55. Surgical Nutrition ..................................................................... 581

Edward E. Cornwell
56. Acute Burn Injury ..................................................................... 585

Jeffrey R. Antimarino and Warren L. Garner
57. Inhalation Injury ...................................................................... 594

John F. Fraser and Michael Muller
58. Management
of the Potential Organ Donor Patient ....................................... 602
Bradley J. Roth
59. Hypothermia in Trauma Patients ............................................. 607

Thomas V. Berne
60. Trauma Scores .......................................................................... 610

D. Bowley and Ken Boffard
61. Crush Syndrome ....................................................................... 618

Gail T. Tominaga
62. Anesthesia of the Traumatized Patient ...................................... 623

Michael J Sullivan and Earl Moore-Jefferies
63. Transfusion Therapy ................................................................. 636

Gay Wehrli and Ira A. Shulman
64. Venous Thromboembolism After Injury ................................... 646

George C. Velmahos
65. Trauma Program Manager ........................................................ 655

Kathleen E. Alo and Pamela M.Griffith
66. Fat Embolism ........................................................................... 663

George Androulakis and Demetrios Demetriades
67. Alcohol, Illicit Drugs and Trauma ............................................ 668

Howard Belzberg
Index ........................................................................................ 674
Editors
Demetrios Demetriades, M.D., Ph.D., F.A.C.S.
Professor of Surgery
Director of Trauma and Critical Care
Division of Trauma and Critical Care
Department of Surgery
Los Angeles, California, U.S.A.
Chapters 10, 12, 13, 18, 35, 46, 66

Associate Professor of Surgery
Unit Chief, Trauma Surgery Service 'A'
Division of Trauma/Critical Care
Department of Surgery
University of Southern California School of Medicine
Chapters 2, 20, 23, 25, 30, 31, 34
Preface
This book has been prepared to serve as a quick and practical guide in the
evaluation and management of trauma patients by residents, surgeons, and
emergency physicians. The style of the text and the liberal use of figures and
algorithms make reading easy and pleasing to the reader. The authors of the
various Chapters have been carefully selected for their extensive clinical
experience in their fields. We are confident that this handbook will serve as
a good and reliable companion of those taking care of trauma patients.
D. Demetriades, M.D., Ph.D., F.A.C.S.
Acknowledgments
We are indebted to Mrs. Reina E. Lopez for overseeing and coordinating
the timely submission of all manuscripts and helping with the editing of this
book.
PREHOSPITAL CARE
CHAPTER 1
Prehospital Trauma Care

Samuel J. Stratton and Mark Eckstein
A. Emergency Medical Service Systems
Emergency medical service (EMS) systems serve to organize out-of-hospital
medical components that move ill and injured individuals into the hospital medical
system. EMS organization in the US is based on state oversight of smaller regional
or local systems. EMS components include: emergency 911 telephone access, 911
communication centers for dispatch of ambulances and other EMS units, EMS
responders (first responders, emergency medical technicians, and paramedics), designated medical command centers for radio communication with field personnel,
and EMS hospital receiving centers.
Background
The role of prehospital providers in the care of the trauma patient has undergone intense scrutiny over the past several years.
The most important steps that prehospital providers can take to minimize morbidity and mortality in the major trauma patient is to secure an airway, protect
the cervical spine, and provide rapid transport to a trauma center.
Historical Perspectives
Military EMS systems date back to the time the first armies were organized.
Civilian EMS systems originated in the 1960s after it was shown that persons
with cardiac disease suffering ventricular tachycardia or fibrillation could be
defibrillated in the field with portable equipment.
Because civilian EMS systems were initially based on an acute cardiac model,
the initial emphasis in out-of-hospital patient care was to stabilize patients in
the field and then transport them to receiving hospitals.
In the late 1970s, the concept of regional trauma systems was adopted by
many local EMS systems. Trauma systems identify trauma-receiving centers
that have expertise and dedicated resources for the acute care of trauma
victims.
As the scope of practice of paramedics expanded and the number of jurisdictions that had paramedics expanded nationwide, the same skills that paramedics successfully applied on cardiac patients were assumed to be of benefit
to major trauma patients.
With the maturing of trauma systems, it was recognized that trauma patients
may better benefit from rapid transport from the field, called load and go,
Trauma Management, edited by Demetrios Demetriades and Juan A. Asensio.
2000 Landes Bioscience.
Samuel J. Stratton, Los Angeles County EMS Agency
and Harbor-UCLA Medical Center Commerce, California, U.S.A.
Mark Eckstein, M.D., Los Angeles City Fire Department
and Los Angeles-USC Medical Center, Los Angeles, California, U.S.A.
rather than stabilization in the field, called stay and play. Providing advanced
life support (ALS) intervention often prolongs the time on-scene, which therefore delays definitive care. This was particularly significant for patients in need
of surgical hemostasis, where the time spent establishing intravenous lines, applying military antishock trousers (MAST), or carefully packaging the patient
actually increased morbidity and mortality by allowing ongoing internal hemorrhage to continue unchecked.
Current trauma management in the out-of-hospital environment emphasizes
safe and rapid transport from the field to the appropriate receiving center.
Most EMS systems now stress the need to minimize the on-scene time while
establishing an airway and protecting the cervical spine where appropriate.
Any attempts at establishing IV access should only be done while en route to
the trauma center.
Trauma Systems
A trauma system is integrated into an overall EMS system that provides all
emergency treatment and transport. A trauma system includes the personnel
and transport resources of an EMS system with the addition of recognized
trauma centers (Fig. 1.1). Trauma centers are hospitals that have dedicated
resources for the acute care of trauma victims.
Trauma centers are based on strict national guidelines that describe the types
of physicians, support staff, equipment, and facilities needed to provide optimal trauma care.
For a comprehensive trauma system, optimal trauma care not only includes the
acute medical care of trauma victims but begins with prevention of
injury and ends with the best rehabilitation processes for trauma victims.
In urban environments, about 7% of the total patients who access the EMS
system through 911 require the specialized care of trauma centers.
B. Clinical Presentation and Management of Trauma

in the Field
The out-of-hospital setting is less controlled than the hospital environment.
Equipment is limited and field personnel are not as highly medically trained as
those in the in-hospital setting. For trauma victims, the emphasis in the field is
recognition of serious trauma based on field assessment, stabilization within the
means available and rapid transport to an appropriate emergency trauma center.
Limitations in the Field

Equipment used in the EMS setting must be portable and durable. Field equipment is generally limited to a hand carried box of essential resuscitation drugs,
airway and intubation equipment, and intravenous fluids, a portable defibrillator; portable suction equipment, backboards, and personal items such as
stethoscopes and scissors.
EMS field personnel in the US are usually maximally trained to the level of a
paramedic (1,000 to 3,000 hours of instruction in all EMS skills). Minimal
training is at the first responder level, which can be 16-40 hours of instruction. Emergency Medical Technicians or EMTs [often referred to as basic life
support (BLS)] receive between 100 and 140 hours of instruction in EMS skills.
Trauma Management
Fig. 1.1. Typical inputs and outputs of a trauma center.
Prehospital care for the major trauma patient always begins with first assessing
scene safety. There may be some of the same hazards present on-scene that
caused the injury to the patient that can pose a danger to would-be rescuers,
including traffic hazards, electrical wires, environmental conditions, or perpetrators in the vicinity. In unsafe environment situations, initial care of a trauma
victim may be delayed while the scene is secured.
Often trauma victims are entrapped within an auto or other vehicle and must be
extricated using heavy equipment (jaws of life). Safe extrication can add considerable time in the field for trauma victims. Often assessment and attempted
resuscitation must be done concurrently with extrication.
During rapid transport, vehicle motion and the need for safety restraints limits the ability to assess and provide care for trauma victims.
General Management of Trauma in the Field

The primary focus for trauma stabilization or resuscitation in the field is airway, breathing (ventilation), circulation, (the ABCs) and spinal stabilization.
Shock, respiratory distress, and altered mental status are associated with high
mortality and must be rapidly identified in the field with subsequent rapid
transport to the nearest appropriate receiving center.
Observing and reporting to the receiving center the mechanism of injury is an

important aspect of field trauma care (Table 1.1).
Airway/Breathing
Ensuring an open airway for ventilation is essential for critically ill trauma
victims. Basic first aid maneuvers such as chin lift or jaw thrust can keep the
tongue and soft pharyngeal tissues from occluding the airway (Fig. 1.2). If
there is concern over possible cervical spine injury, a modified jaw thrust should
be used to open the airway while using the bag-valve-mask (BVM). This technique requires at least two rescuers to be performed properly.
Vomiting or bleeding can often complicate airway management and require
frequent suctioning to prevent aspiration and occlusion of the airway. Particular
attention should be paid to the presence of any airway obstruction, which
may be the result of copious oral secretions, excess blood pooling in the oropharynx from facial trauma, avulsed teeth, or the tongue falling back in the hypopharynx. These scenarios are particularly common when there is coexistent
head trauma resulting in a decreased level of consciousness.
Oropharyngeal or nasopharyngeal airways may be helpful in lifting the tongue
and occluding pharyngeal soft tissues from the airway in some victims.
Although these are basic devices, they must be used with caution as they can
cause upper airway injury or secondary vomiting with subsequent aspiration.
Nasopharyngeal airways should be avoided in head injured victims because
they can cause cerebral spinal fluid contamination by bacteria colonizing the
upper airway through open basal skull fractures.
For an airway obstructed by a foreign body, direct visualization of the upper
airway and removal of the foreign body with Magill forceps is recommended.
If the foreign body cannot be removed with Magill forceps, endotracheal
intubation should be attempted. In rare circumstances, cricothyroidotomy by
properly trained field personnel may be necessary to establish an open airway.
There are no controlled studies showing the benefit of prehospital intubation on
major trauma patients. The studies in the literature are all retrospective.
However the following conclusions can be made. Intubation appears to have a
beneficial effect on major trauma patients by lengthening the time that the
patient can undergo CPR and be successfully resuscitated. In addition, it appears
to improve outcomes in patients with severe head injury.
One must be mindful of the time required to perform intubation in the field.
If intubation can be performed rapidly with a minimal increase of on-scene
time or can be performed while en route, then it has the most potential to
decrease morbidity and mortality. It will improve oxygenation and simultaneously protect the patients airway from aspiration.
Indications for endotracheal intubation of trauma victims in the field include
obstructed airway that cannot be managed with direct laryngoscopy, respiratory failure, depressed mental status with loss of ability to protect the airway,
and cardiopulmonary arrest.
Intubation success rates are typically much lower in the trauma patient as
compared to the medical patient. Trauma patients requiring intubation for
respiratory failure or cerebral resuscitation usually have potential cervical spine
injury, therefore limiting the amount of movement of the head and neck that
can be performed. Vomiting with aspiration is a significant risk during intubation attempts. In addition, these patients usually have a gag reflex or trismus,
Trauma Management
Table 1.2. Revised trauma score: to calculate RTS, add the value code for each
one of the three parameters present
GCS
13-15
9-12
6- 8
4- 5
3
SBP
> 89
76-89
50-75
1-49
0
RR
10-29
>29
6- 9
1- 5
0
Value Code
4
3
2
1
0
GCS = Glasgow Coma Score, SBP = systolic blood pressure, RR = respiratory rate
Fig. 1.2. Illustration of soft pharyneal tissues occluding the upper airway as can
occur with the seriously injured trauma victim with poor muscle tone.
necessitating the use of neuromuscular paralytic agents to facilitate intubation.

Although used in some EMS systems, the safety and benefit of paralytic agents
in the field setting is currently unproven.
Esophageal obturator airways and various types of pharyngeal lumen tubes
are commonly used in the out-of-hospital setting as a backup when endotracheal intubation cannot be accomplished.
Percutaneous (needle) cricothyroidotomy techniques are preferred in the outof-hospital setting for management of the obstructed airway when basic airway management techniques fail and endotracheal intubation cannot be accomplished (Fig. 1.3). This technique is preferred because it can be rapidly
Fig. 1.3. Cricothyroid membrane, the site for emergency airway access by needle
cricothyroidectomy.
performed with a minimum of required training. Field cricothyroidotomy is

indicated when no other accepted technique for airway management has been
successful and personnel have been trained in the technique.
Assisted ventilation is indicated when a patient clinically appears to be
hypoventilating, either by shallow breathing or slow rate. Victims with chest
trauma may be unable to adequately ventilate and often require airway control with assisted ventilation.
For head injured patients, it is generally accepted that ventilation should be
assisted at a normal rate and tidal volume to avoid hypocarbia which can
decrease cerebral blood flow. For the typical adult, normal rate and tidal volume are about 16 breaths per minute at 800 ml of volume.
Needle thoracostomy is indicated for the signs and symptoms of increased
intrathoracic pressure associated with a closed tension pneumothorax. Needle
thoracostomy is accomplished by insertion into the thoracic cavity of a large
bore needle and catheter, allowing release of intrathoracic pressure, through
the second or third intercostal space at the midclavicular line.
Occasionally, an open pneumothorax (most often presenting as a sucking
chest wound) that has been managed in the field with an occlusive dressing
will develop tension. To manage this situation, the occlusive dressing should
be removed to allow relief of the tension pressure.
Circulation
For victims with signs of circulatory collapse, immediate and rapid transport
to a trauma-receiving center is mandatory.
For trauma victims in shock, venous access should be attempted during transport to a receiving center rather than prior to transport in order to minimize
time spent in the field. For entrapped victims undergoing extrication, venous
access can sometimes be established during extrication.
Trauma Management
Field resuscitation fluids are generally limited to isotonic crystalloid (normal

saline or Ringers Lactate). The use of hypertonic saline is controversial and
investigational. Blood products are generally unavailable in the field.
Intravenous (IV) lines have been a mainstay of ALS care for the trauma patient for many years. However, recent studies have found that aggressive administration of IV fluids may actually worsen patient outcome for hypotensive penetrating trauma patients.
The pneumatic antishock garment (PASG) or military antishock trousers
(MAST) may be useful for management of shock due to pelvic fracture or
uncontrolled bleeding of a lower extremity. The device consists of three inflatable compartments that when fully inflated to 60-80 mmHg externally compresses the legs, pelvis, and abdomen. This external compression raises peripheral vascular resistance, potentially supporting the blood pressure of a
hypotensive victim.
Femur fractures and other long bone fractures can result in significant blood
loss in the field. The application of a traction or air splint to a femur fracture
in the field can decrease blood loss into the fracture site.
Spinal Stabilization
Spinal stabilization, the securing of a victim to a rigid spine support device
(backboard), is an important aspect of the prehospital care of trauma victims.
Stabilization of the spine is necessary for limiting potential nervous system
damage from unstable spine fractures or dislocations during movement and
transport of the spine-injured individual. Spinal immobilization should include the entire spine, not just the cervical spine.
Any blunt or penetrating trauma with the potential for disruption of the spine
should be considered an indication for spinal stabilization in the field. Highrisk situations for spinal injury include injuries from diving into water, football injuries; falls from horseback or tractors, rear-end auto collisions, and gun
shot wounds to the neck or torso.
Victims can be cleared from the need for spinal stabilization in the field if they
are alert and have no reported or palpable spinal tenderness or pain, are without signs of intoxication, do not have painful injuries that may distract their
attention from the pain of a spine injury, and are without acute neurologic
deficits including numbness and tingling.
Complications of field spinal stabilization include inability of the victim to
handle airway secretions or bleeding which leads to aspiration, partial airway
obstruction in the unconscious victim, and discomfort.
Head Injury
In the patient with an isolated severe head injury, the emphasis should be on
airway control while protecting the cervical spine. Moderate hyperventilation
should only be performed for patients exhibiting signs of increased intracerebral
pressure (ICP). This is demonstrated by a Glasgow Coma Score of 9 or less.
Ideally hyperventilation should be performed after intubation to minimize
gastric insufflation which can lead to vomiting and aspiration.
In the head injured patient in shock from multiple trauma, fluids should not
be withheld. While the goal is not to cause further increases in the ICP, cerebral perfusion pressure must be ensured. Therefore, intravenous fluids should
be administered to achieve normotension in the multiple trauma patient

with coexistent head injury.
Trauma Triage
Field recognition of major trauma and appropriate triage to a trauma center is
essential for optimal trauma care. Field trauma triage is usually based on a
sequential assessment including physiologic parameters, evidence of severe
anatomic injury, and mechanism of injury (Fig. 1.4).
Regardless of the nature of injury, field presentation with shock, respiratory
distress, or altered mental status is associated with high risk of serious injury
and the need of specialized trauma center care.
Evidence of severe injury is an indicator of the need for high-level trauma
care. Severe head, chest, abdominal, or pelvic trauma requires trauma center
management.
The mechanism of an injury can be helpful in determination of the need for
specialized trauma care. This is particularly true for falls greater than 15 feet,
motor vehicle accidents with severe passenger compartment damage, and penetrating trauma to the neck or thorax.
Some prehospital systems also use the Trauma Score or Revised Trauma Score
(RTS) to triage victims in the field. The RTS is based on the respiratory rate,
systolic blood pressure, and Glasgow Coma Score (Table 1.2).
For multiple-victim incidents it is important to rapidly determine those patients that need immediate care versus delayed care. A common system employed is the simple triage and rapid transport (START) system which uses
respiratory status, perfusion parameters, and mental status to triage victims
into immediate, delayed and minor groups.
Transport
Rapid transport from the scene to an appropriate trauma center is of utmost
importance for the management of trauma. Airway stabilization, insuring
adequate ventilation, controlling external hemorrhage, packaging the victim
with appropriate spinal stabilization and rapid movement of the victim from
the field to a trauma center are the primary steps in efficient prehospital trauma
care. Venous access and other field maneuvers should not delay transport.
Smooth transfer of the trauma victim from the field to the hospital setting is
dependent on ongoing identification of available trauma center resources for
field personnel and notification of trauma centers from the field of incoming
traffic and the specific types of injuries suffered by the victim(s).
Transport under lights and sirens mode is often necessary but dangerous.
This type of transport places the prehospital transport unit at risk of collision
with other vehicles or obstacles and can cause watershed accidents among
other nonemergency vehicles.
Ongoing monitoring of patients while transporting is extremely difficult because of movement and noise. Movement during transport or moving a patient from the transport unit to the hospital gurney can inadvertently result in
dislodgment of an endotracheal tube from the airway.
Helicopter transport has not been shown to offer any advantage over ground
transport in an urban setting. Its use should be reserved for areas where ground
transport is either unavailable or would result in extremely extended transport
10
Trauma Management
Fig. 1.4. A typical field trauma triage algorithm (Adapted from the American College
of Surgeons Field Triage Guidelines).
times. Exceptions to this may be in jurisdictions where helicopter transport is

readily available and can provide a higher level of care than ground-based
paramedics. This often includes the ability to administer paralytic agents for
head injured patients.
11
Table 1.3. Signs of respiratory compromise in the child
Tachypnea (normal rates are age dependent)

Shallow breathing with minimal chest movement
Head bobbing with each breath
Gasping or grunting
Flared nostrils (widening of the nares with inspiration)
Stridor or snoring
Suprasternal, supraclavicular, and intercostal retractions
Accessory muscle breathing with neck and abdominal muscles
Prehospital Pediatric Trauma

Injury is the most common cause of death for children in the United States.
Prehospital management of the injured child requires an appreciation of the unique
characteristics of the growing and developing child. Good pediatric trauma care
requires more than applying adult principles. Children have unique physiologic
responses to trauma based on their age, size, and psychological development.
Multisystem involvement is the rule rather than the exception when dealing
with the injured child. All organ systems should be suspected of injury until
proven otherwise.
The most common causes of immediate death in pediatric trauma are respiratory failure and hypoxia, central nervous system trauma, and hemorrhage.
Tachypnea with signs of increased effort or difficulty breathing may be the
first manifestations of respiratory distress. Table 1.3 lists other signs of respiratory compromise that are helpful in the prehospital assessment of the child.
Injured children can rapidly deteriorate from labored ventilation to an exhausted state of respiratory failure.
Brain injury is more common in children than the adult population but for
given severity levels of brain injury, children have a lower mortality and higher
potential for recovery than do adults.
Unlike the adult, the signs of hypovolemia or significant hemorrhage in a
child are subtle and difficult to identify. The best early sign of hypovolemia is
a weak pulse as opposed to tachycardia, which is often difficult to quantify
because the normal resting heart rate in small children is fast; also fear and
pain may affect the heart rate.
Because of increased physiologic reserve, children sustaining hemorrhagic injury will frequently have minimal signs of impending shock and then rapidly
decompensate.
When required venous access cannot be obtained for stabilization of a child in
the field, intraosseous infusion can be used as an alternative site for volume
replacement (Fig. 1.5).
As in the adult, Ringers Lactate or normal saline are the best initial resuscitation fluids in the field. Usual fluid resuscitation volumes are 20 ml/kg rapid
infusion with reevaluation of circulatory status, up to 60 ml/kg total volume
in the field.
Young children have disproportionately large heads in comparison to the body
and when placing a child in spinal stabilization, padding must be used under
the torso to maintain appropriate alignment of the spine.
12
Trauma Management
Fig. 1.5. Intraoseous infusion: resuscitation fluids infused into the marrow space are
moved into the circulatory system by venous plexuses within the boney stroma.
The skeleton and soft tissues of children are more elastic and flexible than
those of the adult. Because of this anatomic flexibility, significant underlying
organ and vascular damage can occur without obvious visual signs of injury.
Table 1.4 lists signs and types of injuries that can be found in the field that
must be considered potentially unstable.
A frequent combination of injuries occurring when a car strikes a walking
child is Waddells triad. Generally the bumper of the oncoming car strikes the
femur while the fender hits the spleen or liver area, the child flies through the
air and lands on the opposite side of his head. Anticipate that a child struck by
a car will have femur, spleen or liver, and opposite side of the head injuries.
A child who is a passenger in a motor vehicle accident and restrained in a car
seat may be transported from the field in the car seat with the head taped
directly to the back of the seat to provide spinal stabilization.
Because of the short stature of a child, automobile airbags can cause fatal or
serious injury when deployed. Direct face and chest injury often result, but
most important is the potential for cervical spine injury as the childs body is
thrown forward by an impact and the head hyperextended backward by a
deployed airbag.
C. Common Mistakes and Pitfalls

Trauma is not treated in the field; rather the patient is stabilized for transport
for treatment. Safe and rapid transport from the field to an appropriate trauma
treatment center is the foremost task in prehospital trauma care.
13
Table 1.4. Signs and mechanisms of injury associated with potential serious
injury in the child
Poor environmental response: lack of alertness

Difficulty breathing
Signs of shock or circulatory instability
History of unconsciousness postinjury
Significant blunt trauma to the thorax
Fractured ribs
Significant blunt trauma to the abdomen
Pelvic fracture
Considering safe and rapid transport as primary in the field management of

trauma, insuring an open airway and adequate ventilation are the primary
medical tasks in the field.
Prehospital airway management in trauma can be difficult. Some prehospital
systems aggressively encourage advanced airway techniques and some use paralytic agents to facilitate endotracheal intubation. Generally, evidence shows
that if the airway can be maintained during transport and the victim ventilated by means of basic rescue maneuvers, there is less time spent in the field
and a better chance of establishing a secure and timely airway in the emergency center.
Intravenous fluid administration in the field is of secondary concern. Time
should not be taken to establish venous access or administer field fluids. Again,
rapid transport to a trauma center is paramount. Studies have suggested that
aggressive administration of fluids in the field setting of hemorrhagic shock
may be detrimental for some victims, particularly those with penetrating chest
injuries. In general, prehospital fluids should be secondary to moving the patient to the operating room where bleeding sites can be controlled surgically.
The use of the PASG in the field is controversial. Little data exists to support
the use of the device. It is accepted as useful in the setting of pelvic fractures or
for air splinting long bone fractures of the legs. In other settings of hemorrhagic shock the device has not been proven useful and can have detrimental
effects by increasing the rate of uncontrolled hemorrhage. In the setting of
thoracic trauma, evidence suggests that the use of PASG in the field leads to
increased mortality, probably as a result of increased bleeding rates into the
thoracic cavity.
For children under seven years old and those over 65 years old, the usual
methods of field triage for serious trauma are imprecise and clinical evaluation
difficult. Trauma victims at the extreme of ages, pediatric and elderly, are at
higher risk of poor outcome and should be managed with extreme caution.
Mechanism of injury is important information that should be transmitted
from the field to the receiving hospital. For example use of seat belts and air
bag deployment in the setting of an auto accident are important for the receiving trauma center personnel to know in assessment of a patient.
Field trauma triage systems are purposefully designed to over triage victims to
trauma centers so that transport of the seriously injured is usually to trauma
facilities.
14
Trauma Management
References
1.
1
2.
3.
4.
5.
6.
Norcross ED, Ford DW, Cooper ME et al. Application of American College of

Surgeons Field Triage Guidelines by prehospital personnel. J Am Coll Surg 1995;
181:539-544.
Pepe PE, Eckstein M. Reappraising the prehospital care of the major trauma patient.
Emerg Med Clin N Amer 1998; 16:1-15.
Bickell WH, Wall MJ, Pepe PE et al. Immediate vs. delayed fluid resuscitation for
hypotensive patients with penetrating torso injuries. N Engl J Med 1994;
331:1105-1109.
Domeier RM, OConnor RF, Delbridge TR et al. Use of pneumatic antishock
garment (PASG). Prehospital Emerg Care 1997; 1:32-35.
National Association of EMS Physicians. Indications for prehospital spinal immobilization: National Association of EMS Physicians Standards and Practice Committee. Prehospital Emerg Care 1999; 3:251-253.
Eckstein M, Suyehara D. Needle thoracostomy in the prehospital setting. Prehospital
Emerg Care 1998; 2:132-135.
EMERGENCY ROOM CARE
CHAPTER 2
Initial Evaluation and Management

in the Emergency Department
Jack Sava and Juan A. Asensio
Introduction
There are approximately 140,000-150,000 deaths resulting from traumatic
incidents in the United States each year. It is estimated that approximately
one third of these deaths are preventable or potentially preventable.
Trauma is the leading cause of death for people under the age of 44.
Trauma respects no boundaries, neither age, sex or ethnicity. It clearly affects
members of all socioeconomic strata in North America and throughout the world.
Trauma deaths occur in a tri-modal distribution.
- The first peak of death occurs at the time of injury. These injuries are usually so
devastating that only few patients are able to arrive alive but in extremely critical condition to trauma centers.
- The second peak of death occurs in the initial hour from the time of origin of
the traumatic incident and has been dubbed the Golden Hour. The most
important causes of death in this period are generally exsanguination from injuries to the major components of the cardiovascular system, major abdominal
solid visceral injuries, open pelvic fractures and space occupying intracranial
hemorrhagic lesions. It is precisely in this period, when a well organized and
immediate trauma response can be quite effective in decreasing morbidity and
mortality, provided rigid protocols are instituted to evaluate and manage these
patients expediently and definitively.
- The third peak of death generally occurs days to weeks after the initial traumatic injuries in patients that have sustained serious injuries and experience
complications such as sepsis, reperfusion injuries and multiple systems organ
failure (MSOF).
Early in the 1970s the Committee on Trauma (COT) of the American College of Surgeons (ACS) began to establish standards for the development of
regionalized trauma care systems in the United States. Simultaneously, the
implementation of the Advanced Trauma Life Support course (ATLS) was
promulgated to provide basic skills in the initial assessment and care of injured patients. This course describes the necessary steps to assess, identify and
treat injuries during the Golden Hour. It has become the standard of care
nationally and internationally.
The key components of a regional trauma system are an efficient EMS program and well-organized regionalized trauma centers. These centers must have
trauma teams available 24 hours, staffed by trauma and surgical critical care
Jack Sava, University of Southern California, Los Angeles, California, U.S.A.
Juan A. Asensio, University of Southern California, Los Angeles, California, U.S.A.
Initial Evaluation and Management in the Emergency Department
17
experts and emergency medicine, as well as a multidisciplinary team including radiologists, nurses, rehabilitation specialists, and surgical specialists.
- Additionally, there must be immediate availability of operating rooms,
intensive care units, and burn facilities. It has been consistently shown that in
severely injured patients, rapid and direct transportation to a trauma center will
avoid preventable deaths.
- The American College of Surgeons through its verification program has clearly
set forth the standard guidelines for certification and ongoing development of
these systems.
The Trauma Team

Patients are triaged both in the field and in the emergency department.
When specific criteria suggesting a possible serious injury are met, the trauma
team is activated through a trauma alert system. The entire team responds
immediately. The USC Trauma Center criteria for the activation of the trauma
team include systolic blood pressure of less than 90, heart rate of greater than
120, respiratory rate of less than 10 or greater than 29, multiple trauma
patients, patients who are unresponsive to pain (at the scene or in the emergency
room), and age >70 years. In addition, the triage officer may activate the trauma
alert system at his/her own discretion for any reason.
- Ideally, the team arrives before the patient. The trauma surgery attending
physician is the team leader. Each team member must understand their role.
Communication is essential, and discussion of potential scenarios prior to the
arrival of the patient can be very useful.
- The operating room should be notified and made aware of a possible emergent
case.
- The radiology team should be ready and waiting for patients arrival.
Protecting the Trauma Team

- Needlesticks and splashes are endemic in acute trauma management.
- Universal precautions are probably more important here than in any other part
of the hospital, given the patient population, use of sharp instruments and
needles, number of staff, and accelerated pace of trauma assessment.
- Be careful of unexpected sharps such as broken ribs and retained missiles or
foreign bodies.
The team leader is responsible for keeping the resuscitation smooth and calm.
Initial Assessment
All trauma patients are assessed by a primary survey, resuscitation, secondary
survey, and definitive care.
The goals of these phases are as follows:
- Primary survey : Identify injuries that may be life threatening immediately or
within minutes
- Resuscitation: Stabilize and/or treat these immediately lethal injuries
- Secondary survey: Identify injuries that are less rapidly fatal, but still potentially
lethal, as well as all other injuries
- Definitive care: Treatment (surgical or otherwise) of identified injuries
- The more drastic the situation, the more closely this template should be followed. In actual practice many steps will likely proceed simultaneously (i.e.,
primary survey and resuscitation).
18
Trauma Management
Primary Survey
Evaluation of all trauma patients begins with the ABCs:
A: Airway. Establish a patent airway while avoiding cervical spine injury

B: Breathing. Ensure effective ventilation
C: Circulation. Identify shock and life threatening hemorrhage
D: Disability. Briefly assess neurologic status
E: Exposure/Environment. Remove all clothing. Keep patient warm.
Airway
Assessing for a patent airway is the highest priority. Ask the patient a question.
If they can speak normally, they have a patent airway, can breathe on their
own, and have adequate cerebral perfusion for mentation.
Look in mouth. Clear the oropharynx.
Apply pulse oximeter.
Massive facial injuries may cause loss of airway control.
Maintain c-spine stabilization while evaluating and managing airway.
Endotracheal intubation is indicated for :
- inability to adequately oxygenate or ventilate due to thoracic trauma
- GCS < 8. Consider intubation if GCS > 8 but patient will be transported to
other areas where emergency airway management will be suboptimal
- face or neck injuriesblunt or penetratingthat threaten the stability of the
airway
- multiple, severe injuries especially in elderly patients
- severe shock
- very restless, combative patients who put at risk themselves or the care givers.
Rapid sequence intubation is the usual technique of securing the airway. (see
Airway Chapter)
Verify that ETT is in proper position
- Ambubags are fitted with CO2 sensors that change color when the tube is
properly in the airway
- Verify that there are bilateral breath sounds and that there are no sounds over
the stomach. If breath sounds are heard over the right hemithorax only, the tube
is likely in the right mainstem bronchus and should be withdrawn appropriately.
Cricothyroidotomy should be promptly performed if three attempts at intubating a paralyzed patient are unsuccessful or there are massive facial injuries
preventing intubation.
- in children less than 12, cricothyroidotomy is generally avoided, due to an
increased risk of subglottic stenosis. Needle cricothyroidotomy is used until
intubation or tracheostomy can be accomplished
Breathing
Evaluate for effective ventilation
- Assess the chest wall for symmetric rise with inspiration.
- Palpate the trachea to ascertain a midline position. Palpate the chest wall for
subcutaneous emphysema or chest wall deformity.
- Auscultate for breath sounds. If breath sounds are obviously diminished, a chest
tube should be placed immediately to evacuate air or blood. If there is a question
about symmetry of breath sounds, wait for chest x-ray, provided that the patient
is hemodynamically stable and saturating well.
19
Several chest injuries may be rapidly fatal and must be immediately identified
and treated.
- Tension pneumothorax. This may occur in blunt or penetrating trauma. The
diagnosis is clinical, based on decreased breath sounds on the injured side, deviation of the trachea away from the injured side, and signs of respiratory and
hemodynamic collapse, including hypotension and elevated neck veins. Traditionally, treatment is with needle thoracostomy, followed by tube thoracostomy.
- Open pneumothorax (sucking chest wound) prevents effective ventilation. Treatment is tube thoracostomy at a site away from the chest wound, followed by
occlusive dressing.
- Flail chest occurs when two or more breaks occur on at least three adjacent ribs,
creating an island of chest wall that moves paradoxically. Frequently these patients have severe underlying pulmonary contusion and require ventilatory
support.
Circulation and Bleeding

Check heart rate and blood pressure
- Remember that pulse and blood pressure are LATE signs of shock, and will not
be observed until there is severe blood loss or circulatory dysfunction. To identify early shock, keep in mind the various derangements that occur before hypotension or tachycardia:
- Any trauma patient with cool, clammy skin is in shock until proven otherwise.
- Blood flow to the brain may be inadequate, resulting in combativeness or lethargy.
- Sympathetic discharge will cause diastolic hypertension and resultant narrowing of pulse pressure, while systolic pressure may be maintained until the patient
decompensates.
- If available, several monitoring modalities may be used to detect subtle
hypoperfusion, including transcutaneous oxygen and CO2 measurement.
Beware of deceptively normal vital signs in the following patients

- Children have a remarkable compensatory ability, and may maintain relatively
normal vital signs until they are near death, at which time they experience sudden and often irreversible cardiovascular collapse.
- Elderly patients may be unable to mount a compensatory tachycardia, which
may mask shock.
- Athletes, like children, may compensate for blood loss with increases in stroke
volume, until profound hypovolemia causes collapse.
- Patients on street or prescription drugs may not mount tachycardia (e.g., betablockers) or may have inappropriate tachycardia (e.g., cocaine).
Check for pulses

- Carotid. A carotid pulse implies a systolic pressure of approximately 60 mm Hg
- Femoral = 70 mm Hg
- Radial = 90 mm Hg
Establish intravenous access. Frequently patients arrive with intravenous lines

in place, but these must be assessed for adequacy.
- Two large (14 or 16 gauge) upper extremity lines are ideal. Avoid lower extremity
lines if iliac vein or IVC injury is suspected. If peripheral lines cannot be placed,
an 8.5 F introducer (Cordis) is placed, either in the subclavian or femoral vein. If
this is not successful, a greater saphenous vein cutdown is performed 1 cm superior and 1 cm anterior to the medial malleolus.
20
Trauma Management
In children younger than 6 years, interosseous infusion should be considered in cases with difficult peripheral veins when venous access is difficult.
If there is evidence of hemodynamic compromise, consider different types
of shock.
Hypovolemic/hemorrhagic shock
-
most common type of shock seen in trauma patients

neck veins are typically flat
hemorrhage may be internal or external
Initial resuscitation is with 2L Ringers Lactate (RL). This solution offers several
advantages over normal saline (NS). The pH of RL is 6.5, whereas pH of NS is 5.
Use of the more acidic NS contributes to potentially lethal hyperchloremic
metabolic acidosis. Also, shock patients recruit fluid from their interstitial space
to replace lost intravascular volume. RL most closely approximates the electrolyte composition of the depleted interstitial space.
- Colloid solutions (albumin, hetastarch, gelatins) are expensive and have been
associated with worse outcomes. They are not used in acute trauma resuscitation.
- If still unstable, transfuse O- blood (not typed or crossed). Always use a microfilter
and blood warmer.
- Rapid transfuser technology is very useful for rapid delivery of warmed blood
and crystalloids.
Neurogenic shock
- Caused by disruption of sympathetic chain next to spinal cord, resulting in loss
of vasomotor tone
- Patients with lesions in the upper cervical cord lose sympathetic innervation of
the heart and will not be able to mount a compensatory tachycardia. Lesions
below this will be accompanied by appropriate tachycardia.
- Treatment is aggressive fluid resuscitation, and alpha agonists such as dopamine
may rarely be necessary
- Usually, neurogenic shock is associated with serious spinal cord injury. However, rarely, the sympathetic chain may be injured with relatively little injury to
the spinal cord.
Cardiogenic shock
- occurs when the heart is unable to eject blood or sustain an adequate cardiac
output
cardiac contusion causing myocardial akinesia or dyskinesia
pericardial tamponade
tension pneumothorax causing the SVC to twist on its axis, and preventing
venous return via the IVC.
air embolism preventing coronary artery perfusion
myocardial infarction
- The treatment for cardiogenic shock depends on the cause.
MI and contusion are treated with close monitoring, as well as inotropic
agents and antiarrythmic agents as necessary
Pericardial tamponade is treated by emergent surgical decompression
Tension pneumothorax is treated by needle or tube thoracostomy
Air embolism is treated by placement of the patient in Trendelenburg position, and an attempt should be made to aspirate air from the heart using a
pulmonary artery catheter.
21
Control of Hemorrhage
External bleeding should be controlled with direct pressure. Attempts at
clamping and ligation of individual vessels under suboptimal conditions should
be avoided. Remember that blood vessels are frequently found in neurovascular
bundles with important nerves. Attempts at clamping may result in iatrogenic
injury to other structures. Avoid tourniquets unless a decision to sacrifice a
limb to save life has been made.
There are several tips for controlling bleeding in the emergency department:
- Foley catheters may be effectively used in certain scenarios to stop or slow bleeding. Usually the catheter is inserted in the tract of a penetrating injury, the
balloon inflated, and the catheter withdrawn. A clamp is then placed at the level
of the skin to maintain tension.
thoracic inletthe catheter may be used to temporarily compress a bleeding subclavian vessel against the clavicle
chest/intercostalthe catheter may stop intercostal bleeding, and the lumen allows drainage and measurement of hemothorax
facial injuriesmay stop bleeding without resorting to surgery, which is
frequently ineffective and often causes additional injuries
- scalp lacerations may cause exsanguination. They should be rapidly sutured
with a running locking stitch in one layer.
- anterior and posterior nasal packing often controls nasal hemorrhage
Disability
The Glasgow Coma Scale remains the gold standard in grading the mental
status of all trauma patients. This provides a rapid means for quantifying
changes in mentation.
It is essential to frequently and quantitatively reevaluate the level of consciousness. Subtle changes in GCS may be missed by a brief or careless exam, especially in comatose patients.
- PITFALL: Failure to notice deterioration in GCS in unresponsive patients.
Check the pupils for size, symmetry, and reactivity to light. Anisocoria or
blown pupils may occasionally be diagnosed in patients with previous eye
surgery, isolated third cranial nerve injury, or direct ocular impact.
Check for motion of extremities. Note any asymmetry.
The rectal examination gives important information about potential spinal
cord injury.
Patients diagnosed with blunt spinal cord injury should be given high dose
Methlyprednisolone (30 mg/kg bolus + 5.4 mg/kg/hour) Treatment duration
is 24 hours if started within 3 hours of injury, 48 hours if started 3-8 hours
after injury. Steroids should not be started more than 8 hours after injury, and
are not helpful in brain injury or penetrating spinal injury. Used appropriately, they may lower the spinal level at which neurological function is lost. In
the case of high cervical spine injury, this may mean the difference between
spontaneous breathing and ventilator dependence. However, when used late
or in penetrating injuries, they will result in an increase in septic complications with no neurological benefit.
Do as thorough an exam as possible before sedating and paralyzing patient.
22
Trauma Management
Exposure/Environment
All clothing is removed to avoid missed injuries.

Remove any restrictive jewelry.
Hypothermia is one of the biggest enemies of the trauma patient. Decrease in
core temperature of just one to two degrees causes severe coagulopathy, respiratory depression, decreased myocardial contractility, decreased renal and gut
perfusion, and obtundation. Elderly patients, and patients intubated before
arrival at the trauma center are particularly prone to hypothermia:
-
maintain emergency room and operating room temperature high

use warm blankets and circulating air mattresses liberally
warm all intravenous fluids and blood
use warm humidified air in ventilators
Secondary Survey
The secondary survey involves a thorough head-to-toe physical exam and is
accompanied by radiographic studies. The biggest pitfalls in the secondary
survey usually result from failure to examine the areas of the patient that are
inaccessible: The back, buttocks, and perineum. The importance of a complete and thorough examination cannot be overemphasized.
The following are routine parts of examination of the trauma patient:
- Head: Examine for lacerations, hematomas and skull fractures. Frequently the
posterior aspect of the head can only be seen when the patient is log-rolled.
Examine the face for stability. Note periorbital ecchymosis (Raccoons eyes) and
mastoid ecchymosis (Battles sign), which suggest a basilar skull fracture. Also
note any clear fluid leaking from nose or ears (rhinorrhea or otorrhea), which
may be CSF, also suggesting basilar skull fracture.
- Neck:
Palpate the trachea to look for deviation, suggesting tension pneumothorax.

If vascular injury is suspected, listen and feel for bruit or thrill.
All patients with potential cervical spine injuries should be immobilized in
semirigid collars. The collar may be removed for examination if the neck is
stabilized. Missed cervical spine injuries are devastating to the patient, staff,
and hospital. Examination in trauma patients may be unreliable for a number of reasons, including intoxication, head injury, and distracting injury.
However, in select patients with an intact sensorium, no distracting injuries,
and no alcohol or drug use, cervical spine injury may be effectively ruled
out by the following exam:
- Palpate the spinous processes for step-offs or deformity.
- Ask the patient to rotate their head from side to side, and then to flex and
extend, lifting their head off the gurney. If there is any posterior neck
discomfort, the exam should be terminated and the collar replaced.
- Press on the top of the patients head to axially load the cervical spine.
Chest
- Inspect the chest for any wounds or abrasions.
- A seat belt sign over the anterior chest should suggest a forceful thoracic
blow, and should raise concern for blunt thoracic injury.
- Palpate the thoracic cage for fractures. Flail chest is frequently missed on
plain radiography, but may sometimes be seen clinically.
- Auscultate for bilateral equal breath sounds.
23
Remember that chest wounds below the nipple line are potentially
abdominal wounds. Thoracoabdominal wounds are also suspicious for diaphragmatic injury.
- Virtually all patients receive a plain chest radiograph. If there is no spinal
injury, upright films are better.
Abdomen
- Look for distention. Most commonly, this will be due to hemoperitoneum,
but it may also result from retroperitoneal bleeding, inadvertent esophageal
intubation and ventilation, gastric distention, or an undrained bladder.
- Evaluate for tenderness and signs of peritoneal irritation.
- A full bladder or stomach may be a misleading cause of abdominal/pelvic
discomfort. A Foley catheter and nasogastric tube should be placed if not
contraindicated.
- A seat belt mark over the abdomen is an important sign, and suggests an
increased risk for intraabdominal injury.
Pelvis
- The pelvis is examined for anterior/posterior instability, lateral instability, or
acetabular disruption. To evaluate AP stability, place one hand on each anterior
superior iliac spine and push firmly towards the floor, feeling for any crepitus or
instability. Also, press on the sypmphysis pubis, evaluating for motion. For lateral stability, grasp the iliac spines and compress inward, toward the midline.
Most unstable pelvic fractures will be identified by this test. Bend each leg and
flex the hip, feeling for instability and crepitus in the acetabulum.
- If pelvic ring instability is diagnosed, no further examinations should be performed, as rocking the fracture site may increase bleeding.
- Rectal and vaginal exams should be performed. Examine for signs of violation
of vaginal or rectal mucosa, signifying an open fracture. Inspect the perineum
for lacerations. The rectal exam is particularly useful in the following scenarios:
suspected rectal injury. Look for gross blood.
suspected spinal cord injury. Feel for tone. Have the patient squeeze. If possible, test for perianal sensation, indicative of sacral sparing in spinal injuries.
suspected urethral tear. Feel for a high riding prostate. If present, Foley
catheter placement is contraindicated.
- Unstable pelvic fractures may bleed massively into the retroperitoneum. There
are several techniques for controlling this bleeding:
1. Pelvic angiography with gelfoam or coil embolization. Consider early angiography in the following high risk groups:
have clinical evidence of bleeding associated with pelvic fracture
have high-risk fractures (bilateral superior/inferior ramus, sacroiliac separation,
or pubic diastasis > 2.5 cm)
show a contrast blush on CT pelvis, indicative of active bleeding
2. External fixators may be applied in the emergency department, or in the operating room. They work best on open book fractures with pubic diastasis.
3. A sheet may be tied tightly around the pelvis, which will contain hemorrhage
preventing further volume expansion of the pelvis.
Back
- Examination of the back is routine in all trauma patients. In any patient with a
possible spinal injury, the patient must be log-rolled. One team member must
stabilize the head during this procedure.
24
Trauma Management
- Look for any wounds. Clear skin of broken glass and debris to avoid missing
injuries.
- Feel all spinous processes for deformity or malalignment, and to assess for
tenderness
Extremities
- Look for wounds or deformities. Ecchymosis frequently signals an underlying
fracture. External bleeding from extremities is best controlled by direct pressure. A tourniquet is almost never necessary.
- In any limb with a possibility of vascular injury (fracture, dislocation, penetrating wound), a complete vascular exam should be performed, documenting the
presence and character of the pulse. Furthermore, the Doppler occlusion pressure of the injured limb should be compared to an unaffected extremity. A ratio
of affected limb to unaffected limb of less than .95 suggests possible vascular
injury and demands further investigation.
- Injured extremities should be immediately and frequently evaluated for compartment syndrome. This occurs when bleeding or edema elevates the pressure
in a fascial compartment high enough to limit capillary perfusion, resulting in
ischemia and necrosis. Clinical exam of relevant compartments should be accompanied by measurement of compartment pressures when there is any concern of compartment syndrome.
- All fractures should be immediately immobilized. This drastically reduces pain,
helps control bleeding, and prevents further damage to neurovascular structures. Open fractures should be dressed with sterile saline gauze dressings.
- Keep in mind that bony fractures may be the source of substantial blood loss
femur fractures may result in 1500 cc blood loss
humeral or tibial-fibular fracture may result in 750 cc blood loss
rib fractures may result in 125 cc blood loss per fracture
pelvic fracture may result in 250 cc blood loss per break (i.e., each broken
ramus = 250 cc)
Motor nerve function in the upper extremity can be rapidly assessed by testing
the following five nerves:
median: have the patient make an O with their thumb and 2nd finger
radial: have the patient extend their wrist
ulnar: spread fingers apart
axillary: abduct arms
musculocutaneous: flex elbow
Adjuncts
The following are routine in evaluation of all trauma patients:
Monitors continuous ECG and pulse oximetry, as well as intermittent
noninvasive blood pressure measurement, are mandatory
Supplemental O2. Inadequate oxygen delivery is characteristic of posttraumatic shock, and oxygen content of blood is directly related to saturation of
hemoglobin.
12-lead ECG is used to rule out myocardial contusion or infarction
A Foley catheter is placed, unless contraindicated
A nasogastric tube is placed, unless contraindicated by:
raccoons eyes
rhinorrhea/otorrhea
penetrating neck injury
25
AMPLE history
Allergies
Medications
Past illness/Pregnancy
Last meal
Events of injury
Investigations
The following investigations may be used in the further evaluation of the trauma
patient:
Plain x-rays are frequently used as adjuncts to the initial evaluation and resuscitation
Prioritize! The first film should be a chest x-ray, followed by an AP pelvis film
Chest X-ray
identifies pneumo/hemothorax, rib fractures, clavicular fractures, and other
chest wall injuries
used to assess for signs of aortic injury, i.e., mediastinal widening, tracheal/
nasogastric tube deviation, apical capping, loss of detail of the aortic knob
may reveal pulmonary contusion
assesses placement of endotracheal tube and thoracostomy tubes
AP Pelvic X-ray
identifies most fractures, and nearly all unstable fractures. Injuries are best
delineated by CT with fine pelvic cuts.
Cervical Spine
the standard cervical spine series includes lateral, AP, and open-mouth
odontoid projections
remember that cervical spine x-rays are not life saving and should not delay
vital procedures or surgery. If necessary, keep the cervical collar on, maintain precautions, and investigate the cervical spine when the patient is
stabilized
Computed Tomography (CT)

CT head
identifies operable mass lesions and intracranial hemorrhage
indicated in all patients with loss of consciousness, abnormal level of consciousness, or gunshot wound to head
CT cervical spine
CT of cervical spine is performed in most patients with severe head injury,
as they frequently cannot be examined clinically, and they are at risk for
spinal injury
Remember that CT only shows cross-sectional images and may miss
malalignment, dislocation and ligamentous injuries.
CT Abdomen/Pelvis
may be used when clinical evaluation of the abdomen is equivocal or unreliable
Advantages: very sensitive for solid organ injuries and free peritoneal air or
fluid. 80-95% sensitive for pancreatic/duodenal injuries.
Drawbacks: Frequently misses injuries to mesentery, bowel, and diaphragm.
More importantly, takes up to an hour and requires transport. Should not
be used on unstable patients.
26
Trauma Management
CT Chest
it may be used to reliably rule out blunt aortic disruption if there is clinical
or radiographic suspicion of aortic injury
it will accurately identify rib fractures, parenchymal hemorrhages, and flail
segments that may be missed on plain radiographs
it will identify small pulmonary contusions and retained hemothoraces.
for transmediastinal gunshot injuries, the trajectory of the bullet can be
traced by visualization of air bubbles or metal fragments in the path of the
missile . This allows us to be more selective in further diagnostic studies.
CT Spine/Pelvic Bones
used to delineate injuries before definitive treatment
Ultrasound: A focussed ultrasonic exam is used on every trauma patient to

identify fluid in the abdomen and in the pericardium.
Advantages: Very rapid, reliable in expert hands. Useful when there is a question of which body cavity is bleeding.
Drawbacks: User dependent. Only identifies fluid, not specific injuries.
Diagnostic peritoneal lavage (DPL)

used for rapid evaluation of abdomen
Advantages: Very fast. Can be used to rule out exsanguinating abdominal bleeding in a few minutes
Drawbacks: May be false positives/false negatives depending on which cutoffs
are used. May miss bowel injuries.
For rapid assessment of gross intraabdominal hemorrhage, the catheter is inserted and a syringe used to aspirate for gross blood.
More accurate evaluation may be performed by lavaging abdomen with one
liter of saline and evaluating the effluent cytologically. Positive results are:
More than 100,000 red blood cells/ml
More than 500 white blood cells/ml
Fecal or food particles
Elevation of amylase in lavage fluid in the absence of serum elevation raises
concern for pancreatic or bowel injury
Angiography. An experienced and available angiography team is tremendously

helpful in several diagnostic or therapeutic trauma problems in all body areas.
Establishing Management Priorities in Diagnostic

and Therapeutic Dilemmas
One of the most challenging aspects of trauma management is the prioritization
of various diagnostic and therapeutic procedures. Each case demands judgment and
individualization, but the following are examples of common dilemmas.
Patient with Low GCS and Possible Multiple Injuries
Use the ABCs to find out if the patient is stable or in shock. If the patient is
stable, an emergent CT scan of the brain supersedes all other priorities, because
early evacuation of an expanding brain hematoma may prevent irreversible brain
damage. Unnecessary procedures must be avoided or postponed, but usually it
is worthwhile to perform a quick chest x-ray. The patient must be intubated if
the GCS is less than 8 or appears to be worsening.
PITFALL: Do not delay head CT to evaluate the cervical spine, place a Foley
catheter or perform any other procedure that is not lifesaving.
Conversely, if the patient is unstable, do not send them to the CT suite. The
27
source of shock must be found and addressed. The patients may need to be
operated first, and rushed for a brain CT afterwards.
PITFALL: Do not transport unstable patients to the CT scanner. Address lifethreatening hemorrhage before brain injury.
Shock of Unknown Origin

Remember the different types of shock . Identify or exclude sources of cardiogenic shock or neurogenic shock. Usually, if these are not present, the patient is
bleeding. Sometimes this will be confirmed by a drop in hematocrit. The goal is
to find the source of the lost blood, which can only be in a few places:
the chest: This can be ruled out with auscultation and chest radiograph.
the abdomen: Blood in the abdomen is usually identified by trauma
ultrasound. CT is very helpful, but dangerous in an unstable patient. Diagnostic peritoneal lavage is a quick way to detect intraabdominal bleeding.
the pelvis/retroperitoneum: An AP pelvic x-ray will identify any pelvic fracture bad enough to cause significant bleeding.
the thighs. Femur fractures may bleed several units into surrounding tissues
external bleeding. Ask the paramedics if there was substantial blood loss on
scene. Inspect the gurney and floor for evidence of external blood loss.
PITFALL: Do not attribute shock to intracranial injury.
Unstable patient with pelvic fracture and unevaluable abdomen. Is the problem
in the abdomen or in the pelvis?
Perform a supraumbilical DPL. If grossly positive, the patient should immediately
undergo laparotomy. If negative, or only microscopically positive, the bleeding
has probably resulted from the pelvic fracture and the patient should have external fixation or angioembolization. ER ultrasound may also be used to rule
out exsanguinating intraabdominal bleeding.
Patient with Intraabdominal Hemorrhage and Radiographic Findings Suspicious for Aortic Tear
Proceed with laparotomy. Evaluate aorta with spiral CT or angiogram postoperatively. If the patient has a ruptured aorta but survived to hospital, their aorta
is not likely to be bleeding freely. Active hemorrhage in the abdomen or elsewhere should be addressed. Then the aortic injury may be repaired.
Penetrating Thoracoabdominal Injuries (Between Nipple Level and Costal

Margin)
Remember that gunshot injuries to the thorax are associated with abdominal
injuries in 30-40% of cases.
Liver, spleen, stomach, and colon are the most commonly injured abdominal
organs.
evaluate the abdomen using physical exam and ultrasound or DPL
evaluate the chest using auscultation and CXR. Chest tube will drain hemo/
pneumothorax as well as quantifying chest bleeding.
if there are indications for both thoracotomy and laparotomy, the surgeon must
exercise judgement as to which procedure to choose first. If there is any question, open the abdomen, control any life-threatening bleeding. Then pack the
abdomen while you open the chest. When thoracic bleeding is controlled, return
to the abdomen for formal exploration.
28
Trauma Management
References
1.
2.
3.
4.
5.
Cales RH, Trunkey DD. Preventable trauma deaths. A review of trauma care systems development. JAMA 1985; 254:1059.
Moore FA, Moore EE. Trauma resuscitation. Chapter 2. In: Care of the Surgical
Patient. Wilmore DW, Brennan MF, Harken AH et al, eds. 1998; 1-15. New York:
Scientific American I.
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Course for Physicians. Manual. Chicago. American College of Surgeons 1997.
Krantz BE. Initial assessment. Chapter 9. In: Trauma. Feliciano DV, Moore EE,
Mattox KL, eds. 3rd ed., 2000; 153-170 Stamford CT: Appleton and Lange.
Nordenholz KE, Rubin MA, Gularte CG et al. Ultrasound in the evaluation and
management of blunt trauma. Ann Emer Med 1997; 29:357.
CHAPTER 1
CHAPTER 3
Ultrasound in Trauma
Diku Mandavia
Introduction
Ultrasound has been used to evaluate emergency patients since the 1970s but
only in the last 10 years has there been significant interest in the United States. At
many European centers, ultrasound has essentially replaced diagnostic peritoneal
lavage. Many prospective studies done by emergency physicians and surgeons here
in the United States confirm that this modality can be used by nonradiologists with
the reported sensitivity for free intraperitoneal fluid varying from 80-90% and the
specificity 95-100%.
U/S vs. DPL vs. CT

Ultrasound (U/S) has significant advantages over diagnostic peritoneal lavage
(DPL) and computed tomography (CT) for the rapid detection of intraperitoneal bleeding in critically injured patients.
U/S is a fast technique requiring < 5 minutes for a full exam, is noninvasive,
and can be used in unstable patients.
DPL is invasive, takes 10-15 minutes to complete and is complicated by pregnancy and previous laparotomy.
CT scanning provides excellent organ detail including the retroperitoneum
but remains an expensive modality and is not readily available. CT is a relatively slow technique and with transport considered, often takes 45-60 minutes
to complete and thus this modality can only be used in stable patients.
As each method has its advantages and disadvantages, a combination of techniques may be both necessary and optimal.
In many US centers, this has translated into ultrasound replacing DPL as the
initial diagnostic study.
The main advantages of ultrasound can be summarized:
1. Noninvasive
2. No radiation/contrast agents
3. No adverse effects
4. Portable
5. Rapid
6. Repeatable
7. Cost-effective
8. Accurate
Ultrasound Indications and Limitations

Bedside ultrasound is very useful for the rapid detection of:
Diku Mandavia, Department of Emergency Medicine, Cedars-Sinai Medical Center,
Los Angeles County-USC Medical Center, Los Angeles, California, U.S.A.
30
Trauma Management
1. hemoperitoneum,
2. pericardial effusions, and
3. pleural effusions.
Ultrasounds greatest utility is in the evaluation of blunt abdominal trauma
for hemoperitoneum, and in penetrating chest injuries for the detection of
pericardial effusions.
Ultrasound does have limitations. Notably those patients that are morbidly
obese or those with massive subcutaneous emphysema can be difficult to image.
Even in these patients you are often able to obtain sufficient views for clinical
decision making.
31
Incorporating Trauma Ultrasound

Algorithms incorporating ultrasound will vary at different sites reflecting their
experience and subsequent reliance on this technology.
Ultrasound Training
Clinicians can reliably learn trauma ultrasonography with a short training
period. Though this period is not well defined, it appears that this technique
can be taught within a day.
For trauma abdominal sonography the focused exam will concentrate on the
finding of free intraperitoneal fluid rather than delineation of specific organ
injury. Ultrasound will not reliably detect low-grade injuries without hemoperitoneum.
For the echocardiographic exam, the focus will be the sole finding of a pericardial effusion. Other echocardiographic findings such as segmental wall
abnormalities or valvular lesions as may be done by ultrasound technologists
or noninvasive cardiologists will not be part of this focused study.
Ultrasound Equipment
Since the goals for trauma ultrasonography are relatively simple, state of the
art expensive ultrasound equipment is not necessary. Low end systems at
$30,000-50,000 are sufficient for most all of emergency ultrasonography.
Quality hand-held machines starting at $20,000 are available and are especially suited for prehospital applications. Though the initial cost may be steep
for some departments, the cost per exam is minimal when the cost is amortized over thousands of exams.
The ultrasound machine would ideally have two or more ultrasound probes
and a 3.5 MHz probe is a good jack of all trades probe. A small footprint
probe that can allow intercostal scanning is ideal for most exams. The exams
will need to be recorded so print and/or video capability are necessary. Many
new machines include options for digital imaging and ethernet connection
allowing images to be transferred via the hospital radiology network. Size,
portability and durability of the machine are also important, as it is likely the
machine will be moved to different areas on a frequent basis and encounter
unusually heavy wear in a busy emergency department.
FAST-Focused Abdominal Sonography for Trauma

Focused Abdominal Sonography for Trauma or FAST is a simple, quick ultrasound screening exam for hemoperitoneum. Again, the exam is a focused exam
as our only objective is detection of free intraperitoneal fluid. The goal is not
to determine the source of the bleeding such as a ruptured spleen or a liver
laceration, as the determination of the actual injury is often difficult and unreliable by ultrasound. If hemoperitoneum is detected by ultrasound, it is a
strong predictor for the need of therapeutic laparotomy. If intraperitoneal
fluid is seen, most often it will be hemoperitoneum but at times needle aspiration may be necessary to confirm the presence of blood.
Ascites can be confused and may need to be differentiated from hemoperitoneum. Intestinal fluid and urine also will have positive findings on ultrasound,
but both diagnoses also require operative intervention.
FAST consists of focused views of the abdomen including the pericardium
and is performed after the primary survey. Multiple views greatly increase the
32
Trauma Management
Fig. 3.1. Views in trauma scanning.
sensitivity of ultrasonography and standard areas examined include the following:

1. Morisons pouch
2. Pericardium
3. Perispenic space
4. Paracolics
5. Suprapubic view
Morisons Pouch
Morisons pouch (Figs. 3.2, 3.3) is a very useful initial view in the ultrasound
evaluation of the trauma victim. The exact amount of free fluid detected in
Morisons pouch varies but is as little as 250 cc. This view is easily obtained
within 20-30 seconds as the landmarks are easy to find.
The probe is placed in the mid to posterior axillary line at the just below the
nipple level. The liver is identified and the kidney will be adjacent. The space
between these two organs is Morisons pouch and is a potential space that can
fill with fluid.
Free fluid appears as a anechoic or as a black stripe in this area. With time,
hemoperitoneum loses its anechoic consistency and becomes more hyperechoic,
thus the fluid will have a grayer color and an inconsistent appearance.
33
Hyperechoic (white or gray areas) that surround the kidney represent normal
perinephric fat and Gerotas fascia and are not to be confused with free fluid.
Patient positioning in Trendelenburg can improve sensitivity by making this
area more dependent.
Once Morisons pouch is adequately examined, angle the probe cephalad and
examine the diaphragm for fluid above or below. This will be evident by black
areas and small hemothoraces can easily be detected with a little practice.
Pericardium
The pericardium (Figs. 3.4, 3.5) is especially important to evaluate in penetrating thoracic injuries to rule out a pericardial effusion and tamponade.
For this view, the probe is placed in the subcostal area just to the right of the
xiphisternum. It is angled toward the patients left shoulder. To view the
heart adequately, you will need to increase the depth of penetration at this
point. A coronal section of the heart should give you a good four chamber
view of the heart.
The normal pericardium is seen as a hyperechoic (white) line intimately surrounding the heart.
A pericardial effusion is seen as an anechoic (or black area) surrounding the
heart within the pericardium.
A sagittal view should also be used for confirmation, as pulmonary effusions
can be confused with pericardial effusions.
Though beyond the scope of this chapter, a long axis parasternal view of the
heart is the best view to examine the pericardium to avoid any confusion with
pleural fluid.
Perisplenic Area
The perisplenic view (Figs. 3.6, 3.7) is obtained by placing the probe at the
posterior axillary line at the 9-10th interspace. A common mistake when doing this view is not placing the probe posterior enough to adequately see the
kidney. Once the kidney is found, angle the probe slightly cephalad to find the
spleen and carefully look for free fluid surrounding it.
Once the spleen and kidney are fully scanned, angle the probe more cephalad
to examine the diaphragm. As with Morisons pouch, the diaphragm should
be visualized to see a pulmonary effusion or subdiaphragmatic fluid.
Paracolic Views
The paracolic views (Fig. 3.8) can be done in conjunction with Morisons
pouch and the perisplenic view. Simply place the probe in the paracolic area
and examine for free fluid and/or free floating loops of bowel. Fluid is often
detected first on other views limiting the usefulness of the paracolic view and
thus this view is eliminated in some protocols.
Suprapubic View
Ideally this exam is done prior to the placement of a foley catheter. The full
bladder is easily found by placing the probe just cephalad to the pubis. Once
the bladder is found, look for free fluid anterior, posterior and lateral to the
bladder. In females, the uterus will be seen posterior to the bladder. The culde-sac is a very dependent area of the peritoneal cavity and should be carefully
examined for free fluid (Figs. 3. 9, 3.10).
34
Trauma Management
Fig. 3.2. Normal Morisons Pouch. Note there is a clean interface between the
liver and kidney. There are no anechoic or black areas seen which would represent free fluid.
Fig. 3.3. Positive Morisons Pouch. Note that free fluid appears anechoic or black.
Pitfalls in Trauma Ultrasound

To best utilize clinical ultrasonography the clinician must understand the limitations of the technology. The sensitivity for detection of free fluid varies between
80-98% and is definitely operator dependent. In addition, extremely obese patients
and those with extensive subcutaneous emphysema are difficult to examine.
35
Fig. 3.4. Normal subcostal pericardium. Note the hyperechoic pericardium closely
surrounding the heart.
Fig. 3.5. Positive pericardial effusion. The anechoic area surrounding the heart
represents fluid within the pericardial sac.
Common mistakes when performing trauma ultrasound include the following:

1. Failure to do a multiple view examination. Sensitivity is highly dependent on
the number of views obtained thus a full exam is necessary.
2. Failure to consider other etiologies of free intraperitoneal fluid. Intestinal fluid
and intraperitoneal bladder rupture mimic hemoperitoneum, but both require
36
Trauma Management
Fig. 3.6. Normal perisplenic view. Note the absence of anechoic areas.
Fig. 3.7. Positive perisplenic view. Note the anechoic area representing a hematoma.
laparotomy. Ascites will mimic hemoperitoneum but is easily differentiated

with needle aspiration.
3. Failure to do serial exams when the initial examination is negative. Trauma
patients are extremely dynamic and contained injuries may later release causing a positive ultrasound exam. Consider serial exams in those with high clinical suspicion and those with changing vital signs and/or hematocrits.
37
Fig. 3.8. Positive paracolic view. Note the free fluid and free floating loops of bowel.
Normally no fluid should be visible.
Fig. 3.9. Normal suprapubic view. Note the absence of free fluid outside of the
bladder on this transverse suprapubic view.
4. Overreliance on ultrasonography. Use ultrasonography as a single data point

in the entire clinical picture. Use it in conjunction with other data such as mechanism of injury, vital signs, hematocrits, radiographs and clinical suspicion.
Recommended Texts
1.
2.
Ultrasound in Emergency Medicine by Heller & Jehle, WB Saunders, 1995.

Ultrasound in Emergency and Ambulatory Medicine by Simon & Snoey,
Mosby, 1996.
38
Trauma Management
Fig. 3.10. Positive suprapubic view. In this sagittal suprapubic view, free fluid is
seen in the cul-de-sac and anterior to the uterus.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Aaland M, Bryan C, Sherman R. Two-dimensional echocardiogram in hemodynamically stable victims of penetrating precordial trauma. Am Surg 1994; 6:412.
Jehle D. Bedside ultrasonographic evaluation of hemoperitoneum: The time has come.
Acad Emerg Med 1995; 2:575.
Lucciarini P, Ofner D, Weber F et al. Ultrasonography in the initial evaluation and
follow-up of blunt abdominal injury. Surgery 1993; 114:506.
Ma OJ, Kefer MP, Mateer JR et al. Prospective analysis of a rapid trauma ultrasound
examination performed by emergency physicians. J Trauma 1995; 38:879.
McKenney M, Martin L, Lentz K et al. 1000 consecutive ultrasounds for blunt
abdominal trauma. J Trauma 1996; 40:607-612.
Meyer D, Jessen M, Grayburn P. Use of echocardiography to detect occult cardiac
injury after penetrating thoracic trauma: A prospective study. J Trauma 1995; 39:902.
Plummer D, Brunette D, Asinger R. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med 1992; 21:709.
Rozycki GS, Shackford S. Ultrasound, what every trauma surgeon should know. J
Trauma 1996; 40:1.
Rozycki GS, Ochsner G, Schmidt J et al. A prospective study of surgeon-performed
ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma
1995; 39:492.
Rozycki GS, Feliciano D, Ochsner G et al. The role of ultrasound in patients with
possible penetrating cardiac wounds: A prospective multicenter study. J Trauma 1999;
46:543-552.
Shackford S, Rogers F, Osler T et al. Focused abdominal sonogram for trauma: The
learning curve of nonradiologist clinicians in detecting hemoperitoneum. J Trauma
1999; 46:553564.
Thomas B, Falcone R, Vasquez D et al. Ultrasound evaluation of blunt abdominal
trauma: Program implementation, initial experience, and learning curve. J Trauma
1997; 42:384390.
Yoshii H, Sato M, Yamamoto S et al. Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998; 45:45-51.
CHAPTER 1
CHAPTER 4
Analgesia and Sedation in Trauma

William K. Mallon, Grace Ting and Maria Rudis
Introduction
Pain management, sedation, and the control of psychomotor agitation are
important pharmacologic goals in the management of trauma. Existing studies of pain management have revealed poor analgesia and sedation in trauma
patients.
Oligoanalgesia is widespread in trauma care adding physiologic insult to injury. Oligoanalgesia and inadequate treatment of agitation are known to potentiate the adverse physiologic responses to trauma. There are several possible explanations for oligoanalgesia:
Fear regarding hemodynamic fluctuations and respiratory depression associated
with treatment.
Lack of knowledge regarding the current treatment options.
Under-recognition of pain.
Language and communication barriers.
Trauma care traditions.
Physiology of Pain
Trauma affects the physiologic process via direct damage to organ systems, via
shock states, or via the secondary effects of the neurohumoral stress response.
Table 4.1 summarizes some of the ways that pain can exacerbate the trauma
patients physiologic state.
Furthermore, pain slows down the entire healing process by increasing catabolic metabolism. Increased sympathetic outflow stresses all organ systems,
leading to the belief that pain management may potentially improve the recovery process.
One of the major consequences of oligoanalgesia and undersedation is the
associated delay in care. Critical diagnostic studies cannot be performed while
the patient is in agony and exhibiting psychomotor agitation.
The restrained, struggling trauma patient poses a danger to himself and caregivers.
Terms and Definitions

Analgesia does not always yield concomitant sedation, and sedation frequently
provides no analgesia.
Often analgesia and sedation drugs are used to control psychomotor agitation; however, it is possible to control psychomotor agitation without sedation or analgesia. For example, paralysis will obviously control psychomotor
William K. Mallon, LAC + USC Medical Center, Los Angeles, California, U.S.A.
Grace Ting, Department of Emergency Medicine, LAC + USC Medical Center,
Maria Rudis, USC Schools of Pharmacy and Medicine, Los Angeles, California, U.S.A.
40
Trauma Management
Table 4.1. Organ system responses to poorly controlled trauma related pain
Organ Systems
Pathologic Responses to Trauma Related Pain
Neuroendocrine
Increased catecholamines and sympathetic nerve

activity
Increased cortisol, growth hormone, ACTH,
prolactin
Increased renin, angiotensin, aldosterone,
vasopressin
Acute phase reactantsincreased coagualability
Altered immune response
Pulmonary
Decreased pulmonary function

Pneumonia
ARDS
Pneumothorax secondary to barotrauma (yelling,
coughing)
Increased respiratory rate
Acid-base disturbances
Central Nervous System
ICP elevation and herniation

Spinal cord injury due to struggling against
physical restraints and spinal precautions
Cardiovascular
SVR increases with tissue hypoperfusion, lactic

acidosis and ultimately multi-organ system failure
Tachycardia which may complicate assessment of
resuscitative measures
Ectopy and conduction abnormalities
Gastrointestinal
Cushings ulcers
Decreased gut motility
Musculoskeletal
Spasm and immobility

Rhabdomyolysis from struggling against physical
restraints
Genitourologic
ATN/renal failure
Table 4.2. Terms and definitions

Term
Definition
Analgesia
Cerebral resuscitation
Blunting the perception of pain locally or centrally.

Management of ICP in head trauma patients via
drugs, head elevation, or hyperventilation.
Light-controlled depression of sensorium, pain
perception and anxiolysis. Protective reflexes (gag,
respiration) are intact.
Deep-profound depression of awareness, necessitating attention of airway, ventilation and vital
signs. Protective reflexes may be lost.
Small dose of medication given prior to administracontinued on next page
Conscious sedation
Defasciculating dose
Depolarizing drugs
General anesthesia
Nondepolarizing drugs
Oligoanalgesia
Pharmacodynamic
Pharmacokinetic
41
tion of a depolarizing paralytic such as succinylcholine to reduce muscle fasciculation. This

reduces ICP, reduces IOP and decreases incidences
of aspiration.
Nicotinic receptor agonists that dissociate slowly
and causes muscle to contract/fasciculate. During
the time the agonist remains bound to the receptor,
other agonist molecules cannot stimulate the
receptor.
Combined state of unconsciousness, amnesia,
analgesia, and muscle relaxation. No response to
surgery.
Paralytics that are pure antagonist of the nicotinic
receptor, causing muscle paralysis without muscle
contraction (fasciculation).
Failure to provide adequate pain control.
The effects of a drug on the bodys different tissues
and its receptors.
The movement of a medication through the body
and its various tissues or compartments.
Pretreatment drugs
Drugs given to minimize the hemodynamic and
intracranial effects of rapid sequence intubation
drugs.
Psychomotor agitation
Motor agitation due to altered mental status.
Concussion, drugs of abuse, pain, and noxious
stimuli may all cause it.
Rapid sequence induction
Rapid sequence intubation
Sedation
Visual analogue scales
In anesthesiology, the term rapid-sequence

induction is used to describe the initial steps in
the delivery of general anesthesia in unprepared
patients at risk for aspiration of gastric contents.
Induction of a sleep state in preparation for
surgery is the goal of treatment.
The use of appropriate pharmacologic adjuncts to
facilitate endotracheal intubation and to reduce
adverse effects. It is an organized approach to
emergency intubation comprising rapid sedation
and paralysis with minimal or no positive-pressure
ventilation. In addition, adjunctive pharmacologic
agents and techniques are used to minimize
complications such as aspiration, hypoxemia, and
sympathomimetic mediated rises in blood pressure
and ICP.
The production of a restful state of mind, by the use
of a drug.
A common pain assessment tool used for measuring acute and chronic pain. Patient is asked to
make a mark along a 10 cm line with no pain at
one end and worst that pain can be at the other
end.
42
Trauma Management
agitation, but in some cases patients receive neither adequate sedation nor
analgesia.
Paralytics have no analgesic, sedative, anxiolytic or amnesic properties.
The Pharmacopoeia
Analgesics (see Table 4.3)
Narcotics (e.g., morphine, meperidine, fentanyl, sufentanyl)
NSAID (e.g., ketorolac, ibuprofen)
Sedatives (see Table 4.4)
Benzodiazepines (e.g., diazepam, lorazepam, midazolam)

Barbiturates (e.g., methohexital, thiopental, pentobarbital)
Etomidate
Propofol
Antipsychotic (see Table 4.5)

Haloperidol
Droperidol
Dissociative anesthetic (see Table 4.6)

Ketamine
Paralytics (see Table 4.7)

Depolarizing (e.g., succinylcholine)
Nondepolarizing (e.g., pancuronium, vecuronium, rocuronium)
Principle of Dosing
Many of the agents listed have fairly wide dose ranges. Once clinical experience with an agent has developed, dosing becomes more accurate. For these
reasons it is recommended that clinicians gain experience with a few selected
agents rather than attempt to know the entire pharmacopoeia.
Drugs used in combination with each other may have both pharmacokinetic
and pharmacodynamic interactions, therefore combinations should be kept
simple (e.g., fentanyl and midazolam).
Loading doses should be used to achieve the desired effect, then followed by a
continuous infusion as needed.
Reassess efficacy frequently.
Combinations of analgesics and sedatives may be synergistic, which minimizes
dosing requirements.
Doses may need to be increased in those who are young, previously healthy, or
are drug abusers.
Doses should be decreased in some patients summarized in the mnemonic
CLOCK:
Central nervous system disease

Liver disease
Older age
Children and infants
Kidney disease
2.5-15 mg IV q4 hr
5-20 mg IM/SC q4 hr
10-30 mg PO/PR q4 hr
2-5 mg/hr drip
50-150 mg IV/IM/SC
q4 hr
10-20 mg/hr drip
2-150 mcg/kg IV
q1-2 hr
25-50 mcg/hr drip
Meperidine
(Demerol)
Fentanyl
Dosing
Morphine
Narcotics
Medications
Table 4.3. Analgesics
Brief analgesia
Short painful
procedures
Decreasing ICP
during intubation
Relief of
moderate to
severe pain
Drug of choice
for relief of
moderate
to severe pain
Indication
Respiratory
depression
Atrial flutter
and SVT (due to
vagolytic response)
MAO inhibitors
use in past 14 days
(may cause
serotonin syndrome)
Hypotension
Contraindication
Onset < 1 min IV

Duration 0.5-1 hr
Same as morphine except

less hypotension and less
histamine release
Wooden chest syndrome
with higher dosing, due to
dopaminergic stimulation
(can be reversed with naloxone)
continued on next page
Onset 1min IV,

10-15 min IM
Duration 2-4 hr
Less smooth muscle
spasm, constipation
and cough depression
than morphine
Onset < 1 min IV,

10-30 min IM
Duration 4-5 hr
Comments
Same as morphine
Vagolytic response
Accumulation of toxic
metabolite (normeperidine
may cause seizures and
agitation) especially in
renal dysfunction and
in cumulative doses
Nausea and
vomiting
Respiratory
depression
Hypotension
Histamine release
Side effects

43
1-8 mcg/kg IV
q1-2 hr
Sufentanyl
30 mg IV/IM q6 hr
10 mg PO q4-6 hr
200-800 mg
PO bid-qid
Ketorolac
(Toradol)
Ibuprofen
(Motrin)
Contraindication
Relief of mild pain
Bleeding disorders
Peptic ulcer disease
Relief of mildBleeding disorders

mod pain,
Peptic ulcer disease
especially renal colic
Brief analgesia
Short painful
procedures
Indication
GI bleed
Acute renal failure

GI bleed associated with
> 60 mg/dose
Same as morphine except less

hypotension and less histamine
release
Wooden chest syndrome
with higher dosing, due to
dopaminergic stimulation (can
be reversed with naloxone)
Side effects
NSAID
Dosing
Medications
Table 4.3. continued
Reduce dose in
elderly
Onset < 1 min IV

Duration 0.25-1 hr
More expensive
Comments
44
Trauma Management
Same as
diazepam
1-2 mg IV
or 0.04 mg/kg IV
0.05/kg up to
4mg IM
Lorazepam
(Ativan)
Indication
2-20 mg IV/IM
Treat anxiety
or 0.1-0.2mg/kg IV/IM Treat ETOH
2-10 mg PO bid-qid withdrawal
Treat seizures
acutely
Dosing
Diazepam
(Valium)
Benzodiazepines
Medication
Table 4.4. Sedatives
Hypotension
Contraindication
Onset 5-15 min,

max effect
20-30 min
Stacking doses at
45-60 min
Duration 1-6 hr
No active
metabolites
Amnestic in
addition to sedation
Consider
benzodiazepine
withdrawal
Propylene glycol
diluent associated
hypotension and
phlebitis
Onset 1-3 min
Duration 1-2 hr
Active metabolites
Hypotension if other
depressants on board
Prolonged effect in elderly and
liver/renal dysfunction
Hypotension
Respiratory depression
Comments
Side effects

45
1-5 mg IV
or 0.05-0.1 mg/kg IV
5 mg IM
or 0.07 mg/kg IM
Drip 2-10 mg/hr
Peds (6-12yr)
0.025-0.05 mg/kg IV,
max 0.4 mg/kg
Midazolam
(Versed)
3-5 mg/kg IV
1-2 mg/kg IV
5-8 mg/kg IM
Thiopental
(Pentothal)
Methohexital
(Brevital)
Porphyria
Cardiac disease
Epilepsy
ETOH withdraw
Severe liver disease
Asthma
Contraindication
Short procedures Same as thiopental

Induce of general
anesthesia
Induction of
general anesthesia
Conscious sedation
for short procedures
Indication
Comments
Same as thiopental
Less hypotension
Onset 0.2-0.5
seconds
Duration 5-15 min
Onset 10-20 sec

Duration 5-15 min
If laryngospasm
occurs, give more
brevital; decrease
ICP
Hypotension
Laryngospasm
Histamine release causing
bronchospasm
May cause seizure by inducing
transient withdrawal
Decreases ICP
Same as lorazepam
Very short acting,
CNS agitation (from inadequate thus excellent for
or excessive dosing)
short procedures
Onset 1-2 min
Duration 1-2 hr
Drip required for
longer sedation
Side effects
Barbiturates
and related
drugs
Dosing
Medication
46
Trauma Management
Dosing
20-150 mg
IV/IM/PO/PR tid-qid
Drip 1mg/kg/hr
Peds 2-6mg/kg/day
0.2-0.4 mg/kg IV
Drip 5-10
mcg/kg/min
0.5-2 mg/kg IV
Drip 25-100
mcg/kg/min
Medication
Pentobarbital
(Nembutal)
Etomidate
(Amidate)
Propofol
(Diprivan)
Induction agent
in RSI
Induction and
maintenance of
general anesthesia
Induction agent
in RSI
Induction and
maintenance of
general anesthesia
Short procedures
Induction of
general anesthesia
Indication
Elderly with
cardiopulmonary
disease is relatively
contraindicated
Not FDA approved

for age < 12
Prolonged sedation
will inhibit cortisol
production
Same as thiopental
Contraindication
Hypotension
Decrease cerebral
perfusion
Respiratory depression
Decrease ICP
Myoclonic jerks
Nausea and vomiting
Same as thiopental
Side effects
Patients need to
be intubated
Onset 30 sec
Duration 5 min
Minimal
cardiovascular side
effects
Very useful
induction agent in
the emergency
department
Onset < 1min
Duration 3-12 min
after induction
0.1 mg/kg provide
100 sec of sleep
Onset < 1min

Duration 15 min
Comments

47
Dosing
1-2 mg/kg IV
3-4 mg/kg IM
For asthmatic
intubation: 1.5 mg/kg
slow IV then 0.51.0 mg/kg/hr IV
Medication
Ketamine
Theoretical decrease
in seizure threshold
Contraindication
Age< 3 months
URI or pulmonary infection
Tracheal stenosis or
Cardiovascular disease
Psychosis
Relative contraindications:
stimulation of posterior
pharynx, head injury/CNS
mass/possible increased ICP,
glaucoma, hyperthyroidism,
porphyria, asthma (for
conscious sedation)
Contraindication
Psychomotor
agitation
Psychosis
Delirium
Tourettes
syndrome
Huntingtons
disease
Conscious sedation
for brief painful
procedure
Rapid sequence
induction in
asthmatics
Indication
2-5 mg IV/IM
For rapid neuroleptization:
start 5 mg IV, then
double dose (10, 20, 40 and
so on) until desired response,
then repeat dose q 4hr
1-5 mg PO tid to
start, usual effective
dose 6-20 mg/day
Haloperidol
(Haldol)
Indication
Increased transient
stridor and laryngospasm in age
< 3 months
Elevates ICP
Nystagmus and
ataxia (lasting 1-4 hr
after administration)
Emergence
phenomenon
(hallucinations and
nightmares)
Side effects
Onset 3-5min
Duration 1-12 hr
Caution with type Ia
agents and tricyclic
overdoses
Comments
Also analgesic
Maintains protective
reflexes
Onset 1-2 min
Duration 10-30 min
To decrease salivation
and bronchial secretions:
atropine 0.01mg/kg,
max 0.5 mg or
glycopyrrolate
0.005 mg/kg, max 0.25 mg
Comments
Enhances actions of
CNS depressants
May increase QRS
and QT intervals
Extrapyramidal effect
with IM route
Side effects
Table 4.6. Dissociative Anesthetics
Dosing
Medication
Table 4.5. Antipsychotics
48
Trauma Management
Pancuronium
Onset
Duration
0.1 mg/kg IV
2-5 min
45-90 min
1.0-1.5 mg/kg IV(for > 10 kg) 15-30 sec 3-12 min

1.0-2.0 mg/kg IV(for < 10 kg)
Dosing
Nondepolarizing Agents
Succinylcholine
Depolarizing Agent
Medication
Table 4.7. Paralytics
Little cardiovascular
Useful in status asthmaticus
Reversible with physostigmine 100-300 mcg/kg or
neostigmine 25-75 mcg/kg
Rapid onset
Short duration
IM dosing possible if no
IV access
Advantages
Contraindication2
Long action
Prolonged paralysis with
renal impairment
Some histamine release
Contraindications1
Bradycardia
Hypotension
Dysrhythmia
Cardiac arrest
Pulmonary edema
Increased gastric pressure
Increased intraocular pressure
Hyperkalemia
Myoglobinuria
Malignant hyperthermia
Masseter spasm
Disadvantages

49
0.1-0.2 mg/kg IV
0.6-1.0 mg/kg IV
Vecuronium
Rocuronium
30-60 sec
30-90 sec
Onset
25-60 min
25-60 min
Duration
Fast onset
Reversible
Few cardiovascular side

effects
Low risk for histamine
release
Shorter duration than
pancuronium
Reversible
Advantages
4
Contraindication2
Increased heart rate
Contraindication2
Longer duration than
succinylcholine
Disadvantages
1. Crush injuries, glaucoma, penetrating eye injuries, significant neuromuscular disease, one week after burn or trauma, history or family
history of malignant hyperthermia, pseudocholinesterase deficiency, myotonia, muscular dystrophy, paraplegia, and hyperkalemia.
2. Myasthenia gravis.
Dosing
Medication
50
Trauma Management
51
Table 4.8. Local approaches to pain management

Approaches
Utility
Fingers: digital, metacarpal nerve block
Finger trauma with severe

fractures and lacerations
Hand trauma with severe
Elbow dislocation
Shoulder dislocation
Hip fractures
Ankle and foot fractures and
lacerations
Hand: ulnar, radial, median nerve block

Elbow: intra-articular block
Shoulder: intra-articular block
Femur: femoral nerve block
Ankle/foot: saphenous, peroneal, sural
nerve block
Face and mouth
Cornea: topical anesthetics
Upper lip and lateral nose: infraorbital
nerve block
Lower lip: mandibular nerve block
Frontal scalp: supraorbital nerve block
Miscellaneous
Penis: dorsal penile nerve block
Vulva/vagina: pudendal nerve block
Ribs: intercostal nerve block
Rib fractures and flail chest
Complex and painful facial

Genital trauma
Table 4.9. Different causes of pain and agitation in trauma patients

Hypoxia
Hypoglycemia
Airway obstruction
Bladder distension
Hypotension
Pain
Drugs
Seizures
Intracranial bleeds
Fractures
Glass
Tape
Early pulse oximetry, ABG as indicated

Early accucheck to rule out this correctable
problem
Assess in primary survey, check frequently, use
respiratory therapists often as adjunct to care
Foley catheter early
Frequent blood pressure checks and appropriate
resuscitation
Visual analog scale, treat early
Especially sympathomimetics or alcohol
Both preictal and postictal states can produce
agitation
Early CT scan
Splinting, reduction and dressings can decrease
pain dramatically
Check for glass under the patient on a board, in
eyes and other sensitive areas
Check for taped eyebrows, hair, skin folds
52
Trauma Management
Local Approaches to Pain Management

Some painful conditions can be rapidly and safely dealt with by using a local
approach. Intra-articular injections and nerve blocks may obviate the need for
high doses of parenteral opioids. This approach mandates a detail neurovascular exam first, but can be extremely useful. In almost all cases a long acting
agent such as bupivicaine should be used.
Rapid Sequence Intubation (RSI)
RSI uses appropriate pharmacologic adjuncts to facilitate endotracheal intubation. It is an organized approach to emergency intubation comprising rapid
sedation and paralysis with minimal or no positive-pressure ventilation.
Paying attention to sedation and analgesia is essential after intubation because
the patient can no longer gesture or verbalize pain. Maintenance of appropriate sedation and analgesia will:
Prevent pulmonary complications (aspiration, ARDS, pneumothorax)

Promote ventilation and the correction of acid base disturbances
Optimize ICP
Blunt the counter regulatory sympathomimetic surge
Maximize patient comfort
Pediatrics
The approach to pain control and sedation in the pediatric patient is just as
important, if not more important than in the adult. Often the pediatric patient is beyond reassurance and verbal interventions, therefore a pharmacological intervention is essential.
When treating pediatric patients, accurate weights are critical to appropriate
dosing. Since trauma patients cannot be weighed, a Broselow tape should be
used to reach an accurate weight estimate. Age based formulas are less reliable
and should be avoided, and may overestimate weights for Asian and Hispanics.
Pediatric doses can be either greater or less than adults due to differential
pathways of metabolism and elimination rates.
Chloral hydrate and the Demerol/Phenergan/Thorazine cocktail have been
widely condemned in the pediatric literature and have no role in the management of pediatric trauma patients.
Common Pitfalls
While advocating for appropriate analgesia and sedation in trauma patients,
some pitfalls should be recognized.
Even before initiating care, a thorough examination for treatable causes of pain
and agitation should be done.
Noxious stimuli such as taped hair and glass shards should be sought out and
eliminated prior to sedation and analgesia.
Summary
Analgesia and sedation are important elements of trauma care that should be
addressed early, usually in the emergency department.
Appropriate drug selection and titration will improve the patients physiologic
state, prevent diagnostic and treatment delays, and is the only humane approach.
The RELIEF mnemonic will help those involved in trauma care to assess and
treat pain. The tradition of oligoanalgesia is no longer acceptable in the face of
53
an expanded pharmacopioea of titratable short acting and vital signs neutral

drugs.
Record the pain score on the patients chart before and after treatment.
Ease the patients concernsoften the fear of pain is more distressing than the
pain itself. Inform the patient that pain control is a goal of the ED patient care
team.
Look and listen to the patientthey will be the best judge on how much pain
they are having and how much relief they have obtained.
Inquire: always ask the patient if they need pain medication.
Educate ED staff on proper analgesic techniques.
Facilitate multi-disciplinary protocols with nursing and other specialties to
manage common painful conditions in the ED.
An overview of the drugs available leads to the following recommendations:
References
1.
2.
3.
4.
5.
Raj PP, Hartrick C, Pither CE. Pain management of the injured. In: Capan LM,
Miller SM, Trundort H, eds. Trauma Anesthesia and Intensive Care. New York: JB
Lippincott 1991:685-723.
Carr DB, Goudas LC. Acute Pain Lancet 1999; 353:2051-58.
Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J
Emerg Med 1989; 7:620-623.
Pace S. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996; 3:1086-1092.
Acute Pain Management Guideline Panel: Acute Pain Management: Operative or
Medical Procedures and Trauma. AHCPR Pub. No. 92-0032. Rockville, MD:
Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Feb. 1992.
CHAPTER 5
Emergency Airway Management

in the Trauma Patient
Kirsten Robinson and Sean O. Henderson
Overview of the Trauma Airway
In any patient, securing an adequate airway should be the first priority for the
physician. Proper use of medications and procedural techniques will facilitate this
task as well as maximize patient comfort, safety, and therapeutic benefits. The trauma
patient demands special attention to the airway for many reasons. These include:
The possibility of anatomic variables that could make ventilation, intubation,
and placement of a surgical airway difficult: facial fractures, neck/laryngeal
trauma, local hematoma with mass effect, and direct airway disruption secondary to trauma.
Cervical spine (C-spine) immobilization which prevents optimal visualization of airway structures.
Combative behavior whether due to intoxication, hypoxia, pain, etc. This can
create difficulty in both assessment and management of the airway.
Hemodynamic instability. This is of special concern when deciding which
medications to use prior to definitive airway procedures.
Head trauma or altered level of consciousness (ALOC) where increased intracranial pressure (ICP) may be present. Direct stimulation of the larynx
during intubation can elevate ICP placing these patients at higher risk of herniation and secondary brain injury.
Rapid Sequence Intubation

Rapid Sequence Intubation (RSI) refers to use of a sedative followed immediately by a paralytic agent in order to facilitate placement of an oral endotracheal
tube and minimize the risk of subsequent aspiration.
In addition, RSI allows for administration of medications which may provide
therapeutic benefit to the patient by blunting the adverse cardiovascular/cerebrovascular effects that occur with airway manipulation.
RSI is the standard of care for the patient who needs emergent intubation in
whom the time of most recent food ingestion is unknown (and who, therefore, is at risk for aspiration of gastric contents).

Kirsten Robinson, Department of Emergency Medicine, LAC+USC Medical Center,
Sean O. Henderson, Department of Emergency Medicine, LAC+USC Medical Center,
Emergency Airway Management in the Trauma Patient
55
Contraindication
Anticipated difficult intubation in which mask ventilation may not be possible if
intubation fails (massive facial trauma, expanding neck hematoma, etc). In this case,
alternative airway techniques may be mandated (see section D).
Technique
RSI involves the sequential Ps (Table 5.1). Keep in mind that the specifics of
each step will vary depending upon the patient and the injuries present.
Preparation: All of the necessary airway equipment/medications as well as
appropriate staff must be present and the equipment verified to be in working
order.
Preoxygenation: Placing a patient (with spontaneous respirations) on 100%
oxygen for 2-5 minutes will allow for a period of approximately 3-7 minutes
of apnea without desaturation. This permits the physician to avoid bag valve
mask (BVM) ventilation during pretreatment and paralysis. Use of positive
pressure ventilation, as with BVM, can lead to gastric distension which increases the risk of aspiration. Thus, preoxygenation is the key factor towards
minimizing aspiration during RSI. Ideally, this step should be begun in the
field or during the preparation phase.
Pretreatment: In this phase, the patient is given agents to counteract the adverse circulatory effects of intubation. Airway manipulation leads to reflex
neural responses which manifest as tachycardia, hypertension, increased myocardial oxygen demand, fasciculations, increased intracranial pressure (ICP),
and increased intraocular pressure (IOP). The physician can minimize these
sequelae by pretreating with cerebroprotective agents and a defasciculating
dose of paralytic. Ideally, pretreatment should precede paralysis by 3 minutes.
Paralysis with Induction: It is here that one gives a sedative agent followed
immediately by a paralytic. Unless the patient is hypoxic, BVM ventilation
should be avoided as noted above. If ventilation is required, the Sellick maneuver should be performed concomitantly in order to minimize air entry
into the stomach.
Placement of the Tube: After achieving complete relaxation/paralysis, the patient may be intubated. Afterwards, appropriate tube placement should be
confirmed via ausculation, end capnography, chest x-ray (CXR), and pulse
oximeter.
Pharmacologic Therapy in RSI

In this section, we will cover sedatives, neuromuscular blocking agents (paralytics),
and cerebroprotective agents. Generally, those medications with the most rapid onset
of action and shortest half-life are preferredin the case of a failed intubation, the
need for positive pressure ventilation by BVM is minimized. However, the physician should also consider the side effect profile, efficacy, and personal experience
when selecting which drugs to use. With a few exceptions, the specifics of metabolism will not be considered as these drugs are generally for single dose use when used
for RSI.
Neuromuscular Blocking Agents

There are two classes of paralytics: a) depolarizing agents which bind with
the acetylcholine (ACh) receptor at the motor end plate and lead to sustained
56
Trauma Management
Table 5.1. The Ps of RSI

RSI
1. Preparation
2. Preoxygenation
3. Pretreatment
4. Paralysis
5. Pass the tube
depolarizationsuccinylcholine (SCh) is the only agent of this class to consider for

use; and b) nondepolarizing agents which bind competitively at the Ach receptor
and prevent depolarization. SCh is the paralytic most commonly used for RSI because it has the most rapid onset and the shortest duration of action (Table 5.2).
Although rare, there are contraindications to SCh which may mandate use of a
longer-acting nondepolarizing agent.
Succinylcholine
Extremely rapid onset of action of 60 seconds which makes SCh the ideal medication to use for RSI. This is especially true for patients receiving a suboptimal
period of preoxygenation who may not tolerate even short periods of apnea.
SCh is rapidly hydrolyzed by plasma pseudocholinesterase and so has a short
duration of action3-10 minutes.
The dose varies with age: 2 mg/kg for children less than 10 years of age and
1-1.5 mg/kg for adults and older children. The higher dose of 1.5 mg/kg may be
required in patients who receive a defasciculating dose of a nondepolarizing agent.
Side Effects
Unlike nondepolarizing agents, SCh may cause muscle fasciculations. After binding at the ACh receptor, the initial depolarization presents as uncoordinated
muscle activity or fasciculations. These are possibly linked to muscle soreness,
increased intragastric pressure (via fasciculations of the abdominal musculature), and increased ICP/IOP. This side effect may be prevented by giving a
defasciculating dose of a nondepolarizing agent during the pretreatment phase.
Pediatric patients are less likely to have this side effect.
SCh causes cardiovascular changes via its action at ACh receptors in the autonomic ganglia and at muscarinic receptors. These changes may present as hypertension and both tachycardic and bradycardic dysrrhythmias. Pediatric patients are especially likely to experience bradycardia and should receive atropine
0.02 mg/kg during the pretreatment phase. These changes may be of particular
concern in the elderly with underlying cardiovascular disease.
Mild hyperkalemia ( 0.5 mEq/L) can occur because of a transient release of
potassium from the muscle cell after it is depolarized. Even in patients with
renal failure, this elevation of K+ is usually mild. This effect may be severe in
patients with burns, trauma, intraabdominal sepsis, and denervation syndromes.
However, the risk period for dangerous hyperkalemia begins several days after
injury or symptom onset. Therefore, a nondepolarizing agent should be used in
patients with known preexisting hyperkalemia, subacute burns/major tissue trauma,
and subacute/chronic denervation disorders.
57
Table 5.2. Neuromuscular blocking agents used in RSI

Agent
Time
to Onset
Duration
of Action
Dose
(mg/kg)
Side
Effects
Succinylcholine
(D)
60 sec.
3-10 min.
1-1.5
2 for
pediatric patients
IOP, ICP, IGP

fasciculations
K+ (mild)
Pancuronium
(ND)
1-5 min.
40-80 min.
HR, BP
histamine
release
Vecuronium
(ND)
2-5 min.
20-40 min.
Rocuronium
(ND)
1-3 min.
20-25 min.
(dose dep) (dose dep)
0.01 defasciculating
dose
0.1-0.15 intubating
dose
0.01 defasciculating
dose
0.1-0.15 intubating
dose
0.5-1.0
minimal
minimal
D, depolarizing; ND, nondepolarizing; IOP, intraocular pressure; ICP, intracranial

pressure; IGP, intragastric pressure; HR, heart rate; BP, blood pressure
Malignant hyperthermia characterized by muscle rigidity and hyperpyrexia may

occur in those patients who are genetically predisposed (rare). In cases where
patients know that they possess this predisposition, a nondepolarizing agent
should be used.
Decreased metabolism of SCh can occur in patients with genetically abnormal
pseudocholinesterase or in those patients with decreased levels of the normal
enzyme (seen with liver disease, pregnancy, connective tissue disease, cancer,
therapeutic use of cholinesterase inhibitors for myasthenia gravis). This is not a
definite contraindication to use of SCh, but the physician should keep in mind
that the duration of action may be very prolonged in such cases.
Pancuronium (Pavulon)
Onset of action is 1-5 minutes with a duration of action from 40-80 minutes.
Because of the longer duration of action, this agent is most commonly used in
the emergency department as a defasciculating medication at a dose of 0.01
mg/kg. However, pancuronium may also be used to maintain paralysis in patients who are already intubated or may be given rather than SCh for intubation (as in the case of hyperkalemia or other contraindication for SCh). In
these latter two cases, the dose is 0.1-0.15 mg/kg.
Side Effects
The main adverse effects are transient tachycardia and hypertension. This is
generally of little consequence except in those patients with severe underlying
cardiovascular disease.
May also cause histamine release although thought to be minimal.
Like other nondepolarizing agents, may result in prolonged paralysis when given
to patients in conjunction with aminoglycoside medications, tetracycline,
clindamycin, and several other less commonly used medications.
58
Trauma Management
Vecuronium
A structural analog of pancuronium. This agent was originally designed to
minimize the cardiovascular side effects seen with its parent compound and,
in fact, produces little or no cardiovascular changes.
Onset of action is two to five minutes with a duration of action from 20-40
minutes (@ half that of pancuronium). Like pancuronium, vecuronium is
mainly used for defasciculation and to maintain paralysis after intubation.
Defasciculating and intubating doses identical to pancuronium.
Minimal side effects other than the prolonged duration of action seen when
given with aminoglycosides, etc.
Rocuronium
Nondepolarizing agent which is structurally similar to vecuronium.

Designed to be more rapid-acting than other nondepolarizing agents and,
thus, serve as an alternative to SCh and its adverse side effects.
Onset of action is similar to that of SCh, one to two minutes. Duration of
action varies depending upon the dose but ranges from 20-25 minutes.
Dose ranges from 0.5-1.0 mg/kg. The higher doses give more rapid onset of
action ( SCh) but also lead to longer duration of action. Not used for
defasciculation.
Minimal side effects.
Sedatives
The necessity of sedating agents in RSI is twofold: 1) to blunt the adverse hemodynamic and cerebrovascular effects of paralysis and intubation as previously noted;
and 2) to minimize the negative psychologic sequelae of paralysis.
All but the completely unresponsive patient require sedation prior to paralysis, and even the unresponsive patient may warrant the use of a sedating agent
if there is any possibility of an intracranial injury.
As with the paralytic agents, the ideal sedative for RSI in the trauma patient
would have a rapid onset of action, a short half-life, and minimal adverse
hemodynamic effects.
While numerous sedating agents are available, only a relative few are appropriate for use in RSI (Table 5.3).
Etomidate
This is an imidazole derivative unrelated to other sedative/hypnotic agents
and is rapidly becoming the agent of choice for sedation in RSI. Purely hypnotichas no anticonvulsant, analgesic, or amnestic properties.
Onset of action is 60 seconds with a duration of action of five minutes.
Dosage is 0.3 mg/kg.
Benefits:
Decreases IOP, ICP, and cerebral metabolism which makes it ideal for use in
patients with intracranial and penetrating globe injuries.
Has little to no effect on blood pressure and heart rate which makes it unique
among the other sedative agents and ideal for the trauma patient where hypotension and/or shock are often present.
Side effects:
Postprocedural nausea and vomiting.
59
Cortisol suppressionwhile initially thought to be a significant adverse effect,

now felt to be of little consequence after single dose use.
Midazolam
This is the only benzodiazepine well-suited for use in RSI. While other shortacting benzodiazepines exist, this is the only one available for intravenous use.
When adequately dosed, onset of action is 30-120 seconds with a duration of
action of 10-20 minutes.
Commonly given in doses of 0.02-0.1 mg/kg for procedural sedation but
higher doses of 0.1-0.3 mg/kg should be given in RSI as this will produce a
much more rapid onset of action.
Benefits: in addition to sedation, midazolam also provides amnesia, muscle
relaxation, and anticonvulsant activity.
Side Effects
Hypotension
Respiratory depressionthis is obviously of no concern in the intubated patient,
but may be problematic in the case of a failed intubation.
Sodium Thiopental and Methohexital

These are the only two barbiturates which should be considered for use in RSI
and are used mainly for the patient with isolated head injury. These agents are
extremely lipid soluble which allows for rapid penetration into the central
nervous system (CNS) followed by rapid redistribution to lean body tissue.
This explains the prompt induction and short-lived duration of anesthesia.
Kinetics are similar to that of etomidate.
Dose is 2-5 mg/kg for thiopental and 1 mg/kg for methohexital.
Benefits
Anticonvulsant properties (thiopental).
Reduce ICP and cerebral metabolism.
Side Effects
Respiratory depression.
May cause marked hypotension secondary to both myocardial depression and
vasodilatation. While decreased doses may minimize the degree of hypotension,
use of other agents is warranted in those patients with preexisting hypotension
and in the polytrauma patient who is potentially hemodynamically unstable.6
Histamine release which may produce bronchospasm and laryngospasm.
Muscle spasm/myoclonus (methohexital).
Decreased seizure threshold (methohexital).
Fentanyl
A synthetic narcotic which is 50-100 times more potent than morphine.
Onset of action is approximately two minutes with a duration of action 30-40
minutes.
Dose is 3-5 mg/kg.
Benefits
Decreases ICP.
Blunts the cardiovascular changes (tachycardia, hypertension) that may occur
with intubation and administration of SCh.
Provides analgesia.
Time
to Onset
60 sec.
30-120 sec.
30-60 sec.
30-60 sec.
2 min.
Agent
Etomidate
Midazolam
Thiopental
Methohexital
Fentanyl
(also Alfentamil,
Sufentamil)
30-40 min.
5 min.
5-10 min.
10-20 min.
3-5 g/kg
1 mg/kg
2-5 mg/kg
0.1-0.3 mg/kg.
0.3 mg/kg
Dose
Adv: IOP, ICP

hemodynamic stability
SE:
cortisol suppression emesis
Adv: anticonvulsant/amnestic
SE:
tachycardia
respiratory depression
hypotension
Adv: anticonvulsant
ICP, cerebral metabolism
SE:
hypotension
broncho/larygospasm
Adv: ICP
SE:
hypotension
bronch/laryngospasm
seizure threshold
myoclonus
Adv: ICP
analgesic
blunts CV response
hemodynamic stability
reversal with naloxone
SE:
muscle rigidity
bradycardia
Advantages
Side Effects
5 min.
Duration
of Action
Table 5.3. Sedating Agents used in RSI for the trauma patient
60
Trauma Management
1-2 mg/kg
1-3 min
Dose
1.0-2.5 mg/kg
Adv:
ICP, IOP
SE:
hypotension, CO
risk - bacterial contamination
Adv: airway reflexes intact
CO, HR, BP
bronchodilation
SE:
emergence phenomena
ICP, IOP
mycoardial O2 demand
Advantages
Side Effects
ICP, intracranial pressure; IOP, intraocular pressure; CV, cardiovascular; CO, cardiac output; HR, heart rate; BP, blood pressure
5-15 min.
30-60 sec.
Ketamine
Duration
of Action
30 sec.
Time
to Onset
Propofol
Agent

61
62
Trauma Management
Minimal effect on blood pressure.
Easily reversed with Narcan.
Side Effects
Bradycardia.
May see skeletal muscle rigidityinvolvement of the chest wall musculature
can interfere with ventilation. This typically occurs after very rapid injection.
Treatment is with a neuromuscular blocking agent.
Sufentanil and alfentanil are newer, more potent synthetic narcotic agents
which differ from fentanyl mainly in their kinetic profile. Both have an
immediate onset of action and a very short duration of action. Dose is 10-25
mg/kg for sufentanil and 8-20 mg/kg for alfentanil.
Propofol
A sedative/hypnotic unrelated to other agents. Like the barbiturates, propofol
is highly lipid soluble and so has rapid penetration into the CNS followed by
rapid redistribution.
Onset of action is 30-40 seconds with a short duration of action of several
minutes.
Dose is 1.0-2.5 mg/kg for bolus use.
Benefits
Decreases cerebral blood flow, ICP, and cerebral oxygen consumption.
Decreases IOP.
Side Effects
Decreased cardiac output, hypotension.
Difficulty of use: propofol is maintained in an oily, organic emulsion consisting
of soybean oil, glycerol, and egg lecithin. Although a bacteriostatic agent has
been added, but this medication can potentially support the growth of microorganisms. As a result, the use of propofol demands extremely strict adherence to
asepsispossibly a concern in the often chaotic setting of a trauma resuscitation.
Ketamine
This is a dissociative anesthetic related to PCP. The patient remains awake,
but has deep analgesia and amnesia for the event. The principal setting for use
in trauma is for the hemodynamically unstable patient without any possibility
of intracranial injury.2
Onset of action is 30-60 seconds with a duration of 5-10 minutes after IV use
(dont use the IM route for RSI).
Dose is 1-2 mg/kg (IV).
Benefits
Protective airway reflexes are maintainedespecially useful in the trauma setting where the time of most recent food ingestion is uncertain.
Increases cardiac output, heart rate, and blood pressure.
Bronchodilation.
Side Effects
Increases ICP, cerebral oxygen demand, cerebral blood flow, and IOP
Increases myocardial oxygen consumption.
63
Emergence phenomenon may occur including hallucinations and dysphoria.

This is reported to occur mainly in the first few hours after awakening and is
possibly less pronounced in pediatric patients.
Lidocaine
Lidocaine is an amide anesthetic whose usefulness as adjunctive therapy during
RSI has been studied for decades. The effect of lidocaine (via both topical and IV
administration) on heart rate, blood pressure, and ICP has been the subject of numerous investigations. While results of these studies are controversial, the majority
of evidence suggests that lidocaine given IV at a dose of 1.0-1.5 mg/kg during the
pretreatment phase of RSI can prevent the increased ICP which occurs due to SCh
and airway manipulation.
Lidocaine should be used for all patients with head injury or in whom the
possibility of increased ICP exists (ALOC, etc).
Alternate Airway Techniques

In most cases, the initial approach at securing an airway in the trauma patient
should be orotracheal intubation using RSI as described above. Even in potentially difficult airway settings (such as penetrating neck trauma), this is
often the preferred and most effective route as many physicians are experienced in the procedure and it allows for direct visualization of the airway.
There are times when securing the airway via RSI may not be possible and
may even be detrimental: most often this occurs in the setting of severe facial
injury or neck trauma. In these instances where it may be difficult to maintain
oxygenation with BVM ventilation, the use of paralytics may create disaster as
protective airway reflexes and spontaneous respiratory drive will be abolished.
It is critical in the trauma patient for the physician to determine whether the
potential for a difficult airway exists. It is equally important to recognize when
standard techniques such as RSI and BVM ventilation are unsuccessfulthe
failed airway. It is in these cases that alternate means of establishing an airway
must be employed. The failed airway should be considered in the following
situations:
Patients who cant be adequately ventilated by BVM. While a single attempt at
orotracheal intubation is often appropriate, these patients demand an airway
via other techniques (often surgical) if this attempt is unsuccessful. Further attempts at intubation are likely to increase airway trauma and prolong the duration of hypoxia.
Patients who have undergone three unsuccessful attempts at intubation by a
physician skilled in the procedure. This applies even to patients who can be
adequately ventilated by BVM. If three attempts fail, the fourth is unlikely to
succeed.
Many other techniques exist for placement of an effective airwayboth surgical and noninvasive. In general, these techniques should be considered for
use only in the setting of the failed airway. However, some methods such as
the lighted stylet and fiberoptic intubation may be useful as the primary means
of securing the airway when difficulty is anticipated (see following discussion). As with the proper selection of intubation medications, the technique
which is used should depend upon physician experience, availability of necessary equipment, and patient presentation.
64
Trauma Management
The Surgical Airway

Cricothyrotomy
Cricothyrotomy is the definitive mechanism of airway control for the failed

airway and for those patients with massive facial trauma which precludes
orotracheal intubation or other alternate methods. Cricothyrotomy should be
performed in any patient with a failed airway who cant be adequately ventilated by BVM especially if other methods of airway control are not immediately available and appropriate for use.
Preferred invasive airway method (vs. tracheostomy) because it is safer and
easier to perform.
Relative contraindications (considered only relative since this a technique of
last resort):
Coagulopathy.
Distortion of neck anatomy.
Obstruction below the level of the cricothyroid membrane.
Preexisting infection.
Absolute Contraindication: Age less than ten years of age. Because of their
anatomical differences, smaller children require other invasive methods for
the failed airway.
Basic Technique
Vertical midline or horizontal skin incision followed by a horizontal incision
through the inferior aspect of the cricothyroid membrane.
The cricothyroid membrane is ideally cannulated with a cuffed tracheostomy
tube, but one can also use small endotracheal tubes.
Complications
Bleeding
Airway stenosis
Creation of false passage
Laceration of neighboring structures
Mediastinal emphysema
Percutaneous Transtracheal Ventilation

Specific Indications
The failed airway in pediatric patients less than ten years of age where
cricothyrotomy is contraindicated.
Possibly as a temporizing measure for surgical cricothyrotomy.
Relative Contraindications
Proximal airway obstruction. Although this greatly increases the risk of pulmonary barotrauma because of failed exhalation, successful oxygenation can still
be obtained.
Coagulopathy
Distortion of neck anatomy
Preexisting infection
Basic Technique
Cannulation of the airway via a large-bore Angiocath through the cricothyroid
membrane (10-14 g for adults; 18 g for pediatrics).
Subsequent ventilation through the Angiocath using 55 psi wall oxygen source.
Alternatively, the female end of the Angiocath can be connected to the male end
of a 3.0 endotracheal tube and the patient ventilated with BVM.
65
Noninvasive Rescue Airway Techniques

Laryngeal Mask Airway (LMA)
A soft, silicone mask connected to a ventilation tube that is blindly inserted
into the pharynx. The rim of the mask is then inflated which ideally provides
a snug fit at the airway and minimizes air entry into the gastrointestinal tract
during ventilation (see Fig. 5.1).
Indication: For use only as a temporizing measure in patients with failed intubation who cant be adequately ventilated via BVM. Physicians familiar with
its use should consider LMA for the failed airway especially if not skilled in
cricothyrotomy or other alternate airway techniques.
Advantages: Ease of placement. Although use of the LMA requires some instruction, it is easy to useno direct visualization is required and there is a
high rate of successful insertion.
Disadvantages: The LMA has mainly been used in the elective setting where
patients have a known period of preprocedural fasting. The LMA does not
provide adequate protection against aspiration. In fact, aspiration is likely to
occur if the patient vomits.
Esophageal Tracheal Combitube

Double lumen tube which is placed blindly into either the esophagus (preferred) or the trachea. There is a large balloon located proximally that when
inflated prevents the efflux of air through the upper airway (see Fig. 5.2).
After determining where the tube has been placed, the appropriate port can
be used for tracheal ventilation.
Indication: Although mainly studied as an alternate airway management technique for prehospital personnel and persons not skilled in endotracheal intubation, the Combitube can be used in the emergency department. However
with the LMA, its main use should be for the failed airway.2
The Lighted Stylet

A semiflexible, lighted stylet which is attached to a battery handle. The stylet
is placed through an endotracheal tube which is subsequently attached to the
battery handle via a special device.
Technique:
The stylet is placed blindly using transillumination from the lighted tip through
the midline soft tissues of the neck to guide placement into the airway. With
appropriate placement, one should see strong transillumination versus faint as
seen with esophageal placement.
After proper placement, the endotracheal tube can be advanced over the stylet
into the airway.
Indications
The failed airway where previous attempts at intubation have failed.
Since paralysis is not necessary, it may be used instead of routine oral intubation
in cases where a difficult airway is anticipatedfacial trauma, fixed dental
appliances.
Advantages
Reduced concern regarding cervical spine manipulation in those patients with
potential injury.
66
Trauma Management
Fig. 5.1. Laryngeal Mask Airway (LMA).
High success rate.

Ease of use since no direct visualization is required.
Disadvantages
Requires special equipment which may not be as readily available as that for a
surgical airway. Also requires operator experience.
Difficult to use in brightly lighted settings such as trauma resuscitation rooms.
Fiberoptic Intubation
Bronchoscopy is used to directly visualize the glottis. An endotracheal tube
which has been threaded over the end of the bronchoscope can then be advanced into the trachea. Either the nasal or oral approach can be utilized.
Indication: While this technique is most useful as an elective procedure, it can
be useful in the emergency department setting for anticipated difficult oral
intubation especially with distorted neck anatomy where paralysis and a surgical airway may be problematic.
Advantage: Allows direct visualization of the airway.
Disadvantages
May be difficult to properly identify airway structures in the presence of blood
(and other secretions) as with many trauma patients. In fact, this is one of the
principal reasons for failure to intubate via bronchoscopy.3
Requires very specialized equipment which is often not readily available and is
expensive to maintain
Demands a high degree of operator skill and a cooperative patient
Time consuming
Hypoxemia can occur during bronchoscopy which would mandate abortion of
the procedure in order to ventilate the patient.
The Bullard Laryngoscope

A relatively new similar airway modality which employs a long, curved blade
with a fiberoptic scope. A stylet may be attached which can be threaded through
an endotracheal tube so that the scope and tube can be inserted as a unit.
67
5
Fig. 5.2. Esophogeal Tracheal Combitube.
Retrograde Intubation
Placement of an endotracheal tube via an over-the-wire method.
Technique:
Cannulation of the cricothyroid membrane with a large-bore needle directed in
a cephalad direction followed by passage of a guidewire through the needle
directed toward the oropharynx.
Identification of the guidewire in the mouth which can then be secured via forceps.
Passage of the endotracheal tube over the guidewire. Once the tube is palpable
at the cricothyroid membrane, the guidewire can be removed and the tube advanced to the appropriate level.
Rarely used but can be considered for the failed or anticipated difficult airway.
Nasotracheal Intubation
Passage of an endotracheal tube blindly through the naris into the trachea.
The tube should be one size smaller than that used for oral intubation.
Technique:
Initial placement of the tube into the pharynx through the nose.
Advancement of the tube into the trachea during inspiration with negative intrapleural pressure being used to guide accurate placement.
Contraindications
Apnea
Midface and basilar skull fractures
Combative patient
Presence of an upper airway foreign body
Advantages
Used in the awake patient so no paralysis required.
High success rate when performed by experienced individuals.
Very safe in patients with potential cervical spine injury.
Complications
Epistaxismay be minimized by pretreatment with a topical vasoconstrictor.
68
Trauma Management
Trauma to the vocal cords.
Increased intracranial pressure.
Creation of a false passage.
Tactile Digital Intubation

Consists of blind placement of an endotracheal tube using the index and long
fingers to guide the tube over the dorsum of the tongue and through the
glottis.
Rarely used but can be used as a last resort when other methods have failed.
Advantages:
Minimal special equipment or skill required.
Can be done rapidly with little preparation.
Disadvantages:
Higher risk of failure compared to other airway techniques.
Operators hand at risk for bite injuries.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Walls R. Management of the difficult airway in the trauma patient. Emerg Med
Clin North Am 1998; 16:45-61.
Morris I. Pharmacologic aids to intubation and the rapid sequence induction. Emerg
Med Clin North Am 1988; 6:753-768.
Kharasch M, Graff J. Emergency management of the airway. Crit Care Clin. 1995;
11:53-66.
Walls R. Rapid-sequence intubation in head trauma. Ann Emerg Med. 1993;
22:1008-1013.
Schwartz D, Wiener-Kronish J. Management of the difficult airway. Cl Chest Med
1991: 12:483-495.
Walls R. Rapid-sequence intubation in head trauma. Ann Emerg Med 1993;
22:1008-1013.
Taylor P. Agents acting at the neuromuscular junction and autonomic ganglia. In:
Gilman A, Rall T, Nies A, Taylor P, eds. Goodman and Gilmans The Pharmacological Basis of Therapeutics. 8th ed. New York: Pergamon Press, 1990:166-79.
Kovac A. Controlling the hemodynamic response to laryngoscopy and endotracheal intubation. J Cl Anes 1996; 8:63-79.
Schwartz D, Wiener-Kronish J. Management of the difficult airway. Cl Chest Med
1991; 12:483-495.
CHAPTER 1
CHAPTER 6
Shock and Resuscitation

Fred Bongard
Shock is defined as the inadequate delivery of oxygen and nutrients at the cellular
level. It must be understood that shock may be organ specific and that not all organs
are underperfused simultaneously. Indeed, as shock progresses, there exists a hierarchy
of organ perfusion so that some organs such as the heart and brain may be minimally
affected, while other tissues such as skin and muscle may be severely compromised.
Causes of Shock
Hypovolemic
- Hemorrhagic (most common following injury)
- Nonsanguinous fluid loss (e.g., diarrhea, fistulas)
Distributive
- Neurogenic (e.g., after high spinal cord injury)
- Anaphylactic/Anaphylactoid (e.g., drug reaction)
- Sepsis (rarely responsible immediately after injury)
Cardiac
- Cardiac compressive (e.g., pericardial tamponade)
- Cardiogenic (e.g., pump failure with congestive heart failure)
Hypovolemic Shock
Etiology and Pathophysiology
Hemorrhagic shock is the most common form following injury and results
from loss of circulating blood volume either internally or externally.
Hallmark is decreased cardiac output, increased systemic vascular resistance,
decreased central venous pressure, tachycardia, and hypotension.
- Concealed hemorrhage should always be considered in trauma victims. This
represents blood loss into body cavities or tissue plains and generally requires
imaging modalities to detect.
Hemothorax: Each thoracic cavity can accommodate several liters of
blood. A massive hemothorax occurs when more than 1500 mL is contained in the chest. This can severely compromise circulating blood
volume. A history of blunt or penetrating chest injury should prompt
consideration of a hemothorax.
Hemoperitoneum: Intraabdominal bleeding from any source leads to hemoperitoneum. The abdominal cavity forms a capacious potential space
and a large volume of blood is required before a change in abdominal girth
is readily observed.

Fred Bongard, Division of Trauma and Critical Care, Harbor-UCLA Medical Center,
UCLA School of Medicine, Los Angeles, California, U.S.A.
70
Trauma Management
- Do not be fooled into thinking that a nondistended abdomen does not

contain blood. The most common cause of abdominal distention after
injury is aerophagia (typically from bag-mask-valve ventilation) resulting
in gastric distention.
- The intraabdominal organs most commonly injured after blunt trauma
leading to hemoperitoneum are: spleen (25%), liver (15%), and kidney
(retroperitoneal, 12%).
- The intraabdominal organs most commonly injured after penetrating
trauma leading to hemoperitoneum are: small bowel (30%), mesentery
and omentum (18%), and liver (16%).
Retroperitoneal and pelvic hematomas occur following the injury of retroperitoneal structures (such as the kidneys or aorta), or fracture of the pelvis.
Pelvic fractures with posterior element involvement (sacro-iliac joint) are
particularly likely to cause extensive hemorrhage and hypotension.
Orthopedic injuries: Fractures are common causes of concealed hemorrhage.
Because of their hematopoetic function and requisite vascular connections,
long bones such as the femur and tibia can lead to considerable concealed
hemorrhage.
The severity of hypovolemic shock depends not only on the absolute amount
of blood lost, but also upon the rate at which it was depleted, the age of the
patient, and premorbid status.
Table 6.1. Hemorrhagic shock

Blood loss (mL)
Blood loss (% BV)
Pulse Rate
Blood Pressure
Pulse Pressure
Respiratory Rate
Urine Output (mL/hr)
Mental Status
Class I
Up to 750
Up to 15%
< 100
Normal
Normal or
Increased
14-20
> 30
Anxious
Class II
750-1500
15-30%
> 100
Normal
Decreased
Class III
1500-2000
30-40%
>120
Decreased
Decreased
Class IV
> 2000
> 40%
>140
Decreased
Decreased
20-30
20-30
Anxious
30-40
5-15
Confused
>35
Nil
Lethargic
Adapted from American College of Surgeons, Advanced Trauma Life Support for
Physicians, 1993.
Hemodynamic Effects:
- As venous return falls, cardiac output and oxygen delivery decrease.
Increased heart rate and peripheral vasoconstriction: These two compensatory reflexes help to maintain blood pressure. As volume falls, peripheral
vascular resistance increases. This is apparent clinically by an increase in
diastolic blood pressure and a fall in pulse pressure. In the terminal stage of
shock, vasoconstriction fails and pulse pressure widens.
Patient is cool to palpation. Pulses are difficult to feel. Femoral pulse typically palpable until blood pressure falls below 90 mm Hg.
- Venoconstriction displaces pooled blood back toward the heart
Neck veins are collapsed
71
- As glomerular filtration falls, urine becomes more concentrated and urine

output declines.
- As intravascular volume (and hence pressure) falls, transvascular flow occurs.
This allows the movement of blood-free fluid from the interstitial and
intracellular spaces into the intravascular space to refill the vascular volume.
Transvascular refill takes about 20 minutes to begin, and is essentially
complete by two hours.
The extent of transvascular refill is likely limited to a total of 1-2 liters.
- This is the mechanism responsible for the decrease in hematocrit observed
after blood loss. The red cell free fluid that refills the vascular space dilutes
the number of red cells remaining, thereby decreasing the hematocrit.
Metabolic Effects:
- When oxygen delivery is inadequate, ATP must be generated through anaerobic
glycolysis.
Lactic acid is produced (lactate is also known as the ion of ischemia).
Largely responsible for the acidemia which accompanies shock.
- Causes a decrease in pH and fall in serum bicarbonate. Increase in the
base deficit is observed on arterial blood gas analysis.
- The decrease in red blood cell volume and cardiac output produces a decrease
in systemic oxygen delivery.
- Peripheral oxygen consumption stays constant until systemic oxygen delivery
reaches a very low level.
- Maintained oxygen consumption in the face of decreased oxygen delivery
depends upon increased peripheral oxygen extraction.
As more oxygen is removed from the blood delivered, the venous oxygen
saturation (and content) declines. This is apparent on mixed venous blood
- 2 (venous oxygen hemoglobin saturation) will be
gas testing. A fall in SvO
noted.
- 2 is approximately 75%. Even small decreases in SvO
- 2 signify
Normal SvO
important increases in oxygen extraction due to decreased oxygen delivery.
Neuroendocrine Effects
- Secretion of aldosterone and renin. Together, these two hormones increase renal
retention of salt and water, which serve to maintain circulating blood volume
- Secretion of epinephrine, glucagon, and cortisol. These stress hormones
make energy stores available. They also assist in maintaining hemodynamic
homeostasis.
Neurologic Effects
- Sympathetic stimulation increases peripheral vascular resistance to help maintain blood pressure.
Sympathetic stimulation has little effect on intracerebral vessels. Autoregulation of the brains blood flow is maintained until mean systemic blood
pressure falls below approximately 70 mm Hg.
Gastrointestinal Effects
- Decrease in splanchnic blood flow is one of the early consequences of systemic
hypoperfusion. This decrease in oxygen delivery to the gut may permit bacterial
translocation and subsequent systemic sepsis.
72
Trauma Management
Clinical Findings
Changes in heart rate and blood pressure do not reliably indicate the extent of
hypovolemia.
- Younger patients tend to maintain their blood pressure through increased
peripheral vascular resistance with only minimal changes in heart rate. Older
patients who cannot vasoconstrict as completely may maintain a seemingly
normal blood pressure until they decompensate.
Decreased capillary perfusion produces coolness of the skin.

The generalized sympathetic discharge responsible for vasoconstriction also
causes sweating, leading to a moist or clammy sensation.
Absence of jugular venous distention is due to hypovolemia.
- Although jugular venous distention is associated with pericardial tamponade
and/or tension pneumothorax, patients who are hypovolemic may have normal
appearing jugular veins even in the presence of either of these conditions.
Decreased urine output (< 0.5 mL/kg/hr) is due to decreased renal perfusion.
Mental status is an important, and often overlooked, clinical parameter. Patients
who are awake and normally responsive are likely to have adequate perfu--sion.
Be wary of the patient who presents with normal mental status and then becomes
anxious, confused or lethargic. While this may be due to intracranial pathology
(subdural, epidural, or subarachnoid hemorrhage), or to intoxicants, it may
also be due to declining perfusion from worsening shock and unrecognized
hemorrhage.
Laboratory Examination
There is no single laboratory examination which reliably includes or excludes
the diagnosis of shock !!
Hematocrit measures the volume percentage of red blood cells in plasma.
Patients with hemorrhagic hypovolemic shock may have normal or decreased
values of hematocrit. The hematocrit will depend on the amount of blood
lost, the time elapsed since the blood loss, and the amounts of nonsanguinous
fluid and blood transfused.
- Hematocrit declines after blood loss primarily through capillary refill (described
above), in which red cell free fluid moves from the intracellular and interstitial spaces into the intravascular space. This begins approximately 20 minutes
after injury.
A patient presenting shortly after injury may have a relatively normal
hematocrit.
Urine analysis will show concentrated urine with a high specific gravity.
Lactic acid is usually elevated as a result of anaerobic metabolism.
- Serial determination of lactic acid is a useful parameter to follow during resuscitation. Progressive decrease in lactic acid is associated with an improved outcome.
Bicarbonate is decreased and base deficit is increased.

- Base deficit is an approximation of base depletion secondary to metabolic causes.
It is a calculated value reported as part of a blood gas analysis.
The base deficit can be used to calculate the amount of bicarbonate required to correct the acidosis.
[HCO3-] required = Base deficit * 0.4 * Body Weight
73
- Approximately one half of the calculated dose of bicarbonate should be

given as an acute bolus.
Hemodynamic Monitoring
Blood pressure should be monitored by either invasive or noninvasive means.
Whichever modality is chosen, values should be checked every several minutes to insure that therapy is efficacious.
Pulse rate monitoring should accompany the EKG.
Pulse oximetry is useful to ensure that arterial hemoglobin oxygen saturation
is optimized.
- Pulse oximeters are perfusion dependent and may not work reliably in patients
who are in severe shock or are hypothermic and profoundly vasoconstricted.
If the patient has been orotracheally or nasotracheally intubated, end-tidal

carbon dioxide monitoring is helpful to evaluate CO2 excretion. Low values
of end tidal CO2 suggest poor systemic perfusion, which prevents carbon dioxide from returning to the lung. Very low values of end tidal CO2 suggest
cardiac decompensation or endotracheal tube dislodgement or misplacement.
A urinary catheter should be inserted and connected to a calibrated collection
device. Urine output less than 0.5 mL/kg/hr is consistent with inadequate
renal perfusion and continued shock.
- The amount of urine present in the bladder at the time of initial catheterization
is immaterial, as the patient may have had a full bladder prior to the injury. The
initial return should be discarded and zero time begun with new urine collection.
Although specific gravity testing is required to determine objectively how
concentrated the urine is, dark urine suggests hypoperfusion and renal volume conservation. Hemolysis with hemoglobinuria and Rhabdomyolysis
with myoglobinuria may also cause dark urine. A dipstick test for blood will
be helpful in rapidly excluding either of these etiologies.
Central venous catheters are useful in only a limited number of situations and
generally are not needed in the initial evaluation of the trauma patient. Furthermore, their insertion poses real risks such as vascular injury or creation of
a pneumothorax. If a suspicion of pericardial tamponade exists and other
modalities such as echocardiography are not available, a central venous catheter
may be helpful.
Treatment
Resuscitation must follow an organized path.
The first priority is ALWAYS assurance of an adequate airway and gas exchange.
- Endotracheal intubation is usually required.
- When intubation is not possible or feasible (such as when the patient sustains
massive orofacial trauma), cricothyroidotomy is the surgical airway of choice.
- After the airway is secured, 100% oxygen should be used initially until adequate hemoglobin oxygen saturation is assured.
Adequate intravenous access is required for fluid replacement.

At least two large bore upper extremity intravenous catheters should be placed.
- The rate at which fluid can be infused is directly proportional to the cross sectional area of the intravenous catheter. The resistance of these catheters is inversely proportional to the fourth power of the radius. Hence, a smaller catheter
with one-half the radius of another will have 16 times the resistance to flow.
74
Trauma Management
- Although access is often gained through a femoral vein, this route should be
used only when upper extremity access is not possible.
Injuries of the vena cava and/or iliac veins may allow extravasation of fluid
infused through the lower extremities.
Central venous access in the emergency situation is to be condemned as a modality
of last choice. Normally, such catheters are placed with patients positioned in a
manner that will open the thoracic inlet and expose the subclavian vein.
Hypovolemic patients usually should not have their heads rotated (due to
cervical spine precautions) and cannot have towels placed between their
scapulae. For these reasons, the subclavian vein is relatively more difficult to
cannulate and attempts may result in a simple or tension pneumothorax, a
hemothorax, or a vascular injury. Dont do it!
Interaosseous needles are effective and safe in children less than six years of
age.
Resuscitation in adults should begin with rapid infusion of one to two liters of
isotonic electrolyte solution.
- An initial bolus of 20 mL/kg should be used in children.
- The total amount of fluid required for resuscitation is difficult to estimate. Using
the table above, an approximation of the amount of blood lost can be made.
Each 1 mL of blood loss should be replaced with 3 mL of isotonic electrolyte
solution.
The amount of fluid actually required should be based on the patients overall response rather than on a formula. Improvement in mental status, increased urine output, and decrease in tachycardia are favorable indicators.
Some controversy still exists regarding the optimal fluid for resuscitation.
Isotonic fluids (such as balanced salt solutions) have the same osmolality as
body fluids.
- Ringers lactate and normal (0.9%) saline are commonly used.
- Some centers prefer normal saline because it can be mixed with blood.
- Because the chloride concentration in lactated Ringers solution is less than
that found in normal saline, and approximately equal to that of the intravascular space, many prefer lactated Ringers since it does not produce the
metabolic hyperchloremic acidosis caused by resuscitation with normal
saline.
- Electrolytes and water partition themselves in a manner similar to the bodys
extracellular water content: 75% extravascular and 25% intravascular.
- This partitioning usually takes place within 30 minutes after the fluid is
administered.
- Within 2 hours, less than 20% of the infused fluid remains within the
intravascular space.
- Hypertonic saline (3% saline) expands the extracellular space by exerting an
osmotic effect that displaces water from the intracellular compartment.
May also exert positive inotropic effect.
Decreases wound and peripheral edema.
Smaller volume required making it attractive as an agent for resuscitation of
mass casualties in remote sites.
May have other salutary effects.
- Colloids are solutions that rely on high molecular weight species to create osmotic
effects.
75
Colloids tend to stay within the intravascular space for longer periods than
crystalloids.
Smaller volumes are required.
More expensive than crystalloids.
No real advantage over crystalloids.
- Other resuscitation fluids include albumin, starches, and dextrans. While some
modest advantages have been demonstrated for each, they are significantly more
expensive than crystalloid and generally should not be used.
- Although the decision to institute blood transfusion must be individualized, a
general rule is to begin blood infusion when crystalloid infusion exceeds 50 mL/
kg without stabilization or improvement of shock.
This usually occurs after the first three liters of crystalloid have been infused.
Blood is used primarily to restore oxygen carrying capacity volume resuscitation itself should be accomplished with crystalloids.
Fully crossmatched blood is preferable.
Type specific blood is usually available within 10 minutes of a patients specimen delivery to the blood bank. This blood is ABO, but not necessarily Rh,
compatible.
Type O packed cells should be used in the patient with exsanguinating
hemorrhage. Type specific blood should be substituted as soon as it is available.
Dilutional coagulopathy may follow massive blood transfusion, prompting
the need for platelet and factor transfusion.
- Hypothermia from the infusion of cold blood may also lead to
coagulopathy. Every effort should be made to warm the blood during infusion.
- Contrary to popular belief, most patients receiving massive transfusions
do not need supplemental calcium.
M.A.S.T. primarily of historic interest

- Military AntiShock Trousers (also called pneumatic antishock garment) was
popular for a brief time.
- Applied to the lower extremities and abdomen, the garment was used when
access to medical care was delayed (as in extended transport from the battlefield).
Mechanism of action is still debated but may be related to either increased
systemic vascular resistance or an autotransfusion of pooled venous blood.
May still have some role in the management of hemorrhage in select patients with compound pelvic fractures in whom fracture stabilization is delayed.
- Garment may improve the pelvic geometry and reduce the potential space
for hemorrhage.
Pharmacologic agents (such as pressors) are seldom required to treat hypovolemic

shock.
- It is imperative that a patient receive adequate volume resuscitation before the
use of a pressor is even considered.
If a pressor is to be used, the patient should be admitted to an intensive care
unit and central venous pressure or pulmonary artery pressure monitoring
instituted to ensure that volume replacement has been adequate.
76
Trauma Management
There are no uniformly agreed upon endpoints for resuscitation from

hypovolemic (hemorrhagic) shock.
Return of mental status is useful, but patients may have a head injury or may
have ingested alcohol or drugs which confound the situation.
Decrease in base deficit and/or lactic acid concentration are associated with
improved survival.
Increased urine output, in the absence or glucosuria or intravenous dye
administration (which produces an obligatory osmotic diuresis), signifies
improved renal perfusion.
Increased transcutaneous oxygen concentration is impractical in the acute
situation as a resuscitation parameter.
If a pulmonary artery catheter is in place, increased mixed venous oxygen
- 2) and decreased oxygen extraction ratio signal improved
saturation (SvO
systemic oxygen delivery.
Distributive Shock
Occurs when there is inappropriate distribution of blood flow to the viscera.
- An adequate volume of blood may be present, and cardiac output may be
sufficient.
Types include septic, neurogenic, and anaphylactic.

- Septic shock rarely occurs in the acute situation.
Neurogenic shock
Preceded by trauma or spinal anesthesia.
Clinical Findings
Hypotension
Never assume that a hypotensive patient with a spinal cord injury is in neurogenic shock until all potential causes of blood loss (hemorrhagic shock) have
been excluded !
- If the level of spinal cord interruption is below the mid thorax, the proximal
sympathetic nervous system is activated and a tachycardia is observed
- If the level of interruption is high, sympathetic outflow is affected and bradycardia results.
Signs and symptoms of spinal cord injury and spinal shock are often present.
Skin is pink and warm in the denervated areas.
Patient is anxious (if awake) with paralysis of the lower body.
Loss of the peripheral venous muscular pump may also decrease venous return.
Laboratory and Radiographic Examination

Laboratory studies are nonspecific.
Radiographs should be obtained to help determine the level of the spinal injury.
- Computerized axial tomography with saggital reconstruction may be particularly
useful.
Be sure that the patient is adequately resuscitated before transport to the
CT suite.
- Never transport a hypotensive patient to CT scan with the sole intention
of establishing a diagnosis!
77
Treatment
As with all trauma patients, be sure that the airway is patent and that the
patient is breathing.
- In very high injuries (above the fourth cervical vertebrae) breathing may be
compromised by phrenic nerve interruption, making emergent airway intubation for mechanical ventilation an immediate priority.
- Most patients in spinal shock will require airway intubation and mechanical
ventilation. Many will have associated head or thoracic/abdominal injuries that
will require operative intervention.
Infusion of large amounts of fluid will be required to ensure adequate venous

return.
- Blood transfusion is seldom required unless hemorrhage from associated injuries is present.
Prior to the use of pressors, a central venous catheter should be inserted to
be sure that CVP has risen to a normal range with fluid infusion.
- Do not hesitate to continue fluid infusion until CVP has reached 12-15
mm Hg.
Phenylephrine or norepinephrine may be used as pressors.
- These agents should be started at low doses and titrated to a mean blood
pressure of 60-80 mm Hg.
- Weaning from pressors can usually be achieved quickly.
Septic Shock
Occurs in association with overwhelming infection.
Observed features are likely predominantly due to immune response to bacteria, their components, or their products.
Rarely an immediate cause of hypotension in trauma patients.
- Generally occurs days to weeks later after the combination of hypotension and
bacterial inoculation have had a chance to evoke an immune response.
Mechanism of bacterial translocation has been invoked to explain sepsis in
patients without apparent bacterial contamination.
Hypotension with resultant hypoperfusion of the intestines may allow bacteria to translocate across compromised mucosa and into the blood stream
and lymphatics.
- Has been difficult to demonstrate in humans although good animal models exist.
Overall mortality from septic shock is 40-60%.

Aerobic gram-negative bacillary infections are the most common cause.
- Long cascade of reactions is initiated by endotoxin contained in bacterial cell
wall.
- Gram positive organisms and fungi can also causes septic shock.
Clinical Features
Decreased blood pressure with increased heart rate and decreased urine output.
Increased cardiac output with decreased systemic vascular resistance produces
characteristic physical examination of warm and pink extremities.
Underlying signs of infection and/or inflammation usually present.
- In the trauma patient, the chest and abdomen are the most common location.
Infection of devitalized tissue in the extremities should also be considered.
78
Trauma Management
Mental status is usually depressed. Patients may appear anxious and agitated.
Tachypnea usually present. May even manifest as air hunger.
Hemodynamic and Laboratory Findings

Hypotension and tachycardia
Oliguria
If a pulmonary artery catheter is placed, increased cardiac output and decreased
systemic vascular resistance are noted.
- Decreased peripheral consumption of oxygen produces a higher than normal
- 2 ( > 75%) and a lower than normal arteriovenous oxygen content differSvO
ence ( < 4 mL/dL).
Increased white blood cell count with evidence of increased polymorphonuclear

and immature forms.
Disseminated intravascular coagulation as evidenced by decreased fibrinogen
concentration, increased fibrin split products and fibrin monomers, increased
d-dimer concentration, decreased platelet concentration, and increased PT
and PTT.
Hyperglycemia in the early stages
- Decreased glucose concentration may occur late and is an ominous sign, usually
due to failure of hepatic glucose production.
Arterial blood gas determination reveals moderate hypoxemia and metabolic

acidosis.
- Increased based deficit.
- Increased lactic acid concentration.
Subsequent positive blood cultures are present in 45%.
Treatment
Intravenous crystalloid solution, such as normal saline or lactated Ringers
solution, should be infused in sufficient quantity to overcome the
maldistribution of total body water.
- Capillary leaks are common in septic shock, and lead to peripheral and
pulmonary edema.
- Cardiac output and left ventricular filling pressure determinations obtained from
a pulmonary artery catheter should guide the amount of fluid infused.
If the patient is in profound shock, an initial crystalloid bolus of 500 mL
over 10-15 minutes is an appropriate starting point for a 70 kg patient.
Pulmonary artery pressure should be increased to between 10-15 mm Hg.
- Hemodilution is a common consequence, and may necessitate blood
transfusion.
- Minimum level of acceptable hemoglobin concentration before blood transfusion is required is not well defined. Many clinicians use a hematocrit of
25% as a transfusion trigger, but a higher hematocrit may be required in
older patients with established cardiac disease.
- Patients with refractory hypoxemia and decreased arterial oxyhemoglobin
saturation will require higher levels of hemoglobin concentration to maintain adequate oxygen delivery.
Endotracheal intubation and mechanical ventilation will be required in most

patients.
- Adult respiratory distress syndrome (ARDS) is a typical feature of septic shock.
79
ARDS reduces lung compliance and gas exchange.

During mechanical ventilation, an Inspiratory: Expiratory (I:E) ratio approaching 1:1, or inverted (i.e., 1.5:1) may be required for adequate gas exchange.
Pressure controlled ventilation is a useful mode since it allows the clinician
to preset the inspiratory pressure.
Appropriate antibiotics should be infused intravenously

- Broad-spectrum agents, preferably without renal toxicity, are preferred.
Pharmacological Support
- A pulmonary artery catheter should be placed prior to beginning pharmacological support to ensure that adequate fluid infusion has been achieved. The
pulmonary artery catheter is also indispensable for monitoring the effects of
pressor infusion.
- Dopamine is the first choice of pressors
Immediate precursor of endogenous epinephrine.
- Effect is due to release of norepinephrine from sympathetic nerves and
direct stimulation of alpha, beta, and dopaminergic receptors.
- Depletion of norepinephrine in septic states may lead to dopamine
tachyphylaxis.
Effects somewhat dependent on dose.
- At lower doses, has inotropic effect without significant increase in heart
rate.
- Renal blood flow and urine output generally increase in doses less than
5.0 g kg/min.
- When dose reaches 10 g/kg/min, has both chronotropic and inotropic
effect.
- At doses in excess of 10 g/kg/min, alpha-adrenergic stimulation occurs
with increase in systemic vascular resistance.
- Dobutamine has predominantly B-adrenergic effect.
Minor chronotropic effect
Does not rely on preformed norepinephrine stores.
- Loses effect after prolonged administration due to down-regulation of receptors.
- Better choice for long-term infusion than dopamine.
May actually decrease peripheral vascular resistance
- Pressor of choice in patients with adequate blood pressure but depressed
cardiac output.
Infusion begun at 2-5 g/kg. Common dosing range is 5-15 g/kg/min.
- Increased urine output may occur due to increased cardiac output.
- Epinephrine produces dose-dependent increase in both systolic and diastolic
pressure.
Increase in blood pressure is caused by increase in heart rate and myocardial
activity (beta-1 effect) and by an increase in systemic vascular resistance
(alpha-1 effect).
- Causes an increase in myocardial oxygen consumption.
- High potential for arrhythmias.
- More useful in the treatment of cardiac shock than in the management of
septic shock.
- May be of some limited value in hypotensive patients who are unresponsive
to other treatment regimens.
80
Trauma Management
- Be alert for severe hypertension and ventricular arrhythmias, both of which
may be transient.
- Isoproterenol (Isuprel) is a nonselective -adrenergic agonist that is a positive
inotrope and chronotrope.
Venous return is increased because of decreased venous compliance.
Pulmonary and systemic vascular resistances are decreased and may lead to a
fall in blood pressure.
Short duration of action.
- May be useful in patients who do not respond to dopamine or to
dobutamine.
- Typical infusion rates are 0.01 g/kg/min and increased until the desired
effect is obtained.
- Alpha-adrenergic agents.
When blood pressure remains depressed despite adequate fluid resuscitation and institution of dopamine and/or dobutamine, one of these agents
may be tried.
Norepinephrineposes both alpha and beta effects (at low doses). At higher
doses, effect is primarily alpha with marked vasoconstriction, which may
help to increase blood pressure by increasing systemic vascular resistance.
This can decrease renal blood flow and produce mesenteric ischemia. Short
half-life of about 2 minutes. Infusion rates are 0.05-0.1 g/kg/min. Usual
maximum dose is 1 g/kg/min.
Neosynephrine is a synthetic alpha-adrenergic agent that has effects similar to norepinephrine.
Cardiac Shock
Cardiac compressive shock occurs when the pericardial space is compromised
and the cardiac chambers cannot fill.
Most common with stab wounds to the chest which produce bleeding from a
cardiac chamber or from a coronary artery.
Clinical Findings
Hypotension and tachycardia
Distended neck veins
Unlike tension pneumothorax, is not accompanied by deviation of the mediastinum or by change in breath sounds (unless an associated hemothorax is
present)
Laboratory and Diagnostic Findings
Mechanism of injury should prompt suspicion of the diagnosis.

Chest radiography seldom is diagnostic and usually wastes time.
Ultrasonography (echocardiography) is diagnostic.
If echocardiography is unavailable, a central venous catheter will show elevated central venous pressure.
- If an associated injury is present, hemorrhage and volume loss may prevent the
expected increase in central venous pressure.
While pericardiocentesis was recommended in the past, the availability of
echocardiography relegates this modality to one of historic interest only.
81
Treatment
Surgical relief of the tamponade with control of the bleeding vessel
- Pericardiocentesis will produce only temporary results and may be dangerous if
a ventricular or coronary artery injury occurs as part of the procedure.
Cardiogenic Shock
Also known as pump failure

Rarely occurs acutely after trauma except in previously compromised individuals
May occasionally occur with myocardial contusion
Always suspect hypovolemia as a cause of shock before entertaining cardiogenic shock as a diagnosis.
Clinical Findings
Hypotension, tachycardia (bradycardia in the terminal stages), increased systemic
vascular resistance, oliguria, and signs of increased intravascular volume.
- Auscultation may reveal a third heart sound.
- Neck veins are often distended, and if left ventricular failure is present. signs
and symptoms of pulmonary edema will be apparent.
Chest pain may be present in the acute setting.
Laboratory and Diagnostic Findings

Chest X-ray is seldom diagnostic in the acute situation. Evidence of pulmonary
edema and vascular congestion becomes apparent with time.
Concentrated urine with high specific gravity, low sodium, and FeNa (fractional
excretion of sodium) < 1.
If acute myocardial injury is present (infarction or contusion) creatine
phosphokine (MB fraction) and troponin will be elevated.
Increased serum lactate.
If a pulmonary artery catheter is inserted, pulmonary capillary wedge and
central venous pressures will be high (unless hemorrhage has reduced circulating
blood volume), cardiac output low, and systemic vascular resistance high.
- Note the key differentiating factor between cardiogenic and hypovolemic shock
is increased central venous pressure in the former and decreased central venous
pressure in the latter.
- 2 < 75%).
- Decreased mixed venous hemoglobin oxygen saturation (SvO
Increased arterial-venous oxygen content difference ( > 6 gm O2/dl) due to
increased peripheral oxygen extraction.
EKG evidence of myocardial infarction or ischemia may be present.
Treatment
Insure that pericardial tamponade is not present as the cause of decreased
cardiac output and increased central venous pressure!!
Begin supplemental oxygen to insure adequate myocardial oxygen delivery.
A small amount of morphine will facilitate sedation and increase venous capacitance. This helps unload the heart.
A pulmonary artery flotation catheter should be placed to measure filling pressures, calculate cardiac output, and derive oxygen variables.
Intravenous nitroglycerin, nitroprusside, and beta-blockers are useful, but must
be titrated with great care to avoid additional hypotension.
Several pharmacologic agents (previously detailed) may be of help.
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Trauma Management
-
Dopamine
Dobutamine
Epinephrine
Amrinone and milrinone are phosphodiesterase inhibitors which probably
decrease the intracellular breakdown of cyclic AMP.
Increase cardiac output and decrease afterload and preload. Does not cause
tachycardia or arrhythmias.
Particularly useful in the treatment of cardiac, as opposed to, septic shock.
- Loading dose of amrinone is 0.75 mg/kg over 3-5 minutes, followed by a
maintenance infusion of 5-10 g/kg/min.
Initial vasodilator effects may cause marked hypotension with the
institution of therapy.
- Significant side effect includes thrombocytopenia.
- May be used in combination with dobutamine
- Milrinone is more potent and has fewer side effects, but also causes
pronounced arteriolar and venous dilator activity. Initial loading dose is
50 g/kg over 10 minutes, followed by continuous infusion of 0.375-0.75
g/kg/min. Should be used with extreme caution in patients with decreased
afterload (such as septic shock).
Digitalis
Vasodilators such as nitroprusside and nitroglycerin may be used to decrease
systemic vascular resistance and allow the left ventricle to empty.
- Begin nitroprusside at 5-10 g/min and advance in increments of 2.5-5.0 g/min
every ten minutes until an increase in cardiac output is noted.
Use for more than 3 days may lead to cyanide toxicity.
- Monitor thiocyante levels. Toxic level is > 10 mg/dL.
- Begin nitroglycerin at 10 g/min and increase by 10 g/min every 5-10 minutes,
until a total dose of 50-100 g/min is administered.
Doses as high as 400 g/min can be tolerated for several days.
References
1.
2.
3.
4.
Shock. In: American College of Surgeons. Advanced Trauma Life Support Manual.
Chicago, IL: American College of Surgeons, 1993.
Bongard FS. Shock and resuscitation. In: Bongard FS and Sue DY, eds. Current
Critical Care Diagnosis and Treatment. Norwalk, CT: Appleton and Lange 1994.
Holcroft JW. Shock: ICU management. In: Wilmore DW, Cheung LY, Harken
AH et al, eds. American College of Surgeons Scientific American: Surgery. New
York: Scientific American 1998.
Holcroft JW. Shock. In: Wilmore DW, Cheung LY, Harken AH et al, eds. American College of Surgeons Scientific American: Surgery. New York: Scientific American 1998.
HEAD
CHAPTER 7
Management of Head Injury

Peter Gruen
Nonpenetrating Head Injury
Trephination (opening the cranium) is a procedure that was practiced by the
ancient Egyptians and precolonial Aztecs.
Guidelines for the management of severe head injury published by organized
North American neurosurgery (1995).
Incidence
Head injury is the cause of death in about 50% of trauma deaths in the US.
Mechanisms of Injury
The mechanisms of nonpenetrating head injury fall into two major categories:
those due to acceleration-deceleration and those due to focal impact.
Acceleration Deceleration Injuries
Brain Contusion
Contusion is bruising of the tissue just below the pial surface that results from
impact of brain tissue against the skull. Contusions are most common in cortex overlying the rough bone surface of the floor of the frontal (anterior) and
temporal (middle) fossae.
Coup-Contre Coup Injury

Impact injury to the side of the brain contralateral to the head impact (Fig. 7.4)
Tearing of Bridging Veins

Small caliber veins that drain the cortex into the sagittal sinus may be torn. The
tearing of bridging veins usually results in formation of a subdural hematoma.
Elderly patients have atrophied brains with a larger subdural space separating
their cortex from the sagittal sinus. Relatively minor displacements of the
head can result in tearing of bridging veins with slow leakage of subdural
blood (chronic subdural hematoma) in this age group (Fig. 7.1).
Sheering Forces
Sheering injuries to axons result in disruption and loss of neuronal function.
Sheered brain tissue will show evidence of trauma in the form of retraction balls or glial scarring by microscopy. Unfortunately the brain has
Peter Gruen, LAC + USC Medical Center, Los Angeles, California, U.S.A.
85
Fig. 7.1. Epidural with ipsilateral contusion.
no regenerative capacity so the dysfunction resulting from sheering is

irreversible.
The poor prognosis of sheer injuries is due not just to irreversibility but also
due to the frequent involvement of the brain stem area.
- The brainstem reticular activating system that controls consciousness is situated
at a very vulnerable site with respect to sheering injuries which can result in
permanent coma in the absence of any cranial imaging abnormalities.
Sheering injuries frequently are not visible on computerized tomography of

the head (head CT) and are the presumed diagnosis in the majority of head
injured patients who present in coma with a negative head CT scan.
Focal Impact Injuries

A blow with its force focused at one site on the head frequently results in a soft
tissue injury of the scalp and the underlying brain parenchyma. Middle
meningeal artery laceration and epidural hematoma may occur on the
intracranial side of a skull fracture.
Pathophysiology
Ischemia
Ischemia is a well-described consequence of head injury and a major cause of
secondary brain damage.
Cerebral Edema
Increased tissue water and volume due to increased permeability of the blood
brain barrier associated with a failure in the autoregulatory mechanisms of the
cerebral arterial vasculature.
Autoregulation Failure
Normally the systolic and diastolic pressure of the blood in the cerebral
vasculature is maintained within a relatively narrow range in spite of larger
fluctuations in systemic pressures. This autoregulatory mechanism frequently
fails following a cranial injury.
86
Trauma Management
Increased Intracranial Pressure

Intracranial pressure is the result of the pressure due to three volumes contained
within the rigid, nonexpansile skull:
1. the brain parenchyma,
2. the cerebral vasculature, and
3. the cerebrospinal fluid spaces (ventricles, cisterns, sulci).
An increase in any one or more of these volumes will lead to an increase in the
intracranial pressure unless there is a compensatory decrease in one or more of
the other volumes.
Increased intracranial pressure decreases cerebral perfusion according to the
equation: CPP (cerebral perfusion pressure) = MAP (mean arterial pressure)
ICP (intracranial pressure).
Herniation
Brain swelling can lead to occlusion of the subarachnoid CSF circulation

pathways around and through the brain allowing for the occurrence of pressure
gradients. Brain tissue in a higher pressure compartment moving down a
gradient into a lower pressure compartment results in herniation.
Herniation can occur across the midline, from the temporal into the posterior
fossa (uncal herniation) or from the posterior fossa into the vertebral canal
(cerebellar tonsillar herniation).
Clinical Presentation
Neurologic
No Loss of Consciousness
Patients with a focal blow to the head are more likely to have no loss of consciousness than those with an acceleration-deceleration event. The absence of
loss of consciousness in an acceleration-deceleration injury is reassuring that
there is not significant intracranial pathology. However, nausea, vomiting,
focal neurologic deficit are all indications for head CT.
Transient Loss of Consciousness

A transient loss of consciousness is suggestive of a mechanism of injury with
enough force applied to the brainstem that it causes transient neurologic dysfunction at the level of the reticular activating formation.
Loss of consciousness should, therefore, be an indication for obtaining a head
CT scan even if the patient is conscious at the time he is encountered in the
field and remains so in the DEM.
Concussion is the diagnosis given to patients with a head injury significant
enough to cause a transient loss of consciousness, but without traumatic hematoma or cerebral edema detected on head CT.
Seizures
Convulsions are frequent following head injury. They are particularly common in pediatric patients.
Seizures are more common in patients who have subdural hematomas or contusions of the frontal or temporal lobes of the brain but can occur in patients
with negative head CT who are diagnosed as having concussion.
87
Found Down
Until proven otherwise, patients found unconscious with mechanism and time
of injury unknown should have a head CT done.
Intoxicated
Intoxication is present in a large number of head trauma victims and in many
patients who are found down. All intoxicated patients who are found unconscious, with a focal neurologic deficit, or with a GCS less than 15, with or
without external signs of head trauma should have a head CT done.
Lucid Interval
Described as the classic presentation of epidural hematoma, the lucid interval is a period of time postinjury during which the patient is awake and alert
(frequently not even complaining of a headache) while blood is accumulating
in and expanding the narrow space between the brain and the inner side of the
skull, but not yet of sufficient volume to cause impaired consciousness or
other neurologic deficit. Once the volume of the clot reaches a critical threshold the patient can rapidly decompensate neurologically and descend into
deep coma with focal deficit (such as hemiparesis, aphasia) or signs of brainstem
compromise (papillary asymmetry, posturing. abnormal breathing pattern)
and even brain death.
Any patient who could be in the lucid interval particularly those
with a mechanism suggestive of epidural hematoma (temporal blow)
should be observed until a head CT has ruled out an expanding intracranial hematoma mass.
Focal Deficit
Focal deficits are those that can be lateralized to one side, or localized to one
lobar region of the brain:
Weakness (paresis), paralysis (plegia), and hyperreflexia.
Language deficits are usually ascribed to a process resulting in dysfunction of
the temporal lobe on the dominant (90-plus percent of brains) side. Profound
language deficits such as receptive or expressive aphasia (complete inability to
understand or speak) or dysphasia (partial but obvious inability) are usually
due to dominant temporal and posterior frontal pathways, but nondominant
and nontemporal injuries can also cause significant language impairments.
Asymmetry, sluggishness, or absence of a pupillary response can be a sign of
third nerve compression by a herniated temporal lobe but can also be due to
injury to the afferent visual pathway deficit.
Brainstem Findings
The pupillary reflex pathway has an afferent (inward to the midbrain papillary constrictor nucleus) and efferent (outwards from the nucleus) arm. Normally the efferent parasympathetic constrictor innervation to the pupil is opposed by sympathetic innervation with the balance between the two resulting
in a pupil midway between fully constricted and fully dilated. Injury to the
constrictor (Edinger Westfal) nucleus or the outgoing third cranial nerve results in elimination of the parasympathetic constrictor output and a pupil
that remains fixed and dilated by unopposed sympathetics.
Posturing is a sign of brainstem dysfunction.
88
Trauma Management
Extensor posturing, (formerly called decerebrate posturing because of the

animal model in which it was experimentally produced) presents as upper
extremity extension at the shoulders, elbows, wrists, and fingers.
Extensor posturing receives a 2 for Glascow Coma motor score reflecting
the severity of the neurologic dysfunction and poor prognosis when this sign
is present.
Flexor posturing (formerly called decorticate posturing) presents as upper
extremity flexion of the shoulders, elbows, wrists, and fingers.
Flexor posturing receives a 3 for Glascow Coma motor score reflecting the
severity of the neurologic dysfunction and poor prognosis when this sign is
presentonly extensor posturing is a clinically more ominous movement.
Brain Death
Brain death is an irreversible neurologic syndrome characterized by absence of
any central nervous activity above the level of the foramen magnum (cerebrum, basal ganglia, thalamus, cerebellum, brainstem).
The criteria for brain death are discussed in a separate chapter.
Limitations of Clinical Examination

The side of a neurologic deficit does not necessarily predict the side of the
brain with pathology. Herniation of the uncal portion of the temporal lobe
can displace the brainstem against the opposite tentorial edge causing injury
on the side opposite the herniation.
Pupillary asymmetry or nonreactivity can also be misleading. Injury to the
globe, optic nerve, or tracts can result in a deafferentation pupillary deficit
that has a very different significance (not a brainstem injury) than does an
afferent deficit of the third nerve at or near the brainstem pupillary constrictor
(Edinger Westfal) nucleus or along the course of the nerve.
Management
Prehospital Management
Patients with GCS < 8 should be intubated unless there is evidence of severe
orofacial or suspected cervical trauma.
Every patient should receive supplemental oxygen at the scene of injury and
during transportation to the hospital.
Intravenous access may be important in order to maintain blood pressure,
cardiac output, and cerebral perfusion, and to administer anticonvulsants
or sedatives.
Emergency Room Management

Hemodynamic treatment considerations have priority over intracranial.
Hypotension and hypoxia are the major factors associated with worse neurologic outcome following head injury. Patients should be hemodynamically
stabilized before any cerebral resuscitative or surgical interventions are undertaken. Cerebral resuscitative measures that conflict with hemodynamic stabilization should be deferred (such as administration of mannitol to bring down
ICP in a hypovolemic patient).
The Glascow Coma Score (GCS) and pupillary reactivity are the most important prognostic indicators. Patients with a GCS of 8 or less are considered to
89
have severe head injuries and, due to the high association between increased
ICP and low GCS, are candidates for intracranial pressure monitoring.
The clinician must assume that every patient with closed head injury and
headache, vomiting, focal neurologic deficit, or GCS less than 15 has increased
intracranial pressure and/or a lesion requiring evacuation until these are ruled
out by a period of hospital observation and/or head CT and/or intracranial
pressure monitoring.
The optimal angle for head elevation is 30.
In the absence of other injuries and with no concern about hypovolemia intravenous fluid administration (normal saline) at 75 ml/hr-1 is adequate.
To maintain cerebral perfusion, in the absence of ICP data, euvolemia should
be the goal of fluid administration. Central venous pressure monitoring can
be helpful in maintaining adequate volume at low hourly infusion rates.
Diuresis should be administered only to patients with clinical findings (sensorium, motor system, pupils) suggestive of increased intracranial pressure or its
associated epiphenomena (i.e., herniation).
Moderate hyperventilation (PC02 32-35 mmHg) should be considered only
in patients with clinical findings (sensorium, motor system, pupils) suggestive of increased intracranial pressure or its associated epiphenomena (i.e.,
herniation).
- Severe hypocapnia may aggravate brain hypoperfusion.
Sedation and paralysis should be administered for the comfort and safety of
the patient. Whenever possible agents for sedation and paralysis should be
short acting and easily and reliably reversed.
Opiates not only decrease agitation, but also blunt some of the sympathetic
responses seen in head injury, such as hypertension and tachycardia, and
decrease the amount of shivering. Possibly for the preceding reasons but perhaps
by other mechanisms as well, opiates frequently decrease intracranial pressure.
- The opiates have the advantage of being readily reversible with naloxone.
- Haldol (Haloperidol) interferes little with the neurologic exam, but it may cause
extrapyramidal symptoms, and is not pharmacologically reversible.
Benzodiazepines are useful for sedation but are not as readily reversible as
opiates. Like opiates they are respiratory depressants and their use may require
intubation of the patient who otherwise would not require this intervention.
Pharmacological paralysis with long-acting agents (Pancuronium, Vecuronium)
make neurologic exam impossible for several hours. The drugs can be useful
in the ICU to control ICP but in the ER should be limited to a defasciculating
dose administered with a depolarizing agent short-acting (succinylcholine).
- Depolarizing agents (Succinyl-choline) are short acting (usually paralysis wears off
within 20 minutes) but because of the associated violent muscular contractions
they should be administered with a defasciculating dose of a receptor blocker.
- A neurosurgical consultation should be called for every patient with head
injury and loss of consciousness if the CT scan is positive for any acute
traumatic finding.
Intracranial Pressure Monitoring

The indications for intracranial pressure monitoring are a low GCS (< 8) with
an abnormal head CT scan or a GCS 9-12 with abnormal CT scan if the
patient will undergo a prolonged operation for extracranial injuries.
90
Trauma Management
- The Cerebral Perfusion Pressure (CPP) should be kept above 60 mmHg.
- Without valves to create differential pressure among the compartments, the
ICP is the same in the entire intracranial spaceepidural, subdural, subarachnoid, intraparenchymal, intraventricular. An ICP catheter can be placed in any
of these spaces. The advantage of placing an ICP monitor in the ventricular
space (when the ventricles are adequately large so that this is technically feasible) is
that in addition to measuring ICP, CSF can be drained in cases of intracranial
hypertension.
Investigations
A head CT scan should be done on any head injury patient who presents with a
history of loss of consciousness, headache, amnesia, GCS< 15, or localizing signs.
- Findings suggestive of increased intracranial pressure include cisternal obliteration and midline shift (Fig. 7.1).
- Patients who have a positive finding on an initial CT require a repeat study the
next day.
Operating Room Management

Exploratory Burr Holes
Exploratory burr holes are placed in four sites on the side of suspected extraaxial
pathology in patients who present with a low GCS when CT scanning is not
available within a reasonable time frame (1-2 hours) or in patients whose
findings are suggestive of such pathology but who are hemodynamically unstable and must be taken to the operating room for life-saving intrathoracic or
intraabdominal surgery.
- The burr holes should be placed over each of the lobes of the brain where hematomas
are likely to occur and suboccipitally in the posterior fossa (Fig. 7.2).
Craniostomy
After ten days to two weeks a solid clot in the subdural (or much less frequently,
the epidural) space has lysed sufficiently so that it appears on CT scanning as
a liquefied collection. Liquid can be drained through a small diameter catheter
placed through a twist drill hole made through the skull.
Craniotomy
A craniotomy is necessary for the evacuation of acute hematomas associated
with coagulated, solid blood.
Brain Resections
One frontal lobe can be removed (assuming the other is functionally normal)
without a detectable neuropsychologic deficit. The anterior 5 cm of the
dominant and 7 cm of the nondominant temporal lobes can be resected
without a deficit.
Late Complications
Traumatic aneurysms occur at sites where vessels can move against relatively
rigid bony or dural structures such as the falx or clinoid processes. These
aneurysms are frequently unsuspected until the patient is found to have a
subarachnoid hemorrhage. Treatment is the same as for congenital aneurysms:
clipping, wrapping, endovascular.
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7
Fig. 7.2. Location of skin incisions for exploratory burr holes.
Fig. 7.3. Hemispheric acute subdural hematoma.
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Trauma Management
7
Fig. 7.4. Epidural hematoma with contralateral contusion.
Traumatic aneurysms may present days or months after a head injury with a
subarachnoid hemorrhage. Dissections of either the carotid or vertebral artery
may take time to become clinically manifest.
Carotid cavernous fistulae may occur after trauma, especially penetrating. The
treatment of choice for these lesions is endovascular with coils or balloons.
Posttraumatic hydrocephalus typically occurs two weeks or more after head
injury. It can occur in the absence of subarachnoid hemorrhage and usually
presents as a failure to progress in rehabilitation.
Delayed seizures (after day 7 postinjury) are most likely in patients with
intracranial hematomas or contusions in the temporal or frontal lobes, penetrating trauma (especially gunshot wounds), depressed fractures, and intracranial
sepsis. Prophylactic treatment has no effect on the incidence of late seizures.
Postconcussive syndrome presents as cognitive impairment (with or without
findings on neuropsychologic testing of depression, nightmares, emotional
lability, etc.) afflicts a significant number of patients with mild head injury.
Postconcussive symptoms can persist for 6 or even 9 months and may require
antidepressants and psychotherapy
Penetrating Head Injury

Gunshot wounds to the head are different pathophysiologically from closed
injuries.
Delayed swelling can result from the shock waves propagated through the
brain and account for rapid deterioration and death in patients who present
to the DEM shortly after the injury awake and alert.
Surgical intervention is urgent only for those gunshot wounds associated with a
mass lesion causing increased ICP (subdural, contusion, etc). Debridement of a
gunshot wound can be delayed up to 24 hours without significant increased risk
of complications.
93
Gunshot wounds should be debrided to remove any fragments of bone or skin

driven intraparenchymally. These fragments are potential niduses of infection.
Bullets can migrate in the brain over time but do not cause increased brain
injury when they do so and should not be removed unless impinging on a
structure associated with neurologic deficit or pain.
Skull Fractures
A nondisplaced fracture of the skull requires no treatment unless there is an
associated injury to a cranial nerve running within a bony canal or through a
foramen.
Open depressed skull fractures need elevation only if there is an displacement
of the outer aspect of the outer table to the level of the inner layer of the inner
table. The key surgical challenge in surgery for open depressed skull fractures
is identification and closure of dural tears which may require harvesting and
placement of a periosteal or other connective tissue graft.
Basilar skull fractures do not require treatment.
- There is a high incidence of VIIth and VIIIth never injuries (internal auditory
and facial canals run through petrous bone at skull base. Patients with basilar
skull fracture clinically or on CT require careful exam for facial movement and
hearing and may need temporal bone CT.
CHAPTER 8
Maxillofacial Trauma
Dennis-Duke R. Yamashita and Mark M. Urata
Motor vehicle accidents and personal altercations are responsible for two thirds
of all maxillofacial trauma. Fifty to seventy percent of patients with facial injuries
will also have injury to other organ systems. In fact, midface fractures are accompanied by injuries to the head 51%, chest 12%, abdomen 5%, and skeletal system
33%. Few patients actually die as a result of their maxillofacial injuries; however, the
surgeon must act quickly to rule out those entities which can be fatal. Airway compromise, significant aspiration, and massive hemorrhage as well as brain and cervical
spine injuries must be addressed in a timely fashion.
Initial Evaluation
Epidemiology
In general, women have a lower impact tolerance than men owing to a lower
density and thickness of the facial skeleton.
Of the maxillofacial region, the nasal bone has the lowest impact tolerance
with the zygomatic arch following close behind.
The glabellar region overlying the frontal sinus requires the greatest amount
of force amongst the maxillofacial components.
The maxilla is typically more sensitive to horizontal forces while the mandible
is more susceptible to lateral force.
Blunt Trauma
This is the most common cause of maxillofacial trauma typically a result of
motor vehicle accidents, falls, or assaults.
Blunt trauma can generate enough force that the crush injury can be similar
in nature to a GSW except that there is less obvious and perhaps more occult
damage. In fact, a 30 mile/hour collision can result in as much as 80 g of force.
Penetrating Trauma
Gunshot Wounds
Gunshot wounds (GSW) to the maxillofacial region pose a unique situation.
In the GSW, the missile dissipates high levels of energy as it enters the soft
tissue and then encounters the bone producing many secondary missiles that
Dennis-Duke R. Yamashita, Division of Oral and Maxillofacial Surgery, Los Angeles
County-USC Medical Center, University of Southern California School of Dentistry,
Mark M. Urata, Los Angeles County-USC Medical Center, University of Southern
California School of Dentistry, Division of Plastic and Reconstructive Surgery,
University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A.
95
result in tremendous local tissue damage. Our protocol for GSW trauma is to
minimally delay treatment for 48-72 hours until all the soft tissue damage has
manifested. The length of observation is not absolute but one must allow
definitive soft tissue and bony viability to be declared and treat or reconstruct
accordingly. GSW injuries deserve careful debridement, initial soft tissue management (immediate closure versus delayed reconstruction) and careful observation. Severe avulsive injuries may be packed open and followed by delayed
reconstructive procedures including free and rotational flaps. Early stabilization and space maintenance of bony segments (extraskeletal fixation) is of
vital importance to better allow for more ideal reconstruction. Shotgun wounds
typically are less deep, but more dispersed. In either situation, missile removal
is more hobby than therapeutic unless it impinges on vital structures.
Knife Wounds
The assessment of penetrating knife wounds to the maxillofacial region deserves careful scrutiny. There can be very minimal superficial damage with a
great deal of occult damage to vital structures. Careful clinical examination
and appropriate imaging are a necessity to evaluate the path and depth of
instrument penetration.
Physical Evaluation
Primary Survey
Airway
In assessing the A or airway, several factors are related directly to maxillofacial
trauma. Firstly, there is an association between maxillofacial trauma and cervical spine injuries of 12-18%. This occurs primarily with frontal impact causing hyperflexion and is usually accompanied by mandibular fractures. For this
reason, care must be taken to ensure adequate stabilization of the C-spine
while both examining and securing an airway.
Six percent of severe maxillofacial injuries require intubation for adequate
oxygenation. A bilateral fracture through the mandible often called a bucket
handle fracture can lead to airway compromise due to the resultant retraction of the anterior segment and tongue. This also compromises the efficacy
of the chin lift or jaw thrust maneuver. With bilateral mandible fractures, it is
often more appropriate to grasp the anterior segment of the mandible and
hold it anteriorly to displace the tongue from the posterior pharynx while
ensuring stabilization of the cervical spine.
Maxillofacial trauma can also cause airway compromise by dislodging teeth,
dentures, bridgework, or bone into the airway. When assessing the airway, it is
prudent to check for newly fractured or avulsed teeth. Penetrating trauma of
the maxillofacial region, in particular the floor of the mouth and neck can also
lead to loss of the airway due to massive swelling.
In Le Fort injuries there is a risk of inappropriate placement of the nasotracheal
and nasogastric tubes superiorly into the anterior cranial fossa. These complications may be avoided with fiberoptic intubation techniques.
After establishing cervical spine precautions, nasotracheal intubation should
be considered particularly in panfacial fractures. In these patients, the mandible is often comminuted or fractured bilaterally allowing the tongue to retrude
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Trauma Management
and providing a difficult laryngoscopic intubation. If the patient is taken to

the operating room for other concomitant injuries, an elective tracheostomy
should be entertained in anticipation of closed reduction maxillomandibular
fixation or significant long term edema.
Breathing
During this phase of the Primary Survey, the surgeon should expose the neck
and chest for examination. Injuries to the maxilla and mandible can create an
environment conducive to aspiration. Neck swelling, pharynx and tongue
swelling as well as floor of the mouth swelling must all be considered potential
environments for aspiration. Blood, saliva, and gastric contents are often the
culprits. Ventilating a maxillofacial trauma patient with a bag-valve mask in
the face of blood or loose teeth can be catastrophic. Securing an airway by
intubation or tracheostomy with cuff inflation is the safest manner to avoid
such a complication.
Circulation
Profuse life threatening bleeding in maxillofacial trauma is usually associated

either with nasoorbitalethmoidal (NOE) fractures or upper LeFort injuries.
Both of these regions boast a generous vascular supply and placement of petroleum lubricated anterior packs and posterior nasal packs is the initial management if the vessel cannot be easily identified. The anterior packing is placed
against the buttress supplied by the posterior nasal packing. Two Foley catheters placed through the nose into the posterior pharynx and inflated can also
be effective in a posterior hemorrhage. If these modalities fails to stop the
bleeding, repacking the anterior once or twice is indicated. However, direct
pressure on the columella should not exceed 2 hours due to the delicacy of is
blood supply. Moreover, any packing should be removed within 24-72 hours
to avoid masking a CSF leak. Hemorrhage from displaced Lefort fractures
will often subside once the patient is placed in maxillomandibular fixation.
Continued bleeding may require angiography and embolization. Cranial base
fractures can be associated with lacerations of the jugular or carotid which
require vascular surgical intervention. Bleeding from the branches of the internal maxillary artery can be reduced by 90% by ligation of the ipsilateral
carotid and superficial temporal artery.
Disability
This component of the primary survey evaluates the patients level of consciousness, pupillary size, and reaction. Trauma to the orbits can often cause
injury to the optic nerve and thus, a paradoxical pupillary dilatation or Marcus
Gunn pupil is noted when a light is swung between the intact and injured
eyes. With optic nerve injuries, the briskness of response to light is first affected which is followed next by a loss of visual acuity and the aforementioned
Marcus Gunn pupil. A Marcus Gunn pupil is a paradoxical dilation rather
than constriction of the pupil when a light is shone in the affected eye. It is
indicative of damage to the retina or optic nerve back to the chiasm on the
tested side.
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Secondary Survey
It is during the Secondary Survey that the meticulous evaluation of the maxillofacial region is executed. A drivers license or other photograph, dental records,
radiographs, or models of the patient prior to trauma may be invaluable in assessing
what changes have occurred to the maxillofacial region. As an example, some patients
may innately possess a malocclusion. Failure to recognize such preexisting conditions may lead the physician to incorrectly diagnose a traumatic injury to those
structures. The authors preferred method at the Los Angeles County/USC Medical
Center is to conduct this examination utilizing the acronym HEENON C.
(H)Head
It is appropriate to develop and utilize a standardized examination with each
facial trauma patient. Intuitively, one should proceed from superior to inferior, superficial to deep.
Examination of the patient for facial distortions, hematomas, contusions, crepitus, ecchymosis, discoloration, and lacerations is the first component of the
maxillofacial exam.
The face is divided into thirds to evaluate symmetry, shape, and length. The
upper third is from the hair line to the nasofrontal or nasion region. The
middle third is from this point to the subnasale while the lower third is from
the subnasale to the mentum.
LeFort fractures can often cause rotation of the maxilla with a resultant flattened and elongated appearance to the face particularly in the lower third.
This is due to the inferior displacement of the posterior maxilla which creates
an anterior open bite.
The origin of any ecchymosis must be determined to demonstrate whether it
is the result of direct soft tissue injury or bleeding at a fracture interface or
both. Posterior-inferior auricular region ecchymosis also termed Battles sign
is an indicator of basilar skull fracture. Bilateral periorbital ecchymosis is termed
Owls sign and typically is representative of a Le Fort II or III fracture.
A 50% mixture of 3% H202 and saline is used to clean dried blood from the
hair and skin. Wounds should be copiously irrigated and obvious necrotic
tissue should be debrided. Betadine is recommended; however, it may be detrimental to the taste organs of the tongue and should also be avoided near the
globes. Nerves and ducts should be identified, immediately repaired or tagged
for delayed reconstruction. The parotid duct or Stensens duct would be in
peril in any deep laceration crossing a line drawn from the tragus to the alar
base of the nose. Cotton swabs are used delicately in cuts near the eyelids and
oral cavity to ensure detection of through and through lacerations. Palpation
of the skull and meticulous examination to hair bearing regions may reveal
hidden lacerations or fractures.
Simultaneous palpation of the facial bones provides an instant tactile comparison for recognition of bony discontinuity. As demonstrated, the examiner stands
in front of the patient and begins by palpating the entire frontal bone contour.
Next, the supraorbital rims from the medial region sweeping laterally over the
zygomaticofrontal suture and then along the infraorbital rim returning to the
medial region near the frontal process of the maxilla. The zygoma is palpated
from the malar prominence posteriorly along the zygomatic arches over the
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Trauma Management
zygomaticotemporal suture to the tragus. The nasal bones and frontal process
of the maxilla are palpated, proceeding inferiorly over the anterior maxilla to
the region of the anterior nasal spine. The examiner then stabilizes the frontal
region with one hand while straddling the index finger and thumb of the
other hand across the maxillary dentition. Any dentures or removable
prosthodontic devices should be removed prior to the examination. An attempt
to mobilize the maxillary complex independent of the skull is attempted.
Simultaneous palpation of a step off across the nasofrontal region may indicate a
Le Fort II or III fracture.
(E) Eyes
It is our practice to include the examination of the orbit and overlying soft
tissues in the (H)ead exam and concentrate on the globe during this section of
the maxillofacial survey. We start from the anterior of the globe and proceed
posteriorly.
Chemosis, hyphema, and subconjunctival hemorrhage are all common in
orbital trauma and should be duely recorded. Hyphema should be evaluated
for posterior extent by an ophthalmologist.
Epiphora is seen clinically as excessive tearing and in the trauma patient may
be due to a severe orbital injury with disruption of the nasolacrimal system.
Lacerations near the medial canthus are the most likely culprit.
Photophobia and pain may indicate a corneal abrasion. Evaluation with ophthalmic anesthetic drops, flourescein eye drops, and ultraviolet light should
be conducted to confirm this suspicion.
Intraocular pressure should also be measured in the face of obvious orbital
trauma given the possibility of vascular disruption. Normal intraocular pressure is 10-22 mm Hg while pressures over 40 mm Hg require immediate intervention by an ophthalmologist.
The pupillary size and shape is noted as well as their symmetry. One millimeter of difference between the two pupils is considered within the normal range.
Extraocular muscles are checked in the typical H pattern. Restriction in the
upper gaze is consistent with the entrapment of the inferior rectus seen in
orbital floor fractures. Diplopia or double vision in peripheral gaze is often
secondary to the muscular edema and resultant restriction inherent to orbital
complex fractures.
Finally, visual acuity must be evaluated to further rule out optic nerve or retinal damage in each eye.
(E) Ears
As with the eyes, the examination of the associated soft tissues of the auricles
is completed in the (H)ead section.
At this juncture, it is our preference to perform an otoscopic examination
noting the continuity of the tympanic membrane. Blood in the middle ear
may indicate a basilar skull fracture. In mandible fractures, the condyles are
often displaced posterior in the glenoid fossa rupturing the anterior bony or
cartilaginous wall of the external auditory meatus. Minor lacerations and dried
blood on the anterior surface of the canal may be the only clues that this has
occurred.
Placing both index fingers in the bilateral external auditory meatus and instructing the patient to open his mouth allows the physician to note any un-
99
usual excursion of the mandibular condyles. Fractured condyles may have

diminished or exaggerated movement.
CSF otorrhea may indicate a basilar skull fracture.
(N) Nose
The nose should be examined internally with a speculum.
Managing hemorrhage in this arena has previously been discussed under Circulation. Septal hematomas must be drained immediately to prevent avascular necrosis. Once control has been obtained, the packs are removed and the
nasal structures should be thoroughly examined.
LeFort I fractures violate the piriform aperature and disruption of the lateral
nasal walls may be visible. Any violation of the mucosa or displacement of the
turbinates, the septum or other cartilaginous structures should be recorded. CSF
rhinorrhea is a strong indication that a LeFort II, III or nasoorbitalethmoidal
fracture has occurred with disruption of the dura.
(O) Oral Cavity/Oral Pharynx

Again, our examination proceeds in an orderly fashion from the anterior to
the posterior, superior to inferior of the oral cavity.
The integrity of the lips and in particular the vermillian border are critical.
The labial mucosa (abutting the anterior teeth) and the buccal mucosa (abutting the posterior teeth) should be retracted and examined for obvious trauma.
Through and through lacerations are common and utilization of cotton swabs
to explore is highly recommended.
Lacerations near the maxillary second molars at the level of the occlusal plane
should increase suspicion for involvement of Stensens duct. Drying the region with gauze and milking the parotid gland from posterior to anterior
should produce clear serous saliva. Failure to do so may indicate a disruption
of the duct.
Ecchymosis or open lacerations of the gingiva may represent an underlying
fracture of the alveolus, maxilla, or mandible. The palatal mucosa may be
disrupted in a LeFort or alveolar ridge fracture.
Including a set of 4 third molars, there are 32 teeth in the average complete
dentition of an adult as compared to 20 in the deciduous dentition. Avulsed,
subluxated, or fractured teeth as well as a complete or partial dentures should
be recorded The teeth are of paramount importance and serve as the
infrastructure for the reduction and fixation of many facial fractures. Maximum
incisal opening is the distance in millimeters (normal 35-45 mm) between the
incisal edge of the maxillary central incisors and the mandibular central incisors.
An excessive MIO upon passive examination may represent a fractured
mandible. Limited opening can be due to soft tissue swelling, muscle edema, or
fracture of the zygoma, maxilla, or mandible. In isolated zygomatic arch
fractures, the arch may be collapsed which actually prevents the patient from
closing due to interference between the arch and coronoid process of the
mandible.
The Angle Classification of occlusion (interdigitation of the teeth) was
developed in 1890 by Edward Angle, D.D.S. and is based on the position of the
maxillary first molar. Class I normal occlusion finds the mesiobuccal cusp of
the maxillary first molar occluding in the mesiobuccal groove of the mandibular first molar. In a Class II relationship, the lower first molar is posterior
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Trauma Management
to the upper first molar while a Class III occlusion has the lower first molar
anterior to the upper first molar. Malocclusion is a deviation from the normal
relationship between upper and lower teeth. Accurately recording the occlusion, arch alignment, and dental midline, may all contribute to defining a
displaced maxillary or mandibular fracture.
The diagnosis of an open bite (premature contact of the molar teeth resulting
in a lack of contact in the incisor region) is most often due to the posteriorinferior displacement of the maxilla in Le Fort fractures or the posterior-superior bodily rotation of the mandible in displaced bilateral angle or bilateral
condyle fractures.
Finally, the gingiva, tongue, and floor of the mouth should be inspected for
lacerations or a functional deficit which could be attributable to edema or direct
trauma to the muscles or nerves of the region. The submandibular gland empties
into the oral cavity on the floor of the mouth via Whartons duct. This should be
examined in a similar fashion to the manner in which Stensens was evaluated.
(N) Neck
Evaluation of neck trauma is discussed elsewhere in this book. Notation should

be made of any lacerations or the trajectory of bullet or knife wounds into the
maxillofacial region. Severe comminution of the maxilla and mandible is common with a seemingly small entrance wound on the neck.
(C) Cranial Nerves

CN I-Olfactory
In maxillofacial trauma, this may be disrupted as it passes from the cranial
vault through the cribiform plate. Test the sense of smell in each nostril by
presenting the patient with familiar available objects such cloves, coffee, or
soap.
CN II-Optic
Test visual acuity and check the optic fundi.
CN III, IV, VI-Oculomotor, Trochlear, Abducens
Check the extraocular movements in the six cardinal directions of gaze. The
mneumonic SO4LR6 reminds us that CN IV trochelar controls the superior
oblique while the CN VI abducens is responsible for the lateral rectus. Down
and in and lateral movement tests these muscles respectively.
CN V-Trigeminal
Two muscles of mastication can be palpated while they are activated by opening and closing the mouth. These are the temporalis and masseter while the
lateral and medial pterygoids are tested by protrusion and retrusion of the
mandible. Sensation over the forehead, cheeks, and jaws on each side represent the trigeminal distribution of its three branches respectively.
CN VII-Facial
The facial nerve can be damaged almost anywhere along its path from a temporal fracture to a laceration of the cheek. Ask the patient to perform the
following tasks to check the muscles of facial expression:
-
Raise the eyebrows

Frown
Close both eyes tightly against examiners resistance
Show maxillary and mandibular teeth
Smile
101
- Puff out cheeks
CN VIII-Acoustic
Check for hearing acuity and if diminished perform Weber and Rhinne for
lateralization.
CN IX, X-Glossopharyngeal and Vagus
Ask the patient to yawn. Check for symmetrical movement of the soft palate.
A failure of the palate to rise bilaterally usually indicates a lesion of the X.
Unilateral involvement is more consistent with damage to IX. Check the gag
reflex (IX or X) and quality of voice (X).
CN XI-Spinal Accessory
Ask the patient to shrug both shoulders against your hands.
CN XII-Hypoglossal
Have the patient protrude their tongue and note any asymmetry or deviation
from the midline. The hypoglossal nerve can be easily damaged with penetrating wounds in the submandibular region of the neck.
Imaging
Plane Films
A modified Townes view, Waters view, and the Caldwell (posteroanterior) comprise the traditional facial series. The submental vertex view should always be ordered
in the midface trauma patient as it allows evaluation of the zygomatic arches and
malar eminence. The Caldwell, the modified Townes, and the mandibular obliques
make up the mandible series. However, the Panorex radiographic exam is often considered the most valuable in lower third face fractures. The entire mandible can be
visualized with distortion and blurring evident only in the symphyseal and
parasymphyseal portion of the jaw. Often, this can be the only studies available in a
timely fashion and can certainly be used for screening and triage purposes.
Computed Tomography (CT) Scans

Most bony discontinuities are best evaluated by computed tomographic studies. An exception to this rule is nondisplaced fractures of the ascending ramus of
the mandible. The more finite the area being assessed, the thinner the windows
should be made. An example is orbital fractures which are best evaluated with 2-3
mm cuts to accurately demonstrate the thin medial orbital wall (lamina papyracea)
and orbital floor.
These studies may be made with or without contrast. CT imaging without contrast media can best show pure bony problems, while those images with contrast
show the interface and the juxtaposition of hard and soft tissue as well as edema and
cellulitis.
Recently, three dimensional scans produced by computer compilation of thin
cut CTs have been used to plan for surgical approach and possible reconstructive
modalities. As an example, this can be of particular benefit in ordering a 3 D generated reconstructive plate for the patient with a frontal bone defect.
Magnetic Resonance Imaging (MRI)

Currently, MRI evaluations are best reserved for soft tissue injuries and are not
often used as a primary diagnostic tool unless there is a suspicion of vascular injury.
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Trauma Management
General Principles of Treatment of Maxillofacial Injuries
Maxillofacial injuries are most accurately assessed within the first 24-48 hours.
Unfortunately, many maxillofacial trauma patients present after this period.
Their evaluation is compromised by the soft tissue edema which may exaggerate or mask the severity of their bony displacement. Ideally, these trauma patients should be operated on before the onset of edema. Given those circumstances where this is not possible, one may allow the swelling to subside before
deciding whether surgical intervention is required to restore proper functional
anatomy and esthetics. On the other hand, delayed treatment of maxillofacial
injuries can result in suboptimal fracture reductions making alignment of fractured segments difficult due to fibrosis and osteoclastic activity at the fracture
margins. These prolonged delays may require osteotomies and other reconstructive efforts. Waiting up to 1 week allows the edema to resolve and accurate surgical assessment can then be completed. Additionally, operating on an
edematous patient makes dissection and placement of incisions challenging.
Most maxillofacial injuries involve extensive soft tissue violation. Adequate
tetanus vaccination and coverage with oral or intravenous broad spectrum
antibiotics is the rule. Violation of the oral cavity necessitates coverage for oral
bacterial flora, primarily Penicillin.
To ensure the best outcomes for a patient, complex maxillofacial injuries should
be managed by a team approach. With the overlap and convergence of the
specialties (plastic and reconstructive surgery, otolaryngology/head and neck
surgery, oral and maxillofacial surgery, and ophthalmology), one can draw on
all the specialties for the comprehensive treatment of the patient.
Soft Tissue Injury

Anatomic Considerations
The soft tissues of the maxillofacial region are well perfused. Except for the
lips, eyelids, and nose, a rim of tissue may be debrided in lacerations to avoid
excessive scarring from a contused wound edge.
Management
Ice compresses to contusions will assist in limiting soft tissue edema during
the initial 24-72 hours.
As a general rule, facial lacerations should be repaired as soon as possible.
They require thorough and meticulous irrigation and debridement producing
a wound edge that is perpendicular to the skin surface. Buried absorbable
subcutaneous and dermal sutures approximate the edges and produce slight
eversion while the skin is closed with nonabsorbable, nonreactive suture. The
surface sutures are usually removed 5 days later.
In rare instances where repair must be delayed, the wounds are irrigated and
debrided and dressed with a moistened saline gauze. Due to an extensive collateral circulation, these wounds can undergo twice a day dressing changes
and delayed primary closure 24-36 hours later.
Lacerations of the oral cavity, eyelids, lips, ears, and nose require specialty
consultation at most institutions.
Local anesthesia is the method of choice with general anesthesia reserved for
extensive injuries, an uncooperative patient, or special areas of concern such
as the parotid duct and facial nerve.
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Facial Series
Caldwell (Posterioanterior)
Waters
Modified Townes
Submental vertex (must be ordered separately)
Mandible Series
Caldwell (Posterioranterior)
Modified Townes
Mandibular obliques (right and left)
0.5% lidocaine with 1:200,000 epinephrine is used throughout the face except in the regions of the ear and nose.
Dog bites can usually be closed primarily after generous irrigation. The patient should be placed on oral or intravenous antibiotics of amoxicillin and
clavulonic acid. Human bites pose more of a threat and have been treated
with daily dressing changes, IV antibiotics with delayed primary closure 3-4
days later.
Upper 1/3 Facial Fractures

Frontal Sinus Fractures
Frontal sinus is composed of a paired, air filled cavities which are triangular in
cross section.
The anterior table is thick while the thin posterior table provides a separation
between the air cushion and the frontal lobes in the anterior cranial fossa.
Statistical Perspectives
5-15% of all maxillofacial injuries are frontal sinus fractures
The anterior table of the frontal sinus is notably thick and requires 2-3 times
greater force to fracture than the zygoma, maxilla, or mandible.
Due to the energy required to fracture the anterior sinus wall, these are typically
associated with other maxillofacial fractures primarily nasoorbitalethmoidal
(NOE).
The frontal sinus begins pneumatization at age 7 and is completed by age
18-20.
The nasofrontal ducts are remnants of the embryonic connection between
sinuses. They run from the posteromedial aspect of the sinus, through the
ethmoid air cells ending below the middle turbinate of the middle meatus.
Lacerations, contusions, hematoma over the frontal bone, particularly the glabellar region
CSF rhinorrhea
Palpable bony depression
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Trauma Management
Supraorbital paresthesia or anesthesia (V1)

Subcutaneous crepitus
Imaging
Plain radiographs-large, displaced frontal sinus walls with air fluid levels, but
can miss smaller fractures and cannot delineate nasofrontal duct injury
CT scan-best image although it is still difficult to determine nasofrontal duct
violation. Fractures near the midline or crossing the midline that are posterior
must be presumed to have ductal injury.
Management
Nondisplaced anterior table fractures can be observed with broad spectrum
antibiotics.
- Displaced anterior table fractures are managed in accordance with the amount
of comminution and displacement and the resultant cosmetic defect. Suspicion
of nasofrontal duct violation is an indication for exploratory surgery.
- Posterior table fractures displaced more than one wall thickness are managed by
removing the lining mucosa of the sinus followed by the obliteration of the
nasofrontal duct using autologous bone, pericranium, fascia, and muscle. The
remainder of the sinus is obliterated using fat harvested from the lateral thigh or
other convenient location.
Middle 1/3 Facial Fractures

Orbitozygomatic Fractures (Fig. 8.1)
The orbit is composed of eight bones: zygoma, lesser and greater wings of
sphenoid, frontal bone, ethmoid bone, lacrimal bone, palatine bone, and
maxilla.
The infraorbital nerve (V2) travels along the floor of the orbit exiting at the
infraorbital foramen to provide sensation to the anterior cheek.
Tripod, triamalar, malar complex, orbital complex, zygoma, zygomaticomaxillary complex (ZMC) fracture are all terms that describe the same entity. It is
a fracture through the zygomaticofrontal suture, then into the orbit through
the zygomaticosphenoid suture to the inferior orbital fissure to the zygomaticomaxillary suture and buttress and finally the zygomatic arch.
Isolated fractures of the zygomatic arch are common with directed lateral force.
The most common orbitozygomatic fracture is the zygomaticomaxillary complex fracture or zygoma fracture.
90-95% demonstrate paresthesia or anesthesia of infraorbital nerve
Pain
Flattening of the malar prominence
Subcutaneous emphysema
Paresthesia or anesthesia of cheek (V2)
Palpable step off at zygomaticofrontal, infraorbital rim, zygomaticomaxillary
buttress, and zygomatic arch.
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8
Fig. 8.1. The typical orbitozygomatic or zygomaticomaxillary complex fracture
involving the orbital floor and lateral wall. In this diagram, the infraorbital nerve is
spared, but stretching of the soft tissue drape will often cause parasthesia.
Periorbital ecchymosis and edema

Diplopia (due to orbital dystopia or edema)
Epiphora (violation of the nasolacrimal system)
Enophthalmos
Entrapment of orbital contents
Superior orbital fissure syndrome-fractures violating the superior orbital fissure can directly (displaced bones) or indirectly (hematoma) cause ptosis, proptosis of the globe, paralysis of CN III, IV, VI, V1 and decreased sensation over
the forehead, upper eyelid, cornea, conjunctiva, and sclera.
Orbital apex syndrome-consists of everything in superior orbital fissure syndrome with the addition of blindness.
Investigations
CT scan-2-3 mm axial views demonstrate the anterior posterior displacement
of the complex as well as isolated zygomatic arch fractures. Coronal views will
demonstrate the orbital floor violation and displacement of the ZM and ZF
suture.
Facial series with submental vertex view-may be able to appreciate the infraorbital rim, orbital floor, zygomaticofrontal suture, and zygomatic arch violations if CT not available. Opacification of the maxillary sinus due to hemorrhage is a common finding.
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Trauma Management
Management
Most agree that each fracture must be individually evaluated for stability based
on clinical and radiographic findings. Patients with entrapment or enophthalmos due to herniation of orbital contents are obvious candidates for surgical
intervention while those with nondisplaced stable complexes are not.
Isolated zygomatic arch fractures may be reduced with an intraoral or scalp
incision while ZMC fractures may require multiple approaches and complex
reconstruction of the orbital floor and walls.
Nasoorbitalethmoidal Fractures (NOE)

The five bones of the nose are: frontal process of the maxilla, the nasal process
of the frontal bone, the paired nasal bones, the vomer, and the ethmoid.
Orbital fractures that also involve the nasal and ethmoidal bones are sometimes termed nasoorbitalethmoidal or NOE fractures.
The medial canthal tendon inserts along the anterior lacrimal crest of the
frontal process of the maxilla as well as the nasal bone itself. Traumatic disruption of this region in NOE fractures often leads to telecanthus and saddle
nose deformity.
The nasal bones are fractured in 33% of all facial fractures.
Nasal bone fractures are classified as:
Plane 1-simple nasal bone fracture
Plane 2-complex nasal bone fracture
Plane 3-nasoorbitalethmoidal complex fracture
Thirty percent of severe NOE fractures have a CSF leak detected within the
first 24 hours.
Fifty percent demonstrate CSF by 48 hours.
Isolated nasal bone fractures are most often a clinical diagnosis with bruising,
swelling, pain, epistaxis, nasal airway obstruction with a deviated septum or
hematoma.
Periorbital ecchymosis
Saddle nose deformity
Paresthesia or anesthesia of the cheek (V2)
Ocular dystopia
Entrapment
CSF rhinorrhea
Enophthalmus
Telecanthus
Diplopia
Visual acuity changes
Enophthalmos
Imaging
CT scan-axial and coronal scans with 3 mm or less intervals
Facial series
107
Nasal bone films-including 45 occipitomental view and low density soft tissue
views for isolated nasal bone fractures
Management
Nasal fractures are often accompanied by septal hematomas. These are addressed
by an incision along the base of the hematoma along with nasal packing.
Isolated nasal fractures are often treated with closed reduction in the emergency
room with local anesthesia and sedation. Asch forceps are used to realign the
septum and overlying nasal bones. Closed reduction can actually be performed
up to 3 weeks after the initial insult.
Comminuted nasal fractures are treated with intranasal packing and external
splinting.
NOE fractures typically require a combination of approaches with bony
reduction and reestablishment of the position of the medial canthal tendon.
Maxillary Fractures (Fig. 8.2)

The maxilla is considered the cornerstone of the face bridging the cranium
with the mandible.
LeFort I-a bilateral horizontal transmaxillary fracture preserving the nasal base
with lateral extension through the piriform aperature and pterygoid plates
separating the maxillary alveolar process from the rest of the maxilla.
LeFort II-a pyramidal fracture that extends through the nasofrontal junction,
laterally through the lacrimal bones and infraorbital rim (often through the
infraorbital nerve foramen causing V2 paresthesia) continuing inferoposteriorly
along the zygomaticomaxillary suture through the pterygoid plates.
LeFort III-this is complete craniofacial disjunction with separation of the orbits
and maxilla from the cranium. The fracture line is through the nasofrontal
junction laterally through the medial wall or orbital floor, the zygomaticofrontal
suture, the zygomatic arch and through the pterygoids.
The floor of the maxillary sinus remains above the floor of the nose until the
age of 8 years old.
LeFort fractures in order from least to most frequent: II > I > III
Forty percent of all facial fractures involve the middle third of the face not
including the nasal bones.
LeFort fractures generally occur in older children and adolescents rather than
infancy or early adulthood.
Malocclusion
Movement elicited by digital manipulation of the maxilla
Palpable step off possible at maxillary buttress, nasofrontal junction,
zygomaticofrontal suture, zygomatic arch.
Owls or bilateral periorbital ecchymosis
Bilateral subconjunctival hemorrhage
Paresthesia or anesthesia of the cheek (V2)
Visual acuity changes
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Trauma Management
Fig. 8.2. Maxillary Fractures. This series of diagrams demonstrate the bony involvement of LeFort I, LeFort II, and LeFort III fractures. Reprinted with permission from
Dingman RO, Natvig P, eds. Surgery of Facial Fractures Philadelphia: W.B. Saunders
Company, 1964.
Enophthalmos
Orbital dystopia
Diploplia
Entrapment of orbital contents
Trismus
Fractured or avulsed dentition
Imaging
Panorex radiograph-this will demonstrate the condition of the teeth and
surrounding bone.
CT scan-both axial and coronal films of 3mm or less are mandatory in
maxillary fractures.
Management
Oral or IV broad spectrum cephalosporin
LE FORT I: Ideally, the teeth are placed into centric occlusion (their normal
relationship) via closed reduction maxillomandibular fixation (CRMMF).
109
Then, the fractures are fixated with miniplates across the zygomaticomaxillary
buttress and nasomaxillary buttress. In LeFort I fractures with multiple pieces
and instability, CRMMF alone is the treatment of choice and should be
maintained for 4-6 weeks. In edentulous patients with atrophic maxillary
and mandibular alveolus, splints are often used in conjunction with wire
skeletal fixation.
LE FORT II: Disimpaction of the fractured maxillary segment may be required
depending upon whether the fracture has telescoped superiorly or posteriorly.
This may require the use of minimal traction on arch bars to maximal traction
utilizing disimpaction forceps. Following CRMMF, true LeFort II fractures
can be rigidly fixated via a bilateral buccal sulcus incision plating both the
zygomaticomaxillary buttress and nasomaxillary buttress to preserve height
and projection. Unstable infraorbital rim fractures are addressed through an existing laceration, transconjunctival, subciliary, lower lid, or infraorbital incision.
LE FORT III: Most often, disimpaction is not required with this type of
fracture which is usually more mobile.
Lower 1/3 Facial Fractures

Mandible Fractures (Fig. 8.3)
The mandible is the largest and strongest facial bone and is divided into several
regions from anterior to posterior: symphysis, parasymphysis, body, angle,
ramus, coronoid, and condyle.
After location, mandibular fractures can be further divided into favorable and
unfavorable. Favorable fractures are those that by their inherent geometry do
not allow muscular distraction of the involved segments of bone.
Most lateral forces will result in two fractures of the jaw. The discovery of one
fracture should lead the examiner to search for another. Anterior force to the
symphysis will often result in bilateral condylar fractures.
20% of all facial fractures are mandibular fractures
11% of mandibular fracture patients have cervical spine injuries
Causes of mandible fractures
- 47.5% of mandible fractures are due to altercations
- 27.3% of mandible fractures are due to automobile accidents
Force to chin is responsible for 72% of condylar neck fractures

50% of mandible fractures are multiple
Frequency of fracture by regions of the mandible

Condyle
Angle
Symphyseal/Parasymphyseal
Body
Alveolar ridge
Ramus
Coronoid
36%
20%
14%
21%
3%
3%
2%
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Trauma Management
Fig. 8.3. Mandible Fractures.
Paresthesia or anesthesia of lips due to disruption or avulsion of inferior alveolar or mental nerve (V3)
Limited maximum incisal opening (MIO)
Anterior open bite (due to bilateral body, angle, or condyle fractures with
vertical collapse)
Drooling (difficulty managing secretions with limited swallowing capability)
Malocclusion
Mobility of segments-able to move segments of mandible independently, particularly at angle, body, parasymphyseal, and symphyseal fractures
Trismus
Floor of the mouth swelling(may be secondary to edema or hematoma from
fracture)
Splaying between teeth, Fractured or avulsed teeth
Investigations:
Panorex radiograph-best single exam with disadvantage of poorly visualized
symphyseal region
Mandible series-can appreciate three dimensional location of fractured segments
CT-may be useful in panfacial trauma or for localization of displaced condyles
111
Management
Oral suspension or IV penicillin
Unless there are other injuries or possible airway compromise, most mandible
fractures can be treated on an outpatient basis.
Most favorable mandible fractures are amenable to closed reduction
maxillomandibular fixation (CRMMF). This is done by applying arch bars to
the maxillary and mandibular dentition with circumdental wires and then
wiring the jaws together with the teeth in their normal occlusion.
Unfavorable fractures can also be placed in CRMMF if manipulation can lock
them into a stable alignment. However, unstable reduction is an indication
for open reduction and fixation with plates and screws. Rigid fixation can be
of great value, including an earlier return to function and better oral hygiene
and nutrition. Plates for the symphysis and parasymphyseal region are applied
intraorally while the angle, body, and ramus may also be approached extraorally.
Edentulous patients may require either intraoral splints with CRMMF or open
reduction internal fixation.
Condylar fracture are usually treated with CRMMF for 2-4 weeks. However,
those patients with condyles displaced from the fossa require open reduction
to reacquire vertical height of the ramus. The condyles are most often displaced
medially and anteriorly and can be approached through one or a combination of
the following incisions: retromandibular, preauricular, buccal sulcus.
Condylar fractures in children have special treatment considerations: The total
length of closed reduction in children would be less than in adults, usually
between two to four weeks. In isolated condylar fractures, early mobilization
is favored with closed reductions reserved to eliminate functional pain.
External pin fixators or biphasic systems have been used in edentulous
mandibles and severely comminuted fractures such as those caused by
gunshot or shotgun wounds.
Dentoalveolar Trauma
Anatomic Consideration
Dental professionals refer to the surfaces of the teeth visible in the oral cavity
as mesial (anterior), distal (posterior), buccal, lingual, and occlusal.
In both the maxilla and mandible, from anterior to posterior there are usually a
pair of central incisions, lateral incisors, cuspids (canines), 1st bicuspids (1st
premolars), 2nd bicuspids (2nd premolars), 1st molars, 2nd molars, and third
molars.
In the average complete permanent dentition with four third molars, there are
32 teeth. These are assigned with the right maxillary 3rd molar being Tooth #1
proceeding across the maxilla to the left maxillary 3rd molar as #16. The left
mandibular 3rd molar is #17 again numbering across the mandibular dentition to the right mandibular 3rd molar #32.
The deciduous dentition has 20 teeth which are numbered in the same sequence
using the letters A to T.
Trauma to the teeth primarily results in fractures, avulsions, and subluxations.
Subluxations are classified as intrusion (into the socket) or extrusion (out of
the socket).
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Trauma Management
Fractures of the teeth are the most common dentoalveolar trauma.
Eruption Sequence Deciduous Dentition:
-
Central incisors
Lateral incisors
1st primary molars
Cuspids
2nd primary molars
6-7 months
7-9 months
12-14 months
16-18 months
20-24 months
Eruption Sequence Permanent Dentition:
1st molar
Mandibular cental incisors
Mandibular lateral incisors
Maxillary central incisors
Maxillary lateral incisors
1st premolars
Mandibular cuspids
2nd premolars
Maxillary canines
Second molars
Third molars
6 yrs
6 yrs
7 yrs
7 yrs
8 yrs
10 yrs
10 yrs
11 yrs
11 yrs
12 yrs
17 yrs
3.1% of mandible fractures involve alveolar ridge fractures.
Alveolar ridge fractures are noted when a tooth or multiple teeth move with
their supporting alveolus independent of the rest of the maxilla or mandible.
Many patients have preexisting fractures to their teeth and this should be
elicited in the history.
Imaging
Periapical dental films-highest definition of individual teeth demonstrating
fractures and cracks.
Panorex radiograph-demonstrates relationship of bony support to teeth.
Management
The level of the fracture of a tooth will determine the mode of therapy. Enamel
or partial dentin fractures can often be restored by the dentist with resin while
fractures violating the pulp will also require root canal therapy.
Subluxation of teeth is ideally treated by repositioning and splinting with
acrylic or wires or orthodontic bracketing.
Avulsed teeth require immediate stabilization. When a tooth has been avulsed,
the patient should be instructed to place the tooth in sterile saline. The ideal
medium is actually the socket itself, however, the risk of aspiration is often too
great particularly in a child or elderly patient. After 30 minutes out of the
socket, the chances for a successful reimplantation are minimal. Fixation is
usually in the form of interdental wiring, placement of arch bars, placement of
specialized acrylic splints or the placement of orthodontic brackets and wires.
Oral and maxillofacial surgery or dental consultation is strongly advised.
113
Alveolar ridge fractures are usually treated with CRMMF for 4 weeks. This
will simultaneously maintain occlusion and provide stability. In those instances
where occlusion is not as critical, stabilization with arch bars and circumdental
wires can be performed.
References
1.
2.
3.
4.
5.
6.
Dingman RO, Natvig P. Surgery of Facial Fractures. Philadelphia: W.B. Saunders,

1964.
Weinzweig J. Plastic Surgery Secrets. Philadelphia, Hanley & Belfus, Inc., 1999.
Wolfe SA, Baker S: Facial fractures. New York, Thieme, 1993.
Manson PN. Facial fracures. In: Aston SJ, Beasley RW, Thorne CHM, eds. Grabb
and Smiths Plastic Surgery, 5th ed.
Manson PN, ed. Maxillofacial injuries. In: Siegel J, ed. Management of trauma.
New York, Churchill-Livingstone, 1986.
Demetriades D, Chahwan S, Gomez H et al. Initial evaluation and management
of gunshot wounds to the face. J Trauma 1998; 45:39-41.
NECK
CHAPTER 1
CHAPTER 9
Evaluation of the C-Spine

George C. Velmahos
The Magnitude of the Problem
The incidence of cervical spine injuries among blunt trauma survivors is
between 1-3%. The sequelae are serious, with 7% direct mortality and 10-40%
morbidity due to devastating neurologic injuries.
A high rate of missed C-spinal injuries is reported, ranging from 5-30%.
Missed C-spinal injuries are a primary cause of litigation.
The appropriate methods of evaluating the C-spine are widely debated in the
literature. Universal consensus is lacking.
Basic Principles of Initial C-Spinal Precautions

All blunt trauma patients should be placed in spinal precautions and presumed to have a spinal injury before they are evaluated and cleared by clinical
examination and/or radiographic tests.
Patients with penetrating injuries to the neck are much less likely to have
injuries that require spinal immobilization:
1. Stab wounds do not cause spinal fractures, even if the spinal cord is injured.
2. C-spinal fractures may be caused by civilian gunshot wounds but are rarely
unstable. This fact, combined with the high incidence of complete cervical
spinal-cord injuries related to gunshot wounds, results in a very low incidence
of operations to the spine in order to establish stability after such injuries.
3. Small children may be an exception to the above rule due to the small mass
of their vertebrae relative to the bullet.
4. High-velocity bullets from military weapons create extensive damage and
fragmentation. They may cause unstable C-spinal injuries.
The most common method of C-spinal precautions is a hard C-collar. There

are multiple types of C-collar, including the Aspen, Philadelphia, Miami J
and NecLoc collars. The type of collar is less important than a proper fit. A
C-collar will not offer optimal protection if its size is not appropriate for the
patients neck.
Even a hard C-collar does not immobilize the neck completely. A properly
fitted C-collar still allows an estimated 10-25% of the normal range of lateral,
anterioposterior and rotational movements. Taping the head onto the hard
board or offering additional manual stabilization is advisable, particularly for
patients who are suspected to have incomplete C-spinal cord injuries.
A soft C-collar does not offer any immobilization and should not be used at
the acute stage.
A C-collar should never interfere with complete clinical evaluation of the neck.
George C. Velmahos, Division of Trauma/Critical Care, University of Southern California
School of Medicine, Los Angeles, California, U.S.A.
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Trauma Management
9
Fig. 9.1. Atlanto-occipital dislocation indicates major blunt forces have been applied
to the area. This patient was thrown from a moving train. The injury is usually fatal.
The collar should be removed, stabilization should be maintained manually

and the neck should be thoroughly examined.
Removal of the C-collar and manual in-line neck stabilization is used when a
patient needs intubation.
Tools to Evaluate the C-Spine

Clinical examination is an important part of the evaluation of the C-spine. It
requires an alert, nonintoxicated patient and a reassuring, focused physician.
It is simple and can be completed in the following steps:
1. The patient is asked if he or she has any neck pain. A gross motor and
sensory neurologic exam is completed. If the patient reports no pain and the
neurologic exam is negative, proceed to the next step.
2. The C-collar is removed and neck stabilization is maintained by gentle pressure on the forehead of the patient. Each C-spinal vertebra is palpated, and
the patient is asked if there is any tenderness during palpation. It the answer
is negative for tenderness, proceed to the next step.
3. Vertical pressure to the patients skull is applied by pushing on it. The
patient is asked if this maneuver elicits pain. If the answer is negative, proceed to the final step.
117
Fig. 9.2. The C-spine collar provides adequate protection, if it fits properly. For
patients with short thick necks, a good collar fit may be difficult. Additional methods,
such as sandbags on each side of the head or taping the head to the gurney, should
be used in such cases.
4. The patient is asked to move his/her head forward (chin to chest) and
laterally (chin to shoulder) and report any neck pain during movement.
Radiographic evaluation consists of plain films, flexion/extension films, computed tomography, magnetic resonance imaging and myelography.
Plain films include an anterioposterior view, a lateral view, an odontoid view
and two oblique views (five films). The addition of the last two views adds
minimal information and is usually not necessary. A lateral swimmers view
(arm elevated over head) is useful for visualization of the lower cervical vertebrae
when the plain lateral film is not adequate. The plain films should be reviewed
systematically. The lateral film provides the majority of relevant information:
1. All seven cervical vertebrae should be visualized as well as the top of the T1.
2. Prevertebral soft-tissue edema (more than half the length of the vertebra in
front of C2 or the entire vertebra in front of C6) and loss of normal spinal
lordosis are indirect signs of underlying injury.
3. Four lines should be checked for deviation: the anterior and posterior lines
(representing the anterior and posterior longitudinal ligaments), the
spinolaminar line (joining the laminar junctions) and the spinous process
line (joining the spinous processes).
4. Imaginary lines projected from all transverse processes should meet at a single
point. The opposite (fanning) is associated with injuries.
5. Each vertebra should be evaluated carefully for fractures or subluxations.
The intervertebral spaces should also be evaluated.
Flexion/extension views are plain lateral (and sometimes oblique) films after
the patient has extended or flexed his/her neck to the point where pain or
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Trauma Management
9
Fig. 9.3. Spinal dislocation of C5/C6 with complete impairment of neurologic function at this level.
discomfort is elicited. Flexion/extension radiographs detect with high sensitivity inappropriate spinal motion (subluxation, dislocation) produced due to
ligamentous injuries. For this examination, the patient must be awake and
cooperative.
Passive flexion/extension views done under fluoroscopic guidance are diagnostic alternatives for certain groups of clinically unevaluable patients (see
below), but the validity of the method is still unknown.
CT of the C-spine can be focused on suspicious areas suggested by the patients
symptoms or radiographic findings on plain films. In certain groups of
unevaluable patients (see below), these areas may also include the entire C-spine.
CT is highly sensitive for detection of fractures. Nonosseous injuries (ligaments,
disks) may be missed on CT.
MRI is the ultimate radiographic tool to evaluate the C-spine. It allows complete
visualization of osseous and soft-tissue structures from multiple angles. Its
disadvantage is that it is expensive and prevents close monitoring of the patient
during the exam.
Myelography involves the injection of contrast into the spinal canal to evaluate
for compression or discontinuation of flow. It is used infrequently because it
is invasive.
119
Fig. 9.4. Loss of normal lordosis of the cervical spine may be an indirect sign of
injury. This patient had an isolated laminar fracture of C3.
Types of Patients
Patients who require C-spine evaluation may be grouped in the following
categories:
1.
2.
3.
4.
Alert patients without neck pain or neurologic signs.

Alert patients with neck pain and/or neurologic signs.
Unevaluable patients with minimal trauma.
Unevaluable patients with significant trauma.
Each group requires different methods of C-spine evaluation.

Protocols that outline the sequence of procedures needed for the C-spine clearance of the four groups of patients are strongly encouraged. A nonsystematic
approach to the C-spine is subject to diagnostic omissions and errors.
Alert patients without neck pain or neurologic deficits.
Asymptomatic patients who are alert and nonintoxicated can be cleared clinically without radiographic evaluation. The C-collar may be removed if the
clinical examination is negative for C-spinal trauma.
There are multiple studies documenting that this policy is safe.
The role of distracting injuries (painful injuries in other areas of the body) is
debated. Some authors believe that their presence should be a contraindication for clinical clearance. We believe that a careful neck examinationafter
asking a cooperative patient to focus on the neckcan be reliable even in the
presence of distracting injuries. Each such case should be individualized
based on the type and location of distracting injury and the pain it causes.
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Trauma Management
Fig. 9.5. Civilian gunshot wounds to the spine rarely produce unstable fractures.
However, high-velocity bullets from military weapons, as shown here, can cause
extensive injury with resulting instability.
There are a few case reports on occult C-spinal injuries (in the absence of
symptoms). These reports are more likely to result from superficial and careless clinical examination than from a fracture that does not cause even minimal pain.
Alert Patients with Neck Pain and/or Neurologic Deficits

Three initial plain views should be done (anterioposterior, lateral and odontoid).
If there is an abnormality, additional tests may be needed. If there is no abnormality, we recommend flexion/extension views to evaluate stability, and a focused CT of the area of pain to screen for fractures. If no injury is revealed and
the symptoms persist, the case should be individualized. In the presence of
high-risk factors for C-spine injury (osteoporotic spine, significant associated
facial or skull injuries), an MRI may be obtained. In the absence of such
factors, an MRI is still a reasonable test for persistent neurologic symptoms
121
Fig. 9.6. Prolonged application of the C-spine collar may cause skin ulceration at
areas of pressure. In some cases, areas with extensive facial or neck skin necrosis
require skin grafts or flaps.
Fig. 9.7. Clinical examination is highly accurate for alert, nonintoxicated patients.
The spine is palpated with the collar removed, while manual stabilization is provided by the nonexamining hand.
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Trauma Management
Fig. 9.8A. The plain radiograph may be unreliable for

patients who are not clinically evaluable. This patient
with severe head injury has
no findings on the imaged
vertebrae of the plain lateral
film.
Fig. 9.8B. The CT scan of C1 to T1 revealed a potentially unstable C2 fracture.
but not for pain. In the absence of risk factors and in the presence of pain
only, the collar may be removed.
Unevaluable Patients with Minimal Trauma

These are typically intoxicated or head-injury patients with a slightly depressed
GCS. Most of these patients are expected to regain full consciousness within a
few hours.
123
Plain radiography should be performed. Even if it is negative for trauma, the

patient should be left in the C-collar. The patient can be evaluated clinically
once consciousness is regained. If the clinical examination is negative, the Ccollar is removed. If it is positive, the steps suggested in the evaluation of alert
patients with symptoms should be followed.
Unevaluable Patients with Significant Trauma

Complete clinical examination is usually not possible for prolonged periods
of time. The evaluation of the C-spine of these patients is a very difficult
and thus far unsolveddiagnostic problem. Individualization of care of the
C-spine is appropriate.
Rates of C-spine injuries of up to 35% have been reported among such patients. A high index of suspicion should be maintained.
We recommend adequate three-views plain films and a complete CT from C1
to T1. If there is any evidence of spinal trauma, C-spinal precautions are maintained and additional diagnostic or therapeutic maneuvers are done as appropriate. If no evidence of C-spinal trauma is observed, the C-collar can be
removed in the absence of compelling reasons to retain it (e.g., major associated injuries around the neck).
An alternative method is to obtain plain films, a CT of C1 and C2 (or any
other suspicious area) and passive flexion/extension views under fluoroscopic
guidance. This method is time-consuming, labor-intensive, logistically difficult and potentially dangerous. We do not recommend it.
At no point during the prolonged hospitalization of these patients should the
C-collar interfere with their care. The neck should be used for central-line
catheterization if needed. Alternative methods of stabilization (sandbags, temporary manual stabilization, pharmaceutical paralysis) are available when the
C-collar must be released.
Prolonged C-collar placement is associated with skin breakdowns which, if
unattended, may cause significant wound problems. The C-collar should be
released and the neck inspected on a daily basis. Skin pressure-release (e.g., a soft
piece of cloth between the collar and the skin) is appropriate for areas at risk.
Pitfalls in the Radiologic Evaluation of the C-Spine

Reporting a lateral C-spine film as normal when the entire length of the cervical spine is not visualized.
Evaluating the osseous structures only and ignoring indirect signs of C-spinal
injury from the soft tissues. Remember that up to 11% of C-spinal injuries
will involve only ligamentous structures or disks but not the actual bone. In
the presence of a C-collar, a subluxation may be reduced and not be apparent.
The C1/C2 area is often difficult to interpret on plain films. Look for subtle
signs of injury. The atlanto-dental interval (ADI, the space between the posterior surface of the anterior arch of C1 and the anterior surface of the dens)
should be less than 3 mm in adults and 6 mm in children. Widening of this
space indicates injuries to the area.
There are differences in the radiographic appearance of the C-spine in children due to the increased flexibility of their ligaments and bones:
1. Pseudosubluxation of C1 on C2 and/or C2 on C3 are normal findings in
up to 25% of children.
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Trauma Management
Fig. 9.9A. Compression fracture of C6 caused by a heavy object that fell on the
patients head. The anterior wedging indicates severe fracture.
2. The ADI is normal up to 6 mm.

3. Prevertebral soft tissues may be normally wide.
4. The intervertebral distances (particularly between C1 and C2) may be normally wide.
Pitfalls in the Clinical Examination of the C-Spine

Examining the patient who is been given pain medication. No pain medication is allowed before the C-spine examination is completed.
Disregarding minimal pain or attributing it to pressure from the C-collar.
Even minimal pain over the C-spine should prevent discontinuation of Cspine precautions.
Focusing on pain and ignoring neurologic symptoms (numbness, tingling,
decreased strength, etc.).
125
Fig. 9.9B. The CT reveals an unstable fracture with significant retropulsion of bony
fragments, occupying more than 50% of the spinal canal. The patient had a complete neurologic deficit.
Attempting clinical examination in a chaotic environment while other providers perform different procedures on the patient (blood drawing, examination of other parts, etc.). Clinical examination should be done when the patient is calm and can focus on his/her neck.
Intoxication cannot always be assessed easily. The absence of alcohol odor on
the breath of an alert and communicative patient would qualify him/her for
clinical clearance.
Pitfalls of C-Collar Application

Inadequate clinical examination of the neck due to reluctance to remove the
C-collar. The neck should always be examined under manual stabilization
after temporary removal of the C-collar.
A very tight C-collar can compress an edematous neck and contribute to air-
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Trauma Management
way obstruction. It can also compress the jugular veins and increase the intracranial pressure in patients with head injuries.
A C-collar should never prevent therapeutic or diagnostic procedures at the
neck (line placement, laryngoscopy, etc.). Alternative methods of stabilization
should be used temporarily.
References
1.
2.
3.
4.
5.
6.
Velmahos GC, Theodorou D, Tatevossian R et al. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: Much ado about nothing. J
Trauma 1996; 40:768-774.
Berne JD, Velmahos GC, El-Tawil Q et al. Value of complete cervical helical CT
scanning in identifying cervical spine injury in the unevaluable blunt trauma patient
with multiple injuries: A prospective study. J Trauma 1999; 47:896-903.
Blacksin MF, Lee HJ. Frequency and significance of fractures of the upper cervical
spine detected by CT in patients with severe neck trauma. AJR 1995;
165:1201-1204.
Reid DC, Henderson R, Saboe L et al. Etiology and clinical course of missed spine
fractures. J Trauma 1987; 27:980-986.
Williams J, Jehle D, Cottington E et al. Head, facial, and clavicular trauma as a
predictor of cervical spine injury. Ann Emerg Med 1992; 21:719-722.
Marion DW, Domeier R, Dunham CM et al. Practice management guidelines for
identifying cervical spine instability after trauma. J Trauma 1998; 44:945-946.
Also available at: http://www.east.org/tpg (Web site of the Eastern Association for
the Surgery of Trauma).
CHAPTER 1
CHAPTER 10
Penetrating Injuries of the Neck

Anatomy
For trauma purposes the neck is divided into three anatomical zones:
Zone I between the clavicle and the cricoid cartilage,
Zone II between the cricoid cartilage and the angle of the mandible, and
Zone III between the ankle of the mandible and the base of the skull (Fig. 10.1).
Epidemiology
About 20% of stab wounds to the neck have significant injuries and 10%
require surgical intervention.
About 34% of gunshot wound to the neck have significant injuries and 17%
require surgical intervention.
About 70% of transcervical gunshot wounds have significant injuries and 20%
require surgical repair.
Physical Examination
Highly advisable that physical examination is performed according to a written protocol (Fig. 10.2). Failure to do so may result in missing important
signs and symptoms.
The physical examination should be systematic according to systems, i.e., vascular structures, aerodigestive tract, spinal cord, cranial nerves, brachial plexus.
Hard signs are diagnostic of significant injury, soft signs are suggestive of injury and require further investigation.
Vascular Structures
- Hard physical findings: severe active bleeding, large expanding hematoma, unexplained shock, absent or diminished peripheral pulses, bruits.
- Soft physical findings: stable hematoma, mild hypotension, unexplained low
GCS or hemiplegia.
Aerodigestive Tract
- Hard signs: Air bubbling through the wound, dyspnea.
- Soft signs: hemoptysis, subcutaneous emphysema, hoarseness, odynophagia,
hematemesis.
Nerves
- Cranial nerves: Examine 7, 9, 10, 11, 12 nerves.
- Brachial plexus: Examine axillary, musculocutaneous, radial, medial and ulnar
nerves.
- Sympathetic chain: check for Horners syndrome (enophthalmos, ptosis, miosis, anhydrosis).
Chest: Check for associated hemothorax or pneumothorax

Demetrios Demetriades, University of Southern California, Los Angeles, California, U.S.A.
128
Trauma Management
Fig. 10.1. Anatomical
zones of the neck
Investigations
Investigations should be reserved only for fairly stable patients.
Chest and Neck X-rays: Look for hemopneumothorax, subcutaneous emphysema, a widened upper mediastinum, hematomas causing deviation of the
trachea or nasogastric tube, an elevated diaphragm, foreign bodies (Figs.
10.3, 10.4).
10
- Subcutaneous emphysema may be due to aerodigestive tract injury or associated pneumothorax or air from outside.
Color Flow Doppler: The investigation of choice for vascular evaluation. It

should be performed on all stable patients. It has some limitations in the
evaluation of the internal carotid artery near the base of the skull, the proximal subclavian vessels in obese patients especially on the left side, and the
vertebral artery under the bony part of the vertebral canal.
Angiography: It has largely been replaced by color flow doppler, but has an
important role in selected cases.
- Diagnostic indications of angiography:
Shotgun injuries, zone III injuries with a hematoma, zone I injuries with a
widened mediastinum, and inconclusive color flow doppler studies (Fig.
10.5).
- Therapeutic indications of angiography:
Stable patients with a diminished or absent peripheral pulses or bruit, where
angiographically placed stents may be possible. Also, slow bleeding from the
vertebral arteries or branches of the external carotid artery may be controlled
with angiographic embolization (Fig. 10.6).
Esophageal Evaluation: Esophagography and/or esophagoscopy should be performed in patients with proximity injuries and symptoms (subcutaneous
emphysema, odynophagia, hematenesis) or clinically unevaluable patients (Fig.
10.7).
- Esophagography or esophagoscopy alone may miss cervical esophageal injuries.
The combination of the two identifies all significant injuries.
129
10
Fig. 10.2. Protocol for physical examination in penetrating injuries of the neck.
130
Fig. 10.3. Neck xray showing a large
neck hematoma
with displacement
of the nasogastric
tube.
Fig. 10.4. Chest

x-ray showing an
elevated
left
hemidiaphragm
due to a phrenic
nerve injury.
10
Fig. 10.5. Angiogram in a patient

with shotgun in-
Trauma Management
131
Fig. 10.6. Angiogram showing false aneurysms of the facial artery before and after
successful embolization.
Laryngotracheal evaluation: Endoscopy should be performed in all patients

with proximity injuries who are symptomatic or are clinically unevaluable.

Airway management may be a significant problem in patients with large neck
hematomas or major laryngotracheal trauma.
- Pharmacological paralysis for endotracheal intubation in patients with large
hematomas may be risky! Inability to visualize the vocal cords and failure to
insert the endotracheal tube may be catastrophic!
- Cricothyroidotomy in the presence of a hematoma, especially anterior, may

be very difficult and perhaps dangerous.
- Endotracheal intubation without pharmacological paralysis may exacerbate
any hemorrhage and make any hematoma larger due to patient straining and
coughing.
- Awake nasotracheal fiberoptic intubation is the safest way of intubation in
patients with large neck hematomas.
- No efforts should be made to introduce a nasogastric tube before anesthesia.
Patient straining and coughing may aggravate bleeding.
Bleeding control may be achieved by direct pressure. If this fails, balloon tamponade is very often effective (Fig. 10.8).
In patients with zone I injuries avoid intravenous lines on the side of injury, in
order to avoid extravasation of the infused fluids from a proximal subclavian
venous injury.
Operation or Observation
The decision to operate or observe should be made on the basis of a good
clinical examination according to a protocol and appropriate investigation.
The suggested algorithm for the initial evaluation and management is
shown in Figure 10.9.
10
132
Trauma Management
Fig. 10.7. Esophageal leak following

a gunshot wound to the neck.
10
Gunshot injuries should be evaluated and managed like stab wounds.

Only about 10% of stab wounds and 17% of gunshot wounds require
operation.
Transcervical gunshot injuries should be managed like the rest of gunshot
injuries. Although 70% of these patients have injuries to significant neck structures, only 20% require surgical intervention.
Patients selected for nonoperative management are admitted and observed for
at least 24 hours.
133
Fig. 10.8. Balloon tamponade in a patient with zone III injury and severe bleeding.
Operative Management
The standard incision for neck exploration is one along the anterior border of
the sternomastoid muscle. Occasionally a transverse incision may be used for
suspected injuries to the larynx or trachea. Bilateral sternomastoid incisions
may be necessary for transcervical wounds. A clavicular incision alone or
combined with a median sternotomy provide exposure for subclavian
vascular injuries.
Common Mistakes in the Initial Evaluation

and Management of Penetrating Injuries of the Neck
Pharmacological paralysis for emergency room intubation in the presence of a
large neck hematoma. Danger or airway loss!
Attempts to insert a nasogastric tube in the emergency room in the presence
of a suspected vascular injury. Straining and coughing may precipitate major
hemorrhage.
Failure to examine the patient according to a written protocol. Important
signs and symptoms may be missed!
Insertion of an intravenous line on the same side as the neck injury. Infused
fluids may extravasate from a proximal injury to the subclavian vein!
10
134
Fig. 10.9. Algorithm for the initial evaluation and management of penetrating injuries of the neck.
Trauma Management
10
References
1.
2.
3.
4.
Demetriades D, Asensio J, Velmahos G et al. Complex problems in penetrating

neck trauma. Surg Clin North Am 1996; 76; 661-684.
Demetriades D., Theodorou D, Cornwell EE et al. Evaluation of penetrating injuries of the neck. A prospective study of 223 patients. World J Surg 1997; 21:41-48.
Demetriades D, Theodorou D,. Cornwell EE et al. Penetrating injuries of the neck
in stable patients: Physical examination, angiography, or color flow doppler. Arch
Surg 1995; 130:971-979.
Demetriades D, Theodorou D, Cornwell EE et al. Transcervical gunshot injuries:
Mandatory operation is not necessary. J Trauma 1996; 40:758-760.
CHAPTER 1
CHAPTER 11
Carotid Artery Injuries

S. Ram Kumar and Fred A. Weaver
Introduction
Five to ten percent of arterial injuries involve the carotid artery, all but 3-10%
of which follow penetrating trauma. A vascular injury is present in approximately 25% of all neck injuries.
Mortality rates range between 10-30%. The incidence of permanent neurological deficit varies between 40-80%.
Historical Perspective
In 1522, Ambroise Par reported the first successful management of a bleeding carotid injury by ligation. Ligation was used routinely for many years in
the management of carotid artery injuries, resulting in high rates of mortality
and hemiplegia.
Primary repair of the carotid arteries was attempted during the Korean conflict.
In 1973, Bradley challenged the wisdom of primary repair of an injured carotid
artery in patients with a neurologic deficit. He reported autopsies of two neurologically compromised patients with hemorrhagic infarctions after repair of
a penetrating carotid injury.
Later reports have refuted Bradleys contentions and established that primary
repair of all carotid injuries regardless of the neurologic status provides a superior
neurologic outcome.
Penetrating Carotid Injuries

Clinical Findings
Anatomically, injuries are classified into three zones: Iinjuries from the sternal
notch to clavicle, IIinjuries between the clavicle and angle of the mandible
and IIIinjuries above the angle of mandible (Fig. 11.1).
A cervical bruit, thrill, or a rapidly expanding hematoma in the anterior triangle
of the neck is highly suggestive of a carotid injury.
Pulse deficit in the superficial temporal artery, evidence of active bleeding
from the oropharyngeal or neck wounds, widened mediastinum, ipsilateral
Horners syndrome or dysfunction of cranial nerves IX-XII are additional findings often associated with a carotid injury.
Contralateral neurologic deficits may be present, but can be obscured by an
associated head injury, systemic hypotension or the patients use of psychoactive substances prior to the injury.
S. Ram Kumar, Department of Surgery, Division of Vascular Surgery, Keck School
of Medicine, University of Southern California, Los Angeles, California, U.S.A.
Fred A. Weaver, Department of Surgery, Division of Vascular Surgery,
Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A.
136
Trauma Management
Fig. 11.1. Anatomical classification of zones of the neck. Reprinted with permission from: Weaver FA, Yellin AE. Vascular System. In: Donovan AJ, ed. Trauma
Surgery. 1st ed. 1994:207-62. 1994 Mosby-Year Book, Inc
11
Injuries to the esophagus and trachea are frequently associated due to their
proximity.
Investigations
Arteriography is advisable for any Zone I and III penetrating injury. Zone I
injuries may involve the vessels of the aortic arch and hence planning the
proper incision necessitates arteriographic evaluation. Zone III injuries are
difficult to expose and treat surgically. Arteriography aids in formulating an
operative plan or may be used in many instances to guide endovascular management of mid and distal internal carotid injuries.
Arteriography can help recognize unsuspected vertebral, arch, great vessel or
contralateral carotid injuries, or aberrant vascular anatomy in patients who
require operative management.
Zone II injuries with signs and symptoms suggestive of a carotid artery injury
may be screened with a duplex exam with arteriography reserved to confirm
duplex documented injuries (Fig. 11.2).
Head CT scans are important in selected cases to evaluate the presence and
extent of parenchymal brain injury, concurrent intracranial hematomas, cerebral edema or cranial vault injuries.
137
Fig. 11.2. Algorithmic approach to a patient with penetrating neck trauma. Reprinted
with permission from Kumar SR, Weaver FA. Current Diagnostic Techniques in
Vascular Trauma. In: Yao, Pearce, eds. Modern Vascular Surgery. 1st ed. 1999:381-92.
1999 McGraw-Hill.
Management
Low-velocity penetrating injuries that cause intimal defects, pseudoaneurysms
less than 5 mm in size, or adherent or downstream nonobstructive intimal
flaps with intact distal circulation and without active hemorrhage can be safely
observed. Documentation of vessel healing should be obtained by follow-up
duplex scanning or arteriography.
Arterial repair is the preferred option for most other internal or common
carotid injuries regardless of the contralateral neurologic status. However, patients with a dense neurologic deficit and large infarct on CT have a poor
outcome irrespective of treatment. Occlusive internal carotid injuries in an
asymptomatic patient may also be treated nonoperatively. When this is elected,
it is critical to maintain normotension. Anticoagulation, if not contraindicated, is advisable for 3-6 months.
Incision
- For Zone II injuries, the carotid artery is exposed by an incision parallel to the
anterior border of the sternocleidomastoid muscle.
11
138
Trauma Management
- For Zone I injuries, exposure of the proximal portion of the common carotid
artery requires a median sternotomy.
- The mid to distal internal carotid artery is a challenge to expose. Division of the
digastric muscle, osteotomy of the angle of mandible, or anterior subluxation of
the mandible may be required.
The injured artery is repaired by lateral arteriorrhaphy for the simpler wounds
and excision of the injured area with primary anastomosis or interposition
saphenous vein grafts for more complex wounds.
Simple injuries to the external carotid arteries can be surgically ligated or
embolized by an endovascular approach.
Proximal internal carotid artery injuries can be managed by simple repair or
interposition vein graft. Another option is to oversew the injury, then ligate
the external carotid artery distally and divide it. The distal internal carotid
artery is then transposed to the proximal stump of the external carotid artery
(Fig. 11.3).
Use of Shunts
- Shunts are not necessary for proximal common carotid injuries.
- During internal carotid artery repair, intraluminal shunts should be used to
reestablish or maintain cerebral perfusion.
- Shunts should be passed through the lumen of the graft material before being
placed and then the graft sewn in place (Fig. 11.4). The shunt can be removed
just prior to the placement of the last few sutures.
- Systemic anticoagulation with heparin is necessary when shunts are used.
False aneurysms in the distal internal carotid artery can be embolized with
11
Fig. 11.3. Repair of proximal internal carotid

artery injury by transposition to the external
carotid artery. Reprinted
with permission from:
Weaver FA, Yellin AE. Vascular System. In: Donovan
AJ, ed. Trauma Surgery. 1st
ed.1994:207-62.
1994 Mosby-Year Book,
Inc.
139
Fig. 11.4. Use of shunts
during interposition graft
repair of carotid artery
injuries. Reprinted with
permission from: Weaver
FA, Yellin AE. Vascular
System. In: Donovan AJ,
ed. Trauma Surgery. 1 st
ed. 1994:207-62. 1994
Mosby-Year Book, Inc.
detachable balloons at the time of arteriography. Prior to balloon occlusion,

temporary occlusion with monitoring of the neurologic status should be performed. If a contralateral deficit develops an external carotid-internal carotid
bypass may be required prior to permanent balloon occlusion. When balloon
occlusion is used, anticoagulation for 3-6 months is necessary to inhibit thrombus propagation into the middle cerebral artery.
If there is an associated aerodigestive tract injury, vascular repair should be
protected by interposing the belly of the sternomastoid muscle between the
vascular and aerodigestive tract repairs.
Complications
Short-term complications include thrombosis of the repair, perioperative hemodynamic instability causing cerebral infarcts and sepsis that may ensue following dehiscence of an aerodigestive tract repair.
Early diagnosis and treatment offers best prognosis. Injury due to cerebral
ischemia increases with delays in management.
Blunt Carotid Injuries

The mechanism of blunt injury includes direct blows, injuries that cause severe flexion and rotation of the neck and hyperextension injuries with stretch
of the vessel over the transverse processes of the cervical vertebra.
Blunt injury usually involves the internal carotid artery and produces vessel
contusion or intimal tears that lead to dissection, intimal flaps or occlusion.
11
140
Trauma Management
Diagnosis
A high index of suspicion is required, especially in patients with neurological
deficits and minimal physical findings of cervical trauma.
A history of lucid interval of hours to days between the injury and the appearance of neurologic symptoms is the classic presentation.
The patient may complain of hearing a buzzing sound. Clinical findings
may include Horners syndrome or a bruit.
Duplex evaluation has been used to diagnose blunt carotid injuries; however,
arteriography remains the gold standard since intimal flaps and dissections of
the mid and distal internal carotid artery may be missed by duplex exam.
Management
Blunt injuries to the carotid artery are usually not amenable to definitive surgical repair.
Systemic anticoagulation, which limits thrombus propagation and
embolization, is the treatment of choice.
Pseudoaneurysms may develop in up to 30% of patients treated by anticoagulation therapy. Endovascular stenting has been used to treat pseudoaneurysms
with good success.
Outcome depends on the initial neurologic deficit, early diagnosis and adequacy of collateral circulation. If the initial neurological deficit is limited, the
outcome with anticoagulation is generally good.
References
1.
11
2.
3.
4.
5.
Hood DB, Yellin AE, Weaver FA. Vascular trauma. In: Dean RH, Yao JST, Brewster
DC, eds. Current Diagnosis and Treatment in Vascular Surgery. Edition 1 CT:
Appleton Lange, 1998: 405-28.
neck trauma. Surg Clin N Am 1996; 76(4):661-83.
Kuehne JP, Weaver FA, Papanicolaou G et al. Penetrating trauma of the internal
carotid artery. Arch Surg 1996; 131:942-8.
Biffl WL, Moore EE, Ryu RK et al. The unrecognized epidemic of blunt carotid
arterial injuries. Ann Surg 1998; 228(4):462-70.
Weaver FA, Yellin AE, Wagner WH et al. The role of arterial reconstruction in
penetrating carotid injuries. Arch Surg 1988; 123:1106-11.
CHAPTER 1
CHAPTER 12
Subclavian and Axillary Vascular Injuries

Anatomy
The left subclavian artery originates directly from the aortic arch and the right
subclavian from the brachiocephalic artery. The rest of the anatomy is similar
in both sides.
The first part of the subclavian artery lies behind the sternomastoid muscle
and medial to the scalenus anterior muscle. The second part lies behind the
anterior scalenus muscle, and the third part lateral to the scalenus muscle.
Most of the axillary artery lies underneath the pectoralis minor muscle.
The subclavian vein is in front and below the artery. The scalenus anterior
muscle separates the two vessels.
The axillary vein lies inferior to the artery (Fig. 12.1).
Incidence
In about 3% of all penetrating injuries to the neck.

In about 3.5% of all gunshot wounds to the neck.
In about 3% of all gunshot wounds to the chest.
In about 2% of stab wounds to the neck.
In about 1% of stab wounds the chest.
In about 14% of patients with fracture of the 1st rib.
In about 0.4% of patients with fracture of the clavicle.
All patients with scapulothoracic dissociation have vascular injuries.
Many patients are dead or near death on arrival.
Hard Signs Diagnostic of Vascular injury: Severe external bleeding, massive
hemothorax or significant continuous bleeding in the thoracostomy tube in
patients with thoracic inlet injuries, absent or diminished peripheral arm pulses,
bruit or murmur.
Soft Signs Suspicious of Vascular injury: Hematoma, unexplained anemia or
hypotension in the presence of a proximity penetrating injury.
Ankle-Brachial Index (ABI) is part of the standard examination. An ABI higher
than 0.90 is unlikely to be associated with significant arterial injury. However,
small arterial injuries may be associated with a normal ABI.
The presence of a peripheral pulse does not exclude a proximal arterial injury.
A good physical examination can reliably diagnose or suggest all significant
subclavian or axillary vascular injuries.

142
Trauma Management
Fig. 12.1. Anatomy of the subclavian and axillary vessels. Used with permission:
Textbook of Techniques in Complex Trauma Surgery. Asensio J, Demetriades D,
eds. W.B. Saunders (in press).
Investigations
12
No investigations for hemodynamically unstable patients or in the presence of

a threatened extremity.
Chest X-ray: May show an associated hemopneumothorax, the presence of a
missile, a local hematoma (Fig. 12.2).
Color Flow Doppler: The investigation of choice; it is not invasive, it can
evaluate both arteries and veins, and has a high sensitivity and specificity in
experienced hands. However, it is operator dependent and in obese patients it
may not be possible to visualize the proximal vessels, especially the left side.
Arteriography: a) Diagnostic Indications: Widened mediastinum on chest xray, shotgun injuries, inconclusive color flow doppler (Figs. 12.3-12.6).
b) Therapeutic indications: Selected stable patients with bruits or murmurs or
decreased peripheral pulses where angiographically placed stents may be possible (Figs. 12.7A-12.7B).
Note
- The combination of physical examination and color flow doppler by an experienced operator identifies almost all injuries.
- The choice of angiography or color flow doppler should be individualized taking into account the capabilities of the trauma center.
Control any external bleeding by direct compression.
Scoop and run.

No intravenous lines on the injury side
143
If direct pressure cannot control the bleeding, balloon tamponade may be

effective. A Foley catheter is inserted into the wound and advanced as far as it
can go. The balloon is then inflated and in most cases the bleeding is effectively
controlled. If the Foley enters into the pleural cavity through a supraclavicular
wound, the balloon is again inflated and firm traction is applied on the catheter. The traction is maintained by applying a Kelly forceps on the Foley, just
above the skin. The balloon compresses the bleeding subclavian vessel against
the first rib or the clavicle and the bleeding is controlled. This technique controls bleeding into the chest. If external bleeding persists a second Foley may
be inserted and inflated into the wound tract (Fig. 12.8).
Patients with active bleeding, hemodynamic instability, or an ischemic arm,
need urgent operation, without any vascular studies.
Patients in cardiac arrest or imminent cardiac arrest should have an emergency room thoracotomy. Bleeding from the subclavian vessels can be controlled by direct pressure at the apex of the hemithorax.
Operative Technique
Incision: A clavicular incision provides a good exposure for distal subclavian
and proximal axillary vascular injuries. The incision starts at the sternoclavicular joint, extends directly over the medial half of the clavicle and curves
downwards into the deltopectoral groove (Fig. 12.9). The medial half of the
clavicle may be excised or the sternoclavicular joint is disarticulated and the
clavicle retracted. The retroclavicular space is carefully dissected and the subclavian vessels are identified (Fig. 12.10).
- A combination of a clavicular incision and a median sternotomy provides a
good exposure for both, left and right proximal subclavian injuries (Fig. 12.11).
- A trap door incision (a combination of clavicular, upper median sternotomy
and anterior thoracotomy through 3rd intercostal space) has been used for left
proximal injuries. This incision is not recommended.
- An incision over the deltopectoral groove with division of the pectoralis major
muscle about 2 cm from its attachment to the humerous, and division of the
underlying pectoralis minor muscle provides good exposure for distal axillary
vessels (Fig. 12.12).
Management of the Vascular injury

- Arterial injuries should be repaired in almost all cases. In critically ill patients a
temporary stent should be considered. Ligation of the artery is not desirable
because it may cause severe ischemia and aggravate the systemic condition of
the patient.
- If primary repair of the artery is not possible an autologous venous or PTFE
graft should be used. Both types of graft are acceptable.
- Venous injuries should be repaired only if it can be done easily with simple
suturing and without significant postrepair stenosis. Complex venous reconstruction should be avoided. Ligation is well tolerated and except for transient
early edema there are no long-term side effects.
Wound Closure
- Excision of the medial half of the clavicle does not result in permanent disabilities. Regeneration of the bone occurs within a few months.
- If disarticulation of the sternoclavicular joint had been performed, the anatomy
should be restored by suturing the periosteum and the ligaments over the joint.
12
144
Trauma Management
12
Fig. 12.2. Thoracic inlet injury with hematoma near the proximal left clavicle. The
patient had a subclavian venous injury.
Complications
Air embolism may occur in venous injures. It often presents as unexpected
cardiac arrest or arrhythmia. Air bubbles may be seen in the vein. The treatment is aspiration of the right ventricle.
Venous ligation may result in temporary arm edema.
Therapeutic Interventional Radiology

Selected stable patients with subclavian artery injuries (especially false aneurysms or fistulae) can be managed with angiographically placed stents (Figs.
12.7A, 12.7B).
145
Fig. 12.3. Shotgun injury is a strong indication for arteriography.
12
Fig. 12.4. Arteriogram showing partial transection of the subclavian artery.
146
Fig. 12.5. False aneurysm of the subclavian artery.
12
Fig. 12.6. False aneurysm of the axillary artery.
Trauma Management
147
Fig. 12.7A. Traumatic false aneurysm and arteriovenous fistula of the subclavian
vessels.
12
Fig. 12.7B. Patient in Figure 12.7A, successfully treated with endovascular stent.
148
Trauma Management
Fig. 12.8. Foley balloon tamponade of bleeding from the subclavian vessels. Used
with permission: Textbook of Techniques in Complex Trauma Surgery. Asensio J,
Demetriades D, eds. W.B. Saunders (in press).
12
Fig. 12.9. Clavicular incision provides good exposure of distal subclavian and proximal axillary vessels.
149
Fig. 12.10. Proximal subclavian vessel exposure after excision of the medial half of
the clavicle. Used with permission: Textbook of Techniques in Complex Trauma
Surgery. Asensio J, Demetriades D, eds. W.B. Saunders (in press).
Prognosis
The overall survival for patients reaching medical care in about 70%.
Survival for patients reaching the operating room alive is about 85%.
Venous injuries are associated with a higher mortality than arterial injuries, perhaps due to air embolism or inability of the vein to contract and reduce bleeding.
Scapulothoracic Dissociation
It involves disruption of the shoulder from the chest. The clavicle is fractured
or dislocated, the shoulder muscles are avulsed, and the neurovascular structures are severely damaged.
If there is significant preservation of the brachial plexus function, vascular
reconstruction should be attempted.
In the absence of brachial plexus function the arm should be amputated below the shoulder.
References
1.
2.
3.
Demetriades D, Asensio JA, Velmahos G et al. Complex problems in penetrating

neck trauma. Surg Clin North Am 1996; 76: 665-683.
Demetriades D, Chahwan S, Gomez H et al. Penetrating injuries, to the subclavian and axillary vessels. J Am Coll Surg 1999; 188:290-295.
Demetriades D, Rabinowitz B, Pezikis A et al. Subclavian vascular injuries. Br J
Surg 1987; 74:1001-1003.
12
150
Trauma Management
12
Fig. 12.11. A median sternotomy combined with a clavicular incision provides

satisfactory exposure for proximal subclavian injuries. Used with permission: Textbook of Techniques in Complex Trauma Surgery. Asensio J, Demetriades D, eds.
W.B. Saunders (in press).
151
Fig. 12.12. Excision or division and retraction of the clavicle and division of the
pectoralis major and the underlying pectoralis minor expose the subclavian and
axillary vessels. Used with permission: Textbook of Techniques in Complex Trauma
Surgery. Asensio J, Demetriades D, eds. W.B. Saunders (in press).
12
CHAPTER 13
Vertebral Artery Injuries

Anatomy
The vertebral artery (VA) is the first cephalad branch of the subclavian artery.
It enters the vertebral canal at C6 and exits at C1.
Incidence
In about 10% of gunshot wounds to the neck.
In about 5% of stab wounds to the neck.
It may occur in fractures of the C-spine due to blunt trauma.
About two thirds of patients with VA injury have major associated injuries to
other neck structures. Fracture of the spine is the most common associated
injury.
In about 50% of cases there are hard signs of vascular injury (severe bleeding,
large hematoma, bruit).
In about 30% there are soft signs of vascular injury (stable hematoma, mild
hypotension).
In about 20% there are no significant signs of vascular injury.
Investigations
Investigations should be reserved only for hemodynamically stable patients
with no severe active bleeding.
All patients with gunshot wounds involving the transverse processes of the
cervical spine should be evaluated for VA injuries.
Overextension injuries to the cervical spine should be evaluated by doppler
studies for VA injuries.
Color flow doppler may be helpful in selected cases. It can not visualize the
parts of the artery underneath the bony vertebral canal.
Angiography for selected cases with large neck hematomas, bruits, shotgun
injuries, gunshot wounds involving the transverse processes (Fig. 13.1).
Management
Fewer than half of patients with VA injuries require operation. Patients with
thrombosed VA do not need any treatment (Fig. 13.2).
Angiographic embolization is the treatment of choice for patients with continuous slow bleeding or false aneurysm or arteriovenous fistula (Figs. 13.3,
13.4).
Operative management should be reserved only for patients with severe active
bleeding or where angiographic embolization had failed.
153
Fig. 13.1. Gunshot wound of the C-spine involving the transverse foramen.
Angiographic evaluation should be performed in these cases.
13
Fig. 13.2. Angiography showing thrombosis of the VA. No treatment is required.
154
Trauma Management
Fig. 13.3. Vertebral artery arteriovenous fistula, before and after angiographic embolization. (From Demetriades D, Theodorou D, Asensio J et al. Management options in vertebral artery injuries. Br J Surg 1996; 83:83-86, with permission).
Fig. 13.4. VA false aneurysm
before and after successful
angiographic embolization.
Reprinted with permission from
Demetriades D, Asensio J,
Velmahos G, Thal E. Complex
problems in penetrating neck
trauma. Surg Clin North Am
1996; 76:661-683.
13
155
Fig. 13.5A, B. Surgical exposure of the VA: Following an incision along the anterior
border of the sternomastoid muscle, the carotid sheath is retracted laterally or
medially. The trachea and esophagus are retracted medially and the longus colli
muscle is swept off the vertebra. The anterior rim of the vertebral foramen is then
removed with bone rongeurs and the VA is exposed and ligated. Reprinted with
permission from Demetriades D, Theodorou D, Asensio J et al. Management options
in vertebral artery injuries. Br J Surg 1996; 83:83-86.
13
Fig. 13.6. Incision and craniectomy for complex high VA injuries not amenable to
angiographic embolization. Reprinted with permission from Demetriades D,
Theodorou D, Asensio J et al. Management options in vertebral artery injuries. Br J
Surg 1996; 83:83-86.
156
Trauma Management
The operation for VA injuries is one of the most difficult in trauma surgery
and very often involves deroofing of the vertebral canal (Figs. 13.5A,B). For
very high lesions a craniectomy may be necessary (Fig. 13.6).
Prognosis
Isolated VA injuries have a mortality of about 7%.
Thrombosis or ligation of the VA are very well tolerated and neurological
sequelae are extremely rare.
Common Mistakes and Pitfalls

Failure to evaluate for VA injuries in the presence of a fracture of the transverse process of the C-spine.
Underestimate the difficulties of the surgical exposure of the VA! Angiographic
embolization should be the procedure of choice whenever is possible.
References
1.
2.
3.
13
Demetriades D, Theodorou D, Asensio JA et al. Management options in vertebral

artery injuries. Br J Surg 1996; 83:83-86.
neck trauma. Surg. Clin North Am 1996; 76:661-684.
Hatzitheofilou C, Demetriades D, Melissas J et al. Surgical approaches to vertebral
artery injuries. Br J Surg 1988; 75:234-237.
CHAPTER 1
CHAPTER 14
Laryngotracheal Injuries
Uttam K. Sinha and Dennis M. Crockett
Introduction
Experience in managing laryngeal trauma is limited because of the relative
rarity of this injury. External laryngeal trauma accounts for only 1 in 30,000
emergency room visits. Although these injuries are rare, their initial management has a tremendous impact on the immediate probability of survival of
the patient, as well as long-term quality-of-life.
Proper management of laryngeal trauma requires a thorough understanding
of the complex anatomy of the larynx and hypopharynx (Fig. 14.1).
- The skeletal framework of the larynx is made up of three paired and three
unpaired cartilages, a circumferential conus elasticum membrane and two paired
vocal ligaments. While the epiglottis, thyroid and cricoid cartilages are unpaired
and larger, the arytenoid, corniculate and cuneiform cartilages are paired and
smaller. The thyroid cartilage has an anterior angle of approximately 90 in the
male and 120 in the female and provides an anterior fulcrum to which the
vocal ligaments (vocal cords) are attached. During repair of a fracture of the
thyroid cartilage, maintenance of this anterior angle is critical to preserve the
proper length of the true vocal cords and to restore optimum phonatory function.
- The cricoid is the strongest cartilage and forms a complete ring, surrounding
the space immediately inferior to the vocal cords (subglottic space). One of the
critical factors in the prevention of subglottic stenosis following trauma is preservation of the shape and diameter of this cartilage.
- The paired arytenoid cartilages articulate with the cricoid cartilage through synovial joints. They constitute the posterior one-third of the true vocal cords. Full
range of excursion of the vocal cords takes place by the action of intrinsic laryngeal muscles on the arytenoid cartilages. Distortion of the arytenoid cartilage(s)
may occur following external laryngeal injury or traumatic intubation, which
may result in fixation of the cord with associated breathy dysphonia and aspiration.
The larynx is protected anteriorly by the forward projection of the mandible,
and posteriorly by the rigid cervical spine. Nonetheless, injuries occur, and
the resultant damage to the larynx is usually characteristic of the mechanism
of injury. These mechanisms can be divided into the following:
Uttam K. Sinha, Department of Otolaryngology Head and Neck Surgery, University
of Southern California School of Medicine, Los Angeles, California, U.S.A.
Dennis M. Crockett, Department of Otolaryngology Head and Neck Surgery, University
of Southern California School of Medicine, Los Angeles, California, U.S.A.
158
Trauma Management
Fig. 14.1. Normal anatomy of the larynx and hypopharynx at the level of the true
vocal cord.
Blunt trauma, including crushing, strangulation, and clothesline type injuries

Penetrating trauma
Inhalation injuries
Injuries caused by caustic ingestion
Intubation injuries
Motor vehicle accidents are the most common cause of anterior blunt trauma
to the larynx. The incidence of this type of injury is declining for the following reasons:
- Mandatory seat belt laws
- Deployment of air bags
- Better education regarding drunk driving
14
Strangulation injuries occur as a result of compressive forces from assaults

with blunt objects or from attempted suicides by hanging. The magnitude of
the force sustained to the anterior neck should be critically assessed, as delayed profound edema of the larynx may result in loss of the airway.
Clothesline injuries typically occur in motorcyclists or snowmobilists when
the riders neck encounters a fixed horizontal object, such as a clothesline (Fig.
14.12). Many of these injuries lead to immediate death resulting from a crushed
larynx or laryngotracheal separation.
Penetrating trauma commonly occurs as a result of gunshot wounds or knife
injuries. High-velocity weapons may cause massive tissue destruction beyond
the trajectory of the bullet. Knife injuries do not destroy tissue distant to the
path of injury.
Inhalation injuries are caused by superheated air, especially steam. This injury
is usually associated with burns to other parts of the body. An airway should
be secured early in these injuries before fluid resuscitation of the associated
burn injury begins because this will lead to marked edema of the injured
159
laryngeal mucosa with loss of airway. Inhalation injury causes damage mostly
in the supraglottic area, as does caustic ingestion. Both these injuries cause
reflex closure of the glottis for protection of the lower airway.
Laryngeal trauma in the pediatric population is uncommon and differs from
adult laryngeal trauma in several aspects:
-
Larynx is better protected because of its higher position in the neck

Increased soft-tissue damage
Decreased incidence and severity of cartilaginous fractures
Smaller cross-sectional area of the larynx
Higher chance of respiratory embarrassment due to soft-tissue damage in a relatively smaller cross-sectional area of the airway
External Laryngeal Trauma

The spectrum of laryngeal trauma varies from obvious laryngeal fracture to
subtle aberrations of laryngeal function.
Dysphonia is a common symptom of laryngeal trauma.
- Hematoma of the true vocal cord reduces vibratory capacity of the cord.
- Unilateral fixation (arytenoid dislocation) or paralysis (recurrent nerve palsy)
causes breathy dysphonia.
- Any structural alteration in the larynx that changes airflow patterns has the
potential to alter the voice.
- Patient can be completely aphonic in more severe trauma.
Stridor is an ominous clinical finding as it suggests impending airway

obstruction.
- Soft tissue edema, hematoma and displaced fracture of the thyroid cartilage are
common causes of stridor.
- Fracture of the cricoid cartilage with narrowing of the subglottic area may produce stridor.
- Bilateral dislocation of the arytenoid cartilages with fixation of both vocal cords
is an uncommon cause of stridor (unilateral fixation or paralysis of the cord
usually produces breathy dysphonia, unless there is associated soft-tissue edema
or hematoma).
- Bilateral recurrent laryngeal nerve paralysis causing stridor is extremely rare;

both nerves are well protected in the tracheo-esophageal grooves deep to the
sternocleidomastoid and strap muscles.
- Disruption of the laryngeal framework from gunshot injuries or cricotracheal
separation causes stridor; in these instances, no attempt should be made to
cover, compress, or otherwise manipulate such a wound before securing the
airway.
Laryngeal injuries can produce dysphagia and odynophagia. Vertical movement of the injured larynx with swallowing may produce pain and difficulty
in swallowing.
Aspiration is laryngeal dysfunction that may be caused by immobility of one
or both vocal folds. Although not clinically apparent immediately postinjury,
this may become evident later.
Hemoptysis indicates an injury in the upper aerodigestive tract, however this
is a nonspecific symptom.
14
160
Trauma Management
The skin of the anterior neck may reveal contusions or abrasions from blunt
trauma or a line pattern indicative of a strangulation injury. Anterior neck is
palpated to elicit crepitance, tenderness and loss of laryngeal prominence. It is
very difficult to palpate a step-off of the thyroid cartilage fracture, especially
in the presence of anterior cervical soft tissue swelling.
Penetrating injuries are assessed initially without exploration of the wound.
Manipulation of the wound may cause complete obstruction of the airway,
may dislodge a clot causing further bleeding or may further damage the delicate laryngeal structure. The entrance and exit wounds, and trajectory of the
bullet are determined.
Investigations
If the patient is stable, flexible laryngoscopic examination is performed carefully, as minor trauma associated with insertion of the flexible laryngoscope
may precipitate an airway emergency. The larynx and hypopharynx are assessed
for soft tissue edema and hematoma and their location, as well as the presence
of mucosal laceration and exposure of cartilage. The arytenoids are evaluated
for their position and full range of motion with phonation (asking the patient
to say i) and respiration. Failure of the true vocal cords to meet in the same
horizontal plane may also be present, indicating a structural change in the
laryngeal framework or superior laryngeal nerve injury.
Flexible laryngoscopic examination is occasionally impossible to perform in
an acutely injured patient because of the patients inability to cooperate. If the
patients airway and hemodynamics are stable, a noncontrast thin-cut (3 mm)
CT scan of the larynx can be obtained to evaluate the laryngeal skeletal framework in a noninvasive manner (Fig. 14.2). CT allows selecting out the subgroup of patients that do not require surgical intervention. CT adds little to
the preoperative evaluation in patients with the obvious surgical indications
of exposed cartilage or displaced fractures with overlying mucosal laceration.
Initial Management
14
The first priority in the management of a laryngeal injury is to establish an

airway. The patient is then hemodynamically stabilized, and the cervical spine
is kept stable until injury to the spine is ruled out. The most conservative,
reliable method of securing an airway in a patient with suspected laryngeal
injury is tracheotomy performed under local anesthesia with the patient awake
and breathing spontaneously (Fig. 14.3). Endotracheal intubation may further damage the larynx, prove exceedingly difficult, convert an urgent procedure to an emergent one, and interfere with subsequent examination and repair of the larynx. Endotracheal intubation is acceptable when:
- the endolaryngeal mucous membrane is intact
- the laryngeal skeleton is minimally displaced
- intubation is performed by highly skilled personnel
Once the patient is stabilized, laryngeal injuries are further assessed to determine whether the patient requires surgical intervention or can be managed
conservatively.
161
Fig. 14.2. CT findings show fracture of the left lamina of the thyroid cartilage with
blunting of the angle of the thyroid cartilage.
14
Fig. 14.3. Ideally, tracheotomy should be performed at the level of the second or
third tracheal rings, shown by two arrows on right. High tracheotomy (left) has
increased incidence of tracheal stenosis.
162
Trauma Management
Fig. 14.4. Minor mucosal laceration of the left supraglottic without exposure of
cartilage does not need surgical repair.
Nonsurgical Management
14
Patients with laryngeal trauma are extensively evaluated (physical examination, flexible laryngoscopy, CT scan) to select the subgroup who are likely to
do well without surgical intervention.
Medical management assumes that the patient has an otherwise stable airway
and does not require a tracheotomy.
The following laryngeal injuries can be managed nonsurgically:
- Minor endolaryngeal mucosal lacerations not involving the anterior commissure (Fig. 14.4)
- Single nondisplaced, nonangulated fracture of the thyroid cartilage without
overlying mucosal laceration or exposed cartilage
- Minor nonexpanding submucosal hematoma not causing respiratory embarrassment
- Minimum soft tissue edema without respiratory compromise
- Mild abnormal findings upon flexible laryngoscopic examination with normal
CT scan
If a decision for nonsurgical management is made, the following measures

should be taken:
- Elevation of the head of the bed (30-45)
163
- Humidified air
- Corticosteroid therapy instituted early after injury
Surgical Management
Surgical management of laryngeal injuries should be coordinated with all surgical teams involved and with the anesthesiologist.
A vast majority of patients who undergo repair of laryngeal injuries will require a tracheotomy performed under local anesthesia.
In the noncooperative child, tracheotomy under local anesthesia may not be
feasible: the airway is secured via rigid laryngoscopy and bronchoscopy in the
operating room, followed by tracheotomy.
Following induction of general anesthesia, direct rigid laryngoscopy, bronchoscopy and esophagoscopy are performed for detailed evaluation of the
injuries.
If a tracheotomy is performed for soft-tissue edema or hematoma, and direct
rigid examination and CT scan findings are otherwise normal, no further
surgical intervention is required.
Although controversy exists as to the optimum time of repair of laryngeal
injuries, the best results are obtained with immediate or early repair.
14
Fig. 14.5. Fracture of the left thyroid lamina (A) with no endolaryngeal lesion. This type
of fracture can be repaired either by miniplate (B) or wire (C); refer to text for details.
164
Trauma Management
The majority of the laryngeal injuries that require surgical repair can be categorized into three groups:
- Displaced single or comminuted fractures of the thyroid cartilage with intact
endolaryngeal mucosa or with minimal mucosal laceration and no exposure of
the cartilage (Fig. 14.5)
- Fracture of the thyroid cartilage with endolaryngeal injury requiring repair of
the endolarynx by a thyrotomy approach (Fig. 14.6)
- Massive trauma requiring placement of an endolaryngeal stent (Fig. 14.9)
Displaced single and comminuted fractures are repaired by open reduction

and internal fixation (Fig. 14.5A).
- The larynx is completely exposed by raising cutaneous subplatysmal apron flaps.
- The strap muscles are divided in the midline and retracted laterally.
- The fractures are reduced and their positions are maintained by wire (26 gauge)
which is passed through the cartilage by using a curved cutting needle. Care is
taken not to penetrate the mucosa. An 18 gauge needle is cut into two segments
with optimum length to pass the wire through them. The needle segments are
placed on either side of the fracture to prevent the wire from cutting through
the cartilage (Fig. 14.5C). If the cartilage is ossified, a drill is used to thread the
14
Fig. 14.6. Normal anatomy of the larynx is restored following open reduction and
internal fixation of fracture of left thyroid lamina.
165
Fig. 14.7. Displaced figure of the lamina with exposed cartilage (right) needs repair
through thyrotomy approach (shown by dotted lines on the left).
14
Fig. 14.8. Extensive endolaryngeal injuries (right) are repaired through thyrotomy
approach (shown by dotted lines on the left).
wire. To avoid further damage to the cartilaginous skeleton, no fracture site

sutures are tightened until all fractures have been reduced.
- Micro and mini-plates (1.0 mm preferred) can be used instead of wire for internal fixation (Fig. 14.5B).
- Endolaryngeal anatomy should be maintained as close to normal as possible
during open reduction and internal fixation (Fig. 14.6); failure to achieve this
will result in dysphonia.
166
Trauma Management
Fig. 14.9. A Portex endotracheal tube is fabricated for endolaryngeal stenting. Fourcentimeter long stent extends from the supraglottis to the first tracheal ring. The
upper end of the tube is closed with nylon sutures to prevent aspiration. The stent
is secured by two monofilament sutures tied to the skin buttons.
When significant endolaryngeal injuries are encountered, a midline thyrotomy is performed after retracting the strap muscles laterally (Fig. 14.7).
14
- All mucosal lacerations are meticulously repaired.

- A dislocated arytenoid, if present, is reduced (Fig. 14.8).
- Most mucosal lacerations can be repaired by either simple closure or by using
adjacent mucosal advancement flaps. In rare instances in which the soft tissue
defect is too large, a pedicled mucosal flap raised from the adjacent pyriform
sinus is used to repair the defect.
- It is of utmost importance to reconstitute the anterior commissure to maintain
the scaphoid shape of this region and to preserve a normal voice. This is achieved
by suturing the anterior ends of the true vocal cords to the outer perichondrium of
the thyroid cartilage. The thyrotomy is closed using permanent sutures or wire.
The indications for stenting in laryngeal injuries are controversial. The advantages of using a stent should be balanced against the risk of additional pressure
damage to the mucosa. Indications for placement of stents are:
- Injuries involving the anterior commissure
- Severe comminuted fractures of the thyroid cartilage, in which the architecture
of the larynx is not maintained by open reduction and internal fixation of the
fractures
167
The advantages of stenting are:

- Reduced chance of web formation at the anterior commissure
- Improved support of the laryngeal cartilaginous skeleton during healing
- Reduced movement of the larynx during swallowing
Stenting alone without open reduction and internal fixation and closure of
lacerations are unsatisfactory.
A wide variety of stents are available (Figs. 14.9 and 14.10). All should be
roughly in the shape of the laryngeal lumen and made of soft material to
prevent further mucosal damage.
The stent should extend from the false vocal cord to the first tracheal ring for
proper stability and to prevent the formation of adhesions in the laryngeal
lumen. The position of the stent can be maintained by two through and through
monofilament sutures tied to skin buttons (Fig. 14.9).
An Eliachar stent can be introduced into the laryngeal lumen through the
tracheostomy by a blunt instrument (Fig. 14.10). The phalanges of the stent
are sutured to the skin. Alternatively, it can be introduced by direct laryngoscopy (Fig. 14.11).
Early removal of the stent is recommended to minimize mucosal damage.
Usually, 10-14 days are adequate, even in severe injuries.
A variety of laryngeal injuries can be encountered during repair.
- Small defects in the cricoid and tracheal cartilages can be repaired using pedicled
flaps of strap muscle.
- Loss of the anterior portion of the thyroid cartilage can be repaired by suturing
mucosa over a stent.
- Laryngotracheal separation can be repaired by suturing the trachea to the cricoid cartilage, taking care not to injure the recurrent laryngeal nerves near their
entrance into the larynx at the cricoarytenoid joints (Fig. 14.12).
14
Fig. 14.10. The Eliacher stent (left) can be introduced through the tracheostome
and positioned in the endolarynx (right).
168
Trauma Management
Fig. 14.11. The Eliacher stent can be introduced transorally by direct laryngoscopy.
- Repair of a severed recurrent laryngeal nerve is not gratifying.

- In massive trauma where laryngeal reconstruction is not possible, partial or total laryngectomy may be necessary. Fortunately, this is extremely rare.
Postoperative Care
14
The patient should receive antibiotics for 5-7 days.

Proton pump inhibitors or H2-blockers are routinely given to prevent reflux.
Nasogastric feeding tubes are avoided when possible.
The head of the bed is kept elevated.
Stents are removed as soon as possible.
Decannulation is done as soon as the patient tolerates occlusion of the tracheotomy tube.
The patients are followed for at least one year to assess the return of true vocal
cord movement, and development of stenosis.
Complications
Speech, swallowing and respiration are affected to some degree after repair
depending on the severity of the trauma.
Granulation tissue formation occurs especially after placement of stents.
Meticulous closure of lacerations, postoperative antibiotics and H2blockers
and early removal of stents prevent this complication. Profuse granulation
tissue may require endoscopic laser debulking.
169
Fig. 14.12. Laryngotracheal separation occurs from clothesline injuries, left. Anatomy
of a normal cricoid cartilage is shown on right; ant.=anterior.
Laser cordotomy or arytenoidectomy is done for bilateral paralysis or fixation

of vocal cords.
Glottic/subglottic stenosis is managed by standard techniques of laryngotracheal reconstruction.
Tracheal resection and end-to-end anastomosis is performed for stenosis of a
short tracheal segment (4-6 cm).
Outcome
Functional outcome depends mostly on the extent of trauma and quality of
initial repair.
Excellent functional recovery can be expected in patients who do not need
surgical repair.
Superb recovery is also noted in patients that require repair of the cartilages
and no endolaryngeal surgery.
Prognosis is poorest among patients who require stent placement.
Intubation Injuries
The vast majority of endolaryngeal injuries are due to endotracheal intubation.
Injuries are sustained as a result of either faulty techniques or prolonged
intubation.
14
170
Trauma Management
Prevention of intubation trauma is best accomplished by educating personnel

who perform intubation as to the correct techniques of intubation, including
choosing the correct size of the endotracheal tube.
Common injuries encountered following intubation are oropharyngeal,
hypopharyngeal or laryngeal mucosal lacerations, and dislocation of the
arytenoid cartilage.
Superficial mucosal lacerations do not need any surgical intervention. However, deep lacerations are sutured. Through-and-through lacerations at the
level of the pyriform sinus require transcervical repair and drainage, and feeding through a nasogastric tube for 7 days along with antibiotic therapy.
Endoscopic reduction of cricoarytenoid joint dislocation should be performed
urgently.
References
1.
2.
3.
4.
5.
14
Leopold DA. Laryngeal trauma. Arch Otolaryngol Head Neck Surg 1983;
109:106-108.
Olson NR, Miles WK. Treatment of acute blunt laryngeal injuries. Ann Otol Rhinol
Laryngol 1971; 80:705-709.
Schaefer SD. Laryngeal and esophageal trauma. In: Cummings et al. OtolaryngologyHead and Neck Surgery, Third Ed. St. Louis, MO: Mosby Year Book 1999:
2001-2012.
Stanley RB, Hanson DG. Manual strangulation injuries of the larynx. Arch
Otolaryngol Head Neck Surg 1983; 109:344-346.
Whited RE. A prospective study of laryngotracheal sequelae in long term intubation. Laryngoscope 1984; 94:367-377.
CHAPTER 1
CHAPTER 15
Traumatic Brachial Plexus Injuries

Milan Stevanovic and Frances Sharpe
Brachial Plexus Injuries
Brachial Plexus
Injuries to the brachial plexus can result in devastating impairment of upper
extremity motor and sensory function. Recovery from these injuries is seldom complete and depends on the level, extent, and mechanism of injury.
The first repair of the brachial plexus reported in English literature was performed by William Thoburn in 1896 and published in 1900.
Prior to the advent of microsurgical reconstruction, the treatment of brachial
plexus injuries focused on late reconstruction. Reconstructive surgeries included
joint fusions, tendon transfers, and amputations for painful flail limbs.
By the late 1960s, direct microsurgical repair of nerves and the introduction
of nerve grafting significantly changed the early treatment of these injuries.
Epidemiology
Minor stretch injuries to the brachial plexus (burners or stingers) can occur frequently in contact sports, most commonly in American-style football.
These generally have full spontaneous recovery over a period of minutes.
Persistent or recurrent symptoms should be further investigated.
Most often, injuries occur as a closed traction injury. Penetrating injuries,
either laceration or gun shot wounds account for a smaller percentage of injuries.
Over 70% of injuries occur in high-speed accidents. Motorcycle accidents
account for a higher percentage of injuries than motor vehicle accidents. About
2% of motorcycle accidents result in brachial plexus injury. Snowmobile
accidents are a recently increasing cause of brachial plexus injury.
Urban centers have a higher percentage of penetrating injuries to the brachial
plexus from knife and gun shot wounds.
Classification of Nerve Injury

Classification by Degree
Two classification systems of nerve injury are commonly used:

Milan Stevanovic, University of Southern California, Keck School of Medicine,
Department of Orthopaedics, Hand and Microsurgery, Los Angeles, California, U.S.A.
Frances Sharpe, Department of Orthopaedics, Kaiser Permanente, Fontana, California, U.S.A.
172
Trauma Management
Seddon Classification
- neuropraxia: temporary disruption of nerve fiber conduction with nerve
fibers and axonal sheath remaining intact. Full spontaneous recovery occurs
over several weeks.
- axonetmesis: disruption of nerve fibers. The axonal sheath remains intact. Spontaneous recovery occurs, but may be incomplete due to scarring within the
sheath.
- neurotmesis: disruption of nerve fibers and nerve sheath. This usually but not
always represents nerve transection. No spontaneous recovery is anticipated.
Sunderland Classification (MacKinnon Modification)

Describes degree of nerve injury based on neural anatomy
Six types described based on involved structures. I-V: myelin, axon, endoneurium, perineurium, and epineurium. Type VI represents a mixed injury.
Provides a more detailed anatomic understanding of nerve injury.
Classification by Location
Preganglionic lesions are the most devastating injuries. These usually occur as
an avulsion from the spinal cord. To date, there is no possibility for primary
repair.
Postganglionic lesions are described by their location relative to the clavicle
(Fig. 15.1).
- Supraclavicular lesions involve the roots and trunks.
- Retroclavicular lesions involve the divisions.
- Infraclavicular lesions involve the cords and branches.
Closed Injuries to the Brachial Plexus

Most closed injuries to the brachial plexus result from traction to the plexus.
They can also result from direct compression or iatrogenic causes.
The degree of injury and the location of the plexus injury depend upon the
position of the arm at the time of injury, and the direction of the applied
force.
- upper plexus injuries occur when the arm is positioned at the side and a downward force is applied to the lateral shoulder girdle.
- middle plexus injuries occur when the arm is abducted and sustains a posteriorly directed force.
- lower plexus injuries occur when the arm is at extremes of elevation.
15
Traction injuries usually are a neurologically mixed injury and involve multiple levels of the plexus.
- Isolated single nerve is rarely seen from traction injuries. When they do occur, it
is usually at specific sites, where the nerve is anchored to surrounding structures:
suprascapular nerve at the supraspinatus notch
axillary nerve at the quandrangular space
musculocutaneous nerve at the coracobrachialis muscle.
Open Injuries to the Brachial Plexus

Open injuries to the brachial plexus are more frequently seen in urban centers.
They often result from penetration of sharp objects (e.g., knife, glass, chain
saw) or from gun shot injuries.
173
Fig. 15.1. Figure drawing of the brachial plexus showing the anatomic relationship
of the trunks, divisions and cords to surrounding anatomy. The trunks are superior
to the clavicle, the divisions are directly behind the clavicle, and cords and branches
below the clavicle.
Associated vascular and pulmonary injury are commonly seen.

The upper and middle plexus are most vulnerable to stab wounds.
Clinical PresentationPhysical Examination

Once associated injuries are identified and stabilized, evaluation of the brachial
plexus involves a detailed neurologic examination, which must be well documented.
The neurologic examination should be repeated. Initially this is to evaluate for deterioration which may suggest an unrecognized vascular injury causing compression
on the plexus. Later examinations are to confirm the initial examination and to
evaluate for recovery or deterioration.
Evaluation of the brachial plexus begins with the cervical spine. After radiographic clearance, evaluate for local tenderness and active range of motion.
Palpate the clavicle and shoulder girdle for tenderness and/or crepitance suggesting fractures.
Examine the entire extremity for any evidence of laceration or fracture.
Check for clinical findings associated with preganglionic injury (nerve root
avulsion).
- tilting of the cervical spine away from the site of injury suggests complete intradural injury
- characteristic preganglionic pain: may begin in first 24 hours (50%), constant
crushing, burning, electrical shocks, C8/T1 more painful than C5/C6
- Upper trunk findings: anesthesia above the clavicle, paralysis of the
hemidiaphragm, serratus anterior, and/or trapezius
- Lower trunk findings: Horners syndrome: ptosis, meiosis, and anhydrosis.
15
174
Trauma Management
Perform and record a detailed motor examination to include motor grade.

Each muscle need not be tested, but representative muscles from each terminal branch can usually be assessed. The serratus anterior and latissimus dorsi
muscles can usually be examined and help in determining the level of the
injury.
Ipsilateral injuries to the extremity may prevent accurate assessment and grading of function.
- Motor function is graded from 0-5.
M0
No contraction
M1
Visible contraction only
M2
Full active range of motion with gravity eliminated
M3
Full active range of motion against gravity
M4
Strength against moderate resistance
M5
Normal strength
- Sensory examination is complicated by the overlap of segmental and peripheral
innervation patterns. However, autonomous zones have been described for each
spinal root:
C5
distal lateral arm (distal deltoid)
C6
volar thumb tip
C7
volar tip of long finger
C8
volar tip of small finger
T1
medial distal arm (just above medial epicondyle)
See Table 15.1 and Figures 15.1 and 15.2 for help in localizing the level of
injury and involved.

A thorough clinical examination may be limited by the need for emergent
transfer of the patient to the operating room to treat life-threatening injuries
(vascular, pulmonary, or cardiac).
Other factors which may confound the clinical examination include:
15
- variability in brachial plexus anatomy

Pre-fixed and post-fixed brachial plexus are the most common variant.
Pre-fixed has significant contribution from C4 root.
Post-fixed has significant contribution from T2 root.
- associated nerve injuries with neurologic deficits
head trauma
cervical spine trauma
distal nerve injuries
What you should do:

Perform a thorough neurologic and vascular examination. Record all motor
and sensory deficits.
Look for other sites of fracture or lacerations which could cause nerve injury
Maintain a high level of suspicion.
Protect the cervical spine until clinically and radiographically clear.
Investigations
Radiographic Examination
Cervical Spine
- Evaluate for unstable injuries to the cervical spine
- Look for transverse process fractures. Fracture of the transverse process of
175
Fig. 15.2. This describes an easy technique to quickly draw the brachial plexus.
Following steps 1 and 2, three lines representing contributions from the first three
roots are combined to form the long thoracic nerve, three lines representing the
posterior divisions are drawn, and three branches are added to each cord. Courtesy to Dr. George S. Edwards, Jr., M.D., Raleigh North Carolina, who permitted
the printing of his technique.
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Trauma Management
Table 15.1. Nerves arising from the brachial plexus

Origin
Nerve
Muscles
Root(s)
Long thoracic
Dorsal scapular
Serratus anterior
Rhomboids,
levator scapulae
Diaphragm
Phrenic nerve
Trunk(s)
Division(s)
Lateral Cord
Posterior
Cord
Medial Cord
Nerve to
Subclavius
Suprascapular
None
Lateral Perctoral
Upper
subscapular n
Thoracodorsal n.
Lower
subscapular n.
Medial pectoral n.
(Posterior
Cord)
Median nerve
(lateral cord
contribution)
Axillary Nerve
Radial Nerve
15
Cervical
Segments*
C5, C6, C7
C5
C5 contribution
(C3,4,5)
C5, C6
C5, C6
Subclavius
Supraspinatus,
infraspinatus
Pectoralis major
(Clavicular head)
Subscapularis
C5, C6, C7
Latissimus dorsi
Subscapularis and
teres major
Pectoralis major
(sternal head) and
pectoralis minor
C6, C7, C8
C5, C6
Medial Brachial
Cutaneous
Medial
Antebrachial
Cutaneous
Terminal
Branches
(Lateral Cord) Musculocutaneous n
Sensory
C5, C6
C8 and T1
C6, C7, C8
medial
arm
medial
forearm
Coracobrachialis,
brachialis, biceps
lateral
antebrachial
cutaneous
See below for

combined median
nerve
Deltoid and teres
lateral arm
minor
Triceps, brachialis superficial
(lateral 1/3),
radial
anconeus, brachio- nerve to
radialis, extensor
dorsoradial
carpi radialis
hand
longus and brevis.
Through posterior
interosseous nerve:
Supinator, extensor
digitorum, extensor
carpi ulnaris, EDMQ,
APL, EPB, EPL, and EIP
C8 and T1
C8 and T1
C5, C6, C7
C5, C6
C5, C6
C7, C8, T1
177

Origin
Nerve
Muscles
Sensory
Cervical
Segments*
(Medial
Cord)
Median nerve
(medial cord
contribution)
Pronator teres,
flexor carpi radialis,
palmaris longus,
FDS, FDP (index and
long), Thenars (3),
lumbricals 1 and 2).
Through anterior
interosseous nerve:
FPL and pronator
quadratus
Flexor carpi ulnaris,
FDP (small and ring),
palmaris brevis,
hypothenar (3),
lumbricals to 4th
and 5th, interossei (7),
adductor pollicis, and
deep head of FPB
Volar radial
hand
C5, C6,
C7, C8, T1
volar and
dorsal ulnar
hand
C8 and T1
Ulnar Nerve
*Bold indicates dominant segmental innervation when present.

EDMQ: extensor minimi digiti quinti; APL: abductor pollicis longus; EPB: extensor
pollicis brevis; EPL: extensor pollis longus; EIP: extensor indicis proprius; FDS:
flexor digitorum superficialis; FDP: flexor digitorum profundus; FPB: flexor pollicis
brevis
C7 or a 1st rib fracture may indicate intradural injury of the lower two roots.
Chest
- Evaluate for pneumothorax, mediastinal widening, rib or clavicle fractures
- First rib fractures, especially with posterior displacement are associated with
vascular injury.
- An inspiratory chest film may demonstrate paralysis of the hemidiaphragm
(phrenic nerve injury). This helps localize the level of injury and may affect
reconstructive options
Shoulder and Clavicle

- Evaluate for fractures or an unrecognized shoulder dislocation
Angiography
- Normal distal pulses do not preclude the presence of a proximal injury.
- Strong indications for angiography include open injuries, absent or abnormal
pulses, or if there is any doubt regarding the vascular status of the extremity.
- Progressive neurologic deficits following the initial injury may indicate expanding hematoma, pseudoaneurysm, or arteriovenous fistula.
Myelography
- Not as useful in the acute phase due to local swelling, reactive changes, and
intradural blood clots.
- Should be done as a CT myelogram to improve diagnostic accuracy.
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Trauma Management
- Pseudomeningocele suggests nerve root avulsion.
Magnetic Resonance Imaging

- Most useful in closed injuries without associated trauma which mandates immediate exploration.
- Will become increasingly useful with gadolinium-enhanced studies, improved
software, and 3-D imaging capabilities.
Electrodiagnostic Studies
- Useful in monitoring closed injuries or in examining for recovery after repair of
open injuries
- Not helpful in the early stages of treatment.
- Initial studies should be performed at a minimum of four weeks after the injury.
- Useful in determining the level of injury, involved muscle groups, which cannot
be easily examined clinically, and in monitoring for recovery of closed injuries
prior to recommending surgical exploration.
- Sensory nerve conduction velocity preservation in a clinically nonfunctioning
nerve suggests root avulsion.
Intradermal Histamine Test

- Used to distinguish preganglionic from postganglionic lesions
- One percent histamine is injected into anesthetic skin
Production of a flare reaction indicates root avulsion.
No reaction suggests postganglionic lesion.
- Currently this test is not often used.

The emergency room treatment of brachial plexus injuries is dependent upon
the associated injuries.
Stabilize the patient.
Treat the associated injuries.
Protect the patient from iatrogenic injury.
15
- When patient is stable:

Perform a thorough clinical examination
Obtain appropriate studies
In the stable patient, this should at least include radiographs of:
- cervical spine
- chest
- shoulder and clavicle
Arteriography should be considered in any patient with an open or closed

brachial plexus injury.
If immediate surgical intervention is not required, the patient may be transferred to the floor, where definitive work-up can be initiated.
Repeated neurologic examinations should be performed routinely. This is done
on a daily basis throughout hospitalization. Outpatient examination should
be repeated weekly for the first month.
- When the patient is not stable:
Treatment should be directed to stablizing the patient and expediting surgical intervention.
179
Crossmatch blood
Notify the appropriate consulting services.
- Vascular surgery
- Microsurgical team
When the patient requires emergent surgery for associated vascular injury produced by sharp laceration, simultaneous exploration and repair by the microsurgical team is the preferred management of the brachial plexus injury.
Emergent surgery for vascular injuries by other mechanisms may produce brachial plexus injuries not amenable to primary nerve repair. However, the
microsurgical team should be notified to evaluate the extent of injury, tag
disrupted nerve endings, and develop a plan for surgical reconstruction.
Operating Room Managment

Emergent Setting
Brachial plexus injuries alone do not require emergent surgery
Due to the common association with vascular injury to the subclavian or
axillary artery, some brachial plexus injuries are treated emergently.
- Exposure for the vascular injury is parallel to the inferior margin of the clavicle.
- The pectoralis major should be identified at is clavicular origin, and meticulously dissected from the clavicle. This preserves the entire muscle and its
innervation (Figs. 15.3, 15.4).
- Whenever possible, avoid transection of the pectoralis muscle. Although this
provides a quicker exposure of the vascular injury, it creates a significant functional deficit in an already compromised extremity.
The microsurgical team should be present at the time of exposure and if the
patient is stable, brachial plexus exploration and possible repair can be
performed at this time.
Nonemergent Setting
Reconstructive Options
- primary nerve repair;
- nerve grafting; (sural or saphenous nerves)
- nerve transfer (intercostal nerves, accessory nerve, C4, phrenic nerve, or ulnar
nerve)
- neurotization; and
- use of contralateral C7 (reserved for cases of devastating injury with multiple
level root avulsions.)
- neurolysis
Operating Room Preparations

- Availability of appropriate equipment:
scalp evoked potentials;
nerve stimulator;
microscope;
micorsurgical instruments.
- Planning with anesthesia
length of surgery
blood availability
no use of paralytic agents
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Trauma Management
Fig. 15.3. The surgical incision for exploration of the brachial plexus is shown. The
incision parallels the inferior margin of the clavicle. For supraclavicular lesions,
the incision is extended superiorly along the posterior margin of the sternocleidomastoid muscle. For infraclavicular lesions, the incision is extended inferiorly along
the deltopectoral groove.
Timing of Surgery
Early Surgery (Immediate to two weeks)
- Surgical treatment directed at nerve repair, using nerve grafts as necessary
- Sharp penetrating injury
- Injuries associated with vascular trauma
- Sharp iatrogenic injuries
- Known single level nerve injury (from sharp penetrating trauma).
One month
15
- Surgical treatment directed at nerve exploration and repair as possible, nerve

grafting and nerve transfer as indicated
Blunt penetrating trauma (gunshot wounds)
Progressive neurologic or vascular lesions
Preganglionic Lesions
- Treatment in these cases is directed at nerve transfer as indicated, with possible use of nerve grafts.
Two to Three Months
- Surgical treatment directed at nerve exploration, repair, grafting, neurolysis,
neurotization, and nerve transfer as indicated.
- Closed injuries of C5, C6, and/or C7 without evidence of electrical recovery
and with stationary Tinels sign.
Six Months
181
Fig. 15.4. Supraclavicular exposure of the brachial plexus requires division of the
platysma. Below this, the deep cervical fascia covers the jugular vein and scalene
muscles. The fascia is opened and the jugular vein is retracted anteriorly. Dividing
the omohyoid allows the best exposure of the plexus; however, in most cases, it
can be retracted medially and inferiorly. For infraclavicular exposure, the
deltopectoral groove is opened. The pectoralis majors is elevated off of its clavicular origin and reflected inferiorly. Occasionally, the clavicle must be divided for
exposure of the retroclavicular plexus. This should be plated at the completion of
the surgery.
- Generally used as the upper limit for nerve reconstruction. Same treatments
as listed above.
- Prognosis for recovery for transected or avulsed nerves significantly worse if
repair is later than 6 months.
More than One Year
- Surgical treatment generally limited to salvage procedures, including shoulder
fusion, tendon transfers, pedicled and free muscle transfers.
- In cases of plexus compression related to extraneural scarring, neurolysis
may be beneficial even more than two years after injury, as there is usually
sufficient nerve conduction to preserve motor endplates.
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Trauma Management
Postoperative Care
Management for brachial plexus injuries following nerve repair or grafting is
immobilization in a shoulder immobilizer for two to three weeks, depending
on the extent of repair.
Occupational therapy for splinting, muscle stimulation, and education in maintaining passive range of motion should begin in the first week after injury.
Care should be exercised for the first four weeks to maintain shoulder immobilization and prevent rupture at the repair site.
Social services intervention and vocational rehabilitation should be instituted
early. Prognosis for return to work is minimal if more than one year has elapsed
since the injury
Complex Injuries and Complications

Brachial plexus injuries are frequently associated with serious and potentially
life-threatening injuries, which must be recognized in the emergency room.
These incude:
- head injury
- cervical fracture
- vascular injury
- pulmonary injury
- fractures of the chesto and/or shoulder girdle.
Associated life-threatening injuries are seen in up to 15% of patients with
brachial plexus injuries.
Rupture of the subclavian or axilliary artery occurs in 10-20% of injuries,
more commonly in infraclavicular injuries.
Scapulothoracic Dissociation
It represents a closed forequarter amputation and indicates a very high energy
injury.
It is diagnosed radiographically by a laterally displaced scapula, associated with
acromioclavicular joint disruption, sternoclavicular joint disruption, or a displaced clavicle fracture.
It has a high association with severe life-threatening vascular injury.
Associated brachial plexus injuries are common, and usually severe with multiple level root avulsions.
It is often a devastating injury with high morbidity and mortality rates.
15
Pain
Other than disability from motor and sensory loss, one of the most disabling
complications of brachial plexus injuries is pain.
Preganglionic injuries have a characteristic pain component, frequently described as constant burning or crushing sensation, experienced day and night.
- Surgical treatments, including amputation, neurolysis, wrapping of the plexus
with an omental free flap have not been successful in relieving this pain.
- Dorsal root entry zone (DREZ) coagulation, which requires cervical laminectomy and destruction of spinal cord sensory tracts helps with controlling pain
in up to two-thirds of patients. However, it may be associated with increased
neurologic deficit.
183
Postganglionic injuries can be associated with chronic pain.

- It is generally less disabling than pain associated with preganglionic injuries and
can usually be controlled with oral pain medications.
- There are some reports in the literature of pain control using neurolysis and free
omental wrapping of the plexus.
- A permanent in-dwelling brachial plexus catheter for delivery of local anesthetic can be useful in the treatment of severe and refractory pain in postganglionic injuries.
Outcomes
Outcome following brachial plexus injuries depends on the level, and mechanism, and extent of injury.
Outcome goals are based on restoration of a functional limb. Full function is
seldom achieved.
Preganglionic Injuries
- Without surgical intervention, preganglionic injuries result in a flail arm.
- Functional outcome can be improved with nerve transfer, neurotization, and
salvage procedures described above.
Postganglionic Injuries
- Postganglionic injuries have a better prognosis than preganglionic injuries.
- Infraclavicular lesions respond better to repair than supra- or retroclavicular
injuries.
- Postganglionic injuries involving C5, C6, and C7 have better outcome than
those involving C8 and T1.
Factors Associated with Improved Outcome

-
Time to surgery less than four months;

Age of patient (younger patients do better);
Length of nerve graft required less than 7 cm;
Number of strands used for interfascicular repair or cable grafting greater than
four; and
- Presence of neuroma on the proximal stump.
Factors Adversely Affecting Outcome

-
Preganglionic injuries;
Previous surgery for vascular injury
Severe regional trauma
C8 and T1 root avulsions
Quality of Life Assessment

- Despite the devastating affect on upper extremity function, one study evaluating quality of life following brachial plexus injury found the following:
Only 31% of patients felt that their injury had a significant effect on their
quality of life.
Quality of life factor most affected by the injury was the patients financial
status.
54% of patients who were employed prior to their injury returned to work
within one year of the injury.
Constant pain (graded as 3/10) was experienced by 75% of patients, with
intermittant severe pain up to a level of 7/10.
8% of those patients who had constant pain consistently used pain
medications to control their symptoms.
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Trauma Management
Common Mistakes and Pitfalls in Brachial Plexus Injuries

The frequency of associated injuries that can affect upper extremity function
(head injury, cervical spine injury, and fractures of the ipsilateral extremity)
may confuse the diagnosis of brachial plexus injury.
Repeated neurologic examination and maintaining a high level of suspicion
are the key factors in making an early diagnosis of brachial plexus injury.
References
1.
2.
3.
4.
5.
6.
7.
8.
15
Bentoilila V, Nizard R, Bizot P et al. Complete traumatic brachial plexus palsy. J

Bone Joint Surg 1999; 81-A:20-28.
Krauker JD, Wood MB. Intercostal nerve transfer for brachial plexopathy. J Hand
Surg 1994; 19A:829-35.
Millesi H. Surgical management of brachial plexus injuries. J Hand Surg 1977;
2(5):367-379.
Narakas AO. The treatment of brachial plexus injuries. Int Orthop 1985; 9:29-36.
Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction
in 204 patients with devastating paralysis. Plast Reconstr Surg 1999;
104:1221-1240.
Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Reconstruction of finger and elbow
function after complete avulsion of the brachial plexus. J Hand Surg 1991;
16A: 796-803.
Richards RR, Waddell JP, Hudson AR. Shoulder arthrodesis for the treatment of
brachial plexus palsy. Clin Orthop Rel Res 1985; 128: 250-258.
Samardzic MM, Grujcic DM, Antunovic V, Joksimovic M. Reinnervation of avulsed
brachial plexus using the spinal accessory nerve. Surg Neurol 1990; 33: 7-11.
CHEST
CHAPTER 16
Blunt Thoracic Trauma

George C. Velmahos
The Thoracic Cage
Fractures of the ribs, clavicles, scapulae or sternum, although not life-threatening per se, are associated with significant complications.
Fractures of the thoracic cage should always remind the physician of the need
to evaluate underlying organs, vessels and nerves for potential injuries.
Ribs are usually fractured laterally along the mid-axillary line, but rib fractures can occur at any location.
Isolated rib fractures can be caused by relatively small forces. Multiple rib
fractures, or fractures of the sternum or scapula, indicate major impact and
should increase the level of suspicion for underlying injuries.
The thoracic cage in children is elastic. Significant underlying injuries may
occur in the absence of thoracic-cage fractures.
In contrast, the thoracic cage of elderly patients is rigid and inelastic. Extensive
thoracic-cage fractures may occur even with forces that are too weak to cause
internal injuries.
Rib Fractures
Rib fractures produce significant pain that may last for many days.
They may be diagnosed by palpation, plain chest radiography or special rib
views. Chest CT is not a sensitive means of detecting rib fractures.
Upper-rib fractures (1st and 2nd) are associated with thoracic aortic injuries.
Lower-rib fractures are associated with liver and spleen injuries.
All rib fractures are associated with lung contusions, pneumothorax and
hemothorax.
The patients tend to avoid painful respiratory movements. They splint their
diaphragms by taking short and shallow breaths. The lungs are not fully
expanded and become vulnerable to infection.
Pneumonia is the most common complication after rib fractures. The entire
therapeutic philosophy should target the prevention of lung infection rather
than the actual treatment of the rib fracture.
Therapy consists of adequate treatment of pain in order to allow the patient
easy breathing and proper lung expansion. Incentive spirometry and chest
physiotherapy are important therapeutic adjuncts.
Pain treatment consists of:
- Oral medication for ambulatory patients or patients with minimal-to-moderate
pain.
187
Fig. 16.1. Severe lung contusion of the left upper lobe. Compare with the normal
parenchyma of the lower lobe.
- Parenteral medication for patients who have severe pain that limits respirations:
Epidural analgesia is proven to offer the best pain relief. A catheter is inserted into the epidural space of the spine. Disadvantages are that it is invasive and cannot usually be done at the early stages after severe trauma if the
patient is coagulopathic and injuries of the thoracolumbar spine are not
ruled out.
Intercostal nerve block is also an effective form of analgesia. It requires experience, and the analgesic effect is not as reliable as that produced by epidural
analgesia.
Patient-controlled analgesia is a good method of pain relief. However, it is
not the method of choice because it is associated with intravenous
injection and therefore all the associated complications of systemic narcotic administration.
Continuous intravenous analgesia is reserved for severely injured patients
who are ventilated and sedated, and are not expected to recover soon.
Chest physiotherapy is important. The best physiotherapy is mobilization of

the patient out of bed. The patients should be encouraged to breath deeply,
cough and use incentive spirometry.
There is no role for prophylactic antibiotics in this condition.
Flail Chest
A flail chest is defined by fractures of two or more ribs at two or more sites on
each rib. It is an indicator that severe blunt forces have been applied to the chest.
Diagnosis is clinical upon observation of paradoxical movement of the thoracic
wall: the flail segment moves inwards during inspiration (due to the negative
intra-thoracic pressure generated) and outwards during expiration (due to the
positive intra-thoracic pressure). Plain films also show the multiple fractures.
16
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Trauma Management
Fig. 16.2. Flail chest on the rib views of a plain film. Observe the multiple and
severe rib fractures.
16
Fig. 16.3. Elderly patients may have extensive rib fractures without lung contusions, as evident on this CT of the chest.
At least two-thirds of patients with flail chest require intubation. Respiratory

failure is a result of two factors
- ineffective movement of the hemithorax due to the flail segment, and
- most importantly, associated lung contusion. Almost 100% of patients with
flail chest will have significant underlying lung injury.
189
Fig. 16.4. Children can have significant lung contusion in the absence of rib fractures, as shown in this plain chest film.
16
Fig. 16.5. The adult respiratory distress syndrome is a devastating complication
that may follow severe blunt thoracic trauma. It is characterized by bilateral diffuse
patchy infiltrates.
Close arterial saturation and blood-gas monitoring are essential in patients

with flail chest. Early intubation should always be considered. Although the
initial signs and symptoms may not appear significant, normal breathing
190
Trauma Management
becomes progressively impaired and lung contusions expand. Respiratory deterioration usually follows in the next few hours.
Patients with flail chest are at high risk for prolonged respiratory failure and
infectious lung complications.
Pain control is of paramount importance. Epidural analgesia is strongly recommended as soon as possible.
Old techniques of immobilizing the chest by circular bandages are not only
useless but also potentially harmful because they restrict normal breathing
even further.
Surgical immobilization of flailing ribs by plating or wiring has been advocated
by some authors for selected patients. The technique does not seem to offer
significant advantages over expectant therapy and is not widely practiced.
Clavicular Fractures
Fractures of the clavicle are usually benign injuries that require minimal or no
intervention. Surgical intervention is very rarely required to correct grossly
overriding parts of the clavicle.
The diagnosis is obvious on plain chest radiography, and often on clinical
examination.
The association with underlying vascular or neurological structures is weak at
best. Routine vascular imaging of the subclavian vessels is not recommended
for clavicular fractures alone.
Scapular Fractures
Scapular fractures are indicators of severe injury. It is unusual for isolated
scapular fractures to occur.
Scapulothoracic dissociation is defined by the avulsion of soft tissues, including
muscle, vessels and nerves, and the destruction of the shoulder joint. It is
often associated with scapular, distal clavicular and proximal humeral fractures.
It is caused by acute hyperextension of the upper extremity. Except for the
severe osseous injuries, blunt subclavian artery injuries may occur. Brachial
plexus injuries are very common, ranging from simple nerve stretching to
root avulsion. The final outcome is determined by the nerve injuries. Because
these injuries are usually severe, the prognosis for function of the involved
upper extremity is often grave. Amputation due to complete and irreversible
denervation is not uncommon.
Sternal Fractures
16
Fractures of the sternum indicate significant blunt forces have been imposed
on the chest. These fractures are often missed because clinical or radiographical
diagnosis is difficult. Such fractures are not apparent on plain chest radiograph.
Patients with anterior-chest-wall contusions and pain should be further evaluated with sternal views. Often the sternal fracture is visualized on chest CT.
Historically, sternal fractures are associated with blunt myocardial injury. This
association has never been proven. It is recommended that patients with sternal
fractures be evaluated for blunt myocardial injury.
Specific treatment for the sternal fracture is almost never necessary. The healing
rate is excellent.
191
Blunt Pulmonary Trauma

Lung contusions and lacerations, hemothorax and pneumothorax are frequent
events following blunt thoracic trauma.
The lung may be injured by either the blunt object, a fractured rib or the
acute elevation of alveolar pressures when the glottis is closed.
Lung lacerations from fractured ribs mimic lacerations caused by penetrating
trauma.
Intraparenchymal lung lacerations (usually caused by the acute build-up of
intrapulmonary pressures at the time of the accident) may appear as cysts that
contain air and/or blood. These cysts are called hemopneumatoceles. Expectant management is successful, and intervention to drain or repair a
hemopneumatocele is rarely necessary.
Pulmonary contusion is the form of lung injury most frequently encountered
after blunt trauma. It involves an area of the lung with acutely distorted alveolar architecture and subsequent dysfunction of gas exchange.
The shunt occurring in the contused areas is responsible for low partial-arterial-oxygen tension and decreasing arterial saturation.
The initial clinical picture may be misleading. Pulmonary contusion usually
progresses with time. Although the patient may compensate initially, ongoing
loss of alveolar tissue leads to acute respiratory failure. Additionally, the radiographic picture may not be highly abnormal during the first few posttraumatic hours. The extent of the pulmonary contusion usually is not visible on
plain radiography earlier than 12 hours after injury. Chest CT is more sensitive
in defining the real extent of the pulmonary injury.
Thoracotomy to repair blunt pulmonary injuries should be done after
indications similar to those recommended for penetrating trauma, i.e.,
significant intrathoracic bleeding (more than 1 L immediately or more than
200 ml per hour) causing hemodynamic disturbances.
Lung resection after blunt trauma is associated with poor outcome. Traumatic
lobectomies or pneumonectomies are followed by acute increases in pulmonary artery pressures and, often, right cardiac decompensation. The use of
staplers has facilitated the operative procedure. Stapled wedge resections, lobectomies or even pneumonectomies are done safely and rapidly.
Complications of Blunt Pulmonary Trauma

The extent of pulmonary injury and subsequent complications is proportional
to the amount of energy that is dissipated to the pulmonary parenchyma at
the time of injury. Complications include the adult respiratory distress syndrome (ARDS) and pulmonary infections.
ARDS following blunt pulmonary trauma is a major therapeutic problem.
Multiple modes of ventilation, including pressure-control, inverse-ratio, highfrequency percussion and airway-pressure-release ventilation have been used
to manage the extreme forms of ARDS.
Pulmonary infections, i.e., pneumonia and empyema, are not uncommon.
Failure to wean a patient from mechanical ventilation suggests these complications exist.
The long-term functional compromise due to fibrosis of injured alveoli after
blunt pulmonary trauma is not known but seems to be worse than comparable
injuries after penetrating trauma.
16
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Trauma Management
Fig. 16.6. Hemopneumatoceles are associated more frequently with blunt than
with penetrating pulmonary trauma. They usually resolve spontaneously. A giant
hemopneumatocele is presented on this CT. It resolved without surgical intervention.
Blunt Tracheobronchial Trauma

The trachea and major bronchi may rupture due to acute intraluminal pressure elevation after direct impact, or be lacerated after shear forces usually
applied to the level of the carina.
Extensive mediastinal emphysema is the dominant sign on plain chest radiography or chest CT. The emphysema usually extends to the soft tissues and
often involves the entire chest and neck or even more body areas. Severe air
leaks from the chest tube or loss of more than one-third of the delivered tidal
volume in mechanically ventilated patients are also strongly suggestive of tracheobronchial injuries.
Flexible bronchoscopy is the procedure of choice for definitive diagnosis.
Treatment may be expectant (minimal or well-sealed injuries) or surgical. The
approach is usually through a high right thoracotomy.
16
Blunt Esophageal Trauma

Rupture of the esophagus is extremely rare among survivors of blunt
thoracic trauma.
These patients are critically injured and clinically unevaluable, and usually have
severe injuries to adjacent structures such as the thoracic aorta, bronchi or spine.
The diagnosis should be suspected in the presence of air in the mediastinum or
hematemesis in the absence of gastroduodenal injury.
Because the incidence is low, the diagnosis is often delayed and the outcome
is poor.
193
Fig. 16.7. Empyema is a complication related to severe thoracic trauma. It should

be suspected in patients with persistent infection or inability to wean from the
ventilator.
Traumatic Asphyxia
This term is used to indicate respiratory insufficiency due to direct impact on
the chest associated with acute elevation of venous pressures.
Typically, the syndrome occurs after a heavy object lands suddenly on the
upper chest. The acute elevation of venous pressures causes extravasation of
red blood cells from capillaries above the level of the injury. These microhemorrhages are obvious on the skin and conjunctivae, which show a
characteristic red-blue color.
Such micro-hemorrhages may also occur in the brain and cause changes to the
level of consciousness.
Respiratory function may be compromised due to direct damage to the lungs
or the accumulation of edema in the interstitial space around the airway.
Ventilatory support may be required in cases with severe chest compression.
In its usual form, traumatic asphyxia has a benign course and resolves without
major interventions.
Pitfalls in the Evaluation and Management of the Above

Injuries
Reliance on the initial clinical and radiographic picture to estimate the severity of pulmonary injury is misleading. Both are not reliable at the acute stage.
Associated injuries should serve as indicators of significant trauma. Cautious
monitoring is required because clinical deterioration may occur.
Failure to provide patients with rib fractures with adequate pain control causes
the development of respiratory infections because the patients cannot move
sufficient air without pain. The mainstay of management of such patients
should be adequate pain control.
16
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Trauma Management
Immobilization of patients in order to let rib fractures heal is conceptually

wrong. The best method for fast recovery and prevention of complications is
mobilization as soon as possible after the injury.
The mechanism that produces ecchymotic areas at the skin and conjunctivae
in patients with traumatic asphyxia also occurs in the brain. Careful neurologic monitoring is recommended.
References
1.
2.
3.
4.
5.
6.
16
Hoff SJ, Shotts SD, Eddy VA et al. Outcome of isolated pulmonary contusion in
blunt trauma patients. Am Surg 1994; 60:138-142.
Johnson JA, Cogbill TH, Winga ER. Determinants of outcome after pulmonary
contusion. J Trauma 1986; 26:695-697.
Lewis RF. Thoracic trauma. Surg Clin North Am 1992; 69:97-102.
Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg 1982; 196:481-487.
Fulton RL, Peter ET. The progressive nature of pulmonary contusion. Surgery
1970; 67:499-506.
Clark GC, Schechter WP, Trunkey DD. Variables affecting outcome in blunt chest
trauma: Flail chest vs. pulmonary contusion. J Trauma 1988; 28:298-304.
CHAPTER 1
CHAPTER 17
Penetrating Chest Injuries:

Evaluation and Management
Arthur Fleming
Penetrating chest injuries can be separated by mechanism of injury [stab wound
(SW) or gunshot wound (GSW)]; or by the patients response to injury (extremis,
unstable or stable). The patients response is used as the major focal point.
The first written thoracic operative record in North America appeared in the
diary of Cabeza de Vaca in 1635.
Operative intervention for penetrating thoracic trauma in the modern era was
ushered in by the availability of endotracheal anesthesia and antibiotics, the
development of radiology, and greatly facilitated by refinement in the double
lumen endotracheal tube.
Tube thoracostomy became the mainstay in treatment of traumatic hemothorax during the Vietnam conflict and remains so today.
Incidence
Approximately 90% of penetrating chest injuries miss the heart from a series
of 2076 penetrating chest injuries (See Chapter 1, Cardiac Injuries).
Of 250 consecutive GSWs to the chest in our institution, 20% had associated
injuries to the diaphragm or one or more abdominal viscera1.
Penetrating chest injury patients (in the absence of cardiac injury), may present
along an entire spectrum:
Extremis unstable (profound shock) completely stable
Over 70-85% of patients will bleed less than 1500 cc initially and less than
250 cc per hour thereafter and can be managed by chest tube drainage and/or
observation.
The 15-30% of patients who bleed greater then 1500 cc initially and more
than 250cc per hour require operative intervention.

Absent or decreased breath sounds, hyperresonance on chest percussion, and
a penetrating injury to the chest is diagnostic of a tension pneumothorax. It
is sometimes difficult to detect these signs in a noisy resuscitation bay. However, when these signs are coupled with respiratory distress, chest pains, and
Arthur Fleming, Department of Surgery, Martin Luther King Hospital,
196
Trauma Management
air hunger in association with hypotension and tachycardia, the diagnosis

should be complete.
Multiple GSWs or SWs and external blood loss prior to arrival make it difficult to determine which site requires the most urgent care or attention.
Investigations
There should be limited investigations for those patients in extremis or profound shock.
Rhythm strips and pulse oximetry are both desirable in most patients.
Chest x-rays with external radiopaque markers are the mainstays of evaluation
in patients with penetrating trauma.
Transesophageal echocardiograms, ultrasound studies, CT scans and angiography are required in complex cases that are stable.
A tension hemopneumothorax is the only chest injury requiring intervention in
the field. A needle thoracoscopy may be both diagnostic and therapeutic in a
rapidly deteriorating patient.
Administer oxygen by mask or intubate the moribund patient (Note! An
untreated pneumothorax may be made worse with intubation).
Intravenous lines may be started en route to a trauma center.

An x-ray should be obtained in patients prior to chest tube insertion except
when there is a tension pneumothorax or the patient is rapidly deteriorating
(near death).
An x-ray plate placed on the gurney prior to transferring the patient from the
paramedics stretcher facilitates this approach.
The degree of hemo- or pneumothorax can be estimated in a supine film.
An upright x-ray film is obtained in the stable patient.
Radiopaque markers are placed over entry and exit sites so that the trajectory
of missiles and the potential associated injuries can be anticipated.
Fracture of ribs along the lower cortex may identify the potential source of
significant arterial bleeding (in the absence of a trajectory that might suggest
great vessel injuries).
Closed tube thoracoscopy and or observation can manage the majority of
patients with penetrating injuries (70-85%).
- Appropriate local anesthetic is required.
- Patients, who have a massive hemothorax on initial chest x-ray, might benefit
from the insertion of the chest tube in the operating room depending on the
proximity to the emergency room, and the suspected injury that might require
a thoracotomy. Some patients arrest when the tamponading effect is released by
placing a chest tube and further rapid bleeding occurs).
17
Emergency Room Thoracotomy

Reserved for penetrating trauma victims with witnessed signs of life (at some
point).
ECG on arrival shows a narrow-complex rhythm.
Patients with cardiac arrest or imminent cardiac arrest should undergo emergency room thoracotomy (See Chapter 1, Cardiac Injuries).
Penetrating Chest Injuries
197
Direct operating room admissions should be considered when such facilities

and policies are available.
Cross-clamping of the pulmonary hilum is used to control massive hemorrhaging from the lung and to prevent further air emboli.
Aortic and great vessels injuries should be controlled with partial occluding
vascular clamps or cross-clamping and the patient take to the operating room
for definitive surgery.
In the absence of a hemo- or pneumothorax, which is confirmed by both
inspiratory and expiratory films, patients may be observed in a holding area
and discharged if repeat films at six hours are negative.
Management in the Operating Room

The indications for operation in penetrating chest injuries are listed in
Table 17.1.
- Thoracotomy Incision
An anterolateral thoracotomy is used in the unstable patient with the patient supine. Penetrating injury side is opened first.
Transternal extension to the opposite side is an option.
A posterolateral thoracotomy incision is used for esophageal and aortic injuries (right side for the esophagus and the left side for the aorta. Note! The
esophagus can be visualized from the left side below the aortic arch).
- Procedures
Pulmonary tractotomy is used for lung injuries, especially in unstable patients
(using staples and selective vascular ligation).
Pulmonary hilar clamping allows assessment of lung injury and temporary
prevention of further air emboli.
Pneumonectomy may be required for hilar injuries and especially in the
unstable patient.
Intercostal vessels are ligated proximall and distal to injuries.
Tracheal injuries are repaired directly after guiding the endotracheal tube
past the site of injury.
Esophageal injuries require appropriate debridement, primary repair,
coverage with viable tissue (such as an interiostal muscle flap) and adequate
drainage.
Two chest tubes are used when there is both bleeding and a significant air leak.
- Thoracoscopy
Is used to examine the mediastinum, to remove clotted blood, to evaluate
the diaphragm in stable patients, and to control selective bleeding from
intercostal vessels or lung parenchyma in selected cases.
Complex Injuries
Thoracoabdominal Injury: Defined as an injury that occurs between the 6th
and 12th ribs, or appears to pass upward from the subcostal region.
- The intrathoracic portion of the injury is treated as per management indicated
for the Emergency Department or Operating Room. The abdominal region
should be evaluated and treated as for isolated abdominal injuries.
Air Embolism
- May occur with through and through lung injuries and collection of blood and
air within the tract; and
17
198
Trauma Management
Table 17.1. Indications for thoracotomy in penetrating injuries to the chest

(excluding hearts)
Aorta, innominate, subclavian, or carotid artery injuries
Hilar injury (central pulmonary injury)
Endoscopic or radiographic (contrast) study demonstrating injuries to:
Bronchus
Trachea
Esophagus
Massive air leak
Vascular injury at the thoracic outlet
Possibly for mediastinal traverse (diagnostic studies may be required)
Greater than 250 ml blood loss per hour for two or more hours
Greater than 20 ml/kg initially
Massively clotted hemothorax
- May also occur when oversewing entrance and exit wounds to lungs without
doing a pulmonary tractotomy.
- The left ventricle should be aspirated and attempts made to elevate the diastolic
pressure to force the air emboli through the coronary system.
Outcomes
Survival (varies with associated injuries)
-
Overall survival (all thoracic trauma): 90%

Overall hospital survival for emergency thorocotomy: 25%
Hospital survival for GSWs to the trachea: 50%
Hospital survival for stab wounds to the trachea: 90%
Prognostic factors determining survival

- Mechanism of injury (GSW vs. SW)
- Presence of hilar injuries (may be rapidly fatal)
Postoperative Care
Routine chest x-rays and auscultation to determine complete expansion of the
lung and evacuation of air and blood from the pleural space.
Removal of chest tubes when drainage is less than 75-100 ml per 24 hours.
Follow-up in six weeks and six months with chest x-rays and physical
examination.
Late Complications
Posttraumatic empyema occurred in 87 of 5,474 patients (in our institution)
for incidence of 1.6%.
17
Common Mistakes and Pitfalls in Penetrating Trauma to the

Chest
Since seven out of ten patients can be managed successfully with closed tube
thoracostomy, a cavalier attitude and low index of suspicion for major injuries
sometimes exist.
The placement of a chest tube before obtaining the initial chest x-ray may
obscure the true significance of the degree of injury and delay the need for a
thoracotomy.
Penetrating Chest Injuries
199
The lack of chest drainage may mean that bleeding has stopped or that the
chest tube is clotted. Repeat chest x-rays at appropriate intervals are required
to prevent misinterpretation.
References
1.
2.
3.
4.
5.
Oparah SS, Mandal AK. Penetrating gunshot wounds of the chest in civilian practice: Experience with 250 consecutive cases. Br J Surg 1978; 85:45-51.
Liu D, Liu H, Lin PJ et al. Video-assisted thoracic surgery in treatment of chest
trauma. J Trauma 1997; 42:670-674
Mandal AK, Thadepalli H, Mandal AK et al. Posttraumatic empyema thoracis: A
24-year experience at a major trauma center. J Trauma 1997; 43:764-771.
Stratton SJ, Brickett K, Crammer T. Prehospital pulseless, unconscious penetrating trauma victims: Field assessments associated with survival. J Trauma 1997;
45:96-100.
Murray JA, Demetriades D, Cornwell EE et al. Penetrating left thoracoabdominal
trauma: The incidence and clinical presentation of diaphragm injuries. J Trauma
1997; 43:624-626.
17
CHAPTER 18
Cardiac Injuries
Penetrating Cardiac Injuries
Penetrating cardiac injuries are the most lethal organ injuries. More than 80% of
the victims die at the scene. For those victims reaching the hospital alive early diagnosis and immediate operation is the most critical factor for survival.
The first attempt at repairing a cardiac injury was made by Cappelen in Norway
in 1896.
The first successful repair of a cardiac wound was performed by Rehn, in
Germany, in 1896.
Incidence
About 10% of all penetrating chest trauma (from a series of 2076 penetrating
chest injuries). The incidence is similar in both, gunshot wounds and stab
wounds.
Many patients are dead or near death on arrival.
Those reaching the hospital alive are usually in severe shock. Occasionally,
patients with fairly minor cardiac injuries and short prehospital time may be
normotensive on admission.
The victim is very restless, even with fairly mild hypotension. It is possible
that this restlessness might be due to venous stasis in the brain, secondary to
tamponade.
The neck veins are distended in the presence of cardiac tamponade. However, if
there is associated hypovolemia due to blood loss the veins are not distended.
Tachycardia, thready peripheral pulse. The classical pulsus paradoxus described
in tamponade is found in only about 10% of the patients.
The classical Becks triad of cardiac tamponade (hypotension, distant cardiac
sounds, distended neck veins) is found in about 90% of cases.
Every precordial stab wound or gunshot wound to the chest, especially with
hypotension, is a cardiac injury until proven otherwise!

Although in most cases clinical examination is reliable in diagnosing cardiac
injuries, in some situations it is not possible or easy to establish the diagnosis. These
conditions include:
Absence of hypotension on admission (usually in patients with small cardiac
wounds and short prehospital time).
Cardiac Injuries
201
Multiple penetrating injuries in many body areas (i.e., chest, abdomen, extremities). This is not an uncommon scenario in urban trauma centers.
Investigations
Investigations should be reserved only for fairly stable patients where the diagnosis is not certain!
Trauma ultrasound performed by the emergency physician or the trauma surgeon in the emergency room is the fastest and most effective way to diagnose
cardiac tamponade (Fig. 18.1). It should be part of the standard primary survey
and the machine should be located in the emergency room. The technique and
role of the trauma ultrasound are discussed elsewhere in this handbook.
Chest x-ray may be suspicious of cardiac injury in about 30-50% of patients.
Radiological signs suspicious of cardiac injury are:
- Enlarged, globular cardiac shadow (Fig. 18.2)
- Widened upper mediastinum (due to dilated major veins as a result of the tamponade and venous stasis) (Fig. 18.3)
- Pneumopericardium (air in the pericardium due to a pericardial breach)
(Figs. 18.3, 18.4)
ECG may be diagnostic in about 30% of patients. It may show low QRS
complexes, elevated or depressed ST segments, inverted T waves (Fig. 18.5).
Pericardiocentesis is recommended by ATLS protocols. However, it has very
limited value in organized, modern trauma centers. It is associated with a high
incidence of false negative results due to clot formation in the pericardium. In
addition, it is a potentially dangerous procedure especially if is performed on
a restless, hypotensive patient.
Subxiphoid window is used by some centers (Fig. 18.6). The author believes
that it is the most invasive diagnostic procedure in surgery and has very limited value in modern trauma centers. It might delay the definitive cardiac
repair by 10-20 minutes.
Transabdominal, transdiaphragmatic window is an excellent approach for
patients with penetrating thoracoabdominal injuries requiring laparotomy. The
pericardium is grasped and pulled down with a strong forceps and a small pericardiotomy is performed. In the presence of blood in the pericardial sac the
laparotomy incision is extended into a median sternotomy for cardiac repair.
Central venous pressure might be helpful in some cases. A CVP higher than
12 cm H20 is suspicious of cardiac tamponade. It is important to remember
that in the presence of associated hypovolemia the CVP will raise only after
restoration of the blood volume. On the other hand an elevated CVP may be
due to inappropriate positioning of the tip of the catheter or due to the presence of major hemopneumothorax or a restless patient.
In summary, in a modern trauma center the diagnosis of cardiac injury in most
cases should be based on the combination of a good clinical examination and an
emergency room trauma ultrasound.
No attempts for ALS (Advanced Life Support) should be made! Scoop
and run is associated with the best chances of survival! Administer oxygen by
mask or intubate patients with imminent cardiac arrest, and transfer to the
nearest trauma center. An intravenous line might be attempted in the
ambulance en route to the hospital.
18
202
Trauma Management
Fig. 18.1. Cardiac tamponade: enlarged cardiac shadow
18
Fig. 18.2. Cardiac tamponade: note the pneumopericardium and the widened upper
mediastinum.
203
Cardiac Injuries
Fig. 18.3. Pericardial penetration: Pneumopericardium
Fig. 18.4. ECG in cardiac trauma: Elevated ST segments
18
204
Trauma Management
Fig. 18.5. Echocardiogram in ER: Cardiac tamponade
18
Fig. 18.6. Subxiphoid window (used with permission: Trinkel et al. Ann Thorac
Surg 1974; 17:231-236)
Cardiac Injuries
205

Remember that every minute counts! No delays for detailed physical examination, unnecessary investigations or administrative paperwork!
Patients with cardiac arrest or imminent cardiac arrest: Orotracheal intubation with simultaneous emergency room thoracotomy (ERT).
Technique for ER Thoracotomy:

The left chest is opened with an anterolateral thoracotomy through the 5th
intercostal space, just below the nipple in males or below the breast in females
(Fig. 18.7). The intercostal muscles are divided and the pleural cavity is entered. If the exposure is not satisfactory extend the thoracotomy into the right
chest, through the sternum (clamp the transected internal mammary arteries!).
The pericardium is opened longitudinally, above the phrenic nerve.
The pericardial clot is evacuated and the bleeding from the heart is controlled
with manual pressure between the left thumb and the index finger. A figure of
eight suture is placed and tied. Alternatively skin staplers may be applied.
The thoracic aorta is cross-clamped just above the diaphragm and the heart is
massaged (Fig. 18.8). During this period other members of the trauma team
continue with fluid resuscitation, manual ventilation, NaHCO3 and calcium
administration.
If the heart is full but fails to start, apply internal defibrillation (30-40 Kjoules)
or adrenaline through the central line, as indicated.
For persistent asystole or fibrillation apply electrodes through the myocardium of the right ventricle and pace the heart with a pacemaker.
If air bubbles appear in the coronary veins make the diagnosis of air embolism
and aspirate the ventricle.
If the heart recovers, the operation is completed in the operating room.
18
Fig. 18.7. Incision for ER thoracotomy
206
Trauma Management
Fig. 18.8. ER thoracotomy with aortic cross-clamping

Incision
- A median sternotomy is the preferred incision for most cases. It provides excellent
exposure, is fast and bloodless and is associated with a lower incidence of postoperative pain and respiratory complications than a thoracotomy.
- A left thoracotomy is preferred for ER operations and injuries to the posterior
chest. Extension into the right thorax through the sternum may be performed if
necessary.
Cardiac Repair
- The pericardium is opened and the heart repaired as described above.
- No need for routine use of Teflon pledgets for cardiac repairs. They slow down
the repair! Reserve pledgets only for friable thin tissues.
Pericardium
- The pericardium should be closed without tension. Leave opening at the top to
avoid retamponade.
- Leave pericardium open if tension-free closure can not be achieved (i.e., cardiac
failure, fluid overloading).
Chest Wall Closure

- Thoracostomy tube in the mediastinum and in open pleural cavities.
- Sternum closed with wire. Thoracotomy closed with heavy absorbable sutures
around ribs. Closure of the rest of the wound in layers.
18
Complex Injuries and Complications

Coronary Vessel Injury (Fig. 18.9)
- In about 3% of all cardiac injuries
- Only patients with peripheral coronary injuries reach the hospital alive.
Cardiac Injuries
207
Fig. 18.9. ECG following injury and ligation of the LADA
- Ligate the injured vessel and observe for a few minutes. If no arrhythmia develops during the observation period, no further treatment is required. If arrhythmia develops after ligation, remove the suture and apply gentle digital pressure
while a cardiac team prepares for cardiac bypass and repair of the vessel.
Air Embolism
-
Fairly common problem with injuries to the low-pressure cardiac chambers.

Often unexpected cardiac arrest or arrhythmia.
Often air bubbles can be seen in the coronary veins.
The treatment is aspiration of the ventricle.
The prognosis is extremely poor.
Outcomes
- Survival
Overall survival: 10-15%
Overall hospital survival: 30-35%
Hospital survival for GSWs: 10-15%
Hospital survival for stab wounds: 60-65%
ER thoracotomy survival: 10-15%
- Prognostic Factors Determining Survival
Mechanism of injury (GSW vs stab wounds) (Fig. 18.10).
Prehospital time.
Presence of tamponade (improves survival by preventing exsanguination).
Injured cardiac chamber
18
208
Trauma Management
Fig. 18.10. High velocity GSW of the heart
Intrapericardial aortic injuries have the worst prognosis. The combination

of a thin wall with high pressures causes exsanguination or very tense tamponade.
Right ventricular injuries have the best prognosis. The relatively thick myocardium combined with the relatively low pressures prevent rapid exsanguination or tense tamponade.
Injuries to multiple chambers decrease the probability of survival.
- Experience of the trauma team.
Postoperative Care
Routine ECG evaluation (The ECG may show ischemia during the first few
days. It usually returns to normal within a few days).
Routine echocardiographic evaluation for anatomical or functional cardiac
abnormalities.
Late follow up at one month by means of clinical examination, ECG
echocardiography.
Late Complications
18
About 30% of survivors develop late cardiac complications.

Possible late complications: Ventricular or atrial septal defects (Fig. 18.11),
valvular abnormalities, papillary muscle dysfunction, myocardial dyskinesia,
pericarditis.
Many of the complications may not show at the early clinical or echocardiographic
examinations (small defects may enlarge and manifest at a later stage). It is
essential that a late clinical examination should be performed at about one month
after the injury.
Cardiac Injuries
209
Fig. 18.11. Traumatic VSD which was diagnosed many weeks after the injury
Blunt Cardiac Trauma

Definition
Blunt cardiac trauma includes a wide range of pathologies: asymptomatic cardiac contusion, symptomatic cardiac contusion, rupture of the pericardium, valves,
papillary muscles and septum, and free cardiac rupture.
Mechanism of Injury
Direct compression of the heart between the anterior thoracic wall and the
spine.
Deceleration injuries, such as in high speed traffic accidents or falls.
Tearing of the pericardium or myocardium by a fractured rib or sternum.
Major and sudden blunt abdominal trauma. Such trauma may result in a
sudden, massive return of venous blood into the heart and rupture of the right
atrium or ventricle.
Incidence
The reported incidence of blunt cardiac trauma varies from 10-38% of blunt
trauma and depends on the diagnostic criteria used.
Cardiac rupture is found in about 5-10% of motor vehicle accident fatalities
and about 0.5% of blunt trauma hospital admissions.
Diagnosis
There are no generally accepted criteria for myocardial contusion.
Often the victim is clinically asymptomatic but the cardiac enzymes or troponin
levels are abnormal.
Some patients with myocardial contusion may present with cardiogenic shock
or arrhythmias.
18
210
Trauma Management
In cardiac rupture death occurs at the scene of the accident within a few minutes. Very few patients reach the hospital alive.
The diagnosis should be based on the suspicious mechanism of injury, clinical
presentation, and investigations. Seatbelt mark signs over the anterior chest
and fractured sternum or anterior ribs should increase the suspicion of blunt
cardiac trauma.
Investigations
ECG: It should be performed on all patients with serious blunt trauma. It
might show arrhythmia or ischemic patterns.
Troponin levels: Significantly more sensitive and specific than cardiac enzymes
(CPK-MB). In suspicious injuries the troponin levels should be repeated in
about 6 hours. There is no correlation between troponin levels and clinical
presentation or the severity of myocardial injury.
Cardiac enzymes (CPK-MB): They have been replaced by troponin.
Echocardiogram: A trauma ultrasound should be performed by a trauma surgeon or an emergency physician on all major trauma patients in order to look
for free blood in the pericardial sac and the peritoneal cavity. A detailed
echocardiogram by a cardiologist should be performed in symptomatic patients
and in patients with an abnormal ECG or high troponin levels. A transesophageal
echocardiogram is much more accurate than a transthoracic. The
echocardiogram may demonstrate anatomical or functional abnormalities (i.e.,
septal or valvular lesions, hypokinesia of the myocardium, etc.)
Management (Fig. 18.12)

All patients with major blunt chest trauma should have a trauma ultrasound,
ECG, and troponin levels.
Asymptomatic patients with abnormal ECG or troponin levels should be
observed with continuous ECG monitoring, serial troponin level measurements, and an echocardiogram performed by a cardiologist.
Symptomatic patients should be monitored in an ICU environment and treated
with antiarrhythmics or inotropes.
Patients with myocardial contusion tolerate surgical procedures well, provided
they are closely monitored perioperatively.
Patients with cardiac or pericardial rupture need emergent surgical intervention.
Common Mistakes and Pitfalls in Cardial Trauma
18
Patients with cardiac tamponade are very often restless and confused. The
inexperienced surgeon may mistake it for alcohol or drug intoxication!
External massage for cardiac arrest due to cardiac trauma has no beneficial
effect. In fact, it might reduce the chances of successful resuscitation! The
procedure of choice is ER thoracotomy, cardiac repair and internal massage.
Do not give adrenaline or defibrillate an empty heart. It reduces the chances
of successful resuscitation. These procedures should be considered only after
volume restoration!
Early postoperative clinical or echocardiographic evaluation may miss significant cardiac defects. Late re-evaluation at about one month is essential.
Cardiac Injuries
211
Fig. 18.12. Evaluation and management of suspected blunt cardiac trauma
References
1.
2.
3.
4.
5.
6.
7.
Asensio JA, Stewart BM, Murray J et al. Penetrating cardiac injuries. Surg Clin
Nort Am 1996; 76:605-624.
Demetriades D. Cardiac wounds. Experience with 70 patients. Ann Surg 1986;
203:315-317.
Demetriades D, Charalambides D, Sareli P et al. Late sequelae of penetrating cardiac injuries. Br J Surg 1990; 77:813-814.
Rozycki GS, Feliciano DV, Ochsner MG et al. The role of ultrasound in patients
with possible penetrating cardiac wounds: A prospective multicenter study. J Trauma
1999; 46:543-552.
Asensio JA, Berne JD, Demetriades D et al. One hundred five penetrating cardiac
injuries: A 2-year prospective evaluation. J Trauma 1998;44:1073-1082.
Swaanenburg JC, Klaase JM, DeJongste et al. Troponin I, troponin T, CKMBactivity and CKMB-mass as markers for the detection of myocardial contusion in
patients who experienced blunt trauma. Clin Chim Acta 1998; 272:171-181.
Fulda GJ, Giberson F, Hailstone D et al. An evaluation of serum Troponin T and
signal averaged electrocardiography in predicting electrocardiographic abnormalities after blunt chest trauma. J. Trauma 1997; 43:304-312.
18
CHAPTER 19
Lung Injuries
William C. Chiu and Aurelio Rodriguez
Blunt Pulmonary Trauma
Blunt chest trauma may result in life-threatening injuries that require immediate
recognition and treatment. These injuries include tension pneumothorax, open pneumothorax, massive hemothorax and flail chest. The majority of other lung injuries,
such as pulmonary contusion, simple pneumothorax and simple hemothorax may
be treated expectantly or with tube thoracostomy. The decision to intervene with
endotracheal intubation or thoracotomy depends on astute clinical judgment.
The first description of pulmonary trauma without chest wall injury is attributed to Morgagni in 1761.
Hooker showed that pulmonary hemorrhage was the predominant pathophysiologic effect of blast injury to the chest in 1924.
Traumatic wet lung was described for pulmonary contusion in World War II
chest injuries by Burford and Burbank in 1945.
Incidence
Approximately two-thirds of blunt trauma patients sustain a chest injury.
Pulmonary contusion is the most common lung injury and accounts for
30-75% of these injuries.
The symptoms of pneumothorax include dyspnea and pleuritic chest pain.
Some patients may also experience shoulder or back pain.
Typical signs of pneumothorax include tachypnea, hyperresonance to percussion, crepitus from subcutaneous emphysema and decreased or absent breath
sounds on the affected side.
Tension pneumothorax may be associated with tachycardia, hypotension, tracheal deviation and jugular venous distention.
The diagnosis of tension pneumothorax should be made on clinical grounds
and treatment by decompression should proceed expeditiously without delaying for chest radiographic results!
Progressively worsening dyspnea from pulmonary contusion may appear within
minutes or may develop over several days.
Some minor lung injuries are clinically silent.
Hemothorax is associated with dullness to percussion.
William C. Chiu, University of Maryland Medical Center, R. Adams Cowley Shock Trauma
Center, Baltimore, Maryland, U.S.A.
Aurelio Rodriguez, University of Maryland Medical Center, R. Adams Cowley Shock
Trauma Center, Baltimore, Maryland, U.S.A.
Lung Injuries
213
Pulse oximetry and arterial blood gas may demonstrate decreased oxygen saturation and hypoxia.

Physical examination of the chest may be hampered by patient and environmental factors:
The uncooperative or acutely agitated patient may not allow adequate assessment of lung sounds. The obtunded or unresponsive patient may have globally diminished breath sounds.
The noisy setting of the emergency room may interfere with accurate assessment of lung sounds.
Investigations
An anteroposterior chest radiograph should be performed on all blunt trauma
patients.
- The most common radiographic finding with pneumothorax is the peripheral
radiolucent region without lung markings (Fig. 19.1). Associated findings may
include tracheal and mediastinal deviation away from the affected side, depression of the diaphragm or a deep sulcus on the affected side or subcutaneous
emphysema.
- On supine radiograph, a hemothorax appears as a diffuse radio-opacity of the
affected side (Fig. 19.2). On an upright projection, blunting or obscuring of the
diaphragm on the affected side is seen.
- A pulmonary infiltrate suggests a pulmonary contusion, but radiographic findings may lag behind clinical evolution of injury (Fig. 19.3).
- An upright expiratory view may aid detection of a small pneumothorax.
Computed tomography (CT) scan is extremely sensitive in identifying small

pulmonary contusions, hemothoraces or pneumothoraces.
Clinical judgment should be exercised to determine if a chest tube should be
inserted for these small injuries incidentally discovered by CT.
Needle decompression should be performed emergently on unstable, hypoxic
or deteriorating patients suspected of having a tension pneumothorax. The
procedure is performed using a large-bore (e.g., # 14-gauge) angiocatheter
inserted into the second intercostal space, in the midclavicular line on the
affected side. A sudden escape of air indicates relief of the tension pneumothorax. The needle is then removed and the catheter is left in place.

Pneumothorax and hemothorax are treated with insertion of a chest tube.
- Technique for chest tube insertion: The usual insertion site is at the nipple level
(fifth intercostal space) anterior to the midaxillary line.
- Through a small transverse skin incision, blunt dissection of the subcutaneous
tissues and intercostal muscles is performed. The parietal pleura is carefully
punctured with the tip of the clamp and the clamp is spread.
- Digital examination of the thoracostomy is performed to confirm the presence
of a free pleural space and to evaluate for pleural adhesions.
- A large-bore (e.g., # 36-French in adults) chest tube is then advanced posteri-
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Trauma Management
Fig. 19.1. Left tension pneumothorax producing cardiac and mediastinal shift toward the right.
orly toward the apex of the lung. The tube is sutured to the skin and connected
to a collection device.
Less than 10% of blunt chest injuries require an operation.
Massive hemothorax results from the accumulation of more than 1500 mL of
blood in the chest cavity. Autotransfusion of blood drained is desirable. Clinical correlation should facilitate the decision to perform thoracotomy. A continuing blood loss of 200 mL/hour provides additional evidence toward the
need for surgery.
Operative Methods
19
- The goals of surgery for lung injury include control of hemorrhage, control of
major air leak, and debridement of devitalized tissue.
- Many lung lacerations can be treated with the use of stapling devices. Other
injuries may be controlled using nonabsorbable vascular sutures. Deep sutures
are usually required to achieve hemostasis.
- Wedge resection of injured lung parenchyma with a stapler or with the aid of
sutures around an atraumatic clamp may be needed.
- Anatomic lobectomy is occasionally needed when injury to a segmental bronchus is not reparable. The use of a pleural flap to buttress the bronchial stump
may deter bronchopleural fistula formation.
- Pneumonectomy is rarely necessary for lung injury and would only be indicated
for severe hilar injury in which the mainstem bronchus is irreparable or uncontrolled hemorrhage persists.
Lung Injuries
215
Fig. 19.2A. Increased opacity of the right lung field consistent with pulmonary
contusion and hemothorax.
Fig. 19.2B. CT scan of the chest in the same patient confirms the right lower lobe
pulmonary contusion and hemothorax.
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Trauma Management
Fig. 19.3A. Multiple left-sided rib fractures and bilateral parenchymal contusions:
Note the left chest wall subcutaneous emphysema.
Fig. 19.3B. Corresponding CT scan of the chest confirmed extensive bilateral pulmonary contusions, greater on the left, with left subcutaneous emphysema.
19
Lung Injuries
217
Complications
Retained Hemothorax
- Retained hemothorax develops after inadequately drained blood persists and
becomes clotted in the pleural cavity. It results in loss of lung capacity, development of trapped lung or fibrothorax and increases the risk of empyema.
- Clotted hemothorax that is unable to be drained with a chest tube may be
evacuated by video-assisted thoracoscopic surgery (VATS) if performed within
one week of injury. Older lesions tend to be well organized and a limited thoracotomy may be required with manual evacuation of hematoma.
Empyema
- Empyema most often occurs as a pleural infection following hemothorax or
pneumothorax. The diagnosis may be made by direct evidence of purulent drainage from a chest tube or by CT evidence of pleural infection.
- An attempt at CT-guided percutaneous catheter drainage may be made for simple
fluid collections along with intravenous antibiotics. For more established infections that are multiloculated and unsuccessfully drained with a tube, thoracotomy is recommended. At thoracotomy, all infected fluid is evacuated making
sure all loculations are entered, and all infected debris is cleared.
Outcome
Long-term disability from hemothorax, pneumothorax, or pulmonary contusion is most commonly from restrictive lung disease and occurs in up to 10%
of patients.
Penetrating Pulmonary Trauma

Penetrating injuries to the lung are predominantly from stab wounds and gunshot wounds. The diagnosis of injury is more straightforward than in blunt trauma
and may be readily apparent. Since the majority of these injuries can be treated with
tube thoracostomy, the need for thoracotomy after penetrating lung injury is declining. Management priorities include not only treatment of the lung injury, but also
the detection of associated injuries.
Incidence
Between 10-40% of all patients with penetrating trauma have a chest injury.
Following penetrating chest trauma, the incidence of lung parenchymal injury, hemothorax or pneumothorax is between 55-90%.
Approximately 40% of patients with penetrating lung injury also suffer a major
extrapulmonary injury.
On physical examination, the chest wall defect may be the only obvious sign
of injury.
High-velocity missiles and shotgun blasts frequently result in greater tissue
destruction and patients may present with a large chest wall defect.
If the wound is greater than two-thirds the diameter of the trachea, each inspiratory effort would preferentially result in sucking air through the defect
rather than through the tracheobronchial tree.
19
218
Trauma Management
In this open pneumothorax or sucking chest wound, there is immediate equilibration between intrathoracic and atmospheric pressure and inability to ventilate effectively.

Physical examination of penetrating chest wounds can occasionally be misleading
because they only indicate the surface points of injury:
Cervicothoracic wounds require careful assessment of the neck and upper
extremity vasculature.
Central and transmediastinal trajectories require full assessment of the heart,
great vessels, esophagus and tracheobronchial tree.
Thoracoabdominal wounds require evaluation for diaphragmatic and peritoneal penetration.
Investigations
An anteroposterior chest radiograph is obtained in all patients with a penetrating chest wound (Fig. 19.4). If the patient is not in respiratory distress
and hemodynamics are normal, an upright expiratory view aids in detecting a
small pneumothorax.
Besides pneumothorax and hemothorax, radiographic findings of associated
injuries include apical pleural cap, abnormal mediastinum, pneumomediastinum, pneumopericardium or pneumoperitoneum.
There have been a few reports on using CT scan to evaluate transmediastinal
trajectory of gunshot wounds (Fig. 19.5). Clinical decisions based on this test
require careful and accurate interpretation of the findings.
Needle decompression may be necessary in some penetrating chest injuries.
A large chest wall defect or open pneumothorax should be covered with a
sterile occlusive dressing. This dressing should be taped to the skin on three
sides to create a flap-valve effect. During inspiration, the dressing acts as an
occlusive flap preventing air from entering into the pleural cavity. During
expiration, the same dressing acts as a valve allowing pleural air to escape.

As with blunt chest injuries, pneumothorax and hemothorax should be treated
with a chest tube.
Patients in hemorrhagic shock require immediate resuscitation and possibly
urgent thoracotomy.
The potential for extrathoracic injury must be fully assessed.
A carefully selected group of patients with a small pneumothorax associated
with a small stab wound, normal hemodynamics and no hypoxia without
supplemental oxygen may be clinically observed without a chest tube. This
patient should be admitted, observed for at least 24 hours, and serial chest
radiographs must show resolution or lack of progression of the pneumothorax.
19
Patients with a penetrating chest wound arriving in extremis may have a

cardiac injury with pericardial tamponade or exsanguination.
- In emergency thoracotomy for penetrating left chest wounds, a left anterolateral
Lung Injuries
219
Fig. 19.4. Gunshot wound of the chest: CT scan reveals a large right lower lobe
pulmonary contusion.
thoracotomy is performed. With penetrating right chest wounds, a bilateral

thoracotomy is performed for both open cardiac massage and hemorrhage
control.
- Only the occasional patient with massive hemothorax from penetrating lung
injury will require emergency room thoracotomy.
- If emergency room thoracotomy is performed, obvious bleeding sources may be
controlled with application of long atraumatic clamps until these patients can
be brought to the operating room.
Rapid control of massive bleeding may be achieved by application of an

atraumatic clamp at the pulmonary hilum.
In the hemodynamically stable patient, posterolateral thoracotomy with the
patient in the lateral decubitus position is the preferred operative approach for
suspected lung injuries.
In the hemodynamically unstable patient, anterolateral thoracotomy in the
operating room will allow access to most pulmonary injuries.
In addition to the operative methods described for blunt pulmonary injuries,
a useful technique for hemorrhage control is pulmonary tractotomy.
- This procedure involves dividing or unroofing the path of the bullet tract between
atraumatic clamps to expose and accurately identify the bleeding source. Selective ligation of injured vessels may then be performed.
- A handy technique is to perform the tractotomy using a linear stapler/cutter to
simultaneously control the parenchyma and divide the tract.
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Trauma Management
Outcome
After penetrating chest trauma, approximately one-third of patients develops
a complication.
The incidence of recurrent pneumothorax is 23%, residual hemothorax 16%
and empyema 3%.
The survival rate is near 100% for patients with isolated penetrating pulmonary injury requiring only tube thoracostomy treatment.
Among patients with hilar pulmonary injury, the survival rate is only 30-56%.
After thoracotomy for penetrating lung injury, the mortality rate for
pneumonorrhaphy is 20%, lobectomy 55% and pneumonectomy near 100%.
Common Mistakes and Pitfalls in Pulmonary Trauma

In the hypoxic or hemodynamically unstable patient, the diagnosis of tension
pneumothorax should be made on clinical grounds and treatment by decompression should proceed without delaying for x-ray results.
When tubes are malpositioned or clotted, chest tube drainage rate does not
reflect actual ongoing hemorrhage in massive hemothorax. Thoracotomy
should be considered in the unstable patient with persistent hemothorax on
chest radiograph.
In the patient with pulmonary contusion, fluid administration should be controlled to achieve adequate resuscitation, but avoid fluid overload.
References
1.
2.
3.
4.
5.
19
Cohn SM. Pulmonary contusion: Review of the clinical entity. J Trauma 1997;
42:973-979.
Feliciano DV, Rozycki GS. Advances in the diagnosis and treatment of thoracic
trauma. Surg Clin North Am 1999; 79:1417-1429.
McSwain NE Jr. Blunt and penetrating chest injuries. World J Surg 1992; 16:924929.
Richardson JD, Spain DA. Injury to the lung and pleura. In: Mattox KL, Feliciano
DV, Moore EE, eds. Trauma. 4th ed. New York: McGraw-Hill Companies, Inc.,
2000: 523-543.
Rodriguez A, Thomas MD, Shillinglaw WRC. In: Ivatury RR, Cayten CG, eds.
The textbook of penetrating trauma. Philadelphia: Williams & Wilkins, 1996:
531-554.
CHAPTER 1
CHAPTER 20
Blunt Aortic Trauma

Ismael Navarro Nuo, Juan A. Asensio
Introduction
Blunt aortic trauma resulting in aortic disruption and hemorrhage is a life
threatening injury that requires emergency diagnosis and treatment. Usually
there are a significant number of associated injuries that may also be life threatening making the management of an aortic injury much more complex and
challenging.
Other than exsanguination, paraplegia is one of the most devastating complications in this type of an injury.
A high index of suspicion for an associated aortic injury and its appropriate
treatment are key to survival.
Vesalius in 1557 reported the first case of a patient who died of a ruptured
aorta after being thrown from a horse.
Kuhn collected a series of 75 postmortem cases of blunt aortic injury between
1895 and 1925.
Parmley in 1958 collected from the literature over 199 cases of blunt aortic
injuries and described its management and the natural history of untreated
injuries.
In 1952 Henry Bahnson reported an aneurysmorrhaphy for a patient with a
chronic posttraumatic thoracic aortic aneurysm.
DeBakey and Cooley in 1954 resected a posttraumatic thoracic aneurysm and
replaced the aorta with a synthetic graft.
Klassen, in 1958, is credited with the first successful primary repair of an
acute traumatic thoracic aortic injury.
Epidemiology
Eighty-five percent of patients with aortic rupture die within minutes of the
traumatic incident.
Fifty percent of survivors die within 48 hrs if injury is not recognized or
treated. Of these, 38% survive longer than 30 minutes and 12% survive
longer than 4 hours.
Mechanism of Injury
The primary mechanism of injury is rapid deceleration at high speeds.
Ismael Navarro Nuo, University of Southern California, Los Angeles, California, U.S.A.
222
20
Trauma Management
The usual site of disruption is located within 2-3 cm distal to the junction of
the left subclavian artery and the aorta. The posterior aspect of the aorta is the
site most commonly torn.
The mediastinal pleura and other mediastinal structures hold the aorta in
place above. The descending aorta is fixed at the isthmus by the ligamentum
arteriosum, left main bronchus and intercostal arteries. The rapid forces of
deceleration, torsion, bending or direct impact associated with cranio-caudal
movement and horizontal shear movement against the supportive tissues holding it in place are responsible for the tears of the aorta.
Shear forces, compression of the vessel between bony structures and profound
intraluminal hypertension during the traumatic event all summarily act in the
creation of an aortic rupture.
It wasnt until recently that side impacts were recognized as capable of producing aortic ruptures.
A contained hematoma around the site of disruption is the reason for most
survivors reaching the hospital alive.
Blood flow distal to the site of aortic disruption may be interrupted leading to
massive ischemia producing lactic acidosis. This metabolic acidosis can easily
lead to cardiac arrhythmias and death.
Associated Injuries
Ninety percent of patients with blunt injury of the aorta have associated injuries.
Forty-two percent have associated cardiac injuries.
Thirty-three percent demonstrate associated lung injuries.
Twenty to forty-three percent have a CNS injury.
Twenty-five percent have an intra-abdominal or retroperitoneal injury with
active bleeding.
The triad of significant pelvic fracture, left hemidiaphragmatic rupture and
aortic rupture is well described.
ONLY 5-10% will have an isolated aortic injury.
Anatomic Location of Injury

The aortic disruption is usually linear, transverse, and in 35-60% of the cases
it is located posteriorly.
The aortic laceration usually has smooth edges and involves the intima, media
and often all three layers. The edges of the transected tissue may be separated
by as much as a few centimeters and it may include the entire circumference
of the aorta. Occasionally the laceration is longitudinal.
The aortic isthmus is involved in 84-100% of the cases.
The ascending aorta and arch are involved in 3-7% of the cases.
Multiple injury sites throughout the thoracic aorta have been reported in the
literature to have a frequency between 13 and 18%.
The left carotid artery is the least affected vessel whereas the left subclavian
and innominate arteries are occasionally involved.
Diagnosis
There must be a high index of suspicion when there are other associated injuries
Blunt Aortic Trauma
223
20
Fig. 20.1. CXR showing widened midiastinum and deviated nasogastric tube to the
left. Reprinted with permission from: Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In press.
At initial evaluation, 30% of patients will present with dyspnea, back pain,
higher differential blood pressure in the upper extremities compared to the
lower. There may be absence of lower extremity pulses.
Twenty percent of patients may have a midscapular systolic murmur.
The patient may show evidence of left chest wall contusion.
The presence of first to third rib fractures, left clavicular fracture or scapular
fractures, flail chest, or combinations of the above should raise the index of
suspicion for blunt aortic trauma.
Investigations
Chest X-Rays
- Classic radiographic findings in a patient with blunt aortic rupture include a
widened (> 8 cm) mediastinum, loss of the acute contour of the aortic knob,
left apical cap, left pleural effusion, loss of AP window, rightward deviation of a
properly placed nasogastric tube (least frequently seen but highly reliable), displacement of the trachea, depression of the left main bronchus, sternal, clavicular, first rib or multiple rib fractures.
- In 25% of the cases the chest X-ray may be initially normal but reveals abnormal findings on a delayed basis.
- Only 10-20% of patients with an abnormally widened mediastinum on chest
X-ray will actually have a ruptured aorta.
- Some patients may have a normal mediastinum and harbor a ruptured thoracic
aorta.
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Trauma Management
20
Fig. 20.2. Thoracic Aortogram showing contained rupture of the thoracic aorta.
Reprinted with permission from: Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In press.
CT Scan
- Routine helical CT is an excellent diagnostic tool and has to a greater extent
replaced the aortogram for evaluation of the mediastinum in high risk blunt
trauma patients. In many centers it has become the first line investigation for
suspected aortic injury.
- Aortogram is still the gold standard.
- Aortograms may have a 6% false positive rate.
- An aortogram may be obtained to help in the diagnosis if the patient is stable,
or if the CT scan has questionable findings.
MRI
- MRI is helpful but access to the patient during an acute phase of resuscitation
may be a problem.
TEE
- Transesophageal echogram (TEE) is a good adjunct to the diagnosis of aortic
disruption by blunt trauma. The distal ascending aorta and the aortic arch are
difficult to visualize because of the intervening trachea and left main bronchus
and an injury in this area may be overlooked.
Blunt Aortic Trauma
225
20
Fig. 20.3. Spiral CT scan showing aortic rupture. Reprinted with permission from:
Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery.
W.B. Saunders Co., Philadelphia, PA. In press.
Surgical Management
Emergency Department Management
All trauma patients should be evaluated and resuscitated per ATLS protocols.
All other major life threatening injuries must be evaluated promptly.
All other more life threatening bleeding must be controlled first, if the
mediastinal hematoma is deemed to be stable.
Pneumothoraces must be evacuated by the insertion of chest tubes as necessary.
Systolic blood pressure control should be maintained in a range of 90-110
mm Hg in order to allow target organ perfusion but not allow further disruption of the disrupted aorta.
226
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Trauma Management
Fluid resuscitation should be carried out to reach the target pressure mentioned
above. Blood products should be utilized as needed.
In hemodynamically stable patients, permissive hypovolemia and aggressive
minimization of change in pressure over change in time ( dP/dT), which
are widely accepted in the treatment of aortic dissection and aneurysm rupture,
should be considered in patients with blunt aortic injuries.
Intraoperative Management
A double lumen endotracheal tube should be inserted if possible to facilitate
collapse of the left lung and improve visualization of the disrupted aorta.
Hemodynamic monitoring lines should be placed, arterial line in the right
radial artery and a right femoral arterial line or pedal artery to monitor distal
perfusion. Distal perfusion should be maintained at 50-70 mm Hg.
The patient is placed on a Bean Bag to facilitate positioning at a right lateral
decubitus position at 45.
A left posterolateral thoracotomy is the incision of choice to access the
descending aorta. The fourth intercostal space is chosen to enter the chest
cavity. Proximal and distal control should be obtained first. The decision to
approach and repair this injury either by clamp and sew technique or the
utilization of a circulatory assist device is now made.
The utilization of a cell saver apparatus is mandatory in these patients.
The patient is systemically anticoagulated with 5-10,000 units of heparin intravenously provided there are no contraindications like associated intracranial
hemorrhage.
A Carmeda (tm) circuit that is heparin bonded can be utilized to preclude the
use of any heparin intravenously in cases where bleeding from associated injuries
can be fatal.
If circulatory assist devices are to be utilized, a left atrial-left femoral artery
bypass is utilized with a centrifugal pump. Thermal control devices can be
added to the circuit to regulate the patients temperature.
If arterio-venous bypass is to be utilized with an oxygenator in patients with
poor oxygen saturation due to associated pulmonary injury, systemic anticoagulation with 10-20,000 units of heparin is mandated and cannulation can
be done at the inguinal region via femoral artery and femoral vein. Thermal
control can be quite helpful in these patients.
Passive conduits like the Gott shunt (ascending aorta to distal thoracic aorta)
can also be utilized for distal arterial perfusion in lieu of mechanical pumps as
already described above.
The aortic disruption can be handled by primary repair, end-to-end anastomosis or tube graft interposition.
At the completion of the cross clamp period, the patient is weaned off
circulatory assistance and the heparin is reversed with protamine sulfate
intravenously.
The left posterolateral thoracotomy is closed and two 36F chest tubes are left
in place to drain the left thoracic cavity.
An intrapericardial exploration is also done through the left thoracotomy if a
hemopericardium is suspected.
Blunt Aortic Trauma
227
Nonoperative Management
Nonoperative management of patients with a ruptured aorta is being recognized as a further option in patients with severe concomitant injuries unlikely
to tolerate operative repair. Such comorbidities include severe head trauma,
major burns, sepsis, and severe multisystem trauma with hemodynamic instability. There is a place for delayed surgical management in this highly selective
subset of patients should they survive their other injuries, although their mortality is astronomical.
Nonoperative management has also been utilized in some cases of a minor
aortic injury. The diagnostic studies may be positive but with only minor changes.
Routine and frequent follow-up radiologic studies are a must in these patients.
Angiographically Placed Stents

Intraluminal stenting has been utilized for patients deemed nonoperable because of severe comorbidities. Although some success has been reported by
some authors, further evaluation of this technology is mandated.
Morbidity
Paraplegia is a devastating complication of blunt aortic trauma. The overall
incidence is 5-10%.
If aortic cross-clamp times greater than 30 minutes are experienced during
aortic rupture repair, a greater incidence of postoperative paraplegia is generally
encountered.
If circulatory assist techniques with distal systemic perfusion are utilized for
the repair of the aortic disruption or an aortic cross-clamp time of less than 30
minutes is observed, the incidence of postoperative paraplegia will tend to be
in the lower percentage range of 3-5%.
Overall, the incidence of paraplegia (with or without special operative techniques or aortic cross-clamp times) in patients that sustained injury to the
aorta was 9%.
Other possible complications of emergency aortic disruption repair surgery
include phrenic nerve injury, recurrent laryngeal nerve injury, lung lacerations,
pseudoaneurysms, injury to the pulmonary artery during cross clamping or
injury to the thoracic duct resulting in a postoperative chylothorax.
Immediate postoperative complications may include ARDS or sepsis, and rarely
graft infection.
Mortality
Prehospital mortality in patients with blunt aortic injury is approximately
85% in most studies.
In-hospital mortality for untreated patients is 1% per hour for the initial
48 hours.
Repair of blunt aortic disruption carries a 31% operative mortality.
References
1.
2.
Asensio JA, Hanpeter D, Gomez H et al. Thoracic injuries. In: Shoemaker W,

Greenvik A, Ayres SM et al, eds. Textbook of Critical Care. 4th Ed. Philadelphia,
PA: W.B. Saunders Co. 1999; 337-348.
Kuerer H, Curtiss S, Zisman S et al. Thoracic Aortic Transection: Diagnosis, Management and Survival. Surgical Rounds, August, 1998.
20
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Trauma Management
3.
20
4.
5.
Fabian T. Prospective Study of Blunt Aortic Injury: Multicenter Trial of the American Association for the Surgery of Trauma. September, 1996.
Demetriades D, Gomez H, Hanks S et al. Routine helical CT scan evaluation of
the mediastinum in high suspect blunt trauma patients. Arch Surgery 1998;
133(10):1084-1088.
Mattox KL, Wall MJ Jr, LeMaire SA. Injury to the thoracic great vessels. In: Trauma,
4th Ed., Mattox KL, Feliciano DV, Moore EE, eds. New York: McGraw Hill and
Company 1999; Chapter 27:559-582.
CHAPTER 1
CHAPTER 21
Penetrating Thoracic Vascular Injuries

Matthew J. Wall, Jr. and Anthony Estrera
Incidence
Over 90% of thoracic vascular injuries are due to penetrating trauma, with blunt
trauma as the predominant cause of injuries to the descending thoracic aorta.
The actual incidence of thoracic vascular injuries in the general population is unknown as a significant number of victims may never reach the
hospital setting.
Pathophysiology
Penetrating thoracic vascular injuries can present with external or internal
hemorrhage, thrombosis, intimal flaps, or pseudo-aneurysms. External hemorrhage is most common from stab wounds to the base of the neck.
Aortic and vena cava injuries can manifest as hemorrhage into the mediastinum or pleural cavity, presenting as either significant hemothorax, mediastinal hematoma, or cardiac tamponade.
The presence of a distal pulse does not exclude a proximal injury. Vessels can
be completely disrupted with blood flow contained by perivascular tissue.
Some injuries may present with complete thrombosis. An intimal flap allows
exposure of the subendothelium and possible thrombosis. Moreover, if the
intimal flap progresses or enlarges, complete occlusion may result. Thus, the
natural history of intimal flaps is unclear though most recommend operation
on significant lesions. Alternatively, small intimal flaps, similar to those seen
when a cannula is inadvertently placed into an artery, can be observed.
Other nonbleeding injuries can develop pseudoaneurysms that can initially
be small and very difficult to diagnose. They are more often diagnosed late in
the course of patients who were not suspected of having an arterial injury.
- A high clinical suspicion for pseudoaneurysms must be maintained. Evaluation
is based on history, physical exam, or on x-ray. One mode of presentation is
when the pseudoaneurysm exerts pressure on adjacent structures.
- In a patient undergoing arteriography, careful inspection of the study, perhaps
with repeat examination in 2-3 weeks, may diagnose pseudoaneurysms earlier,
and may allow for technically easier repair.
The large diameter of the great vessels predisposes them to missile embolism.
When the missile does not appear on chest x-ray in a patient with a gunshot
wound to the chest, one must entertain the possibility of embolization of the
bullet, assuming an exit wound has been excluded. The patients body should
be surveyed radiographically, and distal pulses checked carefully. Similarly, a
Matthew J. Wall, Jr., Department of Surgery, Baylor College of Medicine,
Houston, Texas, U.S.A.
Anthony Estrera, Department of Cardiothoracic Surgery, College of Medicine,
Houston, Texas, U.S.A.
230
Trauma Management
single vascular injury found at operation with a bullet tract which cannot be
reconstructed suggests missile embolus.
21
- The treatment of missile emboli depends on location. Missile emboli located in

the arterial system or left side of the heart (i.e., left atrium or ventricle) usually
require surgical removal. Missile emboli can lodge in the iliac/femoral vessels or
be devastating if they go to the common carotid artery.
- Venous missile emboli or right sided cardiac emboli usually lodge in the right
ventricle or branches of the pulmonary artery and may be removed if larger
than a B-B.
- Management focuses immediately on the control of bleeding from the chest
injury, and once the patients physiology has stabilized (i.e., resuscitate, correct
hypothermia and acidosis), separate incisions can be made to remove the
embolized missile.
It is interesting to note that even significant injuries clot and stop bleeding. It
is probably disadvantageous to vigorously resuscitate either with fluids, MAST
trousers or pressors to artificially elevate the blood pressure, as this may dislodge a soft clot and increase bleeding. This results in massive swings of the
blood pressure.
- A recent randomized controlled trial in patients with penetrating trauma comparing standard fluid resuscitation with no fluid resuscitation until time of skin
incision and operative control of the vascular injury demonstrated a significant
survival advantage with delayed resuscitation. Thus, cyclic hyper-resuscitation
should be avoided.
Presentation
Thoracic vascular injuries commonly occur secondary to penetrating trauma
from gunshot wounds, stab wounds and iatrogenic causes. Any penetrating
injury that traverses the chest or the base of the neck can produce a thoracic
vascular injury.
Gunshot wounds are particularly unpredictable; it is unreliable to draw straight
lines reconstructing the track of gunshot wounds.
The mobility of the shoulder and neck affects the patients position at the
instant of wounding and may produce surprising trajectories. Attempts to
map trajectories from multiple gun shot wounds are usually fruitless. With
this difficulty, our approach is to have a low threshold for evaluating proximate structures and cavities.
Stab wounds, despite lower energy, can leave a larger wound track through
which the patient can bleed externally.
The thoracic outlet is the most superior region of the thorax bordered by the
manubrium anteriorly, clavicles and first ribs laterally, and the vertebral column
posteriorly.
Thoracic outlet injuries are of particular concern when the injury pattern is
the gunshot wound traversing the upper mediastinum. The wound may track
superiorly such that it avoids the aortic arch, but may injure the brachiocephalic vessels between the neck and the aorta.
If these patients are stable in the emergency center, early arteriography is
warranted for identification of the injury and appropriate planning for
surgical exposure.
231
Prehospital and Emergency Center Issues

Patients with potential thoracic vascular injuries should be transported to an
appropriate facility that can manage thoracic vascular trauma.
Intravenous access should probably be avoided in the upper extremities particularly on the side of injury.
Artificial means to elevate the blood pressure such as intravenous fluids, MAST
trousers, or pharmacologic pressors prior to vascular control are probably detrimental and should be avoided in the urban setting.
The patients should be transported, taking time primarily to establish an airway
with an endotracheal tube if needed.
In the emergency center patients should be examined and managed according
to a plan such as the Advanced Trauma Life Support Protocols.
Cervical hematomas dissecting superiorly should lend consideration for early
airway maneuvers. Early endotracheal intubation is probably the best course
of action. While counterintuitive, prophylactic early tracheostomy in the
emergency center might convert a controlled hematoma into uncontrolled
exsanguination.
After life threatening conditions are addressed the patients injuries are cataloged and the distribution of hematomas, presence of distal pulses as well as
neurological function should be carefully documented if possible.
Aside from a type and cross match for blood, minimal laboratory tests are
necessary.
A trauma surgeon should be involved in the care of these patients as early as
possible.
Exposure and Control

Arteriographic evaluation is often not an option for patients with great vessel
injuries as they are in extremis and these injuries are diagnosed at operation.
When performed in stable patients, due to the large dye column, small
pseudo-aneurysms of the aorta are often difficult to see and require views
tangential to the expected injury to maximize yield.
Alternatively, arteriography is extremely helpful when assessing the brachiocephalic vessels. By delineating the anatomy of the injury, arteriography permits
planning the operative strategy.
In the operating room, the patient is typically positioned on the operating
room table supine and prepped from chin to knees. Single lumen endotracheal intubation is usually adequate.
- Prophylactic antibiotics are given anticipating the need for a vascular graft.
- The groins are prepped so that the saphenous vein is available for a graft for
vessels less than 4 mm.
- The patient in extremis with thoracic outlet injury is approached operatively
via left anterolateral thoracotomy for resuscitation with extension to the right
side for exposure if needed (Fig. 21.1).
- The aorta can be clamped to preserve blood flow to the brain and myocardium.
- The extension to the right chest should be directed superiorly to avoid entering
a low interspace which limits exposure of the upper right hemithorax.
- After proximal control is obtained the incision can be extended by splitting the
sternum and adding neck or supraclavicular extensions if needed.
- If the injury tract is an anterior mediastinal traverse and the patient is unstable,
the median sternotomy with appropriate neck extension may be the empiric
21
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Trauma Management
incision of choice. Bleeding into the chest can be initially managed with packing or with a large Foley balloon catheter placed through the injury to temporarily
arrest hemorrhage.
21
Patients who require empiric life saving operations as well as patients that
require emergency center thoracotomy with thoracic outlet injuries have a
dismal prognosis.
Great Vessel Injuries

Penetrating injuries to the thoracic aorta are usually diagnosed at operation
through an emergent anterolateral thoracotomy. The ascending aorta is most
commonly injured by stab wounds and the descending aorta by gunshot
wounds.
- The overall mortality for penetrating injuries to the thoracic aorta is reported to
be 50-85%.
- Lateral arteriorrhaphy with adjuncts such as partial occluding clamps is the
most common mode of repair. More extensive injuries may require graft interposition and the knitted dacron graft is our graft of choice on the soft aorta of
the young adult.
Because they are short structures, the intrathoracic vena cavae (inferior and
superior) are not commonly injured. Lateral venorrhaphy is the usual method
of repair though extensive injuries of the superior vena cava can require graft
interposition.
- Injuries to the posterior intrathoracic inferior vena cava are particularly difficult
to manage and may require total cardiopulmonary bypass to accomplish repair
via a transatrial route.
The azygous vein, while not often considered a great vessel, is associated with
a significant mortality if injured. Azygous vein injuries are often found late in
the operation and are analogous to vena cava injuries. They are managed with
ligation or simple repair.
Thoracic Outlet Injuries

The incisions required to achieve proximal and distal control are multiple
(Fig. 21.1). An initial best guess may not turn out to be optimal.
- Injuries to the innominate, right subclavian, right and left carotid arteries are
managed through a median sternotomy, with appropriate cervical or supraclavicular extension.
- Injury to the left subclavian artery is managed via a high left anterolateral thoracotomy usually via the third intercostal space for proximal control. Distal control is obtained via a supraclavicular incision and the arterial injury is then identified.
- Though removal of the clavicle may provide needed exposure, it can be a particularly morbid procedure affecting upper extremity function postoperatively.
- Distal subclavian injuries without a medial hematoma can be managed with a
supraclavicular incision for proximal control away from the hematoma, combined with a distal infraclavicular incision for distal control and repair.
The brachiocephalic vessels are particularly soft structures and do not tolerate
either tension or mobilization. Thus, injuries that can not be primarily
repaired will usually require the use of a soft graft such as knitted Dacron.
- Injuries to the innominate artery if small and distal can be managed with primary repair or short segment interposition graft.
233
21
Fig. 21.1. Incisions for proximal vascular control and repair of thoracic outlet injuries.
A) Median sternotomy for innominate, right subclavian, right carotid, and proximal left
carotid arterial injuries. Cervical or supraclavicular extensions can be added if
needed. B) Extension of a left anterolateral thoracotomy forming a book incision.
This incision has significant morbidity with little advantage over separate anterolateral thoracotomy with supraclavicular incision. C) Posterolateral thoracotomy
for exposure of the descending aorta. D) Anterolateral thoracotomy for resuscitation and exposure of the heart and proximal great vessels. This incision can be
carried across the midline for exposure of the hilum of the right lung and the
innominate and right subclavian vessels.(E)
Extensive injuries or injuries adjacent to the aortic arch are best managed
using the bypass principle as described by Johnston et al (Fig. 21.2).
- The chest is opened through a median sternotomy and the proximal hematoma
is avoided.
- A 10 mm knitted dacron tube graft is sewn to a convenient spot on the ascending aorta using a partial occluding clamp.
- Control is obtained at the distal innominate artery.
- The artery is divided and the distal innominate artery is then sewn end to end
to the graft reestablishing flow. To complete the procedure a large partial occluding clamp is placed on the arch of the aorta and the origin of the innominate is
over sewn.
Injuries to the intrathoracic left common carotid artery are managed similarly
to the innominate recognizing that it is a relatively deep structure.
- In the patient in extremis, as a damage control option a carotid shunt may be
placed to temporarily reestablish flow and permit resuscitation in the intensive
care unit prior to definitive repair.
Attempts should be made to document the neurological status of the arm

when dealing with subclavian injuries as significant preoperative associated
brachial plexus injury is common. As the brachial plexus surrounds the artery,
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Trauma Management
21
Fig. 21.2. Technique for control and repair of proximal innominate artery injuries.
A) Severe intimal disruption associated with minimal external hematoma. B)
Aortotomy is performed along the ascending aorta, and a prosthetic graft is sewn
end-to-side. A partial occluding clamp is placed at the origin of the innominate
artery and a vascular clamp across the distal innominate artery. The artery is divided between the clamps. C) The repair is completed by an end-to-end anastomosis of the graft to the distal innominate artery and by over sewing the origin of the
innominate artery.
care must be taken when mobilizing these vessels to avoid a traction injury of
the brachial plexus.
- An incision which in the past was advocated for managing these injuries was the
left trap door or book exposure (Fig. 21.1) This incision has significant
morbidity with very little advantage over the previously mentioned approaches.
Book thoracotomy carries a significant incidence of postoperative causalgia that
can be extremely difficult to manage.
Brachiocephalic Venous Injuries

Contained venous injuries are usually inferred and managed nonoperatively.
Freely bleeding injuries manifest as external hemorrhage, hemothorax or an
expanding hematoma and are managed with primary repair, ligation, or graft
interposition.
235
The jugular or innominate vein, in particular, can be ligated but the superior
vena cava should be reconstructed if possible.
Arterial-venous fistulas are common and managed with arterial repair and
ligation/reconstruction of the vein.
Associated Injuries
Concomitant injuries to the lung are common. In that these patients are cold
and coagulopathic, there may be significant hemorrhage from deep within
the lung. A useful damage control adjunct is the use of pulmonary tractotomy
with selective vascular ligation (Fig. 21.3). The bleeding wound tract is opened
with the stapler or between aortic clamps, and bleeding and air leaks are controlled directly. This procedure allows rapid control of deep bleeding and air
leaks, thus, shortening operation and avoiding formal lobectomy in a patient
with other significant injuries.
Associated tracheal injuries can occur and are diagnosed with physical examination or bronchoscopy. Repair can usually be accomplished with absorbable
suture.
Concomitant esophageal injuries are diagnosed by barium swallow,
esophagoscopy or exploration and can typically be repaired primarily.
Drains if placed in the neck should probably be brought out the side opposite
a vascular repair. A muscle flap can also be interposed to protect a vascular
repair.
Other Issues
When operating on these patients autotransfusion collection systems can be
extremely helpful and appropriate blood products should be available.
Soft prosthetic grafts are preferred for vessels greater than 4 mm in diameter.
Postoperative Issues
Thoracic epidural catheters are useful in managing postoperative pain allowing more vigorous deep breathing and coughing.
Complications and Postoperative Sequelae

While median sternotomy is relatively well tolerated, thoracotomy can significantly affect thoracic physiology.
Difficult weaning from the ventilator should raise suspicion for injury to the
phrenic nerve. This can be investigated using fluoroscopy or ultrasound.
Examination of motor and sensory function of the upper extremity will lead
to early diagnosis of brachial plexus injury.
Rehabilitation
Due to the need for mobility, the shoulder depends on its musculature to
maintain stability. The syndrome of capsular adhesions is particularly difficult
as patients with even short periods of immobility of the shoulder can have
morbidity that can take months to resolve.
Rehabilitation services should be instituted as soon as practical after the injury to try to prevent these sequelae. Shoulder stiffness combined with thoracic incisions can be particularly difficult to manage.
Rehabilitation services are also useful when partial loss of function of the upper extremity has occurred
21
236
Trauma Management
21
Fig. 21.3. Tractotomy for controlling hemorrhage from the lung parenchyma. The
missile tract is opened by dividing the overlying lung between vascular clamps or
a stapler. The bleeding vessels in the tract are ligated, and the lung parenchyma
pedicles are oversewn.
Medical Legal Issues

Thoracic vascular injuries are some of the most complex and intimidating
injuries that the trauma surgeon faces. Patients often present with irreparable
vascular and neurologic deficits.
It is important to preoperatively assess and record these deficits so that a postoperative deficit is not inadvertently attributed to an intraoperative maneuver.
Difficult decisions regarding preservation of structures need to be made in
patients that are dying.
Many times, rapid dissection is required to obtain vascular control and save
the patients life. This can result in neurologic injuries that are predictable.
A bad outcome prima facia is not evidence of malpractice.
References
1.
2.
3.
4.
5.
Mattox KL, Feliciano DV, Beall AC et al. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients epidemiologic evolution 1958-1988. Ann
Surg 1989; 209:698.
Bickell WH, Wall MJ, Pepe PE. Immediate versus delayed fluid resuscitation for
hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331:1105.
Graham JM, Feliciano DV, Mattox KL et al. Management of subclavian vascular
injuries. J Trauma 1980; 20:537.
Johnston RH Jr, Wall MJ Jr, Mattox KL. Innominate artery trauma, a thirty year
experience. J Vasc Surg 1993; 17:134.
Wall MJ, Hirshberg A, Mattox KL: Pulmonary tractotomy with selective vascular
ligation. Am J Surg 1994; 168:665.
CHAPTER 1
CHAPTER 22
Diaphragm Injuries
James A. Murray
Introduction
In the acute setting diaphragm injuries are generally not life threatening but can
be associated with a significant morbidity and mortality due to associated injuries or
herniation with cardiopulmonary compromise. In addition, if undetected in the
acute setting, delayed presentation of diaphragmatic hernias carries an increased risk
of complications.
Sennertus described first postmortem finding of a strangulated diaphragm
hernia in 1541.
Bowditch made the first antemortem diagnosis of diaphragmatic herniation
in 1853.
Riolfi performed first surgical repair of diaphragmatic injury in 1886.
Surgical Anatomy
The diaphragm is a thin muscular sheet that defines the border between the
thoracic cavity and the abdomen. While its peripheral portion is made of
muscle, the central portion is tendinous.
The diaphragm is attached to: the xyphoid anteriorly, the lower six ribs and
costal cartilage laterally, the lumbar vertebrae posteriorly.
The Innervation of the Diaphragm

Phrenic nervesC3-C5 cervical roots
On the diaphragm the phrenic nerve divides into four rami: anterior, anterolateral, posterolateral, posterior.
This branching pattern must be appreciated to prevent injury when incising
the diaphragm.
Diaphragm excursion
During respiration the diaphragm raises:
To the level of the nipples anteriorly (the 5th intercostal space)
To the tips of the scapula posteriorly (the 8th intercostal space)
Classification of Diaphragm Injuries

Wounds of the diaphragm are classified by the duration of time between the
injury and presentation.
Acute phasefrom injury to the time of recovery from the initial insult
James A. Murray, Department of Surgery, Division of Trauma and Critical Care,
University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A.
238
Trauma Management
Chronic phasetime after recovery from initial injury during which the patient
develops gastrointestinal or respiratory complaints. These symptoms are due
to herniation of viscera through the unrepaired defect.
Diaphragmatic Herniation Can Occur in Two Places
22
Intrathoracic herniationthis is the most common. The defect is through

the muscular portion of the diaphragm and allows communication with the
thoracic cavity.
Intracardiac herniationvery rare. Defects through the central infracardiac
portion of the diaphragm allow communication and herniation into the pericardial sac.
Epidemiology of Diaphragm Injuries

Blunt TraumaIncidence
4-6% of patients requiring laparotomy or thoracotomy
May be as high as 9.5% in severe accidents
Front seat, belted passengers are at higher risk, also passengers with improperly placed lap belts at increased risk
Blunt TraumaMechanism
More common with abdominal trauma than thoracic trauma
Due to an increase in abdominal pressure and decrease in abdominal volume
Rib fractures may result in lacerations or avulsion of the diaphragm from its
attachments
Blunt TraumaLocation
75% of blunt diaphragm ruptures on the left

2025% of blunt ruptures involve the right diaphragm
2% of diaphragm ruptures are bilateral
1% of diaphragm ruptures will be intrapericardial
Blunt TraumaAssociated Injuries
Chest trauma60%
Long bone fracture40%
Pelvic fractures35%
Splenic injury45%
Head injury30%
Liver28%
Right diaphragm injuries have a 100% incidence of associated intra-abdominal
injuries.
Left diaphragm ruptures have an 80% incidence of associated intra-abdominal
injuries.
Penetrating Trauma
The incidence of diaphragm injuries depends upon the location of the injury,
the mechanism of injury, the patients clinical status, as well as the method used to
detect diaphragm injuries.
Thoracoabdominal injuries are at greatest risk for diaphragm injuries (20-50%).
Gunshot wounds are more frequently associated with diaphragm injuries than
stab wounds (60% versus 30%).
Diaphragm Injuries
239
Symptomatic patients (those with peritonitis or hemodynamic instability) undergoing laparotomy have a greater incidence than asymptomatic patients diagnosed by laparoscopy (60% versus 25%).
Diagnosis
The diagnosis of diaphragmatic injuries can be very difficult especially in the
asymptomatic patient.
The clinical presentation of patients with diaphragmatic injuries is quite variable.
Patients may:
Be asymptomatic
Demonstrate nonspecific physical findings
Often demonstrate physical findings due to associated injuries, which may
determine the need for operative intervention
In General:
80-90% have significant associated intra-abdominal injuries.
50-90% will present with shock in the emergency department.
25-30% of diaphragmatic injuries will be isolated injuries.
Abdominal Findings
Abdominal distention
Scaphoid abdomendue to herniation of abdominal contents into the thoracic cavity
Abdominal tendernessmay be mild to diffuse peritonitis
Thoracic/Respiratory Findings
Dyspnea, orthopnea
Decreased breath sounds
Associated hemopneumothorax
Bowel sounds in the thorax
Respiratory distress
Cardiac Findings
Tamponade
Cardiopulmonary compromise/shock
Radiographic Findings
Preoperative diagnosis of blunt diaphragm rupture can be suspected or diagnosed
by the initial chest x-ray.
Plain Radiographs of the Chest
Normal CXR
Obscured diaphragm border
Irregular contour of the diaphragm
Hemopneumothorax
Elevated hemidiaphragm (Fig. 22.1)
Air bubble, air-fluid level, or mass above the diaphragm
Nasogastric tube above the level of the diaphragm
22
240
Trauma Management
22
Fig. 22.1. Elevation of the left hemidiaphragm due to a penetrating injury. Only
about 14% of patients with an elevated diaphragm will have a diaphragmatic injury.
A normal chest x-ray does not exclude a diaphragmatic injury. Except for those
findings that demonstrate abdominal contents within the thoracic cavity, many of
these findings are nonspecific.
Contrast studies may be used to diagnose diaphragmatic herniation of hollow
viscera:
Upper gastrointestinal studies
Barium enema
Computerized Tomography
May allow visualization of diaphragmatic hernias (Fig. 22.2)
Diaphragm lacerations or perforations not associated with intestinal herniation will not be visualized by CT scans.
Diagnostic Peritoneal Lavage

Diagnostic peritoneal lavage provides a nonoperative, fairly sensitive, yet nonspecific method for detecting diaphragm lacerations.
The only finding consistent with a diaphragmatic injury is if lavage fluid is noted
in the thoracic cavity or exits through the thoracostomy tube.
Small defects in the diaphragm may be associated with little or no bleeding
Red blood cell counts for a positive lavage vary from 5,000-100,000 cells/mm3
The sensitivity of DPL improves with lower RBC counts.
Diaphragm Injuries
241
22
Fig. 22.2. CT scan demonstrates herniation of the stomach within the left chest.
Diaphragmatic injuries may be associated with 05,000 RBC/mm3, and missed

by DPL.
Isolated Diaphragmatic Injuries

2530% of patients with diaphragmatic injuries due to penetrating trauma will
be completely asymptomaticNo abdominal tenderness and a normal CXR.
This group represents the population at highest risk of missed injuries during
the acute phase and developing delayed complications.
A high index of suspicion must be maintained and aggressive evaluation pursued
in this patient population.
DiagnosisChronic Diaphragmatic Hernias

May present years after the initial injury
Are associated with a high incidence of complications
Due to the nonspecific nature of the complaints and a remote history of trauma
which is often forgotten, or felt to be insignificant, the diagnosis of a chronic diaphragmatic hernia is delayed or not entertained.
Many of the clinical and radiographic findings are similar to those for acute
herniation.
Abdominal Symptoms
Nonspecific abdominal pain
Gastrointestinal obstruction
Abdominal sepsis
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Trauma Management
Thoracic/Respiratory Symptoms
Chronic cough
Respiratory distress
Tympany to percussion
Bowel sounds in the chest
Radiographic Findings
22
Pathognomonic findings include:

Air-fluid levels, gastric or colonic markings in the chest (Fig. 22.3)
A coiled nasogastric tube above the diaphragm (Fig. 22.4)
Any other nonspecific findings such as a pleural effusion, atelectasis, infiltrate
may be present
Contrast studies and CT scans are best suited to aid in the diagnosis of chronic
diaphragmatic herniation (Fig. 22.2).
Surgical Pathology
Blunt rupture of the diaphragm is typically 7-10 cm in length. Herniation is
most likely to occur immediately or soon after injury.
Penetrating injuries are typically 2-4 cm in length. These may go undetected
during the acute phase. These undetected small lacerations are more commonly associated with delayed herniation years after initial injury
Operative Evaluation
Due to the unreliability of physical exam and radiographic findings the only
method currently available to definitively diagnosis a diaphragmatic injury in the
acute setting is by direct visualization. This can be done with laparotomy, laparoscopy,
or thoracoscopy. Asymptomatic patients with penetrating injuries to the
thoracoabdominal region should be aggressively evaluated.
Some authors have suggested mandatory laparotomy to evaluate high-risk
patients suspected of having a diaphragmatic injury.
In the asymptomatic patient this policy is associated with a high negative
laparotomy rate, greater than 75%
There is a significant morbidity and mortality associated with negative
laparotomy
Minimally invasive surgical techniques allow for a thorough visualization of the
diaphragm without prolonged hospitalization and avoid the high complication rate
associated with a negative laparotomy. In addition, isolated diaphragmatic injuries
can be repaired with these techniques.
In the absence of any indication other than the suspicion of a diaphragmatic
injury currently we use laparoscopy to evaluate high-risk patients. High-risk
patients are defined as patients who are hemodynamically stable without abdominal
tenderness with penetrating injuries to either the:
left thoracoabdominal region, or (Fig. 22.5)
anterior portion of the right lower thorax
Laparoscopic Evaluation of Asymptomatic Patients

Following Penetrating Injuries
All patients are admitted for observation and are monitored for evidence of
ongoing bleeding or the development of abdominal tenderness. This is for a
minimal period of 6 hours (Fig. 22.6).
Diaphragm Injuries
243
22
Fig. 22.3. Plain CXR showing a chronic diaphragmatic hernia with the stomach
noted in the left chest.
Fig. 22.4. Diaphragmatic hernia with the nasogastric tube coiled in the stomach
above the level of the left hemidiaphragm.
244
Trauma Management
22
Fig. 22.5. Benign appearing stab wound to the left lower chest in stable patient.
Had laparoscopy not been performed an injury to the diaphragm would have been
missed.
If the patient develops significant abdominal tenderness or demonstrates ongoing bleeding, a laparotomy is performed emergently.
Radiographic evaluation of the chest is performed with a delayed CXR, if
necessary, prior to performing laparoscopy.
If a hemopneumothorax develops, a thoracostomy tube is placed prior to
performing laparoscopy.
If a diaphragmatic injury is identified during laparoscopy (Fig. 22.7) and the
patient was asymptomatic during the observation period, we feel further
exploration of the abdomen is not necessary and the defect is closed with
either laparoscopic suturing or stapling.
If there is suspicion of a hollow viscus injury, further laparoscopic exploration
by mobilization of the colon and stomach will be done.
If any uncertainty remains, a laparotomy will be performed.
Some surgeons prefer thoracoscopy to evaluate the diaphragm. This is an
acceptable technique and has both advantages and disadvantages when compared to laparoscopy. (See Chapter on Minimal Invasive Surgery in Trauma)
Should the surgeon feel that peritoneal penetration or a diaphragmatic defect
is an indication for laparotomy, or that a diaphragm injury should be repaired
by open techniques, the six-hour observation period may be shortened or
omitted. (For further discussion of the techniques, complications and details
please refer to chapter on Minimally Invasive Surgery in Trauma.)
Operative Evaluation of Blunt Injuries

If blunt rupture of the diaphragm is still suspected, operative evaluation should
be performed preferably by laparoscopy, yet some surgeons may choose to perform
a celiotomy or thoracoscopy.
Diaphragm Injuries
245
22
Fig. 22.6. Algorithm for evaluation of penetrating thoracoabdominal injuries.
Should only be performed in hemodynamically stable patients

Minimally invasive procedures can avoid a negative laparotomy
Conditions which May Mimic a Blunt Diaphragmatic Hernia

Diaphragm eventration (Fig. 22.8)
Phrenic nerve paralysis (Fig. 22.9)
Operative ManagementAcute Injuries

Acute injuries are most commonly approached through an abdominal incision
due to the need to evaluate for associated injuries. During any laparotomy for trauma
a thorough evaluation of each leaflet is mandatory. Once identified an Alliss or
Babcock clamp can be placed on the edges of the injury. This allows mobilization of
the injury toward the surgeon and stabilizes the diaphragm during the repair.
Most acute injuries can be repaired primarily.
Nonabsorbable sutures should be used.
These should be placed in an interrupted fashion.
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Trauma Management
22
Fig. 22.7. Appearance of diaphragmatic injury seen during laparoscopy.
Either simple, horizontal mattress, or figure-of-eight suturing techniques can

be used.
A thoracostomy tube is routinely placed to allow re-expansion of the lung and
evacuate any residual hemothorax.
These same principals apply whether the repair is performed during a laparotomy or laproscopically.
Laparoscopic staples have been used in some instances. Experimental evidence
in an animal model has shown no difference in the healing of the diaphragm compared to suturing, open or laparoscopic.
Operative RepairChronic Hernia

Either a thoracotomy or laparotomy may be used for repair of a chronic diaphragmatic hernia.
Most authors state that a thoracotomy is required to allow lysis of adhesions
between the bowel and the chest wall or lung.
Abdominal exploration allows evaluation of the herniated viscus following
reduction and an opportunity to assess viability and the need for resection.
Resection of nonviable bowel is best performed in the abdomen after closure
of the defect, preventing contamination of the thoracic cavity.
Occasionally enlargement of the defect is required to allow reduction of herniated viscera.
Most chronic defects can be closed primarily. If necessary a prosthetic patch
can be used to close the defect if tissue loss is present.
Laparoscopy and thoracoscopy can be used to diagnosis and repair chronic diaphragmatic hernias. The same principles of open reduction and repair apply when
using these techniques.
Diaphragm Injuries
247
22
Fig. 22.8. Eventration of left hemidiaphragm.
Most Common Herniated Viscera
Omentum
Stomach
Colon
Small bowel, spleen and liver are frequently found in the hernia
Prognosis and Outcome

Early morbidity and mortality of acute injuries to the diaphragm are due to
associated injuries.
Early diagnosis and treatment of diaphragmatic hernias has a better prognosis
than do those that are diagnosed late, in the chronic stages.
The morbidity and mortality of chronic diaphragmatic hernias is dependent
upon the presence of bowel ischemia, necrosis, and sepsis.

Inadequate evaluation of the diaphragm during laparotomy
Lack of clinical suspicion for an occult diaphragmatic injury during the acute
phase following injury. Failure to evaluate these stable patients with laparoscopy.
Failure to recognize delayed diaphragmatic hernia in patients with a previous
history of penetrating thoracoabdominal trauma.
248
Trauma Management
22
Fig. 22.9. Phrenic nerve paralysis with the associated elevation of the left
hemidiaphragm
References
1.
2.
3.
4.
5.
Beal SL, McKennan M. Blunt diaphragm rupture. A morbid injury. Arch Surg
1988; 123:828-832.
Demetriades D, Kakoyiannis S, Parehk D et al. Penetrating injuries to the diaphragm. Br J Surg 1988; 75:824-826.
Feliciano DV, Cruse PA, Mattox KL et al. Delayed diagnosis of injuries to the
diaphragm after penetrating wounds. J Trauma 1988; 28:1135-41.
Murray JA, Demetriades D, Cornwell EE et al. Penetrating thoracoabdominal
trauma: the incidence and clinical presentation of diaphragm injuries. J Trauma
1997; 43:624-626.
Murray JA, Demetriades D, Asensio JA et al. Occult injuries to the diaphragm:
Prospective evaluation of laparoscopy in penetrating injuries to the left lower chest.
J Am Coll Surg 1998; 187:626-630.
CHAPTER 1
CHAPTER 23
Esophageal Injury
Juan A. Asensio and Esteban Gambaro
The Edwin Smith Papyrus, written in Egypt between 4-5,000 years ago described amongst its 48 cases, the first reported penetrating wound of the esophagus.
Incidence
It is estimated that at best, busy urban trauma centers admit approximately
five penetrating esophageal injuries yearly.
Blunt esophageal injury from external trauma is even rarer, with 96 cases
reported in the literature since 1900. It is estimated that blunt injuries have an
incidence of 0.001%
Mechanism of Injury
Penetrating injuries are the most common causes of esophageal trauma. Blunt
injury to the esophagus is quite rare.
Other causes of esophageal injuries include spontaneous rupture or Boerhaves
syndrome, perforations from benign and malignant disease such as achalasia
and esophageal cancer, iatrogenic perforations due to endoscopy and balloon
dilatations and perforations secondary to the ingestion of caustic agents. These
injuries are caused by nonexternal causes of trauma and will not be covered
any further.
Associated Injuries
The esophagus, by virtue of its anatomic proximity to other organs is rarely
injured alone. Multiple associated injuries are the rule rather than the exception.
There will be approximately two associated injuries per patient coupled with
the presence of an esophageal injury.
Cervical esophageal injuries are generally associated with injuries to the major
blood vessels of the neck, trachea, cervical spine and spinal cord.
Associated injuries occurring in conjunction with thoracic esophageal injuries
include: major thoracic vascular, cardiac, pulmonary, bony thoracic structures
such as ribs, thoracic spine and neurological injuries.
Associated injuries occurring concomitantly with intraabdominal esophageal
injuries include: gastric, hepatic, and major abdominal vascular injuries.

Cervical esophageal injuries are predominant57%.
Esteban Gambaro, University of Southern California, LAC+USC Medical Center, Los
Angeles, California, U.S.A.
250
Trauma Management
The thoracic esophagus is injured in 30% of the cases.

Abdominal esophageal injuries occur with a frequency of 17% and are the
least common of all esophageal injuries.
Combined thoracic and abdominal esophageal injuries occur with a frequency
of 2%.
In blunt trauma, 82% of injuries occur in the cervical esophagus.
Diagnosis
23
The diagnosis of esophageal injury requires a high index of suspicion.

The esophagus tends to be a relatively silent organ, clinical presentation wise.
Most of the clinical findings will usually be attributable to the large number
of associated injuries present with esophageal injuries.
Physical examination may be characterized by minimal findings.
The classical symptoms attributed to esophageal injuries are: pain29%, dysphagia7% and odynophagia3%. They are not uniformly present. An associated pneumothorax or hemothorax is present in 20% of the cases. Subcutaneous emphysema occurs in 19% of the cases.
Dysphagia, odynophagia and subcutaneous emphysema are much more prevalent in cervical esophageal injuries than in other anatomic locations of the
esophagus.
Thoracic esophageal injuries are generally silent. In rare occasions they may
be diagnosed when a chest tube is inserted and particulate matter and/or food
egress via the chest tube.
Investigations
Cervical esophageal injuries can be diagnosed with an esophagogram which is
80% reliable.
Flexible endoscopy is of no use in the diagnosis of cervical esophageal injuries,
whereas rigid esophagoscopy is of value, but requires that the patient be placed
under general anesthesia.
The combination of an esophagogram and rigid esophagoscopy has over 90%
reliability in establishing the diagnosis of cervical esophageal injury.
Esophagograms are virtually diagnostic for thoracic esophageal injuries.
Flexible endoscopy has been reported to be a valuable adjunct in the diagnosis
of thoracic esophageal injuries.
The diagnosis of intraabdominal esophageal injuries is usually established
intraoperatively.
Surgical Management
Neck injuries should be explored through the standard incision at the anterior
border of the sternocleidomastoid muscle, extending from the mastoid process to the sternoclavicular junction. Immediate control of life threatening
hemorrhage from associated vascular injuries is a must. A thorough and meticulous search to evaluate for the presence of an esophageal injury is then
carried out.
Thoracic injuries can be explored via the standard posterolateral thoracotomy
incision provided that the patients hemodynamic status will allow sufficient
time for positioning.
Esophageal Injury
251
23
Fig. 23.1. Esophagram showing a cervical esophageal injury. Reprinted with permission from: Asensio JA, Demetriades D. Textbook of Techniques in Complex
Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In Press.
A right posterolateral thoracotomy will identify the vast majority of intrathoracic esophageal injuries, whereas a left posterolateral thoracotomy will identify the lowermost intrathoracic esophageal injuries.
Abdominal injuries are approached via a midline incision. A meticulous search
in the area of the gastroesophageal junction is a must to identify intraabdominal
esophageal injuries.
Insufflation of air, sterile saline, and methylene blue dye may identify an esophageal injury not easily seen.
All esophageal injuries should be graded utilizing the American Association
for the Surgery of TraumaOrgan Injury Scale for esophageal injury
(AAST-OIS).
Most esophageal injuries can be repaired primarily82%, with a meticulous
double layer closure of absorbable and nonabsorbable sutures. Between 3%
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Trauma Management
23
Fig. 23.2. Esophagram showing a mid-thoracic esophageal injury. Reprinted with

permission from: Asensio JA, Demetriades D. Textbook of Techniques in Complex
Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In Press.
Fig. 23.3. Neck exploration showing a lacerated cervical esophagus. Forceps point
to the clearly visible nasogastric tube. An autogenous saphenous vein bypass has
been used to repair the associated carotid artery injury. Reprinted with permission
from: Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In Press.
Esophageal Injury
253
and 4% of all esophageal injuries require resection and diversion or resection

and anastomosis. Approximately 11% can be treated by drainage alone.
All esophageal injuries should be drained with closed systems. The drains should
not be placed in direct juxtaposition to the suture line to avoid esophageal
fistula formation.
A useful adjunct to the repair of esophageal injuries is the use of muscle or
pleural flaps.
Abdominal esophageal injuries generally require performing Nissen
fundoplication to buttress the repair.
In cases of an esophageal suture line dehiscence, generally no attempts at further repair will be successful although occasionally they may be attempted.
Treatment will consist of wide drainage and more complex reconstructive procedures including esophagectomy with colonic or gastric interpositions or the
use of very complex muscle flaps.
Mortality
Esophageal injuries carry a significant mortality rate. The mortality rate from
penetrating esophageal trauma is 15% and from blunt trauma 10%.
Factors that increase mortality in esophageal injuries include delays in diagnosis and definitive surgical repair of greater than 8-16 hours.
Mortality rates can triple in patients undergoing surgical procedures after 24
hours.
Morbidity
Esophageal injuries are associated with very high rates of morbidity.
Esophageal related complications include: wound infections10%, empyema8%, mediastinitis6%, esophageal fistulas5% and tracheo-esophageal fistulas1%.
References
1.
2.
3.
4.
5.
Asensio JA, Berne J, Demetriades D et al. Penetrating esophageal injuries. Time

interval of safety for preoperative evaluationhow long is safe: J Trauma 1997;
43:319-324.
Asensio JA, Chahwan S, Mackersie R et al. Penetrating esophageal injuries:
Multicenter study of the American association for the surgery of trauma: J Trauma
(abstract) 1999; 47:207.
Cornwell EE, Kennedy F, Ayad IA et al. Transmediastinal gunshot wounds A
reconsideration of the role of aortography: Arch Surg 1996; 131:949-953.
Weigelt JA. Diagnosis of penetrating cervical esophageal injuries. Am J Surg 1987;
154:619-622.
Winter RP, Weigelt JA. Cervical esophageal trauma. Arch Surg 1990; 125:8:49-851.
23
CHAPTER 24
CT Scan in Chest Trauma

Alison Wilcox and Randall Radin
Lung
Posttraumatic lung disease is often underestimated on conventional radiographs
of the chest. CT scan is very sensitive in identifying and characterizing lung injury.
Contusion
Usually seen in the setting of blunt trauma, defined as an infiltrate seen almost immediately following trauma.
Laceration or Pneumatocele (Figs. 24.1-24.3)

May be seen in both blunt and penetrating trauma.
Defined as an air lucency surrounded by consolidated lung, which represents
intraalveolar hemorrhage.
Lacerations may extend to the pleural surface and result in pneumothorax.
Aspiration
Blood, from either the mouth or nasopharnyx, or gastric contents, usually in
the dependent locations of posterior segments of the upper lobes or superior
segments of the lower lobes. If aspiration occurred while the patient was upright, the infiltrate is typically in the basal segments. The type of aspiration is
evident by its clinical course as gastric contents tend to produce a flagrant
inflammatory response whereas the bland blood aspiration tends to resolve
over several days.
Pleura
Pneumothorax (Figs. 24.4-24.6)
Easily identifiable on CT. Even small pneumothoraces not identifiable on
conventional chest radiographs may be seen, usually anteriorly on the CT.
Hemothorax
CT may identify the high attenuation fluid in the pleural space as blood. If a
significant amount of blood is present in the absence of parenchymal findings, a
vascular injury, from either great vessels or intercostal vessels, may be present.

Alison Wilcox, Department of Radiology, University of Southern California,
Randall Radin, Department of Radiology, University of Southern California,
255
24
Fig. 24.1. Displaced posterior right rib fracture with associated bibasilar lung consolidation, consistent with pulmonary contusion and hemorrhage. A small right
pleural fluid collection is also present, probably representing a hemothorax in the
setting of trauma.
Fig. 24.2. Figure 24.1 in lung windows demonstrates gas lucencies within the pulmonary hemorrhage, consistent with pulmonary lacerations.
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Trauma Management
24
Fig. 24.3. Posterior left rib fracture and associated pulmonary contusion. Within
the consolidation is an air-fluid level, consistent with a pulmonary laceration. A
small amount of chest wall emphysema is also present.
Fig. 24.4. A large right pneumothorax (open white arrow) with mediastinum shift to
the left, indicating that the pneumothorax is under tension. A subtle posterior right
rib fracture is also seen.
257
24
Fig. 24.5. A tension pneumothorax on the left with shift of the mediastinum to the
right. There is clear demarcation between collapsed, consolidated lung and gasfilled pleural space.
Fig. 24.6. Scout image
from figure 24.5 demonstrates the large lucency
in the left lower chest,
consistent with a pneumothorax in a supine
patient. The mediastinal
shift is again seen.
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Trauma Management
Chest Wall
Rib Fractures
CT may occasionally identify rib fractures that are missed on conventional
radiographs, usually in a lateral or inferior location. Conventional films
remain the mainstay of their discovery
Clavicle and Scapula Fractures (Figs. 24.7, 24.8)

May be identified on CT although usually more commonly seen on conventional radiographs.
Sternal Fractures (Figs. 24.9, 24.10)
24
May be the source of significant mediastinal hemorrhage. They are difficult to

identify on conventional films even with sternal views. CT, particularly with
lung windows, often reveals the sternal fracture, which is usually transverse.
Vertebral Fractures (Fig. 24.11)

CT is the study of choice to evaluate spinal fractures. Often unsuspected fractures are identified on CT with associated prevertebral hemorrhage.
Aorta and Great Vessels

Rupture of the aorta causes approximately 16% of all motor vehicle accident
fatalities. Most patients with aortic injury do not survive the initial injury and
are not imaged. The well-known signs of great vessel injury on conventional
radiographs include apical cap; deviation of trachea, endotracheal tube, or
nasogastric tube; indistinct aortic knob or descending aorta, and widening of
the superior mediastinum. The last finding is pathologic only when the patient
is imaged in the upright, full-inspiratory position. As this is often not possible
in critically ill patients, mediastinal widening is often over-interpreted.
Although the use of CT to diagnose great vessel injury is still somewhat controversial, many studies have demonstrated the high specificity and sensitivity
of its use.
Indirect Signs
Mediastinal Hemorrhage
May be associated with sternal or vertebral fractures. Usually venous in origin,
but is worrisome if intimately associated with aorta or great vessels, i.e., obliteration of normal fat planes adjacent to vascular structures.
Direct Signs
Aortic Contour
Focal contour abnormality, usually seen at the level of the left pulmonary
artery at the level of the ligamentum arteriosum.
Intimal Flap and/or Associated Thrombus

Linear defect or thrombus within aortic lumen, again usually seen at the level
of the ductus.
259
24
Fig. 24.7. Right clavicle fracture
Fig. 24.8. Right scapula fracture with associated surrounding hematoma.
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Trauma Management
Fig. 24.9. Four consecutive
images from a CT scan demonstrate an anterior mediastinal
hematoma with a sternal fracture (white arrow). Although
mediastinal hemorrhage may
herald great vessel injury, when
the hematoma is intimately associated with a fracture, the fracture is the likely source. Since the
anterior clear space should contain only fat in the adult patient,
any increased attenuation of mediastinal fat should indicate
blood.
24
Pseudoaneursym (Figs. 24.12, 24.13)

Larger contour abnormality, which is usually focal (to distinguish it from a
true aneurysm which is usually diffuse). The intimal disruption may or may
not be visible.
Aortic Transection (Fig. 24.14)

Discontinuity of ascending and descending aorta, usually with large associated hematoma and/or pseudoaneursym formation
Aortic Dissection
Intimal flap extending for a distance, may involve either the ascending or
descending aorta, though in traumatic dissection the flap usually begins at the
ductus. Aortic dissection is more common when preexisting vascular disease
is present.
Contrast Extravasation (Fig. 24.15)

Rarely identified as patients are usually too unstable to be evaluated with CT.
Bronchus
Usually unrecognized on initial imaging, with frequent delayed diagnosis.
Persistent or increasing subcutaneous emphysema should raise the suspicion
of bronchial injury.
Persistent pneumothorax results from rupture of the mediastinal pleura or injury
to the right mainstem or distal left main bronchus. More proximal bronchial or
tracheal injuries result in pneumomediastinum immediately postinjury.
261
24
Fig. 24.10. Another patient with a sternal fracture and small associated mediastinal
hematoma. The sternum often fractures in the transverse plane and subsequently
may be missed on CT if the image is not through the plane of the fracture. Often the
clue to the sternal fracture is the double density indicating a displaced fracture and
overlapping bone.
Fallenlung signA conventional radiographic description of peripheral rather

than central lung collapse. Though it is rarely identified, it indicates transection of the mainstem bronchus and rupture of the normal hilar attachments.
Endotracheal tube with its tip projecting beyond the expected tracheobronchial
tree indicates that the tube has traversed a tracheal injury. Similarly, expansion of
the tracheal cuff outside the expected confines of the tracheal lumen indicate
tracheal injury.
Diaphragm
The incidence of traumatic rupture of the diaphragm is reported as ranging
from 1-8%. Although many of these patients have abnormal conventional
radiographs, the findings are not specific for diaphragmatic injury. There is
often a delay in diagnosis, or the injury may be found at diagnostic laparoscopy
or incidentally during laparotomy. Israel et al used thin-section helical CT
with coronal and sagittal reformation to detect diaphragmatic injury in the
swine. However, thin-section CT of the chest in all trauma patients is not
routine. CT is therefore often suboptimal. MRI may be helpful in stable patients
or in cases where CT is equivocal. Previously acquired eventrations and
asymmetric diaphragm positioning may mimic pathology (Fig. 24.16).
Collar-signA sensitive and specific sign of diaphragmatic injury demonstrating, in coronal or sagittal images, the herniation of abdominal fat or con-
262
Trauma Management
24
Fig. 24.11. Mediastinal windows of a trauma patient demonstrating prevertebral

hematoma and an associated comminuted vertebral fracture. Since the blood is
posterior, this should indicate possible spine pathology, even if a fracture is not
seen on the thick section chest CT.
Fig. 24.12. Increased attenuation of the mediastinal fat intimately associated with
the aortic arch indicates possible aortic injury. In this case there is an obvious
medial opacified outpouching of the proximal descending aorta (white arrow), which
is diagnostic of a traumatic pseudoaneurysm.
263
Fig. 24.13. Confirmatory
aortogram demonstrates the
contour defect at the level of
the ductus (white arrow),
diagnostic of a traumatic
pseudoaneursym.
24
Fig. 24.14. Complete disruption of the normal appearance of the descending aorta.
This indicates aortic transection with active extravasation. This patient went directly to the operating room without confirmatory aortogram. Notice also the bilateral pleural fluid collections, consistent with bilateral hemothoraces.
264
Trauma Management
24
Fig. 24.15. CT demonstrates active extravasation from a transected aorta. Note the
extravasated blood makes delineation of the aorta impossible.
Fig. 24.16. Bowel and omental fat lateral to and superior to the stomach. In addition there is an abnormal contour of what should be the diaphragm posteriorly
(white arrow), indicating rupture of the diaphragm with herniation of abdominal
contents.
265
tents above the diaphragm with a constriction at the level of the diaphragm
forming the so-called collar.
Esophagus
Usually seen in penetrating trauma but may occur in blunt chest trauma.
Pneumomediastinum is often seen, although the source may not be identified. Extraluminal gas adjacent to the site of injury may lead to the suspicion
of injury to the esophagus (Fig. 24.17).
Pleural effusion is more common on the left side as a result of esophageal
injury. This is often accompanied by left lower lobe atelectasis.
V-sign of NaclerioA sign described on conventional radiographs of a small
crescent of gas forming a V shape between the descending aorta and the left
hemidiaphragm seen with traumatic esophageal rupture (usually secondary to
prolonged, violent vomiting).
Heart
Cardiac contusion is the most common cardiac injury. This is diagnosed with
cardiac enzymes and EKG changes. CT scanning is not useful in diagnosis though it
may diagnose ancillary findings predominately affecting the pericardium.
HemopericardiumHigh attenuation fluid representing blood may fill the
pericardium and may cause cardiac tamponade (Fig. 24.18).
PneumopericardiumThis is usually associated with pneumomediastinum
but may also cause tamponade.
Fig. 24.17. A gunshot wound to the neck, which has fractured the vertebral body.
Note the extraluminal gas posterior to the thyroid gland. The trachea appears intact but the esophagus is not well visualized. This patient had rupture of the esophagus confirmed by esophagography.
24
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Trauma Management
24
Fig. 24.18. High-attenuation fluid surrounding the heart indicates hemopericardium.
Tubes and Lines

CT may correctly identify improper line placement. All tubes and lines should
be identified on every CT scan.
Nasogastric tubeMay be coiled inappropriately or in the distal esophagus.
Inadvertent placement of the NGT in the mainstem bronchus is easily identified (Figs. 24.19-24.21).
Endotracheal tubeThe most common inadvertent placement is into the
right mainstem bronchus (Figs. 24.22).
Subclavian venous lines. May cross the midline into the opposite subclavian
vein. May be placed in the left superior intercostal vein, usually from a left
subclavian vein approach. May be placed intraarterially (Figs. 24.23 and 24.24).
Chest tubesIf not obviously in a pleural location, may be intraparenchymal
or within a fissure. May also be placed in the subcutaneous tissues, which may
not be recognized on a conventional frontal radiograph (Figs. 25 and 26).
References
1.
2.
3.
4.
5.
Wagner RB, Crawford WO, Schimpf PP. Classification of parenchymal injuries of

the lung. Radiology 1988; 167:77-82.
Mirvis SF, Shanmuganathan K, Miller BH et al. Traumatic aortic injury: Diagnosis with contrast-enhanced thoracic CTFive-year experience at a major trauma
center. Radiology 1996; 200:413-422.
Murray JG, Caoili E, Gruden JF et al. Acute rupture of the diaphragm due to
blunt trauma: Diagnostic sensitivity and specificity of CT. AJR 1996; 166:10351039.
Israel RS, McDaniel PA, Primack SL et al. Diagnosis of diaphragmatic trauma
with helical CT in a swine model. AJR 1996; 167:637-641.
Unger JM, Schuchmann GG, Grossman JE et al. Tears of the trachea and main
bronchi caused by blunt trauma: Radiologic findings. AJR 1989; 153:1175-1180.
267
24
Fig. 24.19. Scout image from a CT scan demonstrates a nasogastric tube extending
into the left lower lobe bronchus.
Fig. 24.20. CT scan from Figure 24.19 demonstrates the small caliber of the
nasogastric tube within the trachea.
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Trauma Management
24
Fig. 24.21. CT scan from figure 24.19 demonstrates the small caliber of the
nasogastric tube within the left main bronchus.
Fig. 24.22. Endotracheal tube in the right mainstem bronchus, the most common
place for a misplaced endotracheal tube. There is resulting left lung collapse with
a left chest tube and left rib fracture. The nasogastric tube is in the esophagus.
269
24
Fig. 24.23. A left central line, which appears to be in the left subclavian artery.
(white arrow)
Fig. 24.24. A more caudal image of figure 24.25 demonstrates the venous line
coiled in the aorta.
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Trauma Management
Fig. 24.25. An intrapulmonary chest tube with

surrounding or resulting pulmonary hemorrhage . Chest wall
emphysema and a posterior pulmonary laceration are also present.
24
Fig. 24.26. An improperly position chest tube within the chest wall, anterior to the
scapula. This would probably be missed on the frontal view of the chest.
CHAPTER 1
CHAPTER 25
Emergency Department Thoracotomy

Juan A. Asensio and Kuen-Jang Tsai
Introduction
Indications for the use of the Emergency Department thoracotomy that
appear in the literature range from vague to quite specific. It has been used
in a variety of settings including penetrating and blunt thoracic and/or
thoracoabdominal injuries, cardiac and exsanguinating abdominal or extremity
vascular injuries.
Historic Perspective
Schiff in 1874 promoted the concept of open cardiac massage.
Igelsbrud in 1901 reported the first successful resuscitation of a posttraumatic
cardiac arrest patient with open massage.
In 1956 Zolls introduced the concept of external defibrillation.
In 1960 Kouwenhoven introduced the concept of closed cardiopulmonary
resuscitation.
Beall in 1961 first proposed that patients experiencing cessation of cardiac
action undergo immediate thoracotomy and open cardiac massage, whether
in the emergency, operating, recovery room or ward. He also advocated the
use of immediate cardiorrhaphy in the emergency room.
Physiology
Objectives
Resuscitation of agonal patients with penetrating cardiothoracic injuries.

Evacuation of pericardial tamponade.
Control of thoracic hemorrhage.
Prevention of air embolism.
To perform open cardiopulmonary resuscitation which can produce up to
60% of the normal ejection fraction.
Repair cardiac injuries.
To cross clamp the pulmonary hilum.
To cross clamp the descending thoracic aorta.
Effects of Thoracic Aortic Cross ClampingPositive Effects

Preservation and redistribution of remaining blood volume.
Improvement of coronary/carotid arterial perfusion.
Reduction of sub-diaphragmatic blood loss.

Kuen-Jang Tsai, University of Southern California, Los Angeles, California, U.S.A.
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Trauma Management
25
Fig. 25.1. Left anterolateral thoracotomy incision in the 5th intercostal space. Reprinted with permission from Asensio JA, Demetriades D. Textbook of Techniques
in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In Press.
Increases the left ventricular stroke work index (LVSWI).

Increases in myocardial contractility.
Effects of Thoracic Aortic Cross ClampingNegative Affects
Decreases blood flow to the abdominal viscera to approximately 10%.

Decreases renal perfusion to approximately 10%.
Decreases blood flow to the spinal cord to approximately 10%.
Induces anaerobic metabolism.
Induces hypoxia/lactic acidosis.
Imposes a tremendous afterload onto the left ventricle (LV).
Effects of Thoracic Aortic Cross ClampingUnknowns

Length of safe cross clamp time.
Incidence of reperfusion injury
Indications
Indications for the performance of Emergency Department thoracotomy can
be subdivided into three categories: accepted, selective, and rare.
Accepted Indications Include:
- Patients sustaining penetrating cardiac injuries that arrive in trauma centers
after a short scene/transport time with witnessed and/or objectively measured
physiological parameters (pupillary reactivity, spontaneous ventilation even if
agonal, presence of a carotid pulse, some measurable blood pressure, extremity
movement).
273
25
Fig. 25.2. Depicts the left chest open with a Finochietto retractor. There is a pericardial tamponade compressing the heart. Reprinted with permission from: Asensio
JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B.
Saunders Co., Philadelphia, PA. In Press.
Selective Indications:
- Emergency Department thoracotomy should be performed selectively in patients sustaining penetrating noncardiac thoracic injuries due to its very low
survival rate. Since it is difficult to ascertain whether injuries are noncardiac
thoracic versus cardiac this procedure may be employed to establish a diagnosis.
- Emergency Department thoracotomy should be performed selectively in patients
sustaining exsanguinating abdominal vascular injuries due to its very low survival rate. Meticulous selection of patients should be exercised. This procedure
should be used as an adjunct to definitive repair of the abdominal vascular injury.
Rare Indications:
- Emergency Department thoracotomy should be performed rarely in patients
sustaining cardiopulmonary arrest secondary to blunt trauma due to its very
low survival rate and poor neurological outcomes. Extreme caution should be
exercised in selecting patients for this procedure. It should be strictly limited to
those that arrive with vital signs at the trauma center and experience a witnessed
cardiopulmonary arrest. Most authors would caution against this indication.
Technique
Emergency Department thoracotomy should be performed simultaneously with
the initial assessment, evaluation and resuscitation, using the Advanced Trauma Life
Support (ATLS) protocols of the American College of Surgeons (ACS).
Immediate endotracheal intubation coupled with immediate venous access and
the simultaneous use of rapid infusion techniques complements the resuscitative
process.
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Trauma Management
25
Fig. 25.3. Pericardium is grasped between 2 Allis clamps and a sharp incision is
made anterior to the phrenic nerve. Reprinted with permission from: Asensio JA,
Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders
Co., Philadelphia, PA. In Press.
This technique should only be performed by surgeons that have had appropriate training in the performance of this procedure.
The left arm is elevated and the entire thorax is prepped rapidly with an antiseptic solution.
A left anterolateral thoracotomy commencing at the lateral border of the left
sternocostal junction and inferior to the nipple is carried out and extended
laterally to the latissimus dorsi. In females, the breast is retracted cephalad.
- The incision is carried rapidly through skin, subcutaneous tissue and the pectoralis major and serratus anterior muscles until the intercostal muscles are reached.
- The three layers of these interdigitated muscles are sharply transected with scissors. The pleura is then opened.
- Occasionally, the left fourth and fifth costochondral cartilages are transected to
provide greater exposure.
- A Finochietto retractor is then placed to separate the ribs. At this time the trauma
surgeons should evaluate the extent of hemorrhage present within the left
hemithoracic cavity. An exsanguinating hemorrhage with almost complete loss
of the patients intravascular volume is a reliable indicator of poor outcome.
The left lung is then elevated medially and the descending thoracic aorta is
located immediately as it enters the abdomen via the aortic hiatus. The aorta
should be palpated to assess the status of the remaining blood volume.
The descending thoracic aorta can be temporarily occluded against the bodies
of the thoracic vertebrae.
Prior to cross clamping the descending thoracic aorta, a combination of sharp
and blunt dissection commencing at both the superior and inferior borders of
the aorta is performed, so that the aorta may be encircled between the thumb
and index fingers.
275
25
Fig. 25.4. The descending Thoracic aorta is then sharply dissected. Note the position of the nasogastric tube, as the esophagus is superior to the aorta. Reprinted
with permission from: Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In Press.
- Inexperienced surgeons usually commit the error of clamping the esophagus,

which is located superior to the aorta. A nasogastric tube previously placed can
serve as a guide in distinguishing the esophagus from the often somewhat empty
thoracic aorta.
- A Crafoord-DeBakey aortic cross clamp should then be placed to occlude the
aorta.
If a cardiac injury is present, the pericardium is then opened longitudinally

above the phrenic nerve, pericardial clot and blood are evacuated and the
cardiac injury repaired.
If a pulmonary hilar hematoma or active hemorrhage are present, cross clamping
of the pulmonary hilum with a Crafoord-DeBakey cross clamp may be
necessary.
- If a pulmonary parenchymal laceration is detected it should be clamped with
Duval clamps.
If associated pathology is then encountered in the contralateral hemithoracic

cavity, the sternum is transected sharply and the left anterolateral thoracotomy
is then converted to a bilateral anterolateral thoracotomy.
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Trauma Management
25
Fig. 25.5. The descending thoracic aorta is bluntly dissected and a Crafoord-DeBakey
cross clamp is applied. Reprinted with permission from: Asensio JA, Demetriades
D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In press.
Ligation of one or two internal mammary arteries may be necessary if the left
anterolateral thoracotomy has been extended to the right hemithoracic cavity.
Aggressive ongoing resuscitation is needed with warm pressure driven fluid
via rapid infusers while this procedure is ongoing.
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25
Fig. 25.7. Open cardiopulmonary resuscitation after ventricular cardiorrhaphy.

Reprinted with permission from: Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In press.
Fig. 25.8. Internal defibrillation. Reprinted with permission from: Asensio JA,
Co., Philadelphia, PA. In press.
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Trauma Management
25
Fig. 25.9. Cross-clamping of the pulmonary hilum. Reprinted with permission from:
Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery.
W.B. Saunders Co., Philadelphia, PA. In Press.
Defibrillation with internal paddles may be needed delivering between 10-50

joules.
Epinephrine may also be administrated into either the right or left ventricle or
systemically.
If air embolism is suspected, the ventricles will need to be aspirated.
Occasionally the use of a temporary pacemaker is needed.
If the patient is successfully resuscitated, immediate and expedient transportation to the OR is mandated.
Results
The literature abounds with retrospective series describing the use of emergency
department thoracotomy. Great difficulties, however, exist in evaluating the
results of these series.
279
In the review of over 7,335 patients undergoing emergency department thoracotomy there were 551 survivors. The overall survival rate was 8%.
The survivor rate for penetrating injuries was 10% and for blunt 1.5%.
In two prospective studies dealing with penetrating cardiac injuries the survival
rate in patients undergoing Emergency Department thoracotomy was 14-16%.
In a prospective two year series reporting 215 patients subjected to Emergency
Department thoracotomy, the overall survival rate was 10%. In this series the
only survivors experienced penetrating cardiac injuries. None of the patients
subjected to Emergency Department thoracotomy for blunt cardiopulmonary
arrest, noncardiac thoracic injuries or exsanguinating abdominal vascular
injuries survived.
In a review of 142 pediatric patients undergoing emergency department thoracotomy, there were 9 survivors for 6% overall survival rate.
When stratified by mechanism of injury, pediatric patients undergoing Emergency Department thoracotomy for penetrating injuries had a survival rate of
12% versus a 2% survival rate for blunt cardiopulmonary arrest.
References
1.
2.
3.
4.
5.
Asensio JA, Hanpeter D, Demetriades D et al. The futility of liberal utilization of

emergency department thoracotomy. A prospective study. Proceedings of the American Association for the Surgery of Trauma 58th Annual Meeting, Baltimore, Maryland 1998; 20.
Asensio JA, Hanpeter D, Gomez H et al. Exsanguination. In: Textbook of Critical
Care. 4th Ed. Shoemaker W, Greenvik A, Ayres SM et al, eds. Philadelphia, PA:
W.B. Saunders Co, Chapter 4:37-47.
Asensio JA, Hanpeter D, Gomez H et al. Thoracic injuries In: Shoemaker W,
Greenvik A, Ayres SM et al, eds. Textbook of Critical Care, 4th Ed Philadelphia,
PA: W.B. Saunders Co. Chapter 30:337-348.
Asensio JA, Murray J, Demetriades D et al. Penetrating cardiac injuries: Prospective one-year preliminary report; An analysis of various predicting outcome. J Amer
Coll Surg 1998; 186(1):24-33.
Asensio JA, Berne JD, Demetriades D et al. One hundred and five penetrating
cardiac injuries. A two-year prospective evaluation. J Trauma 1998; 44(6):
1073-1083.
25
ABDOMEN
CHAPTER 1
CHAPTER 26
Evaluation of Blunt Abdominal Trauma

Michael Sugrue
Historical Background
In Ancient Egyptian times, discussion of abdominal injury has been vaguely
reported in the Edward Smith Surgical Papyrus and the Hearst Papyrus 15003000 BC. Progressing through the centuries Hippocrates and Claudeus Galinus
made brief references to abdominal evaluation. It is only in the last 30 years
that significant advances have been made.
The evaluation of blunt injury to the abdomen improved significantly with
the introduction of CT scanning and F.A.S.T.
Before proceeding however, remember the Key Challenges:

2000 Landes Bioscience
Michael Sugrue, Department of Trauma, Liverpool Hospital, Liverpool, Australia
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The Patterns of Blunt Abdominal Injury
26
Specific injury patterns may be seen with the use of seat belts, handlebar injury, sporting injuries. In general the liver and spleen are most commonly
injured in blunt abdominal trauma, Table 26.1.
Recognition of the potential for associated injury is crucial in the evaluation
of the blunt abdominal trauma patient. For example in the presence of an
apparently isolated splenic injury, 10% will have associated injury involving
either the diaphragm or small bowel. In the presence of minor splenic injuries
however such as a Grade 1 injury, one could anticipate less than 4% having
diaphragmatic or bowel injury. Abdominal injury sustained during football or
other contact sports may give rise to isolated splenic or renal injuries.
Specific injury patterns are seen in bicycle handlebar injuries (Fig. 26.1) with
traumatic pancreatic injury and bowel perforation significantly more common. Often handle bar injuries transmit such force as to resemble a penetrating injury.
Falls from heights are associated with intra-abdominal injuries in less than
10% of cases with a prevalence of solid organ lacerations, but occasional bowel
and bladder ruptures can occur. In the evaluation of patients falling from
heights and jumpers, remember retroperitoneal injuries are a significant
source of hemorrhage.
The classic injury patterns relating to common mechanism are as follows:
Seat belt
Lap and sash

Lap belt only
Side impact
Sporting injury
Assault with fist
Horse kick
Jejunal perforation
Duodenal or pancreatic injury
Hepatic/splenic injury
Splenic laceration
Pancreatic injury
Small bowel perforation
History of Injury
In the evaluation of blunt abdominal trauma (BAT), a detailed accurate history is essential to ensure maximum potential prediction of injuries sustained.
In taking the history, use the MIST system:
-
Mechanism of injury
Injury
Signs and
Treatment
Table 26.1. Typical pattern of intra-abdominal injury in blunt trauma

Organ Injury
Spleen
Liver
Renal
Small Bowel
Diaphragm
Bladder
Colon
Abdominal vessels
Other
30
25
20
6
4
4
3
2
6
283
26
Fig. 26.1. Handlebar injury with associated jeunal perforation.
This promotes identification of potential injuries and avoids the pitfalls of a

missed injury, which can occur.
Interaction between the trauma team and paramedics should be crisp and
clear lasting 45-60 seconds. Additional information should be obtained from
the patient in the form of AMPLE (Allergies, Medication, Past Illness, Last
Meal, Events and Environment related to the injury). This AMPLE approach is
advocated by ATLS for good reason. It is particularly important in the assessment of a hemodynamically unstable patient to know what medications they are
receiving. Cardiac and other antihypertensive medication may alter a pulse rate
or have an effect on blood pressure, making clinical examination difficult.
Clinical Examination
Accurate clinical examination is vital in BAT assessment. It is even more
important than with penetrating trauma patients where decision making is
often easier. While there are limitations of the abdominal examination in both
the conscious and unconscious patient, it provides invaluable information in
the early management allowing diagnosis and prioritization.
Clinical examination has significant limitations, however, in the following
circumstances:
-
Unconscious patient
Intoxicated/drugged patient
Uncooperative patient
Seat belt mark
Pregnant patient
Spinal injury
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Trauma Management
Clinical examination of the abdomen is unreliable in approximately 50% of

blunt abdominal trauma patients. Apart from altered level of consciousness,
the variable effect of hemoperitoneum and the variety of potential injury
patterns with variable signs from hollow or solid viscus injury make interpretation difficult. The presence of distracting injuries in the multi-injured patient
may pose an additional challenge.
Strong suspicion of intra-abdominal injury should be considered in the
following patients:
- presence of abdominal tenderness and rebound
- rigid abdomen
- patients with seatbelt marking
26
In patients with seat belt marks (Fig. 26.2), determine if there is tenderness or
guarding away from the seat belt mark. If there is, suspicion of intra-abdominal
injury should be increased significantly. The importance of seat belt marking as
a predictor of intra-abdominal injury varies from series to series. Velmahos1
has identified in motor vehicle victims that a seat belt mark is associated with
an eight fold increase in intra-abdominal trauma compared to patients without seat belt mark, finding that 23% of patients suffered significant intraabdominal organ injury particularly mesenteric laceration, hepatic, duodenal
and jejunal laceration (Fig. 26.3).
Bowel sounds are important in blunt abdominal evaluation, with a reduction
in bowel sounds commonly seen in patients with peritonism and peritonitis
from small bowel injury.
Investigation
Plain X-rays and one shot IVP are of limited importance.
A full blood count is useful as an elevated white cell count may help point
towards a gastrointestinal perforation and liver function tests will obviously
indicate an hepatic contusion.
Hematuria is common after blunt renal injury. It is usually microscopic, which
in asymptomatic patients does not usually require further evaluation. Macroscopic hematuria always needs investigation, usually indicating a major renal
or bladder rupture. Further evaluation of renal pathology is best performed
using a CT scan and bladder evaluation using a cystogram.
Tips and Pitfalls

Thirty percent of major renal injuries may exist with a normal urinalysis.
There may be little correlation between the severity of renal injury and the
presence of hematuria.
Only 30% of patients with gross hematuria have serious renal injury.
One percent of patients with microscopic hematuria have a significant
renal injury.
The choice of definitive investigation in BAT rests with diagnostic peritoneal lavage (DPL), FAST, CT scan and laparoscopy. The choice depends on three key
factors:
1. Patients stability
2. Prediction of underlying organ injury
3. Experience and facilities of the trauma center
285
26
Fig. 26.2. Seatbelt mark.
Fig. 26.3. Underlying bowel injury.
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Trauma Management
Diagnostic Peritoneal Lavage (DPL)

In the presence of hemodynamic instability, a DPL or FAST are ideal in
determining the presence of hemoperitoneum and the need for surgery.
Remember in up to 50% of patients with suspected intra-abdominal injury
who are hypotensive, their hypotension is due to a non-abdominal cause.
Therefore rapid assessment of the abdomen is essential.
A further key issue in the stable patient is whether one will adopt an operative
or nooperative approach. If one is tending to a nonoperative approach, such
as in a patient following contact sport injury with potential splenic injury,
DPL is contraindicated as a positive result will increase the pressure for operative
management, which in a stable patient is inappropriate.
DPL has, in the past, been a gold standard for evaluation of hemoperitoneum.
It is highly sensitive in detecting the presence of intraperitoneal blood. It has
the disadvantage however of not predicting the need for laparotomy per se
and will increase nontherapeutic laparotomy rate.
Problems with Diagnostic Peritoneal Lavage:
26
Techniqueclosed technique, increased risk of bowel perforation

Interpretation of DPL
- While over 50% of surgeons utilize bedside interpretation of DPL effluent, this
is fraught with hazards. Ability to read print through IV tubing is an inaccurate
art. The effluent should be sent for objective laboratory analysis.
- The following constitute a positive DPL:
Red cell count > 100,000/mm3
White cell count > 500/mm3
Alkaline phosphatase > 20 IU/L
Amylase > 20 IU/L
Aspiration of <10cc of frank blood
- The use of Gram stains and detection of vegetable matter is not a particularly
useful technique. Recently it has been suggested that quantitative white blood
cell criteria for detection of intestinal injury, supplemented by an adjusted white
cell count/red cell count ratio, will decrease nontherapeutic laparotomy rate associated with DPL. It is suggested that the white cell count to red cell count ratio of
150 or greater, indicates a gastrointestinal tract perforation requiring surgery.
- Diagnostic peritoneal lavage has the following disadvantages:
Oversensitivegiving rise to nontherapeutic laparotomies
Does not provide organ specific diagnosis
Misses retroperitoneal hematomas and hollow viscus perforations
Invasive
Painful in conscious patients.
- Sequential DPL (Fig. 26.4) is very useful particularly in multisystem trauma
patients undergoing multi-cavity surgery where the DPL catheter can be left in
place and repeat diagnostic peritoneal lavage performed. Remember that 25-30
ml of blood in a patient with a normal hemoglobin will result in a red cell count
of 100,000/mm3.
- Special concerns have been raised in the past in performing DPL in pregnant,
pediatric and in patients with pelvic fractures. FAST should be superior in pregnancy. In pediatric trauma, the problem with DPL is its over sensitivity and the
tendency to lead to nontherapeutic laparotomies, particularly with solid organ
287
26
Fig. 26.4. DPL catheter left in place.
injuries. In pelvic fractures, care must be exerted as false positive rates of up to

30% have been reported. Recent studies have discounted this. The reported
high false positive rate in DPL in the presence of pelvic fractures has been attributed to many factors:
Dissection of the retroperitoneal pelvic hematoma
Direct placement of the catheter into the retroperitoneal hematoma
Extravasation of blood from the retroperitoneal hematoma
Time dependent diapedesis of red cells across the peritoneal cavity. cell count,
alkaline phosphatase or amylase. It is particularly important to avoid a
nontherapeutic laparotomy in patients with pelvic trauma.
Tips
Use an open technique via umbilical cord or linea alba (at the umbilicus),
similar to the technique for open insertion of the laparoscopic insertions of
umbilical posts. Wide bore DPL catheters and IV tubing will greatly speed up
the process.2
CT Scanning
CT scanning of the abdomen in blunt trauma has become increasingly popular.
It has the advantages of:
Providing organ specific information
Determining the presence of hemoperitoneum
Providing a base line for further evaluation
Providing additional information, such as occult pneumothorax
It also has the following disadvantages:
Time consuming
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Trauma Management
Costly
Unsuitable for unstable patients
Requires accurate interpretation
May be abused to place patient in holding pattern, while thinking of what
to do with patient
Tips:
26
CT scanning requires careful protocols:

removing the nasogastric tube in the esophagus, and elevate arms above head
to reduce scatter
administration of oral contrast (should be done in the resuscitation room)
Specially timed studies may be required to look at arterial, venous and portal
venous phases.
This is particularly important in relation to identifying areas of hypoperfusion,
identifying vascular injuries and blushes. Identification of a vascular blush on CT
scan indicates the need for surgery or embolization, due to ongoing hemorrhage. It
is particularly useful in assessing pancreatic injury (Fig. 26.5).
CT scanning has an additional advantage of being able to provide a grade of
organ injury for splenic, renal and hepatic injuries. Combination of organ
injury grading and blood loss estimation will improve the prediction of
requirement for surgery.3 In terms of grading of liver injuries, CT scanning
often overemphasizes the grade of liver injury and often underestimates the
amount of intraperitoneal bleeding. The identification of a vascular blush
on CT scanning in liver, splenic or renal trauma indicates the presence
of active bleeding and potential need for embolization or surgery.
The use of oral contrast is becoming increasingly more controversial with the
recent suggestion that addition of oral contrast does not improve outcome
and may increase the risk of aspiration. Oral contrast however, does provide a
nicer road map for the radiologist however, it may not increase the detection
of gastrointestinal tract perforation.
The signs of gastrointestinal tract perforation on CT scans include (Fig. 26.6):
-
free fluid in the absence of solid organ injury

edema of the mesentery
extravasation of contrast
enhancement thickening and hematoma of the bowel wall
free intraperitoneal gas.
Free intraperitoneal gas in small quantities in the subdiaphragmatic areas can

be difficult to interpret and great care must be taken to avoid undertaking a
laparotomy on the basis of a small amount of free air.
F.A.S.T. (Focused Assessment with Sonography for Trauma)

Since 1980 there has been increasing use of sonography in BAT. Large series
have established its validity in determining hemoperitoneum. FAST does not set
out to determine organ specific injury. The particular advantage of FAST is that:
-
it is simple to perform
takes an average 2-4 minutes
can be performed at the end of the primary survey and repeated later as needed
is noninvasive
289
26
Fig. 26.5. Pancreatic injury clearly seen on CT.
Fig. 26.6. Signs of gastrointestinal tract perforation on CT scan.
FAST itself does not differentiate free fluid from intraperitoneal hemorrhage
and care should be exerted in over-reliance on FAST, particularly in patients
with potential small bowel perforation.
In using FAST, it is important that the operator is credentialled. Random use
of FAST will result in erroneous results leading to unfavorable evaluation of
BAT patients.
290
Trauma Management
Credentialing should involve:

- formal training course
- specific number of peer reviewed scans including a specific number of
positive FASTs4
Tips and Pitfalls
Know your machine.

Watch the use of gain as it may interfere with the interpretation of free fluid.
The pericardial views are most troublesome.
Perform FAST before insertion of urinary catheter.
Surgical emphysema makes FAST impossible.
Remember to re-evaluate the abdomen if in doubt or clinically indicated.
Laparoscopy in Trauma
Laparoscopy has been undertaken in the evaluation of BAT patients for over 40
years. Its only proven value is in the evaluation of suspected diaphragmatic trauma.
Timing of Investigations
26
Prompt evaluation of blunt abdominal trauma will improve not just the management plan but patient outcome. A clear, rapid but thoughtful approach is required.
Tips:
If multiple investigations are to be done, an optimum sequence should be
thought out. For example:
FAST (5 min)
FAST (5 min)
DPL (20 min)

CT (30 min)
DPL (1 hour)
Remember, most conscious patients will need only one evaluation.

FAST should be undertaken as an adjunct to the primary survey, usually within
5-10 minutes of patient arrival.
In the event of multiple procedures being undertaken, such as chest tube
insertion, intubation, urinary catheterization, the team should be appropriately
protected and lead-gowned to facilitate the rapid patient assessment.
Unstable Patients
The evaluation of the unstable patient with blunt abdominal trauma is a

challenge requiring rapid decision making. The priority should be:
A check of airway, breathing and disability to ensure hypotension is not due
to non-circulatory cause.
The next key question to determineIs there intraperitoneal blood? A temptation to perform a laparotomy as an evaluation in the unstable trauma patient
should be carefully evaluated as up to 50% of patients who are hypotensive
with suspected intra-abdominal injuries will have a negative or nontherapeutic
laparotomy. The options in the unstable patient include diagnostic peritoneal
lavage or FAST.
Laparoscopy and CT scanning have no role to play in the abdominal assessment of the unstable trauma patient.
If in doubt and you have limited resources, a diagnostic laparotomy may be
life saving.
291
Problem Areas
Abdominal evaluation is problematic in the following circumstances:
-
Pediatric assessment
Pregnancy
Unconscious, intoxicated or drug affected patients
Associated pelvic trauma
Pediatric Assessment
Tricks: Distraction of the pediatric patient is the key. Discussion about their
school teacher, dog, favorite program on television, or current interests like
Pokemon cards, is a guaranteed way of insuring gentle evaluation. Tenderness
and guarding in the presence of successful distraction indicates significant
abdominal injury and urgent CT scanning should be performed in the stable
child. A DPL in a conscious child is very painful.
Pregnancy
In gravid patients, especially after 24 weeks gestation, abdominal evaluation
requires a dual approach, both for the baby and the mother. Challenges occur
in relation to radiation dose associated with CT scanning and intervention related
to DPL, making FAST an attractive option. Care must be taken in ensuring the
operator is credentialled and sonography of the baby must be undertaken by an
obstetrician, or a suitably qualified radiologist.
- Pitfalls: Ultrasonography is not a particularly sensitive method of detecting
abruption of the placenta. As part of abdominal evaluation in pregnancy,
CTG monitoring in patients with significant injuries should be undertaken
in hospital for a period of at least six hours. In cases of significant risk to the
mother or the baby a CT scan is useful, but fully informed patient consent
must be obtained in relation to radiation exposure.
Unconscious, Intoxicated or Drug Affected Patients

In the stable patient after their head has been cleared, the abdomen should be
scanned. In the presence of an intracranial hematoma, such as an epidural, the
patient should be transferred to the operating room for evacuation and a DPL
or FAST in the operating room rather than proceeding with abdominal CT. If
the head CT is okay, it is safe to proceed with abdominal CT.
Associated Pelvic Trauma

Pelvic fractures pose a challenge in terms of abdominal evaluation. Most pelvic
fracture deaths are related to hemorrhage. The pelvic plain films will usually
provide an insight as to the potential for hemorrhage. Associated injuries are
common and 10% of patients have bladder injuries, 10% spleen, 7% liver, 7%
small bowel, 7% renal and other injuries in 10%. Occasionally there is double
jeopardy where two or more body regions require simultaneous treatment. Physical examination is rather limited in patients with pelvic fracture. It has been
suggested that DPL is associated with false positive results in patients with pelvic fracture, and that laparotomy is undertaken on the basis of false positive
DPL has significantly contributed to increased morbidity and mortality. This is
partly true. To avoid this certain precautions must be undertaken:
- Early DPL (< 30 minutes after admission)
- Avoiding DPL in stable patients with pelvic fracture.
- Altering your criteria for positive DPL to include aspiration of 10 ml or
more of gross blood.5
26
292
Trauma Management
Re-Evaluation of Blunt Abdominal Trauma

While early evaluation and recognition of blunt abdominal injuries is essential, many patients do not often present with classical symptoms, signs or
results in investigations allowing an immediate diagnosis. The evaluation of
blunt abdominal trauma is a process which must evolve in keeping with the
patients condition. Clinical examination including tertiary survey is important.
Evaluation of the patient with BAT should follow a system suitable for your
institution with the resources available to you. Audit and evaluation of your
nontherapeutic laparotomy rate, missed injury rate and complications is
essential to ensure improvement and maintenance of high standards.
The keys to assessment of blunt abdominal trauma:
-
listen to the history

prompt and timely evaluation in the early resuscitation phase
tertiary survey with reassessment
perform the right test for the correctly predicted potential injury.
References
26
1.
2.
3.
4.
5.
Velmahos GC, Tatevassian R, Demetriades DB. Seat belt mark: A goal for increased vigilance among physicians treating victims of motor vehicle accidents.
Am Surg 1999; 65:181-185.
Sugrue M, Seger M, Gunning K et al. A modified combination technique for
performing diagnostic peritoneal lavage. Aust N.Z. J Surg 1995; 65:54-55.
Sugrue M, Knox A, Sarre R et al. Management of splenic trauma: A new CT based
splenic injury system. Aust NZ J Surg 1991; 61:349-353.
FAST Consensus Conference Committee. Focused Assessment with Sonography
for Trauma (F.A.S.T.): Results from an international consensus conference. J Trauma
1999; 46:466-472.
Mendez C, Goubler D, Maier RV. Diagnostic accuracy of peritoneal lavage in
patients with pelvic fractures. Arch Surgery 1994; 129:477-482.
CHAPTER 1
CHAPTER 27
Evaluation of Penetrating Abdominal

Trauma
George C. Velmahos
Penetrating abdominal trauma was managed expectantly until the late 19th
century.
Operative management replaced expectant management in World War I and
reduced mortality significantly.
Selective management was suggested for the first time in 1960. It was practiced first for stab wounds and later for gunshot wounds with success.
Anatomical Definitions
Injuries to the anterior (true abdomen) or posterior (back) abdomen can cause
intra-abdominal organ injuries.
The anterior abdomen is defined superiorly by the nipple line, inferiorly by
the pubic symphysis and laterally by the mid-axillary lines.
The posterior abdomen is defined superiorly by the tips of the scapulae, inferiorly by the gluteal folds and laterally by the mid-axillary lines.
The Objective and the Dilemma

The objective of evaluation of penetrating abdominal trauma is to identify
patients in need of operation while at the same time minimizing the risks
associated with unnecessary procedures.
The dilemma refers to whether the clinical examination is reliable or not,
additional diagnostic evaluation is required or not, and routine operation should
be the standard of care or not.
It is with this objective and dilemma in mind that all the following methods will
be reviewed.
Clinical Evaluation
Every patient with a stab wound or gunshot wound to the abdomen should
have a detailed clinical evaluation including a rectal examination. A nasogastric
and a urinary tube should always be inserted. The clinical examinations should
be repeated frequently.
The two most common clinical signs strongly suggestive of intra-abdominal
organ injury are diffuse abdominal tenderness and hemodynamic instability.
Other signs suggestive of intra-abdominal organ injury are localized abdominal
tenderness, hematuria, hematemesis or blood in the nasogastric tube, blood in
the rectal exam, and diminished or absent lower extremity pulses.
George C. Velmahos, Division of Trauma/Critical Care,
University of Southern California School of Medicine, Los Angeles, California, U.S.A.
294
Trauma Management
27
Fig. 27.1A. The mere presence of a bullet in the abdomen does not indicate the
need for surgical exploration. B. This patient had a CT that shows the bullet lying
on top of the liver without causing any injury.
Unevaluable patients (intoxicated, intubated, sedated, or with associated head

or spinal cord injuries) should be considered to have an intra-abdominal injury
until proven otherwise.
The bullet trajectory does not accurately predict the probability of intra-abdominal
organ injuries.
Evaluation of Penetrating Abdominal Trauma
295
Fig. 27.2. Alternative interventional methods to manage a gunshot wound to the

abdomen exist. This patient was not operated on but had hepatic angiography with
embolization of a bleeding branch of the right hepatic artery.
Fig. 27.3. Additional studies should be done when indicated. This patient had two
transpelvic gunshot wounds, no abdominal tenderness or hemodynamic instability
and blood at the urethral meatus. A retrograde urethrogram showed contrast extravasation
from the membranous portion of the urethra. Surgical exploration was not necessary.
27
296
Trauma Management
Fig. 27.4A. The bullet trajectory is not reliable for predicting significant intra-abdominal injuries and identifying the need for operation. A patient presents with a
trajectory that is highly suspicious for intra-peritoneal penetration and significant
injuries. The entry wound is in the true abdomen.
27
Fig. 27.4B. The exit wound is in the true back.
Is Clinical Evaluation Reliable?

The sensitivity of clinical examination to identify patients in need of operation
exceeds 95% both for stab wounds and gunshot wounds.
It is important to repeat the clinical examination frequently and not rely
exclusively on the initial assessment. Symptoms that are initially masked will
be revealed later.
Additional Diagnostic Tests

A variety of tests have been used to evaluate the abdomen after penetrating
injuries, including diagnostic peritoneal lavage, ultrasound, contrast-injection
297
Fig. 27.4C. Upon exploration, the entry and exit sites to the peritoneal cavity were
close to each other and there was no underlying organ injury.
in the tract (stabbogram), intravenous pyelogram, contrast cystogram and/or

urethrogram, sigmoidoscopy, contrast enema, computed tomography.
Diagnostic peritoneal lavage (DPL) has been used with inconsistent results
for the following reasons:
- There is no universally accepted red-blood-cell count that characterizes the DPL
as positive. For blunt trauma this value is 100,000 RBC/mm3, but for penetrating trauma it is unknown. Values of 100,000, 50,000, 25,000, 10,000, and
1,000 have been used with varying sensitivities ranging from 99-75%.
- A positive DPL does not necessarily indicate the need for operation. False positive
rates of up to 56% have been reported.
- In the presence of diaphragmatic injuries, the negative thoracic pressure may
decrease the volume of intra-abdominal blood or blood-stained DPL fluid, and,
therefore, create false-negative results.
We do not recommend the use of DPL for penetrating abdominal trauma.

Ultrasound performed by the treating physicians in the emergency room has
recently become a widely used test. F.A.S.T. (Focused Abdominal Sonography
for Trauma) evaluates at least three areas (hepatorenal space, splenorenal space,
pelvis) with a possible addition of another two (left and right paracolic gutters) with the single goal of identifying intra-abdominal fluid. Fluid following
trauma equals blood. The test is operator-dependent and not specific, i.e., it
may identify blood but not its origin or significance. The sensitivity of this
test in penetrating abdominal trauma is still unknown. If the limitations of
the test are kept in mind, it can be routinely used because it is fast, easy, and
noninvasive. It can be repeated frequently. We believe that with increasing
experience, ultrasonography will become an important tool in the diagnosis
of intra-abdominal trauma.
27
298
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Trauma Management
Fig. 27.5A. Evisceration is not always an indication for operation, although laparotomy should be considered strongly due to the high incidence (75%) of associated
injuries. This patient suffered a stab wound and was explored because there were
extensive fascial defects. There was no organ injury.
Fig. 27.5B. This patient had absolutely no symptoms following an abdominal stab
wound. The bowel was reduced and the fascia was closed under local anesthesia.
The patient had an uneventful recovery.
299
The stabbogram consists of injection of contrast into the injury tract to detect
possible leakage of contrast into the abdominal cavity. Peritoneal penetration
does not necessarily mean intra-abdominal organ injury. The test is only of
historic value.
Intravenous pyelogram (IVP) and contrast cystogram are useful tests in the evaluation of hematuria following penetrating abdominal trauma when the need for
operation is not clearly established. Helical CT scan (with intravenous contrast
injection and CT-cystogram) has largely replaced these tests because it provides
valuable additional information about organ injuries. IVP may still remain
the test of choice for detailed visualization of the ureters when ureteral injury
is strongly suspected.
One-shot IVP is used under emergency-room conditions in patients who are
suspected to have injuries to the urinary tract. It detects or rules out these
injuries and reveals the presence of a functional contralateral renal unit, which
is important when surgery for removal of the injured renal unit is a possibility.
The test is performed by injecting intravenous contrast and taking a plain
abdominal radiograph 15 to 20 minutes after injection. The test is associated
with a high rate of false-positive and false-negative results. Intraoperative palpation can reveal the presence of a normal-size contralateral kidney if this is
deemed necessary. Intraoperative IVP or dye injection (methylene blue or
indigo-carmine red) can always be performed according to the circumstances.
We do not recommend the use of preoperative one-shot IVP.
Rigid sigmoidoscopy is useful in the evaluation of the extraperitoneal rectum.
Patients with transpelvic trajectories, gluteal gunshot wounds, and proximity
stabbings should be evaluated by sigmoidoscopy. The test is frequently hard
to interpret because of the lack of bowel preparation. Blood found should be
interpreted as a positive test, regardless of whether the actual injury is visualized
or not.
Contrast enema is also used to evaluate the extraperitoneal rectum. It is not
the test of choice and is usually reserved for cases with equivocal findings on
sigmoidoscopy.
Helical computed tomography (CT) is emerging as a valuable adjunct in the
evaluation of penetrating trauma to the abdomen. It provides precise information on the bullet trajectory as well as on the condition of intra-abdominal
organs, particularly retroperitoneal ones. Its indications, although not yet fully
explored, potentially are:
- Patients with equivocal clinical signs.
- Patients with posterior penetrating wounds possibly involving retroperitoneal
organs.
- Patients with right-upper-quadrant wounds who are selected for nonoperative
management.
- Patients who can be discharged directly from the emergency room if an
extraperitoneal trajectory is documented.
Diagnostic Operative Procedures

Diagnostic operative procedures include selective wound exploration and diagnostic laparoscopy and laparotomy.
Wound exploration is done to determine if peritoneal penetration has occurred.
It is best performed in the operating room but can be done at the bedside with
27
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Trauma Management
adequate local anesthesia. Its sensitivity and specificity are not established. It
creates patient discomfort. The presence of peritoneal penetration does not equal
intra-abdominal injury. Simple digital exploration can be even more misleading.
However, in selected cases it can provide a crude idea of the wound-tract
direction. Wound exploration is not indicated in the majority of cases.
Diagnostic laparoscopy at this time is useful only for the evaluation of diaphragmatic injuries. About 40% of patients with penetrating trauma of the
left thoracoabdominal area have diaphragmatic injuries, and among those, the
injury is occult in one-third. Because no other test can reliably rule out diaphragmatic injuries, laparoscopy is an important tool in the evaluation of left
penetrating thoracoabdominal trauma. The value of laparoscopy in other types
of penetrating abdominal trauma is uncertain. False negative results occur
frequently, particularly with retroperitoneal or small bowel injuries. With
increasing surgical expertise. laparoscopy may find new roles in the evaluation of
this form of trauma.
Routine diagnostic laparotomy is still widely used for gunshot wounds though
not for stab wounds. Nontherapeutic laparotomy is associated with complications and is not cost-effective as a diagnostic tool.
The Significance of Evisceration from the Wound
27
Evisceration of abdominal contents from the wound is associated with

significant intra-abdominal organ injury in approximately three-quarters of
patients who have no other indication for laparotomy following penetrating
abdominal trauma.
The type of eviscerating organ (e.g., bowel or omentum) does not predict the
need for operation.
The high incidence of associated injuries should prompt aggressive management
of these patients. Intensive monitoring, additional testing and a low threshold
for laparotomy are appropriate.
Routine Exploration or Selective Management: Resolution

of the Dilemma
There is agreement that stab wounds should be managed selectively. There is
still no consensus on the management of abdominal gunshot wounds.
Reasons commonly cited for routine exploration of abdominal gunshot wounds
are the following:
-
Gunshot wounds are associated with a 90% rate of abdominal organ injuries.
Clinical examination is unreliable
Negative laparotomies are complication-free.
Delayed diagnosis of injuries is associated with devastating consequences.
These reasons are proven wrong by recent research:

- The incidence of abdominal organ injury after gunshot wounds to the anterior
abdomen is 70%; to the posterior abdomen, it is 30%. About one-third of
patients with anterior and two-thirds with posterior abdominal gunshot wounds
will have no clinical significant intra-abdominal injury.
- Clinical examination is reliable. In large prospective studies, it predicted the
need for operation with a sensitivity of 95-100%. If clinical examination is
reliable for stab wounds, it must be reliable for gunshot wounds as well.
301
- Negative laparotomies are associated with complications in up to 20% of

patients, prolonging hospital stay and increasing cost.
- Missed injuries are associated with devastating consequences. Close monitoring
during the asymptomatic period and operation upon development of symptoms
does not increase the risk of complications.
Special Considerations: Gluteal, Thoracoabdominal,

and Transpelvic Injuries
Gluteal injuries are associated with high rates of retroperitoneal injuries, particularly of the rectum. The absence of peritoneal irritation and the potential
tamponade of bleeding may cause a misleading clinical picture. Close observation and additional studies, when appropriate, are recommended. Rigid
sigmoidoscopy should always be done, unless the wound is clearly away from
the rectum.
Transpelvic gunshot wounds are associated with high rates of significant injuries. Selective management is still appropriate, if a high index of suspicion and
low threshold for additional investigation and operation is maintained.
Left thoracoabdominal penetrating injuries place the left diaphragm at risk.
Laparoscopy is the only reliable tool to diagnose such injuries in asymptomatic patients. Laparoscopy should be performed routinely in such patients
when laparotomy is not needed. Right thoracoabdominal injuries may still
produce a high rate of occult right diaphragmatic injuries. However, because the liver is buttressing the perforation, herniation of abdominal viscera is rare. Routine laparoscopy is not required for all right thoracoabdominal
injuries. Anterior right thoracoabdominal injuries are more likely to be
associated with herniation than posterior ones, and may need to be evaluated
by laparoscopy in an individual basis.
Shotgun Wounds
Shotgun wounds behave differently, depending on the distance of the assailant
from the patient, the type of gun and the type of pellets.
Close-range shotgun wounds (less than 10 feet) usually behave like high velocity bullet wounds. At more than 20 feet they produce damage equal to that
produced by low velocity missiles.
The range of pellet spread may provide indications of the injury produced. A
narrow spread (less than 10 cm) usually indicates a close-range shot that is
likely to penetrate the abdominal wall. A spread of over 25 cm is thought to
be associated with a low likelihood for deep tissue penetration.
Because the variability in injury patterns is great, depending on the type of gun
and pellets, the above indicators are unreliable. Clinical examination is the most
reliable tool to evaluate for the presence of significant injuries to the abdominals.
Recommendations for Abdominal Penetrating Injuries

Selective management is appropriate for all anterior and posterior abdominal
injuries caused by firearms or knives. Patients with diffuse abdominal tenderness or hemodynamic instability, and patients who cannot be evaluated clinically, should be operated on immediately. Patients who are clinically evaluable
and have no symptoms should be selected for nonoperative management. Patients with equivocal symptoms should have further diagnostic tests on a caseby-case basis.
27
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Trauma Management
Observation of nonoperatively managed patients should be always performed in

monitored areas with house staff available around the clock. Clinical examinations should be repeated on a frequent basis, preferably by the same experienced
surgeon. If these prerequisites are not fulfilled, mandatory operation may be a
safer solution.
If the decision for operation is made, further testing is unnecessary and potentially harmful. The patient should be taken to the operating room without
delay. Time is of the essence in the management of trauma patients.
References
1.
2.
3.
4.
5.
6.
27
Demetriades D, Velmahos GC, Cornwell EE et al. Selective nonoperative management of gunshot wounds to the anterior abdomen. Arch Surg 1997; 132:178-183.
Velmahos GC, Demetriades D, Foianini E et al. A selective approach to the management of gunshot wounds of the back. Am J Surg 1997; 174:342346.
Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds.
A prospective study of 651 patients. Ann Surg 1987; 205:129131.
Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study
of morbidity. J Trauma 1995; 38:350356.
Nagy K, Roberts R, Joseph K et al. Evisceration after abdominal stab wounds: Is
laparotomy necessary? J Trauma 1999; 47:622626.
Velmahos GC, Safaoui M, Demetriades D. Management of shotgun wounds: Do
we need classification systems? Int Surg 1999; 84:99104.
CHAPTER 1
CHAPTER 28
Hepatic Injuries and Bile Duct Injuries

Thomas V. Berne
Anatomical Considerations
Anatomy
The liver is divided into its right and left lobes by a plane which passes through
the gall bladder and inferior vena cava. The middle hepatic vein often lies in
this plane.
The portal triad structures divide the liver into eight Couinauds segments
(Fig. 28.1).
Anomalies
The most common anomalies are an origin of the right hepatic artery from
the superior mesenteric artery (approximately 15%) and a left hepatic artery
arising from the left gastric artery (10%).
Grading
The standard for classification of liver injuries is that adopted by the American Association for the Surgery of Trauma (Table 28.1). Although difficult to
remember, the first step in learning the classification is noting that lacerations
deeper than 3 cm are grade III injuries or greater.
Blunt
Liver injuries due to automobile crashes, beatings, falls and other external forces
cause a variety of hepatic wounds.
Rupture of Glissons capsule.
Parenchymal fractures, often stellate, radiating outward from the right hepatic dome. There are often irregular fissures extending away from a main
fault. These cracks can extend throughout a lobe and into adjacent lobes.
The fissures often transect major vascular and biliary structures leading to
bleeding and bile leakage into the peritoneal cavity.
The liver may be torn from its ligamentous and vascular attachments.
Intraparenchymal and subcapsular hematomas may also form.
Penetrating
Stab wounds are generally less devastating than missile injuries (usually gunshot wounds).
Thomas V. Berne, Department of Surgery, Los Angeles County University of Southern
California Medical Center, Los Angeles, California, U.S.A.
304
Trauma Management
Fig. 28.1. Anatomy of the liver including Couinauds segment.
28
The extent of injuries from knives varies with the size of the knife and whether
a single thrust was made or a secondary slash was made after insertion.
The magnitude of injury from a missile depends on several factors, particularly the velocity of the projectile and its expansion characteristics.
Such wounds may cause very small holes up to large burst injuries similar to
the stellate blunt injuries.
Diagnosis
Findings
There may be no physical findings.
Mild to moderate tenderness. More severe tenderness and rigidity may indicate associated hollow viscus rupture, particularly in the right upper quadrant.
Abdominal distention.
Hypovolemia (hemodynamic instability, falling Hct/Hbs).
Fever
Ultrasound
Patients with mechanisms of injury suggesting possible abdominal injuries
should have ultrasonic examination of the abdomen carried out immediately.
Blood (fluid) is most often seen in Morrisons pouch, around the liver or spleen
and in the pelvis.
Subcapsular hematomas, intrahepatic hematomas and hepatic fracturing can
sometimes be seen.
305
Table 28.1. Liver injury scale of the American Society for the Surgery of Trauma
I
Gradea
Hematoma
Laceration
II
Hematoma
Laceration
III
Hematoma
IV
Laceration
Laceration
Laceration
Vascular
VI
Vascular
Injury Description
Subcapsular, < 10% surface area
Capsular tear, < 1 cm
parenchymal depth
Subcapsular, 10-50% surface area
Intraparenchymal, < 10 cm in diameter
1-3 cm parenchymal depth, < 10 cm in
length
Subcapsular, > 50% surface area or
expanding
Ruptured subcapsular or parenchymal
hematoma
Intraparenchymal hematoma > 10 cm or
expanding
> 3 cm parenchymal depth
Parenchymal disruption involving
25-75% of hepatic lobe or 1-3
Couinauds= segments within a single
lobe
Parenchymal disruption involving 75%
of hepatic lobe or > 3
Couinauds segments within a single
lobe
Juxtahepatic venous injuries; i.e.,
retrophepatic vena cava/central major
hepatic veins
Hepatic avulsion
Advance one grade for multiple injuries, up to grade III

Reprinted with permission from Moore EE, Cogbill TH, Pachter HL et al. Organ
injury scaling of the liver, spleen and kidney. J Trauma 1995; 38:323-324.
The findings of intra-abdominal fluid usually does not identify the liver as
the source.
May be used regardless of the patients hemodynamic stability.
Computerized Tomography of Abdomen and Pelvis

(Abdominal CT Scan)
The abdominal CT scan is presently the most helpful diagnostic study for
evaluating possible hepatic injury. CT scans made using spiral technology
with intravenous radioopaque dye injection are particularly valuable.
Suitable only for hemodynamically stable patients, or in rare patients who are
semi-stable (tachycardia and mild hypotension responsive to fluids).
Identifies the architecture of hepatic injury and extent of the parenchymal
disruption. (Fig. 28.2)
Allows for CT injury scoring.
Usually identifies the presence of splenic, kidney and bladder injuries.
Care should be taken because pancreatic and intestinal injuries can be subtle
or show no findings at all.
28
306
Trauma Management
Fig. 28.2. High grade (V) liver fracture successfully managed nonoperatively.
Reprinted with permission from Moore EE, Cogbill TH, Pachter HL et al. Organ
injury scaling of the liver, spleen and kidney. J Trauma 1995; 38:323-324.
28
Identifies the presence of intrahepatic Figure 28.3 and subcapsular hematomas

(Fig. 28.4).
Demonstrates intraperitoneal fluid usually blood.
During infusion of radioopaque IV dye the appearance of high density dots
(pseudoaneurysms), streaming or lakes may indicate active bleeding. These
should be studied angiographically and be embolized (Fig. 28.5).
Low attenuation around peripheral sub-segmental portal branches (periportal
tracking) indicates severe liver injury (Fig. 28.6).
Decreased parenchymal density indicates ischemic injury.
May be useful for guiding nonoperative management of abdominal gunshot
wounds.
Diagnostic Peritoneal Language

Once a mainstay of the management of blunt abdominal trauma, its value has
become limited because many injuries which produce significant intraperitoneal
bleeding are now managed nonoperatively if there is no evidence of ongoing
hemorrhage or peritonitis and careful observation is possible.
Greatest value is in the unstable or semistable patient, who has a serious head
injury or pelvic fracture. In such cases if gross blood (10 ml) is obtained upon
aspiration, then the patient should go immediately to the OR for exploratory
celiotomy. If gross blood is not present the patient should receive a head CT
or a pelvic angiogram as they are potentially life saving.
If gross blood is not present, but the RBC count is > 100,000/mm3, the patient
can still be observed based on other findings.
307
Fig. 28.3. Intrahepatic hematomas
28
Fig. 28.4. Large subcapsular hematoma
Initial Nonoperative Management

Blunt
The majority of hepatic injuries can be managed without operative intervention.
Hemodynamically stable patients without peritonitis (exam and/or CT scan) should
be initially managed nonoperatively with careful follow-up observation.
308
Trauma Management
Fig. 28.5. Abdominal CT scan and angiogram following a blunt injury showing an
arterial pseudoaneurysm.
28
Fig. 28.6. Periportal tracking (arrow) on CT scan.
Hemodynamically unstable patients with evidence of active intraperitoneal

hemorrhage or peritonitis should be taken to the operating room for celiotomy.
CT evidence of active hepatic bleeding, or in some instances very severe injury (grade IV and above) with slow bleeding (falling Hb/Hct), should have
angiographic embolization although still hemodynamically stable, assuming
experienced radiologists are available.
309
Penetrating
Selective management for abdominal stab wounds has achieved wide acceptance.
Some centers now also utilize this approach for missile injuries, but routine exploration
of the abdomen is much more widely practiced.
When selective management is utilized, initial nonoperative management is
indicated when there is hemodynamic stability, stable Hb/Hct values, and no
clinical evidence of peritonitis on physical exam and diagnostic studies.
Gunshot wound tracts may often be identified by the presence of gas in the
tissues seen on CT scan. This may be helpful in planning the management of
RUQ injuries.
Initial nonoperative management should be limited to clinically evaluable
(awake) patients and requires frequent re-evaluation.
Operative Management: Liver

The initial operative incision is almost always through the upper midline. It
can be extended downward, off to the right, into the chest as a median sternotomy or as a right thoracoabdominal approach.
Nonbleeding lacerations (usually superficial) can be ignored.
Bleeding superficial wounds can often be controlled by the application of
hemostatic agents and pressure.
If actively bleeding injuries are present and direct control is planned it is very
helpful to mobilize the ligamentous attachments of the liver (round, falciform
and triangular).
More serious parenchymal wounds (fissures or missile tracts) with active bleeding require judgment as to how aggressively they should be opened
(hepatorrhaphy and tractotomy) in order to directly control hemorrhage with
ligatures and hemostatic clips.
Bleeding can often be stopped or markedly reduced by occlusion of the portal
triad at the foramen of Winslow with a soft vascular clamp (Pringle maneuver). If active bleeding continues, suspect a hepatic vein or inferior vena cava
injury or the presence of an anomalous left hepatic artery origin.
Liver fractures which are of intermediate depth can be controlled with deep
(at or just below the bottom of the fissure) sutures using blunt tipped needles
on large (#0 or 1) absorbable suture. These should close the whole depth of
the crack, avoid hilar structures and be tied down firmly but not so tightly as
to cause extensive necrosis. Pledglets of absorbable hemostatic material allow
this tension without cutting.
Occasionally it is helpful to fill a hepatic defect by placing vascularized omentum into such fissures before deep suture closure.
Extrahepatic arterial ligation can be used to control obvious arterial bleeding
but has been largely replaced by selective postoperative angioembolization if
that is immediately available. More accurate control of arterial bleeding is
possible with this technique.
So-called resectional debridement is used for deeper wounds particularly if
such a nonanatomical resection removes a large piece of ischemic liver. Intact
liver tissue is divided by squeezing between the surgeons fingers (finger fracture) to identify vascular and ductal structures. These structures are individually controlled by ligatures or hemostatic clips as they are encountered.
Tracts made by high velocity bullets often present challenging problems. The
28
310
Trauma Management
28
use of one or more Foley catheters (Fig. 28.7) will often control such bleeding. It only rarely recurs when the balloons are slowly deflated 3-4 days later.
Retrohepatic bleeding is particularly troublesome. A hematoma near the IVC
should not be opened unless it is expanding or has already ruptured with
bleeding. If it has been decided that operative repair is indicated, rather than
packing (see below) the abdominal incision should be extended into the chest
as a median sternotomy (usually preferred) or into the right chest (7th or 8th
intercostal space) to obtain adequate exposure. Small lacerations of hepatic
veins or the IVC can be controlled with vascular suture using finger pressure,
sponges on holders or a Satinsky clamp.
Usually some kind of vascular isolation of the liver will be necessary for major
retrohepatic bleeding. Several forms of vascular isolation of the liver have been
advocated. The most easily applied is the multiple vascular occlusion technique of Heaney: clamping of the inferior vena cava in the pericardial sac, the
IVC just above the renal veins, the aorta just below the diaphragm (to avoid
exsanguination into the lower 1/2 of the body) and a Pringle maneuver. Cold
electrolyte solutions and ice saline slush applied to the liver may prolong the
tolerable ischemia time, but is unnecessary if the patient is already hypothermic). With bleeding largely controlled, clipping, suture or ligature of injured
vascular structures is greatly facilitated. Care should be taken to avoid allowing
air to enter open venous wounds to prevent right-sided air embolism.
The decision to pack an extensively injured liver should, if possible, be made
as soon as it is clear that the patients hepatic wound is not amenable to standard
methods of repair. These are most commonly injuries with extensive bilobar
fracturing, large subcapsular hematomas and multiple additional extrahepatic
injuries. This modality should be chosen as the first method attempted to
prevent massive blood loss during predictability unsuccessful attempts at
direct control of hemorrhage. Of course, if direct control is initially attempted
and the usual indicators for damage control (coagulopathy, profound
hypothermia, severe acidosis) occur, the liver should then be packed. Packing
can often control an extensive injury, but if bleeding continues after packing,
angiographic control immediately after the operation should be arranged.
Packing should begin with the placement of gauze laparotomy pads behind
the right and left hepatic lobes to prevent backward pressure on the liver from
causing IVC occlusion. The raw (injured) areas of liver should be covered
with a sheet of hemostatic material or absorbable mesh to lessen bleeding
when the pack is removed. The gauze pack should be placed to create pressure
which occludes the hepatic injuries as the abdomen is closed. Care should be
taken to avoid too tight closure of the abdomen with the development of an
abdominal compartment syndrome (see Chapter [Abdominal compartment
syndrome]).
Rarely, with very extensive liver damage, a total hepatectomy and temporary
portocaval shunt followed by hepatic transplantation can be considered.
Problems with maintenance during the anhepatic state and the rapid availability
of a donor organ make this option of value only where a very active liver
transplant program can be quickly accessed.
Drains should be of the closed (Jackson-Pratt) type and used only for extensive injuries (grade III or above) unless there is obvious biliary leakage.
Injuries to the hepatic artery and portal vein should be repaired using
311
Fig. 28.7. Foley catheter used to control bleeding from bullet wound tract
appropriate vascular techniques under circumstances where this is possible.

The liver can survive if flow through only one of these structures is preserved.
Ligation of the portal vein causes acute portal hypertension with massive bowel
edema. Reports indicates that 10-54%, of patients will survive. With portal
vein ligation a second look operation should be considered to assess intestinal
viability. Arterial ligation is better tolerated but may cause hepatic infarction in
some cases.
Operative Management: Extrahepatic Bile Ducts

The most common injury is to the gallbladder and is usually managed by
cholecystectomy although cholecystorraphy with absorbable suture has been
recommended by some.
Primary repair should be carried out for partial ductal transection or cleanly
incised ductal transections without loss of length.
More complex injuries with more ductal loss will require choledochojejunostomy
to a Roux-en-Y loop.
T- tube or small caliber tube stenting of there repairs in widely practiced.
Suction drainage (Jackson-Pratt type drains) placed near these repairs is essential.
Early Postoperative Management

The postoperative care of these patients requires considerable vigilance to anticipate, prevent and treat complications. Hemodynamic stability should be
achieved as quickly as possible utilizing endpoints of resuscitation with which
the individual surgeon is familiar. This may require aggressive blood coagulation
factor and fluid infusion (see Chapter 6 [Resuscitation]).
An antibiotic, such as a second generation cephalosporin, will usually have
been given preoperatively and should not be continued for more than one day
28
312
Trauma Management
postoperatively even if there has been of hollow viscus injury.

If there is evidence of ongoing bleeding there should be consideration of postoperative angiography.
Frequent intraabdominal pressure measurements should be made.
Aggressive correction of hypovolemia, coagulation defects, hypothermia and
acidosis must begin in the operating room and continue in the ICU.
Late Postoperative Management and Liver Specific

Complications
Pack Removal
Packs should be removed by 48-72 hours postoperatively, unless there are
extenuating circumstances. After that time they become increasingly difficult
to dislodge and more likely to become grossly infected (particularly if there
has been a hollow viscus injury).
Pack removal is facilitated by soaking the gauze with saline (or very dilute
H202 in saline: 15 ml of 3% in 1L) to soften them. Ample blood for transfusion should be available in case of renewed hemorrhage. Repacking is usually
indicated when this occurs.
Sepsis
28
If the clinical picture of sepsis develops an abdominal CT scan is indicated

with instructions for percutaneous catheter drainage of fluid (blood, bile or
pus) collections unless less than 3 cm or located in an inaccessible area. Most
peri- or intrahepatic infected collections can be successfully managed by such
drainage and targeted antibiotic treatment.
Occasionally operative drainage is required, particularly when the infection is
accompanied by a large segment of necrotic liver (sequestrum).
Bile Leaks/Fistulae/Stricture
Drains placed at the time of operation or in the postoperative period can
drain large amounts of bile.
Most such fistulae require little to be done except render the patient infection
free and provide good nutrition. Drains should be left in place.
Fat free diets (difficult to maintain adequate calorie intake), H-2 blockers and
somatostatin are adjunctive but of unproven benefit.
High output for long periods (arbitrarily > 50 ml/day for more than 6 weeks)
should prompt further investigation by CT scan, fistulagram and/or ERCP.
ERCP with stenting across the ampullary sphincter may be helpful.
Almost all such fistulae close, but if after several months closure has not
occurred, particularly if there is a proximal stricture, Roux-en-Y jejunal loop
placement over the hepatic opening, segmental hepatic resection or other operative procedure may be necessary on rare occasions.
Late stricture of extra hepatic bile ducts usually requires reoperation although
percutaneous or transampullary balloon dilatation and stenting may be of value.
Hemobilia
The postoperative triad of jaundice, right upper quadrant pain and upper GI
bleeding is classical. Unfortunately it occurs only infrequently.
313
Fig. 28.8. Angiographic embolization of a bleeding pseudoaneurysm.
Unexplained UGI bleeding must be considered to be hemobilia after any significant liver injury.
Psuedoaneurysm causing bleeding can often be seen on contrast CT scan.
They are best diagnosed and treated with angiography and arterial embolization (Fig. 28.8).
Outcomes
The overall mortality rates for liver injury should be in the range of 10%.
There is a higher lethality of blunt compared to penetrating.
Grade V vascular and Grade VI injuries have > 50% mortality.
Mortality reaches 100% if all portal triad structures are transected.
References
1.
2.
3.
4.
Demetriades D, Gomez H, Chahwan S et al. Gunshot wounds to the liver: The

role of selective nonoperative management. J. Am Coll Surg 1999; 1888:343-348.
Krige JE, Bornman PC, Terblanche J et al. Liver trauma in 446 patients. Surgery
1997; 35:10-15.
Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clinics of No Am 1996;
16:763-782.
Schweitzer W, Tanner S, Bear HU et al. Management of traumatic liver injuries.
BJS 1993; 80:86-88.
28
CHAPTER 29
Splenic Injuries
John A. Androulakis and Michael N. Stavropoulos
Introduction
The spleen is the most commonly injured organ, following blunt abdominal
trauma.
The injured spleen, ranks second behind the liver as the source of life threatening hemorrhage following blunt trauma.
Reigner, performed the first successful splenectomy, following blunt
trauma in 1893.
The nonoperative management of splenic trauma, attempted by Bland Sutton
in 1912, resulted in a 90% mortality.
Routine splenectomy, remained the treatment of choice for injured spleen for
most of the 20th century.
In 1952 King and Shumacker reported overwhelming sepsis as a possible hazard
of the asplenic state in infants.
The recognition of the immunologic significance of the spleen, coupled with
the renewed attention to its blood supply and the development of CT-scan,
has led to a more conservative approach of the management of splenic trauma
in recent years.
Anatomy, Structure and Function

Spleen lies in the left upper quadrant of the abdomen at the level of the eighth
to eleventh ribs.
It is firmly connected to the retroperitoneal space by the splenorenal and
splenophrenic ligaments and to mobile adjacent viscera by gastrosplenic and
splenocolic ligaments.
In children, the capsule is relatively thicker than that of the adults and in
splenic parenchyma there is a large amount of functional smooth muscle and
elastin. These characteristics result in increased splenic salvage in children with
nonoperative management or splenorrhaphy.
The splenic artery, before it reaches the spleen, divides into five or more
branches which enter the hilum of the organ and ramify throughout its substance into the trabecular arteries. This arterial division creates distinct anatomic
segments which allows the surgeon to perform partial resection. The transverse
orientation of the segmental arteries through the splenic tissue without
John A. Androulakis, Department of Surgery, University of Patras Medical School,
Patras, Greece
Michael N. Stavropoulos, Department of Surgery, University of Patras Medical School,
Patras, Greece
Splenic Injuries
315
anastonosis to adjacent vessels accounts for the spontaneous cessation of

bleeding after transerve lacerations of the spleen.
The spleen represents the largest (25%) reticuloendothelial accumulation in
the body. Except for the phagocytosis and synthesis of immunoglobulins which
also occur in other organs, a main role of the spleen is synthesis of new antibodies (IgM). This role is extremely important in infancy and explains the
special susceptibility to infection after splenectomy in children under two years
of age.
Spleen also produces monocytes, lymphocytes and plasma cells and is a source
of tuftsin and properdin. Tuftsin enhances phagocytosis by neutrophils and
properdin is a crucial mediator of complement activation via the alternative
pathway.
Low IgM, properdin and tuftsin and inability of clearance of intravascular
antigens characterize the asplenic state. These deficiencies, result in an increased
susceptibility to infectious complication and overwhelming postsplenectomy
infection (OPSI) in asplenic patients.
Diagnosis
The diagnosis of splenic trauma should be based on the history of injury and
the clinical presentation of the patient. It is confirmed at operation or by
means of CT scan or ultrasound.
Mechanism of Injury
Blunt Trauma
Compression injury (after left lateral impact or direct blow,) may result in
simple splenic fracture or severe stellate fractures. Splenic pulp disruption
beneath an intact capsule produces a subcapsular or intraparenchymal hematoma.
A left lower fractured rib can tear the spleen.
In deceleration injuries, such as in high-speed traffic accidents or falls from
heights, the fixed spleen is subject to shear injury as it is torn at sites of
supporting ligaments. With severe deceleration, the spleen may be totally
avulsed from the retroperitoneum and its hilar vessels (injuries by inertial forces).
Penetrating Trauma
The type of splenic injury depends on the characteristics of the weapon (type of
the gun, length of the knifes blade, etc.) and its trajectory. Gunshot wounds with
civilian weapons and stab wounds that penetrate the spleen cause anatomically
defined injuries, which are usually less severe than blunt ones.
Underlying Splenic Disease

A diseased or enlarged spleen, produced by hematological disorders, infections
or portal hypertension, is more likely to rupture than a normal one, even after a
trivial trauma.
The clinical presentation of the patient with splenic trauma varies from
severe hypovolemic shock to minimal or no symptoms.
The bleeding rate, the age and previous health condition of the patient and
prehospital elapsed time are factors influencing the clinical presentation of
29
316
Trauma Management
the patient at the time of admission. However, the majority of the patients
(75%), show variable signs of hypovolemic shock.
The largest group of patients (with an intact sensorium) complains of diffuse
abdominal pain more severe in the left upper quadrant and frequently accentuated by deep breathing.
Left shoulder pain is a common and clearly useful sign (Kehrs sign), which
often can be elicited by placing the patient in the Trendelenburg position.
Clinical Findings on Physical Examination

The lower chest wall, the abdomen and the flank should be inspected for abrasions, contusions, lacerations or penetrating wounds which may be indicative of
underlying splenic injury.
The patient may be pale with variable tachycardia, hypotension and abdominal distention depending upon the amount of acute blood loss.
The palpation of the abdomen, usually reveals diffuse or localized abdominal
tenderness and muscle guarding.
A palpable mass in the left upper quadrant suggests a large splenic hematoma.
Physical examination of the abdomen after blunt trauma is neither sensitive
nor specific for splenic injury. The delayed recognition of the splenic injury is
one of the most common causes of preventable death, after blunt trauma. The
high index of suspicion, the frequent reevaluation of the patient and prompt
radiological investigations help to solve this problem.
Investigations
29
Chest X-Ray
May be suspicious of splenic injury in up to 50% of patients. Radiological
findings suggestive of significant left upper quadrant injury and suspicious of
splenic trauma are:
Left lower rib posterior fractures (splenic injury occurs in about 20% of cases).
Left pleural effusion. Elevated left hemidiaphragm. Left pulmonary contusion.
Medial displacement of gastric air bubble. Downward displacement of the left
colic flexure.
Diagnostic Peritoneal Lavage (DPL)

It can be utilized in hemodynamically unstable multiply injured patients when
there is an immediate need to know if hemoperitoneum exists.
It is extremely sensitive but not organ specific.
CT Scan
Contrast enhanced CT scan is the principal and most valuable diagnostic
modality, for hemodynamically stable patients. It detects splenic trauma with
high degree of accuracy and may also show evidence of active bleeding or false
aneurysm (contrast blush) which predict the risk of failure of nonoperative
management of blunt splenic trauma (Fig. 29.1A).
The accuracy of CT images permits grading of splenic trauma based on the
CT scan characteristics of splenic injuries (Figs. 29.2, 29.3). It may miss
superficial lacerations.
Hemoperitoneum and perisplenic clots, are the most common CT findings
indicative of splenic trauma, if lacerations are not identified.
Splenic Injuries
317
Fig. 29.1A. Traffic accident: Abdominal CT-scan with intravenous contrast, shows
a ruptured spleen with a false aneurysm (arrow)
Ultrasonography (US)
Is a useful primary imaging modality that can be performed in the Emergency
Room to reveal free intraperitoneal fluid.
US can be used to predict the need for further evaluation or laparotomy as
well as for follow-up of injury healing or progress of absorption of a known
hematoma.
Angiography
Angiography is indicated in patients with a blush on CT scan suggesting active
bleeding or false aneurysm (Fig. 29.1B).
Delayed Splenic Rupture (DSR)

The presence of a subcapsular splenic hematoma, may result in delayed rupture
of the spleen, usually within two weeks of original trauma, but it may occur
many weeks later DSR is possibly attributable to the increased osmolality of
the contents of a hematoma (due to the disintegration of the red cells) which
results in attraction of additional fluid, expansion of the cavity, secondary hemorrhage and finally rupture.
DSR produces sudden shock from profuse bleeding and operative or
nonoperative management is based on the condition of the patient after initial
volume resuscitation.
The diagnosis before rupture can be made by the history of a current trauma,
abdominal symptoms and signs (abdominal and shoulder pain, palpable tender
left upper quadrant mass), an unexplained anemia, and left pleural effusion. It
can be confirmed by U/S or CT scan of the abdomen (Figs. 29.3, 29.4).
29
318
Trauma Management
Fig. 29.1B. Angiography, confirms the presence of a large splenic aneurysm (arrow).
29
Fig. 29.1C. Successful angiographic embolization of the aneurysm. The spleen was
successfully managed nonoperatively.
Splenic Injuries
319
Fig. 29.2. Abdominal CT scan demonstrating Grade IV splenic trauma.
29
Fig. 29.3. Large subcapsular splenic hematoma following blunt trauma. CT scan
appearance.
Grading System of Splenic Trauma

The most recent grading system for splenic trauma is the Spleen Injury Scale
(1994 revision) promulgated by the Organ Injury Scaling (0IS) Committee
of the American Association for the Surgery of Trauma (AAST).
This scale is a classification scheme based on the anatomic disruption of the
spleen, graded 1-5, representing the least to most severe injury, and corresponding to the International Classification of Diseases, 9th revision (ICD-9)
code and Abbreviated Injury Scale (AIS-90) scores. (Table 29.1).
320
Trauma Management
Fig. 29.4. Large subcapsular splenic hematoma following blunt trauma. U/S
appearance.
29
The objectives of this scale are to standardize reports, to guide treatment, and
to evaluate and compare the results of different therapeutic modalities.
Management
Principles
The specific management of the patient with presumed splenic trauma is
directed by the hemodynamic condition and clinical findings of the abdominal
examination.
The hemodynamically unstable patient on admission, who remains unstable
after vigorous resuscitation, with suspected splenic injury following blunt or
penetrating trauma, should undergo urgent operation regardless of age.
A blunt trauma patient, who is hemodynamically stable and has a soft abdomen,
is a candidate for nonoperative management. A CT scan with intravenous contrast
is essential. If contrast blush is present, angiographic embolization should be
attempted (Figs. 29.1A-C).
Nonoperative Management (NOM)

In recent years, the widely accepted NOM of splenic injury in children was
extended to adult patients.
The patient selection criteria for NOM are:
Hemodynamic stability
No clinical or radiological (CT scan) evidence of other intraabdominal
injuries requiring celiotomy.
Limited need for spleen-related transfusion ( 2 units).
321
Splenic Injuries
Table 29.1. Spleen injury scale (1994 revision)
I
II
Gradea
Injury Description
AIS-90
Hematoma
Laceration
Hematoma
Subcapsular, < 10% surface area

Capsular tear, < 1 cm parenchymal depth
Subcapsular, 10-50% surface area;
intraparenchymal, < 5 cm in diameter
1-3 cm parenchymal depth which
does not involve a trabecular vessel
Subcapsular, > 50% surface area
or expanding; ruptured subcapsular
or parenchymal hematoma
Intraparenchymal hematoma > 5 cm
or expanding
> 3 cm parenchymal depth or
involving trabecular vessels
Laceration involving segmental
or hilar vessels producing major
devascularization (> 25% of spleen)
Completely shattered spleen
Hilar vascular injury which
devascularizes spleen
2
2
2
Laceration
III
Hematoma
Laceration
IV
Laceration
Laceration
Vascular
3
4
5
5
Advance one grade for multiple injuries, up to grade III.
Additionally in recent reports, the following subgroups of hemodynamically stable

patients are candidates for NOM of their splenic trauma. These are:
Patients who are neurologically impaired (head injury, alcohol or drug
intoxication).
Patients with small isolated penetrating wounds to the spleen.
Patients of any age, any AAST grade of splenic injury, any degree of
hemoperitoneum and any ISS score.
Guidelines for Nonoperative Management

Candidates for NOM should be observed in SICU with strict bed rest and
prepared for surgery.
Serial physical examinations of the abdomen, by an experienced physician.
Serial Hct and Hgb.
Decompression of the stomach
Strict bed rest for 2-3 days but may be individualized according to the hemodynamic and general status of the patient and the degree of splenic injury.
Resume diet once the potential for urgent operation and any evidence of
associated ileus no longer exists.
Serial CT scan evaluations are only performed in patients with severe splenic
injuries (grade III or worse).
The length of hospital stay (LOS), ranges from 5 to10 days depending on the
patients condition and the degree of splenic injury.
The restriction of activities varies according to the grade of injury. It has been
shown experimentally that an injured spleen managed nonoperatively (healing
by secondary intention), has a wound breaking strength equal to that of a
29
322
Trauma Management
Fig. 29.5. Ruptured spleen. CT scan appearance and operative specimen.
29
normal spleen at 6 weeks postinjury. So, except for the minor grade injuries (I
or II) which need minimal if any restriction of activities, in more severe injuries,
the patient should be advised to avoid vigorous physical activities for about 6
weeks. In subcapsular hematomas, resumption of physical activities should be
considered after resolution of the hematoma. Before the resumption of
activities, a CT scan should be done to ensure that the splenic parenchymal
architecture has returned to normal and to confirm the absence of a splenic
posttraumatic cyst or a pseudoaneurysm formation.
Failure of Nonoperative Management

Any patient who demonstrates hemodynamic instability, signs of peritonitis,
or when the total transfusion requirements (because of the splenic injury)
exceed two units of blood, is immediately taken to the operating room.
The most significant prognostic indicator of failure of nonoperative management in the hemodynamically stable patient is the presence of extravasation
of contrast material on contrast CT scan. CT grading of splenic injury does
not predict the success of nonoperative management.
Success rate of NOM in children is higher than 90%. In adults it is about 70%.
Operative Management (OM)

Principles
The OM of splenic trauma includes splenectomy as well as the various techniques of surgical splenic salvage.
The spleen is assessed visually and is palpated. If it appears to be the primary
site of life threatening bleeding, splenectomy should be done without hesitation.
The decision to perform splenectomy or splenic conservation is based upon
the condition of the patient, the severity of the splenic injury, the presence of
other associated injuries and the experience of the surgeon.
Splenic Injuries
323
Splenic Preservation
Local hemostatic agents and cautery or Argon beam laser.

Suturing with or without omental packing.
In selected cases a splenic mesh may be useful.
Ill-advised attempts to preserve the spleen may result in significant blood loss
and postoperative complications.
Splenectomy
In traumatic splenectomies, after rapid mobilization of the spleen, the splenic
vessels are clamped and ligated en mass. The clamps should be applied as close
as possible to the hilum, in order to diminish the risk of injury to the tail of
pancreas, or the gastric fundus.
- Drains of the splenic bed are not routinely used for either splenectomy or
splenorrhaphy, except in cases with incomplete hemostasis or associated injuries to the tail of pancreas or other organs.
Autotrasplantation of Splenic Tissue (AST)

AST, has been used to decrease the risk of OPSI in patients with irreparable
splenic trauma requiring splenectomy. It has limited clinical application and
more studies are needed to confirm the usefulness of this method.
Complications
Postoperative Local Complications
Left lower lobe atelectasis, pneumonia and pleural effusion are the most common complications.
Left subphrenic abscess (3-13%) is more frequent in patients with associated
hollow viscous injuries.
Pancreatitis or pancreatic fistula may occur either as part of the original trauma,
or more usually as a consequence of iatrogenic trauma to the tail of the pancreas
during operation.
Acute gastric distension is more common in children and is prevented by
nasogastric suction.
Gastric greater carvature necrosis is the result of entrapment of the gastric wall
when securing ligatures after division of the gastrosplenic ligament.
Postoperative hemorrhage may occur following splenectomy (from inadequate
control of the short gastric or hilar vessels) or conservative surgery and may
require transfusion or embolization or reoperation. Reoperation for hemorrhage
is rare, about 2% for splenectomy and about 3% for splenorrhaphy.
Systemic Complications
Thrombocytosis (more than 400.000 platelets /mm3) may present between
the 2nd and 10th postoperative day, in about 50% of splenectomized patients.
This condition is usually resolved within 2 weeks to 3 months.
- It is not clear whether thrombocytosis predisposes to an increased risk of DVT
or PE or not. When the platelet count exceeds 1 million/mm3 or if the patient
has a previous history of thrombosis, the administration of antiplatelet drugs
(i.e., aspirin) is indicated.
29
324
Trauma Management
Overwhelming Postsplenectomy Infection (OPSI)

Splenectomy renders patients susceptible to a major long-term risk of infectious
complications, mainly due to the deficiency for clearance of intravascular
antigens. The most serious of these infections is the rare but highly fatal
syndrome of OPSI.
29
- This syndrome is initially characterized by an abrupt onset of nonspecific flu-like

symptoms, (fever, chills, headache, nausea, vomiting, malaise and abdominal pain).
- This condition progresses rapidly to respiratory and renal failure, cardiovascular
collapse and finally death within hours of onset, if appropriate treatment is not
effectively instituted.
- Usually the causative organisms are encapsulated, with the Streptococcus
pneumoniae responsible for 50-90% of cases followed by Neisseria meningitidis,
Haemophilus influenza type B (especially important in children) and group A
Streptococci, which cover an additional 25%.
- The risk of fatal OPSI is less after splenectomy for trauma than for hematologic
disorders.
- In general the younger the patient undergoing splenectomy and the more severe
the underlying pathological condition, the greater the risk for developing OPSI.
- While the 50-70% of serious infections in adults and the 80% of OPSI in
children occur within two years postsplenectomy, some degree of risk persists
for the duration of life.
- The prevention of OPSI is based on the education of the patient, the
immunoprophylaxis and chemoprophylaxis.
The patients and their families should be informed about the possibility of infections, and a Medi-Alert bracelet should be worn to notify
the asplenic state.
The patients should be taught to recognize the early signs and symptoms of
such infection and to seek early medical care.
Pneumococcal vaccination should be performed after recovery and before
discharge from the hospital. The protection lasts 5-6 years, after which
revaccination is proposed in selected high risk young patients.
Influenza vaccination is recommended annually.
Children < 2 years should be covered with antibiotics (amoxicillin/
clavulanic acid or sefuroxim). Since only 50% of cases of OPSI are caused
by Streptococcus pneumoniae and the vaccine is effective against about 90%
of pneumococcal infections, a two-year course of prophylactic antibiotic
postsplenectomy is recommended, especially for children and immune-suppressed adults. An alternative is the administration of antibiotics at the
first signs of infection as well as prior to any instrumentation or surgical
procedure.
It should be emphasized that the use of antibiotic prophylaxis and the
immunization may reduce but does not eliminate the infectious complications.
- The overall mortality rate of OPSI, varies from 50-70%, but the preventive measures and the early diagnosis of OPSI, with the institution of aggressive supportive care and appropriate antibiotic therapy, has greatly improve patient outcome.
Pitfalls
Delayed diagnosis of splenic hemorrhage following blunt trauma in patients
neurologically impaired.
Splenic Injuries
325
Undiagnosed splenic hematoma can result in delayed splenic rupture and life
threatening hemorrhage.
Attempts to salvage the spleen in the presence of multiple associated injuries.
References
1.
2.
3.
4.
5.
Brigden ML, Pattulo A L. Prevention and management of overwhelming

postsplenectomy infectionAn update. Crit Care Med 1999; 27:836-842
Davis K.A, Fabian TC, Groce MA et al. Improved success in nonoperative management of blunt splenic injuries: Embolization of splenic artery pseudoaneurysm.
J Trauma 1998; 44:1008-1015.
Lynch AM, Kapila R. Overwhelming postsplenectomy infection. Infect Dis Clin
North Am 1996; 4: 693-707.
Pachter HL, Guth AA, Hofstetter SR et al. Changing patterns in the management
of splenic trauma. The impact of nonoperative management. Ann Surg 1998;
227:708-719.
Brasel KJ, Delisle CM, Olson CJ et al. Splenic injury: Trends in evaluation and
management. J Trauma 1998; 44:283-286.
29
CHAPTER 30
Pancreatic Injuries
Introduction
Pancreatic injuries are easily missed and quite lethal. They are generally present
in association with many other intraabdominal injuries. The pancreas when
injured can be an unforgiving organ.
Delays in diagnosis can make what is already a difficult surgical tour de force
quite challenging with resulting increases in morbidity and mortality. Early
diagnosis and repair are the key to improvements in survival.
The first case of pancreatic injury was reported in 1827 by Travers during an
autopsy in the records of St. Thomas Hospital in London.
Laborderie in 1856 reported a case of penetrating trauma in a young girl that
sustained an abdominal laceration with a pocket knife resulting in a prolapse
of the pancreas. This was treated with suture transfixion double ligature and
removal of the protruding portion resulting in a positive outcome.
In 1882 Kulenkampff reported a patient that survived blunt injury to the
pancreas with the subsequent development of a pseudocyst.
Kocher in 1903 described the surgical approach to the mobilization of the
duodenum, the hallmark maneuver used in evaluating both pancreatic and
duodenal injuries.
Incidence
The retroperitoneal location of the pancreas plays a strong role in protecting it
and thus accounts for its low incidence of injury.
Pancreatic injuries occur in approximately 3-4% of all patients sustaining
abdominal injuries.
Mechanism of Injury
Penetrating injuries are the most common causes of pancreatic trauma.
Penetrating injuries account for 70% of all pancreatic trauma.
Associated Injuries
The pancreas, by virtue of its is anatomic proximity to other organs is rarely
injured alone. Multiple associated injuries are the rule rather than the exception.
Isolated pancreatic injuries are usually seen in the form of blunt pancreatic
transections, generally at the neck of the gland.

Walter Forno, University of Southern California, Los Angeles, California, U.S.A.
Pancreatic Injuries
327
30
Fig. 30.1. CT scan showing transected pancreas at neck directly over the superior
mesenteric vessels. Reprinted with permission from: Asensio JA, Demetriades D.
Textbook of Techniques in Complex Trauma Surgery. Philadelphia, PA: W.B.
Saunders Co. In Press.
The most frequently injured organs found in association with pancreatic

injuries include: the liver19%, stomach16%, spleen11%, colon and
duodenum8%.
Abdominal vascular injuries occur with a frequency of 14%. Major arterial
and venous injuries range from 4.5-5.5%.

The most frequent site of pancreatic injury is the pancreatic head and
neck37%.
The pancreatic body is injured in 36% of the cases.
The least frequently injured portion is the pancreatic tail26%.
Multiple sites of injury occur in 3% of the cases.
328
Trauma Management
Fig. 30.2. ERCP showing a leak from a transected main pancreatic duct secondary
to a GSW. Reprinted with permission from: Asensio JA, Demetriades D. Textbook
of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA.
In press.
Diagnosis
30
The diagnosis of pancreatic injury requires a high index of suspicion.
The diagnosis of pancreatic injury presents a greater challenge after blunt
trauma than after penetrating trauma.
Clinical presentation can range from a patient presenting in extremis to a picture of perfect hemodynamic stability.
Patients presenting a prehospital history of a direct force applied to the
midepigastrium, especially those having been struck by steering wheels, patients sustaining head-on collisions or either right or left sided impacts may
harbor pancreatic injuries.
Because of the pancreass retroperitoneal location, early manifestations of injury may be absent.
Physical examination may be characterized by minimal findings. Tenderness
of the right upper quadrant, midepigastrium or left upper quadrant as well as
rebound tenderness, abdominal rigidity or acute peritoneal signs may be present
in a patient harboring a pancreatic injury.
Abdominal discomfort and pain may be totally out of proportion to the physical
examination findings as peritoneal irritation may occur rather late and may
become apparent only when blood or pancreatic enzymes, initially contained
within the retroperitoneum, have extravasated into the peritoneal cavity.
Pancreatic Injuries
329
Fig. 30.3. Operative slide showing a pancreatic injury in the head secondary to a
GSW. Reprinted with permission from: Asensio JA, Demetriades D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In press.
Investigations
Laboratory tests provide little help in the early diagnosis of pancreatic injuries.
The serum amylase should not be used as an indicator for exploratory
laparotomy.
- The serum amylase can indicate the presence of pancreatic injury, but may show
a wide range of elevations in 10-90% of the patients in whom it is measured.
- As many as 40% of patients that sustain pancreatic injury may have a normal
initial serum amylase level.
- The serum amylase level is a measure of ductal obstruction. The closer the ductal obstruction to the duodenum, the greater the glandular mass secreting behind the obstruction leading to diffusion of amylase into the gland, which is
then absorbed by pancreatic venous capillaries, lymphatics or the peritoneal
membrane as in the case of ductal transection. Therefore the more proximal
obstruction, the greater the rise of the amylase level.
The serum amylase level may have a predictive value in patients admitted for
observation and should be monitored at 6-hour intervals. A persistently
elevated arising amylase level may of prognostic significance.
Plain films of the abdomen are generally of little value in establishing the
diagnosis of pancreatic injury. Transverse process fractures of the L1- L2 vertebrae,
when present, suggest that the pancreas be investigated for possible injury.
30
330
Trauma Management
Ultrasound, although valuable in detecting free intraabdominal fluid and solid

organ injury, is not reliable for the diagnosis of pancreatic injuries.
CT scan, of the abdomen with intraluminal and intravascular contrast has a
high degree of accuracy in detecting injuries to the pancreas. Pancreatic edema,
gross enlargement of the gland, direct visualization of a parenchymal fracture
or hematoma, fluids separating the splenic vein and pancreatic body and
thickened left anterior renal fascia are significant findings.
- CT scan although quite reliable, may occasionally miss pancreatic injuries,
especially if done early postinjury. A repeat scan is recommended in suspected
pancreatic trauma.
Diagnostic peritoneal lavage may be positive in a high number of patients

with pancreatic injuries, however, the positivity is due to associated intraperitoneal injuries and not the duodenal injury itself, as the pancreas is a retroperitoneal organ.
- The presence of significant amounts of amylase in the peritoneal lavage fluid
correlates with the presence of intraabdominal injury, but this finding is not
specific for pancreatic injury.
The use of ERCP preoperatively will identify the presence of a pancreatic

ductal disruption, although its use in the acute diagnosis of pancreatic injuries
is not feasible.
MRCP (Magnetic Resonance Cholangio-Pancreatogram) is a promising
technique, especially in the evaluation of the integrity of the pancreatic duct.
Surgical Management
30
The pancreas must be thoroughly explored and its anterior and posterior aspects
visualized directly.
There are three basic exposure maneuvers and two advanced maneuvers to
visualize the pancreas in its entirety.
- The three basic maneuvers consist of a Kocher maneuver which will allow visualization of the anterior and posterior portions of the head of the pancreas. The
next maneuver to be performed consists of dividing the gastrohepatic ligament
to gain access to the lesser sac. This facilitates inspection on the superior border
of the pancreas including the head, body and both the splenic artery and vein.
The third basic maneuver consists of transection of the gastrocolic ligament and
displacement of the stomach cephalad, which permits full inspection of the anterior aspect of the gland along its entire length.
- The two more advanced maneuvers to visualize the pancreas consist of the Aird
maneuver which involves mobilizing the splenic flexure of the colon and splenic
ligaments to rotate the spleen and the pancreas from lateral to a medial.
Transection of the retroperitoneal attachments at the inferior border of the
pancreas with cephalad rotation of the pancreas will allow for exposure of the
posterior aspect of the pancreas.
Findings that raise the suspicion for the presence of pancreatic injuries include the presence of a central retroperitoneal hematoma, bile staining in the
retroperitoneum, edema surrounding the pancreas and lesser sac or any pancreatic hematoma or perforation.
The sine qua non of pancreatic injury is the presence of ductal injury.
All pancreatic injuries should be graded utilizing the American Association for
the Surgery of TraumaOrgan Injury Scale for pancreatic injuries (AAST-OIS).
Pancreatic Injuries
331
The simplest surgical techniques should be selected to manage the lower grade
injuries while reserving the more complex techniques for the management of
the more severe and advanced grade injuries.
Basic surgical principles include debridement of devitalized tissue, conservation of pancreatic tissue to preserve function, and meticulous repair when
necessary of pancreatic lacerations with nonabsorbable sutures.
The uncinate process is absent in 15% of the patients. Normally a resection to
the left of the superior mesenteric vessels extirpates approximately 65% of the
gland. Although this is an extensive resection, it is not associated with the
development of pancreatic insufficiency. When the uncinate process is absent
a resection to the left of the superior mesenteric vessels will result in resection
of 80% of the glandular mass and in occasional cases this predisposes to the
development of pancreatic insufficiency.
Intraoperative pancreatography carries risks and should be used as a last
resort. It can be performed through an open duodenotomy and intubation of
the ampulla of Vater. An alternative is a needle cholangiogram which
occasionally allows for visualization of the pancreatic duct.
Intraoperative ERCP has very rarely been utilized to assess ductal integrity.
All pancreatic injuries should be drained with closed systems.
Approximately 60% of all pancreatic injuries can be treated by external drainage alone. Approximately 70% of pancreatic injuries can be treated by simple
pancreatorraphy plus drainage.
Injuries that consist of lacerations or violations of the pancreatic capsule,
parenchyma and involving minor ducts, but not the major pancreatic ductal
system account for 20% of the injuries and can be treated by pancreatorrhaphy
and drainage.
Injuries that lacerate the pancreatic capsule and parenchyma involving the
major ductal system account for 15% of all pancreatic injuries and are generally
treated with resection.
Injuries that involve the major ductal system but occur to the left of the superior
mesenteric vessels should be treated by distal pancreatectomy and splenectomy.
This can be rapidly performed utilizing a stapler. We recommend oversewing
the staple line with nonabsorbable sutures and the pancreatic duct, if identified,
individually ligated.
Injuries lacerating the pancreatic capsule, parenchyma and involving the
major ductal system if occurring at the neck or to the right superior mesenteric
vessels can also be treated with pancreatectomy, although this will be an
extended distal pancreatectomy. In cases in which the uncinate process is
absent, a consideration for preservation of the distal pancreas with a
pancreaticojejunostomy must be entertained.
Combined pancreaticoduodenal injuries can be treated either by pyloric
exclusion, or in rare cases duodenal diverticularization provided that the
duodenum can be repaired primarily.
Pancreaticoduodenectomy is formidable procedure and is uncommonly needed
in cases of combined pancreaticoduodenal injuries.
The indications for pancreaticoduodenectomy (Whipple procedure) are listed
below:
- Massive and uncontrollable bleeding from the head of the pancreas, adjacent
vascular structures, or both.
30
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Trauma Management
- Massive and unreconstructable ductal injury in the head of the pancreas.
- Combined unreconstructable injuries of the following; duodenum, head of the
pancreas, and common bile duct.
Approximately 28% of all pancreatic injuries are managed by distal pancreatectomy. Only 4% of patients require pancreaticoduodenectomy (Whipple
procedure).
Mortality
Mortality rate ranges from 5-54%. Mortality for Whipple resection is
about 33%.
Most early deaths are caused by exsanguination from associated vascular injuries versus the pancreatic injury itself.
Late mortality can generally be attributed to the pancreatic injury and associated complications which include; sepsis, pancreatic fistulas and multiple
systems organ failure.
Mortality rates can be as high as 90% especially in those patients that undergo
delayed surgical intervention.
Morbidity
Approximately 37% of all pancreatic injury cases will experience complications.
Pancreatic morbidity is represented primarily by pancreatic fistula formation.
30
- A pancreatic fistula is defined as drainage of greater than 50 mls that persists

longer than two weeks with elevated amylase and lipase levels.
- Most pancreatic fistulas are treated with bowel rest, hyperalimentation and the
use of a somatostatin analogue.
- Posttraumatic pancreatic fistulas occur in approximately 14% of the cases. Fistulas develop in 42% of patients that undergo pancreatorrhaphy and drainage,
and in 34% of patients that are treated with simple drainage alone. Fistulas
develop in 27% of patients subjected to distal pancreatectomy.
- Surgical reintervention is needed for the definitive treatment of pancreatic fistulas in less than 2% of the cases. However, reintervention should be considered
for fistulas of greater than two months duration with unrelenting production of
high volumes.
Pancreatic abscess is the second most frequent complication with an

incidence of 8%.
Posttraumatic pancreatitis has an incidence of 4%.
Pseudocysts occur in 3% of all cases while late hemorrhage occurs in 1% of
the cases.
Pancreatic exocrine and endrocine insufficiency occurs uncommonly.
References
1.
2.
Asensio JA, Demetriades D, Hanpeter D et al. Issue editors. Management of Pancreatic Injuries. Current Problems in Surgery. Vol XXXVI, No. 5, p325-420. Wells
SA Jr. Ed. St. Louis, MO: Mosby-Yearbook. May 1999.
Asensio JA. Operative pancreatograms at 2:00 AM? In: Critical Decision Points in
Trauma Care. Proceedings of Postgraduate Course No. 5; American College of
Surgeons, p55-57, October, 1992.
CHAPTER 1
CHAPTER 31
Duodenal Injuries
Introduction
Duodenal injuries are often silent, easily missed and quite lethal. They are generally present in association with many other intraabdominal injuries. Delays in diagnosis and repair can make surgical management a more complex and technically
challenging endeavor and increase an already heavy burden of morbidity and mortality. Early diagnosis and repair are the keys to achieving survival and good outcomes.
Larrey reported the first successful outcome from penetrating duodenal injury in
1811.
The first successful surgical repair of a duodenal rupture was reported in 1896
by Herczel secondary to blunt trauma.
Incidence
The retroperitoneal location of the duodenum plays a strong role in protecting it
and thus accounts for its low incidence of injury.
Duodenal injuries occur with the frequency of 3-5% of all patients sustaining
abdominal injuries.
Mechanism of Injury
Penetrating injuries account for 78% of all duodenal trauma. Blunt injuries
account for 22% of all duodenal trauma.
Duodenal injuries can be caused by falls from great heights or by direct impacts.
Crush injuries of the duodenum may occur when a direct force is applied
against the abdominal wall that is transmitted to the duodenum which is then
projected posteriorly against the vertebral column. A good example of crush
injuries are steering wheel injuries.
Shearing injuries occur when acceleration and deceleration forces are applied
to the duodenum. A cause of these are falls from great heights.
Duodenal rupture occurs secondary to blunt trauma and is generally confined
to the retroperitoneum. These injuries are highly lethal if not detected and
repaired promptly.
Associated Injuries
The duodenum, by virtue of its anatomic proximity to other organs, is rarely
injured alone.
Associated injuries occur with a frequency of 87%.
Walter Forno, University of Southern California, Los Angeles, California, U.S.A.
334
Trauma Management
31
Fig. 31.1. UGI showing dye extravasation and a duodenal injury at the second
portion of the duodenum. Reprinted with permission from: Asensio JA, Demetriades
D. Textbook of Techniques in Complex Trauma Surgery. W.B. Saunders Co.,
Philadelphia, PA. In press.

The most frequent site of duodenal injury is the second portion33%.
The third and fourth portions are injured in 20% of the cases.
The least frequently injured portion of the duodenum is the first portion14%.
Multiple sites of injury occur in 14% of the cases.
Duodenal Injuries
335
Fig. 31.2. CT scan showing a double lumen of the duodenum consistent with a
duodenal transection. Note edema and fluid surrounding the transected duodenum. Also note the increased space between the duodenum and right kidney. Reprinted with permission from: Asensio JA, Demetriades D. Textbook of Techniques
in Complex Trauma Surgery. W.B. Saunders Co., Philadelphia, PA. In press.
Diagnosis
The diagnosis of duodenal injury, especially after blunt trauma, requires a
high index of suspicion.
Clinical presentations can range from a patient presenting in extremis to a
picture of perfect hemodynamic stability.
Patients presenting with a prehospital history of direct force applied to the
mid-epigastrium, especially those having been struck by steering wheels, patients sustaining head-on collisions or right-sided impacts and those sustaining falls from great heights may harbor duodenal injuries.
Because of the duodenums retroperitoneal location, early manifestations of
injury may be absent.
Physical examination may be characterized by minimal findings. Tenderness
of the right upper quadrant or mid-epigastrium as well as signs of rebound
tenderness, abdominal rigidity or acute peritoneal signs may be present in a
patient harboring a duodenal injury.
In retroperitoneal rupture of the duodenum, physical findings may be absent
until duodenal secretions extravasate into the abdominal cavity.
31
336
Trauma Management
31
Fig. 31.3. Retroperitoneal blow-out of the second portion of the duodenum detected after 48 hours. Note the bile staining within the surrounding tissue and the
periduodenal inflammatory process. Reprinted with permission from: Asensio JA,
Co., Philadelphia, PA. In Press.
Investigations
Laboratory tests are often of little help in the early diagnosis of duodenal
injuries.
- Serum amylase level is unpredictable. Its elevation is usually moderate.
The serum amylase level may have a predictive value in patients admitted for
observation and should be monitored at six hour intervals. A persistently elevated or rising amylase level may be of prognostic significance.
Duodenal Injuries
337
Plain films of the abdomen are useful only if positive. Positive findings include: air collections outlining the upper pole of the right kidney, retroperitoneal gas, air around the right psoas and in the retrocecal region. These findings are difficult to detect and are often absent or missed.
UGI contrast studies can diagnose duodenal leaks secondary to injury or duodenal hematomas.
Ultrasound, although valuable in detecting free intraabdominal fluid and solid
organ injury, is not reliable for the diagnosis of duodenal injuries.
CT scan of the abdomen with intraluminal and intravascular contrast has a
high degree of accuracy in detecting injuries to the duodenum. Increase in the
space between the duodenum and right kidney is a significant finding, as is
extraluminal gas or duodenal wall thickening.
- The CT scan, although quite reliable, may occasionally miss duodenal injuries.
MRI has been described as a diagnostic tool, but remains unproven.

Diagnostic peritoneal lavage may be positive in 50-70% of patients harboring
duodenal injuries. However, the positivity is due to associated intraperitoneal
injuries and not the duodenal injury itself, as the duodenum is a retroperitoneal
organ.
Surgical Management
The duodenum must be thoroughly explored with all four portions visualized
directly.
The duodenum is mobilized by incising the lateral peritoneal attachments
and sweeping the second and third portions medially. The ligament of Treitz
can also be transected for mobilization of the fourth portion of the duodenum.
Findings that should increase the suspicion for the presence of a duodenal
injury include: crepitus along the duodenal sweep, bile staining of paraduodenal
tissues, documented bile leak or the presence of a right side retroperitoneal or
pararenal hematoma. These findings should always be investigated, and never
ignored.
All duodenal injuries should be graded utilizing the American Association for
the Surgery of TraumaOrgan Injury Scale for duodenal injuries (AAST-OIS).
The simplest surgical techniques should be selected to manage the lower grade
injuries while reserving the more complex techniques for the management of
the more severe and advanced grade injuries.
Basic surgical principles include debridement of duodenal injuries to viable
tissue and meticulous double layer closure for all duodenal injuries.
Approximately 75-85% of all duodenal injuries can be repaired primarily
utilizing simple surgical techniques. Duodenal injuries should be drained with
closed systems; however, these drains should not be placed directly in juxtaposition to the suture line to avoid duodenal fistula formation.
Tube duodenostomies should be used rarely. This procedure is controversial.
It may be used to decompress the duodenum and protect the suture line. It
should be placed retrograde through the proximal portion of the jejunum.
The technique of jejunal or serosal patches may be used rarely to protect a
suture line.
The original duodenal diverticulization procedure should be used rarely and
only when precise indications exist, these being an injury through the first
portion of the duodenum, pylorus and/or gastric antrum with or without an
31
338
Trauma Management
associated pancreatic injury. Reconstruction of these patients requires a vagotomy, gastrojejunostomy and retrograde tube duodenostomy but routine bile
duct drainage with a T-tube is not used.
Pyloric exclusion is the recommended surgical procedure for patients that
incur duodenal injuries encompassing greater than 50% of the circumference
of the duodenum with or without associated pancreatic parenchymal injuries,
provided that the duodenal injury can be primarily repaired. It does not require
a vagotomy. The pylorus is closed with a running nonabsorbable suture and a
gastrojejunostomy is performed.
- The pyloric closure will generally open spontaneously in a period of time ranging from four to six weeks and gradually the gastrojejunosotomy will close.
Marginal ulceration is quite uncommon.
Pancreaticoduodenectomy is a formidable procedure and is uncommonly

needed in cases of combined pancreaticoduodenal injuries.
- The indications for pancreaticoduodenectomy (Whipple procedure) are listed
below:
- Massive and uncontrollable bleeding from the head of the pancreas, adjacent
vascular structures, or both.
- Massive and unreconstructable ductal injury in the head of the pancreas.
- Combined unreconstructable injuries of the following; duodenum, head of the
pancreas and common bile duct.
The mortality of patients undergoing Whipple procedures averages 31-36%.
Mortality
31
Duodenal injuries carry a significant mortality rate.

Most early deaths are caused by exsanguination from associated vascular injuries.
Deaths solely ascribed to duodenal cause range from 6.5-12.5%.
Factors that increase mortality in duodenal injuries include the presence of
associated pancreatic and common bile duct injuries.
Late mortality can generally be attributed to the duodenal injury and associated
complications which include: sepsis, duodenal fistulas and multiple systems
organ failure.
Mortality rates can be as high as 50% in patients undergoing surgical procedures
after 24 hours.
Morbidity
Duodenal injuries are associated with very high rates of morbidity. Approximately 64% of all duodenal injury cases will experience complications.
Duodenal morbidity is represented primarily by duodenal fistula formation
resulting from failure of surgical repair secondary to suture line dehiscence
and occasionally by duodenal obstruction.
- Posttraumatic duodenal fistulas occur in approximately 7% of all cases and carry
a mortality of 14%.
- Duodenal fistulas are quite difficult to manage and pose great problems with
fluid and electrolyte balance.
Duodenal obstruction occurs between 1 and 2%.

Intraabdominal abscesses occur with a frequency of 11-18%.
Postoperative pancreatitis occurs in between 2.5 and 15% of the cases.
Duodenal Injuries
339
References
1.
2.
3.
4.
5.
Asensio JA, Buckman RF. Injuries to the duodenum In: Shackelford RT, Zuidema
GD, Ritchie WP, eds. Shackelfords Surgery of the Alimentary Tract, 4th Ed. Philadelphia, PA: W.B. Saunders, 1995; Volume II, Chapter 10:110-123.
Asensio JA, Stewart BM, Demetriades D. Penetrating Injuries to the Duodenum
In: Ivatury RR, Cayten CG, eds. Textbook of Penetrating Trauma Philadelphia,
PA: Lea & Febiger 1995; Chapter 49: 610-630.
Asensio JA, Stewart BM, Demetriades D. Complex injuries of the Duodenum. In:
Maull KI, Rodriguez A, Wiles III, CE, eds. Complications in Trauma and Critical
Care. Philadelphia, PA: W.B. Saunders 1995; Chapter 32:364-379.
Asensio JA, Gomez HA, Falabella A et al. Duodenal trauma. In: Rodriguez A,
Ferrada R, Asensio JA et al, eds. The Pan-American Trauma Society Textbook of
Trauma. Cali Colombia: Feriva and Co. 1997; Chapter 26:343-357.
Asensio JA, Feliciano DV, Britt LD et al. Issue Editors. Management of Duodenal
Injuries. Current Problems in Surgery. Wells SA Jr. ed. St. Louis, MO: MosbyYearbook. Nov. 1993; Vol. XXX, No. 11:1021-1100.
31
CHAPTER 32
Colon/Rectal Injuries
Claudia E. Goetter and William F. Fallon Jr.
Colorectal Trauma
Colon injury is the second most frequently encountered intraabdominal injury
pattern in penetrating trauma. It uncommonly occurs in blunt trauma (2-5% of
patients).
Injury to the rectum, anus, and sphincter apparatus occurs infrequently.
Development of the management of colon and rectal trauma is from the U.S.
military experience (WW I through Vietnam) with high velocity gunshot or fragmentation wounds. Extensive tissue destruction and contamination often resulted
in septic complications if the colon injuries were repaired. From this developed
mandatory colostomy for colon injury and the four basic tenets of management of
rectal injury: repair of injury, proximal fecal stream diversion, distal washout of
rectal stump, and presacral drainage. More recent civilian experience has challenged
many of these dictums for mandatory use.
Pertinent Anatomy
The posterior portions of the ascending and descending colon are retroperitoneal. Injury may occur here without obvious anterior injury.
The rectum is 12-15 cm long with the upper portion intraperitoneal and
covered by serosa. The middle portion is covered by peritoneum over its anterior surface and is retroperitoneal posteriorly. The distal portion of the rectum
is completely below the peritoneum (Fig. 32.1).
Because of the lateral bends in the rectum the distance from the anus to the
peritoneum is only 3-5 inches. Intraperitoneal injury is possible even with
short objects of injury.
Penetrating Trauma
Bowel injury (large or small) is present in 90% of anterior gunshot wounds
and 50% of stab wounds. Flank and back injuries are less likely to penetrate
the peritoneum.
Gunshot wounds (80%) to the lower abdomen, pelvis, buttocks or gluteal
region, perineum and upper thighs can have a trajectory through all levels of
the rectum, involving the sphincter muscles and penetrating the peritoneum
(Fig. 32.2). Stab wounds or impalement (3%), including rectal insertion of
objects (6%), are less common and can cause a similar pattern of injury
depending upon the length of the implement.
Iatrogenic injuries due to obstetric or endoscopic procedures, diagnostic contrast
enemas and intraoperative misadventure may occur in patients with previous
bowel preparation allowing primary repair without diversion.
C.E. Goetter, University Hospitals of Cleveland, Cleveland, Ohio, U.S.A.
W.F. Fallon Jr., Metro Health Medical Center, Cleveland, Ohio, U.S.A.
341
Fig. 32.1. Rectal anatomy showing the three regions of the rectum. Reproduced
with permission from Haas et al. Civilian injuries of the rectum and anus. Diseases
of the Colon and Rectum. 1979; 22:17.
Blunt Trauma
Blunt colon injuries are usually due to shear injury to the bowel or mesentery
from deceleration. Blow-out injuries from compression are less common but
can occur.
Blunt trauma is an infrequent cause of rectal injury (5-10%). However, the
amount of energy associated with this mechanism of injury is so great that the
rectal injury is often only one component of multisystem injury and hemorrhagic shock. There is significant risk for infectious sequelae if not identified
early or treated aggressively. The cause of this type of injury is usually motor
vehicle, motorcycle or pedestrian-vehicular accidents.
Pelvic fractures, particularly open pelvic fractures, have potential for rectal
injury. This occurs due to penetration of bony fragments through the wall of
the rectum and is almost always below the peritoneal reflection. Vascular and
urologic injuries are frequently associated. The bladder and urethra must be
evaluated in every patient with possible rectal injury.
Rectal tears can also occur with less severe injury such as a fall or straddle
injury resulting in disruption of the attachments to the pelvis or from shear
forces from pelvic structural deformation. These injuries are usually below
the peritoneal reflection and may be either partial or full thickness. Often
only the presence of extraperitoneal, retroperitoneal air on plain radiography, subcutaneous emphysema on physical examination, the presence of pelvic
hematoma or abscess on computerized tomography of the pelvis indicate
the presence of an injury.
32
342
Trauma Management
Fig. 32.2. GSW trajectory shows the short distance from the perineum to the abdomen and multiple associated injuries. Reproduced with permission from Maull et
al. Penetrating wounds of the buttock. S, G & O 1979; 149:856.)
32
Devascularization injury with full thickness rectal necrosis is very rare due to
the to the rich collateral blood flow through the pelvis. Embolization of the
internal iliac vessels and operative pelvic exposure may severely compromise a
blood supply that is already limited due to pelvic injury or preexisting vascular
disease.
Insufflation injury due to air or water under high pressure may result in
rectal rupture, retroperitoneal hematoma and intraabdominal perforation.
This has been reported with water-skiing and Jet ski activities. Suction injuries with transrectal evisceration in children due to swimming pool drains
have been reported as well.
Diagnosis
A high index of suspicion must be maintained to diagnose colon and rectal injuries as these may initially present with only minimal indications of injury. Missed
injury in this organ system may be devastating.
Signs and Symptoms

Patient with hemodynamic instability should complete the diagnostic workup
and resuscitation in the operating room. Exsanguination is the overwhelming
cause of early death with this injury, hence the management of shock takes
precedence. DPL may show fecal contamination or a WBC count greater than
200. Symptoms of injury may be minimal in the unresponsive, hypotensive
patient and signs of injury may not initially be detected. Rectal examination is
performed when feasible.
343
Patients with trauma to the torso should be suspected of having a colon

injury. Diagnosis is usually made at laparotomy for other reasons. Signs of
peritoneal irritation are seen with intraperitoneal injury, but may develop only
after a period of observation in small perforations or devascularization injuries.
In stable patients, history of straddle injury, pelvic fracture or trajectory of
penetrating injuries should suggest the possibility of rectal injury. Symptoms
of abdominal pain, pelvic or rectal pain and tenesmus are common. Careful
inspection of the anus, perineum and gluteal region may identify lacerations
with extension into the anus or rectum.
Wounds should not be probed or vigorously explored as this may cause severe
bleeding. In impalement injury, the object must be left in place and removed
only under controlled circumstances, usually the operating room, to prevent
sudden, unexpected exsangination.
The history of the events may not be apparent and there may be delay in
presentation due to embarrassment or events of abuse. Blunt injuries include
minor falls or straddle injury. Penetrating injuries include minor impalement
injury, sexual assault, autoerotic or homosexual activity or rectal foreign bodies. These injuries are predominantly intraluminal and are almost always below the peritoneal reflection. There is usually evidence of sepsis with either
systemic signs or leukocytosis with delayed presentation.
Clinical Evaluation
A digital rectal examination is performed to evaluate sphincter tone, severe
pain on examination, palpable defect or mass, bony fragments in or against
the rectal wall and evidence of either gross or occult blood in the stool.
The presence of intraluminal blood is highly suggestive of rectal injury
regardless of the vector of wounding; its absence does not reliably exclude the
presence of rectal injury.
Proctosigmoidoscopy is essential with suspicious trajectory or entrance wounds.
While not perfect, the combination of digital rectal examination and proctosigmoidoscopy has about 95% diagnostic accuracy and should be performed together with a suspected rectal injury. Further studies add little
to this accuracy rate.
Radiographic Evaluation
CT scanning of the abdomen and pelvis with triple contrast can help evaluate
the course of a tangential penetrating injury to the back or flank but may be
difficult to perform and interpret. Scans with mesenteric hematomas or with
free fluid and no solid organ injury are suspicious for hollow viscus injury. CT
can help define the extent of pelvic sepsis with delayed presentations of rectal
injury and provide the option of percutaneous drainage.
There is little utility for radiographic evaluation of rectal injury in the acute
setting. Patients with subtle or delayed presentations may have soft tissue air
or abscess as their only evidence of injury.
Plain radiographs of the pelvis may reveal extraluminal or extraperitoneal air
or may be the first indication of a foreign object within the rectum (Fig. 32.3).
Anteroposterior and lateral views localize the foreign body.
Intrarectal contrast studies must be used cautiously as barium contamination
may worsen septic complications in synergy with fecal contamination.
32
344
Trauma Management
Fig. 32.3. Retroperitoneal staining indicates possible posterior injury. Reproduced

with permission from Burch JM. Injury to the colon and rectum. Trauma, 4th edition. Mattox, Feliciano, Moore ed. Phila, PA: McGraw-Hill 2000:766.
Management
Operative Treatment
32
Preoperative preparation includes vigorous fluid resuscitation, bladder catheterization and broad spectrum antibiotics against bacteroides and other enteric
organisms.
Operation is performed in modified lithotomy position if rectal injury is
suspected. A rigid sigmoidoscope should be available. Patients with exsanguination
may require the supine position initially with repositioning once hemorrhage
control is achieved. Full abdominal exploration, hemorrhage and contamination
control should be completed prior to managing specific intestinal injuries. In an
abbreviated damage control laparotomy, the injured colon may be resected
with staplers and left closed off until reoperation.
Nonoperative Treatment
In some circumstances, the choice may be not to operate. Patients who have
sustained extraperitoneal iatrogenic injury from diagnostic procedures, minor
partial thickness impalement injury and some patients who have free
intraperitoneal air but no abdominal symptoms following endoscopic
procedures may potentially be nonoperatively managed. Patient selection is
critical and they must be followed closely with serial examinations. Gastrointestinal tract rest, intravenous fluid replacement and broad spectrum
antibiotic therapy is begun. Delay in abdominal exploration when symptoms
develop can be fatal.
345
Intraperitoneal Injury
Small colon injuries may be subtle, particularly those at the splenic flexure or
in the retroperitoneal portions of the colon. Colon in a trajectory path or
associated with bloodstaining of the retroperitoneum must be fully mobilized
and carefully inspected (Fig. 32.3).
Discrete injury from low velocity penetrating trauma associated with little or
no peritoneal soilage can be successfully managed with primary repair alone.
Selected injuries without devascularization and significant contamination can
be resected and anastomosis performed.
Patients with shock, more extensive injury, multiple organ injury, significant
intraabdominal contamination by feces in combination with blood or barium,
or delay in operation warrant conservative treatment with formation of a
diverting colostomy.
The most significant factors for infectious complications in civilian rectal
injury are delay in the detection of the rectal injury or delay in the performance
of the diverting colostomy. Despite the trend to primary repair without
colostomy in colon injury, the risk of pelvic sepsis due to the retroperitoneal
location of the rectum mandates a colostomy in almost all circumstances.
Controversy surrounds the role of distal washout, presacral drainage and type
of colostomy.
Those who have primary repair without colostomy receive no further surgical
treatment. Those with injury treated by colostomy and resection whose injury
was above the peritoneal reflection also require no further treatment. Repair
with exteriorization is rarely performed today. Repair with proximal diversion
is usually reserved for rectal injury.
Drainage of the retrorectal space may be indicated if significant retroperitoneal, presacral and pararectal dissection was done to treat injury to the
midportion of the rectum. This may be via the perineum near the anococcygeal
raphe or transabdominally using closed suction drainage (Fig. 32.4).
Distal rectal washout is controversial as there is potential for increasing fecal
contamination into the extrarectal tissues in penetrating trauma, though others
have noted a decreased incidence of infectious sequelae. It clearly decreases
infectious sequelae in rectal injury from blunt trauma, open pelvic fracture
and major perineal soft tissue injury. Washout is performed at the termination
of the abdominal portion of the procedure via a mushroom catheter through
a pursestring suture in the wall of the distal colon. The anal sphincter is dilated
and large stool is gently manually removed. Several liters of warm crystalloid
are irrigated through the mushroom catheter until clear.
Subperitoneal Injury
Full thickness injury should be treated in the same manner as the intraperitoneal
rectum. A diverting sigmoid loop colostomy is most frequently used because
there is often no need for resectional treatment and it is unnecessary to enter
the abdomen to accomplish presacral drainage if there is no associated
intraperitoneal injury. Distal rectal washout minimizes further fecal contamination. Rectal repair is difficult because exposure is limited. Repair is usually
deferred until the risks of fecal contamination and infection are minimal.
32
346
Trauma Management
Fig. 32.4. Proximal diversion and presacral drainage as practiced routinely in the
past. Reproduced with permission from Baylor College of Medicine.
Severe rectal destruction is uncommon but usually requires a Hartmanns

procedure and distal washout is accomplished by local irrigation at the
perineum. Repeated local debridement is frequently needed. Rarely, abdominoperineal resection is required.
Perineal and Sphincter Injury
32
Damage to the sphincter may be direct or via disruption of nervous or vascular supply. The associated risks are infectious early and incontinence later in
the patients course.
Rectal mucosal lacerations are repaired with interrupted absorbable sutures in
the submucosal layer. The sphincter is repaired with interrupted sutures through
the muscle sheaths and repairing the remainder of the injury in layers. This
may be difficult and may be deferred for elective repair in patients with multiple or complex injuries.
Even without a documented rectal injury, complex pelvic or perineal injuries
may require fecal diversion to control septic sequelae. Open pelvic fractures
should always have fecal diversion.
Foreign bodies can be removed in the emergency department if they can be
grasped easily at the anal canal. General anesthesia is necessary for foreign
objects that are large, have sharp edges or that have become lodged higher.
Gentle technique and ingenuity are required for the atraumatic removal. Blind
use of grasping forceps should be avoided. The patient is prepared for laparotomy in the event that the foreign body cannot be removed. Usually the
object can be manipulated into range of the proctoscope for grasping and
347
removal though rarely the colon will have to be opened and the object extracted. A thorough proctoscopic inspection following foreign body removal
is essential to be sure that no objects are retained and that there is no evidence
of significant injury to the rectal wall.
Outcome
Early fatalities are due to exsanguination, almost never due to colon or rectum
injuries. Late fatalities are due to sepsis and multisystem organ failure (1-5%) which
may be due to intestinal injury. Rates of abscess (3-10%) and fistula (1-5%) are
lower for primary repair, probably due to primary repair being performed in less
severely injured patients.
Mistakes and Pitfalls

Rectal injury can only be diagnosed with a strong index of suspicion. This
diagnosis is often overlooked in multiply injured patients.
Penetrating trauma may result in retroperitoneal colon injury without evidence of anterior injury. This is also missed by DPL. Mobilize the colon adequately to examine the posterior surface.
Bullets which have passed through the colon will contaminate soft tissues.
Remove them if possible and beware of them as a septic focus postoperatively.
When in doubt, perform a colostomy!
References
1.
2.
3.
4.
5.
Fallon WF Jr. The present role of colostomy in the management of trauma. Diseases of the Colon and Rectum 1992; 35:1094.
Burch JM, Feliciano DV, Mattox KL. Colostomy and drainage for civilian rectal
injuries: Is that all? Annals of Surgery 1989; 209:600.
Brunner RG, Shatney CH. Diagnostic and therapeutic aspects of rectal trauma:
Blunt versus penetrating. The American Surgeon 1986; 53:215.
Ivatury RR, Licata J, Gunduz Y et al. Management options in penetrating rectal
injuries. American Surgeon 1991; 57:50.
Barone JE, Yee J, Nealon TF Jr. Management of foreign bodies and trauma of the
rectum. Surgery, Gynecology and Obstetrics 1983; 156:453.
32
CHAPTER 33
Genitourinary Tract Trauma

Eila C. Skinner
Kidney Injuries
Incidence
Kidneys injured in approximately 10% of all trauma patients
Blunt trauma accounts for 90% of renal injuries
Hematuria present in about 95% of cases
- Degree of hematuria does not correlate with severity of injury.
- Some severe injuries, such as vascular pedicle injuries, may have no hematuria
- Hematuria out of proportion to degree of trauma suggests preexisting renal
abnormality (i.e., hydronephrosis)
Injury Severity
Minor injury
- contusion, subcapsular hematoma, superficial laceration
- account for 70% of all injuries
Major injury
- deep laceration into collecting system, shattered kidney, pedicle injuries
Associated Injuries
Present in 80-95% of penetrating trauma with renal injuries
Present in 40-50% of severe blunt trauma with major renal injuries
Nature and extent of associated injuries predicts mortality
Radiologic Evaluation
Adequate visualization of injury is key to safe management.
Indication for radiologic studies
- All penetrating trauma with hematuria or close proximity to kidneys
- Blunt trauma with gross hematuria or microhematuria and any hypotension
IVP is still valuable screening tool

- Over 90% accurate in identifying injury
- Often not able to completely characterize injury
CT scan with IV contrast is more accurate to characterize injury.

- May be used as primary study or to further evaluate abnormal IVP
- Should be performed on any stable patient with poorly visualized kidney on
IVP
- With faster spiral scanners, need to request delayed views to see contrast in
collecting system
Eila C. Skinner, University of Southern California, Los Angeles, California, U.S.A.
349
Fig. 33.1. CT scan showing fractured left kidney secondary to blunt trauma. Extravasation of contrast is obvious posterior to the kidney, but the ureter appears
intact. This was successfully managed with observation.
- Ideal for determining depth of laceration, degree of extravasation of urine,

hematoma, segmental devascularization, and pedicle injuries
- Repeat CT should be done prior to discharge in cases of major injuries or
extravasation to ensure absence of significant urinoma
Angiography
-
Best first study for stab wounds with gross hematuria

Accurately identifies active bleeding and arterio-venous fistulas
Can embolize vessel
Often avoids need for open surgery
Preserves more renal parenchyma than partial or total nephrectomy
Management
Goal is maximum renal preservation with minimum complications.
Blunt Injuries
Most blunt renal injuries can be managed nonoperatively.
-
Bed rest until all gross bleeding stops

Serial hemograms
Follow-up blood pressure check in 2-3 months
Repeat imaging in 2-3 months for major injuries
Indication for renal exploration

- Severe life-threatening bleeding
- Major urinary extravasation, especially around renal pelvis (minor extravasation may be observed)
May have disruption of uretero-pelvic junction
More common in children with blunt trauma
- Large devascularized renal segment
33
350
Trauma Management
- Expanding or pulsatile retroperitoneal hematoma at urgent laparotomy (without preoperative xrays)
Penetrating injuries more often require exploration

- Stab wounds may be managed nonoperatively with same indications for exploration as blunt trauma
Gunshot wounds have high risk of delayed complications due to blast effect.
- Many centers perform exploration
- If not explored, must be carefully monitored with repeat CT scans
Pedicle injuries
- Laceration of main renal veinmay be repaired (or ligated on left if gonadal
and adrenal branches are intact for collateral flow)
- Laceration or thrombosis of main renal artery may be repaired, but often kidney is not salvageable
Thrombosis without bleeding:
- Due to high-speed deceleration injury
- May be revascularized within first few hours.
- If recognized later, can observe. May require delayed nephrectomy due to
hypertension.
Expected renal salvage rates

- Blunt traumaover 90%
- Penetrating trauma70-85%
Technique of surgical management of injured kidney

- Obtain vascular control of renal artery and vein through retroperitoneum prior
to reflecting colon.
- Dissect off Gerotas fascia (avoid subcapsular dissection).
Useful techniques include:
- Upper or lower pole partial nephrectomy
- Wedge resection of injured area
- Mattress sutures to control bleeding
- Restore capsule with peritoneal patch if necessary
- Wrap repair with omentum
- Drain with suction drains
Complications
33
Unnecessary exploration results in higher nephrectomy rate, especially in more

severe blunt trauma.
Continue bleedingmay be managed by selective embolization.
Urinoma
- Need to rule out missed ureteral injury.
- Ensure outflow down ureter is openmay require stent.
- Drain urinoma percutaneously.
Delayed renal vascular hypertension

- Can result from even minor injuries such as contusion
- May require partial or total nephrectomy
Ureteral Injuries
Epidemiology
Rarely due to external trauma (most often iatrogenic surgical injury)
More likely due to penetrating traumagun shot or stab wounds
351
Delay or missed diagnosis is very common
Investigations
IVP with tomography
- 94% sensitive for ureteral injury
- Most often see some proximal dilation as well as extravasation
CT scan with excretory phase

- See extravasation around ureter
Retrograde pyelography is definitive study

- Confirms site of injury
- May be able to pass stent
Management
Early diagnosis (within 5 days of injury)
- Usually do open repair
- Avoid stripping ureter out of Gerotas fasciapreserve vascular supply from
gonadal vessels
- Debride injured section of ureter (especially important in GSW due to blast
effect)
- Upper or mid-ureterend-to-end spatulated repair
- Lower ureterreimplant ureter into bladder with psoas hitch if needed
- Stent and drain repair
- Omental wrap if available
- If large section of ureter is destroyed and primary repair impossible
Ligate ureter and place nephrostomy tube (open or percutaneously), with
plan for delayed repair.
Nephrectomy is rarely necessary.
Delayed diagnosis (beyond 5 days)

-
Best managed nonoperatively

Stent from below if possible
Percutaneous nephrostomy if cannot pass stent
Drain urinoma if present
Delayed repair or ileal interposition after 3 months if stricture forms
Bladder Injuries
Epidemiology
Bladder is mostly extraperitoneal when emptywhen full peritoneal surface
expands
Injury may be due to blunt or penetrating trauma
Often associated with pelvic fracture
Diagnosis
Over 95% have hematuria, usually gross
Any pelvic trauma with hematuria should have cystogram
- Cystogram should include filled (at least 300 cc) and emptied views
- CT cystogram appears to be equivalent in accuracy to standard films (only done
if CT scan already planned to evaluate trauma)
33
352
Trauma Management
Fig. 33.2. Cystogram showing intraperitoneal bladder rupture. This should be

repaired and a suprapubic tube placed.
33
Type of Injuries
Injuries classified into extraperitoneal or intraperitoneal by cystogram findings
(may have both)
- Extraperitoneal more common, often associated with pelvic fracture.
Need to fully evaluate distal ureters in all cases (with IVP, CT or intraoperative
exploration)
Management
Intraperitoneal Injury
- All should be explored and repaired
- Repair injury from inside of bladder with absorbable suture
- Place large bore suprapubic tube and pelvic drain
Extraperitoneal Injuries
353
- May be managed with Foley catheter only if extravasation small

- Must ensure adequate drainage
- Indication for exploration:
Large amount of extravasation
Possible bony fragments within bladder
Difficulties with catheter drainage (i.e., clots) with minor injuries
- Technique
Enter bladder anteriorly, avoid disturbing pelvic hematoma (especially with
pelvic fracture).
Repair from within with absorbable suture.
Place large-bore suprapubic catheter and pelvic drain.
Urethral Injuries
Epidemiology
Most often associated with blunt trauma, especially in association with pelvic
fractures or straddle injuries
Classified into anterior and posterior injuries
Dried or fresh blood at the urethral meatus on exam is pathognomic of urethral
injury
Inability to pass urine
High floating prostate on rectal examination
Extravasation in the scrotum
Investigations
Imaging is by retrograde urethrogram.
- Indicated in all cases of suspected urethral trauma, especially pelvic fracture
Anterior (penile and bulbar urethral) injuries

- Usually caused by straddle fall onto hard object
- Occasionally caused by penetrating injuries
- Often extravasates blood and urine into scrotum and perineum (butterfly
hematoma)
- Management
Establish urinary drainage, usually with percutaneous suprapubic tube.
Exploration is rarely indicated. It should be considered in penetrating injuries
and in blunt trauma with large lacerations.
- Surgical Technique
Deglove penis from corona (circumcising incision) for distal injuries
Approach from perineum below scrotum for bulbar injuries.
Debride and repair with fine absorbable suture.
Leave catheter for 7-10 days.
Do antegrade urethrogram prior to removing catheter.
Posterior (membranous) urethral injuries

- Presentation
Over 90% associated with pelvic fracture
Usually unable to void
Prostate may not be palpable on rectal exam (high-riding prostate)
High incidence of associated injuries and severe pelvic bleeding
33
354
Trauma Management
In children, disruption may extend through prostatehigher risk of

complications
- Management
Goals of management:
- Establish urinary drainage
- Minimize long-term complications, including impotence, incontinence,
and stricture
In most cases, open suprapubic tube bladder drainage with planned for
delayed repair is the best approach
In selected cases, a guidewire may be passed endoscopically using flexible
cystoscopes from above and below, and a catheter passed over the wire into
the bladder.
Attempts at primary suture repair or open realignment are contraindicated
increase risk of bleeding and impotence.
Penile Injuries
Skin Injuries
- May occur from bites or penetrating injuries
- Generally can be cleaned, debrided and sutured
- Use broad-spectrum antibiotics
Degloving
- Circumferential loss of skin at the base of the penis can result in interruption of
distal lymphatics and severe edema.
- Usually requires discarding any distal shaft skin and using delayed skin grafts.
Strangulation
- Results when constricting band is left on base of penis-ring, condom catheter,
rubber bands, etc.
- Need to reduce edema with wrapping
- May require anesthesia to remove object
Penile Fracture
33
Results from sharp angulation of erect penis

Often patient reports sudden pain and an audible crack
Causes severe bleeding within Bucks fascia
Penis becomes acutely grossly edematous and ecchymotic
Need to do urethrogram/urethroscopy if hematuria present
Requires exploration
Deglove penis from corona
Locate fracture
Debride and repair with fine polypropyline suture with knots inverted
May occasionally result in erectile dysfunction
Amputation
- Often self-inflicted by psychologically ill patient
- Amputated part should be placed in sterile bag on (not in) ice
- Requires microsurgical repair, including arteries, veins, the corporal bodies, and
urethra
- Place suprapubic bladder catheter for urinary drainage
- Skin is often sloughedmay require skin grafts
355
Scrotal Injuries
May be blunt or penetrating injury
Need to evaluate for injury to urethra or rectum
Scrotal skin injuries
- Lacerations or avulsions may be debrided and sutured, or left open if grossly
contaminated.
- In complete loss of scrotal skin, testes can be placed in the thigh, or kept covered with moist dressings until delayed mesh skin grafting is performed.
Testicular Injuries
- Patient presents with severe pain and scrotal swelling
- If testis is palpable, ruptured testis will feel very irregular
- Scrotal ultrasound may be helpful
Accuracy only about 75%
Exploration is usually required unless testis is clearly palpably normal.

-
Trans-scrotal incision
Open tunica vaginalis
Debride extruded seminiferous tubules
Repair tunica with fine absorbable suture
If testis is devascularized or severely shattered, perform orchiectomy
Drain hemiscrotum with small Penrose drain
References
1.
2.
3.
Sagalowsky AL, Peters PC. Genitourinary Trauma. In: Walsh PC, Retik AB, Vaughan
ED et al, eds. Campbells Urology, 7th Edition. Philadelphia: WB Saunders Company 1998; 3085-3120.
Skinner EC, Parisky YR, Skinner DG. Management of complex urologic injuries.
Surg Clinics of North Am 1996; 76:861-878.
McAninch JW, Carroll PR. Renal exploration after trauma, indications and reconstructive techniques. Urol Clin North Am 1989; 16:203-212.
33
CHAPTER 34
Abdominal Vascular Injury

Juan A. Asensio and Matias Lejarraga
Introduction
Abdominal vascular injuries are amongst the most lethal injuries sustained by
trauma patients. Many of these patients present in cardiopulmonary arrest
and require drastic life saving measures, such as emergency department thoracotomy, aortic cross clamping and open cardiopulmonary resuscitation. To
compound the problem, exposure of retroperitoneal hemorrhaging vessels is
quite difficult and requires extensive dissection and mobilization of
intraabdominal organs.
Historical Perceptive
Eck, a Russian surgeon, in 1877, was the first to perform a permanent union
between two intraabdominal blood vessels when he performed an anastomosis between the portal vein and inferior vena cava.
Dorfler, in 1899 recommended fine round needles and sutures to include all
layers of the vessel.
Clermont, in 1901 successfully performed an end-to-end anastomosis of a
divided inferior vena cava with continuous fine silk suture.
Voorhees, in 1956 pioneered the use of abdominal aortic prosthetic grafts.
Incidence
In military conflicts abdominal vascular injuries account for about 3% of all
vascular injuries.
In civilian series injuries to abdominal vessels account for about 30% of all
vascular trauma treated in urban trauma centers
Penetrating abdominal injuries are the most common causes of abdominal
vascular injuries and account for approximately 90-95% of all abdominal vascular injuries.
Approximately 25% of all patients undergoing laparotomies for gunshot
wounds of the abdomen sustain abdominal vascular injuries.
Approximately 10% of patients undergoing exploratory laparotomy for stab
wounds of the abdomen will have abdominal vascular injuries.
Associated Injuries
The abdominal blood vessels, by virtue of their retroperitoneal location and
anatomic proximity to other organs are rarely injured alone.
Matias Lejarraga, University of Southern California, Los Angeles, California, U.S.A.
357
It is estimated that approximately 2-4 associated intraabdominal injuries occur with abdominal vascular injuries.

Abdominal vascular injury associated with blunt trauma most commonly
occurs in upper abdominal arteries and veins.
Penetrating injuries are unpredictable and may occur within any area of the
abdomen often affecting more than one vessel.
Diagnosis
The clinical presentation of patients that have sustained abdominal vascular
injuries will depend on whether they present with a contained retroperitoneal
hematoma or free bleeding within the abdominal cavity. Obviously those with
contained retroperitoneal hematomas will present either hemodynamically
stable or with some degree of initial hypotension responsive to intravenous
fluids, whereas those with free retroperitoneal and intraabdominal hemorrhage will present profoundly hypotensive.
The presence of penetrating abdominal injury associated with massive
abdominal dissention and shock usually signals the presence of an uncontained
intraabdominal hemorrhage secondary to injury of one of the major abdominal
vessels.
Abdominal discomfort and pain as well as physical examination findings consistent with peritoneal irritation or signs of peritonitis may be due either to
the abdominal vascular injury or to associated abdominal organ injuries frequently associated with intraabdominal vascular injuries.
The presence or absence of femoral, popliteal, dorsalis pedis and posterior
tibial pulses should be documented in both extremities.
Investigations
Laboratory tests provide little help in the early diagnosis of abdominal vascular injuries. As many patients present with profound hypotension, there are
few investigations that can actually be instituted.
The use of ultrasound will prove useful in detecting the presence of
intraabdominal fluid.
A plain radiograph of the abdomen is of diagnostic value particularly in
patients sustaining gunshot wounds so that the location and trajectory of the
missile can be evaluated.
A CT of the abdomen may be obtained in hemodynamically stable patients
that have sustained blunt trauma and may be useful in detecting retroperitoneal hematomas or nonvisualizing kidneys secondary to blunt injury to the
renal vessels.
Surgical Management
Emergency Department
All trauma patients should be evaluated and resuscitated per ATLS protocols.
In patients presenting with a strong suspicion of abdominal vascular injuries,
it is not advisable to place intravenous lines in the femoral veins in case there
34
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Trauma Management
are iliac venous or inferior vena caval injuries that may be actively hemorrhaging.
Broad spectrum antibiotics are administered prior to surgical intervention.
In patients presenting in cardiopulmonary arrest an emergency department
thoracotomy will be needed in order to perform open cardiopulmonary massage
and to cross clamp the descending thoracic aorta.
Time is of the essence and these patients must be rapidly transported to the
OR without any further radiographic evaluations or delays.
Intraoperative Management
In the operating room the entire patients torso from neck to mid-thighs is
prepared and draped. The area of the mid-thighs is quite important should
the necessity arise to obtain an autogenous saphenous vein graft.
Abdominal injuries should be explored through a midline incision extending
from xyphoid to pubis. Immediate control of life threatening hemorrhage
followed by immediate control of sources of gastrointestinal spillage are early
goals to achieve. The next step in the management of abdominal injuries consists of thorough exploration of the abdominal cavity.
Since the abdominal vasculature resides in the retroperitoneum, a thorough
exploration of these structures must be performed utilizing a systematic approach
of the anatomic zones of the retroperitoneum.
The first and most important goal to achieve in the management of abdominal
vascular injuries is hemorrhage control. As in all vascular injuries proximal
and distal control of the hemorrhaging blood vessel is ideal. However, in
exsanguinating abdominal vascular injuries achieving this rapidly could be
quite difficult.
In the case in which the patient decompensates during laparotomy, the
abdominal aorta can be controlled either digitally at the aortic hiatus, by the use
of an abdominal aortic root compressor or by placement of an aortic cross clamp.
Once the exsanguinating hemorrhage has been controlled, the trauma surgeon
should classify the hemorrhage or hematoma into one of the three zones of
the retroperitoneum.
There are three zones of the retroperitoneum. Zone I, Zone II, Zone III.
- Zone I begins at the aortic hiatus and ends at the sacral promontory; it is located
midline and courses on the top of the spinal column. This zone is divided into
Zone I supramesocolic and Zone I inframesocolic.
- There are two Zones II. Right and left and are located at the pericolic gutters.
- Zone III begins at the sacral promontory and encompasses the pelvis.
34
Zone I supramesocolic contains the suprarenal abdominal aorta, the celiac

axis and the first two parts of the superior mesenteric artery (superior
mesenteric artery: Part 1 from its origin at the aorta to the point where the
inferior pancreaticoduodenal artery emerges, part 2 from the inferior pancreaticoduodenal to the origin of the middle colic artery, part 3 from the middle
colic artery to the point of origin of the major jejunal branches, ileocolic and
right colic, and part 4 the main trunk of these branches). This zone also contains
the infrahepatic suprarenal inferior vena cava, the infrarenal inferior vena cava
as well as the proximal portion of the superior mesenteric vein.
Right and left zones II contain the renal vascular pedicles.
Zone III contains both common iliac arteries and veins, as well as their internal
and external branches.
359
The portal-retrohepatic area is a special area which contains the portal vein,
hepatic artery and retrohepatic vena cava.
As soon as the trauma surgeon has identified and classified the hemorrhage
or hematoma into one of the zones, he must then approach this zone to
obtain vascular control and to expose the injured blood vessel to attempt
definitive repair. Each zone requires a different and complex maneuver to
expose these vessels.
Zone I supramesocolic is generally approached utilizing a maneuver that
rotates the left-sided viscera medially. This approach requires transection of
the avascular line of Toldt of the left colon, along with incising the lienosplenic
ligament and rotating the left colon, spleen, tail and body of the pancreas as
well as the stomach medially. This exposes the aorta from its entrance into the
abdominal cavity via the aortic hiatus and includes exposure of the origin of
the celiac axis, superior mesenteric artery and the left renal vascular pedicle.
Alternatively the left kidney can be mobilized medially, although this is generally
not done.
- An alternative maneuver is to perform an extended Kocher maneuver along
with transecting the avascular line of Toldt of the right colon and mobilizing
medially the right colon, hepatic flexure, duodenum and head of the pancreas
to the level of the superior mesenteric vessels and incising the retroperitoneal
tissue to the left of the inferior vena cava. This maneuver exposes the suprarenal
abdominal aorta between the celiac axis and the superior mesenteric artery. This
has as a disadvantage that the exposure obtained is below the level of any wounds
of the supraceliac aorta and the hiatus.
Maneuvers used to expose injuries in Zone I inframesocolic include displacing the transverse colon and mesocolon cephalad, eviscerating the small bowel
to the right, locating the ligament of Treitz, transecting it along with the tissue
alongside the left of the abdominal aorta until the left renal vein is located.
This exposes the infrarenal aorta.
- To expose the infrarenal inferior vena cava the avascular line of Toldt of the
right colon is transected along with a Kocher maneuver sweeping the pancreas
and duodenum to the left and incising the retroperitoneal tissues that cover the
inferior vena cava.
Exposure to right and left Zones II depends as to whether the perirenal

hematoma or active bleeding is located laterally or medially. If active bleeding
is found medially or there is an expanding hematoma, vascular control of the
vessels in the pedicle is preferable.
- On the right, this is achieved by mobilizing the right colon and hepatic flexure
as well as performing a Kocher maneuver, exposing the inferior vena cava
infrarenally and continuing the dissection cephalad by incising the tissues
directly over the suprarenal infrahepatic inferior vena cava. This is done until
the right renal vein is encountered. Further dissection superiorly and posteriorly
to the right renal vein will locate the right renal artery.
- On the left, the left colon and splenic flexure are mobilized. The small bowel is
then eviscerated to the right. The ligament of Treitz is located and the transverse
colon and mesocolon are displaced cephalad. This should locate the infrarenal
abdominal aorta; cephalad dissection will locate the left renal vein as it crosses
over the abdominal aorta. The left renal artery will also be found superiorly and
posteriorly to the left renal vein.
34
360
Trauma Management
- Alternatively, if a perirenal hematoma or bleeding is found laterally with no extension into the hilum of the kidney the lateral aspects of Gerotas fascia can be
incised and the kidney elevated and displaced medially to locate the hemorrhage.
Exposure to the vessels in Zone III can be achieved by taking down the avascular
line of Toldt of both the right and left colons and displacing them medially.
Utilizing a combination of blunt and sharp dissection, the common iliac
arteries and veins will then be located. Meticulous attention must be paid to
locating the ureter as it crosses the common iliac artery. Dissection is then
extended in a caudad direction opening the retroperitoneum over the vessels.
The routine principles of vascular surgery also apply to the management of
the abdominal vascular injuries. Adequate exposure, proximal and distal control,
debridement of the vessel wall, prevention of embolization of clot or plaque,
irrigation with heparinized saline, judicious use of Fogarty catheters, meticulous
arteriorrhaphy or venorrhaphy with monofilament vascular sutures, avoiding
narrowing of the vessel during repair, insertion of an autogenous or prosthetic
graft when applicable and intraoperative angiography when feasible, are the
mainstays of successful repair.
The management of vascular injuries in Zone I, supramesocolic will consist of
primary arteriorraphy of the suprarenal abdominal aorta when feasible, and in
rare occasions the insertion of a Dacron or PTFE graft.
- Injuries to the celiac axis are usually dealt with by ligation.
- Management of injuries to the first two zones of the superior mesenteric artery
should be dealt with by primary repair whenever possible. Intense vasoconstriction makes this quite difficult. These injuries can also be ligated as theoretically
there are sufficient collaterals to preserve the viability of the small and large
bowel. However, profound vasospasm may lead to intense ischemia and bowel
necrosis. The first two zones of the superior mesenteric artery can also be
repaired either with an autogenous or prosthetic graft. The insertion of a
temporary shunt has also been described.
The management of injuries to Zone I inframesocolic employs some of the

same techniques as in zone I supramesocolic. In Zones 3 and 4 the superior
mesenteric artery should also be repaired, although the main jejunal and colic
branches of Zone 4 may be individually ligated.
34
- The management of inferior mesenteric artery injuries usually consists of

ligation.
- The management of injuries to the infrahepatic suprarenal inferior vena cava, as
well as the infrarenal inferior vena cava, will consist of lateral venorrhaphy whenever feasible. If through and through injuries are found in these vessels both
anterior and posterior aspects of the vessel must be repaired. Although the
infrahepatic suprarenal inferior vena cava has no venous tributaries it is quite
difficult to mobilize. In general, these repairs are accomplished by extending
the injury in the anterior wall and repairing the posterior wall from within. This
vessel can be mobilized by rotating the right kidney from left to right outside of
the renal fossa; however, this maneuver is quite treacherous and not recommended.
When there has been massive destruction of the infrahepatic suprarenal inferior
vena cava, ligation can be considered; however, survival rates are low. Rarely prosthetic grafts have been utilized in this position. The management of injuries to the
infrarenal inferior vena cava consist of lateral venorrhaphy. In the presence of
through-and-through injuries, primary repair can be accomplished either by
361
extending the venotomy or rotating the vessel. However, this can be quite
challenging and involves ligating many of its lumbar veins which are quite
fragile. We recommend performing the repair from within the vessel. The
infrarenal inferior vena cava can be ligated in cases of massive destruction.
Ligation is generally well tolerated.
- Injuries to the superior mesenteric vein should be primarily repaired although
they can be ligated with serious sequelae to the circulation of the small and large
bowel.
Injuries to either right or left Zones II can be quite challenging. Injuries to the
renal artery can be either primarily repaired or resected and grafted utilizing
either an autogenous or prosthetic graft. Rarely an aortorenal bypass can be
performed utilizing a distal site in the anterior wall of the abdominal aorta.
Repairs to the renal arteries are quite difficult. Frequently ligation of the renal
artery is performed with subsequent nephrectomy. Injuries to the renal veins
can also be repaired with primary venorrhaphy or ligation. An injury to the
right renal vein that cannot be successfully repaired requires ligation and will
demand that a nephrectomy be performed secondary to the lack of venous
collaterals. Ligation of the left renal vein is generally well tolerated provided
that it is performed proximally and close to the inferior vena cava as there are
venous collaterals such as the gonadal and renolumbar veins to handle the
venous outflow.
Injuries to Zone III can also be quite challenging to manage as they are often
associated colonic and genitourinary injuries resulting in contamination.
Injuries to the common iliac arteries can be primarily repaired via arteriorrhaphy. Autogenous and prosthetic grafts can also be utilized to repair
common iliac arteries. Internal iliac artery injuries are generally dealt with by
ligation. Injuries to the external iliac artery can be primarily repaired via
arteriorraphy. Iliofemoral bypasses can be performed with autogenous or prosthetic grafts. Although it is quite uncommon to find a saphenous vein of
adequate size to perform an iliofemoral repair. When there has been massive
destruction of either the common or internal iliac arteries, ligation may be
needed. Arterial flow can be restored utilizing a cross over femorofemoral or
axillofemoral bypass. These bypasses have the disadvantages of having to
involve uninjured vessels and have a high incidence of thrombosis. Injuries to
the iliac veins either common, external or internal can be dealt with by ligation,
as this is frequently well tolerated, although they can also be dealt with by
lateral venorrhaphy. Occasionally access to an injured right external iliac vein
may demand transection of the ipsilateral right iliac artery as the vessel lies
below the artery.
Whenever a trauma surgeon performs an abdominal vascular repair, serious
considerations must be given to second look operations to assess for bowel
viability.
Contamination from gastrointestinal or genitourinary injuries pose great risks
for the development of infections in prosthetic grafts inserted to bypass injured vessels. Whenever possible all grafts either autogenous or prosthetic should
be reperitonealized. Similarly, for all vascular repairs adjacent to gastrointestinal suture lines, an effort should be made to interpose viable tissue, generally
omentum, between the suture lines to prevent vascular-enteric fistulas or anastomotic dehiscence and blow-outs.
34
362
Trauma Management
Mortality
Abdominal vascular injuries carry a significant mortality rate.
The incidence of exsanguination for penetrating abdominal aortic injuries at
both the suprarenal and infrarenal locations is about 55%.
The incidence of exsanguination from penetrating injuries to superior mesenteric artery is about 25%.
The incidence of exsanguination from both penetrating and blunt trauma to
inferior vena cava is about 33%.
The incidence of exsanguination for blunt and penetrating injuries to the
portal vein is about 30%.
The overall mortality rate for abdominal vascular injuries is about 54%.
Exsanguination accounts for about 85% of all mortality.
Complications
Abdominal compartment syndrome is very common.
Other important complications include thrombosis, dehiscence of suture lines
and infection.
Vessel occlusion is not uncommon when repairs have been performed in
vasoconstricted vessels, such as the renal artery or superior mesenteric artery.
The systemic hypovolemia/and intestinal hypervolemia syndrome is common
when the portal vein or superior mesenteric vein have been ligated, as there is
little venous outflow from the enteric circulation and limited time for the
development venous collaterals.
Aortoenteric fistulas may develop if no viable tissue is interposed between an
aortic and enteric repair, most frequently the stomach.
Limb ischemia and compartment syndromes can occur in patients in which
there has been a delay in restoration of arterial blood flow. The same complication can occur in patients, that because of poor venous collaterals do not
tolerate ligation of the inferior vena cava or iliac veins.
References
1.
2.
3.
34
4.
5.
Asensio JA, Hanpeter D, Gomez H et al. Exsanguination. In: Shoemaker W,

Greenvik A, Ayres SM et al, eds. Textbook of Critical Care. 4th Ed, Philadelphia,
PA: W.B. Saunders Co. 1999; 4:37-47.
Feliciano DV. Abdominal vessels. In: Ivatury R, Cayten CG, eds. The Textbook of
Penetrating Trauma. Baltimore, MA: Williams and Wilkins 1996; 56:702-716.
Asensio JA, Berne JD, Chahwan S et al. Traumatic injury to the superior mesenteric artery. Amer J Surg 1999; 178(3):235-239.
Demetriades D, Theodorou D, Murray J et al. Mortality and prognostic factors in
penetrating injuries of the aorta. J Trauma 1996; 40(5):761-763.
Asensio Ja, Forno W, Gambaro E et al: Abdominal Vascular Injuries. The Trauma
Surgeons Challenge. Annales Chirurgiae et Gynecologiae, 2000; Vol 89:71-78.
CHAPTER 1
CHAPTER 35
Abdominal Compartment Syndrome

Definition of Abdominal Compartment Syndrome (ACS)
Increased intraabdominal pressure associated with any of the following
tachycardia or hypotension
decreased urine output
hypoxia or elevated peak inspiratory pressure or unresponsiveness to mechanical
ventilation.
Pathophysiology
Normal, resting intraabdominal pressure in the horizontal position is 0 cmH20

Early postlaparotomy pressure is < 10 cmH20
Intraabdominal pressure 20-30 cmH20 may be harmful
Intraabdominal pressure > 30 cmH20 is associated with major adverse events
from all body systems
Cardiovascular effects of ACS
Tachycardia
Low stroke volume
Elevated CVP and PCWP
Increased afterload
Respiratory effects of ACS
Elevated peak inspiratory pressure
Decreased Pa02/Fi02
Unresponsiveness to mechanical ventilation
Kidney effects
Decreased urine output
Decreased glucose reabsorption
Brain
Increased intracranial pressure
May have a detrimental effect on head injuries
Abdominal viscera
Decreased blood flow in celiac artery and superior mesenteric artery
Decreased blood flow to intestinal mucosa
May increase bacterial and toxin translocation
Abdominal wall
Decreased blood flow
May increase the incidence of wound infection and fascial dehiscence
Note: In the presence of resuscitated shock the adverse effects of the ACS may
appear at lower intra-abdominal pressures.

364
Trauma Management
Risk Factors for ACS

Local risk factors
Severe abdominal trauma
Damage control operations
Retroperitoneal hemorrhage
Superior mesenteric vessel injury
Edematous bowel
Portal vein ligation or thrombosis
Aortic cross-clamping
Tight abdominal closure
Systemic risk factors
Massive transfusions
Prolonged hypotension
Fluid overloading
Hypothermia
Intraabdominal Pressure Monitoring

Direct measurements
Through an intraperitoneal catheter
Indirect measurements
Nasogastric tube
Inferior vena cava catheter
Foley catheter in the bladder
The bladder pressure technique is the most widely used method for
intraabdominal pressure monitoring
Technique of Bladder Pressure Measurement

Place patient in horizontal position.
50-100 mls of normal saline are instilled into the bladder through the
Foley catheter.
Cross-clamp the tube of the collecting urine bag.
Insert a needle into the specimen-collecting port, proximal to the clamp.
A CVP set is connected to the needle and the pressure is measured using
standard techniques. The pubic symphysis should be used as the zero point
(Fig. 35.1).
Alternative Technique for Bladder Pressure Measurement
35
Place patient in horizontal position.

Instill 50-100 mls of normal saline in bladder, through Foley catheter.
Create a U-shape loop with the Foley catheter and the urine collection tube
with the lowest point of the loop touching the mattress. The distance between
the pubic symphysis and the meniscus of the fluid in the tube is the bladder
pressure (Fig. 35.2).
Diagnosis of ACS
The diagnosis is suspected on clinical examination and confirmed by bladder
pressure measurements.
Clinical findings may include
Tachycardia and in severe cases hypotension
365
Fig. 35.1. Bladder pressure measurements using a CVP set connected to a Foleys
catheter. The pubic symphysis serves as the zero point.
Elevated peak inspiratory pressure, persistent hypoxia, poor compliance.

Decreased urine output
Tense abdomen
Bladder pressure > 25-30 cmH20
Prevention of ACS
The risk of ACS decreases significantly with appropriate measures.
Adequate resuscitation
Avoid fluid overloading
Avoid hypothermia
Keep bowel warm and moist
Do not close the abdomen if it cannot be achieved without tension
35
366
Trauma Management
Fig. 35.2. Bladder pressure measurements with U-shape loop created with the Foleys
catheter. The pressure corresponds with the distance between the pubic symphysis
and the meniscus of the fluid in the tube.
Do not close the abdomen in damage control laparotomies

In high-risk patients monitor the bladder pressures
New therapeutic modalities which may be useful in preventing ACS but still
need clinical verification.
Mannitol
Immunomodulators (anticytokines, oxygen free radical scavengers)
Treatment of ACS
35
Treatment should be started without any delay in order to avoid organ dysfunction. The improvement usually takes place immediately.
Decompressive celiotomy is the only effective treatment. It may performed in
the operating room or the ICU.
Decompressive laparotomy without appropriate preparation may be associated
with severe complications. Hypotension or cardiac asystole may develop in
about 10% of cases during opening of the abdomen. This decompensation
may be due to sudden hypovolemia due to volume loss in the vasodilated
intra-abdominal organs or sudden release of cytokines and products of anaerobic metabolism into the systemic circulation.
The complications during decompressive laparotomy may be prevented by
preoperative administration of 2 L of 1/2 NS + 50 g Mannitol/L + 50 mEq
NaHC03/L.
The abdomen is closed temporarily with a prosthetic material such as PTFE,
various meshes, or an opened 3-liter dialysis fluid bag (Fig. 35.3). The vacuum
pack technique4 is strongly recommended because it facilitates the subsequent
definitive abdominal wall closure (Figs. 35.4A,B,C).
367
Fig. 35.3. Abdominal wall closure with plastic sheet from a 3-liter dialysis fluid bag.
Technique of Vacuum Pack Abdominal Wall Closure

Place clear plastic sheet from a 3 L IV dialysis bag between bowel and peritoneum (Fig. 35.4A).
Place a thick layer of moist gauze dressing over the plastic sheet. Two closed
suction drains are placed over the gauze.
A second plastic sheet is placed over the gauze and drains and fixed to the skin
(about 2 cm from the edge) with stapling (Fig. 35.4B).
A large self-adhesive transparent drape (Op-site, Tegaderm) is placed over the
whole abdomen. The drains are connected to continuous low suction. The
whole dressing becomes firm and stabilized (Fig. 35.4C).
Definitive Abdominal Closure After Decompressive

Laparotomy
In some cases improvement of the bowel edema may allow definitive closure
with or without a prosthetic mesh and undermining of the skin within a few
days of decompressive laparotomy.
In many cases definitive closure is possible only many weeks or even months
after the initial operation. Skin grafting of the exposed bowel may be necessary
as a temporary measure, in order to avoid bowel fistulae and fluid and protein
losses from the open abdomen (Fig. 35.5). The definitive closure is attempted
usually 6-8 months later, when the wounds have healed and the nutritional
status has improved. The fascial defect is closed with a nonabsorbable mesh
and the skin is approximated after extensive undermining.

Delayed diagnosis of ACS because of low index of suspicion
Primary closure of the abdomen following a damage control operation.
Almost all patients will develop ACS! The abdomen should be closed with a
temporary prosthetic material.
35
368
Trauma Management
Fig. 35.4A,B,C. Abdominal wall closure with the vacuum pack technique.
Fig. 35.4B. Abdominal wall closure with the vacuum pack technique.
35
Closure of the abdomen under tension, after laparotomy for complex trauma!
Failure to monitor the bladder pressures after complex abdominal trauma!
Decompressive laparotomy to relieve ACS without appropriate preoperative
preparation. Risk of severe hypotension or cardiac asystole!
References
1.
Eddy V, Nunn C, Morris JA. Abdominal compartment syndrome. Surg Clin N

Am 1997; 77:801-812.
369
Fig. 35.4C. Abdominal wall closure with the vacuum pack technique.
Fig. 35.5. Temporary abdominal closure with skin grafting on the bowel. The patient
will develop a large incisional hernia, which will require repair at a later stage.
2.
3.
4.
Ivatury RR, Diebel L, Porter JM et al. Intra-abdominal hypertension and abdominal

compartment syndrome. Surg Clin Nort Am 1997; 783-800.
Bongard FB, Ryan M, Dubecz S et al. Adverse consequences of increased intraabdominal pressure on bowel tissue oxygen. J Trauma 1995; 39:519-525.
Brock WB, Barker DE, Burns RP. Temporary closure of open abdominal wounds:
The vacuum pack. Am Surg 1995; 61:30-35.
35
CHAPTER 36
Damage Control Operations

Richard J. Mullins and John C. Mayberry
Definitive Surgical Therapy Versus Staged Sequential
Therapy
History
H. Harlan Stone reported in the early 1980s the first damage control operation
to manage patients who developed coagulopathy during a laparotomy
performed for trauma. Dr. Stone concluded that with this approach the risk
of death by exsanguination in this high risk group of patients was reduced
from 93 to 35%.
Other trauma surgeons expanded the indications for premature termination
of a trauma laparotomy. Morris et al calculated that one in ten patients benefited from a staged celiotomy for trauma. They described refinements
in decision making regarding packing and unpacking for abdominal bleeding in
patient in extremis.
Damage control, a term coined by Rotondo et al, is a tactical maneuver and
its application has been expanded in the past 20 years as an alternative technique to a surgeons persistence with the conduct of a procedure until either
its definitive completion or the patients demise.
Damage Control Strategy

Damage control is a tactic that is intended to preserve a patient who is at risk
of being overwhelmed by physiologic dysfunction caused by the patients injuries. Complete repair of injuries is achieved through a series of surgical interventions performed over days.
The damage control premise is that a single prolonged operation in seriously
injured patients subjects the patient to a physiologic shock of magnitude and
duration from which they cannot recover.
The goal in damage control is to return to the operating room for definitive
repairs of the stable and physiologically improved patients.
Bail-Out or a Preemptive Intervention

Surgeons who accept the hypothesis of damage control should decide, as a
premeditated guideline, what will be the scope of damage control application
in their practice (Table 36.1). Damage control can be seized upon at the end
of a surgical procedure as a rescue intervention in critically unstable patient.
Alternatively damage control can be adopted early in a surgical procedure as a
precautionary process in a patient judged to be at high risk for physiologic
Richard J. Mullins, Oregon Health Sciences University, Portland, Oregon, U.S.A.
John C. Mayberry, Oregon Health Sciences University, Portland, Oregon, U.S.A.
371
Table 36.1. The application of damage control used as either:

Bail-Out Procedure
Aborted termination of surgery in a patient at imminent risk of death
Preemptive Intervention
Calculated early decision to accomplish definitive correction of injuries in a
series of procedures
deterioration. Delay of damage control, until it is a bail-out procedure, risks

the patients condition will deteriorate into irreversible physiologic dysfunction.
On the other hand selecting damage control early may mean an unnecessarily
premature termination of surgery in patients who would otherwise have recovered from a single definitive procedure. In this circumstance, damage control subjects the patient to risks and expense of multiple procedures and prolonged surgical therapy.
Surgeons should decided what is their preference in the application of damage
control and be prepared to make a prompt choice should they encounter a
patient who is a candidate for damage control.
Indications for Damage Control

Criteria are available which can guide the surgeon in decision making regarding
which patient is a candidate for damage control (Table 36.2).
Shock
Hypotension
The duration of hypotension was recommended as an indication for damage
control (Table 36.2).
Volume of Blood Transfused

An easily quantized indication of the magnitude of shock is the number of
units of blood required to be transfuse into a patient to accomplish resuscitation from shock.
Some authors advocated damage control if more than 15 units of blood
are needed.
Others have concluded the threshold should be based upon estimated blood
loss, with one author advocating a threshold of greater than four liters of
blood loss.
Hemodynamic Measures
Measures of central venous or left atrial filling pressure can be used as a guide
to hypovolemia. Persistent evidence of hypovolemia despite ongoing resuscitation may be an indication that further dissection and attempts at repair
should be deferred until homeostasis has been achieved.
However, these measurements may not be readily obtained in the operating
room during a emergent surgical procedure in a patient with rapid fluctuations in intravascular volume.
36
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Trauma Management
Table 36.2. Published indications for damage control

Absolute Indications
Hypothermia
Less Than 35 C
Less Than 34 C
Less Than 33 C
Acidemia
pH < 7.10, pH < 7.2 pH < 7.25
Bicarbonate Deficit Exceeds 15 Meq/L
Coagulopathy
Incessant Microvascular Bleeding
None Cloting Blood
Prothrombin Time In Excess Of 19 Seconds
Fibrinongen Less Than 100 mg/dL
Relative Indications
Sustained Systolic Blood Pressure < 70 mmHg
Blood Loss In Excess Of 4 Liters
Transfusion Approaching 15 Units Of Blood
Injury Severity Score Over 35
Excessive Risk to Geriatric Patients

Geriatric patients may benefit from implementation of damage control surgery
if their hemodynamic status is precarious.
Acidemia
Arterial pH
Arterial blood gas pH in the range 7.10-7.25 has been suggested as an indication
for damage control.
The surgeon should remain aware that there is an accelerating risk to a patient
whose arterial pH is declining rapidly and not depend entirely upon a single
pH value to support the decision to implement damage control.
The arterial pH can be depressed by elevated partial pressures of the respiratory
gas carbon dioxide and thus alveolar hypoventilation, and not hypoperfusion,
can be the cause of acidemia.
Bicarbonate Deficit
A bicarbonate deficit which exceeds 10 mEq/L indicates a seriously stressed patient.
If bicarbonate deficits exceeds 15 mEq/L the risk of death exceeds 50%. As
the intraoperative bicarbonate deficit increases, the patient is a more suitable
candidate for damage control.
36
Lactate
Some surgeons prefer to depend upon lactate levels to quantitate the magnitude
of shock. While elevated serum lactate may be a more sensitive indication of
cellular hypoxia, obtaining a lactate level is often delayed compared to
the availability within minutes of an arterial blood gas analyses.
373
Hypothermia
Core Body Temperature
The body temperature threshold considered critical has varied among authors
(Table 36.2). Core body temperature less than 34 C is associated with a
reduction in coagulation cascade effectiveness, and patients this cold have a
greater risk for bleeding.
In patients having an exploratory laparotomy, the exposure of wet viscera to
ambient air results in substantial heat loss. These patients benefit from damage
control.
Coagulopathy
Micro Damage Control Operations for Bleeding
Bleeding in the critical trauma patient has multiple causes. Hypothermia, depletion of coagulation proteins and platelets, and activation of fibrinolysis can
individually, or in concert, cause bleeding.
The excess bleeding attributable to hypothermia is a directly reversible coagulation disorder achieved by warming the patient, something that is difficult to
do during a laparotomy. Damage control provides an interval to catch up by
infusion of fresh frozen plasma, cryoprecipitate and platelets to replenish depleted coagulation factors, and warm up the patient.
Laboratory Test Dependent Diagnosis of Coagulopathy

Coagulation laboratory tests can provide an indication the patient has developed
an acute bleeding disorder.
However these laboratory tests require a delay, and just as valuable in guiding
the decision to default to damage control because of coagulopathy, is the
surgeons observations and judgement.
Monitoring coagulation tests can provide direct evidence that therapy is
accomplishing the intended goal of damage control.
Ancillary Issues Indicating the Benefits of Damage Control

The physiologic criteria for imminent, catastrophic physiologic failure are well
established.
Other criteria, such as the total number of injuries sustained by the patient,
the complexity of these injuries, the time required to accomplish definitive
repair, and the experience of the surgeon may be useful in determining the
need for damage control.
As excellent indication for damage control is a fatigued and overwhelmed
surgical team. Damage control has the advantage that critical decisions which
do not necessarily need to be made immediately can be deferred.
Damage control should supplement the triage decisions made when managing severe multi trauma patients in a mass casualty incident, particularly when
the number of surgeons or operating rooms are limited.
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Trauma Management
Categories of Injuries Amenable to Damage Control

Damage Control During a Laparotomy
Initial Hemostatic Control
The initial step in a laparotomy when hemorrhage is encountered is to pack
off the four quadrants of the abdomen, and attempt to achieve by that means
control of hemorrhage. The next step is to determine the site, or sites, of
bleeding. Control of large arterial vessel hemorrhage is usually accomplished
by either vessel ligation or vascular repair. Small arterial or venous vessel bleeding
in most circumstances can be temporarily controlled by compression with
laparotomy gauze pads.
After major hemorrhage has been controlled, the laparotomy pads are
systematically removed, and individual bleeding points cauterized, clamped or
suture ligated.
If the laparotomy pads have achieved a dry field, and the patient has other
organs that need repair, the surgeon should decide whether to proceed with
damage control. Many trauma surgeons have concluded in retrospect the
imprudence of their persistent efforts to achieve complete removal of all
tamponade laparotomy pads and found damage control a useful alternative.
After the patients physiologic status is improved, the patient is returned to
the operating room for removal of the packs (Fig. 36.2).
Management of Hollow Viscous Injuries

For over 20 years, surgeons using damage control have reported the safety and
effectiveness of deferral of bowel reconstruction until the second operation.
Thus the ends of bowel are ligated or totally occluded by staples or sutures.
One advantage of waiting to perform an anastomosis is that the surgeon can
be conservative in resections in patients in shock and rely upon a second look
within a few hours up to two days, when the patients hemodynamic status
has improved, to determine the viability of the bowel.
Damage control enables construction of stomas to be deferred, thus avoiding
the need to make new abdominal wall wounds in coagulopathic patients.
The same techniques can be applied to ureter and bile duct injuries, although in
these organs, stents can be inserted into the lumen to achieve temporary
drainage.
The Abdominal Compartment Syndrome
36
The abdominal compartment syndrome is a multiple organ dysfunction syndrome that occurs when pressure within the abdominal cavity exceeds a critical
level.
Visceral ischemia occurs in patients with the abdominal compartment syndrome.
Two hallmarks of the abdominal compartment syndrome are oliguria and
impaired pulmonary mechanics.
Specific causes of the abdominal compartment syndrome in trauma patients are
sudden accumulations of free peritoneal fluid, intra-abdominal and retroperitoneal hematomas, marked visceral edema or distention from intraluminal fluid or
air, and the laparotomy pads inserted for compression and hemostasis.
Patients with damage control laparotomy are commonly at risk for the
abdominal compartment syndrome. If a primary fascial closure is attempted
375
Fig. 36.1. The simple technique for measuring abdominal compartment pressure is
to determine the height from the pubic symphysis of a column of fluid in the bladder catheters tubing. The threshold pressure consistent with the abdominal compartment syndrome is 30 cm H2O. Reprinted with permission from: Mayberry, J.
Critical Care Clinics 2000; 162. 2000 WB Saunders.
Fig. 36.2. Laparotomy gauze pad is being extracted from the undersurface of the
liver where the pack had been inserted at the first damage control procedure into a
deep liver laceration.
in a high risk patient, the surgeon should monitor if closure causes an unacceptable increase in peak airway pressure during ventilation with tidal
volumes under 10 ml/kg. If airway pressures do escalate, prosthesis closure of
the abdomen should be accomplished. The bladder pressures can be easily
measured by determining the height of a meniscus of fluid in the Foley
catheter tubing above the symphysis pubis (Fig. 36.1). If the height of the
36
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Trauma Management
Fig. 36.3. Mesh closure of a patient with a distended abdomen after damage control precludes the development of the abdominal compartment syndrome.
fluid column exceeds 30 cm and the meniscus fluctuates during ventilation,

the patient is as substantial risk for visceral ischemia from the abdominal compartment syndrome. Without decompression, the abdominal compartment
syndrome will lead to irreversible organ failure.
Mesh Closure of the Laparotomy Wound

An alternative to primary fascia closure is insertion of a prosthetic material to
bridge the wound edges.
Prosthesis closure of the abdomen must achieve sufficient pressure within the
abdomen to assist with tamponade, while not creating a tense abdomen and
the abdominal compartment syndrome (Figs. 36.3-36.5).
Monitoring the abdominal pressures and other signs of postoperative development of the abdominal compartment syndrome is essential. A compartment syndrome may develop despite the use of prosthesis closure!
Damage Control in Patients with Open Pelvic Fracture
36
Patients with open wounds and a pelvic fracture are at risk for death by exsanguination. Arterial and venous injuries in the deep pelvis can be a source of
unstoppable hemorrhage when there is a wound, commonly a groin crease
laceration, which extends to the perineum. Direct access to the bleeding vessels through the wound for suture ligation is often impossible, and furthermore placing these patients with an unstable pelvis in lithotomy position can
exacerbate bleeding.
A damage control method to achieve hemostasis in patients with an open
pelvic fracture is to tightly pack the perineal wounds with gauze, and then
with a running suture closure of the skin achieve tamponade.
A damage control exploratory laparotomy should be performed if there is
evidence of intra-abdominal hemorrhage.
377
Fig. 36.4. Opening the mesh for second procedure enables re-exploration without further damage to fascial edges. The polyglycolic acid mesh does not
unravel with incision.
Fig. 36.5. It is always beneficial with damage control closure to attempt to interpose omentum between bowel and prosthetic.
36
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Trauma Management
Supplemental hemostatic techniques after damage control procedures in the

operating room are angiographic embolization of bleeding arterial pelvic vessels.
Damage Control for Severe Extremity Fracture

The principal of early fixation of long bone fracture has been widely adopted.
However while it is possible to immediately repair multiple fractures, there
are also circumstances where it is impracticable to subject the patient to sustained limb salvaging surgery.
The use of external fixators to immobilize the extremities has been advocated
as damage control in these patients.
Temporary use of intraluminal vascular shunts may be used to sustain perfusion of an ischemic extremity until acidosis and coagulopathy can be corrected.
Patients with severe shock and prolonged procedures on their extremities can
develop the abdominal compartment syndrome even thought they did not
have a direct abdominal injury.
Tactics and Pitfalls During Follow-Up Surgery

in Damage Control
Following a damage control procedure the patient should be returned to the
operating room, as soon as the core body temperature, the tissue perfusion,
and coagulopathy improve (usually within 12-48 hours).
In some cases the optimal time to return the patient to the operating room is
after the surgical team has rested and recruited assistance.
Continuous bleeding or hematocrit plummeting despite blood transfusion or
persistent hypotension after damage control are indications to return to the
operating room. In some such circumstances, control of hemorrhage can only
be accomplished with ligation of major arterial vessels with the consequence
of organ or extremity loss.
Worsening acidemia may indicate the patient has infected fluid collection or
dead tissue (i.e., bowel) which needs prompt drainage or eradication.
Role of Angiographic Embolization in Damage Control

In selected circumstances, patients with both blunt and penetrating trauma,
and persistent hemorrhage in poorly accessible areas can be managed with
angiographic techniques. Embolization of arterial bleeding of even 2-3 mm
vessels can be immediately hemostatic in patients with coagulopathy.
Returning to the Operating Room
36
Patients whose wounds were closed with gauze packs should have the
packs removed within 48 hours, especially in the presence of hollow viscus perforations. Bacterial overgrowth in these gauze packs may occur
and these can become a source of bacteremia as well as setting the stage
for local abscess formation.
Prolonging the removal of gauze packed against viscera can be a problem because the gauze becomes adherent. Soaking the gauze with saline while gently
working the gauze free can avoid tears to fragile organs and vessels.
379
Infection Risks
The use of gauze pads to tamponade bleeding has been associated with an increased risk of intra-abdominal infection. The range of intrabdominal abscess
has been 10-70%.
While data on duration of antibiotic usage in patients without damage control suggests only 24 hours of antibiotic therapy is required in patients who
have a bowel injury and prompt surgical correction, it is not known how long
antibiotics are indicated in patients who have damage control procedures.
The current preference in our practice is a second generation cephalosporin
continued until all packs are removed.
Retained Foreign Bodies

In patients who have damage control there is an increased risk that the patient
will have a retained foreign body, particularly a gauze pack. When damage
control is used, a process should be developed for assuring during follow up
procedures all foreign bodies are removed. These procedures would include
methods for counting subsequently removed gauze packs and obtaining a
completion x-ray.
Enteral Access
Edema and intraluminal distention can make the turgid bowel cumbersome
to manipulate. In damage control it is prudent to defer until later operations
insertion of intraluminal tubes.
Method for Abdominal Wound Closure

The ideal method of abdominal closure should be effective in prevention of
evisceration and massive fluid loss, quickly accomplished, be inexpensive and
have a low complication rate.
Definitive closure of the abdominal wound is not advisable in the first damage
control procedure because of the risk of abdominal compartment syndrome.
References
1.
2.
3.
4.
5.
Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with
onset during laparotomy. Ann Surg 1983; 197:532-5.
Morris JA Jr, Eddy VA, Blinman TA et al. The staged laparotomy for trauma. Ann
Surg 1993; 217:576-86.
Rotondo MF, Schwab CW, McGonigal MD et al. Damage control: An approach
for improved survival in exsanguinating penetrating abdominal injury. J Trauma
1993; 35:375-83.
Garrison JR, Richardson JD, Hilakos AS et al. Predicting the need to pack early
for severe intra-abdominal hemorrhage. J Trauma. 1996; 40: 923-927.
Mayberry JC, Mullins RJ, Crass RA et al. Prevention of abdominal compartment
syndrome by absorbable mesh prosthesis closure. Arch Surg 1997; 132:957-62.
36
CHAPTER 37
CT Scan in Abdominal Trauma

Sravanthi R. Keesara and Nabil A.Yassa
Introduction
Trauma to the abdomen accounts for 10% of the traumatic deaths in the
United States.
Most of these abdominal injuries are from motor vehicle accidents, but
penetrating wounds are also common.
Blunt trauma injures solid organs more often than hollow organs.
- Solid organs (liver, spleen) may have lacerations and/or subcapsular hematomas.
- Hollow organs (bowel, bladder, gallbladder) may rupture from increased pressure.
Deceleration Injuries
- Deceleration causes shearing forces that result in lacerations at points of fixation, such as at the ligamentum teres in the liver or in vessels.
Penetrating Trauma
- Low velocity penetrating trauma (knives, low-velocity bullets) cause damage to
organs in their paths, by direct laceration and crushing.
- High velocity injuries (high velocity bullets, bombs) may cause damage to tissues away from the missile tract, by transient cavitation or shock waves.
Combination Injuries
According to the mechanism of injury, certain injuries occur together. If one
injury is seen, the scan should be scrutinized so as not to miss additional injuries
after the first or most prominent injury has been detected.
Right package: Right lung contusion/lacerationRight rib fracturesRight
pneumothorax/hemothoraxLiverRight kidneyRight adrenalRight
hemidiaphragm.
Left package: Left lung contusion/lacerationLeft rib fracturesLeft pneumothorax/hemothoraxSpleenStomachLeft kidneyLeft adrenalLeft
hemidiaphragm
Midline package: Left lobe of liverSternumLower ribsHeart/pericardiumTransverse colonSmall bowelMesenteryPancreasDuodenum
AortaIVC
Chance type fracture: Lap-type seat belts: Physical exam shows a seat belt
burn (hematoma)Spinal injurySmall bowel or mesenteric injuryBladder injury
Pelvic fractures: Bladderurethravaginarectum

Sravanthi Keersara, University of Southern California, Los Angeles, California, U.S.A.
Nabil A. Yassa, University of Southern California, Los Angeles, California, U.S.A.
381
Investigations
- This minilaparotomy (first done in 1965) is a saline lavage of the peritoneum.
- DPL provided a go/no go answer for surgical intervention, but it has been
found that bleeding often stops on its own or is from a source that may not need
surgery.
- There is a nontrivial 5% complication rate.
Ultrasound (US)
- Focused US of the abdomen for trauma, an idea that originated in Germany,
has been suggested as a replacement for DPL.
- US is nearly equivalent to DPL in finding free intraperitoneal fluid, is
noninvasive, and can be performed quickly (< 3minutes) and serially over minutes or hours. Advantages of US over CT include the lack of need for patient
preparation or movement, ability to be performed even while resuscitating the
patient, its rapid acquisition and ability to be done serially.
- US can be performed on hemodynamically unstable patients to help determine
the need for laparotomy. A quick and thorough search for extra-abdominal bleeding may be performed if US is negative.
- Drawbacks of US include the fact that US is very operator-dependent and is
difficult to do on some patients due to patient body habitus, inability to roll the
patient due to open wounds and that even major retroperitoneal injuries and
free air and bowel injuries may be missed.
Computed Tomography (CT) of the Abdomen

- CT has helped decrease the number of explorative, nontherapeutic laparotomies.
- The new generation helical and multidetector/multislice CT scanners have a
turn-around time for the abdomen that is now under 10 minutes and multiple
exams can be performed in a short time on the same patient. In addition to
getting an injured patient back to treatment more quickly, shorter scan times
decrease motion artifacts. Other advantages include better vascular/parenchymal opacification, reconstructed images with overlapping areas that pick up
smaller injuries, and multiplanar reconstructions (in sagittal and coronal planes)
that help diagnose injuries of the diaphragm, GB, and spine.
CT Technique
- The abdominal scan should include the inferior part of the chest to pick up
associated injuries and extend through the pelvis.
- The scans need to be reviewed in soft tissue, lung, narrow and possibly bone
windows to pick up lung contusions, pneumothoraces, pneumoperitoneum,
bone injury, and subtle abdominal organ injury.
- According to the mechanism of injury, certain injuries occur together. If one
injury is seen, the scan should be scrutinized so as not to miss additional injuries after the first or most prominent injury has been detected.
IV Contrast
- If no contrast allergy or severe renal insufficiency is present, IV contrast is used.
- Nonionic contrast is preferred to decrease the possibility of vomiting as the
patient may have a full stomach and/or head injuries.
- The Foley catheter should be clamped to allow the bladder to fill with contrast.
- Precontrast CT may show acute blood (denser than adjacent soft tissues) better
than postcontrast images, but protocols done for trauma do not include
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Trauma Management
precontrast images as the hematomas missed on postcontrast only images have
been shown to be clinically insignificant.
- Contrast-enhanced CT scans maximize the difference between enhancing
parenchyma and nonenhancing hematomas and lacerations. Contrast enhancement also better shows active hemorrhage and contrast-opacified urine
extravasations.
CT and Bladder Contrast

- Water-soluble contrast is given orally or through a nasogastric tube (NGT).
- This was previously controversial due to the possibility of aspiration in an
obtunded patient and due to time lost in waiting for contrast to move through
the bowel. IV metoclopramide (10-20 mg) given with the oral contrast and
suction through the NGT after the study decreases the possibility of aspiration;
and since most bowel injuries are in proximal small bowel, little time is lost to
wait for contrast transit.
- Oral contrast helps to identify bowel leak and to differentiate between unopacified
fluid-filled bowel loops and free fluid.
- Rectal contrast may be given when colonic injury is suspected. This is especially
important in cases with penetrating injury, hematochezia, or pelvic fractures.
Thin patients who have little fat may also benefit from rectal contrast.
- Bladder contrast may be used for a CT cystogram when bladder injury is
suspected.
CT Evaluation of Abdominal and Pelvic Hemorrhage

Very small volumes of abdominal and pelvic hemorrhage can be detected and
since this may be the most obvious initial clue for abdominal injury, this should
prompt a thorough search for organ injury.
Quantification of the hemorrhage on CT to help management was attempted
in the past, but this is now considered less useful because some stable patients,
even with a large hemoperitoneum, do well without surgery.
More important to treatment than the amount of fluid is its location and its
appearance on CT and its location.
Appearance of Fluid
37
- CT density is measured in Hounsfield units (HU) and can help determine the
type of fluid.
- 0-10HU suggests water-density fluid: Urine, bile, chyloperitoneum, pre-existing ascites, DPL fluid.
- > 30HU suggests blood. Recent hemorrhage may be homogeneous or inhomogeneous according to age, physical state, and location.
- 30-45HU suggests fresh unclotted blood (immediately after hemorrhage) or
lysed clotted blood (after several days).
- 40-60 and up to 100HU suggests clotted blood (which occurs within hours).
- 0-20HU suggests serum (after clotting, the unclotted portion) or old lysed clotted
blood (after 2-3 weeks).
- 80-300HU suggests active arterial extravasation of blood mixed with IV contrast,
which warrants emergency surgery or embolization (Figs. 37.1, 37.2, 37.3).
- The sentinel clot sign is a sensitive sign of visceral injury. The densest blood is
near the area of extravasation as it clots in an attempt at hemostasis. This sign is
especially helpful in a patient with multi-organ injury to find the major source
of the hemorrhage.
383
Fig. 37.1. Left external iliac artery with active contrast extravasation and retroperitoneal hematoma. (arrow). The image is limited by streaky artifacts from patients
upper extremities being adjacent to the pelvis.
Fig. 37.2. Splenic fracture with active extravasation. (arrow)
- Hematocrit effect is the layering of less dense serous fluid on the more dense
dependent, sedimented erythrocytes and clot (Fig. 37.4).
- Pleural and peritoneal blood is less dense than intramuscular, retroperitoneal,
or parenchymal blood.
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Trauma Management
Fig. 37.3. Liver laceration with hemoperitoneum and active extravasation. (arrowhead). Spleen (S) is nonperfused indicating infarction.
Fig. 37.4. Hemoperitoneum with hematocrit effect. (arrow)
37
Location of Fluid
- Hemoperitoneum initially collects near the source of the injury and then spills
over into more dependent portions of the peritoneal cavity. This is another
important reason to include the entire pelvis, which may collect the majority of
the fluid from any intraperitoneal injury.
385
- If CT shows intraperitoneal fluid and no other injuries, this may point to a selflimited injury of a parenchymal organ that does not require any treatment, but
because it may indicate a more serious injury like bowel rupture that requires
emergency laparotomy, further investigation is needed. HU measurement of
the fluid may be performed: If the HU is consistent with blood and there is
associated free intraperitoneal air, oral contrast extravasation, thickened or hyperemic bowel, or triangular fluid collections between leaves of mesentery, this
suggests bowel injury. A repeat CT with additional oral and rectal contrast may
help to confirm.
- A repeat CT may be performed after 12-24 hours to search for signs of abdominal injury not present on initial scan.
Shock from hypovolemia and inadequate fluid resuscitation is a common finding in a trauma patient. It can be suggested on CT by the following signs:
- A small constricted aorta.
- A collapsed IVC.
- Abnormally intense contrast enhancement of the bowel wall and kidneys.
CT Pitfalls in Hemorrhage Evaluation

- The HU of blood can be lower than expected and be mistaken for water-density fluid in the following cases:
Pre-existing underlying anemia.
Dilutional effects from intraperitoneal fluid such as ascites, urine, or bowel
contents.
Volume averaging of peritoneal fat or artifacts.
- If the HU of the fluid is high, acute vascular extravasation should be considered, but other possibilities include the following:
Oral contrast extravasationlook for adjacent injured bowel and the location of the material. The CT with IV contrast can be repeated after a delay.
Contrast-enhanced urine extravasationlook for adjacent injured urinary
tract. Delayed CT scanning will show arterial blood to be getting less dense
and contrastenhanced urine leak to be more dense.
Splenic Trauma
The spleen is the most frequently injured organ in blunt abdominal trauma
and accounts for 40% of the abdominal organ injuries.
CT Findings
- CT is very sensitive in diagnosing splenic injury and also identifies associated
injuries in the chest (rib fractures, lung contusions, diaphragmatic injuries),
and the left upper quadrant.
- Spectrum of Splenic Injuries
- Lacerations, which appear as hypodense irregular branching linear areas, are
often associated with hemoperitoneum. Splenic injuries are associated with
perisplenic fluid and fluid in the phrenocolic ligament, and the left paracolic
gutter (Figs 37.2, 37.5).
- Intrasplenic hematomas are broader low density, homogenous or heterogeneous,
zones within the splenic parenchyma.
- Contusions are less well defined than hematomas.
- Subcapsular hematomas are low-attenuation crescentic fluid collections that
compress the adjacent contrast-opacified splenic parenchyma.
- A shattered spleen consists of small fragments caused by multiple crossing
lacerations (Figs. 37.6, 37.7).
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Trauma Management
Fig. 37.5. Subtle splenic laceration with small perisplenic hematoma. (arrowhead)
Fig. 37.6. Shattered spleen (S) with perisplenic hematoma. (arrow) (Renal cyst (R)
incidentally noted on the right.)
37
- Infarction may be caused by a disruption of hilar blood vessels and are

nonperfused global or wedge-shaped areas that extend to the surface of the spleen
(Fig. 37.3).
- Delayed rupture, up to 10 days after the initial injury, does occur. This is associated with subtle low-grade injury and subcapsular hematoma.
387
Fig. 37.7. Fractured spleen (SP) (arrowheads), involving the vascular pedicle. Note
the distended stomach (ST).
Management of Splenic Injuries

- Several grading systems to help predict management have been published, but
because these are based on anatomic criteria rather than the more predictive
physiologic criteria (e.g., rate of bleeding) and because CT underestimates injury,
these do not accurately predict the need for splenic surgery.
- Grading systems are not predictive of a need for surgery, but they do correlate to
the rate of healing, which usually takes 4-6 months.
- With the conservative non-surgical approach, if there are clinical indications of
complications, repeat CT may be needed.
- Surgery or embolization is needed if there are large nonperfused portions of
spleen, active hemorrhage, or false aneurysms.
CT Pitfalls in Splenic Evaluation

- CT scan obtained too early after contrast injection shows an inhomogeneous
pattern of opacification. Repeat CT after equilibrium may be obtained in
confusing cases.
- The spleen can show an apparent increase in size on follow up scans which is
actually the return to normal size after the initial adrenergic contraction in
response to volume loss or parenchymal injury.
- Splenic clefts may be mistaken for lacerations, but these have a smooth contour,
are medially located, and are not associated with a hemoperitoneum.
- An elongated left lobe of liver or atelectactic left lung may be confused with
splenic injury.
- Motion, beam-hardening, or streak artifacts, volume averaging, and unusual
windows settings also may cause confusion.
37
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Trauma Management
Hepatic Trauma
Due to its relatively fixed position, large size, and friability, the liver is the
second most commonly injured intraabdominal organ in blunt abdominal
trauma. Although only half as common as splenic injury, hepatic injury results
in greater morbidity.
CT Findings
- Lacerations are hypodense irregular linear, or branching regions, which often
parallel hepatic and portal venous vasculature. (Fig. 37.8). Parallel lacerations
that produce isolated parenchymal fragments produce what has been called the
bear claw pattern.
- Hemoperitoneum, produced if the lacerations extend beyond thin capsule, may
be large due to the dual blood supply and the decreased ability for hemostasis
(veins). Liver injuries are associated with fluid in Morisons pouch (hepatorenal
space) and the right paracolic gutter.
- Multiple lacerations around the confluence of the hepatic veins or IVC may
suggest vascular damage. Preoperative notice of possible venous laceration will
help prepare surgeons for massive hemorrhage when liver is lifted off the IVC.
- Periportal tracking appears as hypodensity along the course of the portal vein.
In trauma patients this tracking may have several causes:
a) If the tracking is focal and associated with liver laceration or hematoma,
dissection of blood or bile along course of portal veins may be the cause.
b) More often, the tracking is diffuse and caused by lymphedema and elevated
central venous pressure caused by rapid expansion of intravascular fluid in
the trauma resuscitation.
- Intrahepatic hematomas are mass-like, well-defined hypodense homogeneous
or heterogeneous regions in the parenchyma (Figs. 37.9A,B).
- Contusions are less well defined than hematomas.
- Subcapsular hematomas are hypodense crescentic lenticular fluid collections
that cause compression of underlying parenchyma, often associated with rib
fractures and penetrating trauma.
- Focal devascularization, wedges of isolated hypodense, nonperfused liver, may
be produced by multiple lacerations.
- Active hemorrhage is a focal, irregular area of hyperdensity, sometimes with
adjacent sentinel clot (Fig. 37.3).
- Intrahepatic or subcapsular gas may be seen in areas of laceration 2-3 days after
trauma and this is probably due to necrosis rather than infection.
Management of Hepatic Injuries
37
- Several systems for grading hepatic injuries have been suggested, but as with
spleen, none correlate with the need for surgery or with subsequent complication.
- Delayed complications due to portal triad injury or devitalized liver tissue occur
in 20% of liver injuries so a repeat CT before discharge is more important after
liver injury than after splenic injury. Any of the following may be found:
a) Recurrent bleeding.
b) Arterioportal fistula, shown by early, intense contrast enhancement of
the portal vein.
c) Pseudoaneurysm, round focal areas of intense enhancement adjacent to
arteries.
d) Biloma, low density round or crescentic areas. Bile in a hematoma delays
healing.
e) Obstructive jaundice from mass effect of biloma or hematoma
389
Fig. 37.8. Liver laceration. (arrow) (StomachS)
CT Pitfalls in Liver Evaluation

- Diffuse periportal tracking can occur in patients with lymphatic obstruction
and dilatation of lymphatic channels caused by hepatitis, liver transplant, cardiac failure, cardiac tamponade, and malignant tumors of the liver. This may be
differentiated from the focal tracking associated with liver injury.
- A prominent cleft in the undersurface of the liver may look like a laceration, but
as in the spleen, this will have a smoother contour and not be associated with a
hemoperitoneum.
- Dilated bile ducts may have the appearance of branching lacerations especially
on noncontrast images, but careful analysis can differentiate the two.
- An unusually elongated left lobe of the liver that may appear separated from the
right lobe may appear to be a laceration.
- Streak or beam-hardening artifact from air-fluid levels in the stomach or from
ribs, motion artifacts, volume-averaging and unusual window settings can cause
confusion.
Gallbladder Trauma
Gallbladder trauma is rare because of its well-protected recess. It may occur
when the gallbladder is distended and is often associated with liver or duodenal
injuries.
Alcohol causes gallbladder distention by increasing bile flow and causing contraction of the spincter of Oddi, making the gallbladder more prone to injury
at the same time that the alcohol is making trauma more likely.
CT Findings
- Rupture may cause the gallbladder to collapse and spill bile and blood around
it. Most commonly, the bile leakage is pericholecystic and contained. This fluid
is extraperitoneal so peritoneal lavage may be negative. Intraperitoneal spillage
is also possible.
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Trauma Management
Fig. 37.9A. Intrahepatic hematoma A. Precontrast images show high density blood.
(arrows)
Fig. 37.9B. Postcontrast images show blood to be low density compared to the
enhancing adjacent parenchyma. (arrows)
37
- Blurring of gallbladder contour, focal wall thickening or discontinuity of the

gallbladder wall, and an enhancing mucosal flap in the gallbladder lumen all
may be present.
- Hyperdense hemorrhage may collect in the lumen, which may distend the gallbladder enough to cause mass effect on the duodenum.
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- Avulsion of the gallbladder may be associated with major blood loss from
lacerations of the cystic artery.
- Coronal/sagittal reformations on helical CT help to demonstrate the avulsion
of the gallbladder out of its fossa.
Management of Suspected Gallbladder Trauma

- Ultrasound and/or hepatobiliary radionucleide imaging may confirm the
diagnosis. Follow-up CT scan after 3 weeks may also prove useful.
CT Pitfalls in Gall Bladder Evaluation

- The findings from gallbladder injury are nonspecific (for example, the blood
may have come from liver injury), so gallbladder injury is sometimes difficult
to diagnose.
- GB can reseal after microperforation creating the appearance of a false positive
finding.
- Hyperdensity in the gallbladder may be mimicked by milk of calcium bile,
residual contrast from ERCP, vicarious excretion of IV contrast material, or
reflux from oral contrast via a patulous sphincter.
Bile Duct Trauma

Traumatic injury to the biliary system is even less common than that to
the gallbladder, but is much more serious as it is associated with a high
mortality rate.
Injury occurs at areas of relative fixation, for example, at the sites where the
hepatic duct exits the liver or where the bile duct enters the head of the pancreas.
The diagnosis of bile duct injury is challenging clinically and is rare before surgery.
CT Findings
-
Bile may be contained in an extraperitoneal location.

Free uninfected intraperitoneal bile may produce no symptoms.
Edema may be seen in the hepatoduodenal ligament area.
Associated liver and duodenal injuries are common.
Associated injuries of the portal vein or hepatic artery are rare because these are
more elastic than the bile ducts.
Pancreatic Trauma
The pancreas is uncommonly injured with blunt trauma. When it does occur,
it is usually a result of an anterior midline blow (by a steering wheel, for instance) that causes compression of the pancreas against the vertebral column.
It is often associated with injury to the duodenum or liver. Traumatic pancreatic injury is more common in children probably because they have less surrounding fat to buffer a direct blow.
CT Findings
- Intrapancreatic contusions and hematomas appear as hypodensities in a focally
or diffusely enlarged pancreas.
- Lacerations or fractures are linear hypodense areas that are perpendicular to the
long axis of the pancreas. These are usually in the neck or head, where the
pancreas overlies the spine. Since the elastic pancreatic parenchyma may resume
normal contour even with transsection, there may only be the minimal CT
findings of peripancreatic subtle edema or fluid (Fig. 37.10).
- This fluid may collect in the anterior pararenal space, around the superior mesenteric artery, in the transverse mesocolon and the lesser sac, or between the pancreas
and splenic vein. It may result in left anterior pararenal fascial thickening.
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Trauma Management
Fig. 37.10. Pancreatic laceration. (arrow)
Management of Suspected Pancreatic Trauma

- A retroperitoneal fluid collection may be the only finding to suggest a pancreatic duct interruption.
ERCP or MRI may confirm diagnosis.
A follow-up CT after 12-48 hours is more sensitive than the initial CT scan.
CT Pitfalls in Pancreatic Evaluation

- The pancreatic parenchyma may resume normal contour after laceration, so the
only finding of injury may be peripancreatic fluid.
- The fat plane separating normal pancreas from adjacent unopacified duodenum or jejunum may simulate fracture of the pancreas. Repeat scanning with
additional oral contrast may clarify.
- Physiologic thinning of the pancreatic neck may also cause confusion.
- Volume-averaging, beam-hardening and streak artifacts, motion artifacts, and
unusual window settings can cause confusion.
Bowel and Mesenteric Trauma

Several mechanisms can injure the bowel in blunt trauma.
- Direct compression of the bowel between the anterior abdominal wall and the
spine causes injury.
- Blow-out injury can occur from increased intraluminal pressure.
- Tangential shearing forces can tear sites of fixation and cause injury.
37
The second and third parts of the duodenum are the most commonly injured
parts of the bowel. Duodenal injury, which includes bowel wall hematoma
and perforation, is caused by midline compression, so the pancreas should be
closely evaluated for associated injuries (Figs. 37.11, 37.12)
- A large hematoma can cause a bowel obstruction.
- Fluid, extravasated oral contrast, gas in the retroperitoneal right anterior pararenal
space, or an abnormality in adjacent head of the pancreas can suggest a duodenal
393
Fig. 37.11. Duodenal hematoma. (arrows)
Fig. 37.12. Small bowel perforation with bowel wall thickening (curved arrow)
and a small amount of mesenteric air (long arrow) and fluid. (short arrow)
injury. If the injury is near the ligament of Trietz, the fluid or gas may be seen
within the peritoneal space.
The jejenum and ileum are commonly injured at points of fixation such as the
ligament of Trietz or the ileocecal valve.
The colon, the least common part of bowel to be affected in blunt trauma, is
injured by compression. Penetrating trauma of the back and flank is a more
likely cause of colonic injury.
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Trauma Management
Isolated mesenteric injury is rare but may occur if the mesentery is avulsed
from the bowel.
- The CT has a sensitivity of 90% for bowel and mesenteric injuries.
CT Findings of Bowel or Mesenteric Trauma

- Bowel dilatation may be seen (Fig. 37.7).
- Bowel wall thickening of greater than that of adjacent bowel loops is seen in
both hematomas and rupture. Wall thickening of 3 mm has been mentioned as
abnormal, but with incomplete distention, this is difficult to determine (Figs.
37.11, 37.12) Narrow CT window settings may help pick up a subtle intramural
hematoma.
- Free intraabdominal fluid may be present. This may be low-density bowel contents or high-density acute blood. Free fluid in the absence of solid organ injury
should prompt a careful search of bowel and repeat CT with additional oral
contrast may be warranted (Fig. 37.12).
- Interloop fluid, triangular-shaped collections between the fat-density leaves of
the small bowel mesentery, suggests bowel or mesenteric injury.
- Misty mesentery, streaky opacities in the mesenteric fat, correlates with smallintestine rupture. This streakiness may indicate edema from direct mesenteric
injury or chemical irritation from spilled intestinal contents, or it may be caused
by a small amount of fluid or blood.
A sentinel clot or active extravasation of contrast-enhanced blood may be
spotted next to the injury.
- Extraluminal air can be seen in the peritoneum (subdiaphragmatic, anterior to
the liver, or between the leaves of the mesentery) (Fig. 37.12), or the
retroperitoneum (anterior pararenal space).
The free air may be subtle and consist of only a few air bubbles that can be
best distinguished from intraluminal air and from fat on broad (i.e., lung)
CT window settings.
Although some causes of free air are not surgical emergencies (see pitfalls),
even a small amount of free air should prompt a careful search for other CT
and clinical signs of a serious bowel perforation.
- Extravasated oral contrast material, although not common, is the most specific
sign. Narrow CT windows may help pick up subtle amounts.
- Bowel wall discontinuity is also not common, but obviously very specific.
- Bowel wall enhancement with hyperemia may also occur with injury.
- Shock bowel can occur with severe hypoperfusion, such as with inadequate
fluid resuscitation.
The small bowel wall may be diffusely thickened and enhance more
than normal. The bowel lumen may be dilated with fluid. The colon is
normal however.
A slit-like IVC, small reactively constricted aorta, decreased splenic and
increased renal enhancement are associated findings.
Fluid resuscitation will return the bowel function to normal.
CT Pitfalls in Bowel/Mesenteric Injuries
37
- Some patients may have extraluminal air not caused by a significant bowel
perforation. Sealed-off intestinal microperforations caused by barotrauma also
result in intraperitoneal air, but have no lasting sequela. Dissection of air
from chest into the peritoneal cavity can also occur from a pneumothorax,
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subcutaneous air, chest tubes, or mechanical ventilation. Free air from the female
genital tract or bladder rupture are also possibilities.
- Bowel wall enhancement may be seen in hypoperfused bowel (e.g., shock bowel)
as well as in bowel rupture.
- CT artifacts as elsewhere in the abdomen can mask or create the appearance
of injury.
Renal Trauma
Renal injury is common in blunt abdominal trauma and is often associated
with injuries of the adrenal gland (Fig. 37.13) or other organs. The vast majority
of these are minor injuries that dont need surgery.
Preexisting conditions, such as hypdronephrosis, infection, and poorly protected
horseshoe kidneys, make the kidney susceptible to injury even from minor
trauma.
Clinically, traumatic injury of the urinary tract is rare if there is no hematuria,
no hypotension, and no pelvic fractures.
- Hematuria, even microscopic, is more specific than hypotension in predicting
renal injury.
- Renal pedicle injury, which may have no hematuria, is an important exception.
The most accurate current imaging method to define the extent of renal damage
is by CT. Triple-phase CT scanning increases sensitivity of renal injury
detection:
- The arterial phase of the CT scan can assess the renal artery.
- The nephrographic phase best evaluates renal parenchymal and venous injury.
- Delayed CT images obtained after 2-10 minutes help to rule out urine leak.
CT Findings and Management of Renal Injury

- Fluid from renal injury can consist of the following:
Hemorrhage.
Active arterial extravasation of blood mixed with IV contrast that may be
surrounded by less dense blood clot.
Extravasated urine mixed with contrast material, which will be contiguous
with the urinary collecting system.
Arterial bleed is sometimes difficult to separate from urine as they are both
very dense initially. The delayed scans after 2-10 minutes will show that the
arterial leak gets diluted and less dense after contrast is stopped, but the
urinary leak becomes more dense.
- Renal injury has been placed into categories that correlate to management.
Category I (75-85%) includes renal contusions and small corticomedullary
lacerations that do not communicate with the collecting system. Category I
injuries need only conservative treatment.
- Renal cortical lacerations appear as irregular, linear, hypodense zones, usually extending from the periphery of the renal parenchyma.
- Intrarenal contusions may appear as patchy hypodense zones. A striated
nephrogram, probably from stasis of urine in the blood-filled tubules, similar to the nephrogram of pyelonephritis, and is another appearance of
contusion.
- Subcapsular hematomas may be associated and are superficial crescentic areas that compress and distort the normal contour of the opacified renal
parenchyma. As with subcapsular hematomas in other organs, the capsule
remains intact and contains hemorrhage.
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Trauma Management
Fig. 37.13. Left adrenal gland (A) hematoma. Right kidney (R) global infarct.
37
Category II (10%) refers to renal lacerations that communicate with the collecting system and to fractured kidneys. Associated hemorrhage and urine can
leak into the renal parenchyma and the leaves of the renal fascia as well as into
the anterior pararenal space. Treatment is controversial. Even major cortical
lacerations are sometimes treated with just a ureteral stent.
- Fracture of the kidney (category II) occurs when lacerations connect two
cortical surfaces of the kidney through the hilum. The fractures usually
parallel intravascular tissue planes so they do not injure the major \vessels
(Fig. 37.14)
Category III (5%) refers to shattered kidneys and injuries to the renal vascular
pedicle. As in category II injuries, fluid can leak into the parenchyma and into
the perirenal spaces.
a) A shattered kidney occurs when multiple lacerations traverse the kidney and
fragment it into several pieces. Unlike simple fractures, a shattered kidney
does include injury to the major segmental vessels that usually result in major
blood loss.
b) Renal pedicle injuries include arterial and venous injuries.
- Traumatic renal artery occlusion is caused by deceleration injuries that
stretch the proximal renal arteries to produce intimal tears that thrombose
and produce arterial occlusion. This may have CT findings of renal or
segmental infarction (Figs. 37.13, 37.15, 37.16).
- Traumatic renal vein thrombosis may also occur as a result of deceleration
injury. The CT scan may show an acutely enlarged kidney, persistent
nephrogram on the delayed scans. The actual thrombus in a dilated renal
vein is sometimes discernible.
Category IV refers to ureteropelvic junction (UPJ) disruption and laceration to
the renal pelvis. The CT scan may show:
a) Massive amounts of extravasated urine are seen in the medial rather than
dorsolateral aspect of the perirenal space; absence of renal parenchymal
injury and lack of ureteral opacification are also noted.
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Fig. 37.14. Right kidney fracture with perinephric hematoma and urine extravasation. (arrow)
Fig. 37.15. Segmental infarct of the left kidney. (arrow). Left transverse process
fracture is also noted.
b) Absence of renal parenchymal injury and lack of ureteral opacification.

c) Retrograde ureteropyelography can confirm the disruption of the UPJ.
d) Similar changes may be seen in the rare traumatic ureteral transsection, which
is associated with fluid around the psoas muscle as well.
CT Pitfalls in Renal Trauma Evaluation

- Striated nephrogram may be seen in both infection and contusions.
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Trauma Management
Fig. 37.16. Global infarct of the right kidney due to occluded right renal artery.
(arrow)
- If no delayed images are obtained, collecting system injuries may be missed.

- CT artifacts can cause confusion as elsewhere.
Diaphragm and Lung Bases

The lung bases can be evaluated on the abdominal CT for pneumothoraces,
lung contusions, and rib fractures (Fig. 37.17).
The left hemidiaphragm is more commonly injured because the liver protects the right.
- Hemidiaphragm hematoma is possible (Fig. 37.18).
- Hemidiaphragm rupture is often unrecognized initially, sometimes for years,
unless incidentally picked up on an imaging study, at surgery, or if visceral herniation or strangulation occurs (Fig. 37.19).
Vascular Injury
IVC
Injury to the IVC after blunt trauma is rare, but its evaluation is important to
evaluate fluid replacement.
37
- Assessment of fluid replacement may be made on the basis of the appearance of

the IVC: If it is round and plump, it implies that fluid replacement is adequate.
If it is flat and thin, fluid replacement is not sufficient and it implies impending
shock. This sign of hypovolemia occurs before clinical manifestations of hypotension or tachycardia. This is especially important in the young where BP and pulse
are normal even with massive volume depletion, due to marked vasoconstriction.
- Injury to the IVC is more common in penetrating trauma.
Irregularity of the caval contour may be seen.
Retroperitoneal hemorrhage with the inferior vena cava at its epicenter may
also be seen.
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Fig. 37.17. Left rib fractures with associated lung contusion. (arrow)
Fig. 37.18. Hematoma in the right crus of the diaphragm. (C)
Aorta
As with the IVC, a small-constricted aorta suggests hypovolemia and possible
impending shock.
When aortic trauma is suspected, a single, combined chest-abdomen-pelvis
CT scan with one IV contrast bolus is possible with helical CT. Dissection,
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Trauma Management
Fig. 37.19. Left diaphragmatic rupture with herniation of the stomach into the
hemithorax. Note that the stomach (s) is pressed against the left heart (h) border.
pseudoaneurysm, irregularity of the aortic wall, and periaortic hematoma may

be seen (Fig. 37.20).
Traumatic Pseudoaneurysm
Pseudoaneurysms are eccentric saccular collection of contrast adjacent to the
injured artery that may contain thrombus. These have an eccentric focus of
hyperdensity and surrounding low and heterogeneous density hematoma
(Fig. 37.21).
Bladder Trauma
The bladder may be injured by blunt or penetrating trauma. Bladder injury
occurs most frequently in association to pelvic fractures (Fig. 37.22). Susceptibility to injury directly correlates to the degree of distention.
- Intramural contusions or hematomas may occur from a direct blow.
- Bladder rupture can be of two types.
a) Extraperitoneal rupture (80-90%) may occur as a result of direct injury to
anterior bladder wall by pelvic fracture fragments or from shearing forces at
bladder base.
b) Intraperitoneal rupture (15-20%) usually occurs as a result of a direct blow
to the bladder dome of a full bladder.
37
If the bladder is not filled, its injuries may be missed on CT. The Foley catheter is clamped for at least 5 minutes before the start of scanning. If the bladder is not filled on the original CT, the bladder can be drained, filled with
dilute contrast, and reimaged to obtain a CT cystogram. This is very sensitive
for bladder injuries, and by comparing to the precystogram study, bladder
extravasation can be distinguished from bowel or vascular extravasation.
- If urethral injury is suspected because blood found at the urethral meatus or the
Foley catheter cannot be passed easily into the bladder, the urethra is evaluated
by a retrograde urethrogram, usually before the CT scan.
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Fig. 37.20. Aortic (a) transsection with extensive extravasation.
Fig. 37.21. Traumatic left groin pseudoaneurysm of left femoral artery with brightly
enhancing eccentric focus of contrast and surrounding blood. (arrowheads)
CT Findings of Bladder Trauma

- Intramural hematoma/contusion can appear as focal or diffuse bladder wall
thickening with possibly low-density areas.
- The two types of bladder rupture may be differentiated on CT, which is of
clinical importance because intraperitoneal rupture needs surgery.
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Trauma Management
Fig. 37.22. Bilateral pubic rami fractures (curved arrows) with associated obturator
internus (o) hematomas.
a) In extraperitoneal rupture extravasated urine and contrast is seen in the

perivesicular fat, and it may extend into the perineum, scrotum, thighs,
retrorectal presacral space, and into the anterior abdominal wall. The
potential space in the anterior abdominal wall between transversalis fascia
and parietal peritoneum, extends superiorly in the abdominal wall and
can surround the anterior and lateral portions of the peritoneal cavity.
Fluid in this space may mimic intraperitoneal rupture at CT.
b) In intraperitoneal rupture extravasated urine and contrast material is in the
peritoneal cavity surrounding the bladder and bowel loops, in perirenal
recesses, in pericolic gutters, and in the Pouch of Douglas (Figs. 37.23A, 37.23B)
CT Pitfalls in Bladder Evaluation

- If the bladder is not filled, injury may be missed.
- Patients with urethral injury often cannot have a Foley catheter placed, so bladder
filling may be variable and CT cystography cannot be performed.
- In extraperitoneal rupture, the extravasated fluid can extend into the potential
space in the anterior abdominal wall and mimic intraperitoneal rupture.
References
1.
2.
3.
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4.
5.
Novelline RA, Rhea JT, Bell T. Helical CT of abdominal trauma. Radiologic Clinics
of North America 1999; 37:591-612.
Shuman W. CT of blunt abdominal trauma in adults. Radiology 1997 ;
205:297-306.
Amorosa TA. Evaluation of the patient with blunt abdominal trauma: An evidence
based approach. Emergency Medicine Clinics of North America 1999; 17: 63-75.
Lee JKT, Sagel SS, Stanley RJ et al. Computed body tomography with MRI
correlation. 1998;1298-1341.
Barloon TJ, Weissman AM. Diagnostic imaging in the evaluation of blunt
abdominal trauma. American Family Physician 1996; 54:205-209.
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Fig. 37.23A. Intraperitoneal bladder rupture: KUB
shows extravasation of bladder
contrast.
37
Fig. 37.23B. CT shows contrast in the paracolic gutters. (arrows)
ORTHOPEDIC INJURIES
CHAPTER 1
CHAPTER 38
Extremity Compartment Syndrome

George C. Velmahos and Pantelis Vassiliu
Definition and Mechanisms
Compartment syndrome occurs when the pressure increases within the tissue
surrounded by a tight fascial envelope beyond a critical level necessary to
maintain tissue perfusion. In the vast majority of cases, the increase in pressure is caused by tissue edema or intracompartmental bleeding.
Because the body is a compilation of compartments, the syndrome may occur
literally anywhere, including the extremities or cranial, thoracic, and abdominal cavities.
The extremity compartment syndrome occurs more frequently in the lower
rather than upper extremities and calves rather than thighs.
The most common causes of extremity compartment syndrome are: fractures,
vascular injury, extensive soft tissue contusion, prolonged external pressure,
and burns. However, multiple other less frequent causes may lead to increased
intracompartmental pressures: snake bite, electrocution, intensive exercise,
acute venous obstruction, infiltrated infusion.
Pathophysiology
An initial ischemic insult by any of the above mentioned causes produces cell
damage and increases the capillary permeability. Postischemic swelling occurs
leading to further compression of the intracompartmental tissue and aggravating the cellular ischemia.
During the ischemic phase, the macrophages are primed. Upon reperfusion,
the sudden supply of abundant oxygen to the ischemic tissue leads to formation of oxygen free radicals which are responsible for ongoing cellular damage
and increased fluid leak in the third space with resulting edema.
Although compartment syndrome may not be apparent during the ischemic
phase (as in arterial occlusion), it may rapidly form after reperfusion (as in
reconstitution of arterial blood flow).
The compliance of the fascia progressively decreases as the intracompartmental
pressure increases. Experiments have shown that after a pressure of 20 mmHg,
relatively small increases in intracompartmental volume (bleeding, tissue swelling) cause exponential increases in pressure.
Because at the capillary level the intravascular pressure is 20-30 mmHg, the
elevation of extravascular pressure to these levels may lead to occlusion of
capillaries and tissue ischemia, even if the blood flow is maintained in the
high-pressure system of the main arteries.
The different tissues in the compartment have different levels of tolerance to
pressure. Nerve tissue is the most sensitive to it, shows signs of dysfunction
Trauma Management, edited by Demetrios Demetriades and Juan Asensio.
Pantelis Vassiliu, Division of Trauma/Critical Care, University of Southern California
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Trauma Management
early, and is most unlikely to return to normal function after relatively short
periods of increased pressure.
Anatomy of Extremity Compartments

Lower Extremity:
- Calf (Fig. 38.1): There are four compartments; anterior, lateral, superficial posterior, and deep posterior. The anterior compartment lies between the tibia and
the fibula and contains the anterior tibial artery and deep peroneal nerve, which
innervates all the muscles of the compartment and supplies sensation to the first
web space of the foot. It is the most frequently involved compartment of the
four. The lateral compartment lies over the fibula and contains the superficial
peroneal nerve but no major vessel. The superficial posterior compartment contains the sural nerve. The deep posterior compartment contains the tibioperoneal
arterial trunk and the tibial nerve.
- Thigh: There are three compartments; anterior, posterior and lateral. The
lateral compartment contains the neurovascular bundle and is the least
frequently involved of the three. The sciatic nerve travels through the posterior compartment.
- Gluteal: The three muscles of these compartment (gluteus maximus, medius, and
minimus) are invested by the fascia lata. The sciatic nerve is in this compartment.
Upper Extremity
- Forearm: There are two compartments; volar and dorsal. The volar compartment contains all the flexors of the hand, as well as the ulnar and radial arteries,
and median and ulnar nerves. The dorsal compartment contains the mobile
wad, which may be considered as a separate compartment.
- Arm: There are three compartments; deltoid, anterior or biceps, and posterior
or triceps. The axillary nerve is within the deltoid compartment. The brachial
vessels and musculocutaneous, median, and ulnar nerves are in the anterior
compartment, whereas the radial nerve is in the posterior.
Hand and foot compartments: Infrequently, there is a need to decompress the

hand or foot compartments. There are four hand compartments: central palmar, thenar, hypothenar, and interosseus. Similarly, the foot has four compartments: central, medial, lateral, and interosseous.
Symptoms and Signs

The 6 Ps constitute the hallmark of compartment syndrome: pain, pressure,
paresthesia, paralysis, pulseless, and pallor. The two latter are present only in
late stages. Even in the presence of a fully developed compartment syndrome,
initially there is distal pulse and appropriate color. Pressure stands for the
tactile feeling of a tense compartment. Pain is characteristically out of proportion even in the presence of associated extremity injuries. Stretching the muscles
included in the involved compartment exacerbates the pain. Paresthesia is an
early symptom and needs to be evaluated along the distribution of the involved nerves, whereas paralysis indicates prolonged pressure on the nerve.
Measurement of Pressures
38
Intracompartmental pressures are measured directly by the introduction of a

needle into the compartment, connected to a pressure transducer. The most
frequently used device is the StrykerTM pressure monitor (Stryker Instruments,
Kalamazoo, MI).
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Fig. 38.1. Compartments of the calf with the corresponding nerves.
Although there is no absolute normal or abnormal pressure, experimental animal work and human studies support that pressures less than 20mmHg do
not usually cause major problems in the majority of cases. Pressures above 30
mmHg are considered clearly abnormal, and pressures in the 20 to 30 mmHg
range are in the gray zone.
The diagnosis of compartment syndrome should not be based exclusively on
the measurement of pressures. A correlation of the patients symptoms with
the measured pressures is imperative for correct diagnosis.
When the suspicion of compartment syndrome arises, all the compartments
of the involved extremity should be measured (Fig. 38.2).
Complications of Compartment Syndrome

Local and systemic complications may arise.
Local complications may lead to muscle necrosis and infection (particularly if
the skin integrity has been violated). Necrotic muscle is converted slowly to
anelastic fibrous tissue with development of Volkmans contractures.
Systemic complications are more obvious during the time of reperfusion.
Because accumulated toxic substances are released in the general circulation at
the time of reperfusion, central organs, including the heart, lungs, or kidneys
suffer an acute insult. Death may occur.
Myoglobinuria and renal insufficiency may result due to muscle breakdown.
Acute respiratory and cardiac failure are also possible. The likelihood of significant systemic insults is proportional to the amount of ischemic muscle.
Therefore, reperfusion of compartments which contain large muscles, ischemic
for prolonged periods of time, is associated with a higher incidence of systemic cardiorespiratory abnormalities.
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Trauma Management
Fig. 38.2. Placement of needle for correct measurement of all calf compartments.
Complications associated with the fasciotomy include infection, venous stasis,

inadequate muscle pump function, and disfigurement.
Treatment
38
The treatment of compartment syndrome is immediate pressure release by

opening of the fascial envelope.
Usually, two skin incisions are used for compartment syndrome of the calf
(Fig. 38.3). A lateral incision midway between the tibia and fibula is used to
decompress the anterior and lateral compartments. A medial incision, about 2
finger-breadths medial to the tibia, is used to decompress the superficial and
deep posterior compartments.
A one-incision four-compartment fasciotomy, although more technically challenging, can be used at this level (Fig. 38.4). All four compartments can be
decompressed by a lateral incision, overlying the fibula, by elevating adequate
skin flaps.
One lateral skin incision is usually adequate for compartment syndrome at
the thigh level. The anterior and posterior compartments can be approached
by this incision. In the infrequent occasion that the medial compartment is
involved, an additional medial incision is necessary.
Two skin incisions are used for compartment syndrome at the forearm level.
The volar compartment can be decompressed by a medial S-shaped or straight
incision, and the dorsal by a straight lateral incision.
One medial skin incision across the biceps/triceps groove is adequate to
decompress both the anterior and posterior arm compartments.
Mannitol has osmotic diuretic and oxygen-free-radical-scavenging actions. As
such, it is suggested to be given before reperfusion to protect against systemic
insults. It can also be given as prophylaxis against the development of com-
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Fig. 38.3. Two-incision four-compartment fasciotomy at the calf.
partment syndrome. Due to the possibility of diuresis-associated hypotension, it is only recommended for hemodynamically stable patients.
Closure of Fasciotomies
Closure of the fasciotomy site is desirable as soon as possible to decrease infection rates, improve wound care, and shorten hospital stay. A number of methods
can be used.
Primary skin closure is ideal but not often feasible due to muscle bulging.
The shoelace technique (Fig. 38.5) can bring progressively the wound edges
together by applying gradual tension through a heavy suture or vessel loop
that is threaded through staples placed on the skin edges at the primary operation. The tails of the loops are pulled together on a daily basis, decreasing
gradually the distance between the wound edges.
The SureClosureTM device (manufacturer, city, state) is an alternative method
of progressive primary skin closure. One or multiple devices can be applied
under local anesthesia with good results (Figs. 38.6A and 38.6B).
Skingrafting is frequently required due to excessive muscle bulging and inability to close the skin primarily by any method.
Prophylactic or Therapeutic Fasciotomies

Because delayed diagnosis of compartment syndrome is related to significant
local and systemic complications, many authors recommend prophylactic
fasciotomy for patients who have the following criteria:
- Ischemia longer than 6 hours.
- Combined arterial and venous injuries of the popliteal artery (particularly if
venous ligation is required).
- Extensive soft tissue damage.
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Trauma Management
Fig. 38.4. One-incision four-compartment fasciotomy at the calf.
On the other hand, other authors prefer to avoid doing a procedure that is
associated with short- and long-term morbidity for a disease that is not yet
present. They recommend that fasciotomy be done only for established
compartment syndrome.
We have found that prophylactic fasciotomy increases the risk for local
complications and decreases the incidence of primary wound closure, and
recommend against it.
Pitfalls in the Diagnosis and Treatment of Compartment

Syndrome
The following diagnostic pitfalls must be avoided:
- Failure to suspect the possibility of compartment syndrome development-based
on the type and amount of injuryand follow the patient closely.
- Failure to recognize the importance of pain out of proportion, and attribution
of the severe pain to the existing injuries (remember: a reduced and immobilized fracture should not hurt much after a while).
- Failure to correlate the pressures with clinical signs. Normal or near-normal
pressures do not exclude the possibility of compartment syndrome (particularly
in the presence of hypotension). Monitoring methods have limitations and should
not be exclusively relied upon, if the clinical symptomatology suggests otherwise.
- Failure to examine under casts or wrapping bandages. This is maybe the most
frequent diagnostic pitfall. We recommend that patients who need splints,
casts or covering dressings should have windows opened for frequent
clinical evaluations.
The following therapeutic pitfalls must be avoided:
38
- Inadequate fasciotomies (Fig. 38.7). Subcutaneous fasciotomies are rarely

adequate. Proper long skin incisions are necessary in the majority of occasions.
411
Fig. 38.5. The shoelace technique. The ends of the vessel loops are pulled progressively every day until the skin edges reapproximate.
Fig. 38.6A. Application of SureClosure on a wide fasciotomy wound.
38
412
Trauma Management
Fig. 38.6B. Final result
All involved fascial layers should be opened. The deep posterior compartment is
often inadequately decompressed due to its deep anatomical location.
- Redevelopment of compartment syndrome after skin closure. Close follow-up
is necessary in the hours after primary skin closure, particularly, if closure was
done soon after fasciotomy.
- Although not proven, mannitol should be given before fasciotomy in patients
with stable hemodynamics. We recommend a drip of 1mg/kg mannitol with 40
mEq NaHCO3 in 1000 ml of lactated Ringers solution.
References
1.
2.
3.
4.
5.
6.
7.
38
In: Mubarak SJ, Hargens AR, eds. Compartment Syndromes and Volkmans Contracture. Philadelphia: WB Saunders 1981:1-227.
Perry MO. Compartment syndromes and reperfusion injury. Surg Clin N Am
1988; 68:853.
Mabee JR, Bostwick TL. Pathophysiology and mechanisms of compartment syndrome. Orthop Rev 1993; 22:175.
Velmahos GC, Theodorou D, Demetriades D et al. Complications and nonclosure
rates of fasciotomy for trauma and related risk factors. World J Surg 1997; 21:247.
Blaisdell FW. Is there a reason for controversy regarding fasciotomy? J Vasc Surg
1989; 9:828.
Harris I. Gradual closure of fasciotomy wounds using a vessel loop shoelace. Injury
1993; 24:565.
Almekinders LC. Gradual closure of fasciotomy wounds. Orthop Rev 1991; 20:82.
CHAPTER 1
CHAPTER 39
Penetrating Extremity Injury

Edward Newton
Much experience with penetrating vascular injuries of the extremities has been
gained during military conflicts. The high rate of amputation seen during the
American Civil War has progressively declined as diagnostic and surgical techniques improved to allow successful repair of complex vascular injuries.
In most countries the incidence of penetrating and blunt vascular injury to
the extremities is approximately equal. In the United States, more than 70%
are due to gunshot, shotgun or stab wounds.
Incidence
The incidence of penetrating injury to the extremities increased dramatically
from 1980-1995 when it began to decline, reflecting the pattern of civilian
handgun violence in general.
Almost 90% of these injuries occur in males, the majority younger than 40
years old.
Penetrating wounds of the limbs may be isolated or may occur in the context
of multiple trauma. In many of these cases injuries to other systems may take
precedence in terms of stabilization.
Tissues at risk from penetrating trauma include arteries, veins, nerves, bones,
joints and soft tissues, and any combination of such injuries is possible and
will affect the clinical presentation.
In many cases the diagnosis is immediately apparent as massive bleeding from
the wound occurs. However, in other cases the vascular or peripheral nerve
injury is occult and not immediately apparent on clinical examination.
Conscious patients will complain of local pain at the wound site, particularly
if a fracture is present. Of particular interest is the presence of signs and symptoms of ischemia in the extremity distal to the wound. Hard clinical findings of vascular injury include:
-
Absent or diminished distal pulses

Unexplained hypotension or anemia
Pallor
Pulsatile bleeding
An expanding or pulsatile hematoma
An audible bruit or palpable thrill over the wound

Edward Newton, Department of Emergency Medicine, University of Southern California,
414
Trauma Management
Soft clinical findings are less predictive of vascular injury but should prompt
further investigation. These include:
39
Isolated peripheral nerve deficit

Wound in proximity to a neurovascular bundle
Diminished pulses compared to the unaffected side
Prolonged capillary refill distal to the injury
A nonpulsatile hematoma
Paresthesia, paralysis
Limitations of Physical Examination

Occult injury to nerve or artery is common after penetrating trauma, particularly if the patient is obtunded, intoxicated or otherwise unable to provide
history or cooperate with the neurologic examination.
Reliance on a pulse deficit to signify vascular injury is fraught with danger
because pulses remain palpable in up to 20% of arterial injuries. Occasionally
the pulse may be transmitted through a soft clot or by collateral arterial supply.
Certain injuries are subacute on initial presentation. Arteriovenous fistulas
(AVF) can occur when there is simultaneous injury to adjacent artery and
vein. Although this connection may be present initially, it often matures over
several days before it becomes clinically apparent. Pseudoaneurysm formation
similarly takes time to fully develop and there may be no abnormal findings
on the initial clinical examination.
Pulses may be nonpalpable if the patient is in shock, or is severely hypothermic. Certain patients may have congenitally absent pulses in some anatomic
locations. Pre-existing vascular disease may similarly obliterate pulses so that
comparison to the uninjured limb is essential. A pulse deficit may be due to
constrictive dressings or casts rather than a vascular injury and these should be
removed if a pulse deficit is discovered.
Soft tissue edema associated with trauma progresses over 24-48 hours.
Consequently, signs and symptoms of a compartment syndrome may not be
apparent initially on physical examination. Frequent re-examination is required
in all cases of penetrating limb injury to exclude this complication. Certain
compartments are deep and difficult to palpate.
Because of the need to discover vascular injuries within the limits of warm
ischemic time (approximately six hours) and the limitations of physical examination, in the past many vascular surgeons routinely explored penetrating
wounds. With the advent of angiography, these wounds then underwent routine angiography. The high rate of negative studies has prompted the search
for less invasive but accurate means of detecting vascular injuries.
Angiography performed for proximity wounds results in discovery of an
unsuspected vascular injury in 16% of cases.
Investigations
The exact nature of the investigation of penetrating limb injuries depends on
the degree of hemodynamic stability that the patient achieves. Unstable patients may require immediate surgical intervention without the benefit of any
ancillary investigation.
In stable patients injured extremities are examined by plain radiographs in AP
and lateral projections to detect foreign bodies, fractures, dislocations, air or
415
39
Fig. 39.1A. Gunshot wounds to both lower extremities. Diminished peripheral pulse
and bruit in right leg.
effusion in the joints. The number of intact bullets plus the number of bullet
holes should equal an even number. Missing bullets must be located by serial
radiographs of adjacent anatomic areas. For example, it is not uncommon for
a bullet to penetrate through the upper arm into the chest.
Patients demonstrating hard findings of arterial injury can be taken directly to
the operating room for exploration.
A hand held Doppler unit will often detect peripheral pulses when they are
not palpable. However, the Doppler is subject to the same limitations as palpation of the pulse in terms of false negative and false positive examinations.
In patients with soft findings of vascular injury an Ankle-Brachial Index or
Arterial Pressure Index can be calculated. A standard blood pressure cuff is
inflated on the injured and then the uninjured extremity and a ratio of injured
to uninjured systolic pressure is calculated. A ratio less than 1.0 is considered
abnormal and prompts further investigation by angiography. Lowering the
cutoff to 0.90 increases the specificity but decreases the sensitivity of the test
and misses too many significant injuries.
Angiography is considered the gold standard for detecting arterial injury in an
extremity. Because it is invasive with well-defined complications and requires
mobilization of specialized resources, arteriography is no longer routinely used
for all penetrating extremity trauma even with soft signs of injury. Indications
for arteriography include suspicion of arterial injury based on hard findings of
injury in a stable patient, a positive ABI, or suspicion of an AV fistula or
pseudoaneurysm on physical examination.
Newer ultrasonic modalities for detecting vascular injury have emerged recently
and have replaced more invasive examinations. Color flow Doppler is relatively
portable, noninvasive devices that can detect injuries in both arteries and veins.
416
Trauma Management
39
Fig. 39.1B. Angiography shows a popliteal arteriovenous fistula.
Measurement of compartment pressure is indicated if compartment syndrome

is suspected based on physical examination or symptoms of ischemia. Commercial devices or a standard manometer can be used to measure compartment pressure. Elevation of pressure beyond 30 mm Hg is abnormal and pressures greater than 45 mm Hg or 15 mm Hg less than diastolic blood pressure
require immediate fasciotomy.
Patients with penetrating trauma are managed according to standard field
protocols. Patients who manifest hypotension or who have a potentially serious mechanism of injury are transported expeditiously to a trauma center.
Intravenous lines can be started in uninjured limbs in route to the hospital
and a fluid challenge of 20 cc/kg of crystalloid administered.
Active bleeding is compressed by direct digital pressure and the injured limb
is splinted.
417
Emergency Department Management

Resuscitation is continued according to ATLS principles. If not already established, two large bore peripheral intravenous lines are started in uninjured limbs.
Digital pressure is applied to actively bleeding wounds if accessible. Blind
clamping of arterial bleeding is discouraged because of the risk of causing
damage to adjacent peripheral nerves. Similarly, placement of tourniquets is
discouraged because they result in increased compartment pressure and a higher
incidence of venous thrombosis.
History should be obtained if possible regarding the time and mechanism of
injury, handedness, occupation and avocation, presence of symptoms of neurovascular injury, and any conditions that may predispose the patient to wound
healing complications such as diabetes, AIDS, asplenia, malignancy or
immunosuppression.
Management of the patient with an arterial injury must be expedited so that
reperfusion can take place within the warm ischemia window of six hours. Delay
beyond this time can result in irreversible myonecrosis or ischemic neuropathy.
Wounds that produce severe soft tissue damage, open fracture, joint penetration are treated with prophylactic broad spectrum antibiotics such as cefazolin.
Tetanus vaccination status should be determined and appropriate boosters
administered.
Orthopedic consultation is indicated for patients who have sustained fractures or dislocations.

Operative strategy is dictated by the overall condition of the patient and the
specific injuries identified. Coordination of several specialists may be necessary. Patients who are moribund with acidosis, hypothermia and coagulopathy
may require a damage control operation with temporary vascular shunting
and later definitive repair once resuscitation is completed.
Temporary vascular shunts of synthetic material can restore perfusion to an
extremity while more critical procedures are completed.
The timing of repair is controversial. If time allows, orthopedic repair should
precede vascular repair because of fear that manipulation of bone during orthopedic reduction may disrupt a vascular repair. Fracture reduction also restores the anatomic positions and more clearly indicates the length of graft
required. Internal fixation of fractures can be performed if wounds are minimally contaminated. Otherwise external fixation is used.
When possible, end to end anastamosis of a transected artery is performed if
undue tension on the repair can be avoided. If too large a segment of artery is
damaged, autologous venous grafts are the preferred material for grafting. Appropriate sized saphenous vein grafts are generally used. Alternatively, synthetic grafts can be used in large caliber arteries (above shoulder and above
knee) but these tend to thrombose if used in smaller caliber vessels.
Proximal and distal thrombectomy with a Fogarty catheter should be performed before completing the repair to remove any clots that may have formed
during the procedure. Infusion of a dilute 1:10 solution of heparin can prevent early thrombosis following the repair without causing systemic anticoagulation and bleeding complications.
Adequate wound coverage is essential to prevent infection.
39
418
39
Trauma Management
Fasciotomy is indicated if signs of compartment syndrome occur, if a major

artery or vein is ligated, or if the ischemic time exceeded six hours.
Repair of major venous injuries is controversial. In the past, venous injuries
were simply ligated with relatively little effect on the survival of the patient.
However, postoperative edema, deep venous thrombosis and compartment
syndrome are more common when the vein is ligated rather than repaired
primarily. If the patients condition permits and the vein can be relatively
easily repaired, it should be done. Otherwise the vein can be ligated.
Increasingly percutaneous endovascular techniques have emerged as alternatives
in managing certain vascular injuries. Endovascular placement of a sleeve can
successfully exclude a pseudoaneurysm or AV fistula. Also, silastic beads,
thrombogenic coils or gel clots can be placed under fluoroscopic guidance
to repair these injuries.
Outcomes
Mortality varies tremendously depending on which vessel is involved. High
prehospital mortality rates are seen for subclavian artery and vein injuries,
iliac or femoral vascular injuries. Operative mortality for subclavian injuries
remains approximately 15%. However, the vast majority of patients who survive
to reach the hospital will survive in spite of severe vascular injury. Mortality in
these patients is primarily related to injury to other systems, although occasional
cases of air embolism or postoperative pulmonary embolism may be fatal.
The amputation rate for penetrating injury to the extremities is lower than for
blunt trauma in which severe mangling of bone, nerve and soft tissues usually
determines the need for amputation.
Denervated or flail limbs and those with severe soft tissue injury may
require amputation in spite of a successful vascular repair.
With current vascular repair techniques, the overall amputation rate is
approximately 6% for penetrating extremity wounds.
Postoperative Care
Patients must be followed closely following vascular repair. A reperfusion
injury has been described for the extremities as well as for the brain and other
organs. This phenomenon results in free radical formation, progressive edema
and ultimately, compartment syndrome.
Early thrombosis of the repair is relatively common and approximately 2.5%
of cases require reoperation for thrombosis or leakage of the anastamosis. Pulses
should be examined frequently in the postoperative period and flow can be
assessed periodically with ultrasound or color flow Doppler.
Infection of grafts is relatively common as well and the patient should be
assessed two to three days postoperatively for signs of infection such as fever,
erythema or purulent drainage. Broad spectrum antibiotics are routinely
administered following vascular repair so wounds should be cultured if infection
develops because unusual organisms may be selected.
Deep venous thrombosis (DVT) is common and may be difficult to distinguish
clinically from posttraumatic edema. Doppler studies are accurate in detecting
venous thrombosis. If a DVT occurs, it may be necessary to place a Greenfield
filter in the IVC as systemic anticoagulation may be contraindicated in multiple
trauma patients.
419
Late Complications
Inadequate restoration of blood flow to the extremity is associated with
intermittent claudication This complication is seen with stenosis at the site
of repair or if one of several arteries is ligated e.g., either the ulnar or radial
artery in the forearm.
Development of a pseudoaneurysm may take many weeks and complications
of these injuries are often delayed. Complications occur because of distal
arterial embolization or compression neuropathy as the aneurysm grows.
AV fistula is often missed on initial presentation. Late symptoms of ischemia,
venous engorgement, edema and rarely, high output congestive heart failure
can occur.
Late infections can occur in the vascular graft or in bone. Symptoms of
osteomyelitis include fever, purulent drainage, and pain and they occur in
the vicinity of a fracture site. Septic embolization can occur from an infected
graft. The average delay in presentation of arterial graft infection was 30 months
in one series.
Retention of lead bullets within a synovial joint can result in subsequent lead
toxicity. Consequently, these foreign bodies should be removed.
It has been suggested that repaired arteries manifest accelerated atherosclerosis
leading to late arterial insufficiency.
Injury to peripheral nerves may render the limb useless. There is a 40-fold
increase in suicide among patients with flail upper extremities and depression
is common.
References
1.
2.
3.
4.
5.
Weaver FA, Papanicolaou G, Yellin AE. Difficult peripheral vascular injuries. Surg
Clin North Amer 1996; 76:843-59.
Raskin KB. Acute vascular injuries of the upper extremity. Hand Clin 1993;
9:115-129.
Demetriades D, Chahwan S, Gomez H et al. Penetrating injuries to the subclavian
and axillary vessels. J Am Coll Surg 1999; 188:290-5.
Modrall JG, Weaver FA, Yellin AE. Diagnosis and management of penetrating
vascular trauma and the injured extremity. Emerg Med Clin North Amer 1998;
16:129-144.
Fry WR, Smith S, Sayers DV et al. The success of Duplex ultrasonographic scanning
in the diagnosis of extremity vascular penetrating trauma. Arch Surg 1993;
128:1368-72.
39
CHAPTER 40
Popliteal Vessel Injuries

Michael S. Walsh and John P. Raj
History
Popliteal artery injuries were managed in World War II by ligation of the
vessel and this was associated with an amputation rate of 73%.
With experience in reconstruction and grafting, the amputation rate was
reduced to 32% during the Korean War and 29% in Vietnam.
Incidence
Popliteal artery injuries account for 20% of all battlefield and 5-10% of all
civilian arterial injuries.
The popliteal artery is injured in 6% of all lower limb injuries.
33% of patients with complete knee dislocations sustain popliteal artery injuries.
16% of patients with posterior knee dislocations will have associated arterial
injuries.
Anatomy
The blood supply to the foot and leg (Fig. 40.1) is dependent on the popliteal
artery. The collateral circulation around the knee joint is usually not sufficient
to supply the needs of the leg and the foot.
Fig. 40.1. The popliteal artery and its branches.

Michael S. Walsh, Department of Surgery, The Royal London Hospital, Whitechapel, London
John P. Raj, Department of Surgery, The Royal London Hospital, Whitechapel, London
421
Clinical Features and Investigations

Signs and Symptoms
Clinical signs may be divided into hard signs or soft signs.
- Hard signs signify significant injury to the popliteal vessels and include a cold
ischemic extremity, absent or decreased distal pulses, pulsatile bleeding from
the popliteal fossa, an expanding or pulsatile hematoma and the presence of a
bruit or thrill.
- Soft signs include a nonexpanding hematoma, paraesthesias or paresis and proximity of a wound to the neurovascular bundle.
The presence of peripheral pulses does not always exclude a vascular injury.
Doppler
Doppler ultrasound is a useful adjunct for the assessment of vascular status.
An ankle/brachial pressure index of less than 1.0 in the injured limb is a significant predictor of arterial injury.
The need to use the Doppler to find a pulse suggests there is a significant
vascular injury.
An absent Doppler signal at presentation is a bad prognostic sign.
X-Rays
X-rays may give an indication of a vascular injury if there is a large soft tissue
swelling or if there are fractures, dislocations or foreign bodies around the
knee joint.
Pulse Oximetery
The use of the pulse oximeter to diagnose a vascular injury is limited as patients who are injured may be hypothermic and peripherally vasoconstricted.
Often, even the oximetry may be normal even in the presence of significant
vascular injury.
Duplex Ultrasonography
This is a useful screening tool in patients who have no signs of vascular injury
but have injuries that are in proximity to major vascular structures.
Duplex scanning may diagnose arterial and venous injuries.
The interpretation of duplex scanning is highly operator dependent.
Angiography
Angiography is the gold standard for the diagnosis of vascular injuries and may
be performed in the radiology suite or on-table if the patient is unstable. An
angiogram is indicated in patients with soft signs of vascular surgery.
Intraoperative angiography should be performed if vascular injuries are
suspected proximal or distal to the operative site.
Management
Life threatening injuries are treated first, followed by limb threatening injuries.
Patients with lower extremity injuries may fall into four groups:
- Group I: Patients who are clinically unstable with signs and symptoms of vascular
injury. They will need rapid stabilization and surgery. If required, an on-table
angiogram may be performed.
40
422
Trauma Management
40
Fig. 40.2. Angiogram of a gunshot wound of the popliteal artery.
- Group II: Patients who are clinically stable and have signs and symptoms of
vascular injury. They need an angiogram to determine the extent of the injury
followed by surgery.
- Group III: Patients who are clinically stable with injuries in proximity to vascular structures but have no signs of vascular injury. These patients need a duplex
ultrasound.
- Group IV: These are patients who are stable with no injuries in proximity to
vascular structures and no signs of vascular injuries. These patients should be
treated appropriately for their injuries only.
Immediate Surgery
Patients with hard signs such as a cold ischemic extremity, absent or decreased
pulses, presence of a bruit or thrill, an expanding or pulsatile hematoma or pulsatile bleeding should be taken to theatre as soon as possible for exploration. If
required, an on-table angiogram should be performed. This is especially useful
when injuries at multiple levels are suspected.
Damage Control Surgery

This technique should be considered in patients with complex injuries who
are likely to develop severe physiological derangement or will need transfer.
The immediately life threatening injuries should be treated first and the patient
stabilized before proceeding to definitive vascular repair. Damage control
consists of inserting a shunt to re-establish leg perfusion until the patient is fit
for definitive repair.
Shunts should also be inserted if it is anticipated that associated orthopedic
repairs will take a prolonged time.
423
Surgical Procedure
The incision depends on where the injury is: for above knee injuries, a medial
thigh incision is best; for below knee injuries a lower leg incision medially is
performed.
Obtain proximal and distal control first either with slings or vascular clamps.
Inspect and debride damaged tissue. Remove intraluminal thrombus proximally
and distally using a Fogarty catheter.
On-table angiography should be used liberally in order to identify any thrombus
not easily accessible to the first passage of the catheter and to identify other
injuries.
Flush with heparinized saline.
The actual repair depends on the nature of injury.
Crural Vessels
Injuries to the crural vessels frequently coexist with popliteal vessel injuries. If
an injury to the crural vessels is overlooked then the popliteal repair is
unlikely to result in limb salvage.
If popliteal vessel injuries extend to involve the crural vessels, then the incision
can be extended distally on the medial side of the leg. The medial attachments of
soleus can be taken down to expose the trifurcation of the popliteal artery.
If possible, at least two of the crural vessels should be repaired.
Vascular Repair
Vascular repair of the popliteal vessels is technically demanding and requires
careful attention to detail.
Simple lateral suture is the method of choice for closing simple transverse
lacerations. Use an interrupted 5/0 or 6/0 vascular suture.
Vein patch angioplasty is the method of choice for closing lacerations if there
is a risk of narrowing the vessel. A suitable piece of vein can be harvested from
nearby subcutaneous tissue. Trim the patch to size with gentle curves at each
end and to such a width so that, when sutured in place it does not lead to
narrowing or undue bulging of the popliteal artery. Use a continuous suture
method, making sure that all layers of the vessel wall are taken and placing the
sutures close together.
In the case of a transection, an end-to-end anastomosis may to be performed.
Trim off the damaged artery and cut the ends of the vessel obliquely to reduce
the risk of stenosis. Ensure that the vessel ends can be approximated without
undue tension.
If the vessel ends cannot be approximated without tension, then an interposition graft should be placed. This should normally consist of the long saphenous
vein. The vein should be harvested from the groin rather than the ankle since
it is stronger and subsequent aneurysmal dilatation is less likely.
Bypass procedures should be considered with complex vascular injuries or
when contaminated wounds or large amounts of soft tissue loss mean that an
extraanatomical bypass is required to ensure graft cover, avoid graft infection
and maintain the circulation.
Ideally a completion angiogram should be performed to ensure that the
anastomosis and the distal run-off are satisfactory.
40
424
Trauma Management
Popliteal Vein Injury
40
Venous injuries should be repaired before repair of the artery.

The popliteal vein should be repaired using the same techniques of control
and repair outlined above.
Veins are not only more friable than arteries but they may also bleed
more extensively since they have little medial muscle and spasm is less likely to
occur.
Associated Orthopedic Injuries

The limb should be stabilized orthopedically before proceeding to vascular
repair. This ensures that subsequent manipulation of the limb does not compromise the vascular repair.
If the orthopedic procedures are likely to be prolonged, temporary shunts to
maintain perfusion of the limb should be inserted.
Vascular injuries should be ruled out before a tourniquet is applied to an
injured limb.
Fasciotomy
Fasciotomies may be required to relieve compartment pressures following
reperfusion injury. Patients may lose entire muscle compartments as a result
of ischemia following increased compartment pressures.
Fasciotomies are indicated prophylactically when the ischemic time is greater
than 6 hours, following combined artery and vein injury, when there has
been a complex reconstruction or when there is severe soft tissue injury.
They are also indicated when the popliteal vein is ligated.
A four-compartment fasciotomy to relieve all the compartments in the leg
must be done, leaving the wounds open.
If a fasciotomy is not performed for any vascular injury, then compartment
pressures should be measured. Fasciotomy should be performed if pressures of
greater than 30 mm Hg are recorded.
A-V Fistulae
AV fistulae are seen in about 6% of penetrating injuries around the knee.

Clinical features include a palpable thrill or a pulsatile mass.
Surgical treatment gives excellent results.
The interposition of a small muscle pedicle between artery and vein at the
time of repair will reduce the incidence of recurrence.
Pseudoaneurysms
May be seen even after seemingly trivial trauma to the popliteal region, they
are seen in both blunt and penetrating trauma
Iatrogenic Injuries
They occur as a complication of angioplasty and high tibial osteotomy,
arthroscopic surgery, and total knee arthroplasty.
Results
The limb salvage rate after reconstruction following penetrating injuries
is about 72%.
425
Results are good if there is no delay in operation (< 15 hours after injury),
liberal use of four-compartment fasciotomies, and aggressive management of
the soft tissue injury.
Injuries involving the trifurcation are associated with a very high amputation
rate.
Vascular injuries after explosions are associated with a worse prognosis.
Amputation is required in the presence of irreversible ischemia or extensive
tissue damage such as that sustained in severe crush injury.
Amputation may also be needed after extensive nerve damage.
Delay in resuscitation and definitive treatment may increase the risk for
amputation.
Involvement of more than two long bone fractures is predictive of amputation.
Amputation rates following blunt injury ranges from 36-54% in different series.
Patients with no pulse or Doppler signals at presentation are more likely to
require amputations.
Patients with major soft tissue injury and shock are also more likely to require
amputations.

Not being aware that the popliteal vessels can be injured in any injury involving
the knee joint.
Not recognizing the clinical features of a vascular injury.
Failure to realize that crural vessels may also be involved.
Not performing a thrombectomy at the time of an arterial repair.
Failure to recognize a compartment syndrome if a fasciotomy is not performed!
References
1.
2.
3.
4.
5.
Ordog GJ, Balasubramaniam S, WasserbergerJ et al. Extremity gunshot wounds:

Part oneidentification and treatment of patients at high risk of vascular injury. J
Trauma 1994; 36(3):358-368.
Snyder WH. Popliteal and shank arterial injury. Surg Clin North Amer 1988;
68(4):787-807.
Weaver FA, Papanicolau G, Yellin AE. Difficult peripheral vascular injuries. Surg
Clin North Amer 1996; 76(4):843-859.
Martin LC, McKenny MG, Sosa JL et al. Management of lower extremity arterial
trauma. J Trauma 1994; 37(4):591-599.
Merrill KD. Knee dislocations with vascular injuries. Orthopedic Clin North Amer
1994; 25(4):707-713.
40
CHAPTER 41
Hand Trauma
Christopher Shean and Stephen Schnall
Introduction
Evaluation of hand trauma requires a systematic approach. Adherence to
principles and guidelines allows for optimal treatment.
History
A detailed history must be obtained and include:
-
Age
Occupation
Hand dominance
Mechanism of injury
Time elapsed since injury
Presence of systemic diseases
Tetanus prophylaxis
Allergies
Alcohol, tobacco, and substance abuse
Previous hand injuries
The importance of thorough history taking cannot be overemphasized.

Decision-making in hand surgery is performed only after evaluating the
entire patient situation. Treatment plans for similar injuries will vary depending
on factors such as age and occupation.
Many reconstruction and microsurgical operations are ill-advised in patients
that smoke cigarettes or have systemic diseases effecting their blood vessels.
Physical Examination
Observation is paramount; one should always attempt to compare to the
uninjured side. There is absolutely no need to poke in the wounds to make
a diagnosis. In fact, examination for most tendon and nerve injuries may be
performed with the wound covered. Important findings of a hand examination may include:
-
Swellingmay indicate fracture or ligament injury

Discolorationvascular status
DeformityFracture or dislocation
Break in the normal cascade of the fingers Normally at rest, the fingers of the
hand are in gentle flexion with progression to more flexion from index to little
finger. With tendon disruption, this normal cascade will be altered (Fig. 41.1).
- Location and nature of the wounds clean, contaminated, or infected

Christopher Shean, LAC + USC Medical Center, Los Agneles, California, U.S.A.
Stephen Schnall, LAC + USC Medical Center, Los Agneles, California, U.S.A.
Hand Trauma
427
41
Fig. 41.1. Hand posture of patient with flexor tendons to long finger lacerated.
Note the loss of normal cascade of the fingers witht he long finger held in extension.
Anatomically-Based Hand Examination

- The anatomy of the hand is highly specialized and refined for both intricate
movements and strong grip. The fingertips are composed of skin that has great
sensitivity. Injuries to structures within the hand can be diagnosed using a sequential exam based on knowledge of hand anatomy.
- The framework of an anatomically-based hand examination can be organized
into stepwise assessment of specific systems. A summary of this framework is as
follows:
Muscles
Muscles that move the hand and fingers can be divided into extrinsic and
intrinsic muscles groups, depending on whether the muscles originate in the
forearm or the hand.
Extrinsic hand muscles originate in the forearm and insert in the hand. This
group of muscles can be further subdivided into flexor and extensor muscle
groups. Extrinsic flexor muscles originate in the volar forearm and flex the
wrist and fingers. Extrinsic extensor muscles originate in the dorsal forearm
and extend the wrist and fingers.
Intrinsic hand muscles originate and insert in the hand.
The intrinsic muscles of the hand include the thenar muscle group, the
hypothenar muscle group, the adductor pollicis muscle, the lumbricals and
the interosseous muscles.
- Lumbricals and interosseous musclesthese two muscle groups merit special
attention due to the complexity of their actions. The lumbrical muscles originate
on each flexor digitorum profundus tendon and insert at the radial aspect of the
extensor apparatus of the corresponding digit. Because the lumbrical tendon
passes volar to the axis of rotation of the metacarpophalangeal (MCP) joints, it
serves as a flexor of this joint. However, because the action of the lumbrical muscle
428
41
Trauma Management
is also mediated by the extensor apparatus distal to the MCP joint, the lumbricals
serve to extend the proximal and distal interphalangeal joints.
- The interosseous muscles originate from the metacarpal shafts and exist in two
groups. The dorsal interossei insert on the extensor apparatus of their corresponding fingers to abduct the fingers from the axial line (i.e., the third finger). The
palmar interossei insert on the extensor apparatus of their corresponding fingers
to adduct the fingers toward the axial line. In addition, both dorsal and palmar
interossei assist the lumbricals in flexion of the MCP joints and extension of the
PIP and DIP joints.
Nerves
The median nerve delivers motor fibers to the pronator teres, flexor carpi
radialis, flexor digitorum sublimis, palmaris longus, flexor digitorum profundus
to the index and long fingers, flexor pollicis longus, and the pronator quadratus
in the forearm. The anterior interosseous branch of the median nerve carries
the motor fibers to the latter three muscles. The median nerve then continues
into the hand, passing under the transverse carpal ligament to innervate the
thenar muscles and the radial two lumbrical muscles. The recurrent motor
branch of the median nerve carries the fibers to the thenar group.
The ulnar nerve delivers motor fiber to the flexor carpi ulnaris and flexor
digitorum profundus to the ring and small fingers in the forearm. The ulnar
nerve then continues into the hand, passing through the ulnar tunnel or Guyons
canal to innervate the hypothenar muscle group, the ulnar two lumbricals,
each of the interossei muscles, the adductor pollicis, and the deep head of the
flexor pollicis brevis.
The radial nerve delivers motor fibers to every extrinsic extensor muscle in the
forearm. It then continues onto the hand where it carries only sensory fibers
and supplies no muscles with motor fibers.
The sensory distribution of the median, ulnar, and radial nerves in the hand
are displayed in Figure 41.2. It can be seen that median nerve can be reliably
evaluated by testing the sensation to the pulp of the index finger; the ulnar
nerve by testing the pulp of the small finger; and the radial nerve by testing
the dorsum of the first web space.
Examining sensation to the hand in a child with an injured hand can sometimes
be difficult. In these situations, testing for sensation is more effectively performed
by checking for light touch with a piece of tissue rather than with sharp/dull
testing by pinprick. An additional method is to submerge the injured hand in
water until wrinkling occurs. Since wrinkling of the skin is mediated by the
autonomic fibers carried in the sensory nerves, abnormal wrinkling response
(i.e., absence of wrinkling) is diagnostic.
Circulation
The hand usually has abundant collateral circulation and redundancy in its
vascular supply. The radial and ulnar arteries anastomose with each other via
the superficial and deep palmar arches and give rise to the digital arteries.
However, there is extensive variation in the distribution of the radial and ulnar
arteries. For this reason, the Allens test is helpful in assessing for situations in
which one artery has dominance.
- The Allens test is performed by compressing both arteries at the wrist, squeezing
the hand to exsanguinate the fingers, then releasing one of the arteries to evaluate
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41
Fig. 41.2. The sensory distribution of the median, ulnar and radial nerves in the hand.
the filling time to the digits by that artery. Normal refill occurs in less than five
seconds. Occasionally, the refill of one of the arteries will be delayed and thus
diagnosing a situation in which one artery has dominance. In such situations,
injury to one artery can compromise circulation to several digits.
- Capillary refill can also be used to evaluate circulation to the hand by compressing the nailbed to cause blanching of its underlying capillary bed. The compression is then released and the time for the bed to refill is assessed. Normal refill
occurs in one to two seconds. Delayed refill may indicate a situation in which
arterial insufficiency exists. Brisk refill, however, may indicate a situation in
which vascular congestion exists.
Hand Exam Maneuvers

Tinels Sign: Tapping over the median nerve at the wrist in a patient with
carpal tunnel syndrome may produce tingling paresthesias in the median nerve
sensory distribution.
- Tinels testing can also be used to assess regeneration of axons after nerve injury.
When the growing ends of a regenerating nerve are tapped, a similar tingling
paresthesia can be elicited in that nerves sensory distribution. Thus, recovery
after nerve injury or repair can be assessed. However Tinels testing gives no
indication of the quality and quantity of eventual nerve recovery
Phalens Test: Wrist flexion increases the pressure on the median nerve. In
patients with carpal tunnel syndrome, wrist flexion may produce paresthesias
in the fingers rather rapidly. Phalens test is a one-minute wrist flexion test
used to help diagnose carpal tunnel syndrome. It is helpful to perform the test
on both wrists at same time for comparison. However, since carpal tunnel
syndrome commonly affects both wrists in a single patient, a timed Phalens
test may prove more helpful. Paresthesias induced by less than 60 seconds of
wrist flexion are suggestive of the diagnosis.
Extrinsic Muscle Tightness: When the extensor tendons become adherent or
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Trauma Management
scarred down over the wrist or forearm, the tendons may limit flexion of the
fingers. This situation can be diagnosed by testing PIP joint flexion, with
varying degrees of MCP joint flexion. In a patient with extrinsic muscle tightness, PIP joint flexion is present when the MCP joint is held in extension.
However, when the MCP joint is held in flexion, PIP joint flexion will be
limited.
Intrinsic Muscle Tightness: When the intrinsic muscles of the hand become
scarred or fibrotic, their excursion and extensibility become limited. This can
lead to characteristic findings on hand examination. The intrinsic muscles, as
discussed previously, function to flex at the MCP joints and extend at the PIP
and DIP joint. When the intrinsics are scarred and shortened, the PIP joints
can be passively flexed with the MCP joints held in flexion. However, passive
PIP joint flexion is limited with the MCP joints held in extension.
Quadriga Syndrome: The tendons of the flexor digitorum profundus originate from a common muscle belly. Therefore any change in the length of one
FDP tendon affects the function of the others. Quadriga syndrome occurs
when one FDP tendon is shortened with respect to the other tendons. This
syndrome may arise in many situations. One example is after avulsion of the
FDP tendon from its insertion into the distal phalanx. If during repair of this
injury, the tendon requires advancement for secure fixation into the distal
phalanx base, then that tendon will be shortened relative to the other tendons.
Examination will reveal a flexion deficit of the uninjured digits, which have
normal passive range of motion.
Tenodesis: The posture of the relaxed hand is determined by the tenodesis
effect. The tenodesis effect dictates that a balance of the resting tone of the
flexor and extensor muscles produces the posture of the joints in the hand.
With the wrist slightly flexed, the relaxed fingers and thumb are normally
held in extension. With progressive extension at the wrist, the fingers and
thumb will normally assume a more flexed posture. The tenodesis effect is
helpful in the uncooperative patient, because injuries to the hand that disrupt
the balance between the flexors and extensors, (for example, a flexor tendon
laceration) will produce discernible changes in hand and finger posture.
Management
All injured hands should be radiographed to rule out foreign bodies, fractures,
and dislocations. Comparison x-rays of the uninjured hand can be helpful. A
minimum of three views should be taken: AP, lateral, and oblique. As radiographs are two dimensional representations of three dimensional objects, the
presence and location of foreign bodies, fractures or dislocations might be
overlooked if an adequate x-ray series is not obtained.
Dressings if applied should be bulky and nonconstricting. It is extremely important to try to avoid circumferential bandages that might become constricting with posttraumatic swelling.
Appropriate splinting of the injured hand is necessary for patient comfort and
to prevent contractures. Generally, the hand is held in the safe position with
the metacarpophalangeal joints flexed to approximately 45-60, and the proximal and distal interphalangeal joints extended to neutral.
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431
Lacerations
The size of a laceration is not related to the amount of damaged structures
underlying the skin. Every flexor tendon crossing the wrist may be transected
through a skin laceration less than one centimeter in length.
- The practice of probing a laceration in search of injured structures is no longer
necessary. One may wonder if lacerations should be explored to clamp bleeding
vessels. This practice, also, should be abolished. Nearly all lacerated vessels will
coagulate and cease bleeding after the sustained application of direct pressure.
Flexor tendon lacerations occur with penetrating injuries to the volar aspect
of the hand and forearm. The posture of the hand and fingers at the time of
injury will effect the relationship of the skin laceration to the tendon laceration.
That is, if the fingers are flexed at the time of injury, as they would be if a
person were grabbing a knife, then the distal flexor tendon stump will be
found distal to the skin laceration.
- Flexor tendon injuries have been classified into zones I to V, which have
prognostic significance. These zones are as follows:
Zone Idistal to the insertion of the flexor digitorum sublimis (FDS) tendon
Zone II (no-mans land)from the distal palmar crease to the insertion of
the FDS tendon, this is the zone in which the tendons traverse a fibroosseous
tunnel
Zone IIIthe region from the origin of the lumbrical muscles to the
beginning of the fibroosseous tunnel, that is from the distal aspect of the
transverse carpal ligament to the distal palmar crease
Zone IVthe region of the carpal canal
Zone Vproximal to the wrist
- Controversies exist related to nearly every aspect of flexor tendon surgery.
Research suggests that strength of a tendon repair is related to the size of the
suture used and the number of suture strands that cross the repair site. However,
with increasing suture size and strands across the repair site, there is increased
resistance to tendon gliding. An ideal tendon repair would be strong enough to
permit early active motion, without adverse effects on the tendon passage through
the fibroosseous tunnel. The importance of postoperative rehabilitation after
tendon repairs cannot be overemphasized. Early active motion has beneficial
effects on tendon healing. However, there is a significant risk of repair site rupture
with many repair types and early active motion. For that reason, most protocols
include early passive motion or dynamic splinting. Research toward developing
an ideal repair pattern continues.
Treatment principles for extensor tendon injuries are similar to those for flexor
tendon injuries. The importance of postoperative rehabilitation is again
paramount. However, the thickness of extensor tendons is less and no
fibrosseous tunnel exists on the dorsum of the hand. The unique anatomy of
the extensor apparatus and its insertions on the phalanges can be disrupted in
locations that lead to specific finger deformities if not addressed early after
injury. Examples of these finger deformities include mallet finger and
the boutonniere and swan neck deformities.
- Mallet fingers occur after rupture of the terminal extensor tendon insertion into
the distal phalanx. This usually occurs after a sudden blow to the tip of the
extended finger. Clinically, the distal phalanx droops into flexion and there is loss
of active extension at the DIP joint. Radiographs must be obtained because at
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Trauma Management
times the tendon avulses from its insertion with fragment of bone. Occasionally,
the size of the avulsed fragment and degree of injury to the dorsal joint supporting
structures leads to subluxation of the DIP joint. This is one generally agreed
upon indication for operative repair. The results of closed treatment of mallet
fingers without subluxation at the DIP joint is superior to operative treatment.
- Flexion of the PIP joint and DIP joint hyperextension characterize boutonniere
deformity. It results from the volar subluxation of the lateral bands usually
following unrecognized central slip rupture from the base of the middle
phalanx. Early diagnosis of central slip ruptures is important in avoiding this
deformity. Clinically, a patient with acute disruption of the central slip will
present with a swollen PIP joint and tenderness at the central slip insertion site.
If unrecognized, boutonniere deformity can result. Treatment of flexible
boutonniere deformities is with prolonged splintage. Established boutonniere
deformities with joint contractures require complex reconstructive procedures
and intensive postoperative rehabilitation.
- PIP joint hyperextension and DIP joint flexion characterize swan neck deformity.
It results from the dorsal subluxation of the lateral bands usually following
rupture of the FDS tendon insertion or injury to the volar plate of the PIP
joint. It can, however, develop after chronic mallet finger deformity.
Amputation and Replantation

With the advancement of microsurgical techniques and instruments, successful
replantation of amputated digits has become almost routine. Many determinants effect the outcome of replant surgery. Mechanism of amputation
(i.e., clean laceration vs. avulsion injury), time elapsed since injury, care of
amputated part, patient factors such as cigarette smoking and systemic disease,
and age of the patient are among the many possible variables which may alter
prognosis. Because of this complexity, controversy exists regarding the
indications for replantation.
- Generally accepted indications include amputations through the hand and wrist,
thumb amputations (Fig. 41.3), multiple-digit amputations, and amputations
in children.
- Contraindications to replantation include single border digit amputations,
avulsion or crush injuries, amputations through zone II, prolonged warm
ischemia time (> 12 hours for digits and > 6 hours for more proximal sites),
multiple-level amputations, prior impaired hand or digital function, and extreme
contamination. In general with each contraindication, functional results after
replant are worse than the function obtained if a revision and closure of the
amputated part had been performed primarily.
When replantation is indicated, several factors are important to a successful

result. Appropriate care of the amputated part is essential. The detached part
should be wrapped in saline dressings, cooled in a container placed on ice, and
transported to the hospital with the patient. Once at the hospital, radiographs of
both the residual limb and the amputated par t should be
obtained to assess damage to the bones and joints and to survey for possible
retained foreign matter.
In general, the sequence of replant surgery follows an order of stabilizing the
skeletal structures, repairing lacerated tendons, then performing microsurgical
repair or reconstruction of the vessels then nerves.
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41
Fig. 41.3. Replantation of thumb amputation. A and B) clinical photographs of the

amputated thumb, C and D) photographs of the successfuly replanted thumb.
Hand Fractures and Dislocations

In general, most hand fractures and dislocations can be reduced by closed
means. It is only when they cannot, that open reduction is indicated. Similarly, most hand fractures and dislocations can be held by external means until
stable and healed enough to be left unsupported. It is only when the fractures
are unstable by closed means, that percutaneous pin fixation or internal fixation is indicated.
A glossary of common hand fractures and dislocations follows:
PIP Joint Dislocations: Dorsal dislocations of the PIP joint are the most frequently encountered articular injury in the hand. Most are easily reducible
and stable after reduction. These can be managed with early mobilization in a
splint that blocks the final 20 of extension. Unstable joints must be protected
in a position of flexion to prevent redislocation. Occasionally, the volar plate of
the PIP joint can become interposed in the joint and block closed reduction.
Phalangeal and Metacarpal Shaft Fractures: As mentioned above, the majority
of hand fractures is best treated with closed management. Indications for operative management include:
- failure of closed reduction to maintain length and/or rotational or angular
alignment
- displaced intraarticular fractures in which joint congruity is lost
- unstable fractures with soft-tissue injuries which prevent normal rehabilitation
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Trauma Management
MCP Joint Dislocations: These dislocations can be simple or complex. Simple

MCP joint dislocations usually present with a history of marked hyperextension at the joint that was easily reduced. If not, simple dislocations are readily
reduced in the emergency room and managed with buddy tapping and early
motion. Complex dislocations involve a much greater soft tissue injury. The
angle of hyperextension is much less and the metacarpal head may be prominent in the palm. The displaced metacarpal head may become trapped volarly
between the FDP tendon and the lumbrical muscle. Because of this fact, these
dislocations often require open reduction.
Boxers Fractures: Fractures of the fifth metacarpal neck resulting from an
axial load to the metacarpal head are termed boxers fractures. There are a
variety of treatment protocols for this common fracture ranging for immediate mobilization to closed reduction and cast immobilization. Angular deformity up to 70 has been found to have minimal functional sequelae. However, no rotational malalignment is acceptable. It is also important to ensure
that the skin over the knuckle is intact. If it is not, the wound is presumed to
be the result of contact with a tooth while punching, and requires operative
irrigation and debridement to avoid infection.
CMC Fracture-Dislocations: Fractures at the CMC joints of the hand typically
occur to the fourth and fifth CMC joints as a result of these joints relative
mobility. The fifth CMC joint is additionally destabilized after injury by the
proximal pull of the ECU tendon. It is important to recognize the dislocation
component of this injury to avoid long-term dislocation. These injuries are
generally reduced without difficulty, however are unstable after reduction.
For this reason, closed reduction and percutaneous pinning of CMC fracturedislocations is advised.
Gamekeepers Thumb: A complete tear of the ulnar collateral ligament of the
thumb MCP joint is called gamekeepers thumb. It results from a
hyperabduction stress to the thumb. It is important to recognize whether or
not the rupture of the collateral ligament is complete. Incomplete injuries can
be treated nonsurgically. However, with complete tears of the ligament, the
adductor pollicis aponeurosis and extensor hood of the thumb can become
interposed between the torn ligament and its area of attachment. Complete
tears will, thus, not heal without surgery. A complete tear of the ligament is
presumed if there is greater than 40 of instability of the MCP joint with a
radially directed stress applied to the joint held in 30 of flexion.
Bennetts and Rolandos Fractures: An oblique, intraarticular fracture of the
base of the thumb metacarpal is called a Bennetts fracture. A comminuted
fracture at the base of the thumb is a Rolandos fracture. In both, the first
metacarpal dislocates dorsally and proximally due to the action of the abductor pollicis longus. These can be treated by closed means, however often fixation is required to hold the metacarpal reduced while the injury heals.
Scaphoid Fractures: The most commonly fractured bone in the wrist is the
scaphoid. Clinically, patients with scaphoid fractures present with tenderness
in the anatomic snuffbox, just distal to the radial styloid. Often radiographs at
the time of injury do not reveal a fracture. In this circumstance, the wrist
should be immobilized in a spica cast and repeat radiograph can be taken after
10-14 days. Resorption at the fracture site should permit identification of the
fracture if present. Radionuclide scanning can be used to confirm diagnosis of
Hand Trauma
435
scaphoid fracture as early as 24 hours after injury. Scaphoid fractures are managed with 10-12 weeks of spica cast immobilization if nondisplaced. Displaced fractures require open reduction.
Soft Tissue Coverage

Many injuries to the hand are accompanied with soft tissue loss, which can
vary from small and insignificant to large requiring reconstructive techniques
to obtain coverage. To effectively manage hand trauma, a collection of various
coverage procedures should be utilized as indicated.
Split and full thickness skin grafts are commonly employed and have distinct
advantages and disadvantages. A split thickness graft that includes the epidermis and a portion of the dermis is advantageous because it readily takes. However, it is associated with increased contraction, which can lead to deformity
and is less durable. Full thickness skin grafts take less well than split thickness
because of its increased thickness. These grafts, however, are more durable and
contract less. Full thickness grafts are well suited for coverage about joints,
where skin excursion demands are greater.
- A variety of flaps have been described based on the abundant vascular supply of
the hand. If circumstances will not permit coverage by a local hand flap, a
reversed pedicle flap based on the radial artery in the forearm (Fig. 41.4) is
readily available for coverage on the hand. If required, tissue from distant locations such as groin flaps and free tissue transfers may be used to cover soft tissue
deficits of the hand. The objective of obtaining adequate soft tissue coverage
during reconstructive procedures of the hand cannot be overemphasized.
References
1.
2.
3.
4.
Green DP, Hotchkiss RN. Operative Hand Surgery. 3rd ed. Churchill Livingston.
1993.
The Hand, examination and diagnosis / American Society for Surgery of the Hand.
3rd ed. Churchill Livingston. 1990.
Hand Surgery Update / American Society for Surgery of the Hand. American
Academy of Orthopedic Surgery. 1996.
Lister G. The Hand: Diagnosis and Indications. 3rd ed. Churchill Livingston. 1993.
41
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Trauma Management
41
Fig. 41.4. Radial forearm flap. A) Clinical photograph during the elevation of the
forearm flap. B) shows elevated flap and soft tissue defect to be covered on dorsum
of hand, C) photograph taken after placement of the flap on dorsum of hand
CHAPTER 1
CHAPTER 42
Long Bone Fractures and the General

Surgeon
Jackson Lee
Patients who are involved in blunt force trauma frequently sustain concomitant injuries to the axial skeleton. It is important to understand some of the
considerations involved in the diagnosis and management of fractures of the
long bones so as to allow for cooperative care of these injures in order to
maximize patient outcome.
Recent advances in the care of the multiply injured patient have greatly
improved the mortality rate. Survival, however, should not be considered the
final goal in the care of the injured patient. The goal of any well-organized
trauma service should not be focused on just saving lives, but on restoring the
injured person back as a functioning member of society. An understanding of
the considerations for the management of long bone fractures will greatly
facilitate this final goal.
Long Bone Fractures as a Result of Blunt Force Trauma

The presence of long bone fractures in a multiply injured patient is a reflection
of the energy expenditure that the patient has been subjected to. The magnitude
of this energy expenditure has systemic effects that are still being elucidated.
Recently, there has been considerable interest in the effects on the inflammatory
system and its role in pulmonary failure and multi-system organ failure.
It is important to distinguish whether the patient with long bone fractures has
sustained this as an isolated injury or in association with other organ system
injury. The amount of energy expenditure that is required to sustain a long
bone fracture frequently will lead to occult injures to other organ systems.
Initial Evaluation
The initial evaluation and resuscitative efforts should always be focused on
the A,B,Cs.
The initial skeletal evaluation should be focused on determining which
extremities are injured so those appropriate radiographs can be obtained at
the time of secondary survey. A careful documentation of the neurovascular
status should be performed at this time. Frequently, this is the only window of
opportunity to obtain such important information since in many cases the
patient will subsequently be intubated or at the minimal, sedated. Size and
quality of open wounds should be well documented and at this time they
should be superficially irrigated and dressed with sterile dressings to prevent
further contamination. Finally, the injured extremity should be splinted to
prevent further injury to soft tissues and neurovascular structures.
Jackson Lee, University of Southern California School of Medicine,
LAC + USC Medical Center, Los Angeles, California, U.S.A.
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Trauma Management
Once the primary survey has been completed and initial resuscitation has
been well underway, the anatomic diagnosis of the long bone fractures should
proceed. This is accomplished with plain orthogonal projections of the affected
limbs. Radiographs should always be obtained using an AP and a lateral film
since films are a two dimensional representation of a three-dimensional object.
Acceptable extremity films should always include the joint above and joint
below. With these films, the lesion can be adequately characterized. In certain
instances where the patient is in extremis and requires immediate life preserving
operative intervention, such as an immediate thoracotomy, laparotomy, or
craniotomy, radiographic diagnosis may be delayed and subsequently obtained
in the surgical suite at the completion of the emergent procedure. It is important
to obtain an anatomic diagnosis of the long bone fractures early in the
peri-injury period to facilitate appropriate decision making.
Management
The multiply injured patient will benefit from early stabilization of long bone
fractures. Depending upon the patients clinical condition however, this initial
stabilization may or may not necessarily be the definitive stabilization.
The advantages of early stabilization have been well documented. Early
stabilization facilitates patient mobilization and simplifies nursing care. By
minimizing the need for the patient to be in the forced supine position,
pulmonary shunting will be decreased. From the point of view of the injury,
there will be a decrease in the bleeding from fracture and soft tissues at the
zone of injury, and a decrease in the pain thus decreasing the need for respiratory
depressing opiates in the peri-injury period. Systemically, there would be a
decrease in the local and systemic inflammatory response.
The decision to perform temporary or definitive stabilization should be made
jointly with the general surgeon, neurosurgeon and orthopedic surgeon and
should be made in real-time and based on the patients physiology.
The stabilization of long bone fractures should proceed as soon as the patients
clinical condition permits. Frequently, definitive stabilization can proceed after
successful emergent exploratory laparotomy or thoracotomy where major
sources of bleeding have been controlled, resuscitation has proceeded
concomitantly with the surgery, and the patient is not coagulopathic. If the
patients condition is not normalized using objective criteria, then the patient
should be brought to the ICU with the goal of undergoing a brief period of
additional resuscitation before returning to surgery to complete long bone stabilization. It is important to utilize objective criteria to make this determination
and refrain from using arbitrary statements such as too much anesthesia or
too much surgery as this will lead to a missed opportunity syndrome.
Prioritization
In assessing the orthopedic injuries, certain types of injuries have a much
greater impact on patient outcome and are thus addressed first. This
prioritization should be made by the most senior and experienced orthopedic
surgeon in consultation with the general surgeon, anesthesiologist, and if
applicable, the neurosurgeon. This prioritization should be constantly updated
in real time and take into account the patients overall status. Multi-trauma
patients can decompensate in an unpredictable manner.
Long Bone Fractures and the General Surgeon
439
Open Fractures
When a fracture of a long bone is associated with a disruption of the soft
tissue envelope, it immediately becomes a nidus of future sepsis in a multiply
injured patient. The presence of foreign material along side necrotic soft tissues
and bone becomes an excellent culture media for bacterial flora. If this nidus
remains unchecked, this can be a source of sepsis. The only effective means to
address this situation is aggressive surgical debridement through complete
visualization of the entire zone of injury. Following debridement, in order to
prevent further soft tissue injury due to continued fracture site motion and to
eliminate dead space as a source of infection, skeletal stabilization is performed.
Open fractures are graded in their degree of severity by the use of the GustiloAnderson grading system. In this widely used grading system, open fractures
are classified by Types I, II, IIIA, IIIB, and IIIC.
- Type I refers to a relatively small wound usually less than 1 cm in size and is
believed to be an inside out injury whereby the bone protrudes from inside out
to cause a break in the skin.
- Type II is a wound of size of greater than 1 cm but less than 10 cm.
- Type IIIA is a large extensive wound greater than 10 cm with large flaps but
with good bone coverage. In general, these wounds are still closeable without
the need for tissue transfers.
- Type IIIB is a wound with extensive periosteal stripping and will require local
or free tissue transfers for closure.
- Type IIIC is any open fracture that has a neurovascular injury that requires
repair for limb viability.
- Any wounds with farm contamination are immediately graded as a III regardless of the size of the wound.
- Although originally the grading of open fractures was dependant on the initial
wound size, more recently the concept has evolved to grading intraoperatively
after a through examination of the zone of injury.
The debridement tactic involves systematic identification and removal of all

necrotic tissue and bone. Frequently, however, it is not always possible to predict
the fate of marginal tissues. In this situation, the tissue in question is allowed
to remain and given time to declare themselves, thus necessitating a repeat
debridement in 24-48 hours after the initial debridement. For this reason, and
also to avoid the creation of an anaerobic environment, open fracture wounds
are rarely closed primarily. More recently, when the debridement process leaves
large areas of dead space, the space is managed with the use of an antibiotic
bead pouch. The bead pouch is created by placing antibiotic beads that are
made intraoperatively using polymethylmethacrylate cement and a heat stable
antibiotic such as tobramycin powder and sealing the wound closed with a
gas-permeable barrier such as OPSITE. The purpose of the beads is to allow
the gradual elution of antibiotics into the local area thus maintaining an aseptic
environment within the dead space, avoiding the formation of a
hematoma that can subsequently become infected. These beads are generally
removed at time of repeat debridement to allow for wound closure.
Parental antibiotics are also used in open fractures. In general, Type II fractures
and higher requires the use of a first generation cephalosporin and an
aminoglycoside. Penicillin is added in cases of farm contamination. Antibiotics
are given for 48 hours and restarted for an additional 24-48 hours for repeat
debridements until the wound is closed.
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Trauma Management
The Severe Open Tibial FractureLimb Salvage vs Primary

Amputation
42
One of the most difficult decisions an orthopedic trauma surgeon must make
is limb salvage vs primary amputation in the face of a severe open tibia. Generally these are grade IIIB and IIIC injuries. With modern reconstruction
techniques such as bone transport, vascular bone transfer and bone grafting,
extreme cases of bone loss can be effectively managed. Free tissue transfer has
proven to be extremely valuable in managing extensive soft tissue loss. Despite
these advances, however, many cases of successful limb salvages are really
examples of technology over reason. The true measure of success in these cases
should include a measure of the functionality of the reconstructed tibia as well
as the person attached to the tibia. It is not uncommon to find in many of
these cases, patients that are depressed, unemployed, divorced, and addicted
to narcotic medications, and essentially functionally disabled. Primary
amputation would have avoided these problems.
The problem then becomes how to identify which patients would be candidates
for primary amputation. In addition to objective clinical criteria, ideally psychological and social factors should also be factored into the decision. Clearly,
a patient that cannot be out of work for a prolonged period of time and does
not have a strong social support system cannot tolerate a prolonged lengthy
reconstructive process.
Even the most experienced orthopedic trauma surgeons cannot agree on a
standard course of action. It is well accepted, however, that if amputation is an
option, it should be performed on the day of injury as opposed to delaying the
decision until a later time. Patients are much more accepting of an amputation
when performed primarily than of one performed after an initial debridement.
In the first scenario, the patient accepts the amputation as a result of the injury,
while in the second scenario, the patient views the delayed amputation
as a failure of treatment.
Several investigators have attempted to place clinical criteria into scoring systems
hoping that they can be used as predictors of success or failure of salvage. Such
systems include the mangled extremity syndrome index (MESI), predictive
salvage index (PDI), limb salvage index (LSI) and the mangled extremity
severity score (MESS). Although the original authors of each of these scoring
systems report great success, other investigators have not been able to reproduce
their enthusiasm. The predictive value of each of these scoring systems has
had variable sensitivity and specificity, and as such, can be used as a guide to
decision making, and should not be applied rigidly(1).
Vascular factors that tend to indicate failure of salvage attempts include warm
ischemia time greater than six hours, blunt infrapopliteal injuries, blunt trifurcation injures, and blunt vascular injury associated with a significant
muscular crush injury. The severity of the soft tissue injury can be a factor,
particularly if a comorbidity exists that would preclude timely reliable soft
tissue reconstruction. Advanced age bodes towards amputation. Overall
injury score should be taken into account, since these patients are not good
candidates for lengthy repeat surgeries, and cannot tolerate an additional
inflammatory load. Prolonged hypotension will tend to extend the zone of
injury of the local tissues and thus is a factor for amputation. It is well accepted
441
that damage to the posterior tibial nerve, leading to loss of plantar sensation,
is a good predictor of amputation. Amputation is highly likely with an ipsilateral foot or ankle injury and concomitant high-grade open tibial injury.
Compartment Syndrome
Extremities that are subjected to high-energy blunt trauma can suffer
compartment syndrome. The extremities are composed of fascial spaces, the
compartments, which consist of muscles, nerves, arteries and veins. These
facial spaces are of fixed volume because of the inexpansiveness of fascial. If
the volume of a fixed space is increased, the laws of physics dictate that the
pressure of that space will increase. Compartment syndrome occurs when the
pressure in a fascial space increases to the point of causing ischemic injury to the
structures that traverse that compartment. Injury can precipitate a compartment
syndrome through hemorrhage, increased capillary permeability secondary to
inflammation, and postischemic swelling secondary to prolonged extrinsic
compression.
Classically, the five Ps have been described as signs of a compartment syndrome.
The five Ps are Pressure, meaning a feeling of tightness on external compression,
Pallor, duskiness of the soft tissues, Pain, an increased perception of pain,
Pulselessness, and Paresthesia. Of the five Ps, pulselessness, and pallor, and
parasthesia are all late signs and as such are not useful clinical indicators. The
most reliable sign in an awake and alert patient is pain, and more specifically,
pain out of proportion for the injury. In addition, passively stretching the
involved compartment will result in significantly increased pain. Clearly, a
patient with a tibial fracture will have pain, but this pain is usually controllable
with immobilization and analgesic medication. A patient with a compartment
syndrome will continue to have uncontrollable pain despite these measures.
The index of suspicion should be high in any injury that is secondary to highenergy trauma, since there is likely a significant soft tissue injury. The presence of
an open fracture does not preclude compartment syndrome which have been
reported in 6-9% of cases.
The difficulty in diagnosing a compartment syndrome occurs when the patient
is not awake.
Since compartment syndrome is related to tissue perfusion pressure the
hypotensive patient can experience a compartment syndrome without overt
signs. In these cases, compartment pressure measurement is indicated.
Several techniques of measuring compartment pressures have been described.
These include using an 18-gauge needle attached to a manometer, wick
catheters, slit catheters and stic catheters. For continuous measurements, the
wick and slit catheters are most accurate. The stic catheter has the advantage
of portability but is only reliable when used for momentary measurements.
The pressure threshold for fasciotomy has been the subject of much debate.
Authors have suggested fasciotomy for pressures anywhere from 30-45 mm
Hg. These pressure recommendations have all been based on different
measurement methods. Unfortunately, most of these recommendations do
not take into account the patients blood pressure, and thus may not be as
valuable in a hypotensive poly-trauma patient. The methodology that does
take into account the patients condition utilizes a concept referred to as the
delta P. Originally described as the difference between mean arterial pressure,
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Trauma Management
42
a recent study demonstrated a high degree of reliability of using the difference

between diastolic pressure and measured compartment pressure. In this study,
a delta P measurement of diastolic pressure minus the measured compartment
pressure of less than 30mm Hg. was deemed significant.
When indicated, fasciotomy should be performed emergently. Fasciotomy in
an isolated injury is limb saving, but in a multiply injured patient, it must be
considered life saving. Complications of an isolated missed compartment
syndrome have been classically referred to as Volkmans ischemic contracture,
which refers to an extremity where the muscle groups are fibrosed and
contracted and are nonfunctional. In a multiply injured patient, missed
compartment syndromes can lead to myoglobinuria, renal failure, and sepsis,
thus possibly contributing to multiple system organ failure.
Fasciotomy is a relatively simple procedure as long as there is an understanding
of the anatomy. The forearm has three compartments, a superficial and a deep
flexor compartment, and an extensor compartment. Decompression of all three
compartments is easily accomplished using a volar Henrys approach. When
decompressing the forearm, consideration should also be given to the carpal
tunnel as well to avoid compression of the median nerve.
The tibia has four compartments, which include the anterior, lateral, superficial
and deep posterior. Decompression can be accomplished using the classic twoincision technique where a medial and lateral incision is made and the respective
fascia identified and incised. Similarly, using a long single lateral incision, the
intermuscular septum between the anterior and lateral compartments is
identified, and the respective compartments are released adjacent to the septum,
followed by identifying and incising the fascia of the superficial posterior
compartment. The deep posterior is identified by retracting the peroneal
compartment anteriorly and the superficial compartment posteriorly and
following the interosseous membrane. The compartment is released by
releasing the compartment off this membrane. It is important to keep in mind
the location of the peroneal nerve as it can be injured. In addition, in an
injured extremity, the anatomy may be distorted. It is also important to keep
incisions wide and to release the fascia to the level of the musculotendinous
junction in order to ensure a complete decompression. If the diagnosis has
been delayed, it is vital to debride necrotic muscle at this time. The presence
of a fracture is an absolute indication for immediate fracture stabilization after
decompression. All open tibia fractures should have four compartment
fasciotomies performed as part of their irrigation and debridement.
In addition to the forearm and tibia, compartment syndromes can occur
although less frequently, in the hand, foot, thigh, buttocks, and arm. If clinically
present, these too must be addressed.
Fractures with Associated Vascular Injury

Long bone fractures with an associated vascular injury that jeopardizes the
viability of the limb are of extremely high priority. Generally the diagnosis is
not difficult, with presenting signs such as profuse arterial bleeding, expanding
hematoma, absent distal pulses, and pallor of the limb. With impending limb
loss, a formal arteriogram is not indicated and can only serve to prolong
ischemia time.
443
A frequent area of contention occurs regarding the sequencing of these cases,

whether the fracture stabilization should occur first versus the vascular repair.
Both camps raise valid points. If fracture stabilization occurs after a meticulous
vascular repair, then there is the risk of reinjury to the repair when the extremity
is brought out to length and alignment. On the other hand, fracture stabilization
may be a lengthy procedure and thus will prolong ischemia time if it were to
occur prior to vascular repair. Clearly, it makes no sense to perform a vascular
repair only to keep the fracture unstabilized, since the repair would be doomed
with any subsequent motion, or to ask that the fracture be maintained in an
malaligned manner. And conversely, it makes no sense to perform lengthy
fracture stabilization and permit the extremity to become ischemic. Rigidity
in thinking in these cases is to be condemned. The proper course of action
should be arrived at after a thorough review of the fracture complexity, and
the period of ischemia. The surgical approach for the fracture stabilization
and the vascular repair should also be discussed among the specialist involved
to avoid creating narrow soft tissue bridges that would place the extremity in
jeopardy. From an orthopedic standpoint, if the fracture stabilization is
complex, a temporary bridging external fixator can be applied above and
below the injury to achieve control of alignment and length prior to vascular
repair. If the vascular repair is complex and the fracture stabilization is relatively
simple such as intramedullary nailing or simple plate fixation, a temporary
shunt can be placed. When the vascular injury occurs in an open fracture, the
area should undergo appropriate irrigation and debridement prior so that
vascular repair can occur in a clean soft tissue bed.
Cooperation among the specialists will lead to execution of the prime objective,
that of a viable and functional patient.
Fracture of the Femoral Neck in the Young Patient

This injury is of a very high priority because of the disruption of the blood
supply to the femoral head and subsequent development of avascular necrosis.
Fractures of the femoral neck in the young polytrauma patient differ greatly
from the more common femoral neck fractures of geriatric patients. In the
latter case, the injury occurs because of osteopenia secondary to advancing age
and is a result of relatively low energy. In addition, in the elderly population,
if disruption of the blood supply to the femoral neck occurs, prosthetic
replacement of the femoral head provides an excellent functional solution in
this time limited low demand situation. In the young patient, a fracture of the
femoral neck occurs after considerable energy expenditure and most likely
results in displacement and disruption of the blood supply.
Early diagnosis, reduction and stabilization provide the only means of
minimizing the likelihood of avascular necrosis.
The diagnosis of a femoral neck fracture is not difficult and is frequently noted
on the AP radiograph of the pelvis of the trauma series. Once suspected on the
pelvic film, follow up AP and lateral hip films are needed to further define the
anatomy of the fracture.
Although less common but not rare, and often missed in as much as 30% of
the time is the related entity of an ipsilateral femoral neck femoral shaft fracture.
In this situation, there is a fracture of the femoral shaft and a concomitant
fracture of the femoral neck. The femoral shaft fracture is usually obvious but
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Trauma Management
the fracture of the femoral neck is frequently not well visualized. Explanations
for why the femoral neck component is often missed include poor quality
films, femoral neck obscured by splints, external rotation of the proximal femur
due to the shaft fracture, and lack of vigilance. It is not unusual to diagnose
the femoral neck fracture by review of the pelvic cuts of the abdominal CT
scan. Once diagnosed, timely stabilization of both fractures should be a priority
to avoid avascular necrosis (Fig. 42.1A,B).
Floating Knee
42
Ipsilateral fractures of the femur and tibia are referred to as floating knee injuries
(Fig. 42.2A,B). Clearly a result of high energy blunt force trauma, these injuries
frequently result in significant disability in 60-70% of patients.
Until the fractures are stabilized, there are risks of popliteal artery injury and
irreversible injury to the common peroneal nerve.
Patients with this injury seem to experience significant rates of pulmonary
dysfunction such as ARDS, fat emboli syndrome and pulmonary emboli.
Early stabilization of both lesions is helpful in minimizing disability and
complications.
Femoral Fractures
Early stabilization which is defined as within the first 24 hours after injury or
when the patient has achieved a normalizing base deficit with a normal lactate
level, and is normothermic, normotensive, and not coagulopathic, has been
associated with decreasing the length of ICU stay, decreasing pulmonary
complications such as ARDS, fat and pulmonary emboli syndrome, decreasing
deep venous thrombosis, facilitating nursing care, and decreasing the need for
analgesics. The mechanism by which this occurs is not well known and is
most likely multifactorial, but early stabilization may contribute to a decreased
the systemic inflammatory response to trauma.
The majority of femoral shaft fractures are best managed by locked intramedullary nailing. Intramedullary nailing can be performed in a traditional
antegrade manner where the nail is inserted through the piriformis fossa, or
more recently there has been increased enthusiasm to perform nailing in a
retrograde manner where the nail is introduced through the intercondylar
region of the femoral condyle. Antegrade nailing in most surgeons hands
requires the use of a fracture table and image intensifier. Retrograde nailing
can be performed on any radiolucent table with an image intensifier and is
ideally suited for the multiply injured patient with concomitant spine or chest
injuries, obese patients, and bilateral femoral shaft fractures in that the setup
time is minimal. Further studies are currently underway to determine if there
are any long term consequences of violating the knee joint.
Much has been written recently about the association between intramedullary
nailing and the worsening of ARDS in multiply injured patients with a
preexisting concomitant pulmonary parenchymal injury. Standard intramedullary nailing involves the process of reaming. Initially, it was thought that the
reaming process might contribute to this phenomenon. Reaming is the process
by which the intramedullary canal is widened prior to insertion of the nail. It
is performed by using an instrument that essentially cores out the intramedullary bone to a defined diameter. Reaming is done to allow for the insertion of
445
Fig. 42.1A, B. Multiply injured

blunt trauma patient sustaining
an ipsilateral femoral neck/
femoral shaft fracture. This was
stabilized emergently by performing an open reduction
internal fixation of the femoral
neck with interfragmentary
screws, followed by intramedullary nailing of the femoral shaft
using a miss-a-nail technique.
Fig. 42.1B.
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Trauma Management
reaming process causes embolization of marrow contents into the systemic

circulation and it is believed by some that this material is harmful to an already injured pulmonary parenchyma. Current animal and clinical studies
have not been able to clearly demonstrate reaming as the culprit and have
served to provide more questions than answers. Nonetheless, currently, an
unreamed technique is an option, however it results in insertion of an implant
which may be mechanically inferior but is frequently chosen when faced with
this circumstance. Unreamed technique can be utilized in both antegrade and
retrograde nailing. Delaying the stabilization of the femur fracture, however,
has been shown to be detrimental in this circumstance.
Intra-Articular Fractures
Fractures that involve the articular surface of a joint require special considerations. In these injuries, the cartilage of the joint is disrupted and thus warrants
meticulous reconstruction. Examples of such injures include fractures of the
tibial plateau (Fig. 42.3), tibial plafond, supracondylar humerus, and supracondylar femur. These injuries are frequently complex and require complex preoperative planning to effect a good outcome.
Frequently, additional studies are needed such as CT scans with 3-D reconstruction to further define the anatomy. These injuries therefore are not generally
definitively addressed in a multiply injured patient emergently.
To promote patient mobilization and to minimize the detrimental effect of fracture site motion and irritation, temporary bridging external fixation is applied
initially. Once the appropriate studies are obtained, soft tissue swelling has subsided, and the patients condition is optimal, joint reconstruction can proceed.
Stabilization Options for Long Bone Fractures

External Fixation
External fixation is utilized as a temporary means of achieving skeletal stabilization and is primarily used for the patient in extremis (Fig. 42.4). They can
also be used temporarily to span a joint in intra-articular fractures and serve as
portable traction. When necessary, they can be applied in an ICU setting
under local anesthesia.
Intramedullary Nailing
As previously discussed, intramedullary nailing is the method of choice for
most long bone shaft fractures such as the femur and tibia. Nails are inserted
through a percutaneous technique and do not require surgical exposure of the
fracture site, thus minimizing trauma to the soft tissues and minimizing blood
loss. These implants have the capability to be locked at either or both ends
thus allowing them to be used regardless of comminution and yet permit
reliable control of length and rotation. These devices are load sharing and
thus allow earlier weight bearing prior to complete fracture consolidation,
and are thus advantageous in the multiply injured patient.
Plate Fixation
Plate fixation is commonly used for stabilization of fractures of the forearm
and humerus and is frequently the technique of choice for intra-articular
fractures. Traditionally, plate fixation requires extensive exposure of the fracture
site. More recently however, percutaneous techniques have become popular.
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Fig. 42.2A, B. Multiply injured blunt

trauma patient with a fracture of the
left femur and left tibia, a Floating
Knee. Patient underwent immediate
intramedullary nailing of the femur
and tibia.
42
Fig. 42.2B.
448
Fig. 42.3. A fracture of the tibial plateau, and example of an intra-articular fracture. Notice the disruption of the articular surface of the
tibia.
42
Fig. 42.4A, B. Multiply injured

patient with a femoral shaft fracture and injury to the superficial femoral artery. Patient underwent temporary external
fixation of the femur.; A), prior
to vascular repair. B) see next
page.
Trauma Management
449
Fig. 42.4B Intramedullary nailing of the femur was performed
several days later as definitive
treatment for the femoral shaft.
42
References
1.
2.
3.
4.
5.
Tornetta P III, Olson SA. Amputation versus limb salvage. In: Springfield DS, ed.
Instructional Course Lectures 46. Rosemont, IL: American Academy of Orthopedic
Surgeons 1997:511-518.
Amendola A, Twaddle B. Compartment Syndromes In: Browner B, Levine A,
Juipiter J, Trafton P, eds. Skeletal Trauma. 2nd ed. Philadelphia: WB Saunders,1998:
365-389.
Pape H-C, AufmKolk M, Paffrath T, et al. Primary intramedullary femur fixation
in multiple trauma patients with associated lung contusionA cause of posttraumatic ARDS? J Trauma 1993; 34:540548.
Charash WE, Fabian TC, Croce MA. Delayed surgical fixation of femur fractures
is a risk factor for pulmonary failure independent of thoracic trauma. J Trauma
1994; 37:667672.
Bosse M, Kellem J. Orthopaedic management decisions making in the multipletrauma patient. In: Browner B, Levine A, , Juipiter J, Trafton P, eds. Skeletal Trauma.
2nd ed. Philadelphia: WB Saunders 1998:151-164.
CHAPTER 43
Pelvic Fractures and the General Surgeon

Jackson Lee
Anatomy
The pelvis is made up of three bones, the sacrum and two innominate bones.
The innominate bone itself is made up of three bones that fuse during growth,
the ischium, the ilium, and the pubis.
The three bones fuse in the area known as the triradiate cartilage of the
acetabulum, which forms the socket portion of the hip joint. The three bones
of the pelvis themselves do not have any inherent; they are stabilized by
ligamentous structures. Of the named ligamentous structures, the posterior
ones are the strongest. Comprised of two groups, the posterior sacroiliac
ligaments, long and short, are strong enough to withstand and transmit the
force of weight bearing from the lower extremity to the spine and thus provide the major structural integrity to the sacroiliac joint. The less strong anterior sacroiliac ligaments provide additional stability. The ligaments that form
the symphysis pubis maintain the integrity of the pubic ring. In addition,
there is a set of sacrotuberous ligaments that connects the posterior sacrum to
the ischial tuberosity and resists vertical rotation of the innominate bone. The
sacrospinous ligament, which connects the sacrum to the ischial spine helps
resist external rotation of the ilium.
Pelvic stability can be violated by any combination of a break in the integrity
of the bony structures or by loss of integrity of the ligamentous structures.
When disruptive forces are applied, several factors determine which structure
fails. In older patients who are osteopenic, generally, the bony structures fail.
Depending on the degree of osteopenia, this may require very trivial forces.
Conversely, in young patients with very strong bony structures, there will be a
tendency for ligaments to fail. In addition, the rate of force application plays
a significant role.
A subset of pelvic injuries includes fractures of the acetabulum. Acetabular
fractures occur when forces are transmitted along the femoral shaft through
the femoral neck and across the femoral head onto the acetabulum. Depending on the relative degree of abduction/adduction, flexion/extension of the
hip joint at the time of force application, certain fracture patterns or dislocations can occur.
Pelvic disruptions can occur through several common mechanisms of force
application. The first mechanism is an anterior/posterior force application.
Jackson Lee, University of Southern California School of Medicine,
LAC + USC Medical Center, Los Angeles, California, U.S.A.
451
This can occur when a pedestrian is struck head on by an automobile. The

force, which is directed in a posterior direction from anterior, causes an external rotation moment to the ilium or hemipelvis. This causes a disruption of
the symphysis pubis and injury to the anterior sacroiliac ligaments. The pelvis
books open and hinges on the strong posterior sacroiliac ligament. Variations
can occur by applying an external rotation force to both femurs and hips, or
by falling from a height and landing on ones back. In these injuries, the
posterior sacroiliac ligaments remain intact and competent.
Another mechanism (Fig. 43.1), which is in fact the most common is the
lateral compression injury. In this mechanism, a lateral directed force is applied
on the iliac wing, such as would occur when a car from the side strikes a
pedestrian. If the magnitude of the force is low, this will cause a fracture to
occur on the anterior aspect of the sacral body with the bone failing in compression and there is a concomitant fracture of the pubic rami. In this situation, the
posterior sacroiliac ligaments are spared because they are essentially relaxed by
the injury. If the magnitude of the forces is high, a pivoting occurs around the
sacral body and thus causes the posterior sacroiliac ligament to be placed under
tension and thus failing or a fracture through the iliac wing can occur. Because
the sacrotuberous and sacrospinous ligaments are relaxed in this force
application, they remain competent and thus there is still some stability
vertically and rotationally.
The third mechanism that occurs is when the forces are applied to the pelvis
in a vertical manner such as would occur from a fall from a height. Essentially,
in this mechanism, there are either injuries to the posterior sacroiliac ligaments
or fractures of the iliac wings and pubic rami that lead to complete vertical
instability.
Initial Assessment
The recognition of a pelvic fracture may by subtle or obvious. Indications of a
pelvic injury may include leg length inequality, scrotal hematoma or swelling,
or hematomas around the iliac wings or lower back. If suspected, palpation of
the iliac wings will provide useful information about the gross stability of the
pelvic ring. More subtle instability can be assessed later on with specific radiographic views and stress views. During the primary survey, however, there is
no role for these views.
As with all other musculoskeletal injuries, the integument should always be
examined, taking note of open wounds and lacerations, suggesting an open
injury. Lacerations involving the perineum have great implications regarding
the outcome. These patients may require a diverting colostomy to manage
bowel contamination.
One should also examine for Morel-Lavale lesions. These lesions are closed
degloving injuries where the subcutaneous tissue is torn or sheered away from
the underlying fascia forming a cavity filled with hematoma and liquefied fat.
This lesion is significant in the multiply-injured patient because these lesions
can become infected if not recognized and treated in a timely manner, thus
presenting a septic load to a patient that may not be able to tolerate one.
Open drainage and debridement, followed by dressing changes and packing
best manage these lesions. Wound management is by delayed primary closure.
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Trauma Management
43
Fig. 43.1. CT demonstrating a sacroiliac joint dislocation in a patient with an AP

compression injury. Despite the widening, the posterior sacroiliac ligaments were
intact in this case.
It is always important to keep in mind the likelihood of associated injures

when dealing with a patient with a pelvic fracture since the energy transference that occurs does not discriminate among structures. It is very common
for these patients to also sustain injuries to abdomen, chest and head. The
most common direct causes of mortality are head and thoracic injuries.
When evaluating a patient with a pelvic fracture for intraabdominal bleeding,
it is important to avoid violation of the retroperitoneal space to allow for
tamponade. If a diagnostic peritoneal lavage is contemplated, it should be
performed using a supraumbilical approach to prevent a possible entry into
the retroperitoneal space through the reflection of the peritoneum that follows
the round ligament below the umbilicus.
Injuries to the genitourinary track are very common and occur approximately
15% of the time. This can include injures to the renal parenchyma, bladder,
and urethra. Signs of genitourinary injury include hematuria, blood at the
meatus, and a high riding prostate in a man. The presence of blood at the
meatus or a high riding prostate in a man is highly indicative of a urethral
injury and is an indication for a retrograde urethrogram prior to Foley insertion
in a hemodynamically stable patient. However in the absence of these findings
urethral injury cannot be ruled out. In a hemodynamically unstable patient, a
single attempt to place a catheter is made by a qualified urologic specialist. In
females, catheter placement may be attempted without a urethrogram. Bladder
injuries in both men and women correlate with the number of pubic rami
fractures. In female patients with pubic rami fractures, it is also important to
evaluate for lacerations in the vagina, which communicate with the fracture
site, thus necessitating at the minimum a bimanual exam and ideally a speculum
examination.
453
Injuries to the pelvic ring frequently are associated with injuries to the peripheral nerves. Very commonly, the L5 nerve root is injured when there is a
significant lesion posteriorly. The L5 root enters the pelvis under the L5
transverse process and crosses the sacral ala approximately 2 cm medial to the
sacroiliac joint and joins the sacral plexus. The sacral roots exit their respective
foramen to form the plexus. Fractures involving the sacral body can cause
injury to the sacral roots. Frequently patients with pelvic fractures requires
early intubation and as such, require early examination and documentation of
their neurologic status so as to not to lose this baseline information. Examination should include sensation and motor testing to the lower extremity as well
as perianal sensation.
The primary survey should include an AP pelvis film. Examination of this
film should allow a good estimation of the mechanism of injury, identify
fractures and allow inferences of ligamentous injury (Fig. 43.2).
Initial Management of Bleeding

In the majority of cases, pelvic bleeding is venous or from fracture surfaces.
Control of such bleeding can be achieved by avoiding coagulopathy and providing tamponade. Coagulopathy can be secondary to the dilutional effects of
resuscitation fluids and blood products as well as hypothermia.
Tamponade can be achieved by limiting the ability of the retroperitoneal space
to increase in volume. In a patient with an intact pelvis, the potential retroperitoneal space can hold a volume of approximately 2 liters. In the advent of
a pelvic injury in which the pubic symphysis is widened by 2 cm more than
normal, the potential retroperitoneal space has been estimated to increase to 6
liters. It stands to reason then that controlling the displacement of the pelvic
ring can facilitate tamponade.
In the field, the MAST suits may be useful especially for long transportations.
MAST suits have been shown to stabilize the pelvis.
A simple and effective method of controlling pelvic displacement is tying a
hospital sheet around the patients iliac wings. In the absence of lower extremity
injury, internally rotating both limbs will also serve to decrease pelvic displacement. Both of these methods are essentially equivalent to aplying an
external fixator.
External fixation is a simple, rapid and effective means of applying early
stabilization of the pelvic ring in the emergency department. In addition to
controlling potential retroperitoneal volume, it will minimize fracture
site motion, thus preventing the dislodgment of newly formed clots and will
minimize further injury to the soft tissues. It will also allow a patient to be
transported from department to department without fear of further displacement. External fixation has been shown to decrease the mortality rate in unstable
pelvic injuries and has decreased transfusion requirements. For external
fixation to be maximally effective, it must be applied early before development
of a large retroperitoneal hematoma, otherwise the hydraulic forces of the
hematoma will not allow reapproximation of the pelvic ring. External fixation
is not used as definitive treatment of the pelvic fracture and thus an anatomic
reduction is not necessary and valuable time should not be spent adjusting
the frame to achieve an accurate reduction. The use of external fixation is
not indicated in mechanically stable injuries and is relatively contraindicated in
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Trauma Management
43
Fig. 43.2. Multiply injured patient with a fracture of the left acetabulum and a
subtrochanteric femoral shaft fracture.
cases where there is a floating iliac wing or a fracture of the acetabulum since
control of the pelvic volume is not possible.
- There are two basic frames that have been described. The traditional frame is an
anterior frame utilizing Schantz pins inserted between the inner and outer tables
of the anterior iliac wings and attached to a trapezoidal frame. This frame has
the advantage of being simple to apply and has a low complication rate. In
patients with a significant posterior lesion, it tends to offer less rigid control of
the posterior lesion. This was more of an issue when external fixation was the
only known means of definitively treating these lesions to union.
- For the patient in extremis, a simple construct consisting of one pin in each
ilium can be utilized. Despite the advantages of external fixation, it use remains
controversial.
- More recently, a C clamp frame has been described. This frame can be applied
anteriorly to control an anterior lesion or can be applied posteriorly to close a
posterior lesion. In applying this frame posteriorly, there is a risk of causing
injury or further injury to the superior gluteal artery. In addition, intrapelvic
protrusion has been reported. Some authors have suggested that these frames be
applied under radiographic control, and thus may be less useful in the emergency department. The efficacy of the C clamp device is currently under study.
Selective angiography can be useful in those patients where bleeding is arterial. Ideally, a process of elimination can identify these patients, where other
sources of bleeding have been ruled out. This would include patients who
have mechanically stable pelvic injuries, externally stabilized patients and
patients who are not candidates for external fixation in which thoracic and
abdominal sources have been eliminated. Interestingly, in a recent series of
hemodynamically unstable patients with unstabilized pelvic injures in which
455
thoracic and abdominal sources of bleeding were ruled out, only 30% had
angiographically treatable lesions, thus supporting the belief that
hemodynamical instability is a result of venous bleeding. A concern regarding
angiography has been raised in patients with acetabular fractures that may
require an extended illiofemoral approach for open reduction. In this surgical
approach, the gluteal muscles are detached completely from their origins on
the ilium and from their insertions on the femur, thus the flaps viability is
solely dependent upon the superior gluteal artery and other branches of the
internal iliac artery. If the internal iliac artery or superior gluteal artery is
embolized, and a sufficient period of time has not occurred to allow for
revascularization, the viability of the flap may be jeopardized. In this group of
patients, embolization should only be undertaken when a treatable lesion has
been identified.
Fracture Fixation
Definitive fracture fixation is usually not undertaken until signs of active
bleeding are absent. This usually does not occur until postinjury day 2 or 3.
There is one major exception to this however. An ideal opportunity occurs
when a patient has a widened pubic symphysis or a parasymphyseal fracture
and undergoes exploratory laporotomy for an abdominal injury. At the
completion of the laparotomy, the midline incision is extended to the pubis
and plate fixation of the symphysis is undertaken. Performing this fixation
imparts significant stability to the pelvic ring, allows immediate removal of
the external fixator, and simplifies later supplemental posterior fixation.
Definitive fracture fixation requires an accurate diagnosis of the anatomic
lesions. Generally the posterior lesion is the most difficult to define. Once the
patient is stable to undergo further diagnostic studies, pelvic inlet and outlet
views are obtained. The pelvic inlet view is taken with the x-ray tube aimed at
a 40 caudad direction and results in a film that allows excellent definition of
rotational and AP displacement of the iliac wings. It can also demonstrate
subtle displacements of the sacral-iliac joint. The outlet view, taken with the
x-ray tube aimed 45 cephalad shows the sacral body in a true AP projection
and thus allows definition of sacral fractures and injuries to the sacral foramen. It
is also well suited to defining vertical displacement of the iliac wings. A CT
scan provides further definition of the injury. In extremely complex situations,
3-D reconstructions may be helpful.
When an acetabular fracture is present, Judet views are obtained. These
additional views permit the classification of the acetabular fracture and thus
allowing one to arrive at a surgical tactic for joint reconstruction. Judet views
are essentially 45 internal and external rotation views of the acetabulum and
are taken with the pelvis rotated along its longitudinal axis and centering the
x-ray beam on the acetabulum. Evaluation of these films is beyond the scope
of this review and the reader is referred to classic works for further information.
Once the anatomy of the injury is defined, a determination is made on the
stability. Stability is defined as the ability of the pelvis to resist normal
physiologic forces. Stability may be inferred based on the fracture pattern,
physical examination and serial radiographs. Lesions that prove to be unstable
are addressed using internal fixation. Fractures of the acetabulum are evaluated
based on the stability of the hip joint, the presence of intra-articular fragments
and joint congruity (Fig. 43.4).
43
456
43
Trauma Management
The goal of fracture fixation is centered on restoring the posterior anatomy.

Fractures of the sacral body and dislocations of the sacroiliac joint are usually
fixed using iliosacral screws functioning in a neutral or interfragmentary
capacity (Fig. 43.3). These screws are directed into the body of S1, and on rare
occasions, into the body of S2. The placements of these screws are guided by
image intensification. Iliosacral screws can be placed percutaneously if the
fracture is minimally displaced. Displaced fractures will require open reduction,
either through a retroperitoneal anterior approach or a posterior approach
requiring the patient to be placed prone. Fractures involving the iliac wings
are fixed using interfragmentary screws placed between the inner and outer
tables and neutralized using plates.
The anterior lesions, which include pubic symphysis disruptions and
parasymphyseal fractures, are fixed using compression plating. Fractures of
the pubic rami may or may not need stabilization depending on the stability
of the injury.
When the posterior lesion is unilateral, the uninjured side can undergo
immediate weightbearing. Weightbearing on the injured side is delayed until
the fracture or the ligaments have healed sufficiently.
References
1.
2.
Burgess A, Jones A. Fractures of the pelvic ring. In: Rockwood C, Greene D, eds.
Fractures in Adults 4th ed. Philadelphia: JB Lippincott, 1996: 1575-1615.
Tournetta P III. Pelvis and Acetabulum:Trauma. In: Beaty J, ed. Orthopaedic
Knowledge Update 6. Chicago: American Academy of Orthopedic Surgeons 1998:
427-439.
Fig. 43.3. A patient with bilateral sacroiliac joint disruption stabilized with bilateral
sacroiliac screws and plate fixation of the symphysis pubis.
457
43
Fig. 43.4A, B. Patient with a transverse fracture of the acetabulum. Plate fixation
was performed using a Kocher-Langenbach approach, a posterior approach performed with the patient in the prone position.
3.
4.
5.
Kellam J, Browner B. Fractures of the pelvic ring. In: Browner B, Levine A, Jupiter
J et al, eds. Skeletal Trauma 2nd ed. Philadelphia: WB Saunders 1998: 1117-1179.
Gruen GS, Leit ME, Gruen RJ et al. The acute management of hemodynamically
unstable multiple trauma patients with pelvic ring fractures. J Trauma 1994;
36:706-713.
Poole GV, Ward EF, Muakkassa FF et al. Pelvic fracture from blunt trauma: Outcome is determined by associated injuries. Ann Surg 1991; 213:532539.
CHAPTER 44
Spinal Injuries
Larry T. Khoo, Wei-Lee Liao and Gordon Engler
Cervical and Cervicothoracic Injuries
One of the most mobile and flexible sections of the human spinal column is the
region spanning C1 to T2. The cervical spine can be divided into four distinct
regions each with their own unique biomechanical, anatomic, and pathological
features. These are the 1) occipito-atlanto-axial (O-C1-C2) region, 2) the upper
cervical spine (C3-C5), 3) the lower cervical spine (C5-C7), and 4) the cervicothoracic
junction (C7-T2).
The Edwin Smith papyrus written 5000 years ago identified cervical spine
trauma as devastating injuries and pronounced them as lesions not to be
treated.
Improvements in legal statutes, restraint systems, emergency transport
systems, and general awareness and prevention have decreased the number of
complete cervical spinal cord injuries in the last 20 years.
The advent of modern neuroimaging techniques and modern spinal instrumentation techniques have improved the ability of physicians to rapidly
diagnose, treat, and mobilize patients with cervical injury.
Incidence
There are approximately 5000 to 8000 new cases of traumatic spinal cord
injury (SCI) each year in the United States of which 50-60% involve the
cervical spine. This high proportion is due to the relative mobility of the region
and the inability of passenger restraint systems to constrain the head and neck.
The most common causes are vehicular accidents (50%) sports-related (20%),
assault-related (20%), and accidental falls or blunt trauma (10%).
There is a bimodal distribution of cases with a peak in adolescents and
young adults (age 15-30) and a second smaller cluster at age 50-70 due
to degenerative disease.
The lifetime cost for each patient with quadriplegia averages over $1.5 million.
Classification
Numerous classification schemes have been formulated to categorize the mechanism, bony stability, and degree of neurological injury for cases of cervical
injury. They serve to predict the severity of each lesion, the need for early
stabilization and surgery, and the ultimate expected outcome of the patient.
Larry T. Khoo, LAC + USC Medical Center, Los Angeles, California, U.S.A.
Wei-Lee Liao, LAC + USC Medical Center, Los Angeles, California, U.S.A.
Gordon Engler, LAC + USC Medical Center, Los Angeles, California, U.S.A.
Spinal Injuries
459
44
Fig. 44.1. Three-column classification by Dennis. 1) Supraspinous ligament, 2) interspinous ligament, 3) capsular ligament, 4) intertransverse ligament, 5) ligamentum flavum, 6) posterior longitudinal ligament, 7) posterior annulus fibrosus,
8) anterior annulus fibrosus, 9) anterior longitudinal ligament.
- The three-column model of vertebral stability forms the basis for clinical decision-making in spinal trauma (Fig. 44.1)(see also Thoracic and Lumbar Fracture
section). This model applies equally well to cervical, thoracic, and lumbar spine
injuries.
- For cervical injuries, there are more classification schemes than for thoracolumbar injuries due to the unique anatomy of the upper cervical vertebral bodies.
Overall, these are similar in their mechanism and morphology to systems used
for the thoracic and lumbar spine as well (Table 44.1A, Fig. 44.2). An example
of cervical fracture classification is provided in Table 44.1B. Several of the more
unique cervical patterns of fracture will be presented later on in the Surgical
Indications section.
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Trauma Management
Table 44.1A. McAfee classification of vertebral fractures

Injury Type
Pathology
Wedge-compression fracture
Stable burst fracture
Isolated anterior column failure

Anteriorand middle-column compression
failure, posterior column intact
Compressive failure of anterior and middle
columns, disruption of posterior column
Horizontal vertebral avulsion injury with center
of rotation anterior to vertebral body
Compressive failure of anterior column, tensile
failure of posterior column. The center of
rotation is posterior to anterior longitudinal
ligament
Disruption of spinal canal alignment in
transverse plane, shear mechanism common
Unstable burst fracture

Chance fracture
Flexion-distraction injury
Translational injuries
44
Fig. 44.2. Schematic of McAfee fractures classification. A) Wedge-compression fracure,

B) flexion-distraction fracture (true Chance fracture), C,D) translational fracture, E) flexion-disraction fracture (bony Chance fracture), F) burst fracture (unstable).
Spinal Injuries
461
Table 44.1B. Example of cervical fracture classification

Atlanto-occipital dislocation and fracture
Occipital condyle fractures
Fracture dislocations
Atlas C1 ring fractures (Jefferson fractures, any combination of fractures
through ring)
Combination C1-C2 fractures (atlantoaxial rotatory subluxation with/without
other fracture)
Hyperextension fracture-dislocations of subatlantal spine
Posterior fracture-dislocation of the dens (i.e., odontoid fractures I,II,III)
Traumatic spondylolisthesis of the axis (Hangmans fracture and variants)
Hyperextension sprain (momentary) dislocation with fracture
Hyperextension fracture-dislocation with fractured articular pillar
Hyperextension fracture-dislocation with comminution of the vertebral
arch
Hyperflexion fracture-dislocations of subatlantal spine
Anterior fracture-dislocation of the dens (i.e., odontoid fractures I,II,III)
Hyperflexion sprain (rare). Posterior ligaments disrupted, but facets not
locked.
Unilateral or bilateral locked articular facets with or without fracture
Teardrop fracture-dislocation
All patients with head or high-energy trauma, neurological deficit, or complaints
of neck pain must be presumed to have a cervical spine injury.
A significant number of cervical spine injuries with neurological compromise are immediately fatal due to cardiorespiratory insufficiency from autonomic denervation.
Less than one-third of patients with fractures of the cervical spine will have
associated neurological deficits. Patients with ligament injuries, however, have
a much higher incidence of devastating sequelae (over 65%). The degree of
neurological compromise and vertebral instability is usually greater in these
cases. Dislocations are the leading cause of cervical injury related death.
A systematic examination of every motor and sensory level is needed to accurately assess the level of clinical injury. This can often differ from the radiographic injury level. The American Spinal Injury Association has formulated a
standardized system to stratify the degree of patients deficits (Table 44.2A/B).
Patients should be classified as either complete (no distal sparing of motor,
sensory, or reflex function beyond level of injury) or incomplete (sparing of
motor, sensation, peri-anal sensation, and/or rectal tone). This with the degree of bony instability helps dictate whether surgery is indicated (Table 44.6).
Stereotyped patterns of cervical spinal cord injury are well described and are
useful for descriptive, management, prognostic and archival purposes (Table 44.3).
For occipito-atlanto-axial injuries, an onionskin pattern of facial sensory loss
due to trigeminal tract injury, lower cranial nerve palsies (especially sixth nerve),
carotid and vertebral artery dissections, strokes, and infarctions may all be
encountered.
Cervical injuries have a high frequency (over 60%) of associated damage to
44
462
Trauma Management
Table 44.2A. American spinal cord injury association (ASIA)Grading scale of

neurological impairment
Grade
Description
Complete. No sensory or motor function below level of neurologic

deficit level. Sacral sparing is absent
Incomplete. Sensory but not motor function is preserved below the
neurologic deficit level.
Incomplete. Motor function is preserved below the neurologic deficit
level, and the majority of key muscles below the neurologic deficit
level has a muscle grade lower than 3
Incomplete. Motor function is preserved below the neurologic deficit
level, and the majority of key muscles below the neurologic deficit
level has a muscle grade higher or equal to 3.
Sensory and motor function is normal.
B
C
D
E
44
Table 44.2B. Asia motor scoring system (100 points)

Right
Left
Level
Muscle
Action to test
Sensory landmark
0-5
0-5
C4,5
0-5
0-5
0-5
C6
C7
C8
Shoulder abduction
or elbow flexion
Cock up wrist
Elbow extension
Squeeze hand
Lower shoulder
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
T1
L2
L3
Deltoids
or Biceps
Wrist extensors
Triceps
Flexor digitorum
profundus
Hand instrinsics
Iliopsoas
Quadriceps
0-5
0-5
0-5
0-5
0-5
0-5
50
50
Abduct little finger

Flexion at the hip
Straightening of the
knee, Patellar reflex
L4
Tibialis anterior Dorsiflexion
of the foot
L5
Extensor
Dorsiflexion of
hallucis longus the great toe
S1
Gastrocnemius Plantarflexion
of the foot,
Achilles reflex
S2-4 Anal sphincter, Rectal volition,
bladder
Bulbocavernosus
reflex
TOTAL POSSIBLE POINTS
Thumb
Middle finger
Little finger
Armpit
Inner thigh
Just above patella
Medial malleolus
Great toe
Lateral malleolus
Rectal sensation
(score only motor)
the great vessels to the neck, thyroid, esophagus, trachea and lungs, mediastinum, ribs, brain stem, oropharynx, skull base, and facial bones. Overall, SCI
is associated with other organ injury in 40-60% of cases.
Cervical fractures have a 16-20% incidence of noncontiguous distal spine
fractures.
Neurogenic shock with hypotension (SBP<90) and bradycardia is frequently
encountered in patients with cervical spine injury above C5-6. This is a result
of sympathetic outflow denervation and resultant unopposed parasympathetic
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Spinal Injuries
Table 44.3. Neurological syndromes of SCI

Syndrome
Description
Treatment / Prognosis
Bulbar-Cervical
A lesion above C4 that produces

almost immediate cardiopulmonary arrest and death if CPR
is not started within minutes.
Ventilator dependent. Very poor
prognosis and long-term
survivability.
no acute surgery unless

highly unstable
wait for hemodynamic
and autonomic stability
Central Cord
A lesion, occurring almost exclusively in the central portion of

cervical spinal cord, that produces sacral sensory sparing
and greater weakness in the
upper limbs than lower limb.
Often preexisting congenital or
degenerative stenosis.
Hyperpathia to sensory stimuli
is common. Lhermittes sign
sometimes seen
classic teaching is to
postpone surgery
allow for cord edema
and hematoma to pass
delayed surgery to
correct stenosis
good chance of delayed
leg function recovery
Anterior Cord
A lesion that produces dissociated if compressive element

loss of motor function and of
seen, early surgical
sensitivity to pain and
decompression may be
temperature, while preserving
warranted
proprioception. Bilateral
worst prognosis with
paraplegia. May be result of
only 20% motor recovery
either anterior spinal artery
ischemia or compression from disc
or bone.
Brown-Sequard
A lesion that produces relatively

greater ipsilateral proprioceptive
and motor loss and contralateral
loss of sensitivity to pain and
temperature. Usually from penetrating trauma, epidural hematoma, radiation, large disc
herniations, spondylosis
best prognosis of incomplete lesions

90% regain ability to
ambulate independently
rare indications for
surgery except sometimes
for debridement after
penetrating trauma
Cauda Equina
Injury to the lumbosacral nerve

roots within the neural canal
resulting in areflexic bladder,
bowel, and lower limbs. Usually
poor return of bowel/bladder
function
surgery usually
beneficial within 24-48
hours
delayed root escape or
improvement common
44
464
Trauma Management

Conus Medullaris Injury of the sacral cord (conus) as with cauda equina
and lumbar nerve roots within
syndrome
the neural canal, which usually
results in an areflexic bladder,
bowel, and lower limbs. Sacral
segments may occasionally show
preserved reflexes, e.g., bulbocavernosus and micturition reflexes.
44
cardiovascular input. Loss of muscle tone distal to the level of injury causes
peripheral vascular pooling and relative hypovolemia. This is exacerbated by
dehydration in the field and associated blood loss which causes true hypovolemia.
Such patients are hypotensive with decreased cardiac output and are characterized by a warm shock type of clinical picture.

For the awake patient, a careful physical and neurological examination can
accurately define the level and degree of cervical injury. Due to the often
complex trauma involved in cervical spine injury, such a thorough exam is
not possible for several reasons:
- Head trauma causing obtundation or neurological deficits masking spinal cord
injury.
- Obtundation of the patient due to shock, hypoxemia, or toxins.
- Critical trauma to other organ systems requiring more urgent management.
- Patients can have a syndrome of Spinal Shock which must be differentiated
from neurogenic shock. Spinal shock is believed to be the spinal equivalent of
concussive injury to the brain. Findings include a loss of distal segmental reflexes
and a loss of the bulbocavernosus reflex as a result of this mechanism. Neurological examinations made in the face of such spinal shock must be qualified.
The majority of these patients resolve within 5-10 days, but some may take
several months.
- Exaggerated sympathetic and parasympathetic responses to simple stimuli such
as cough, touch, gag, or valsalva maneuver are common after spinal cord injury
(SCI) and make management problematic. This syndrome is commonly
referred to as dysautonomia. Atropine, pressors, beta-blockers, and even pacemakers are sometimes needed to manage this difficult problem which can last
from a few weeks to even a year.
Investigations
For most cases of complex trauma and cervical injury, physical examination
and radiographic evaluation form the two pillars of emergent diagnosis. A
complete set of emergency room cervical radiographs should include:
1. Standard lateral c-spine visualizing the occiput to at least C6
2. Anteroposterior (AP) view and an open-mouth (OM) view of the odontoid
(Fig. 44.3)
3. Lateral swimmers view to examine the cervicothoracic junction (C6-T2) as
fractures in this region are often missed by standard c-spine views.
Spinal Injuries
465
44
Fig. 44.3. Odontoid fracture. a) Lateral x-ray with anterolisthesis and fracture of
dens tip, b) open-mouth view showing type II fracture line at base of dens, c) axial
CT showing fracture at base of dens, d) classification of odontoid body fractures.
A standard lateral view will detect 65-79% of cases. The addition of

the AP and OM views will increase the sensitivity to 90-95%. The
integrity of the spinal canal is, however, not well demonstrated by any
of these views (Figs. 44.3, 44.4).
Computed tomographic (CT) scans are used to delineate the bony anatomy
of fractures or deformities seen or suspected on plain radiographs. In many
trauma centers, high-speed spiral CT scanning of C1-T1 has become the
standard screening tool for cervical injury. CT axial images are the best way to
visualize canal compromise by bony fragments. Sagittal reconstructions are
helpful to visualize the canal and the overall alignment of C1-T2. Concurrent
use of myelography with CT increases the sensitivity for other soft-tissues not
well visualized by x-ray (i.e., herniated discs, hematoma).
The greatest weakness of plain radiographs and even CT scanning is their
insensitivity to ligamentous and soft tissue injury. Subluxations, dislocations,
and other deformities have often spontaneously realigned by the time the
patient reaches the emergency room.
- Careful inspection of the prevertebral soft-tissue thickness, the atlanto-dens
interspace, the basion-dens distance, MacGregors lines, the interspinous process distances and alignment, the alignment of the bodies and facets, and the
disk spaces themselves can provide subtle clues of underlying ligamentous
466
Trauma Management
44
Fig. 44.4. C4/5 bilateral locked facets. a) lateral x-ray with more than 50% displacement and soft-tissue swelling, b) axial CT showing inferior facets of C4 anterior to superior facets of C5, c) sagittal MRI with deformity and acute herniated disk
compressing cord.
injury. Interpretation of all films by a qualified and experienced person is

mandatory.
Subluxation greater than 3.5 mm at any level on lateral x-ray or angulation greater
than 11 of one body relative to the next highly suggests ligamentous laxity.
On a lateral C-spine film, a pretracheal soft tissue thickness greater than 6 mm
at the base of C2 or 22 mm at the midbody of C6 is highly suggestive of
ligamentous injury or underlying fracture.
An atlanto-dens interspace greater than 4-5 mm in adults as seen on a lateral
x-ray is abnormal. In children, this soft-tissue can be up to 6-9 mm in thickness
normally.
Rule of Spence states if the sum of the lateral overhang of both C1 lateral
masses on C2 is greater than 7 mm as seen on the OM view, the transverse
ligament holding the odontoid to the C1 ring is likely torn and requires
additional immobilization as a standard collar is inadequate.
Spinal Injuries
467
Spinal cord injury without radiographic abnormality (SCIWORA) is seen in

a subgroup of those rare children who have spinal cord injury. They are usually
1.5-16 yrs of age. On MRI and surgery, the cord will show contusion, transection, stretch injury, or meningeal rupture. There is a latent period between the
time of injury and objective sensorimotor findings of 30 minutes to 4 days in
54% of children. MRI will often demonstrate soft tissue injury in these cases.
Flexion-Extension x-rays are controversial in the acute setting and carry a risk
of worsening pre-existing injury. They are used to detect occult ligamentous
instability especially that of the posterior complex.
- The patient should be cooperative, alert, and neurologically intact.
- There should be no fractures or subluxations on the screening films.
- The patient should be instructed to slowly flex the head and stop if there is
pain. Typically, the patient is lying supine during these films but can be allowed
to sit if he is able to. A lateral film is taken at 5-10 increments or at the point
where the patient can go no further. This same procedure is repeated in extension.
Normally, a small degree of anterior subluxation distributed over all cervical
levels is seen in flexion with preservation of the normal contour lines.
Magnetic-resonance imaging (MRI) is the best means of assessing injury to

the ligaments, spinal cord parenchyma, and other paravertebral soft tissues. It
is indicated for patients with incomplete or complete deficits, neurological
deterioration, fracture level different from level of deficit and suspected cases
of ligamentous injury. Recent studies have shown a high rate of missed disk
herniations and canal compromise by x-ray and CT (Fig. 44.4c).
- Global use of MRI for patients with cervical injury is limited by prolonged
scanning times, lack of adequate equipment and support staff to monitor critical
patients in the MRI area, and unavailability of the MRI scanner after hours.
Emergent CT myelography via C1-2 puncture to achieve adequate dye concentrations may be used as an alternative in such cases. CT scanning of the spinal
canal with the use of high dose intravenous contrast has also been used to visualize
hematoma, tumor, and infections in the epidural space.
Education of emergency medical personnel, paramedics, and police officers in
proper extrication techniques and immobilization of the cervical spine is crucial
to prevent exacerbation of SCI in the field. Proper placement and positioning
of a rigid cervical collar and securing the patient to a rigid backboard for
transport are essential elements of field management.

In the face of other critical or life-threatening injuries, treatment of cervical
spine injuries can take second priority as long as the patients neck is properly
immobilized and there is no evidence of evolving deficit. Special areas of concern
for cervical injury patients include:
- Hypotension should be treated without any delay in order to avoid secondary
cord damage.
- Progressive respiratory compromise from cervical injury and thoracic trauma
may require emergent intubation. For cases with a high suspicion of SCI and
instability, fiberoptic intubation is optimal as it requires little neck movement.
If technically unfeasible, standard endotracheal intubation is reasonable with
in-line cervical traction to limit movement.
44
468
Trauma Management
- Paralytic ileus is common after SCI and should be treated with nasogastric
tube placement to prevent vomiting, aspiration, and to decompress the
distended abdomen.
- An atonic bladder can become severely distended after SCI due to loss of
voluntary control. An indwelling catheter should be placed to decompress the
bladder and to accurately assess the patients volume status.
- Heating and cooling blankets are often needed to treat poikilothermia (loss of
thermoregulation) resulting from vasomotor paralysis in SCI patients.
In a series of double-blinded studies (NASCIS I, II, and III), the use of glucocorticoids has not been conclusively shown to have a significant impact on
SCI patients. Subgroup analysis of the same data has suggested that complete
and incomplete patients who received the drug within 8 hours of injury may
have beneficial motor or sensory effects at 6 weeks, 6 months and 1 year.
44
- Despite the controversy, many trauma centers in the country have adopted
protocols for use of glucocortioids in the management of acutely injured
patients. The most common protocol applies to all patients with spinal cord
injuries presented within 8 hours of injury. High doses of methylprednisolone
sodium succinate (MPSS), are administered as a 30 mg/kg loading dose followed
by continuous 5.4 mg/kg/hr dosage for 23 hours.
- Relative contraindications to acute steroid administration include penetrating
injuries such as stab and gunshot wounds, life-threatening systemic instability,
pregnancy, narcotic addiction, very young age, evidence of severe sepsis or
infection, and a history of a compromised immune system.
- Several other pharmacotherapy agents such as Tirilizad, Lazaroids are currently
being investigated. Their clinical benefits remain unclear.
Immobilization with a cervical collar and backboard is indicated for all

patients with suspected cervical injury during the acute phase of their
evaluation. Extreme care during patient transport, transfers, and movement
are essential as well.
- For many patients, a hard cervical collar is inadequate for immobilization beyond
the first few hours. Examples include:
- Cases of severe ligamentous injury at any level
- Severe fractures of the occipito-atlanto-axial areas
- Type I, II, III odontoid fractures
- Severe flexion distraction injuries
- Fractures of the cervicothoracic region
In such cases, additional immobilization can be provided by a variety of possible devices. These devices can be applied in the emergency room by experiences personnel.
- SOMI braceSternal-Occipital-Mandibular-Immobilzation adds additional
rigidity over Philadelphia collar to upper cervical spine by addition of cervical
posts. Yale orthosis is similar. The SOMI provides moderate resistance against
flexion but is inadequate for preventing extension due to weak occiput support.
- HALO braceConsists of a form-fitting, lightweight chest vest attached to a
CT compatible ring that is anchored to the skull via a set of pins. It is very
effective at limiting movement in all planes of the upper cervical spine and can
also be used as an adjunct after operative fusion. It is not completely rigid with
significant snaking forces especially at the lower cervical spine and
cervicothoracic junction. Some complications associated with its use are patient
Spinal Injuries
469
intolerance, pneumonia, pin-site infections, and cerebrospinal fluid leakage. They

have a 25-50% rate of failure when used alone for bilateral jumped facets and
other severe flexion-dislocation injuries. HALO should not be placed acutely in
patients with unstabilized thoracic or abdominal injury as access to these areas
will be severely limited.
- Gardner WellsOne of numerous cranial tongs that are used to not only
maintain normal alignment but also to reduce fracture-dislocations and to
decompress fragments from the canal via ligamentotaxis. A HALO ring may be
used in place of traditional tongs such that it may be attached to a vest at the
appropriate time (i.e., after operation).
Surgical Indications
For the majority of cervical spine injury patients early surgery is not warranted
due to the attendant risks of polytrauma and multiorgan instability. There are
few indications for emergent surgery on spinal injury. These include progressive
neurological deficit, incomplete injury, an enlarging hematoma with neurological compression, gross cerebrospinal fluid leak, heavy contamination and
soilage due to open or penetrating trauma, and acutely worsened deformity
that cannot be reduced by closed means.
In patients with complete spinal cord lesions, early surgery does not result in
significant return of function over that observed by just rehabilitation alone
after one year. The aim of delayed surgery is for stabilization to allow for early
mobilization of the patient, psychological benefit, and the initiation of an
aggressive rehabilitation program. For most cases, surgery within one week is
effective in minimizing pulmonary and infectious complications from SCI.
For patients with incomplete spinal cord injury, a careful search for a compressive fragment or other element compromising the spinal canal should be
made. For incomplete injury that does not improve with traction or worsens
during observation, early surgical decompression and stabilization may facilitate
some return of function and prevent further deterioration. An exception is the
central cord syndrome which is described in Table 44.3. For such cases, the
majority of surgeons will delay intervention for 4-6 weeks to allow resolution of
the spinal cord edema and for maximal return of neurological function.
A detailed discussion of the techniques of spinal surgery is beyond the scope
of this manual. Briefly, spinal surgery is divided primarily into anterior and
posterior approaches. The exact choice in approach depends on the pathology
and area of instability found in each case. Anterior techniques include cervical
discectomy, corpectomy, with strut grafting, and cervical plating. Posterior
approaches include the use of interspinous, interlaminar, interfacet wiring with
bony grafting. Modern advances in instrumentation have also made the use of
lateral mass screws and plates as well as pedicle screws and rod systems possible in the cervical spine. Complex deformity correction is difficult intraoperatively and should be essentially completed by closed reduction means. Due
to the weaker nature of cervical constructs, HALO or other rigid cervical
orthoses is needed postoperatively to supplement the fusion for several weeks.
Specific C-Spine Injuries

Atlanto-occipital (AO) Dislocation
- 1% of cervical spine injuries
44
470
Trauma Management
- Extreme range of presentation: intact or with bulbar-cervical dissociation and
arrest. May also have lower cranial deficits and worsening with cranial traction
(see below).
- Stability depends on ligaments of occipito-atlanto-axial complex of which the
alar ligaments and tectorial membrane are the most important for AO stability.
- Cervical traction should not be used to reduce this dislocation. Can use 2-4 lbs
for immobilization purposes. It is controversial whether AO injuries should be
operatively fused or simply immobilized with a HALO brace for 4-8 months.
Atlas (C1) Fractures
44
- Account for 3-13% of cervical fractures. Patients will have an isolated fracture
of C1 (56%), combination C1-2 fractures (44%), head injuries (21%), and
noncontiguous subaxial cervical spine fractures (9%).
- Sir Geoffrey Jefferson fractureclassically described as fracture through
thinnest portion of C1 arch in four places causing a blowout appearance
with centrifugal displacement of the ring. This fracture is unstable as a result.
- There are many variants of C1 ring fractures ranging from isolated linear breaks
which are stable to the above. Careful x-ray and CT visualization is needed to
diagnose them. See Investigations below Rules of Spence.
- Most are neurologically intact due to the large canal diameter at C1.
- Isolated C1 (Atlas) Fractures
Based on the rules of Spence, nondisplaced fractures (37%) can be treated
in a SOMI or standard cervical collar. Fractures with a total displacement of
< 7mm (47%) can be managed in a rigid collar, SOMI, or HALO vest.
Those with > 7 mm total displacement (16% of cases) should be managed
with prolonged HALO immobilization.
Few cases require surgical intervention. Nonunion after bracing is rare.
Hangmans Fractures
- Also known as traumatic spondylolisthesis of the axis resulting from hyperextension and axial loading. This results in a bilateral fracture through the pars
interarticularis which connects the C2 body to the posterior laminar ring.
- There is usually accompanying angulation and subluxation of C2 on C3.
- Type 1-Less than 3 mm subluxation. Stable. Rare deficit. Can be immobilized
- Type 2-C2/3 disk and posterior longitudinal ligament disrupted with greater
than 4 mm subluxation and angulation over 11. Rarely have a deficit, but may
have early instability requiring surgery.
- Type 2aLess displaced but more angulation (> 1.5) than type 2. These are
result mainly from a severe flexion injury and require surgery. Cervical tong
traction often worsens the angulation.
- Type 3C2/3 facet capsules are disrupted with fracture through isthmus as
well. Both the anterior and posterior longitudinal ligaments are torn. Facets
often locked. Mainly from severe flexion. These are rare injuries usually with
neurological deficit and can be fatal.
As a group, 95% are neurologically intact with most minor deficits recovering
in 1 month. Persistent pain and occipital neuralgia is not uncommon.
Nonsurgical reduction of stable Type 1 and 2 fractures produces adequate
reduction in 97-100% of cases. A simple collar or SOMI for 8-14 weeks is
adequate in over 95% of patients.
Unstable type 2, 2a, and 3 fractures, should undergo early immobilization
with either gentle traction with minimal weight or a HALO vest. If reduction
Spinal Injuries
471
is achieved with gentle traction, a trial of HALO vest immobilization for

8-12 weeks in type II fractures. Inability to reduce type II injury, failure of
external immobilization, disk herniation, progressive deficit, and type III
fractures should undergo surgical fixation.
Odontoid Fractures (Fig. 44.3)

- Account for 10-15% of cervical spine fractures and usually require significant
force in the young (i.e., MVA, fall from height, etc). In patients over age 70,
simple falls with head injury can produce fractures in an osteoporotic C2 body.
- There is a high incidence of immediate fatalities estimated at 25-40% in the
field. Common symptoms are high posterior cervical pain, paraspinal spasm,
the need of the patient to support the head with the hands when rising from the
supine to the upright position, upper extremity paresthesias, and hyperreflexia.
- They are subclassified on the basis of the vertical location of the fracture
(Fig. 44.3d).
Type 1-fracture through tip of dens, may be unstable
Type 2-fracture through base of dens, most common
There is a 30% nonunion rate for cases > 4 mm displacement.
For cases with > 6 mm displacement, up to 70% nonunion reported.
Surgical treatment is recommended for patients over 7 years old who have
> 6 mm displacement, instability in a HALO, and nonunion.
Type 3-fracture through the body of C2 involving the marrow, over 90% of
these cases will heal with HALO immobilization and analgesics.
Subluxation and Locked Facets

- Minor flexion injuries may cause subluxation or unilateral locked facets if there
is a rotary component. Severe flexion injuries can result in bilateral locket facets.
Facets that are not completely locked are termed perched facets (Fig. 44.4).
- Patients with unilateral locked facets are usually neurologically intact.
- Bilateral locked facets are usually associated with a greater amount of injury to
the facet capsules and long spinal ligaments. As such they have a much higher
proportion of neurological injury.
- Attempts at early reduction with traction and manipulation under radiographic
guidance are indicated. Caution to exclude a herniated disk seen in 10-30% of
these cases should be exercised. Up to 70% of these patients may fail subsequent
HALO immobilization and require surgery. Patients with bilateral locked facets
should undergo surgical ORIF.
Thoracolumbar Spine Fractures

The region of the human spine from T1 to L5 can be divided into three
distinct segments based on their anatomical differences and predisposition to
injury.
- The thoracic segment, from T1 to T9, has a lower incidence of fracture owing
to the relative stability afforded by the rib cage. Because a greater amount of
force is required to overcome this stability, fractures in this area typically herald
serious injury to the thoracic cavity and content.
- The region between T10 and L2, commonly known as the thoracolumbar spine,
is where the majority of spine injuries occur. The lack of support from the rib
cage and its relatively more rigid construct make the thoracolumbar spine more
vulnerable to external forces by acting as a stress riser at this region.
44
472
Trauma Management
- The region from L3 to S1 forms the lower lumbar spine. Due to its greater
mobility, this segment of the spine experiences a different fracture pattern when
compared to the rest of the spine.
Incidence
Approximately 40,000 potentially unstable injuries to the thoracic and lumbar
spine occurred each year in the U.S, an incidence of 1 per 20,000 per year;
50-70% occurred between T10 and L2.
Most common mechanisms of injury include motor vehicle accidents (40%),
violence (36%), sports (15.2%), and falls (7.5%) with patients are predominantly male and under 30 years of age.
Classification
44
Like the cervical spine, many classification schemes have been proposed to
describe spinal fractures.
Three-column theory: The spinal column is divided in three distinct parts.
The anterior column includes the anterior longitudinal ligament, the anterior
annulus, and the anterior half of the vertebral body. The middle column consists
of the posterior longitudinal ligament, the posterior annulus, and the posterior
half of the vertebral. The posterior column encompasses the neural arch, facet
joints, and capsules, ligamentum flavum, and remaining ligamentous complex
(Fig. 44.1).
- Failure of at least two columns leads to instability and is indicative of surgical
management.
The McAfee classification identifies six fracture types based on their morphological features on CT scans (Table 44.1, Fig. 44.2).
The clinical work-up and management of patients with thoracic and lumbar
(TL) injury is very similar to that already described for cervical SCI.
Roll patient to allow inspection and palpation of spinal column, checking for
localized tenderness, gaps between spinous processes, swelling, and deformities.
Even in cases of established thoracic or lumbar fracture, patients should not
be kept on a backboard for very long. Usually strict flat bedrest is adequate
during the acute management of the patient. Once the patient has been
stabilized, a TLSO (Thoracic-Lumbar-Sacral Orthoses), 3-point extension,
Jewett, LSO, or other rigid brace can be placed to allow for some mobilization of
the patient.
The degree of neuronal compromise is assessed by performing a careful neurological examination, including a complete evaluation of patients motor and
sensory functions. The ASIA impairment scale helps define the extent of neural injury (Table 44.2A, 44.2B).
Several subtypes of incomplete neural injury have been described and should
be identified (Table 44.3).
An alternative way to categorize a fracture and determine treatment is to
consider the degree of injury (Table 44.4).
For thoracic and lumbar injuries, 70% will have no neurological deficit at
presentation.
- The majority of patients with only compression fractures have no deficit
473
Spinal Injuries
Table 44.4. Stratification of instability for treatment

Injury Degree Pathology
First
Severe compression fractures
(> 40%) or seat belt injury
Treatment
External immobilization
Second
Burst fractures with or

without neurologic injury
Open reduction and

stabilization
Third
Severe burst fractures with

3-column involvement or
fracture-dislocations
Realignment and/or
decompression and
stabilization
- Patients with mild bony flexion-distraction injuries and seat-belt type injuries
are usually intact.
Patient may experience spinal shock, producing neurologic impairment away

from suspected site of spinal injury that usually resolves within a few days.
Neurogenic shock from isolated thoracic and lumbar injury without cervical
involvement is rarer but can occur.
Autonomic hyperreflexia can occur in 30-50% of patients with lesions above
T7 (see C. Rehabilitation and Chronic Management).
It is essential to elicit bulbocavernosus reflex and check for anal tone as part of
the neurologic examination. Preservation of perianal pinprick sensation, voluntary rectal tone, and great toe flexion are considered signs of sacral sparing
and reflect some structural continuity of the spinal tract. Attempts to preserve
and improve the neural functions should be done in a timely fashion.
Investigation
Radiographic assessment of the injury forms the cornerstone of diagnosis and
management of spinal injuries. The common modalities include plain x-rays,
computed tomography, and magnetic resonance imaging.
As opposed to the cervical spine, there is no standardized set of thoracic and
lumbar radiographs. When the patient is awake and able to relay where he has
spinal tenderness, AP and lateral views of the spine should be obtained in that
region. These films must include recognizable vertebral landmarks (i.e.,
cervicothoracic junction, lumbosacral junction, eleventh/twelfth rib) such that
one can accurately count and localize the level of fracture and injury. For a comatose or noncooperative patient, it is generally prudent to obtain a full set (AP/
lateral thoracic, lumbar, sacral) of films to rule out injury (Fig. 44.5).
If one fracture is detected, a complete spinal series is indicated to rule out
noncontiguous fractures even if the patient is not symptomatic at other levels.
Such concurrent fractures occur in 10-30% of cases.
No well-defined rules for detecting ligamentous instability exist for the thoracic
and lumbar spine as they do for the cervical spine. A careful inspection of the
distances between the spinous processes on the AP view and for any other
evidence of subtle deformity can help detect ligamentous injury.
Patients with severe fractures of the thoracic spine should have a full radiographic evaluation of the bony rib cage and sternum as there is a high incidence
of associated fracture. For lumbosacral fractures, a full radiographic evaluation
of the pelvis and proximal femurs is indicated as well.
44
474
Trauma Management
44
Fig. 44.5. Thoracolumbar (T12) fracture. a) lateral x-ray of a T12-thoracolumbar

burst fracture, b) sagittal MRI shows conus compression by bone and hematoma, c)
axial CTs show sagittal split, laminar fracture, and bone fragments in canal.
CT is the diagnostic test of choice to delineate the bony anatomy. For thoracic
fractures between T2-T8, the scapula and upper extremities make lateral radiographs virtually impossible. CT scanning with sagittal reconstruction in
this area is the only good way to visualize the alignment and bony relationships here. Intrathecal contrast and/or myelograms should be considered to
evaluate soft tissue masses within the canal. For severe thoracic and lumbar
fractures, concurrent CT scanning of the thoracic and abdominal cavities is
prudent as well.
MRI is helpful in assessing the integrity of the spinal ligaments, which are
crucial in determining the stability of the spinal elements. MRI is indicated if
patient has
- progressive neurologic deterioration,
- incongruous neurologic and skeletal injuries,
- unexplained neurologic deficit.
Preoperative digital spinal angiography can be performed to identify and avoid

surgical interruption of the radiculomedullary artery of Adamkiewicz. This
artery occurs at T5-8 in 15%, T9-12 in 75%, and L1 or L2 in 15% of patients. Severe fractures of the thoracic and lumbar spine are sometimes (<10%)
associated with vascular injury to the great vessels. Standard angiography or,
recently, high-speed CT angiography should be used in any suspicious cases.
Spinal Injuries
475
Prehospital management of the patient with thoracic and lumbar injury is
very similar to that described for cervical patients. Particular attention to maintain the patient on a backboard during transport and to keep him as flat as
possible is essential. Braces for the thoracolumbar area are not usually applied
in the field as access is needed to the chest, abdomen, and pelvis during acute
trauma management.

It is essential to identify and address any life-threatening injury before attending to the patients spinal cord injury. However, proper precautions should be
taken to prevent further neurological injury.
Concomitant injuries occur in 47-60% of patients of spinal injury. These
injuries may confuse or mask the clinical presentation of spinal injury. A complete trauma work up is necessary to delineate these injuries.
Persistent localized tenderness despite normal radiographs is associated with
occult fracture in more than 30% of patients.
Hemodynamic stability is often compromised in patients with spinal cord
injury. Hypotension is a common presentation secondary to either neurogenic shock, or hypovolemic shock.
Neurogenic shock is characterized by a loss of vascular tone followed by an
increase in vascular capacitance. It is typically associated with cord trauma
above T6 resulting in sympathetic denervation. It is rarely seen in thoracolumbar injury. It is treated with volume replacement followed by vasopressors if
shock persists.
Lumbosacral spinal injuries are often accompanied by pelvic trauma. A complete pelvic, renal, gynecologic, urologic investigation should be performed.
Surgical Indications
The stability of the injury, determined by structural integrity and neurological status, dictates the management of the patient (Table 44.5).
For stable fractures, a conservative management combining adequate immobilization and appropriate physical therapy will suffice. The only exception is
when canal compromise and neural deficit are documented and deterioration
occurs.
In case of unstable fracture, prompt surgical stabilization and decompression
has been shown to produce early mobilization and fewer late complications
resulting from prolonged bed-rest.
When the canal is compromised, surgical decompression of the spinal cord
may lead to a better long-term prognosis and improved recovery.
Though controversial, early surgical management in these patients has led to
early mobilization and resulted in less long-term complications

When to Operate
The primary accepted indication for emergent surgical treatment in a patient
with a thoracolumbar fracture is progressive neurologic deterioration.
For patients with multi-system injury, early surgery (24-48 Hrs) can result in
increased blood loss and is associated with a higher incidence of complications.
44
476
Trauma Management
Table 44.5. Surgical management guidelines for SCI

Spine Structure
Neurologic
Treatment
Stable
Stable
Stable
Normal
Complete
Incomplete
Unstable
Unstable
Complete
Incomplete
Nonsurgical
Nonsurgical
Decompression and stabilization,
anterior or posterior
Posterior stabilization
Decompression and arthrodesis,
anterior with plates, posterior or 360
What Approach to Take
44
Patient with a distractive injury of the posterior elements that occurred with
flexion-distraction injuries, Chance-type injuries, and fracture-dislocations are
best treated with posterior instrumentation.
Patients with unstable burst injuries and incomplete paraplegia associated with
high-grade spinal canal stenosis from anterior bony or soft-tissue compression
may benefit in the long term from immediate anterior decompression.
Patients with unstable burst fractures and lesser degrees of canal stenosis can
be treated by posterior instrumentation.
Indications for anterior decompression and grafting include anterior neural
compression and increasing neurologic deficit, incomplete recovery, persistent
pain, deformity, or pseudoarthrosis. Late indications for surgery again include
nonunion, persistent instability, pain, and pseudoarthrosis as well.
Intraoperative somatosensory-evoked potential (SSEP) monitoring is indicated
in patients who are neurologically intact or who have incomplete paraplegia.
Outcome of SCI Patients

Rehabilitation
Studies have indicated that early initiation of rehabilitation results in earlier
discharge and improved mobility. Rehabilitation should be a multi-disciplinary
effort, including contribution from physicians, nurses, physical and occupational
therapy, social workers, and psychologist.
The primary goal is to restore physical strength, improve daily living skills,
and achieve emotional stability.
Studies have demonstrated that patients admitted to the system within 24
hour of injury are less impaired at discharge than those with same impairment
who are admitted later.
The long-term survivability in spinal cord injury depends on the age of patient
at injury and the extent of the injury (Table 44.6).
Because of their often sedentary lifestyle, difficulty in adjustment, and use of
urinary catheterization, health providers of patients with spinal cord injury must
be aware of some potentially fatal long-term complications (Table 44.7). Prolonged ventilator dependence, chronic atelectasis and recurrent pneumonia, deepvein thrombosis, spasticity, Charcot-type progressive deformity, syringomyelia,
shoulder-hand syndrome are all problems facing the chronic SCI patient.
Autonomic hyperreflexia (AH) is a particularly dangerous aspect of chronic
SCI management. It is characterized by an exaggerated autonomic response
477
Spinal Injuries
Table 44.6. Survivability of SCI subgroups based on age

Age at injury
20
40
60
Paraplegic
Incomplete
33.2%
18.0%
6.5%
Paraplegic
Complete
32.1%
17.0%
5.9%
Quadriplegic
Incomplete
27.4%
13.8%
4.2%
Quadriplegic
Complete
20.1%
9.3%
1.9%
Table 44.7. Leading causes of death in SCI

Cardiac disease
Diseases of the respiratory system
Accidents, poisoning, violence
Circulatory disease
Infection
Genitourinary
Neoplasm
20.9%
20.5%
9.7%
8.8%
8.8%
4.0%
3.9%
(usually sympathetic) to normal or mildly noxious stimuli. These include

bladder distension or irritation (76%), colonic distension or impaction (19%),
skin ulcers or infection (4%), DVT, and other cutaneous or visceral stimuli.
- It occurs in 30% of quadriplegic and high paraplegic patients from 4-16 weeks
after injury and usually does not occur in lesions below T6.
- It is manifested by paroxysmal HTN (90%), anxiety, diaphoresis, piloerection,
pounding headache, mydriasis, blurred vision, flushing (25%), tachycardia
(38%), bradycardia (10%), fasciculations, increased spasticity, priapism, and
Horners syndrome. Hyperhydrosis and facial flushing with pallor and vasoconstriction elsewhere differentiate AH from pheochromocytoma.
- Treatment includes elevating the HOB, eliminating the offending stimulus (check
bowel, bladder, skin, binding clothes, etc), seizure prevention in hypertensive
crisis, antihypertensive medications (nifedipine, hydralazine, nipride), and
relief of spasm with diazepam which is also an anxiolytic.
- Recurrent AH can be treated by phenoxybenzamine (alpha-blockade), betablockers, Pyridium to prevent UTI, good bowel/bladder/and skin regimen, and
appropriate anesthesia during any manipulation or procedures.
References
1.
2.
3.
4.
5.
Aebi M. Surgical treatment of cervical spine fractures by AO spine techniques. In:

Bridwell KH, DeWald RL, eds. The Textbook of Spinal Surgery. Philadelphia:
Lippincott 1991; 1081-1105.
Chapman JR, Anderson PA. Thoracolumbar spine fractures with neurological deficit. Orthop Clin 1994; 25(4):595-611.
Fessler RG, Masson RL. Management of thoracic fractures. In: Menezes AH,
Sonntag VKH, eds. Principles of Spinal Surgery New York: McGraw-Hill 1996;
899-918.
Harris JH, Mirvis SE. The radiology of acute cervical spine trauma, 3rd ed. Baltimore: William & Wilkins 1996.
Rizzolo SJ, Cotler JM. Unstable cervical spinal injuries: Specific treatment approaches. J Am Acad Ortho Surg 1993; 1:57-66.
44
478
Trauma Management
6.
7.
44
Waters RL, Adkins RH, Hu SS et al. Penetrating injuries of the spinal cord: Stab
and gunshot injuries. In: Frymoyer JW, ed.The Adult Spine: Principles and Practices, 2nd ed. Philadelphia: Lippincott-Raven 1997; 919-930.
Wilberger JE, Sarkarati M, Benzel EC et al. Medical management of adult and
pediatric spinal cord injury. In: Benzel EC, ed. Spine Surgery: Techniques, Complication Avoidance, and Management. New York: Churchill Livingstone 1999;
1303-1320.
MISCELLANEOUS TOPICS
CHAPTER 45
Pediatric Trauma
M. Margaret Knudson
Epidemiology of Pediatric Trauma
Injuries remain the number one cause of death and disability among children
and adolescents. Most deaths that occur in children occur in the prehospital setting;
thus injury prevention programs are the most effective method of preventing death
following injury. Data on the mechanism of injury in pediatric trauma collected by
the National Pediatric Trauma Registry (NPTR) is shown in Figure 45.1.
Note that most of these children were not using appropriate protective devices
when the injuries occurred. Other data from the NPTR has shown that:
blunt injuries are the most prevalent in all age groups
falls are the major mechanism of injury in children < 10 yrs old
pedestrian injuries carry the highest mortality in children < 10 yrs old
in adolescents, motor vehicle trauma is the major mechanism
in adolescents, GSW are the most lethal (10% mortality)
overall mortality in children reaching a hospital is low, 3%
those that die in the hospital do so within 24-96 hours
Prehospital Care
As with adult trauma patients, injured children should be transported quickly to
a center equipped to care for them. This might be a general trauma center or a
pediatric hospital that also serves as a trauma center. All prehospital vehicles that
transport the injured must carry equipment for various sizes of children. Appropriate prehospital measures for injured children include:
application of oxygen
intubation of children in shock, or with airway compromise
intubation of children with major head trauma (i.e., GCS < 8)
measurement of oxygen saturation with pulse oximetry
measurement of blood pressure with proper-sized cuff
application of measures to prevent heat loss
establishment of IV access only if transport time >20 minutes
maintaining cervical spine precautions
Resuscitation
Airway
Intubation of a child should proceed promptly if the child has airway compromise, a major head injury (GCS<8), or is hypoxic and or in shock.. The technique
of rapid sequence intubation is outlined in Algorithm 1. Important considerations
in pediatric airway include:
M. Margaret Knudson, University of California, San Francisco, California, U.S.A.
Pediatric Trauma
481
45
Fig. 45.1. Mechanism of injury in pediatric trauma. Data from the 1999 Report of
the National Pediatric Trauma Registry.
482
Trauma Management
45
errors in airway management have resulted in prehospital deaths

infants are obligate nose breathers; thus the nares should be cleared
the sniff position (advanced midface) holds the airway in neutral
the sniff position can be obtained by placing a small towel behind the occiput, while maintaining spine precautions
simple clearing of the airway should be attempted first
for children less than 12 years, nasotracheal intubation in contraindicated
the appropriate sized endotracheal tube can be estimated from the diameter of
the childs small finger (Table 45.1)
the pediatric larynx is anterior and cephalad compared to an adult
the pediatric trachea is short (5 cm at birth) and soft
cuffed endotracheal tubes are generally not used
once the tube is secured, listen in the axilla for breath sounds
confirm placement of the endotracheal tube with a chest x-ray
emergency room tracheostomy is contraindicated in a child
the preferred surgical airway is a temporary needle cricothyroidotomy
Venous Access and Fluid Resuscitation

Once the airway has been secured, resuscitative efforts should be directed at
establishing intravenous access. A protocol should be established (and followed) so
that valuable time is not wasted by numerous attempts at establishing lines.
Development of hypotension following hemorrhage is a relatively late sign of shock
in children and demands prompt attention (Table 45.2).
make two attempts at peripheral access
preferred peripheral access sites include the back of the hands, antecubital
fossa, and saphenous vein at the ankle
Table 45.1. Appropriate tube sizes for children

Age
Endotracheal Tube
Thoracostomy Tube
Premature infant
Toddler
6 year old
Adolescent
2.5 mm
3.0 mm
5.5 mm
7.0 mm
12F
20F
24F
32 F
Adapted from Lubitz DS, Siedel JS, Chameides L et al. A rapid method for
estimating weight and resuscitation drug dosages from length in the pediatric age
group. Ann Emerg Med 1998;17:567.
Table 45.2. Normal vital signs by age
Infant (< 1y)

Preschool (<5y)
Adolescent (>10y)
Pulse
Systolic blood pressure
Respiratory Rate
160
140
120
80
90
100
40
30
20
Adapted from: ATLS, 1997, American College of Surgeons, Pediatric Trauma,

Chapter 10.
Pediatric Trauma
483
if two attempts are unsuccessful move on to alternative methods

preferred alternative method in a child < 6 years is intraosseous access
established at the proximal tibia (uninjured extremity) or distal femur
preferred alternative method in a child > 6 years is a percutaneous femoral line
placed by an experienced physician
once venous access has been established, follow the resuscitation protocol outlined in Algorithm 2
note that all fluids should be warmed
crystalloid boluses can be given three times
if the child remains unstable after three boluses, blood should be administered
while preparing for surgical control of bleeding
Head Trauma
Head injuries are the major cause of death among injured children and those
that survive have a high rate of permanent disability. Mass lesions are relatively less
common in children than in adults but intracranial hypertension is more common
(see Fig. 45.2).
The management of major brain injuries in children includes:
avoidance of secondary brain insults (hypotension/hypoxia)
liberal use of CT scans
rapid control of scalp lacerations as children can lose significant amounts of
blood from these areas
early intubation for children with GCS 8
use of the pediatric version of the GCS (Table 45.3)
liberal use of ICP catheters to monitor cerebral perfusion pressures
use of measures to control seizures and fever
early attention to nutritional needs
maintaining a euvolemic state
maintaining CO2 in the normal range (35 mm Hg)
Spinal Cord Injury

The relatively large size of the head and weak cervical musculature make the
upper cervical spine more susceptible to injury in the young child. In older children,
the lower cervical spine is injured most frequently. Radiological evaluation of the
pediatric spine can be challenging for the following reasons:
normal skeletal growth centers can be mistaken for fractures
the growth center of a spinous process may resemble a fracture
basilar odontoid synchrondosis appears at the base of the dens in children < 5
years of age
apical odontoid epiphyses appear as separations (5-11 years old)
pseudosubluxation occurs as an anterior displacement of C2/C3
movement at this joint of up to 3 mm may be normal
increased distance between the dens and the anterior arch of C1 occurs in
20% of young children
spinal cord injury may occur without radiologic abnormalities (SCIWORA)
in as many as 50% of children
SCIWORA should be treated with a steroid bolus and the injury confirmed
with MRI scanning
45
484
Fig. 45.2. CT scan of
the head in an infant.
Note the major skull
fracture and severe
swelling with right to
left shift and obliteration of the right
lateral ventricle.
45
Trauma Management
485
Pediatric Trauma
Table 45.3. Adaptation of the GCS for children: Verbal score

Response
Score
Appropriate words, smiles, follows

Cries but consolable
Inconsolable, persistently irritable
Restless, agitated
No response
5
4
3
2
1
Adapted from: ATLS 1997, American College of Surgeons, Chapter 10: Pediatric
Trauma.
Chest Trauma
Major chest injuries are the second leading cause of death in pediatric trauma.
Rib fractures occur less commonly than in adult patients, but when they do occur
are indicators of major chest injury. Cardiovascular injuries can also occur following
major chest trauma. Evaluation and treatment of chest injuries in children includes:
a high index of suspicion for pulmonary contusion which is usually not evident
on the initial chest x-ray but may present later as hypoxia
performance of a surface echocardiogram in children with evidence of major
chest injury and/or cardiac arrhythmias
insertion of the appropriate-sized chest tube for pneumo- or hemothorax (see
Table 45.1)
evaluation of the aorta by spiral CT scanning and/or thoracic four-vessel
angiography in children with a major mechanism of injury (high speed MVA,
fall or pedestrian struck), a widened mediastinum on chest x-ray or mediastinal
hematoma seen on spiral CT
performance of bronchoscopy in children with a large amount of subcutaneous
emphysema, major air leak or persistent pneumothorax after insertion of a
chest tube, in search of major bronchial disruption.
Abdominal Injuries
Evaluation: Abdominal injuries are common in the pediatric population and
represent an area where prompt recognition and treatment can significantly impact
morbidity and potentially mortality. Because of the difficulty in examining the
pediatric abdomen, patients who meet the following criteria should be considered
for objective evaluation of the abdomen:
major mechanism of injury
abdominal pain/tenderness
abdominal wall/flank abrasions or bruises
history of hypotension
uncorrected base deficit
unexplained drop in Hct level
presence of pelvic fracture
presence of rib fractures
presence of hematuria
associated major head/spinal injury precluding accurate exams
45
486
Trauma Management
Most children will be stable and are best evaluated by CT scanning of the abdomen and pelvis, usually performed with both IV and GI contrast agents. Unstable
children benefit from a bedside ultrasound examination (FAST exam or focused
sonographic assessment for trauma) which examines the pericardial space, right and
left perirenal spaces, and the pelvis for the presence of blood (fluid) (Fig. 45.3).
Bedside, portable ultrasound exams performed by the surgeon have replaced diagnostic peritoneal lavage in the evaluation of the pediatric abdomen in most trauma
centers. Table 45.4 lists the advantages and limitations of abdominal CT versus
ultrasound in the evaluation of blunt abdominal trauma.
Solid Organ Injuries
45
The liver and the spleen are the most frequently injured organs in the abdomen
and more than 90% of these injuries will respond to observational treatment in the
pediatric population (Fig. 45.4). The protocol for successful management of solid
organ injuries in the pediatric population includes:
establishing the severity of injury by CT scanning
admission of all children to the ICU for at least 24-48 hours
serial Hct/Hb levels until stable
serial abdominal exams by an experienced surgeon
resumption of ambulation when Hct is stable and hematuria resolved
resumption of diet when ileus resolves
discharge from the hospital when eating/ambulating
follow-up scan prior to discharge for all splenic/renal injuries
follow-up scan prior to discharge for selected liver injuries
prompt operative intervention for persistent or delayed hemorrhage,
hemodynamic instability, signs or symptoms of missed intestinal injuries or
renal necrosis/major extravasation (Fig. 45.5)
follow-up imaging for all injuries prior to resuming contact sports
Fig. 45.3. Ultrasound exam of the right upper quadrant demonstrating free fluid
(blood) between the liver and kidney.
487
Pediatric Trauma
Table 45.4. Ultrasound versus abdominal CT scanning

CT Scanning
Ultrasound
Hemodynamic stability
Location
Ease of repeatability
Organ specificity
Sensitivity for fluid
required
X-ray department
moderately easy
high
high
Evaluation of retroperitoneum
Sensitivity for intestinal injuries
Experience required
detailed
limited
for interpretation
not necessary
bedside
very easy
low
depends upon
amount
limited
limited
for performance
and interpretation
45
Fig. 45.4. CT scan of the abdomen in a child, demonstrating a splenic injury with
extravasation of intravenous contrast suggesting active bleeding.
Intestinal injuries: Approximately 5% of all children who sustain blunt abdominal trauma will have a hollow viscus injury. These injuries may initially be subtle,
but morbidity increases with operative delay. Unfortunately, neither CT nor ultrasound is sensitive to the presence of a hollow viscus injury, and because most solid
organ injuries are treated nonoperatively, the treating physician must be aware of
the signs/symptoms/associated findings in children with intestinal injuries, which
include:
the presence of a lap-belt mark on the abdominal wall
the presence of a lumbar Chance fracture (Fig. 45.6)
the presence of fluid on the abdominal CT scan without an associated solid
organ injury
bowel wall thickening, free air, or contrast extravasation seen on abdominal
CT scanning
488
45
Trauma Management
Fig. 45.5. CT scan of the abdomen in a child showing right renal injury with active
extravasation.
uncorrected base deficit

rising WBC postinjury
delayed development of nausea/vomiting/abdominal tenderness/or distention
following blunt abdominal trauma
Pancreatic/duodenal injuries: A direct blow to the epigastrium from the handlebars of a bicycle, a kick, or impact during contact sports can injure the duodenal
and/or the pancreas. Most duodenal injuries in children are not full-thickness and
result in a submural hematoma that responds to nasogastric suction and watchful
waiting. Most pancreatic injuries can also be treated without operation, unless there
is evidence of major ductal disruption (Fig. 45.7)
Fractures
Pelvic fractures are unusual in pediatric trauma but their presence suggests
associated intra-abdominal and/or genitourinary tract injuries. The following features
are characteristic of extremity fractures in children:
growth plate involvement can result in a shortened extremity
incomplete fractures may involve only one cortex (Greenstick)
bending can occur without fracture lines (buckle fracture)
fractures may be absent on initial films and seen only on subsequent imaging
vascular injuries accompany supracondylar fractures at the elbow or knee
proportionally more blood is lost from fractures in children when compared
to adults
failure to recognize/promptly treat fractures can result in permanent disabilities
decreased use of the extremity may be a subtle sign of fracture in a small child
who cannot complain of pain
a search for extremity fractures should be part of the tertiary survey following
trauma
Pediatric Trauma
489
Fig. 45.6. MRI scan demonstrating thoracic spine fracture resulting from a lap belt. This
child was paraplegic.
45
Child Abuse
Approximately 5/10,000 children suffer from abuse or neglect and many children
die each year following intentional injuries inflicted by their parents or caregivers.
Signs and symptoms of abuse include:
a history of repeated emergency visits for minor injuries
a discrepancy between the story provided by different caregivers
doctor or ER shopping by caregivers in order to avoid suspicion
bites and burns (including cigarette) in unusual places
lower extremity burns that spare the feet (emersion)
evidence of multiple fractures of different ages, especially in children less than
3 years old
multiple subdural hemorrhages without skull fracture
retinal hemorrhages
perioral or genital injuries
490
Trauma Management
45
Fig. 45.7. Pancreatic injury following child abuse. Note the near total separation of
the head/body of the pancreas at the level of the spine.
Recognition or suspicion of child abuse requires that the physician report the
case to the child protective services agencies immediately. In addition to fulfilling
the law, this reporting may save the child from mortal injuries in the future.
Psychological Factors
Despite recovery from the physical trauma, many children fail to recover from
the emotional trauma and these disabilities may persist for life. Parents too may
require treatment for the emotional trauma that affects them during their childs
hospitalization and recovery from major injuries, and tend to underplay the psychological symptoms of their children. True PTDS symptoms are present in at least
50% of children who are hospitalized following trauma. The symptoms of psychological stress that are common in children following a major injury include:
sleep disturbances
behavior changes include rage attacks
decreased academic performance
intrusive thoughts
separation anxiety
mood disturbances
phobias
accident related play
Interventions directed at recognizing and treating these psychological problems
in injured children could have a significant impact on their ability to fully recover
from their trauma
Performance Indicators
Because death following trauma is relatively uncommon among injured children
when compared to adults, the quality of a pediatric trauma system must focus on
Pediatric Trauma
491
morbidity, not mortality. Review of the system and commitment to continuous

improvement must be the goal of all who provide care to injured children. Table 45.5
lists topics for performance reviews in pediatric trauma.
Injury Prevention
Injury prevention has the potential to significantly impact death and disability
following pediatric trauma. Currently available injury prevention measures could
prevent most unintentional injuries in children. Active prevention measures, which
require some action by the parent/child (i.e., seatbelts or carseats), are less effective
than passive measures (i.e., airbags). Examples of injury prevention programs that
have been show to be effective in the pediatric population include:
bicycle helmet use decreases head injuries by 85%
smoke detectors and fire-retardant clothing reduce the incidence of burns
traffic calming measures reduces pedestrian injuries
safe storage of firearms reduces unintentional shooting deaths by 23%
car seat use prevents ejection/injuries in infants
community based violence prevention programs have resulted in a 50%
reduction of assault and gun injuries in some communities
Sadly, most parents and physicians are poorly educated in the area of injury
prevention. Attention to this important topic in the next century has the greatest
potential to impact the lives of children and adolescents.
Table 45.5. Examples of pediatric trauma performance measures

Appropriateness of resuscitation volumes
Problems with vascular access
Problems with intubation/extubation
Problems with hypo/hypercapnea
Missed injuries
Failure to provide rehabilitation services
Failure to provide psychological support for family and child
Adapted from: Resources for Optimal Care of the Injured Patient. 1999 Committee
on Trauma, American College of Surgeons.
References
1.
2.
3.
4.
5.
6.
Tepas JJ. Resuscitation of the injured child. In: Trunkey DD, Lewis FR eds. Current Therapy of Trauma, 4th edition. St. Louis: Mosby Inc. 1999;. 81-88.
American College of Surgeons Committee on Trauma: Pediatric Trauma. In: Advanced Trauma Life Support for Doctors, American College of Surgeons Press,
Chicago 1977; 353-375.
Fallat ME, Casale AJ. Practice patterns of pediatric surgeons caring for stable patients with traumatic solid organ injury. J Trauma 1997; 43:820-24.
Kurkschubashe AG, Fenday DG, Tracy TF et al. Blunt intestinal injury in children; diagnostic and therapeutic considerations. Arch Surg 1997; 132:652-58.
Wesson DE, Scorpio RJ, Spence LJ et al. The physical, psychological, and socioeconomic costs of pediatric trauma. J Trauma 1992; 33:252-57.
Rivara FP, Grossman DC, Cummings P. Injury prevention (Part 1). NEJM 1997;
337:542-48 and NEJM (Part 2) 1997; 337:613-18.
45
CHAPTER 46
Geriatric Trauma
The geriatric population is the fastest growing group of the general population,
and geriatric trauma accounts for a significant portion of admissions to trauma centers. Due to different physiology, different types of injuries and different outcomes,
geriatric trauma patients often require a much more aggressive evaluation and management than younger patients.
Epidemiology
Falls are the most common mechanism of injury in the geriatric population.
Ground falls are very common due to many factors: impaired proprioception,
muscle weakness, dementia, syncopic episodes.
Motor vehicle accidents (MVA) are the second most common mechanism of
injury in this age group. Longer reaction times, preexisting medical problems
and impaired vision and hearing are important contributing factors.
- In Los Angeles there are about 10 trauma deaths due to MVA per 100,000
population older than 60 years. This is much higher than younger age groups.
Auto-pedestrian accidents are the third most common cause of injury in the
geriatric population.
- In Los Angeles there are about 9 deaths due to pedestrian accidents per 100,000
population older than 60 years. This is more than twice the rate observed in
younger individuals.
Suicides are very common in older age groups.

- In Los Angeles there are about 23 deaths due to suicide with penetrating trauma
per 100,000 males older than 65 years. In females of the same age group, this
figure is 1 per 100,000.
Age-Related Physiology and Effect on Trauma

- Dementia may complicate clinical evaluation.
- Brain atrophy and fragile bridging veins predispose to subdural hematomas.
- Epidural hematomas are not common due to firmer adherence of the dura on
the skull in elderly individuals.
- Anticoagulant medications predispose to intracranial hemorrhages even after
minor injury.
- The incidence of intracranial hemorrhage in individuals older than 60
years, after minor head injury is about 16% as compared to only about
6% in younger victims.
Spine
- Higher incidence of spinal fractures due to osteoporosis
- Higher incidence of upper cervical spine injuries, especially odontoid fractures
- Narrowed spinal canal predisposes to cord injury
Geriatric Trauma
493
- Higher incidence of central cord syndrome following overextension injury to

the cervical spine.
Cardiovascular System (CVS)

- Decreased cardiac output, inability of the heart to respond to endogenous or
exogenous signals to increase the output.
- Associated ischemic myocardial disease or conduction abnormalities
- Hypertension
- Medication such as beta-blockers, calcium channel blockers, diuretics may
affect the clinical presentation, the resuscitation efforts, and the outcome.
Respiratory System
- Decreased pulmonary compliance, vital capacity, pO2.
- Due to reduced physiological reserves, respiratory failure may appear much earlier
and after fairly moderate trauma.
Kidneys
Decreased creatinine clearance and concentration ability
Diminished tolerance to hypotension and nephrotoxic drugs.
Initial Evaluation and Management

Due to the limited physiological reserves, any delays in diagnosis and treatment
can be fatal. Early, aggressive evaluation and monitoring are essential, even for
fairly moderate-severity trauma.
During the Primary Survey of the ATLS remember the following age-related
conditions:
Airway/C-Spine
Dentures
Upper cervical spine fractures (especially odontoid) are not uncommon and
may not give severe clinical signs.
Breathing
Flail chest may not be very obvious on clinical examination due to rib cage
rigidity.
Respiratory decompensation may occur rapidly due to reduced respiratory
reserves and severe chest pain. Early intubation and respiratory support is
recommended in borderline cases, before transportation for complex or
prolonged radiological investigations.
Circulation
The initial blood pressure and pulse rate may be misleadingly normal and
cardiovascular collapse may occur quickly and unexpectedly. Many geriatric patients are on cardiac medications which may interfere with the cardiac response
to trauma. Diuretics may be associated with significant intravascular depletion.
A normal blood pressure or mild hypotension in a hypertensive patient may
signify hypotension.
The heart often fails to increase the cardiac output in order to meet increased
oxygen demands. Early blood transfusions to maintain the hemoglobin at
slightly higher levels than in younger individuals, may be helpful.
The hypotension is more likely to be cardiogenic in origin than in younger
patients. Always consider the possibility of myocardial infarction.
46
494
Trauma Management
Disability
Preexisting dementia may interfere with GCS reliability.
Subdural hemorrhages are common and may not be clinically obvious on
admission. Liberal CT scanning is recommended.
Exposure/Environment
Geriatric patients lose temperature very easily and hypothermia occurs much
faster than in younger populations. Take appropriate steps to prevent this
serious complication.
Specific Anatomic Injuries in Geriatric Patients

Head/Spinal Trauma
-
High incidence of subdural hematomas, low incidence of epidural hematomas.

Central cord syndromes without skeletal injury.
Survival and neurological outcome are worse than younger populations.
Higher incidence of upper C-spine injuries. Liberal CT scanning.
Chest trauma
46
- Multiple rib fractures are associated with a high incidence of respiratory failure
and death. Adequate pain control, preferably by epidural anesthesia, is highly
desirable. Early mechanical ventilation may be necessary.
- Higher incidence of aortic rupture. Liberal CT scanning of the mediastinum
even in moderate injuries.
Abdominal Trauma
- More difficult to evaluate clinically due to blunting of peritoneal signs. Liberal
use of abdominal CT scanning.
- Nonoperative management of solid organ injuries (liver, spleen) is less successful than in younger populations.
Skeletal Trauma
- Long bone fractures even with fairly minor trauma, such as ground falls.
- Long bone fractures are associated with significant morbidity and mortality and
they should be treated as severe injuries. Admission to the ICU, Swan-Ganz
placement, and early operative management are critical for a good outcome.
General Management
Aggressive early evaluation, monitoring, and management. Stable looking
patients may deteriorate and die very fast!
Moderate severity injuries (i.e., multiple rib fractures, long bone fractures,
pelvic fractures) require ICU admission. Swan-Ganz catheter placement is
strongly recommended in order to optimize fluid administration. The geriatric patient can easily go from hypovolemia to overloading and cardiac failure.
Close monitoring and a liberal policy of endotracheal intubation for geriatric
patients transported from the emergency room to the radiology suite for multiple investigations.

Underestimate the risks of relatively moderate trauma in geriatric trauma.
Sudden, unexpected, and catastrophic deterioration may occur.
Underestimate the significance of otherwise minor rib fractures. Pneumonia
and respiratory failure are very common. Adequate analgesia and liberal use of
epidural anesthesia are very important.
Geriatric Trauma
495
Underestimate the importance of minor head injuries. There is a high incidence of intracranial pathologies. Liberal policy of head CT scan should be a
standard practice.
Send a geriatric trauma patient even with fairly minor injuries, from the emergency room to the radiology suite for multiple investigations without close
continuous monitoring. Sudden deterioration may occur in a suboptimal environment. Consider a liberal policy of endotracheal intubation and respiratory support during prolonged radiological investigations.
References
1.
2.
3.
4.
5.
Demarest GB, Osler TM, Clevenger FW. Injuries in the elderly: Evaluation and
initial response. Geriatrics 1990; 45:36-42.
DeMaria EJ. Evaluation and treatment of the elderly trauma victim. Clin Geriatr
Med 1993; 9:461-471.
Knudson M, Lieberman J., Morris J et al. Mortality factors in geriatric blunt trauma
patients. Arch Surg 1994; 129:448-453.
Martin RE, Teberian G. Multiple trauma and the elderly patient. Emerg Med Clin
North Am 1990; 8:411-420.
Santora TA, Schinco MA, Trooskin SZ. Management of trauma in the elderly
patient. Surg Clin North Am 1994; 74:163-186.
46
CHAPTER 47
Trauma in Pregnancy
John Fildes and Timothy Browder
Introduction
Trauma is the leading cause of death from ages 1 through 44. It reaches its
peak during the ages of 15 through 35 when as many as 80% of deaths are
caused by injury. This is also the peak age for pregnancy. Research shows that
trauma is the leading cause of death during pregnancy.
The incidence of intentional injuries such as assaults, domestic violence and
homicide are increased during pregnancy.
The guiding principal in the treatment of a pregnant trauma patient is to treat
the mother first. The best way to help the baby is to help the mother. The
treatment priorities for the pregnant patient are the same as for the nonpregnant patient. In this chapter the nuances of physical examination and clinical
evaluation will be presented with special attention towards the physiologic
changes of pregnancy.
Primary Survey
Approach the injured pregnant patient in a systematic fashion. Examine and
address the airway, breathing, circulation, and disability. Also expose the patient to
identify all injuries. It is an error to concentrate on the pregnancy and its potential
problems before insuring that the maternal life threats have been identified and
managed.
Airway: Be sure that the airway is patent and unencumbered. Make liberal use
of oxygen. The fetal oxygen hemoglobin dissociation curve is positioned to
the left of the maternal curve. Small changes in the maternal oxygenation can
result in significant changes in the fetal oxygenation. High flow oxygen through
a non-rebreather mask is adequate for spontaneously breathing patients.
- In the event that endotracheal intubation is required the rapid sequence
technique is preferred. Urgent intubation is a common practice in obstetrical
anesthesia for fetal distress. These experiences here have demonstrated that rapid
sequence intubation can be safely performed. The best agents include those that
are short acting, rapidly metabolized and possess a long history of safety in
pregnancy. Morphine, midazolam and succinylcholine are commonly used in
this setting. Cricoid pressure must be maintained during intubation.
- Aspiration is a common complication in obstetric intubations. This is caused
by relaxed lower esophageal sphincter pressure, decreased gastric emptying and
increased gastric acidity. Ventilator settings must keep the oxygen saturation
near 100%.

John Fildes, University of Nevada School of Medicine, Las Vegas, Nevada, U.S.A.
Timothy Browder, University of Nevada School of Medicine, Las Vegas, Nevada, U.S.A.
Trauma in Pregnancy
497
Breathing: Auscultation must be performed at the axilla and apex of both

lungs. The diaphragm is pushed higher as pregnancy advances. This is
particularly true in a supine position. Breath sounds may not be present in
the lower chest as they are in a nonpregnant patient. Care should be taken
during insertion of a chest tube so that the diaphragm is not injured.
- The physiological changes in advanced pregnancy include increased tidal volume
and minute ventilation but not tachypnea. This should be interpreted as a sign
of respiratory distress. Functional residual capacity is decreased which alters
pulmonary reserve. Oxygen desaturation can be very rapid.
Circulation
- Maternal hemodynamics must be aggressively supported. Begin by establishing
two large bore IV sites above the diaphragm. Patients should be resuscitated
with isotonic crystalloid solution and blood as appropriate.
- Maternal circulatory volume is increased by as much as 30-40%. During
hemorrhagic shock, the maternal blood volume is supported by uterine vasoconstriction. This shunts blood to the mother and may result in fetal distress.
Therefore, tachycardia and hypotension are late signs of maternal hemorrhage.
It is wise to aggressively resuscitate these patients until their circulatory status is
more precisely assessed.
- The supine hypotensive syndrome can occur in women in the second half of
pregnancy. The uterus is large enough to compress the inferior vena cava and
bifurcation of the iliac veins. This reduces the return of preload to the heart.
Rotating the patients right side upward 15 to 20 degrees and manually
displacing the uterus to the left can reverse the supine hypotensive syndrome.
Patients who are in spinal immobilization can be left on the backboard with the
cervical collar in place and the entire apparatus can be elevated on the right side.
Disability: A quick neurological survey includes the Glasgow coma scale,

pupillary reactivity and the presence or absence of movement in all four
extremities. Injuries to the brain can be lateralized by the pupillary examination. The Glasgow coma scale determines the mental status. The level of
injury to the spinal cord is determined by the combination of motor and
sensory findings seen on physical exam. Spinal cord injuries at any level will
obscure important physical findings in the abdominal and obstetrical exam.
Exposure: The patients must be completely exposed so that all injuries can be
identified. Care must be taken to prevent hypothermia through the use of
warming lights, blankets and warmed IV solutions.
Secondary Survey
This is the first system by system physical exam performed on the patient. It is
also the first time that the fetus is assessed. Labs and x-rays are ordered at this
time. The patient usually receives medications as required. Each of these
issues requires special consideration in the pregnant trauma patient.
Remember the guiding principal is: treat the mother first. Missed injuries in
the mother will have a negative impact on fetal well being. So be sure to order
all necessary labs, diagnostic studies and medications.
Perform a complete examination of the neurologic, cardiac and pulmonary
systems.
Abdominal Exam: The abdomen should be inspected, auscultated, palpated
and percussed. Signs of shock and peritonitis mandate laparotomy just as they
47
498
Trauma Management
would in a nonpregnant patient. The abdominal exam is the first time when
the uterus is examined. Check the fundal height carefully. In the supine position,
the fundus reaches the umbilicus between 20 and 24 weeks (Fig. 47.1). This is
a critical piece of information for clinical decision making.
- If fetal distress is present then resuscitation is intensified. Maternal injuries must
be rapidly identified and surgically addressed. If the pregnancy is 24 weeks or
more then simultaneous emergency caesarian section must be performed. If the
pregnancy is less than 24 weeks then intensifying resuscitation and addressing
maternal injuries treats fetal distress. Caesarian section is not recommended on
such an immature fetus because survival is poor.
47
Pelvis and Vaginal Examination: Evidence of pelvic fracture or instability must

be identified. The pelvic ligaments soften as the pregnancy progresses. Pelvic
relaxation can result in a widening of the pubis that mimics diastasis. Identify
point tenderness in this area as a marker for acute injury. The pelvic outlet
tracts must be examined. A complete rectal exam must be performed. A vaginal
examination is performed using sterile gloves. The presence of blood or amniotic
fluid in the vagina, cervical tenderness and uterine contractions are serious findings that must be communicated to the consulting obstetrical team immediately.
Laboratories: CBC, blood chemistry, PT/PTT, and blood type are commonly
ordered for trauma patients. The CBC may show a reduced hemoglobin and
hematocrit. This anemia of pregnancy is seen in the second and third trimesters. It is caused by a disproportional expansion of the plasma volume
compared to the red blood cells. Hemoglobin less than 11 g/dL is abnormal.
The PT/PTT should be normal.
- The blood type should be checked for Rh status. Trauma can cause disruption
of the placenta with admixture of maternal and fetal blood. Rh-negative mothers can receive fetomaternal transfusion from an Rh-positive fetus. In ninety
percent of cases this Rh antigenemia can be neutralized by the administration
of 300 international units of Rh-immune globulin within 24 hours of injury.
The Kleihauer-Betke test can be used to calculate the volume of fetal blood
present in the maternal circulation. Additional doses of Rh-immune globulin
can be given if required. Three hundred international units of Rh-immune
globulin will neutralize 30 ml of fetal blood.
X-rays: All necessary x-rays should be obtained. The greatest risks of fetal
radiation exposure is during the first trimester. A missed maternal injury is
more likely to have a negative effect on the fetus than the judicious use of
diagnostic x-rays. Radiographs of the C spine, chest, and extremities can be
performed with a lead apron across the abdomen. The absorbed radiation
dose is negligible. Care should be taken not to exceed five rads of radiation
exposure at anytime. This is most important when x-rays of the lumbar spine,
pelvis, and hips are being performed. Abdominal trauma should be initially
evaluated by ultrasound. If CT scan is required the spacing of cuts passing
through the uterus should be increased to 1 cm.
Medications: Medication safety is a common issue in the treatment of patients
who are pregnant. The most common medications administered to trauma
patients are analgesics, antibiotics and tetanus toxoid. Analgesics like morphine
and meperidine have been used for many years and possess a good safety profile.
If necessary they can be reversed with naloxone. Second and third generation
cephalosporins are safe and effective against the most common organisms
Trauma in Pregnancy
499
47
Fig. 47.1. In the supine position, the fundus reaches the umbilicus between 20 and
24 weeks.
encountered in a trauma situation. Tetanus toxoid and tetanus immune globulin

are safe and should also be administered when required.

Prepare the OR as you would for a major trauma case. There should be adequate IV access, fluid and blood warmers and ample blood products.
The abdomen should be entered through a midline incision. This will allow
the uterus to be moved from side to side and all quadrants to be exposed. If a
cesarean section needs to be performed, a transverse uterine incision can be
made using the exposure provided by the midline abdominal incision. If the
500
Trauma Management
pregnancy is less than 24 weeks gestational age, uterine injuries should be

directly repaired and expectant management exercised. There is no need to
evacuate the uterus when fetal death is present. Spontaneous delivery will
usually occur within 24 to 48 hours.
Hysterectomy is indicated only when there is irreparable injury to the pelvic
and uterine vascular structures.
If the pregnancy has advanced beyond 24 weeks, obstetrical and neonatal
support should be immediately available. The development of fetal distress
may require caesarian section and resuscitation of the infant.
Occasionally the fetus is injured too. A second surgical team should be
assembled to manage the newborns injuries.

The management of a traumatized pregnant patient requires strong trauma
team leadership. Well meaning support staff and consultants will try to divert
attention towards the fetus. It is imperative that the mothers care be prioritized
in order to support the fetus. Remember the guiding principal is: treat the
mother first.
References
1.
2.
47
3.
4.
5.
Fildes J, Reed L, Jones N et al. Trauma: The leading cause of maternal death.
J Trauma 1992; 32:643-645.
Esposito TJ, Gens DR, Smith LG et al. Trauma during pregnancy: A review of 79
cases. Arch Surg 1991; 126:1073-1078.
Henderson SO, Mallon WK. Trauma in pregnancy. Emerg Med Clin North Am
1998; 16:209-228.
Kissinger DP, Rozycki GS, Morris JA Jr et al. Trauma in pregnancy: Predicting
pregnancy outcome. Arch Surg 1991; 126:1079-1086.
Perlman MD, Tintinalli JE. Evaluation and treatment of the gravida and fetus
following trauma during pregnancy. Obstet Gynecol Clin North Am 1991;
18:371-371.
CHAPTER 1
CHAPTER 48
Interventional Radiology in the Care

of the Trauma Patient
Trevor D. Nelson and M. Victoria Marx
Diagnostic Arteriography (Figs. 48.1, 48.2)
In the setting of trauma, arteriography is useful to identify or exclude arterial
injury, arterial occlusion, and/or an arterial source of hemorrhage.
The diagnostic arteriogram may be followed by a percutaneous interventional
procedure such as embolization or stenting.
Indications
Blunt trauma to the chest with imaging findings or clinical history suggestive
of aortic or great vessel injury.
Pelvic fractures with clinical or radiological suspicion of significant bleeding.
Selected cases with penetrating trauma for evaluation of proximity vessels (i.e.,
neck) or active bleeding for areas which are difficult to access surgically.
Long bone fracture with expanding hematoma, vascular compromise, or proximity to a critical vessel. For example, popliteal artery injury has a high association with posterior fracture-dislocation of the knee.
Selected hemodynamically stable patients with solid organ injuries, with clinical
or CT evidence of active bleeding or aneurysms.
Contraindications
Hemodynamic instability is a strong contraindication for angiography. Bleeding from pelvic fractures or other surgical inaccessible areas are the only exemptions.
Allergy to iodinated contrast
- A history of contrast reaction requires appropriate prophylaxis prior to
arteriography.
- Optimal premedication consists of 50 mg oral prednisone 13, 7 and 1 hour
prior to arteriography, followed by 50 mg IV diphenhydramine. In cases where
prior reaction has been severe, IV administration of an H2 blocker, such as
cimetidine, is also recommended.
- A reasonable premedication protocol in an emergency situation, where a 13
hour delay is not in the best interests of the patient, is intravenous administration of 100 mg hydrocortisone, 50 mg diphenhydramine, and 300 mg cimetidine
at the start of the procedure.
Trevor D. Nelson, Department of Radiology, LAC + USC Medical Center, Los Angeles,
California, U.S.A.
M. Victoria Marx, Department of Radiology, LAC + USC Medical Center, Los Angeles,
California, U.S.A.
502
Trauma Management
Fig. 48.1A. Aortic rupture secondary to deceleration injury. Portable

chest xray demonstrates
widening of the upper
mediastinum (arrows)
with loss of aortic knob
definition. Life support
appliances, snaps, and
a zipper overlie the
image. The presence of
these extraneous items is
distracting but serves to
suggest
that
the
patient is quite ill.
48
Fig. 48.1B. Aortogram demonstrates a traumatic pseudoaneurysm (arrows) projecting off the left posterolateral aspect of the aorta about 3 cm) beyond the origin of
the left subclavian artery. The pseudoaneurysm indicates that there has been a
rupture of the aorta at that point.
Interventional Radiology in the Care of the Trauma Patient
503
Fig. 48.2. Brachial pseudoaneurysm and arteriovenous fistula secondary to knife

wound. A. This brachial arteriogram (image centered at the elbow) demonstrates a
large pseudoaneurysm projecting off the ulner-interosseous trunk just past the origin of the radial artery. The faint streak of contrast in the soft tissues of the elbow
represents early filling of the basilic vein, better demonstrated in the next image.
Fig. 48.2. B. The pseudoaneurysm is well filled with contrast. Contrast also fills the
basilic vein (arrow), indicating the presence of an arteriovenous fistula arising from
the area of injury. Because this injury involves supply to the hand, percutaneous
treatment was bypassed in favor of open surgical repair.
Renal Insufficiency
- Iodinated contrast is nephrotoxic especially in hypotensive patients.
- In select cases, use of an alternative contrast agent, such as carbon dioxide or
gadolinium may be appropriate. These agents are not used routinely because
image quality is inferior to that provided with standard contrast.
Coagulopathy
- Coagulation factors and platelet count should be corrected prior to arteriography in order to minimize the risk of procedure-related hemorrhage.
- Prothrombin time (PT) should be less than 1.5 times control.
- Partial thromboplastin time should be less than 150% of normal.
- Platelet count should be greater than 50,000/ml.
Pregnancy
- Ionizing radiation should be avoided during pregnancy if possible. If, however,
arteriography is necessary for the medical care of a pregnant woman, it should
48
504
Trauma Management
be performed. The health of the fetus depends upon the health of the mother.
All hospitals have access to radiation physicist support if fetal dose calculation
is required.
Complications
Complications of arteriography can relate to the iodinated contrast, the arterial
puncture, or the internal catheter manipulation.
Contrast Reaction
- Although the majority of allergic-type contrast reactions are minor and selflimited, death can occur in about 1/20,000 reactions. See table below for details
regarding contrast reactions.
Incidence related to type of contrast
Reaction Severity
Mild
Moderate
Severe
48
Example
Nausea / vomiting
Localized urticaria
Bronchospasm
Diffuse urticaria
Cardiovascular collapse
Laryngeal edema
Ionic
Nonionic
5%
1%
0.5%
0.1%
0.05%
0.01%
- Major risk factors for development of a contrast reaction are a history of prior
reaction, and/or reactive airway disease.
- Patients with a history of a prior contrast reaction require steroid premedication
prior to each contrast exposure (see above for specifics).
- The use of nonionic contrast for arteriography is standard in most angiography
suites. If it is not in standard use, nonionic contrast should be used in all
patients at high risk for, or with a history of, contrast reaction.
- Prehydration (unless contraindicated) will reduce the severity of reactionassociated hypotension.
- Standard intraprocedural monitoring includes pulse oximetry, EKG monitoring,
and frequent recording of blood pressure. All angiographic suites must have
supplies for, and personnel experienced in, management of contrast reactions.
- Patients should be instructed to notify staff if chest tightness, throat tightness,
or nasal congestion occur during the procedure. Early intervention will decrease
severity of a reaction.
Contrast-Induced Nephropathy
- Contrast-induced creatinine elevation is usually mild and temporary. In rare
instances, however, short-term or permanent hemodialysis may be necessary for
treatment.
- Maintenance of adequate hydration during and after arteriography can decrease
the nephrotoxic effect of contrast.
Puncture Site Complications

- At the end of a diagnostic arteriogram, the arterial catheter is removed and the
arteriotomy is compressed, either manually or mechanically, for 10-15 minutes.
Patients must then remain supine with the affected leg straight for 4-6 hours
(2 hours for a femoral vein puncture used for pulmonary arteriography).
505
- Puncture site complications include bleeding, hematoma, pseudoaneurysm, and

arterio-venous fistula. In rare cases, infection can also occur.
- At the femoral artery location, the incidence of significant puncture site complications (those requiring operative intervention or transfusion) is less than
1% for diagnostic arteriography. Incidence is higher (3-5%) when arteriography is followed by a percutaneous interventional procedure such as embolization
or vessel recanalization. This increase in risk relates to increased catheter diameter,
increased procedure time, and increased need for intraprocedural anticoagulation.
- Several puncture site closure devices have become commercially available recently.
These devices are inserted through the percutaneous puncture tract at the end
of the arterial procedure to plug the tract and/or to close the arterial defect. Use
of these devices is proliferating rapidly. Their role in the management of trauma
patients has not yet been determined.
- Risk factors for the development of puncture site complications include hypertension, coagulopathy, underlying atherosclerotic disease, inadequate
postprocedure compression of the puncture site, and inability of the patient to
cooperate with instructions to remain immobile.
- Pseudoaneurysm at the puncture site can be treated by ultrasound-guided compression of the pseudoaneurysm, with or without direct thrombin injection.
- An arterio-venous fistula manifests as a palpable thrill at the puncture site. The
diagnosis can be confirmed with ultrasound. Many small AVFs close spontaneously. Those that persist may be managed with percutaneous embolization or
surgical ligation.
Complications of Intra-arterial Catheter Manipulation

Intravascular injury can occur as a result of catheter and guide-wire manipulations. Types of injury include rupture, dissection, intramural hematoma, thrombosis, and nontherapeutic embolization of thrombus. Scrupulous technique, a large
selection of catheterization equipment, and high quality imaging are required to
avoid these injuries. In a dedicated angiographic laboratory, incidence of catheterrelated complications is less than 1% for diagnostic arteriography and is about 5%
for more complex interventional procedures. Most catheter-related complications
are recognized during the angiographic procedure and can be managed immediately
by percutaneous means.
Complications Specific to Pulmonary Arteriography
- Acute right heart failure
- Cardiac arrhythmiaincluding right bundle branch block, ventricular tachycardia, ventricular fibrillation, and asystole.
Periprocedural Care Issues

Postprocedure care should include:
- Bed rest keeping the leg with the puncture site straight.
- If an upper extremity arterial access site was used, the affected arm should be
kept at rest for 24 hours.
- Frequent vital signs, puncture site checks and peripheral pulse examinations for
the first 24 hours. A typical protocol is to assess the patient at 15 minute intervals
for one hour, 30 minute intervals for 1 hour, 1 hour intervals for 2 hours, and 4
hour intervals for 20 hours. Outpatients can be discharged at 4 hours and
followed with a phone call at 24 hours.
- Maintenance of hydration.
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Trauma Management
- Assessment of Renal Function. This is particularly critical in diabetic patients
who take oral metformin for glucose control. Metformin must be withheld for
at least 48 hours following any administration of intravascular contrast, and
then should not be restarted until serum creatinine level is demonstrated to be
at its baseline level.
Therapeutic Embolization (Figs. 48.3-48.5)

Definition and Embolic Materials
Therapeutic embolization refers to the intentional occlusion of blood vessels
using percutaneous transcatheter techniques under fluoroscopic guidance. A variety
of embolic materials are available; choice of embolic agent varies with indication
and operator preference. In the trauma patient, the most commonly used embolic
agents are oxidized cellulose sponge (Gelfoam), polyvinyl alcohol sponge (PVA,
Ivalon), and metallic coils. Their characteristics are noted below.
Gelfoam
Gelfoam is supplied in small sterile sheets. For intra-arterial application, the
material is cut into tiny (about 1 mm) cubes. The interventional radiologist
suspends the cubes in contrast and injects them into the arterial tree under
fluoroscopic guidance. The cubes move with arterial flow until they lodge in a
branch roughly equivalent to their diameter. The level of embolization can be
controlled in a rough manner by increasing or decreasing the size of the cubes.
48
- Gelfoam is a temporary embolic agent. The material will become phagocytized, and the vessel will recanalize in about 5-10 days. Gelfoam is frequently
used to treat diffuse posttraumatic hemorrhage, such as is seen with pelvic
fractures, where the goal is to stop hemorrhage quickly without creating long
term vascular compromise.
Polyvinyl Alcohol Sponge

Polyvinyl alcohol sponge is the material out of which kitchen sponges are
made. Medical grade PVA is supplied in 1cc vials of sized particles that range
in diameter from 50-1200 microns. For injection, the interventionalist suspends
the particles in contrast and injects them into the arterial tree through an
angiographic catheter under fluoroscopic control. Larger sizes are used typically
to control hemorrhage, to act as a carrier for delivery of intra-arterial chemotherapy, and to occlude arteriovenous malformations. The smaller sizes are
typically reserved for indications where tissue necrosis is a desired endpoint
such as tumor embolization. The larger the particle, the more central the level
of arterial occlusion.
- PVA is inert and results in permanent, or at least long-term, vessel occlusion.
Recanalization can occur after weeks to months. In the setting of diffuse
traumatic hemorrhage, PVA is less frequently used than Gelfoam, but may
be indicated if initial Gelfoam embolization fails, or if hemorrhage recurs
following initially successful Gelfoam embolization.
Metallic Coils
Metallic coils are ideal for focal occlusion of a vessel at a point source of
hemorrhage or injury. Coils are designed to occlude vessels that range in size
from 1-15 mm in diameter. An embolization coil is made of a short segment
of guidewire material that is covered with strands of Dacron fiber. The fibers
are biocompatable and thrombogenic. For insertion, the coil is straightened out
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Fig. 48.3A. Mesenteric branch vessel hemorrhage due to gunshot woundsource

of hemorrhage not found at exploratory laparotomy. Postoperatively, the patient
had persistent hemorrhage from a left upper quadrant drain. A. Superior mesenteric arteriography demonstrates extravasation of contrast from a small mesenteric
branch (arrows) in the left upper quadrant. Note its proximity to the large surgical
drain in the pancreatic bed.
48.3B. Digital subtraction

subselective arteriogram
done in preparation for
embolization of bleeding
vessel. The tip of the catheter (long white arrow) is
just proximal to the site of
hemorrhage. A large collection of extravasated
contrast pools against the
surgical drain (black arrow
indicates drain). The short
white arrow indicates the
artery distal to the site of
hemorrhage. This vessel
was occluded with a series of microcoils introduced via the angiographic
catheter.
48
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Fig. 48.4. Hemorrhage related to
pelvic fracture. Embolization with
Gelfoam particles. A. Early phase
film during pelvic arteriogram.
Note that the right-sided pelvic vessels are smaller and less well filled
than those on the patients left. This
finding is the result of compression
by a large right sided pelvic hematoma.
Fig. 48.4B. Later phase film during pelvic arteriogram. Multiple

sites of punctate hemorrhage
(black arrows) are identified in the
right internal iliac arterial tree.
48
Fig. 48.4C. Selective right internal

iliac arteriogram done in preparation
for embolization. Black arrowheads indicate the location of the
angiographic catheter tip. The long
black arrow demonstrates an exact
site of hemorrhage from a branch of
the obturator artery along the pelvic
sidewall. The white arrows indicate
puddles of extravasated contrast. The
bleeding vessels were occluded with
Gelfoam particles to provide temporary occlusion.
Trauma Management
509
Fig. 48.5. Hemorrhage related to

femur fracture. Embolization of
the deep femoral artery with metallic coils. A. Following internal
fixation of a right femur fracture,
this patient developed a rapidly
expanding thigh hematoma. Deep
femoral arteriography (white arrowheads indicate location of
catheter tip) demonstrates extravasation of contrast (white
arrows) from a muscular branch
vessel in close proximity to the
site of fracture.
48.5B. In preparation for embolization, the catheter has been advanced into the bleeding branch
(arrowheads indicate location of
catheter tip). White arrows indicate pooling of extravasated contrast from the lacerated vessel.
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Trauma Management
48.5C. Final arteriogram following

occlusion of the bleeding vessel with
multiple metallic coils. Arrows
indicate coils. Arrowheads indicate
catheter tip. Note absence of extravasated contrast.
48
to allow its passage through an angiographic catheter. The device regains its
predetermined coil shape as it emerges from the tip of the catheter. In order to
use coils, the interventionalist must advance the catheter to the exact site of
intended coil deposition. The coil is deployed under fluoroscopic guidance.
The diameter of the coil should be slightly greater than that of the vessel so
that radial forces will keep it in stable position.
- Metallic coils are made of either stainless steel or titanium. They are visible on
plain radiographs. They will not cause electronic metal detectors to alarm because they are so small.
Other
A variety of other materials are used for therapeutic vascular occlusion. They
include detachable balloons, new particulate materials, liquid sclerosants (e.g.,
absolute alcohol), and glue. None of these agents are widely used to treat
trauma patients.
Indications
Hemorrhagewhen surgical intervention has failed, or in situations where
surgical intervention is associated with an unacceptably high risk of failure,
morbidity and/or mortality. In most instances, hemorrhage requiring percutaneous embolization is the result of bony fracture, nonpenetrating trauma
with solid organ fracture, or penetrating trauma due to gunshot wound or
knife wound. Examples include:
-
Intraperitoneal hemorrhage resulting from hepatic or splenic injury.

Retroperitoneal hemorrhage from renal or muscular injury.
Pelvic hemorrhage related to pelvic fracture.
Muscular hemorrhage of the upper or lower extremities related to penetrating
trauma or fracture.
511
- Facial hemorrhage related to fracture.
Vascular injuryTraumatic arterio-venous fistula, pseudoaneurysm, or

dissection may benefit from embolization.
Prophylactic EmbolizationProphylactic embolization of both internal iliac
arteries may be used to control an expanding retroperitoneal hematoma
associated with pelvic fracture even if no clear bleeding site can be found.
Contraindications
All contraindications to arteriography apply also to therapeutic embolization.
Inability to safely deliver embolic agent to the desired location is a contraindication to therapeutic embolization. The most common reason for this
is technical inability to thread the angiographic catheter into a peripheral
enough, and/or stable enough, position. With modern microcatheters and
guidewires, this problem is relatively rare.
Complications
All complications of arteriography apply also to therapeutic embolization.
Target organ ischemia can occur if the site of arterial occlusion is peripheral to
all collateral arterial supply. This problem is unusual in trauma patients because
the embolic materials used in this setting occlude vessels at the small artery
level; most organs have rich collateral networks beyond this level.
- Organ ischemia is most likely when liquid sclerosing agents or extremely small
embolic particles (< 150 micron diameter) are used. Organ ischemia is rare
following embolization with Gelfoam cubes or PVA particles greater than
250 micron in diameter.
- Risk factors for development of organ ischemia are embolization of the small
bowel or colon, diabetes, atherosclerotic disease and previous radiation therapy
to the region.
- Focal organ ischemia is expected following renal embolization. This is welltolerated in patients with normal baseline renal function.
- Focal organ ischemia may lead to infection and abscess formation. This is of
particular concern following splenic embolization.
Nontarget Embolization
Nontarget embolization occurs when embolic material is deposited in an
unintended location. Nontarget embolization may or may not result in
organ ischemia. Nontarget embolization is most frequently the result of
technical error.
- Nontarget embolization to the lungs occurs when embolic material passes through
an arterio-venous fistula.
Postembolization Syndrome
Postembolization syndrome consists of fever, nausea, and pain referable to the
site of embolization. Leukocytosis may also occur. The syndrome is the result
of organ ischemia. It typically resolves in 24-48 hours. It is seen infrequently
in trauma patients; it is much more common following embolization of hepatic or renal tumors where tumor necrosis is the intention of the procedure.
- Note that on cross-sectional imaging, gas bubbles are commonly present in the
embolization bed. They are the result of tissue necrosis and do not correlate
with the presence of infection.
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Trauma Management

Preprocedure preparation should include:
- An intravenous prophylactic dose of broad-spectrum antibiotic.

- All postprocedure care measures listed for diagnostic arteriography.
- Serial hematocrit determination. Falling hematocrit may signal a need for repeat embolization, a need to search for a new site of hemorrhage, or a need for
surgical intervention.
- Monitoring for (and possible management of ) postembolization syndrome and/
or infection. See complications above for details of postembolization syndrome.
Stents and Stent-Grafts (Fig 48.6)

Definition
An intravascular stent is a tubular metallic mesh scaffold that is designed to
buttress open a diseased blood vessel. It is most commonly used to treat symptomatic arterial stenoses related to atherosclerotic occlusive disease. Stents come in a
variety of diameters and lengths; they can be inserted percutaneously. They have
been in widespread use since about 1990.
- A stent-graft is a metallic vascular stent that is covered or lined with
biocompatible fabric such as polytetrafluoroethylene. The fabric acts as a physical barrier between the intraluminal and extraluminal space.
- Although not yet FDA approved for treatment of traumatic vascular injury, the
use of stent-grafts for management of arterial trauma is rapidly gaining acceptance in the clinical community.
48
Evolving Indications
Traumatic DissectionParticularly in locations with difficult surgical access
such as the intrathoracic carotid artery or the vertebral artery.
PseudoaneurysmA stent-graft will exclude the pseudoaneurysm from arterial
flow and result in thrombosis.
Arterial RuptureA stent-graft will seal the rupture.
Arteriovenous FistulaA stent-graft will occlude the fistulous communication
between artery and vein
Evolving Contraindications
All contraindications to arteriography apply also to stent and stent-graft
placement.
Vessel size that is too small to accommodate an implanted device. Minimum
arterial diameter for stent and/or stent-graft placement is currently 6 mm.
Vessel size that is too large for available devices. Stents and stent-grafts can be
custom-made but there is rarely the luxury to wait for this step in the acutely
injured patient.
Technical factors related to arterial anatomy. Vessel tortuosity and proximity
of the lesion to critical branch vessels may make stent placement impossible
or extremely high risk.
Ongoing bacteremia which could seed on the device and result in endarteritis.
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Fig. 48.6. Subclavian artery pseudoaneurysm resulting from iatrogenic injury. Treated
with covered stent placement. A. A subclavian arteriogram was performed to evaluate a pulsatile mass at the base of the right neck following a failed attempt at
dialysis catheter placement. This early arteriogram film demonstrates narrowing of
the subclavian artery (SC) and faint filling of a large vascular space (black arrows).
BC = brachiocephalic artery; C = carotid artery; V = vertebral artery.
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48.6B. Late phase film from the same arteriogram demonstrates the large
pseudoaneurysm more clearly (black arrows).
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Trauma Management
Fig. 48.6C. A Palmaz stent covered with a short segment of 4 mm diameter PTFE
graft material was deployed across the arterial defect. On this final arteriogram,
arrows indicate the ends of the stent-graft. Note that the vertebral, carotid, and
subclavian arteries remain patent. The pseudoaneurysm no longer fills with contrast. Black arrow indicates a small embolization coil deployed in the proximal
thyrocervical trunk. This was placed to prevent backfilling of the pseudoaneurysm
which arose in close proximity to that branch vessel.
48
Fig. 48.6D. Follow-up

arteriogram done 4
months after stentgraft placement demonstrates durability of
the result. Black arrows
indicate ends of the
stent-graft. SC = subclavian artery; C =
Carotid artery; white
arrow = embolization
coil; RT = right.
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Fig. 48.7. Pulmonary angiogram and inferior vena

cavagram performed in
preparation for vena cava
filter placement. A. Left
pulmonary arteriogram
demonstrates a large acute
embolus (upper margin
outlined by white arrows)
in the descending pulmonary trunk. A smaller more
distal embolus is also noted
(black arrows).
Complications
All complications of arteriography apply to stent and stent-graft placement.

Device misdeployment
Device migration
Device infection
Device thrombosis
Device leakThis complication is specific to stent-grafts where exclusion of
extravascular pathology is a desired endpoint.

- An intravenous prophylactic dose of broad-spectrum antibiotic.
- Imaging studies to allow complete and accurate characterization of the arterial
lesion and the artery size. In addition to arteriography, computed tomography
and intravascular ultrasound may be necessary for treatment planning.

- Immediate follow up physical examination and imaging to assess vessel patency
and to confirm that underlying lesion has been adequately treated.
- Delayed follow up assessment to ensure that treatment is durable.
Vena Cava Filter Placement (Figs. 48.7, 48.8)

Definition and Overview of Devices
Vena cava filters are percutaneously implanted devices that are used to prevent
pulmonary embolism in select patients. Eighty-five to 95% of pulmonary
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Trauma Management
Fig. 48.7B. Contrast

cavography demonstrates
that the inferior vena cava
is patent without filling defect or evidence of anatomic anomaly. Caval diameter just below the renal
veins is 21.2 millimeters,
which is appropriate for
any design of filter placement.
48
emboli arise in the iliofemoral veins; therefore, most vena cava filters are placed
in the inferior vena cava (IVC). Hence the common designation IVC filter.
The filters can be used, however, in the superior vena cava to trap thrombi
originating in the upper extremities.
The devices are made from a variety of metals including stainless steel, titanium, and nitinol (a nickel-titanium alloy). They are deployed in the vena
cava under fluoroscopic guidance and assume their functional shapes upon
release from their deployment systems.
Four filters are FDA-approved for use in the United States. All are permanent
and all are associated with roughly equivalent efficacy and complication rates.
All may be inserted from the jugular or femoral approach.
Temporary filters, designed for patients at temporary risk for pulmonary embolism, are under investigation.
The four vena cava filters available in the United States are:
- Greenfield filter (Boston Scientific Inc., Natick, MA). This is the oldest filter
design, introduced into clinical use in about 1975. The design resembles the
skeleton of a badminton birdie or an umbrella. There are actually three variations of the Greenfield filter available currently: the original 24 Fr design, a 12
Fr titanium version and a 12 Fr stainless steel version.
- LGM filter (also known as the Venatech filter) (Braun/Vena-Tech, Evanston,
IL). This filter is similar in design to the Greenfield filter but its ribs are flat
rather than round and its introducer system is slightly smaller. In addition, it
incorporates vertical struts peripherally to prevent tilting.
- Birds Nest filter (Cook Inc., Bloomington, IN). This filter consists of two
V-shaped struts that anchor the device to the caval wall. In between the struts is
a nest of tiny metal wires. This filter design allows placement in vessels up to 4 cm
in diameter; the other designs are limited to vessels less than 2.8 cm in diameter.
517
Fig. 48.8. Radiographic

appearance of four types of
vena cava filter available in the
United States. All are in position in the IVC below that level
of renal veins. A. Stainless steel
over-the-wire Greenfield
filter. Arrows indicate location
of filter feet. Density where the
filter legs join is termed the
filter nose.
48.8B. LGM Venatech filter.

Arrowhead indicated filter
nose. White arrows indicate
location of filter base. Black
arrow indicates the upper end
of one of the lateral struts
which serve to minimize tilting
of the filter within caval lumen.
- The Simon-Nitinol filter (C.R. Bard, Inc., Covington, GA). This filter consists
of two sequential filtering cones. It has a very flexible 7 Fr introducer system,
which may be inserted from a peripheral upper extremity vein.
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Trauma Management
48.8C. Birds nest filter.

Only the V-shaped struts
are visible on most radiographs. The upper strut lies
with its feet (black arrows)
pointed towards the patients
head and its apex (black
asterisk) pointed towards
the patients feet. The lower
strut lies in the opposite orientation with feet (white
arrows) pointed caudally
and the apex (white asterisk) pointed cranially. Anchoring barbs are located
on each filter foot. In between the struts lies a nest
of fine stainless steel wire
that is not discernible on
this image.
48
48.8D. Simon-nitinol filter.

This filter has two levels of
filtration: An upper mushroom (black arrow) and a
lower cone that is similar in
design to the Greenfield filter. The base of the lower
cone is indicated with the
white arrow. White arrowhead indicates the filter
apex.
Technical Points
Contrast cavography is required prior to filter deployment to exclude variant renal vein or caval anatomy and to identify intraluminal thrombus. The
presence of either may impact the filter deployment site.
Pulmonary arteriography may be performed immediately prior to, and through
the same venous access site, as filter placement.
519
Indications
Deep venous thrombosis and/or documented pulmonary embolus plus any of
the following:
- Contraindication to anticoagulation
- Failure of anticoagulation as manifested by progression of a DVT or recurrent
PE while on adequate anticoagulation.
- Complications of anticoagulation such as stroke, gastrointestinal hemorrhage,
spontaneous retroperitoneal hematoma, adrenal hemorrhage, heparin-induced
thrombocytopenia, and coumadin-related fat necrosis.
Prophylaxis against pulmonary embolism in patients at high risk for development of lower extremity deep venous thrombosis. This indication is highly
relevant to the trauma patient population because pulmonary embolism is
one of the most common causes of unexpected death in this group of hospitalized patients. Predisposing factors include:
-
Multiple, severe, long bone fracture

Complex, pelvic fracture
Spinal cord injury
Severe, closed head injury
Any other combination of injuries likely to result in prolonged immobilization
Contraindications
All relative contraindications to arteriography apply to vena cava filter
placement.
- Note: vena cava filter placement can usually be accomplished safely in
coagulopathic patients using small profile devices from the internal jugular or
upper extremity approach.
Absence of venous access to the desired filter deployment site due to chronic
or acute venous occlusion.
Insufficient length of patent cava for deployment. In the inferior vena cava,
this can occur with acute or chronic IVC occlusion that extends up to the
hepatic veins.
Complications
All complications of arteriography apply to vena cava filter placement.
Recurrent pulmonary embolism despite a properly functioning filter. This
occurs in 2-5% of patients with IVC filters.
Chronic lower extremity swelling occurs in 5% of patients with IVC filters.
Filter misdeployment. This occurs as a result of technical error.
Filter migration. When IVC filters migrate, it is usually towards the iliac vein
confluence away from the heart. Migration into the heart, however, has
been reported. Percutaneous retrieval of migrated filters is possible.
Filter fracture. This occurs rarely as a result of chronic mechanical stress.
Penetration of filter legs through the caval wall into aorta or bowel has been
reported as a rare complication of some filter types.
Pneumothorax occurs in less than 1% of procedures done from a jugular
vein access site when venous puncture is performed using real-time ultrasound guidance.
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Trauma Management

- All preparation measures noted for diagnostic arteriography.

- The head of the bed should be elevated at least 30 during the initial bed rest
period if the jugular vein approach was used for filter placement.
- Supplying the patient with a wallet card identification card for the filter that has
been implanted.
- Clear indication in the medical record of the presence and location of a caval filter.
Imaging-Guided Vascular Access and Associated Venous

Interventions (Fig 48.9)
During the initial management of an acutely injured patient in the emergency
department environment, imaging guidance for vascular access is rarely necessary. However, during prolonged hospitalization, central venous access sites
can thrombose and/or become progressively difficult to catheterize. When
this happens, use of imaging guidance in the interventional radiology suite
can increase the likelihood of success and decrease the complication risk of
vascular access catheter placement.
Catheter Types and Indications
48
Note that a wide variety of catheter material, sizes and designs are available.
Detailed discussion of each is beyond the scope of this text. General classes of venous
access catheters are noted below. All are designed to lie with their tips in the central
vena cava.
Standard Central Venous Catheter (CVC)
- Access sites: internal jugular, external jugular, or subclavian vein.
Peripherally Inserted Central Catheter (PICC)

- Access sites: antecubital, basilic, cephalic, or brachial vein.
- Indications: intermediate term (1-20 weeks) venous access.
- Role of peripheral access: to decrease risk of infection.
Tunneled Central Venous Catheter (i.e., Hickman and Broviac catheters)

- Access sites: internal jugular, external jugular, or subclavian vein.
- Indications: long-term venous access where clinical care requires frequent infusion encounters for delivery of medication, hydration, and/or hyperalimentation.
- Role of the tunnel: to stabilize the catheter via a tissue ingrowth cuff and to
decrease risk of infection requiring catheter removal.
Contraindications
Coagulopathysee angiography section for guidelines regarding management
of coagulopathy.
Ongoing bloodstream infection. Placement of a permanent central venous
catheter should be postponed until the patient has been on antibiotics for a
minimum of 48 hours and blood cultures are negative for bacterial growth.
Central venous occlusionsee below for associated procedures.
Known allergy to central venous catheter material. Central venous catheters
are made of either silicone or polyurethane. If a patient has a sensitivity to one
of the materials, care must be taken to use the alternate type of catheter.
521
Fig. 48.9. Foreign body retrieval: PICC catheter fragment in pulmonary arterial
tree. A. Portable chest x-ray demonstrates a long catheter fragment in the pulmonary vascular tree. One end of the fragment lies in a peripheral right pulmonary
arterial branch (indicated by two white arrows). The other end of the fragment lies
in the descending left pulmonary artery (indicated by single white arrow).
Note: iodinated contrast is rarely required for central venous catheter placement. Therefore, neither allergy to contrast, nor renal insufficiency, is a contraindication to image-guided venous access catheter placement.
Associated Venous Procedures

Foreign body retrieval: Guidewire and/or catheter fragments can be retrieved
from central venous circulation, heart or pulmonary arterial tree using fluoroscopic guidance and angiographic snares.
Fibrin sheath stripping: Central venous catheters frequently become coated
with a thin layer of fibrin that may prevent aspiration through the catheter
and limit infusion. It is possible to prolong the life of these catheters by using
an intravascular snare to strip the fibrin off the catheter. This procedure requires fluoroscopic guidance but no contrast. The fibrin sheath embolizes to
the lungs. This is well-tolerated in most people occasionally a patient will
experience focal self-limited chest pain. Most patients have no symptoms related to the procedure. The procedure should be avoided in patients with
limited pulmonary reserve or pulmonary hypertension.
Thrombolytic therapy: Acute central venous thrombosis can be treated with
catheter directed lytic therapy if clinical symptoms warrant aggressive intervention. The major risk of this therapy is hemorrhage.
Central venous angioplasty: Central venous stenosis can result in debilitating
symptoms such as chronic lower extremity swelling and SCV syndrome. Central venous stenosis can also result in poorly functioning dialysis grafts and
48
522
Trauma Management
Fig. 48.9B. Midportion of the retained catheter fragment has been snared (white
arrow). The catheter is in the process of being retracted into the inferior vena cava.
Black arrows indicate the ends of the catheter fragment.
48
Fig. 48.9C. The catheter is being pulled down the inferior vena cava (arrow). It was
removed via a femoral vein sheath without complication.
523
limit usable venous access sites. Balloon angioplasty can result in temporary
or permanent improvement in central venous luminal area.
Central venous stent placement: Permanent stent placement is indicated for
symptomatic central venous stenoses that do not respond to balloon angioplasty
or recur following balloon angioplasty. Risks are the same as those for arterial
stent placement.
Nonvascular Drainage Tube Placement (Figs. 48.10, 48.11)

Definition
Drainage tubes may be placed percutaneously, using imaging guidance into fluid
collections, the renal collecting system, and the biliary tree. Gastric and transgastric
jejunal feeding tubes can be placed in a similar fashion. Although there are a wide
variety of tubes available, they share several common characteristics: all are made of
flexible polyurethane-like material that allows for a thin-walled design; all are designed
to track over an angiographic guidewire; all are designed with internal fixation devices, such as pigtails, to help guard against dislodgement; and all have multiple
sideholes to facilitate drainage or infusion. Diameters range from 614 French.
Imaging guidance modalities for insertion include fluoroscopy, CT, ultrasound used
alone or in combination.
Indications
Indications noted below are specific to trauma patients. Other indications for
percutaneous tube placement exist but are not pertinent to this population.
Fluid Collections: The most common indication for drainage tube placement
in trauma patients is intra-abdominal or pelvic abscess occurring as a delayed
complication of injury. Other fluid collections, such as lymphocele, urinoma,
biloma, empyema, and infected pancreatic pseudocyst are also amenable to
percutaneous drainage.
Renal Collecting System: Percutaneous nephrostomy is indicated to control
traumatic upper urinary tract leak or to drain upper urinary obstruction.
Gastrointestinal Tract: Long term enteric nutritional support is required by
many severely injured patients. Percutaneous fluoroscopically-guided gastrostomy or gastrojejunostomy tube placement is one of several ways to secure
long-term stable access to the gastrointestinal tract for feeding. This method
may be preferred for patients who have contraindications to general anesthesia, per-oral endoscopy, or abdominal surgery. Percutaneous gastrostomy may
also be performed to decompress gastric or small bowel obstruction.
Contraindications
Lack of a safe percutaneous access route to the target site.

Coagulopathy.
Allergy to iodinated contrast
Ascites, peritoneal dialysis, ventriculo-peritoneal shunt. Although not absolute contraindications to percutaneous tube placement, the presence of ascites, or an intraperitoneal medical device, increases the risk of immediate and
delayed complications in instances where the tube traverses the peritoneal cavity.
48
524
48
Trauma Management
Fig. 48.10. Biliary leak following motor vehicle accident. Existence of bile leak
was noted at exploratory laparotomy but site of ductal injury could not be identified. Therefore, two subhepatic Jackson-Pratt drains were placed. Postoperatively,
a percutaneous transhepatic biliary drainage tube was placed. A. Scout film from
biliary drainage tube injection. Black arrows indicate the percutaneous transhepatic
drainage tube. JP drains lie adjacent to it. White arrowhead indicates a Dobhoff tube.
Fig. 48.10B. Cholangiogram. The biliary drainage

tube is now filled with contrast (black arrow). Contrast
fills intrahepatic ducts (left
ducts are indicated with
black arrowheads). Contrast extravasates from the
central left duct (white
arrow); some of it drains into
the JP drain. The leak healed
over a 4 week period.
525
Fig. 48.11. Ureteral laceration with urinoma. A. CT scan demonstrates a large fluid
collection along the right psoas muscle. A needle has been placed in the collection
(arrow) in preparation for drainage tube placement. Fluid had high creatinine level.
48
Complications
Immediate complications
- Hemorrhage
- Sepsis
- Nontarget organ injury
Delayed Complications
- Tube blockage, fracture, or dislodgment. Tubes that will be in place for a prolonged period of time should be changed electively at regular intervals to minimize the risk of tube-related complications. Reasonable tube change intervals are:
Biliary drainage tube
Nephrostomy tube
Gastrostomy tube
Gastrojejunostomy tube
Fluid collection tube
6-8 weeks
12-14 weeks
9-12 months
12-16 weeks
4-6 weeks
- Cellulitis: Cellulitis, or more severe infections, at the tube insertion site can be
prevented by optimizing skin care. Treatment of an insertion site infection
may require local, oral, or intravenous antibiotic care depending on severity.
Surgical drainage and/or tube removal may also be required in severe cases.
- Granulation tissue. Granulation tissue at a site of tube insertion can be minimized by stabilizing the position of the external portion of the tube. It is treated
with silver nitrate cauterization.
- Tract erosion. The diameter of a percutaneous tract can enlarge beyond that of
526
Trauma Management
Fig. 48.11B. Antegrade pyelogram following right percutaneous nephrostomy demonstrates ureteral transection with urine
leak (black arrow). A percutaneous
nephrostomy tube has been inserted into
the kidney via a lower pole calyx. White
arrow = localizing needle in the renal pelvis used to inject contrast to guide tube
placement. Arrowhead = urinoma drainage tube. Although the drainage tubes controlled the leak temporarily, this ureteral
injury required operative repair.
48
the tube going through it. The risk of this problem is minimized by ensuring
that the tube remains in stable position, and functions properly. If tract erosion
occurs, placement of a larger diameter tube may be required to prevent
pericatheter leakage of bodily fluid. In severe cases, tube removal may be necessary to allow healing of the tract.
References
1.
2.
3.
4.
5.
6.
Kandarpa K, Aruny JE, eds. Handbook of Interventional Radiologic Procedures.

Boston: Little, Brown & Co., 1996.
Ben-Menachem Y. Angiographic control of hemorrhage in trauma. In: Coldwell
D, ed. Radiologic Interventions: Embolotherapy. Baltimore: Williams & Wilkins,
1997; 6-60.
McArthur CS, Marin ML. Stent-Grafts for Vascular Trauma. In: Dolmatch BL,
Blum U, eds. Stent-grafts. Current Clinical Practice. New York: Thieme, 2000.
Savader S, Ronsivalle JA. Permanent inferior vena cava filters. In: Savader S, Trerotola
SO, eds. Venous Interventional Radiology with Clinical Perspectives. New York:
Theime, 1996.
McDermott VG, Schuster MG, Smith TP. Antibiotic prophylaxis in vascular and
interventional radiology. Am J Roentgen 1997; 169:31-38.
King BF Jr. Intravascular contrast media and premedication. In: Bush WH, Kreck
KN, King BF Jr, Bettman MA, eds. Radiology Life Support. London: Arnold, 1999.
CHAPTER 1
CHAPTER 49
Minimally Invasive Surgery in Trauma

James A. Murray
Introduction
Minimally invasive surgery is a useful diagnostic and therapeutic tool in a
small group of selected patients with blunt or penetrating trauma.
Laparoscopy in Trauma
History
Heselson in 1963 described laparoscopic evaluation of penetrating abdominal
trauma and its use in avoiding negative laparotomies.
Indications
Penetrating left thoracoabdominal trauma for suspected diaphragmatic injuries,
in a hemodynamically stable patient with no signs of peritonitis.
- The incidence of diaphragmatic injury in gunshot injuries to the left
thoracoabdominal area and no peritoneal signs is about 13%. In stab wound it
is about 26%.
- Laparoscopic repair of a diaphragmatic injury may be performed with staples or
sutures.
Penetrating injuries to the anterior right thoracoabdominal area

- Although the liver protects against herniation in posterior and lateral right
diaphragmatic injuries, anterior injuries are not adequately protected and
herniation may occur.
Tangential gunshot wounds to the abdomen in the absence of signs of peritonitis in order to evaluate peritoneal evaluation. This is not a generally accepted
indication because peritoneal violations is not necessarily associated with significant intra-abdominal injury requiring surgical repair.
Blunt torso trauma in a hemodynamically stable patient with a persistently
elevated diaphragm, in order to rule out diaphragmatic rupture.
Laparoscopy has also been used to detect intraperitoneal bleeding and solid
organ injuries. These indications have not gained popularity and have limited
or no practical use.
In ICU critically ill patients with suspected acalculous cholecystitis.
For diagnosis and repair of delayed diaphragmatic hernias.
Limitations
Laparoscopy has major limitations in detecting hollow viscus perforations,
pancreatic and other retroperitoneal injuries.
James A. Murray, Division of Trauma and Critical Care, Keck School of Medicine
of the University of Southern California, Los Angeles, California, U.S.A.
528
Trauma Management
In the presence of associated severe head trauma, abdominal insufflation may

increase the intracranial pressure. Laparoscopy in this condition is relatively
contraindicated.
Technical Aspects of Laparoscopy

Laparoscopy has been performed at the bedside in the emergency room under
local anesthetic with intravenous sedation. It has not gained significant
popularity because it is usually painful and the small scopes used do not
provide adequate visualization of the diaphragm.
Most centers perform laparoscopy in the operating room because it has the
following advantages.
-
Able to perform both diagnostic and therapeutic procedures

Able to rapidly convert to laparotomy
Additional ports may be placed for retraction and better visualization
Larger scopes may be used for better visualization
Better positioning of the patient allows maximal visualization
Patient Positioning
- After placement of the trocars the bed can be rotated with the affected side up
to allow better inspection of the area of concern.
- Reverse Trendelenburg position allows for better inspection of the diaphragm.
- The site of the injury should be prepped into the field, By pushing on the injury
site the surgeon can identify the corresponding intra-abdominal region.
- The ipsilateral thorax should be prepped in the event a thoracostomy tube is
required.
Port Placement
49
- A supraumbilical port (1-5 cm above the umbilicus) or occasionally one in the

upper quadrant allows better visualization of the upper abdomen and the
diaphragm especially for lateral and posterior thoracoabdominal wounds.
Pneumoperitoneum
- The pneumoperitoneum can be induced with either a Veress technique or open
technique depending on the surgeons preference.
- The patient should be closely monitored during insufflation of the abdomen. If
a defect in the diaphragm is present a tension pneumothorax may rapidly develop.
The surgeon and anesthesiologist should be communicating closely during
this time.
Signs of a tension pneumothorax include: Hypotension, tachycardia,
hypoxemia, elevation of peak airway pressures, reduction of tidal volumes,
if pressure control ventilation is being used.
- The development of a tension pneumothorax requires immediate release
of the pneumoperitoneum and decompression of the thoracic cavity with
a thoracostomy tube.
- Once the thoracostomy tube is in place, insufflation may be reattempted.
Occlusion of the defect in the diaphragm will be necessary in order to achieve
sufficient pneumoperitoneum and can be achieved by initially using slightly
lower insufflation pressures to allow placement of a second port. A Babcock
forceps can be used to grasp the defect and occlude it. If a pneumoperitoneum
cannot be maintained, conversion to a gasless technique is possible if the
appropriate retractors are available, but a laparotomy may be necessary.
529
Laparoscope
- A 0 laparoscope provides adequate visualization for most diagnostic procedures, especially for anterior injuries.
- For posterior and lateral wounds or therapeutic procedures a 30 angled scope
provides better visualization, especially in the recesses above and behind the
spleen and liver.
Thoracoscopy in Trauma
History
- Branco in 1946 used thoracoscopy to evaluate penetrating thoracic injuries.
Patient selection
- The patient must be hemodynamically stable.
- Due to the need for double-lumen intubation, the patient must be able to tolerate
single-lung ventilation.
- In patients with an obliterated pleural space, thoracoscopy is contraindicated.
Indications
In selected cases with suspected diaphragmatic injury
- Posterior diaphragmatic injuries are better visualized by thoracoscopy than
laparoscopy
- Laparoscopy is preferable during the acute phase because it offers the advantage
of evaluation of the intra-abdominal cavity.
- Diaphragmatic repair may be performed with staples or sutures
In cases with suspected delayed diaphragmatic hernias

- Reduction of the hernia and repair of the defect may be performed
thoracoscopically.
Assessment and possibly control of ongoing slow intrathoracic bleeding

- The patient should be hemodynamically stable.
- A pericardial window may be performed.
- Bleeding from the thoracic wall or the lung may be controlled with electrocautery
or hemoclips.
Evacuation of a retained hemothorax

- The evacuation ideally, should be performed within 3-5 days after the injury,
before clot organization takes place.
Decortication for posttraumatic empyema or lung entrapment due to

fibrothorax.
Thoracoscopy versus Laparoscopy

Many advantages and disadvantages are present when comparing thoracoscopy and laparoscopy for evaluating patients with occult diaphragmatic injuries.
Advantages of thoracoscopy over laparoscopy:
-
Avoids the potential complication of a tension pneumothorax.

The posterior aspect of the diaphragm may be better visualized.
Residual blood may be evacuated from the thorax.
Repair of the diaphragm may be technically easier.
Disadvantages of thoracoscopy over laparoscopy

- Requires double lumen intubation to allow the lung to be collapsed.
- Due to the concern about an intra-abdominal injury, if a diaphragmatic injury
is present the abdomen must be evaluated with either laparoscopy or laparotomy.
49
530
Trauma Management
- Thoracoscopy requires a thoracostomy tube postoperatively, if not required preoperatively, which may prolong hospitalization.
Technical Aspects
Due to the rigidity of the thorax insufflation is not required.
Both thoracoscopic and standard open instruments can be used for thoracoscopy.
In order to obtain maximal visualization of the thoracic cavity the ipsilateral
lung needs to be deflated. This usually requires a double lumen endotracheal
tube for intubation.
Patient Positioning
- Generally the patient is positioned in the full lateral decubitus position. Preparations should be made in the event a posterolateral thoracotomy is necessary
Port Placement
- If a chest tube is present this site can be used for the initial port and allows
evaluation of the thoracic cavity prior to placing subsequent ports.
- In the absence of a chest tube the first port can be placed in the sixth or seventh
intercostal space in the midaxillary line.
- Once the thoracic cavity is inspected additional ports can be placed higher in
the chest, typically in the third or fourth intercostal spaces in the anterior and
posterior axillary lines.
- If possible some of the ports can be placed to allow incorporation into a thoracotomy incision.
- By rotating the camera between each port, full inspection of the thoracic cavity
is possible.
Thoracoscope
49
- A 0 scope can be used but a 30 angled scope provides better visualization of

the costophrenic recesses.
- After evacuation of residual clots the thoracic cavity can be fully inspected. By
moving the camera and instruments between each port, all areas of the thoracic
cavity can be inspected and accessed for therapeutic procedures. If difficulty is
encountered or an area is not fully accessible, additional ports should be placed.
This should allow evacuation of all retained clots, control of hemorrhage, repair
of diaphragmatic injuries and inspection of the pericardium and pericardiotomy.
- Chest tubes can be positioned under direct thoracoscopic visualization.
- Upon completion of the procedure the lung should be inspected to insure it
inflates properly.

Laparoscopy may miss hollow viscus perforations.
During abdominal insufflation in the presence of a diaphragmatic injury there
is a risk of tension pneumothorax. Close monitoring of the blood pressure,
heart rate, Sa02 , and airway pressures are critical.
References
1.
2.
Fabian TC, Croce MA, Stewart RM et al. A prospective analysis of diagnostic

laparoscopy in trauma. Ann Surg 1993; 217:557-565.
Murray JA, Demetriades D, Asensio JA et al. Occult injuries to the diaphragm: A
prospective evaluation of laparoscopy in penetrating injuries to the left lower chest.
J Am Coll Surg 1998; 187:626-630.

3.
4.
5.
531
Zanzut LF, Ivatury RR, Smith RS et al. Diagnostic and therapeutic laparoscopy for
penetrating abdominal traumaa multicenter experience. J Trauma 1997;
42:825-829.
Oschner MG, Rozycki GS, Lucente F et al. Prospective evaluation of thoracoscopy
for diagnosing diaphragmatic injury in thoracoabdominal trauma: A preliminary
report. J Trauma 1993; 34:704-9.
Uribe RA, Pachon CE, Frame SB et al. A prospective evaluation of thoracoscopy
for the diagnosis of penetrating thoracoabdominal trauma. J Trauma 1994;
37:650-654.
49
CHAPTER 50
Ballistics of Gunshot Injuries

Kenneth G. Swan and K.G. Swan, Jr.
Introduction
Despite the recent decrease in crime and murder rates, physicians and surgeons
today still face a steady influx of patients who have been wounded by guns, many with
increasing caliber1 and rate of fire, the bullets from which are more tissue destructive
and potentially traveling at greater velocities. Those treating such patients should be
knowledgeable about wound ballistics and the ballistic properties of modern weapons.
Explosive mixture of saltpeter, charcoal and sulfur described by Roger
Bacon, 1242
Introduction of firearms in Europe in the 14th century.2
First recording of a gunshot wound by the German surgeon, Pfolspeundt, 1460
Invention of the rifle in the 15th century
Alleged poisonous nature of gunshot wounds (GSW), 15th and 16th centuries
Recognition that injured tissues were crushed rather than poisoned, mid
16th century
Replacement of black by smokeless powder and smooth by rifled barrels,
19th century
Revolver patented by Samual Colt, 1835
Machine gun introduced by Richard Gattling, 1860s
Hollow nosed bullets designed and distributed from British arsenal in Dum
Dum, India, 19th century
Cavitation recognized as a principle in wound ballistics by Woodruff 18983
Hague Conference 1899 outlawed Dum Dum bullets, mandated copper
jacketing of lead bullets in war
High velocity refined and implemented (M-16 rifle, 3240 feet per second),
20th century.
Incidence
Gunshot wounds (GSW) are the eighth leading cause of death in the United
States today,4 killing approximately 35,000 Americans and wounding almost ten
times that number with an estimated cost to US taxpayers of four billion dollars per
year.5 Although motor vehicle crashes are the leading cause of trauma deaths in the
US today (44,000 per year),4 these have declined significantly in recent years whereas
those from guns have not. If current trends continue, guns are predicted to be the
leading cause of trauma death by the year 2003.5
Kenneth G. Swan, Department of Surgery, UMDNJ/New Jersey Medical School,
Newark, New Jersey, U.S.A.
K.G. Swan, Jr., Department of Surgery, UMDNJ/New Jersey Medical School,
Newark, New Jersey, U.S.A.
Ballistics of Gunshot Wounds
533
Definition of Terms
Ballistics
The science of the motion of a projectile through the barrel of a firearm (internal
ballistics), during its subsequent flight through space (external ballistics) and
during its final complicated motion after striking the target (terminal ballistics)
Wound Ballistics
Terminal ballistics when the target is in animal tissue
Caliber
Diameter of bullet/missile or barrel/bore of weapon, expressed in hundredths
(two digits) or thousandths (three digits) of an inch or in millimeters
Round or Cartridge (Fig. 50.1A)
Casing, powder, primer and bullet
Bullet (Fig. 50.1B)
Missile contained in cartridge
Shell
Cartridge casing
Muzzle
Distal end of the barrel; Breech: proximal end of the barrel
Muzzle Velocity
Velocity of missile as it exits the muzzle of a gun
Range
Distance covered by fired missile (effective, maximal effective, maximal)
Kinetic Energy
Mass times velocity squared divided by two
Dissipation of Kinetic Energy, Kinetic energy transfer equals KE impactKE exit
Secondary Missiles
Objects to which kinetic energy of missile is imparted in GSW
Cavitation
Separately covered subsequently
Powder Burn
Tattooing of target by incinerated powder (Fig. 50.2)
Yaw (Fig. 50.3A)
Deviation of base of missile (versus point) from its long axis of flight
Tumbling
Forward rotation of missile on its long axis of flight (Fig. 50.3B)
Entrance Wound
Wound of presumed entrance of missile in target
Exit Wound
Wound where missile presumably exited target
Small Arms
Pistols or rifles carried by one person
Semiautomatic Weapons
Weapons which chamber a round automatically. Trigger must be pulled for
each round fired
Automatic Weapons
Weapons which fire continuously with one trigger pull
Chamber
Breech end of the barrel, where trigger mechanism and firing pin are located
50
534
Trauma Management
50
Fig. 50.1. A) Shotgun cartridge cutout to reveal contents: powder, wadding and
pellets. B) Handgun cartridge cutout to reveal powder and bullet further cut to reveal
copper jacket and lead core.
Handgun
Small arm fired with one hand (pistol or revolver) (Table 50.1)
Rifle
Shoulder held small arm, barrel of which is grooved helically to impart spin to
the bullet (Table 50.2)
Kinetic Energy (KE) and Its Dissipation or Transfer (KE)

KE = missile mass (M) x missile velocity (V) squared / 2
M = bullet weight in grains
535
Fig. 50.2. M-16 rifle

wound of left side of
soldiers chest showing
entrance (powder burns)
and exit wounds.
50
V = bullet velocity in feet per second
KE = M(VENVEX)2 / 2
EN = entrance
EX = exit
Wound damage correlates dissipation or transfer of kinetic energy.
As exit velocity approaches zero, maximal dissipation of kinetic energy or its
transfer is accomplished and maximal tissue damage for that missile occurs.
Many design features alter bullet velocity within the target.
- Copper jacketing of bullets (often called full metal jacketed or military rounds)
minimizes the deformation of the softer lead within the target (Fig. 50.4).
- Soft pointed bullets (Fig. 50.4A) (those without a complete copper jacket)
deform on impact and dissipate kinetic energy as velocity is reduced within
the target.
- Hollow pointed (Fig. 50.4B) (Dum Dum) bullets tend to flatten on impact
and impart maximal kinetic energy transfer.
- Black talon rounds (Fig. 50.5A, B) combine the properties of soft pointed
536
Trauma Management
B
Fig. 50.3. A) Yaw is the lateral movement of a projectiles base along the long axis
of its flight. B) Tumbling is the forward rotation of a missile along its long axis of
flight.
Table 50.1. Ballistic properties of handguns and their bullets

Caliber*
50
Bullet Weight
(Grains)
50
71
158
250
25
32
38
45
Muzzle Velocity
(Ft/S)
820
910
870
860
Kinetic Energy
(Ft-Lbs)
75
130
267
413
*Size in hundredths of an inch

1grain = 60 mg.
At the muzzle
Table 50.2. Ballistic properties of rifles and their bullets

Caliber*
Model
22
223
30
308
Long Rifle
M-16
AK-47
M-14
Bullet Weight
(Grains)
40
55
122
147
Muzzle Velocity
(Ft/S)
1255
3240
2300
2750
*In hundredths (two digits) or thousandths (three digits) of an inch

At the muzzle
Kinetic Energy
(Ft/Lbs)
141
1289
1470
2520
537
Fig. 50.4A. 380 caliber handgun rounds left to right copper jacketed, noncopper
jacketed and hollow pointed.
and hollow pointed bullets as well as configure a partial copper jacket into symmetrical barbs with unique wounding potential.
Secondary Missiles
A primary missile (bullet) may impart kinetic energy to dense tissues such as
bone or teeth and endow them with wounding potential. (Fig. 50.6)
Secondary missiles also can derive from inanimate objects such as coins or dog
tags found on the target.
Secondary missiles of teeth must be considered when gunshot wounds to the
face occur. These are infective and must be identified radiographically, particularly if lodged in the brain where brain abscess may ensue.
Cavitation
Low velocity missiles tend to push tissue aside producing a path of injury
approximating the transverse diameter of the missile (Fig. 50.6).
As velocity increases kinetic energy of the missile is transmitted laterally to
form within milliseconds a water vapor filled cavity at sub-atmospheric pressure.
The cavity continues to enlarge even after passage of the missile causing damage well beyond the actual path of the missile (Fig. 50.6).
Negative pressure within the cavity can suck air borne material such as dust
and microorganisms into the wound.
Cavitation is inversely proportional to the tensile strength of the target, i.e.
greatest in liver, least in bone, intermediate in skeletal muscle.
50
538
50
Trauma Management
Fig. 50.4B. 223 caliber M-16 rifle rounds left to right copper jacketed and soft
pointed.
Fragmentation
Low velocity missiles (<103 feet/sec) tend to retain their configuration within
the target (Fig. 50.6).
Very high velocity missiles* (~3 x 103 ft/sec) tend to yaw, tumble and fragment
within the target (Fig. 50.6).
Such fragments take erratic courses within the target and dissipation or transfer of kinetic energy is maximized as is tissue destruction.6
* Definition of high versus low velocity is imprecise. In general, handguns are
considered low velocity (<103 feet per second) and rifles and shotguns high velocity (>103 feet per second). The importance of these definitions lies in a missiles
greater tendency to cause cavitation and to fragment as it approaches velocities
of 3 x 103 feet per second.7
Multifactorial Aspect of Wound Ballistics

No single result can be predicted with complete certainty.8
Kinetic energy dissipation, transfer, cavitation, fragmentation are all complexly
inter-related.
539
Fig. 50.5A. Black talon 9 mm round, side view with recovered bullet showing
flattening of nose and barbs from copper jacket.
50
Fig. 50.5B. Same as 5A except seen nose first
540
Trauma Management
50
Fig. 50.6. Schematic representation of bullet/missile traveling through target. A)

Low velocity, no cavitation, entrance and exit small; B) High velocity, cavitation, entrance and exit small; C) High velocity, thinner target, larger exit; D)
High velocity, large cavity, small entrance, exit may not occur; E) Higher velocity, asymmetric cavitation as bullet begins to deform, tumble and fragment;
F) Deformation of bullet and creation of secondary missiles upon penetrating
bone.
541
Target mass and composition are added variables.

Secondary missiles are neither uniform nor predictable.
Wound ballistics is thus, an imprecise science in contrast with internal and
external ballistics, both of which are relatively precise in mathematic expression.
Shotgun Wounds
Shotguns have smooth as opposed to rifled barrels or bores.
The shotgun cartridge contains many pellets or a single slug (Table 50.3).
The mass of the missile/missiles is approximately 10x that of a rifle or a handgun bullet.
Muzzle velocity ~1500 feet per second
Dissipation of kinetic energy in air is rapid, hence wound damage is much
more dependant upon range.
At close range ( 5 meters) the shotgun, regardless of pellet size, can produce
a devastating wound.
Surgical Excision of Bullets: Indications
Plumbism, saturnism
Embolization, migration
Occasionally, a source of infection
Associated foreign body (e.g., clothing)
Erosion into neighboring structures
Forensic concerns
Stigma
Phobia
Longterm risk of cancer in extremity sinus tracts
Rubber and Plastic Bullets

Used in riot control to reduce wounding caused by lead
Have caused skull fractures (close range), even death from brain injury
Injuries from rubber bullets 4x that from plastic bullets (Northern Ireland
experience)
Pneumatic Weapons
Muzzle velocities in excess of 100 feet per second are possible.

BB and pellet guns fire missiles.177 inches in diameter (18 caliber).
Fatalities from brain and myocardial damage have been reported.
Eye injury and loss of eyesight are relatively more common injuries.
Explosive Bullets
Uncommonly seen today

Lead oxide within bullet tip
British used fulminate of mercury, 1862
Detonation on impact
Relatively high failure rate, potential danger to health care workers
Lead Intoxication
Plumbism, Saturnism
Rare but long recognized complication of retained lead bullets or their
fragments
50
542
Trauma Management
Table 50.3. Ballistic properties of shotguns and their loads; standard shotgun
cartridges
Gauge
Diameter
(in)
Caliber
Pellet or
slug weight
(oz)
Grains
#9 Pellets,
8 caliber
Kinetic
Energy
(ft. lbs.)
410
20
12
0.410
0.615
0.729
410
615
729
0.562
0.875
1.000
070
420
480
328
512
588
385
800
2100
Location in synovial lined spaces, joints, meningeal spaces especially problematic

Insidious nature, long interval between wounding and symptoms
Encephalopathy, colic, anemia, proteinuria, death
Diagnosis is based on elevated blood or urine levels of lead
Chelation is possible, surgical removal may be necessary
Microbial Contamination of Bullet
Bullets have been thought to be heat sterilized by internal ballistics.

Experimental evidence and anecdotal data indicate this is not necessarily true.
Bullets should not be ruled out as possible sources of infection.
Missiles which traverse the colon and lodge in muscle are especially infective.9
Missiles which deform on impact (e.g. black talon) can drag clothing into
wound and cause cloth foreign body, which is highly infective.
Wadding within shotgun cartridges can be driven into wounds where it is
both radiolucent and infective
Bullet Embolism
50
Bullets or missile fragments may enter vascular structures.

Venous emboli may travel to the right heart and the lung.
Venous emboli in lower extremities may fall by gravity to distal locations or
lodge in valves.
Arterial emboli may cause acute arterial insufficiency, necrosis and gangrene if
not identified.
Shotgun wounds to the chest and neck may result in pellet embolism to the
brain and indicate skull radiography.
Buckshot colic is caused when a shotgun pellet embolizes or erodes into a
ureter
Shooting Incident
Documentation of the wounding event should be part of the medical history.

Weapon: either handgun (low velocity), rifle or shotgun (high velocity).
Caliber: either of weapon or its bullet
Range: distance between shooter and victim
Such information is usually known by the victim, witnesses or law enforcement officials.
543
Medical Legal Concerns
Treating physicians and others often are careless with forensic evidence.
Cut around and not through bullet holes in clothing of the victim.
Save garments with bullet holes or powder burns.
Submit bullets or fragments received from the victim to the Surgical Pathology Dept.
Sign the base of the bullet and record the signature in the medical record.
Describe number, location and size of apparent entrance and exit wounds.
Indicate, if possible, entrance versus exit wounds.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Caruso RP, Jara D, Swan KG. Gunshot wounds: bullet caliber is increasing. J Trauma
1999; 46:462-465.
Billroth CAT. Historical studies of the nature and treatment of gunshot wounds
from the fifteenth century to the present time. Translated by CP Rhoads. Yale J
Biol Med 1931-1932; 4:16-36, 119-148, 225-257.
Woodruff CE. The causes of the explosive effect of modern small caliber bullets.
NY Medical Journal 1898; 67:593-601.
Hoyert DL, Kochanek KD, Murphy SL. National Vital Statistics Reports from the
Centers for Disease Control and Prevention. National Center for Health Statistics.
National Vital Statistics System 1999; 47:19.
Violence in America: Public Health CrisisThe Role of Firearms. The Violence
Prevention Task Force of the Eastern Association for the Surgery of Trauma. J
Trauma 1995; 38:163-168.
Swan KG, Swan RC. Gunshot wounds: Pathophysiology and Management, 2nd
Edition. Yearbook Medical Publishers, Chicago, Illinois, 1989.
Swan KG, Swan RC. Principles of ballistics applicable to the treatment of gunshot
wounds. Surg Clin North Amer 1991; 71:221-239.
Fackler ML. Letter to the Editor. J Trauma 1997; 43:386-387.
Tzeng S, Swan KG, Rush BF. Bullets: A source of infection? American Surgeon
1982; 48:239-240.
50
CHAPTER 51
Blast Injuries
Avraham I. Rivkind and Tal Luria
Target Population and Environmental Characteristics
Civil casualties caused by terrorist acts are an ever-growing global problem.
The contrivances, either homemade or military devices, are designed to spread
death and destruction to the utmost, and to that end they rely mostly on
explosives that propel metallic fragments. From the point of view of the bombmaker, blast is a desirable side effect, and in many instances it is even the
primary goal. The chain of violence targeted at the innocent citizen has brought
blast injuries from he battlefield to our front door.
Patterns of Injury
Explosions produce compound injuries of types that many hospitals have barely
experienced. This chapter deals specifically with blast injuries, which are differentiated into four patterns of mechanism of injury, as follows:
Primary mechanism injurycaused by the resultant force of the blast wave
itself and by its effect on air expansion; hence, perforation of the ear drum,
different types of lung and intestinal injuries.
Secondary mechanism injurycaused by the wreckage, i.e., fragments of casing, metal, glass, masonry, etc. being propelled at high speed by the force of
the explosion.
Tertiary mechanism injurycaused by the rapid passive movement of the
body by the blast wave, inflicting damages ranging from bruising to loss of
limbs, severed at the site by the blast wave.
Flash burns consequent on the heat generated by the explosion.
Environmental Effects
Blasts Occurring
- In wide open-air spaces: upon detonation of an explosive charge in a completely
open space, the resulting blast wave strength decreases exponentially with its
distance from the epicenter of the explosion, leaving most of the damage to be
done by secondary and tertiary mechanisms of injury.
- In closed spaces: in contrast to open-space blast injuries, the causative factor
here is mainly the primary mechanism of injury, albeit closely followed by secondary and tertiary mechanisms of injury. The limiting walls reflect the shock
wave, thus increasing the generating pressure and lengthening its duration. The
same is applicable to flash burns.
- In confined spaces: this is a new category, which was defined by us after bomb
explosions in partly roofed street markets and malls. The injuries share some of
Avraham Rivkind, Hadassah Medical Center, Jerusalem, Israel
Tal Luria, Hadassah Medical Center, Jerusalem, Israel
Blast Injuries
545
the characteristics of the aftermath of blasts in an open space (shrapnel wounds

and severed limbs) and in closed space (ear injuries and flash burns).
- Under water: characteristically belong in the realm of explosions initiated by

the military. They cause severe primary blast injuries, with little or no damage
due to other mechanisms of injury.
It should be borne in mind that each environment targeted for explosion carries
its own particular characteristics, which run from the size of the explosive device
itself and the materials used to the density of the crowd, proximity of the bystanders
to the epicenter of the explosion, the type of blast-energized debris, the clothing
worn by those exposed to the blast, to the ambient temperature and humidity. All
these factors affect the preponderance of specific wounds.
Specific Mechanisms of Injury

Primary Blast Injuries
This type of injury affects vital parts of the body, as follows:
EarThe tympanic membrane is a very delicate structure that is liable to
suffer injuries from rather low blast forces. Clinical signs are tinnitus, deafness,
bleeding and/or perforation.
LungBecause of the expanding nature of the alveoli, quite high pressures
are needed to cause blast injury to the lungs. Most lung injuries will therefore
be seen in conjunction with multiple shrapnel wounds, limb(s) severed by the
blast itself, moderate to severe burns and fractures, with clinical appearance of
tachypnea and dyspnea that must be verified by chest X-ray and objective
evidence of hypoxia.
CardiovascularThe immediate response to the blast wave consists of a singular
form of cardiogenic shock, resulting from myocardial depression without compensatory vasoconstriction. Severe hypotension, profound bradycardia and
low cardiac output, as opposed to normal systemic vascular resistance and
stroke volume, constitute this unique physiologic state. Transient papillary
muscle ischemia may become part of the clinical picture.
IntestineThe gastrointestinal tract, being rather expandable and flexible,
sustains primary blast injuries only when exposed to relatively high blast
pressures, such as are encountered in underwater explosions. Intestinal involvement may appear hours to days after the primary injury, with signs of peritonitis
and/or ileus which are undiscoverable in the interim period.
Nervous SystemVagal parasympathetic excitation causing bradycardia,
reduced cardiac index together with shallow breathing sometimes ensuing in
apnea. Numerous changes in the brain, involving chiefly the microglia, may
occur. As a consequence of nerve injury, patients suffer from headache and
pain along the limbs.
AmputationWhere the blast wave causes internal fracture of bone, the
immediately following blast wind will complete the process of severing the
limb. Such amputations are usually seen in the shaft of long bones.
Secondary Blast Injuries

This specific damage is inflicted by fragments originating in the explosive
device itself, or such as are caused by debris from the nearby environment,
propelled by the blast wind and hitting the victim in various topographical
areas of the body. Especially endangered are exposed parts, i.e., head, neck
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Trauma Management
and extremities, although the wind force may cause fragments to penetrate
into the torso (Fig. 51.1). Shrapnel may cause perforation of vascular structures and other viscera. Multiple shrapnel wounds should be suspicious of
additional internal injuries.
Tertiary Blast Injuries

This type of injury is due to the blast wave displacing the whole body, or part
of it, at high velocity which is terminated by impact with a solid surface (walls,
vehicles, etc.) or with a very large fragment of debris. The outcome of this
violent thrust are bruises and bone fractures from head to foot, laceration of
internal organs (most commonly muscles and spleen), brain or lung contusion, and even the end phase of amputation (by the blast itself).
Flash Burn Blast Injuries

The heat generated by the explosive device, as well as the blazing objects at the
site that caught fire in the wake of the explosion, present the danger of burn
casualties. The bulk of burns occur in conjunction with other injuries, such
as wounds caused by blast-propelled debris and/or blast lung. The exposed
body parts (head, neck and extremities) are most prone to be involved in
flash burn damage; nonetheless, secondary burns may be caused by ignition
of the victims clothing.
Investigation
Patients who have been exposed to air blast might, at first sight, appear unharmed, but in reality they may have serious internal injuries (Table 51.1).
Hence, all appropriate diagnostic tools should be utilized to detect injuries in
susceptible organs (e.g., ears, lungs, the great vessels, intestines, spleen, liver,
vascular bed of the intestines) that can not be assessed by the naked eye or
simple physical examination.
Treatment should be managed according to the ATLS protocol.
Primary Investigation
51
Blood samples for blood gases are a sine qua non in order to assess the patients
lung function.
Chest X-ray must be performed so as to provide:
- Verification of pneumo/hemothorax
- Evidence of the classic butterfly appearance of a lung that sustained blast
injury (Figs. 51.2A, 51.2B); in our experience, the incidence of blast lung
injury varies from 4.5% in open-space bomb explosion victims to 13.2%
in closed-space detonation casualties
- A starting point in the approach to the lung condition
- A first means to assess eventual widening of the mediastinum, a condition that
may be indicative of vascular injury, and if confirmed should prompt the use of
angiographic procedures (Figs. 51.3, 51.4).
ECG is necessary in all blast injury victims, irrespective of age, to assess eventual
involvement of the heart.
Secondary Investigation
Ear examination, to search for micro- and macro drum perforation and
hemotympanum
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Blast Injuries
Fig. 51.1. Abdominal X-ray demonstrating a nail in the abdominal cavity.
Table 51.1. Probability of lung injury in patients suffering from compound

insults*
Shrapnel to head and abdomen
Burns (10%) + abrasion to face +
abdominal injury
Burns (10%) + skull fracture (s)
Rib cage fracture
Open space
33%
Confined space Closed space

N/A
100%
36%
83%
N/A
22%
100%
N/A
100%
87%
100%
*The data relate to damage caused by explosive devices composed of 10-15 kg

TNT, nails and pellets.
N/A, data not available.
Diagnostic peritoneal lavage (DPL) serves to assess peritoneal contents for

blood and internal organ injury; an indwelling catheter should be left in place
for re-examination after 48 hours of hospitalization and treatment in the
intensive care unit.
Focused abdominal sonography for trauma (FAST) should be applied to explore the
peritoneum for free fluid, laceration of the liver, spleen, kidney and intestines.
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Trauma Management
Fig. 51.2A. Chest x-ray on admission showing widened mediastinum. Note first signs of butterfly pattern.
51
Fig. 51.2B. Classic appearance of butterfly pattern.
Management
Prehospital
The site of an explosion causing blast wounds is considered a hot zone in the
sense that a second explosive device may go off at any moment in the immediate
Blast Injuries
549
Fig. 51.3. CT scan of the thorax showing disruption of the aorta caused by a flying nail.
Fig. 51.4. Angiography
demonstrating laceration
of the innominate artery.
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Trauma Management
vicinity. Therefore, the goal should be to spend as little time as possible at the
site where a premeditated explosion has occurred or in a location where multiple
explosions might be expected, taking of course into account the condition of
the wounded. In any event, the advocated policy is scoop and run, while
following the ATLS guidelines regarding airway breathing and circulation.
Intravenous lines, using peripheral large bore catheters, may be established on
the way to the hospital.
In-Hospital
Special attention should be paid to the possible presence of some unique
manifestations, as outlined below:
Tension Pneumoperitoneum
Air in the peritoneal cavity may be caused by hollow viscus injury, or it may be
a manifestation of barotrauma to the lung caused by either the blast itself or
by ventilation (see below).
Pneumoperitoneum has a devastating effect on hemodynamic and respiratory
physiology, which is expressed, inter alia, in reduced venous return, reduced
compliance (by about 40%) and reduced FRC.
This specific injury should receive immediate attention by means of bedside
laparotomy followed by closure of the abdomen with artificial materials, such
as saline bags (a.k.a., the Bogota Bag), to prevent accumulation of pressure.
in the abdominal cavity.
Ventilation
51
Respiratory management in patients suffering from blast injury is a mandatory and urgent part of the treatment spectrum. The blast lung injury (BLI)
score is an effective tool to assess lung involvement, as shown in Table 51.2,
and plan treatment accordingly. A prime aim is to provide sufficient amounts
of oxygen to the tissues in order to prevent deterioration of the already compromised patient. Table 51.3 lists the modalities to be used according to the
BLI score.
Prophylactic chest tube insertion in case of moderate to severe BLI score should
be considered because of the enhanced risk of tension pneumothorax; the
latter, in turn, is due to the high pressure used to attain adequate oxygenation
coupled with the massive damage already sustained by the lung parenchyma.
In considering the option of bilateral chest tube insertion, the general condition of the patient plays a primary role.
Acute respiratory distress syndrome (ARDS) may result from alveolar disruption, intrapulmonary hemorrhage, smoke inhalation, aspiration, shock, fluid
loading, and secondary infection.
Delayed Intestinal Perforation

Intestinal perforation may occur directly upon either primary or secondary
blast injury.
Intestinal perforation may manifest itself as long as 48 hours after the initial
blast injury. The late sequelae are due to a peculiar cause and effect: damaged
mucosa allows the introduction of mucus into the bowel wall under pressure.
The mucus dissects the intestinal layers that results, after a latent period, in
multiple minute perforations.
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Blast Injuries
Table 51.2. Blast lung injury (BLI) severity score

PaO2/FIO2
Chest radiograph
Broncho-pleural fistula
Severe BLI
< 60
Massive bilateral
lung infiltrates
Yes
Moderate BLI
60 200
Bi- or unilateral
lung infiltrates
Yes/no
Mild BLI
> 200
Localized lung
infiltrates
No
Table 51.3. Treatment according to BLI score

BLI
Mild
Moderate
Severe
PEEP
< 5 cm H2O
> 5 cm H2O
>10 cm H2O
Assisted ventilation
No PPV
PPV
PCV, one-lung, N2O, HFJV, ECMO
PEEP, positive end expiratory pressure

PPV, positive pressure ventilation
PCV, pressure controlled ventilation
HFJV, high frequency jet ventilation
ECMO, extra corporeal mechanical oxygenation
Major blast trauma increases the probability of covert intestinal perforation.

Close observation during the first 48 hours is essential to detect concealed or
developing perforation.
Diagnostic means are physical examination, DPL, abdominal sonography.
Surgical intervention is obligatory upon the first signs of perforation of the
intestines.
Fungal Infection
Explosions in confined spaces, especially street markets, may be opportune spaces
for victims to contract fungal disease.
Risk factors for the development of candidemia include smoke inhalation,
extensive burns, open wounds and multiple blood products. We have encountered development of candidemia in 58% of those admitted to the ICU after
being injured by an explosive device that had been placed in a partly covered
street market.
Early respiratory colonization (1-4 days after injury) of Aspergillus or Rhizopus
sp. was noted by us in 19% of the hospitalized blast injury patients.
Posthospital Care
Chronic pain, a side effect seen in many patients surviving blast trauma may be
due to damage caused to
microglia in the CNS inducing local neuronal insult
peripheral nerves
articular joints, either by local trauma or ischemia due to emboli
Decreased lung function, recurrent pneumonia, and hyperactive airways.
Peritoneal adhesions causing intestinal obstruction and/or abdominal cramps as
a consequence of undiscovered micro-perforations in patients managed conservatively.
Posttraumatic stress disorder is a common reaction in survivors of blast injuries,
which may be compounded by incidents of terrorism.
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Trauma Management
References
1.
2.
3.
4.
5.
51
Cooper GJ, Maynard RL, Cross NL et al. Casualties from terrorist bombings. J
Trauma 1983; 23:955-967.
Katz E, Ofek B, Adler J et al. Primary blast injury after a bomb explosion in a
civilian bus. Ann Surg 1988; 209:484-488.
Irwin RJ, Lerner MR, Bealer JF et al. Cardiopulmonary physiology of primary
blast injury. J Trauma Injury Infect Crit Care 1997; 43:650-655.
Hull JB, Cooper GJ. Pattern and mechanism of traumatic amputation by explosive blast. J Trauma Injury Infect Crit Care 1996; 40:S198-S205,
Pizov R, Oppenhein-Eden A, Matot I et al. Blast lung injury from an explosion on
a civilian bus. Chest 1999; 115:165-172.
CHAPTER 1
CHAPTER 52
Forensics for Trauma Care Givers

Thomas T. Noguchi
Medicolegal Issues
Not all trauma cases will end up in court, but trauma caregivers should be
aware that in every step of your patient care, there is a medicolegal aspect to be
considered.
It would be too late to worry about the medicolegal issues when you receive a
subpoena to appear in court.
It is important to be aware of the pitfalls dealing with medicolegal issues and
be ready and prepared.
Questions may be asked long after the patient has left the emergency room.
Good documentation is critical.
Lawyers Interest
What
Who
Where
When
Why
How
What was the weapon?

Who did it?
Where did it happened?
When did it happened?
Why did it happened?
How did it happened?
Case 1: Issue: Knife Wound: What Was the Weapon?

A friendly fight escalated to knife fighting. A passerby found an unconscious
man in a pool of blood. The patient was taken to the Medical Center. In the
middle of the pool of blood, there was a pocketknife. Was this knife the weapon?
Wound in the chest appeared larger than a wound caused by a pocketknife. A
larger kitchen knife was found in a nearby trashcan. Had the size of the stab
wound not been stated, the pocketknife may have been erroneously stated as
the weapon, which caused the wound.
Case 2: Issue: Who Did It?

A group of gang members confronting another gang, began a turf fight. A
man in the front of a group received a through-and-through gunshot wound
to the chest. Many members of his gang behind him were shooting. In the
emergency room, the physician noted the gunshot wound in the chest, but
documented no detailed description. During the cross examination, a lawyer
challenged the physician that the two wounds caused by the throughand-through gunshot were similar, the gunshot wound in the right shoulder
may be the entrance wound, suggesting that a member of his own gang standing
behind him may have accidentally shot him. The lawyer created a reasonable
doubt as to who shot him.
Thomas T. Noguchi, Emergency & Medical Surgery, LAC + USC Medical Center,
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Trauma Management
The photograph reveals a ring of abrasion caused by a bullet as it enters the

tissue. This phenomenon can also be observed on the clothing. During the
cross-examination attorney will check the certainty and credibility of witnesss
statement. If it is not written, it is impossible to remember in detail, and
under questioning, your testimony can become unclear or uncertain (Fig. 52.1).
Citation: Entrance wound: There is a rim of abrasion caused by the bullet as it
enters the tissue. A few grains of unburned powder and blackened edges caused
by burned powder are seen.
Case 3: Issue: When Did It Happen?

The child was found unconscious and brought into the emergency room. The
story given to the physician was that the child had fallen from the crib. In
order to check the statement, the age of the bruises became important. Were
they fresh or were there signs of healing? The baby sitter was suspected to have
caused the bruises. In order to establish credibility, independent medical opinion
based on the appearance of the injuries may be sought (Fig. 52.2).
Citation: Four bruises on the left leg: child suspected of being a victim of abuse.
Issue was raised whether or not these marks could have been caused by a hand.
Case 4: Issue: Where Did It Happen?

Issue became very heated when the family of an unconscious man initiated
litigation against the arresting police officer. The man under influence of alcohol
was disturbing the peace on the street. The police officer responded to the
scene and the man resisted arrest and a struggle ensued, resulting in his fall.
The allegation was that he was beaten by the police officer. Close examination
of the wound on the back of his head revealed a grid like pattern of the lid of
a manhole. The matter was settled.
Case 5: Why Did It Happen?

The defense attorney gave self-defense as reason. It would be important to
know whether or not the assailant had lunged toward the defendant and fearing for his life, the defendant had shot him. The defense attorney needs to
vigorously claim the gunshot wound in the chest was the entrance wound.
EvidenceCare of Wound
52
The wound is also evidence to the lawyer and judge. Any object removed
from clothing and the body should be described, saved and photographed.
Wound Characteristics Change with Time

Describe the wound accurately as you first see it at the initial examination, since
its appearance and character will change with time and treatment. Descriptions of
the wound many days after the fact will be of very little value. Record the following:
Size
Shape
Color
Consistency
Architecture
Architecture includes the anatomic landmark and changes of structure near the
wound.
555
Fig. 52.1. Entrance wound. There is a rim of abrasion caused by a bullet as it enters
the tissue. A few grains of unburned powder and blackened edges caused by burned
powder.
52
Fig. 52.2. Four bruises in the left leg suspected victim of child abuse. Issue was
raised that if marks were caused by a hand squeezed.
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Trauma Management
Contemporary and factual information will have much bearing on the final legal
decision making.
Adversary System
Adversary technique is very different and foreign to us, but it is important to
know why this is done. The legal profession is dedicated to the search for truth by
taking an adversary position and carefully examining the evidence. The opposing
attorney will conduct a cross-examination of your knowledge to make sure the evidence as introduced, is pertinent and relevant to the case. For every medical decision
we make at the Medical Center for the care of the trauma patient, medicolegal issues
can be raised. Often the lawyer questions each issue by saying how do you know for
sure?
Accuracy and Credibility

Although we are often under pressure to move on to another case, it is very
important to document basic information on each case as it is being handled: date
and time, right and left designation, treatment given, sequence of event, etc. If there
were a series of small errors in documentation, despite your diligent work, the jury
can only interpret that the treating physician was NOT careful. Your descriptions
would be more accurate in detail, if it is documented right away.
Chain of Custody of Evidence
52
An unbroken chain of custody of evidence must be recorded.

Record should include who received the evidence first and gave it to whom,
and in sequence all persons who handled the evidence until the evidence is
introduced in court.
An object found in or on the body, such as bullet, should be saved, placed into
the standard container as written in the procedure manual for the institution.
Know what happens after an object is placed in container. Who was present at
the time of transfer.
Do not give evidence to anyone who may claim to be the representative of the
investigative agency. Your evidence is the only one in the world. Do not lose
track of it. Know where it is at all times.
The following information should be documented in the patient record and the
specimen container:
Name of patient
ID/case number
Description of the object, size, shape, color, consistency
Location where taken
Day and time taken
Removed by whom
Whoever takes custody of the evidence needs to sign for it with written date and
time of transfer, location, the name of person from whom received and the name of
receiver. Whoever received the evidence will be responsible for the custody until he/
she releases it to another person.
This record of the chain of custody must be kept, because it may be asked to be
presented in court as proof of the authenticity of the evidence. If there is no proof of
continuous and unbroken chain, any information or test data obtained from the
evidence may not be admissible. This means that the evidence does not exist as far as
the court is concerned.
557
Range of Fire
Contact Wound
The contact entrance wound may not show an abundance of gunshot residue on
the skin surface. Most of the gunshot residue will have been driven into the wound
with small amounts of burned and unburned powders on the edge of the gunshot
wound and on the clothing. Sometimes, we observe a muzzle impression mark.
Close Range WoundThree Inches

Gunshot residues on the white cloth (experimental shot) consist of burned and
unburned gunpowder, which often contains a primer compound, and occasionally
minute fragments of shavings from the bullet and casing. Granular fine dots are
unburned powder, generally disk-shaped and the fine soot is burned power. Because
of absorption by the clothing, these fine particles may not be found on the skin.
Occasionally, a shaved bullet is found on the clothing fabric. For this reason, clothing
should be also properly saved (Fig. 52.3).
Citation: Gunshot residue deposited from the muzzle of Smith and Wesson
(S & W) .38 Special revolver. The cloth-covered board was placed three inches
away. The barrel was placed perpendicular to the board.
Distance Gunshot Wound

Although gunshot residue may be found at a distance of two feet from the muzzle,
it is difficult to recognize in shots beyond 12 inches. However, lack of recognizable
gunshot residue does not mean that the wound is due to a distant shot, because the
residue may have been absorbed by the layers of clothing.
Atypical Gunshot Wounds

Groove like GSW: A groove-like gunshot wound may be observed, which
may often be mistaken for laceration (Fig. 52.4).
Citation: There is an entrance wound on the right. The exit wound extends as a
groove like wound
Stellate entrance woundCharacteristic blasting tear. It is often mistaken for

an exit wound because it is large and irregular. When a muzzle is firmly pressed
on the scalp, basting gas enters into the subgeleal tissue, causing a tearing
effect. Whenever the tissue is above a hard substance, such as the skull, explosive
blast gas undermines into the subcutaneous tissue and bursts open the skin
(Fig. 52.5).
The entrance wound with marked tear in the right temporal area. There is a
portion of rim of abrasion (indicated by arrow).
Tearing effect on clothing: Contact shot made on a sheet of cloth placed over
a wood board shows the marked tearing of the fabric (Fig. 52.6).
Citation: Tearing effect of blasting gas. Gunshot residue is underneath the fabric.
Gunshot residues may be absorbed by an object, such as the sleeve, during a

struggle, so the round gunshot residue could appear as half moon shaped. The
assailants sleeve may also contain a portion of gunshot residue. Ovoid pattern
may be seen when the shot hits at an angle.
Intermediate target: the bullet strikes an intermediate target, such as a glass
plate causing shattering and enlarging the scattering pattern.
Exit wound may sometimes have the appearance of an entrance wound, when
the exit wound is shored or in contact with a hard surface such as when the
victim is lying on the floor.
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Trauma Management
Fig. 52.3. Gunshot residue deposited from the muzzle of Smith and Wessen (S&W)
38 Special revolver. The cloth-covered board was placed three inches away. The
barrel was placed perpendicular to the board.
52
Fig. 52.4. There is an entrance wound in the right and the exit wound which
extends as a groove like wound.
Error Rate
Determining the entry and exit wounds in clinical setting may be difficult. It
should be kept in mind that not all gunshot wounds will be typical. There are factors preventing the forming of a textbook like pattern. Compared with the data
559
Fig. 52.5. The entrance wound with marked tear in the right temporal area. There is a
portion of rim of abrasion.
from forensic autopsy reports, the error rate of predicting the entrance and exit
wounds under clinical conditions increases to approximately 50% in multiple gunshot
wounds. For this reason, it is important to describe the gunshot wound as accurately
as possible.
How the Distance of Shooting Is Determined

The crime laboratory generally conducts test shootings and compares the gunshot
residue pattern on the wound and clothing. Unless such test shots are made, it is
difficult to precisely determined the muzzle distance.
Bullets
Preservation of the striation is essential. Metal forceps with a protective rubber
tip should be used to extract the bullet. The bullet is often found beneath the skin
and sometimes found it between the layers of the clothing.
Citation: Striation marksStriation marks on the sides of bullets come from
the rifling of the gun barrel. From the left: a .38 Special lead bullet, a .38 semijacketed bullet and a deformed 9mm fully-jacketedbullet (ball) fired from a
semi-automatic pistol.
EvidenceOther Wounds
Stab Wound
Size and type of the stabbing weapon
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Trauma Management
Fig. 52.6. Striation marks Striation marks on the sides of bullets come from the rifling of
the gun barrel. From the left, .38 Special lead bullet, .38 semi-jacketed bullet and
deformed 9mm fully jacket bullet (ball) fired from the semi-automatic pistol.
52
Fig. 52.7. Tearing effect by blasting gas See gunshot residue is deposited underneath of the fabric.
561
Length and thickness and characteristics such as serrations

Defense wound
Blunt Wound
Direction and the amount of force
Identifiable pattern such as bumper mark
Issue of Degree of Intoxication

The patients state of mind can be important in litigation. The standard toxicological test on blood and urine should be routinely ordered. Often the
degree of intoxication or affected physical and mental state under influence of
drug becomes an important deciding fact. Specimens drawn a day late will
not represent the state of intoxication at the time of the event.
Clothing
Clothing is very important evidence. Blood stains and blood-spattering patterns
can be recognized. To the naked eyes, fine evidence may not be visible, but with
the use of photographs and chemical tests, such pattern can be recognized.
Gunshot residues would be important for determination of the range of fire
and position of the gun.
Lost buttons or tears in the clothing can be important factors in solving issues.
How to preserve it: Clothing should be hung to dry without causing contamination of bloodstains.
Properly dried clothing is essential for DNA and other serological testing. The
assailant may have deposited biological fluid on the clothing of the victim.
Occasionally, bite marks may be found and saliva may be collected.
Testimony in Court
Preparation Before Going to Court
Subpoena
When you receive a subpoena, you should respond and prepare for the case.
Subpoena is a legal document for you to appear in the court at a specific time and
place or produce specified document for the attorney to examine prior to the legal
proceeding.
Consult your attorney and do not ignore the notice. You may be cited for contempt of court if you ignore it. If you are not able to appear in the court at the
specified time, notify the attorney who is issuing it so another date can be set. Once
the court date is set, it is difficult to change the date. The subpoena may instruct you
to be on call or on one-hour call.
Understand Why Lawyer Asks Certain Questions

Unlike us concentrating on treating the patient to save a life, the lawyer represents the interests of his client and is dedicated to resolving the legal conflict,
working vigorously to win the case. Using the adversary system, the lawyer
seeks the truth to help his client.
We are often offended when the lawyer asks questions and challenges our
opinion. The lawyer has a job to cross-examine you to make sure the evidence
is properly introduced and admitted.
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Trauma Management
Without written detailed description, such as acute symptoms, swelling, redness, fresh blood, or findings of older healing injuries such as with marginal
zone of discoloration, scar, etc. it will be difficult or impossible to remember
all the details which may be asked in court.
Burden of Proof
Burden of proof is laid to the party initiating the litigation. In criminal and
civil cases, the requirement for proof is different. In criminal cases, the district
attorney must present the proof of guilt of the defendant beyond a reasonable
doubt. In civil cases, the acceptable proof would be based on the preponderance
of evidence that it is more likely to be true than not.
Hypothetical Question
Attorneys may ask for an opinion after asking a hypothetical question. This
question may be long and contains some of the facts, and you will be asked if
you have an opinion. If the answer requires yes or no, state so. Then you
will be given opportunity to explain. If the question is not answerable, the
judge may allow your explanation.
Deposition
In preparation for trial in a civil case, a deposition is often taken. Your testimony is taken in a court of law with an attorney for both parties present and
is recorded by a certified court reporter. Nowadays, video taping is also often
done. It is a part of the discovery procedure and may result in a settlement
without going to trial. Trauma caregivers should not consider this procedure
to be less important than court proceeding.
In some states, deposition is also taken in criminal cases.
Day of Testimony
52
Be well prepared and be confident.

Wear a business suit or dress conservatively.
Keep your facts straight on date, time, sequence of events.
Remember the lawyer is well prepared to cross-examine you.
Take all documents that were requested. No additional material should be
with you.
Listen to the lawyers question and answer it briefly. Do not be argumentative.
Do not volunteer answers. The lawyer has specific questions and answers in
mind. The lawyer deals with one piece of evidence at a time.
When you take the stand, the jury sees you for the first time. The jurys job is
to determine your reliability and whether you are a credible witness or not.
Watch your tone of voice, body language and facial expression.
Look and maintain eye contact with the jury. Do not look down while you are
speaking. This may be interpreted by the jury that you are uncertain.
In using charts or X-ray films, first point to the relevant item, then look at the
jury and talk to the jury. Do not talk to the black board or the display.
Remember that you are not an advocate. Simply and briefly, directly answer the
questions asked with no elaboration. Witness should not be biased or partial. Your
credibility is important. This is a serious business and trauma caregivers should be well
prepared. We should be sincere, factual witnesses and not take sides.
CHAPTER 1
CHAPTER 53
Endocrine Problems in Trauma

Elizabeth O. Beale
Introduction
Endocrine diseases are important in trauma patients because:
Clinical features are often similar.
Some endocrine diseases, particularly diabetes mellitus and hypothyroidism,
are common and are associated with important medical disorders and longterm medication.
Trauma frequently exacerbates a pre-existing endocrine disorder.
In extreme cases, fatal exacerbation can occur.
Trauma may cause development of a new endocrine disorder.
Diabetes mellitus (DM) and Hyperglycemia

DM is defined as a fasting plasma glucose > 126 mg/dL or two random plasma
glucoses > 200 mg/dL.
Causes of DM
80% NIDDM; 10% IDDM; 10% specific causes e.g., exocrine pancreas disorder.
Incidence of DM in Exocrine Pancreas Disorders

Distal pancreatectomy: 20-40% 40-80% pancreas resection: 40%
80-90% pancreas resection: > 60% 100% pancreas resection: 100%
Acute pancreatitis: 2-18%.
Causes of Hyperglycemia in the Trauma Patient

Stress (this increases insulin counterregulatory hormones: cortisol, epinephrine, glucagon); infection (overt or occult); overfeeding (parenteral or oral);
medications (glucocorticoids, sympathomimetic agents, cyclosporine); insufficient insulin or oral hypoglycemic agents ( missed therapy, increased needs);
volume depletion.
Clinical
No history of diabetes does not exclude the diagnosis.
Acute Medical Problems: hyperglycemia, hypernatremia, hyperkalemia or
hypokalemia, diabetic ketoacidosis (DKA), nonketotic hyperglycemia (NKH),
myocardial infarction, gastroparesis, abdominal pain, infection.
Associated Chronic Medical Problems: cardiovascular disease, peripheral vascular disease, hypertension, renal impairment, peripheral and autonomic neuropathy, impaired vision due to retinopathy or cataracts, obesity, foot ulcer.
Trauma and its management can convert a stable chronic medical problem into
an acute unstable condition. In particular excess fluid during resuscitation can
precipitate fluid overload and nephrotoxic drugs can cause overt renal failure.
Elizabeth O. Beale, LAC + USC Medical Center, Los Angeles, California, U.S.A.
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Trauma Management
Diabetic Foot Ulcers and Trauma

Diabetic foot ulcer is the cause of two-thirds of nontraumatic limb amputation in the USA. Nontraumatic is a misnomer as the majority of ulcers start
with minor foot trauma. Signs of an acute inflammation may be absent due
to impaired circulation. The mainstays of treatment are extensive debridement, good local wound care, relief of pressure and close monitoring. Osteomyelitis is likely to be present in an ulcer in which bone is visible, the ulcer
depth is > 3 mm or if the patient has an ESR > 40 mm/hr with no other
apparent cause. X-rays, CT and MRI can help diagnose osteomyelitis.
Posttraumatic Osteomyelitis
Trauma is a major cause of osteomyelitis in diabetics. Infection may be introduced at the time of the accident (especially MVA) or during management
(especially by orthopedic devices) and is usually polymicrobial. The usual site
of osteomyelitis following major trauma is the tibia or femur. Treatment
involves careful debridement, obliteration of dead space, good wound drainage,
wound protection and specific antibiotics.
Management of Uncomplicated Diabetes Mellitus

and Hyperglycemia
A reasonable goal in the acutely ill patient is a plasma glucose between
100-200 mg/dL.
Therapy depends on the degree of trauma and hyperglycemia:
- Minor trauma and normoglycemia: continue usual treatment and monitor
glucose regularly.
- Minor trauma and mild hyperglycemia: SQ regular insulin (Table 53.1).
- Moderate to severe trauma or moderate to severe hyperglycemia: IV regular
insulin (Table 53.2).
53
Measure glucose hourly until levels are 100-200 mg/dL for 4 hours, then
2-4 hourly.
Monitor potassium and phosphorous in patients on IV insulin as they may
fall rapidly.
Increase the infusion rate by 50% increments for each glucose range > 200
mg/dL if glucose is not in the goal range by 3-4 hours. Insulin requirements
increase with severe infection or illness, glucocorticoids, vasopressor infusions,
excessive calories and in patients significantly > 70 kg.
Decrease the infusion rate if the glucose falls > 80 mg/dL/hour and in patients
much < 70 kg.
Guidelines for Semi-Elective Surgery in Patients

with Diabetes Mellitus
Preoperatively: Schedule diabetic patients for morning surgery. Do not give
the usual oral hypoglycemic therapy or regular (short-acting) insulin on the
morning of surgery. Do give one-half of the patients usual morning dose
of long-acting insulin SQ. Start dextrose containing IV. Measure the preoperative glucose:
< 200 mg/dL: no preoperative insulin is necessary;
200 mg/d: add Human Regular insulin to the dextrose IV fluids (5 units
regular insulin/L 5% dextrose) and follow the insulin algorithms above. Use
565
Table 53.1. SQ regular insulin algorithm

Blood Glucose
(mg/dl)
Regular SQ Insulin
(units/4-6 hourly)
200-250
251-300
301-350
> 350
2
4
6
8
Table 53.2. IV regular insulin infusion algorithm

Blood Glucose
(mg/dL)
Regular Insulin Intravenous Infusion Rate

(units/hr)
< 100-0
101-120
121-150
151-20
201-250
251-300
301-350
351-400
> 400
0
1
1.5
2
2.5
3
4
6
8
Standard IV infusion: 250 Units Human Regular Insulin in 250mLs of 1/2 NS: i.e.,
1 Unit/mL
the SQ algorithm insulin if the patient is usually controlled on oral agents and
the IVI algorithm if the patient is usually controlled on insulin.
< 100 mg/dL:-give 1/2 ampule 50% dextrose. Recheck glucose in 1/2 hour.
Repeat if glucose remains <100 mg/dL.
During anesthesia and in the postanesthesia recovery room: Glucose should
be measured hourly and IV insulin infusion used to control glucose.
Postoperatively: Measure the immediate postoperative glucose and manage as
for preoperatively.
Emergency Surgery in Patients with Diabetes Mellitus

Immediately check glucose, urea and electrolytes, ABG and pH, urine and plasma
ketones. If there is DKA or HNK delay surgery (if possible) for 3-4 hours until
these are controlled. In patients without severe metabolic problems, treat as for
semi-elective surgery. An apparent acute surgical abdomen may be due to DKA:
if the patient is < 25 years the problem is more likely to be metabolic, if > 25
years it is more likely to be a true acute surgical problem. When there is doubt as
to the cause of the abdominal pain, and if clinically feasible, conservative medical management should be undertaken to correct the metabolic problems. The
pain will usually resolve in 3-4 hours if metabolic in origin.
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Trauma Management
Management of Hyperglycemia on Parenteral Nutrition (PN)

If the glucose is persistently > 200 mg/dL:
STEP 1: Add 0.1 units of regular insulin/g dextrose to the PN solution (e.g., 20
units/L of 20% dextrose).
STEP 2: Increase the PN insulin by 0.05 units of regular insulin/g of dextrose/
day up to 0.2 units of insulin/g dextrose (e.g. 40 units/L of 20% dextrose).
STEP 3: Add supplemental SQ insulin.
STEP 4: Start a separate insulin infusion.
Diabetes mellitus Emergencies

Diabetic Ketoacidosis (DKA)
This is a potentially fatal complication of DM that may be precipitated by trauma.
Causes Of DKA in the Trauma Patient

Missed therapy, excess stress hormones, infection.
Clinical
Polyuria, polydipsia, weakness, visual disturbance, altered mental state, nausea,
vomiting, abdominal pain, Kussmauls respiration, ketotic fetor, hypothermia.
Investigations
Hyperglycemia: in 15% of patients serum glucose is < 300 mg/dL.Serum bicarbonate: < 15 mEq/L. There is typically an increased anion gap metabolic
acidosis. Hyponatremia: this is frequently pseudohyponatremia due to the
high glucose levels. Ketonemia: significant at a serum dilution of 1:2. Ketones
may be falsely negative. Potassium: high or low (with total body depletion).Tall
peaked T-waves on EKG with hyperkalemia. Phosphate: high or low (with
total body depletion). Hyperamylasemia, lipasemia: these do not necessarily
indicate pancreatitis.
Principles of Management
The acronym D.I.A.B.E.T.E.S helps with remembering the important points
in management.
53
NB: The following are typical doses and may need to be adjusted for the
individual patient.
D: Dehydration. Give 2-3 liters of normal saline (NS) in the first 2-3 hours.
Then adjust fluids according to volume status and serum sodium level.
I: Insulin Usually 5-10 U/hr. Give 0.1 U/kg bolus then 0.1 U/kg/hr IVI . Always
use Human Regular insulin. Aim to decrease the serum glucose by about 75
mg/hr. Continue insulin until a few hours after the anion gap has returned to
normal and is stable.
A/B: Acid Base. Bicarbonate has not been shown to improve outcome, but many
physicians will give it if the pH is < 6.9.
E: Electrolytes. KCl 40 mEq/hr IVI. Avoid if EKG shows tall, peaked T-waves.
Phosphate if <1.0 mg/dL. Phosphate can cause calcium to fall so magnesium
may be given to stimulate PTH action and maintain normocalcemia.
T: Triggers. Ascertain and treat the cause of DKA especially infection and myocardial infarction.
567
E: Evaluate progress. Use a flow chart. Monitor vital signs, fluid balance, insulin,
electrolytes.
S: Sugar. Hypoglycemia can occur rapidly with irreversible brain damage.
Measure hourly glucose until glucose is in the normal range, then 2 hourly.
Change to a dextrose solution when glucose is < 250 mg/dL but continue insulin
until the anion gap is normal.
Nonketotic Hyperglycemia (NKH)

Causes of NKH in a Trauma Patient
Trauma, infection, gastrointestinal bleeding, pancreatitis, myocardial infarction
thiazides, glucocorticoids, phenytoin.
Clinical
Typically occurs in patients > 60 years who are socially isolated and bedridden. Two-thirds of patients have no history of DM. Profound dehydration. 50%
of patients are initially misdiagnosed as having a primary neurologic defect.
25% have coffee ground naso-gastric aspirate. 60% have underlying infection. Many have underlying renal and cardiac dysfunction.
Investigations
Glucose: > 600 mg/dL: usually in the 1000 mg/dL range; WCC:
15,000-20,000; hemoconcentration; osmolarity > 340 mosm/L; hyponatremia;
hyperkalemia or hypokalemia; small increase in anion gap but no ketoacidosis.
Management
Fluids: the initial replacement fluid is usually NS but 1/2 NS can be given if
Na > 145 mEq/L. Rehydrate cautiously due to possible underlying cardiac
and renal failure. Replace the first 1/2 of fluids over 12 hours and the second
1/2 in next 12 hours.
Insulin: In NKH glucose will fall with fluids alone. Insulin may cause glucose
and fluid to shift into cells causing shock. Therefore insulin should be given
only once the patient has been fluid resuscitated and if glucose remains high.
Insulin is usually required in lower doses than that used for DKA. Monitor
serum glucose carefully to avoid hypoglycemia.
Search for and treat underlying cause.
Hypoglycemia
This may rapidly cause brain damage. Clinical features may easily be mistaken
for those due to trauma.
Causes of Hypoglycemia in the Trauma Patient

Sudden withdrawal of nutritional support, especially parenteral nutrition.
Withdrawal or decreased doses of corticosteroids or sympathomimetic agents.
Renal dysfunction, severe hepatitis, sepsis, diabetic gastroparesis. Primary or
secondary adrenal insufficiency, hypothalmic or brain stem injury. Insulin or
oral hypoglycemic agents. Excessive loss or use of glucose. Alcohol. Propranolol.
Salicylates. Antihistamines.
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Trauma Management
Clinical Features
Tachycardia, restlessness, sweating, altered mental state including coma.
Investigations
Stat glucose level on any patient with altered mental state. When glucose < 60
mg/dl adrenaline rises; < 50 mg/dl: cognitive dysfunction.
Management
Treat for presumed hypoglycemia if unable to check glucose levels immediately.
If alert and not NPO: give 15 grams glucose orally. This is equivalent to 2
cubes of sugar or 1/2 cup (4 oz) fruit juice. If not able to take orally and IV
access available: give 25-50 grams 50% dextrose water IV. If not alert and no
IV: Give 1 mg glucagon IM or SQ. Check glucose every 15 minutes and repeat
treatment until glucose is greater than 80 mg/dL.
Thyroid
Nonthyroidal Illness Syndrome (NTIS) or Euthyroid Sick
Syndrome or Low T3 Syndrome
This refers to thyroid function test abnormalities in an euthyroid patient and is
found in up to 75% of hospitalized patients. It may be difficult to differentiate from
hypothyroidism and less commonly from hyperthyroidism.
Causes of NTIS in a Trauma Patient

Any moderate to severe acute or chronic illness. Medications: dopamine,
dobutamine, glucocorticoids, frusemide, anticonvulsants, NSAIDs
Clinical Features
Clinically euthyroid, but features of the acute illness may make this difficult
to determine.
Investigations
Avoid doing thyroid function tests unless there is a strong clinical suspicion of
thyroid pathology.
There is no certain way to differentiate hypothyroidism from NTIS but
hypothyroidism is suggested by a history of thyroid disease or surgery, clinical
features of hypothyroidism and certain lab features:
53
Lab Test
TotalT3
TotalT4
T3RU
TSH
freeT4
NTIS
N or
N or
N
Hypothyroidism
N or
or
Hyperthyroidism
N or
Management
Usually no treatment is necessary. T3 and T4 therapy have been recommended
in cases with a very low T4 (< 4 g/dL). The condition usually resolves with
resolution of the primary illness.
569
Hyperthyroidism
Symptoms and signs of sympathetic stimulation are similar to those occurring
with trauma.
Rarely, trauma may precipitate thyrotoxic storm in a patient with pre-existing
thyrotoxicosis.
More commonly trauma and therapy for trauma (dopamine, glucocorticoids)
suppress TSH leading to a biochemical picture similar to hyperthyroidism in the
absence of clinical thyrotoxicosis.
Causes of Hyperthyroidism in the Trauma Patient

Thyroiditis may rarely occur secondary to vigorous palpation of the neck,
manipulation of the thyroid gland during neck surgery or seat belt trauma.
Pre-Existing Causes for Hyperthyroidism

Graves disease, toxic multinodular goiter (MNG), solitary toxic nodule, postpartum thyroiditis (5-10% of postpartum women), subacute thyroiditis,
overmedication with exogenous thyroid hormone.
Clinical
Thyroiditis causes transient neck pain and tenderness. The thyroid is diffusely
enlarged in Graves disease, irregularly enlarged with MNG. Tachycardia, palpitations, anxiety, tremor, acropachy, pretibial myxedema, proptosis, ophthalmoplegia, weight loss, fatigue, associated conditions e.g., DM, cardiac failure.
Investigations
Thyroid hormones: increased serum T4 and T3, decreased serum TSH. Thyroid scan (this is seldom indicated in the acutely ill trauma patient): thyroiditis shows decreased uptake, Graves disease: diffuse increased uptake, toxic
MNG: heterogeneous uptake, solitary nodule: localized uptake.
Management
There are three treatment options but only medical therapy is indicated in the
acutely ill trauma patient.
Medical: methimazole: initial dose: 15-60 mg/day; maintenance: 5-15 mg/
day or propylthiouracil: initial dose: 50 mg 8 hourly; maintenance:100 mg 8
hourly. Monitor for agranulocytosis (every 2-4 weeks), liver toxicity, skin rashes.
Beta-blockers can be used to reduce sympathetic stimulation: use with caution
with cardiac decompensation. For rapid reduction in thyroid hormone levels,
ipodate or iodine solutions may be used.
Radioactive iodine and surgery: these are definitive ablative therapies for
patients with hyperthyroidism well-controlled on oral medication.
Hypothyroidism
2-3% of the US population are hypothyroid. 10-20% of women > 50 years have
subclinical hypothyroidism (high TSH only). 6% of postpartum women have
transient hypothyroidism.
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Trauma Management
Causes of Hypothyroidism in the Trauma Patient

Inadvertent stopping of thyroid replacement therapy; secondary to hypothalamic or pituitary injury or surgery; ischemic necrosis of the pituitary
with severe shock.
Injury to the thyroid is more likely to cause acute thyrotoxicosis than
hypothyroidism.
Pre-Existing Causes for Hypothyroidism

Hashimotos disease, prior radioiodine or surgery, hypopituitarism.
Clinical
Signs and symptoms may develop insidiously after withdrawal of treatment or
hypothalamic-pituitary. Fatigue, cold intolerance, hypertension, bradycardia, cardiomegaly, congestive cardiac failure, carpal tunnel syndrome, delayed relaxation
of tendon reflexes, periorbital swelling, enlarged, normal or small thyroid,
reduced respiratory drive, failure to wean from ventilator, constipation, megacolon, confusion, psychosis, subnormal temperature response with infections.
Hypotension and heart failure have been reported during surgery with severe
hypothyroidism.
Investigations
High TSH, low serum T4 and T3. Similar changes may occur with NTIS.
Normochromic, normocytic anemia, or iron deficiency anemia with heavy
menses. Hyponatremia (due to SIADH), hypercholesterolemia, raised CPK.
There may be associated adrenal insufficiency (with low serum cortisol). EKG:
bradycardia, low voltage.
Management
53
In the acutely ill patient, treat for hypothyroidism if there is a strong clinical
suspicion of the condition. The usual treatment in young individuals is
levothyroxine (LT4) 1.6 g/kg/day.
Elderly patients and those with known or suspected heart disease are started
on a lower dose of LT4 (25 g/day) which is increased only every 2-3 months
until the TSH is normal. Patients who are NPO for a few days can go without
therapy due to the long half-life of T4. 70-80% of the daily oral T4 dose can
be given IV to patients unable to take orally long-term.
Emergency surgery in patients with known uncontrolled hypothyroidism: if
there is no known ischemic heart disease give LT4 and monitor postoperatively
for complications. In patients with known ischemic heart disease proceed
without LT4 to limit oxygen demand.
Mortality and major complication rates in patients with mild to moderate
hypothyroidism undergoing emergency surgery are similar to rates in
euthyroid patients.
Thyroid Emergencies
Thyroid Storm
This rare but frequently fatal condition may be precipitated by trauma. Signs of
sympathetic excess may be attributed to trauma.
571
Causes of Thyroid Storm in the Trauma Patient

This may occur in a patient with pre-existing, poorly controlled hyperthyroidism and trauma (to the neck or elsewhere), surgery (thyroid or nonthyroid),
infection.
Clinical Features
The features are of severe thyrotoxicosis, usually with a fever > 102F.
Lab Tests
Low TSH. Raised T4,T3, glucose, urea, calcium, liver enzymes. Raised WCC
and anemia.
Management
Do not wait for laboratory confirmation. Treat on clinical suspicion. PTU
300-400 mg or methimazole 10-40 mg po or by NG tube immediately and
6-8 hourly or if NPO, give rectal methimazole 30-40 mg 6-8 hourly. 1 hour after
antithyroid drugs give 1-2 gm sodium iodide IV and give every 24 hours or 5
drops saturated solution of potassium iodide po every 6 hours. Dexamethasone 2 mg IV every 6 hrs. Propranolol 40-80 mg po or 1-2 mg IV every 6-8
hrs: use cautiously with cardiac failure. Oxygen, IV fluids + phenobarbital,
glucose, B vitamins. Antipyretics and external cooling if temp >105F.
Myxedema Coma
A rare condition with a 100% mortality if untreated that may be precipitated by
trauma. The altered mental state, hypothermia and bradycardia may be attributed
to head injury.
Causes of Myxedema Coma in a Trauma Patient

Myxedema coma usually occurs in an elderly patient with pre-existing
hypothyroidism and a precipitating event such as trauma, prolonged cold
exposure, infection, surgery, myocardial infarction, respiratory failure, GIT
bleeding or CNS depressant drugs.
Clinical Features
The features are of severe hypothyroidism with hypothermia, bradycardia,
stupor, decreased hypoxic and hypercapnic ventilatory drive, pericardial, pleural
and peritoneal effusions. There is relative insensitivity to catecholamines before
starting LT4 therapy and hypersensitivity after.
There may be a goiter or a thyroidectomy scar.
Investigations
Raised TSH. Low T4 and T3. Anemia, hyponatremia, hypoglycemia, raised
cholesterol, increased CPK. CO2 retention, hypoxemia. EKG: sinus bradycardia, AV block, low voltage, T-wave flattening, increased QT interval.
Management
Do not wait for laboratory confirmation. Treat on clinical suspicion: LT4 0.5 mg
IV followed by 0.025-0.05 mg each day until patient can take orally. Then LT4
po 0.05-0.1 mg daily. Hydrocortisone 75 mg IV every 6 hours until adrenal
insufficiency is excluded. CVS, respiratory support. Slow external rewarming for
moderate hypothermia, central if severe.
53
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Trauma Management
Thyroid Nodules
Thyroid nodules are present in 6% of the population and are usually detected
incidentally. About 10% are malignant and are typically painless with normal
thyroid function tests. The patient should be referred for further work-up
especially if there is hoarseness, rapid growth of the nodule, obstruction or
evidence of local invasion.
Goiter
A goiter may cause airway obstruction in the trauma patient. The goiter may
be retrosternal and undetectable on neck palpation. When endotracheal
intubation is necessary, awake fiberoptic intubation is recommended. Obstruction may occur postextubation in a patient with no obstruction prior to
intubation. A flow-volume loop can help detect upper airway obstruction:
extrathoracic obstruction primarily decreases inspiratory airflow and intrathoracic obstruction, expiratory airflow.
Adrenal Insufficiency (AI)

This generally refers to an insufficiency of endogenous glucocorticoids. Mineralocorticoid insufficiency may also occur with primary adrenal insufficiency and
with severe medical illness. AI is fatal if untreated and responds only to glucocorticoids, but diagnosis is difficult. It is much commoner than previously recognized in
critically ill patients.
Incidence
Trauma patients: blunt abdominal trauma: 0.1%; evidence of adrenal injury
on CT scan following blunt abdominal trauma:5%; SICU trauma patients: 0.7%.
ICU patients: overall: 1%; patients > 55 years with a stay of > 2 weeks in the
ICU: 10%.
Causes of AI in the Trauma Patient

AI is rarely caused directly by trauma as this requires > 90% of the adrenal
cortex to be destroyed but may develop secondary to disease processes.
Causes of AI in the Critically Ill Patient
53
Infections: bacterial esp. TB, meningococcemia; viral especially HIV; fungal.

Adrenal hemorrhage and infarction due to massive retroperitoneal bleeding,
thrombocytopenia, anticoagulant therapy.
Abrupt withdrawal of chronic high dose glucocorticoid therapy or megestrol
acetate therapy.
Transient ACTH deficiency postabdominal surgery in elderly patients.
Cytokine induced inhibition of ACTH.
Panhypopituitarism due to tumors, infections, infiltrates, head trauma,
aneurysm.
Increased metabolism of cortisol: phenytoin, phenobarbital, rifampicin.
Changes in cortisol synthesis: ketoconazole, etomidate.
Causes of AI in the General Population

Autoimmune adrenalitis (including Addisons disease), metastases, Sheehans
syndrome, pituitary apoplexy, isolated ACTH deficiency, withdrawal from
glucocorticoid therapy.
573
Clinical
Clinical signs are notoriously nonspecific and signs and symptoms may be
altered by the trauma or therapy. Adrenal hemorrhage causes acute onset of
flank pain and hypotension. Orthostatic hypotension, shock, nausea, vomiting,
gastro-intestinal pain, constipation, psychosis hyperpigmentation, vitiligo, loss
of axillary and pubic hair, fever, weakness, fatigue, anorexia, arthralgia, myalgia,
weight loss.
Investigations
Baseline and stimulated serum cortisol: these are often unhelpful in the trauma
patient as results usually take 2-3 days to obtain and there is no serum cortisol
level at which the diagnosis of adrenal insufficiency can definitely be excluded.
There is a growing consensus that in ICU the baseline serum cortisol should
be > 15 g/dL and the stimulated serum cortisol 30-60 minutes after 250 g
ACTH IV >18-20 g/dL.
The concept of relative adrenal insufficiency is replacing that of absolute AI.
There is no exact definition but it should be suspected in a patient with
hypotension poorly responsive to vasopressors, a response to ACTH stimulation < 7-10 g /dL, and improvement with physiological replacement doses
of glucocorticoids (100 mg hydrocortisone 8 hourly).
Eosinophilia, lymphocytosis, mild normocytic, normochromic anemia,
hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia. ACTH is not
helpful in the acute situation but if over 100 pg/mL suggests primary adrenal
insufficiency.
Adrenal CT scan: enlarged adrenals occur with active TB, fungal infection, metastases, HIV infection and lymphoma; atrophy with chronic
autoimmune adrenalitis.
Pituitary and hypothalamus scanning: MRI may detect soft tissue lesions of
the pituitary and hypothalamus; CT scanning may show bony invasion or
calcification.
Management
Maintenance therapy: for patients with known adrenal insufficiency and a
nonstressed clinical state: hydrocortisone 15-20 mg in morning, 5-10 mg in
early afternoon. Prednisone (2.5-7.5 mg nightly) or dexamethasone (0.250.75 mg nightly) may be used in place of hydrocortisone. Glucocorticoids can
be given IV if patient is NPO or vomiting. Fludrocortisone 0.05 mg-0.2 mg
daily for primary AI.
Stress therapy for patients with known or suspected adrenal insufficiency and
a stressful clinical state (e.g. trauma, infection, diagnostic or surgical procedures): for mild to moderate stress give 2-3 times the usual maintenance dose.
For severe infections or surgery give 100mg hydrocortisone intravenously
8hourly. Taper stress doses over 1-2 days after stress has resolved.
Adrenal crisis: start treatment on clinical suspicion. Do not wait for cortisol results. Give hydrocortisone 100 mg IV 8 hrly.If biochemical testing is
not complete give dexamethasone 4 mg daily in place of hydrocortisone as
this does not cross-react with the measurement of serum cortisol. Usually
several liters of 0.9% dextrose saline are needed. Look for the cause.
53
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Trauma Management
Adrenal Incidentalomas
Adrenal incidentomas are detected incidentally on 1-5% of abdominal CT
scans. There may be features of hormone excess (Cushings syndrome, pheochromocytoma) or a malignant primary. Serum potassium is often abnormal
with cortisol-producing adenomas. Investigations include a malignancy
work-up and cortisol and catecholamine measurements. The lesion is usually
electively resected if biochemically active or > 6 cm.
Hypercalcemia
Hypercalcemia is often detected on routine screening and needs further
work-up. Severe cases can be life-threatening. Signs and symptoms may mimic
those due to trauma.
Causes of Hypercalcemia in the Trauma Patient

1) Immobilization hypercalcemia may occur after spinal cord injury, burns, or
hip fracture. This is mostly seen in adolescent males and is probably due to
hypersensitivity to parathyroid hormone. 2) During the recovery phase of
acute renal failure. 3) Parenteral nutrition. 4) Pseudohypercalcemia with venous
stasis during blood draw and with severe dehydration.
Causes of Hypercalcemia in the General Population

Malignancy 45%. Hyperparathyroidism 45%. Other: 10%.
Clinical
Irritability and confusion, weakness, fatigue, anorexia, photophobia, volume
depletion, cardiac depression, bradyarrhythmias, heart block, cardiac arrest,
constipation, polyuria, nephrolithisiasis
Investigations
If hypercalcemia is detected, the level should be checked twice to confirm the
diagnosis. If necessary, correct serum calcium for either hyperproteinemia or
hypoproteinemia. EKG: short QT, prolonged PR interval, T wave changes.
Abdominal X-ray: nephrolithiasis
Management
53
This depends on the level of hypercalcemia and the clinical condition.

Mild, chronic hypercalcemia (11-12 mg/dL): oral phosphate can be given if
the serum phosphate is < 4 mg/dL pending definitive treatment. Granulomata
are treated with glucocorticoids.
More severe and symptomatic hypercalcemia: rapid volume expansion with
NS 2-4 L/d until normovolemic. Furosemide 80-100 mg IV every 1-2 h may
be given to a well-hydrated patient to aid sodium and calcium diuresis. Monitor
for fluid overload and replace electrolytes as needed.
Block bone resorption with pamidronate 90 mg infusion over 24 hours until
levels normalize then 30-60 mg every few weeks for long-term control.
Calciton in-4-8 U/kg every 12 hours SQ or IM for rapid short-term control.
Life-threatening (e.g., 18-20 mg/dL or severe clinical features): hemodialysis,
IV EDTA.
General: mobilize patient as soon as possible; restrict calcium intake; avoid
hypercalcemic drugs: thiazides, vitamin A and D; look for cause: serum PTH
level; malignancy work-up.
575
Diabetes Insipidus (DI)

DI is caused by decreased antidiuretic hormone (ADH, vasopressin) or resistance
to its action. Untreated DI can cause fatal dehydration or permanent brain damage due
to hypernatremia. Overtreatment can cause fatal overhydration and hyponatremia. DI
must be differentiated from other causes of polyuria in the trauma patient
Cause of DI in Trauma Patients

This is usually central DI.
1) Head injury. DI usually occurs with severe closed head injury but has been
reported with very minor head injury. The usual cause is an MVA that shears
the pituitary stalk or causes hemorrhage and ischemia in the posterior pituitary
or hypothalamus. 2) Cerebral hypoxemia e.g. following asphyxia, cardiac arrest
or shock. 3) Cerebral edema and herniation. 4) Postneurosurgery.
Other Causes of DI
1) Central DI (insufficient ADH) due to tumor, strokes, infections, neurosurgery. 2) Nephrogenic DI (resistance to ADH) due to acute or chronic renal
failure, hypercalcemia, hypokalemia, sickle cell disease, drug related (lithium,
demeclocycline, loop diuretics).
Clinical
Onset of DI ranges from hours to days postinsult. The patient is often unconscious due to head injury. 70% have skull fracture. 40% have cranial nerve
damage. Polyuria often > 250 mL/hour. Polydipsia: if conscious. Triphasic DI
has been described in trauma and neurosurgical patients: i.e., DI, followed by
inappropriate antidiuresis, then recurrent DI. Most posttraumatic DI after
mild head injury resolves in 3-5 days but resolution has been reported up to
10 years after the accident, and it may be permanent.
Investigations
Polyuria typically > 3 L/day. Intake depends on level of consciousness and
whether thirst mechanism is intact. Serum sodium > 145 mEq/L. Posm> 295
mOsm/kg. Urine SG < 1.010. Uosm < 300 mOsm/kg.
Management
1) Exclude other causes of polyuria: overhydration, solute diuresis especially
mannitol, myoglobin following Rhabdomyolysis, urea during recovery phase
from acute renal failure, glucose. 2) Give water to restore and maintain
hydration: conscious patients with mild DI can drink ad lib if their thirst
mechanism is intact. Otherwise give IV dextrose water (low solute fluids). 3)
Central DI is treated with DDAVP. The usual starting dose is 1 mg and
maximum dose is 1-4 mg 12 hourly. To avoid dangerous overhydration monitor
urine output and serum electrolytes hourly. DDAVP should only be
readministered when dilute polyuria restarts. 4) Give stress doses of hydrocortisone until associated adrenal insufficiency has been excluded. 5) Nephrogenic
DI is treated with 12.5-25 mg hydrochlorothiazide daily or bid.
Growth Hormone (GH)

GH is not indicated as anabolic therapy in critically ill patients due to increased
mortality. GH has been shown to decrease dependence on parenteral nutrition
53
576
Trauma Management
by 40% in the short bowel syndrome when used in conjunction with glutamine
and a modified diet.
References
1.
2.
3.
4.
5.
53
Gavin LA. Perioperative management of the diabetic patient. Endocrinology and

Metabolism Clinics of North America 1992; 21:2 457-475.
De Groot L. Dangerous Dogmas in Medicine: The nonthyroidal illness syndrome.
JCEM 1999; Volume 84 (1):151-164.
Robinson GA. Verbalis JG. Diabetes insipidus. In: Bardin CW, ed. Current Therapy
in Endocrinology and Metabolism. 6th ed. St Louis Missouri: Mosby-Year Book
Inc. 1997:1-7.
Wilmore D, Lacey J, Soultanakis R et al. Factors predicting a successful outcome
after pharmacologic bowel compensation. Annals of Surgery 1997; 226(3) 288293.
The Endocrine Response to Acute Illness. Jenkins RC, Ross RJM, eds. Frontiers of
Hormone Research. Volume 24 Karger Switzerland 1999.
CHAPTER 1
CHAPTER 54
MOF Failure: MOF Syndrome

H. Gill Cryer
Definition
The multiple organ dysfunction syndrome is characterized by widespread systemic organ dysfunction of variable severity after injury, infection, or other
major physiologic insult. It is now recognized that the syndrome is a dynamic
continuous process that usually begins with a systemic hyperinflammatory
process which may progress or resolve but is followed by a hypoimmune
response which may resolve or progress over a variable length of time.
It is likely that all organ systems are involved in the process to some degree but
the clinical presentation varies considerably between individual patients.
The most common organ to develop obvious clinical failure is the lung followed
by the liver, kidney, gut, and cardiovascular system.
Multiple organ dysfunction syndrome has now become the number one cause
of late death in trauma and surgical patients.
1969 Francis Moore and colleagues clearly described the syndrome
physiologically and pathologically in their treatise entitled Posttraumatic
pulmonary insufficiency.
1975 Eiseman and colleagues coined the term Multiple Organ Failure and
stressed the importance of avoiding surgical technical complications in
preventing the syndrome.
1980 Fry and colleagues demonstrated the importance of uncontrolled
infection and proposed it as the principle etiology of the syndrome.
1985 Goris and colleagues demonstrated that at least 50% of patients with
multiple organ failure syndrome did not have an obvious source of infection
and proposed that a dysregulated hyperinflammatory state led to generalized
autodestructive inflammation in the majority of patients with this syndrome.
Diagnosis of Multiple Organ Failure

Clinical diagnostic criteria for multiple organ system failure are not yet
standardized. Currently the syndrome is defined and quantitated based on
variable severity of organ dysfunction markers in the lung, kidney, gut, liver
and sometimes the hematologic and neurologic systems.
Several authors have developed multiple organ dysfunction scores in an attempt
to define this process, which can be used in a number of different ways. It
probably makes best sense to follow the score across time beginning on the
first day of injury.

H. Gill Cryer, UCLA Medical Center, Los Angeles, California, U.S.A.
578
Trauma Management
Table 54.1. Multiple organ failure score

Pulmonary dysfunction*
Renal dysfunction
Hepatic dysfunction
Cardiac dysfunction
Grade 1
ARDS score > 5
Creatinine
> 1.8 mg/dl
or dialysis
Bilirubin
> 2.0 mg/dl
DO2I 600
with inotropes
Grade 2
ARDS score > 9
Creatinine
> 2.5 mg/dl
Grade
ARDS score > 13
Creatinine
> 5.0 mg/dl
Bilirubin
> 4.0 mg/dl
DO2I 450-600
with or without
inotropes
Bilirubin
> 8.0 mg/dl
DO2I < 450
with or without
inotropes
ARDS: Adult Respiratory Distress Syndrome

*ARDS score = A+B+C+D+E
A. Pulmonary findings by plain chest radiography
0 = normal
1 = diffuse, mild interstitial marking/opacities
2 = diffuse, marked interstitial/mild air-space opacities
3 = diffuse, moderate air-space consolidation
4 = diffuse, severe air-space consolidation
B. Hypoxemia
(PaO2/FiO2
0 = > 250
1 = 175-250
2 = 125-174
3 = 80-124
4 = < 80
C. Minute
Ventilation
(l/min)
0 = < 11
1 = 11-13
2 = 14-16
3 = 17-20
4 = > 20
D. Positive End
Expiratory Pressure
(cmH2O)
0=<6
1 = 6-9
2 = 10-13
3 = 14-17
4 = > 17
E. Static
Compliance
(ml/cmH2O)
0 = > 50
1 = 40-50
2 = 30-39
3 = 20-29
4 = < 20
Incidence
Five to seven percent of emergency surgical procedures.
15% of patients with injury severity score 15
50% of patients with injury severity score 25 and 6 unit blood transfusion
over 24 hours.
Predisposing Factors
54
Shock (25%)
Massive blood transfusion ( 6 units) 30%
Massive crystalloid resuscitation ( 6 liters) 30%
Infection (25%)
Chest injury (10%)
Multiple long bone fracture (10%)
Retained necrotic or inflamed tissue (10%)
Pathogenesis
Remarkably the pathogenesis of the multiple organ failure syndrome remains
incompletely understood, but it is most likely related to some combination of a
dysregulated hyperinflammatory response, maldistribution of microcirculatory
blood flow, ischemia reperfusion injury, and dysregulation of immune function.
MOF Failure: MOF Syndrome
579
The initiating event is thought to be hyperactivity of the inflammatory response

characterized by generalized mediator activation, hypercoagulability,
complement activation, activation of immune cells including mast cells,
PMNs, monocytes, and macrophages in a generalized fashion which attacks the
endothelial lining of micro blood vessels in various organs causing increased
permeability and a generalized inflammatory response in the affected tissues.
In addition, a complicating factor seems to be plugging of the microcirculation
as a result of deposition of fibrin, leukocyte plugging and generalized swelling
of endothelial cells as a result of the inflammatory response.
As the inflammatory response progresses and the microvascular blood supply
decreases in various organs, organ dysfunction ensues gradually over time as
the process affects more and more of the organs tissue.
Eventually the dysregulated hyperinflammatory response is replaced with a
counter hypo inflammatory response after a variable period of time. A hypo
immune response ensues with elaboration of counter inflammatory mediators
such as interleukin-10, interleukin-13, and PGE2. As a result a change in
T-helper cell phenotype occurs from predominantly Th1 to Th2 lymphocyte
populations. These and other factors lead to a decreased ability of fixed macrophages and circulating PMNs to counter bacterial and viral invasion. If this
process continues unabated a chronic infectious state results with gradual
deterioration of the patient until death.
The patient may succumb as a result of overt organ dysfunction or as a
subsequent complication of overwhelming infection.
The multiple organ dysfunction syndrome is now known to be a dynamic
process which occurs with variable clinical sequalae both in terms of severity
and changes over time.
There appear to be two distinct groups of patients, one, which develops the
syndrome quite early usually after a major injury or episode of hemorrhagic
hypotension, and a second group which develops the syndrome later often as
a result of a surgical complication or the late development of infection. In
actuality these two presentations are probably different clinical manifestations
of the same underlying process.
It now appears that the syndrome can be either mild or severe in its initial
presentation and may progress in a variety of ways.
Therapeutic Maneuvers and Treatment

Prevention
Our ability to treat the full blown multiple organ failure syndrome is limited,
and therefore, the most successful strategy is to identify the patient at risk for
developing multiple organ failure before they have developed it or while it is
in its initial mild phase.
It is imperative to limit the number of operative complications.
Debride necrotic tissue, stop contamination, and prevent hematoma formation.
Important decisions include definitive operation versus damage control procedure to prevent coagulopathy, hypothermia, massive blood loss and
abdominal compartment syndrome.
54
580
Trauma Management
Optimal resuscitation by maximizing oxygen delivery and consumption with

appropriate blood product usage and the use of controlled reperfusion
techniques to minimize ischemia reperfusion injury.
Adequate oxygenation but avoidance of pulmonary injury with high airway
pressures and high FiO2. Ventilator settings should minimize airway pressure
and FiO2 by the use of moderate levels of PEEP, inverse ratio ventilation and
permissive hypercapnia.
Nutritional support should be started early using enteral immune enhancing
diets in-patients at high risk. TPN supplementation with avoidance of high
carbohydrate and lipid infusion.
Infection should be treated aggressively often times with empiric antibiotics
and antifungals.
Immune enhancementat the present limited to immune enhancement diets;
however, the near future may bring means to modulate the immune system in
a more organized fashion.
Organ Specific Support

These areas are treated in greater depth in other chapters of this manual.
Cardiovascular: maximize DO2 and VO2 with cardiotonics, keep hemoglobin
between 10-12, and perhaps use colloids after initial crystalloid resuscitation.
Pulmonary: moderate levels of PEEP minimizing peak airway pressures and
FiO2, permissive hypercapnic and frequent position changes.
Renal: avoid nephrotoxic drugs, maintain organ perfusion, maintain tubular
flow with manitol and loop diuretics, maintain nonoliguric state and perform
dialysis early when oliguria develops.
GI, liver: feed enterally early using feeding tubes past the ligament of Treitz
while decompressing the stomach. GI bleeding prophylaxis with H2 blockers or
sucralfate; consider monitoring gastric mucosal blood flow with tonometry.
Immune system: immune enhancing diets, new concepts, and antioxidants.
References
1.
2.
3.
4.
5.
54
Cryer H Gill. Ischemia reperfusion as a cause of multiple organ failure. Baue, Faist,
Fry. Multiple organ failure. In press.
Eiseman B, Bert R, Norton L. Multiple organ failure. Surg Gyn 1997; 144:323-326.
Sauia A, Moore FA, Moore EE. Multiple organ failure can be predicted as early as
12 hours after injury. J Trauma 1998; 45:291-303.
Cryer HG, Leong K, McArthur DL et al. Multiple organ failure: by the time you
predict it its already there. J Trauma 1990; 46:597-606.
Barquist E, Kirton O, Windsor J et al. The impact of antioxidant and splanchnic
directed therapy on persistent uncorrected gastric mucosal pH in the critically
injured trauma patient. J Trauma 1998; 44:355-359.
CHAPTER 1
CHAPTER 55
Surgical Nutrition
Edward E. Cornwell
Introduction
The ancient Greeks and Egyptians are credited with the first use of a nonoral
route of nutrition, administering wine, milk, or broth by the use of rectal
syringes. In the late 1700s John Hunter instilled nutrients into the stomach
by way of a catheter and syringe.
One of the earliest descriptions of the parenteral route was by Sir Christopher
Wren who infused wine into the veins of dogs in 1656.
In more modern times Dudrick and associates adopted a method of infusing
concentrated dextrose solution into the jugular veins of dogs, and in 1952
Aubaniac described the method for percutaneous placement of a subclavian
venous line.
Since the early 1970s, when hyperalimentation was used for patients with
gastrointestinal fistulas, nutritional support by way of enteral and parenteral
nutrition has become a multidisciplinary endeavor involving physicians, nurses,
dieticians, and pharmacists. The concept of nutritional support for critically
ill and injured surgical patients is one of the major medical advances of the
last quarter of the 20th century.
The Goal of Nutritional Support

The goal of nutritional support in the management of trauma patients is to:
- prevent nutrient deficiencies that may be brought on by the increased metabolic demands associated with critical injury;
- provide appropriate doses of nutrients consistent with existing metabolic demands;
- avoid complications related to the technique of provision of nutritional support;
- improve patient outcome as it relates to septic complications, wound healing,
and regaining of daily functions.
Who Should Receive Nutritional Support?

There is no evidence supporting routine nutritional support of surgical patients with normal baseline status who are not critically ill.
Nutritional support is reserved for patients who are malnourished on admission or have diseases (severe trauma, burns, severe surgical infections) that
place them at high risk for the development of malnutrition.
- Malnutrition is defined as impairment of normal anabolic processes caused by
insufficient energy or protein.
- Malnutrition in surgical patients may result from; a) decreased caloric or protein intake (e.g., secondary to GI obstruction, anorexia); b) nutrient losses
Edward E. Cornwell, The Johns Hopkins Medical Institution, Baltimore, Maryland, U.S.A.
582
Trauma Management
(secondary to diarrhea, malabsorption); c) increased nutrient requirements (e.g.,
secondary to major injury or infection).
What Components Should Be Provided?

Recommended nutrient provisions were formulated by the 1997 Consensus
Statement on Applied Nutrition in ICU patients by the American College of
Chest Physicians. Caloric requirements are typically expressed in terms of
total energy expenditure (TEE). TEE is determined by three components:
- Basal Energy Expenditure (BEE) is the caloric expenditure of a person at rest
whos fasted more than 10 hours.
- Diet Induced Thermogensis (DIT) is the energy expenditure for food consumption (eating, digestion, absorption, hydrolysis) and is typically 5-10% of TEE.
- Activity Energy Expenditure (AEE) represents energy secondary to physical
activity (the work of breathing, etc) and may account for 15-40% of TEE.
- Most patients will be adequately fed with 25-30 total kilocalories/kg body
weight/day.
- Protein sources should account for 15-20% of the total calories administered
per day (estimated at 1.2-1.5 g/kg/day).
- Carbohydrate sources should be responsible for 30-70% of the total calories
administered, up to 2-5 g of glucose/kg/day.
- Fat sources should account for 15-30% of the total calories administered per day.
- The caloric and protein requirements need to be increased in certain clinical
settings such as patients with systemic inflammatory response syndrome (SIRS)
or with major head trauma.
- Multivitamins and trace elements such as copper, manganese, selenium, and
chromium are also supplied.
Which Route?
There is ample laboratory and clinical evidence to suggest that nutrition should
be provided enterally whenever possible. The advantages of enteral support
relative to total parental nutrition (TPN) are:
- lower cost
- promotion of intestinal function and bile flow by stimulating secretion of
intestinal hormones such as gastrin and cholecystokinin
- prevention of intestinal mucosal atrophy
- maintenance of mucosal integrity
- inhibition of bacterial overgrowth
- avoidance of central venous catheter related complications (pneumothorax,
catheter infection)
- lower incidence of noncatheter related septic complications.
When to Feed
55
The advantages of enteral nutrition are largely lost if initiated once sepsis/
hypermetabolism has already occurred. While not precisely known, it would
appear that obtaining approximately 50% of nutritional requirements within
the first 48 hours after injury is a reasonable goal.
- Enteral feeding stimulates increased gut oxygen demand, and case reports have
described intestinal infarction associated with the initiation of early jejunal
feeds in hypermetabolic patients requiring vasopressors. Therefore jejunal feeds
should be initiated only after hemodynamic stability has been achieved.
Surgical Nutrition
583
Formulas for Nutritional Support

A large number of stock formula preparations for both parenteral and enteral
feeds are available for use by patients in hospitals. These formulas vary from
hospital to hospital, and most patients receive adequate support with one of
the stock formulas. With both parental and enteral preparations, the occasional patients requiring custom mixing of amino acids, dextrose, and fats
may be achieved if supplementation of individual nutrients is desired.
Immune-Enhancing Diets
With appreciation of the gut as a major immune organ, special attention needs
to be given to immune-enhancing diets. Certain nutrients which exert pharmacologic effect and modulate healing and immune function are considered
essential components of immune-enhancing diets. These include:
- Arginine, a semi-essential amino acid which is involved in collagen synthesis
and increases the response of peripheral T lymphocytes to mitogens.
- Glutamine is an amino acid that is mobilized from peripheral tissue such as
skeletal muscle during the early catabolic response to major trauma. The use of
glutamine deficient diets has been associated with intestinal mucosal atrophy
during stress states in several animal models.
- Omega-3-fatty acids are present in fish oils, canola oil, etc. They are thought to
enhance the immune response by decreasing the synthesis of prostaglandins
that are inhibitory to the function of immune cells.
- Synthetic ribonucleic acids (RNA) have been postulated to support proliferation of intestinal crypt cells and lymphocytes.
Early studies showing clinical benefits of the immune-enhancing diets were

criticized because the group receiving experimental diets frequently benefited
by receiving a greater amount of caloric and nitrogenous (protein) support,
thus making it difficult to determine whether the benefits were attributable to
immune enhancement or the increase in nitrogen and calories.
- On the basis of the existing studies, and in consideration of the increased expense
associated with immune enhancing diets, recommendation cannot be made for
the routine administration to all trauma patients.
- The weight of the literature would support providing this to the most severely
injured patients, such as those identified by injury severity scores (ISS) > 21.
Complications
Complications of enteral nutrition occur in about 10-15% of patients and
include:
- Diarrhea
There are multiple potential causes of diarrhea related to enteral feeding

including:
low fiber solutions
administration of hypertonic formulas
use of formulas with high fat content
- Aspiration
Treatment to prevent aspiration includes:
Monitoring gastric residual volume (every 4-6 hours)

Cessation of feedings when residual volumes exceed 100-150 cc. The head
of the bed should be elevated to at least 30% at all times.
55
584
Trauma Management
- Mechanical complications of enteral feeding include:
improper placement of the tube (into the trachea or sinus),
sinusitis from prolonged nasoenteric intubation.
- Feeding tube obstruction is a frequent problem that occurs with coagulation of
the enteral formula. Tube clearance has been described with agents such as
carbonated drinks, pancreatic enzymes, or streptokinase.
Complications of parenteral nutrition may be mechanical, infectious, or

metabolic.
- Mechanical complications include complications of central venous catheterization including pneumothorax, catheter misdirection, arterial puncture, or
air embolism. Venous thrombosis may occur as a delayed complication that
manifests as ipsolateral arm and neck swelling.
- Catheter-related sepsis occurs in 2-8% of adults receiving central TPN. Skin
flora is the most important source that colonizes the catheter tunnel.
- Metabolic complications include hyperglycemia, hyperlipidemia and associated
reticuloendothelial cell dysfunction, and hepatic complications (elevation of
transminases, cholestasis, and fatty infiltration).
- Electrolyte and acid base abnormalities may also complicate TPN administration.
Refeeding of the malnourished patient promotes intracellular shifts of magnesium, potassium, and phosphate. Hypophosphatemia is a common resulting
abnormality that may cause hemolysis, Rhabdomyolysis, and increased hemoglobin oxygen affinity due to decreased production of 2,3-diphosphoglycerate.
Metabolic acidosis has been described to occur related to acid moieties present
in TPN solution.
References
1.
2.
3.
4.
5.
55
Brown RO, Hunt H, Mowatt-Larssen CA et al. Comparison of specialized and

standard enteral formulas in trauma patients. Pharmacology 1994; 14:314-320.
Cerra FB, Lehmann S, Konstantinides N et al. Improvement in immune function
in ICU patients by enteral nutrition supplemented with arginine, RNA, and menhaden oil is independent of nitrogen balance. Nutrition 1991; 7:193-199.
Kudsk KA, Minard G, Croce MA et al. A randomized trial of isonitrogenous enteral
diets after severe trauma. An immune-enhancing diet reduced septic complications.
Ann Surg 1996; 224:531-543.
Mendez C, Jurkovich GJ, Garcia I et al. Effects of an immune-enhancing diet in
critically ill injured patients. J Trauma 1997; 42:993-942.
Moore FA, Moore EE, Kudsk KA et al. Clinical benefits of an immune-enhancing
diet for early postinjury enteral feeding. J Trauma 1994; 34:607-615.
CHAPTER 1
CHAPTER 56
Acute Burn Injury

Jeffrey R. Antimarino and Warren L. Garner
Epidemiology
There are more than 2 million people burned In the United States each year.
Approximately 10% of these burns will require hospitalization.
Children between the ages of 1-5 make up 50% of the burned population.
The most common cause in this age group is scald injury.
Structural fires account for only 5% of all burn admissions but are responsible
for almost half of the burn-related deaths.
Classification
Burn injuries are classified by size and depth.
- First-degree burns are superficial injuries to the epidermal layer of the skin. The
skin is red, dry and painful. Sunburns are classic examples of first-degree burns.
- Second-degree burns involve the epidermal and the upper portion of the dermis.
These burns are also described as partial thickness. Clinically, it may be difficult
to distinguish between superficial and deep second degree burns. The skin is
typically red, edematous and has a wet and glistening appearance. Blisters are
common. The skin blanches on palpation. Superficial dermal involvement may
take 7-10 days to re-epithelialize; however, deep dermal involvement may take
as long as three weeks to heal. An antimicrobial dressing such as Silvadene should
be used until complete re-epithelialization takes place.
- Third degree burns involve the entire thickness of the skin. This is also termed
full thickness injury. The skin is pale, dry and does not blanch on palpation.
The skin is typically insensate and may have a leathery texture.
- Fourth degree burns involve underlying tissues such as fat, muscle and bone.
The size of the burn is classically described as percentage of the total body
surface (TBSA). There are many ways to determine the TBSA. The easiest
way to estimate the percent burn is to use the Rule of Nines (Fig. 56.1). In
this method the body is divided into regions and each region is quantified as
a multiple of nine. Each arm and the head are 9%; the legs are 18% and the
torso is 36%. These numbers are slightly different for infants since their head
occupies a greater surface area percentage than an adult head. The most
accurate method is to use predetermined charts of body percentage, Lund-Browder
charts (Fig. 56.2). Another method is to use the patients hand to estimate
percent involvement, as the human palm is roughly 1% of the total body
surface area.
Only second and third degree burns are included in the estimation of burn size.

Jeffrey R. Antimarino, LAC + USC Burn Center, Los Angeles, California, U.S.A.
Warren L. Garner, LAC + USC Burn Center, Los Angeles, California, U.S.A.
586
Trauma Management
Fig. 56.1. Wallaces Rule of Nines for estimation of burn size.
Admission Criteria
The American Burn Association has published generalized guidelines for
admission to a burn center (Table 56.1).
Pathophysiology and Tissue Response
56
The mechanism of tissue damage is two-fold following a burn injury.

First, the initial thermal injury causes three zones of injury. The Zone of
Coagulation is an area of irreversible cell death and protein coagulation. The
immediate surrounding area is called the Zone of Stasis. This is an area of
decreased perfusion and is at risk for further cell death. The most peripherally
affected area of injury is called the Zone of Hyperemia. This area will usually
go on to heal spontaneously.
Second, the thermal injury causes the release of several local inflammatory
mediators such as prostaglandins, bradykinins, histamine and cytokines. These
vasoactive mediators cause significant alterations in the capillary endothelium
and basement membrane, which results in tissue edema and ischemia. It is
this local reaction that can cause further tissue loss in the Zone of Stasis.
Acute Burn Injury
587
Fig. 56.2. Estimation of burn size - Lund and Browder Chart.
Table 56.1. Guidelines for referral to a burn center

1.
Second and third degree burns > 10% TBSA in patients less than 10 years of
age and greater than 50 years of age.
2. Second and third degree burns > 20% in all other age groups.
3. Second and third degree burns with serious threat of functional or aesthetic
impairment involving the face, hands, feet, perineum and major joints.
4. Third degree burns > 5% in any age group.
5. Inhalation injury with any burn.
6. Electrical burns, including lightning.
7. Circumferential burns.
8. Burn injury in patients with significant premorbid medical conditions that
could complicate management, prolong recovery or affect mortality.
9. Any burn patient with concomitant trauma in which the burn poses the
greatest risk of morbidity or mortality. If the trauma injury poses the greatest
risk, then the patient should be treated in a trauma center until stabilized.
10. Hospitals without qualified personnel or equipment for the care of children
should transfer burned children to a burn center with these capabilities.
56
588
Trauma Management
Burn injury not only affects local tissues but can also initiate a systemic
response. Burns larger than 15-20% TBSA cause a significant release of
vasoactive mediators into the systemic circulation. These mediators cause
endothelial cells in distant capillary beds to change shape, resulting in capillary
leak syndrome. This results in hypovolemia due to large shifts of fluid and
proteins out of the vasculature and into the tissues. Large burns also activate
the complement and coagulation cascades resulting in thrombosis of the
microvasculature. The accumulation of oxygen free radicals in burned tissue
also increases tissue damage and increases edema.
Other organ dysfunction is common after larger TBSA burn injuries. Myocardial suppression is seen in burns greater than 40% TBSA, possibly due to
the release of the inflammatory cytokine TNF. Patients with large burns have
been found to have suppression of most immune functions including decreased
neutrophil chemotaxis, phagocytosis and killing; decreased cell-mediated and
humoral-mediated immune responses as well as impairment of other cell
types including macrophages and natural killer cells. Hemolysis is also
common in large burns. Red blood cell destruction can be as high as
40% of the circulating volume.
Fluid Resuscitation
Volume status is a concern for any person sustaining a second or third degree
burn; however, only burns involving greater than 20% TBSA need formal
fluid resuscitation. Burn injuries less than 20% TBSA can be treated with
liberalized oral intake and intravenous fluids to maintain urine output 0.5 cc/
kg/hr for an adult and 1 cc/kg/hr for a child.
There have been several formulas derived to resuscitate patients with large
burns; however, the Parkland formula has become the standard method.
- According to the Parkland formula, in the first 24 hours a patient should
receive 4 cc/kg/%TBSA burned of Ringers lactate. Only the body percentage
of second and third degree burns is used for this calculation. Half of the calculated fluid should be given in the first eight hours from the time of the burn.
The other half is given over the subsequent 16 hours.
- Example: a 70 kg man sustains a 50% second and third degree burn. Using the
Parkland formula he would require 14 liters of lactated ringers in the first 24
hours (4 cc x 70 kg x 50). During the second 24 hours following a burn about
half of the fluid given during the first 24 hours is needed.
- It must be emphasized that the Parkland formula or any other formula is only a
guide. The goal of any resuscitation attempt is to maintain adequate end organ
perfusion. Generally, urine output is an accurate measurement of volume status
and tissue perfusion. The formula should be adjusted to maintain adequate urine
output as described above. The formula should also be adjusted depending on the
patients underlying medical condition such as cardiac or pulmonary disease.
56
The use of 5% albumin in the resuscitation protocol is controversial. It is

certainly detrimental if used within the first 24 hours since this will result in
extravasation of proteins into the surrounding tissues, which leads to increased
pulmonary and tissue edema. In patients with very large injuries and resuscitations (greater than 60% TBSA), there may be a benefit from albumin
administration (0.5 cc/kg/%TBSA burned 5% albumin). There is little clinical
evidence that the use of hypertonic solutions or dextran decreases the amount
Acute Burn Injury
589
of fluid needed for adequate resuscitation and some evidence that these solutions
increase end organ dysfunction.
The use of Swan-Ganz catheters is beneficial in those patients who do not
respond as expected or where the urine output may not be an accurate reflection
of volume status. Patients with serious inhalation injury, burn-induced cardiac
dysfunction or pre-existing congestive heart failure, renal or hepatic
insufficiency are good indications for the use of a Swan-Ganz catheter.
Acute Management
All burn patients should be evaluated as a trauma victim. The first priority is
to establish an adequate airway, ventilation and systemic circulation. A primary
survey should be performed to identify and treat any immediate life threatening
injuries. A secondary survey, head-to-toe examination, should then be performed.
Approximately 15% of burned patients have concomitant injuries.
Patients that have sustained large burns become hemoconcentrated; therefore, a burn patient with a low hematocrit on arrival to the emergency room
should be examined for other sources of blood loss. During the secondary
survey all burn wounds should be gently washed and any loose or dead skin
should be debrided.
Access lines should be placed soon after arrival, if possible, in unburned sites.
Any line placed prior to the skin being thoroughly cleansed should be replaced within 48 hours to lessen the risk of infection. Patients with large burns
including the extremities will need an arterial line, as the tissue edema that
develops due to the burn may interfere with the blood pressure cuff s ability
to measure an accurate blood pressure.
A nasogastric or Dobhoff tube for alimental feeding should also be placed
soon after admission. It is extremely important to begin nutritional support
within the first 6 hours after admission for three reasons.
- First, burn victims develop a large catabolic process secondary to the systemic
inflammatory response. The basal metabolic rate may rise to 3-5 times normal
rates. The Curreri formula (25 kcal/kg + 40 kcal/TBSA) can estimate the patients
caloric requirements. The protein requirement also rises. An average person
requires approximately 1gm of protein/kg/day. Patients with large burns require two to four times that amount.
- The second reason for beginning tube feeds is to prevent translocation of intestinal bacteria. It is not uncommon for a large burn to cause an ileus. If a patient
is not tolerating tube feeding, the use of Reglan and/or Erythromycin may be
helpful.
- The third reason for beginning tube feeds is to prevent stress ulceration. Patients
with large burns have been shown to have a high incidence of developing gastric
ulcers, specifically called Curlings ulcers. Early tube feeding decreases the risk
of developing these ulcers.
Escharotomy
Circumferential full thickness burns can impair blood flow to underlying
tissue as well as distal parts of extremities. As the tissues swell due to the
release of local and systemic vasoactive cytokines, the skin in a full thickness
burn is unable to expand. The skin therefore, can act as a tourniquet. The
burn eschar needs to be incised in order to allow expansion of the tissues and
to maintain tissue perfusion. Full thickness burns are insensate; therefore
56
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Trauma Management
escharotomies may be performed at the bedside using a scalpel or electrocautery with minimal sedation.
Escharotomies are performed along the medial and lateral aspects of the upper
and lower extremities. If the hands are involved then incisions along the dorsum
of the hand, along the radial border of the thumb and small finger and along
the ulnar border of the index, long and ring fingers
If the chest is involved, incisions are made vertically along the mid-axillary
lines, and horizontally following the costal margin and the clavicles. It is
unnecessary to incise vertically over the sternum.
Incisions need only be carried through the eschar until reaching the subcutaneous fat layer. It is important to incise along the entire length of the eschar. If
perfusion is not restored, compartment pressures should be measured and
fasciotomies performed if necessary.
Wound Management
After initial inspection of all burned areas, all necrotic or loose skin should be
debrided, blisters should be ruptured and all areas should be gently cleaned
with mild soap and water. The wound should be treated with a daily antimicrobial dressing. The treatment of intact blisters is somewhat controversial,
although the senior author believes that removal of most blisters and initiation of antimicrobial dressings results in simplified and effective care.
Systemic antibiotics are not effective in preventing wound infection and should
be started only if there are signs of cellulitis.
There are several topical antibiotic dressings that can be used. The most
commonly used agent is silver sulfadiazine (Silvadine). Silvadine has many
advantages. It has a wide spectrum of coverage, has few complications, is painless
and easily removed. Polysporin and Bacitracin are common agents. They are
inexpensive and painless; however have a narrow spectrum of coverage.
Bactroban is a relatively newer agent. It has a broader spectrum than polysporin
and bacitracin but is expensive. Mafenide (Sulfamylon) is the only agent that
effectively penetrates the burn eschar. It is the agent of choice for treating
significant burns to the ears to prevent chondritis. Mafenide can cause metabolic acidosis. The newest agent is Acticoat. This is a gauze-like dressing made
of silver. Acticoat is moistened with sterile water and then placed directly over
a wound or skin graft. The water releases the silver ions, which have excellent
antimicrobial properties. The advantage to Acticoat is that the dressing need
only be changed every three to four days.
Inhalation Injury
Inhalation injury has an enormous impact on the survivability of a burn.
The evaluation and management of this pathology are described in a separate chapter.
Indications for Surgery
56
Surgery is indicated for all full thickness burns to the face, hands and involved
joints. Surgery is also indicated for full thickness burns larger than 1-2 cm2 on
the trunk or extremities and partial thickness burns that have not healed within
three weeks from the time of injury.
The goal of surgery is to remove all nonviable tissue and close all open wounds.
In the vast majority of patients this can be accomplished with one procedure
Acute Burn Injury
591
that should be performed within a week of injury. This decreases septic

complications, speeds wound healing and increases the rate of functional
recovery. In the case of a large burn with limited donor sites, the surgery must
be carefully planned to meet these criteria. Excisions must be prioritized. In
patients with massive injuries the first priority should be to excise those areas
that can most significantly decrease the necrotic load: torso and extremities.
The face has the lowest priority since it is a small area and due to the rich
blood supply becomes infected less often.
The choice to stage excisions or debride all necrotic tissue and use other
products along with autografts to close the wound in one sitting depends
upon the individual surgeons preference.
Skin Grafts and Skin Alternatives

There are several options for closure of the wound bed after debridement of
all nonviable tissue. Partial thickness wounds will re-epithelialize spontaneously
and do not require an additional procedure for wound closure. Full thickness
wounds require skin grafting or some alternative. The most useful and common
method of skin grafting is to use autologous split thickness skin. Harvesting at
0.008-0.015 inch, depending on the patients age and the donor site, creates a
donor wound which heals spontaneously in 10-14 days. Unmeshed split
thickness grafts, also called sheet grafts, are the best coverage when long-term
flexibility and appearance are the primary consideration. They should always
be used to cover areas of the face and hands and should be strongly considered
when grafting any burn in a child. The downside is that in large burns, donor
sites are limited; therefore, it is difficult to graft an entire large wound with
sheet graft. Meshed grafts also offer advantages. The need for a large donor
site is decreased. Meshed grafts have a lower incidence of loss due to seroma
and hematoma. The disadvantages of meshed grafts are that they never lose a
cobblestone appearance and have a higher rate of contraction.
There are many alternatives to autografting. Allograft, cadaveric skin, is the
traditional method to temporarily close a wound bed after excision. Allograft
encourages vascular ingrowth so the wound bed is better prepared for subsequent autografting. The disadvantages of allografts are its limited supply,
variable condition of the skin since donors may be elderly and the small risk
of viral transmission. Research advances have led to the development of both
synthetic and bioengineered alternatives to allografts. The first of these products, Biobrane, is a sheet of nylon mesh impregnated with collagen that is
bonded to a silicone rubber membrane. Biobrane can be used to cover partial or full thickness wounds to help prevents fluid loss and to prevent bacterial invasion. Trancyte is a product that combines Biobrane with a protein
matrix derived from neonatal fibroblasts. This protein matrix is proposed to
contain wound-healing factors. Trancyte can be used to cover partial or full
thickness wounds. Trancyte promotes rapid epithelialization of partial thickness wounds. It is more resistant to infection than other products. Integra is
a permanent dermal replacement product. Integra consists of a bilaminar
membrane of bovine Type I collagen crosslinked with chondroiton-6-sulfate
and a silicone elastomer epidermal equivalent. Integra is used in full thickness wounds. It causes vascular ingrowth into the dermal component. This
process takes 2-3 weeks. At that time the silicone layer can be removed and
56
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Trauma Management
an ultra thin, .006 inch, split thickness skin graft can be used to cover the
Integra.
Nonthermal Burns
Chemical Burns
Chemical burns constitute a small percentage of admissions to a burn center.
These injuries can occur at home by mishandling common cleaning agents or
at work by industrial exposure. Unlike flame injuries, chemical injuries can
continue to cause damage as they are absorbed by the tissues.
The degree of injury from a chemical burn depends upon the agent, the concentration of the agent and the duration of exposure.
The most important part of therapy is irrigation of the exposed area with
copious amounts of water. The water will dilute the chemical agent.
As a rule, acids tend to be less damaging than alkaline agents. The acidic
agents are neutralized quickly; however, alkaline agents hydrolyze fats and
proteins as they are absorbed. These reactions form ions that induce further
chemical reactions, which continue to penetrate into tissues. Alkaline burns
are more common than acidic burns because these agents make up common
household cleaning agents including bleach, sodium hydroxide (Drano) and lime.
Electrical Burns
Electrical injuries make up less than 5% of burn center admissions. These
injuries can be initially deceiving because the apparent skin involvement is
small compared to the amount of destruction that may have occurred.
Electrical injuries are divided into high and low voltage. Low voltage injuries
are usually seen with household currents. These injuries are usually small thermal injuries without the sequelae seen in high voltage injuries. High voltage
injuries (>1000 volts) have skin involvement at contact sites and larger
destruction of deeper tissues. These currents can cause cardiac arrest,
dysrhythmias and Rhabdomyolysis. All patients sustaining a high voltage injury should have an EKG and electrolytes sent on admission to the emergency room. A Foley catheter should be placed immediately to check for
Rhabdomyolysis. The extremities should be examined for compartment syndromes. Most sequelae of high voltage injuries occur within the first 24 hours
after the time of injury. If the original EKG is negative and the patient has no
history of cardiac disease then cardiac monitoring is unnecessary. It should
also be noted that these patients should be carefully examined for fractures as
high voltage injuries have a significant incidence of falls.
Patient Outcomes
56
Patient outcomes have improved drastically over the past two decades. In 1971,
50% of patients admitted with a burn 40% TBSA died. In 1990, the same
patient would routinely survive. Increases in survival are due almost exclusively
to improvements in resuscitation, the treatment of inhalation injury and
improvements in critical care practices.
There is data that shows that many burn survivors can readjust after the injuries
and regain a lifestyle that is satisfactory to them. A study in 1989 showed that the
most significant variables influencing return to work after injury are degree of
Acute Burn Injury
593
burn, burns to the hands, type of work and age of the patient. On average, a
person sustaining a 5% TBSA burn will return to work within one month, a
person with a 10% TBSA burn will return within six months and patients
with 20% TBSA burns return within 1-1.5 years. Patients less than 45 years of
age are also more likely to return to work.
Burn patients require a large support system after surviving their injuries to
help integrate back into their lifestyles. These people must have not only a
strong social circle but must also be willing to participate in interdisciplinary
groups such as counseling, occupational and physical therapy.
56
CHAPTER 57
Inhalation Injury
John F. Fraser and Michael Muller
Introduction
Inhalation injury may be defined as an airway or pulmonary parenchymal
injury due to the components of smoke: heat, particulate matter, irritants,
and asphyxiants.
In the presence of burns, inhalation injury is a greater contributor to overall
mortality and morbidity than either percentage body surface area burn or age,
with the majority of victims dying at the scene, due to hypoxia and asphyxiation.
Inhalation injury is present in between 20 and 30% of all burn victims.
Whilst the mortality associated with cutaneous burns has fallen dramatically,
this improvement has not been reflected in inhalation injury. The difficulty in
diagnosis and quantification of the injury, and the delay in symptom presentation account for some of these problems. There is significant morbidity and
mortality both immediately and throughout recovery.
History
Recorded as early as the first century AD, by Pliny, describing the killing of
prisoners by exposure to greenwood fires.
Major recognition received after the Coconut Grove Night Club disaster Nov
28th 1942 in the United States in which 491 people were killed.
At Risk
Unable to escape fire due to
- Extremes of age
- Immobility due to other trauma
- Reduction of level of consciousness: alcohol, drugs, effects of smoke.
Lack of functional smoke detector

Chronic pulmonary disorders: asthma, COPDmorbidity of smoke inhalation increased.
Assessment of Smoke Inhalation Patient

History
-
Was the fire in an enclosed space.

Duration of exposure.
What type of material burned, e.g., paints, chemicals.
Level of consciousness on scene.
Note: Burns and smoke inhalation victims should be treated as a trauma

patient, with trauma protocol being followed as routine. This includes cervical
immobilization until injury is excluded.
John F. Fraser, University of Queensland, Royal Brisbane Hospital, Herston, Australia
Michael Muller, University of Queensland, Royal Brisbane Hospital, Herston, Australia
Inhalation Injury
595
Inspection
- Stridor: indicates severe laryngeal edema and the possibility of imminent airway obstruction
- Voice hoarsenessan excellent warning sign
- Tachypnea
- Use of accessory muscles
- Persistent cough
- Soot in oropharynx
- Singed nasal hair
Examination
-
Confusion/disorientationindicating hypoxia and/or presence of asphyxiants

Wheeze
Soot-stained sputum
Central facial burn
Burn involving central face: 60% incidence of inhalation injury.
Burn involving no facial burn or only peripheral facial burn has 20%
incidence of inhalation injury.
- Increasing size of cutaneous burn indicates an increased likelihood of smoke
inhalation
Investigations
Arterial Blood Gasesmandatory
- Oxygen saturation(SaO2)however, SaO2 is inaccurate in the presence of significant carboxyhemoglobin (COHb) or methemoglobinemia.
- CarboxyhemoglobinThere is a significant variation in carboxyhemoglobin
concentrations in the community. Breakdown in hemoglobin results in minor
concentrations, and a city lifestyle is associated with significant concentrations.
Chest x-rayFrequently normal initially but essential nonetheless as baseline

assessment and to exclude trauma.
BronchoscopyThe gold standard for diagnosis of inhalation injury.
Xenon 133 lung scanA useful adjunctive test when bronchoscopy equivocal.
Smoke inhalation/burn injury are frequently associated with other trauma
and appropriate examination should be undertaken.
Pathophysiology
Inhalation injury induced by smoke can be separated into:
Thermal Injury
- Air of 300C at the oropharynx is cooled to 50C on arrival at the trachea. The
vocal cords also reflexively adduct at 150C. Direct thermal injury below the
cords, is therefore uncommon. Steam, however, is an important exception as it
has a latent heat capacity that is 4,000-fold that of dry air and can thus inflict a
severe thermal injury to the lower airway. This results in depilation of the cilia
and cast formation from sloughing of the necrotic tracheal and bronchial mucosa.
Small airway plugging and air-trapping with subsequent bronchopneumonia
and atelectasis then occurs.
Irritants and Toxins

- Smoke is a heterogeneous substance whose composition depends on the material
combusted and the environment in which the combustion occurred. There are
two separate phases of toxins: particulate and gaseous.
57
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Trauma Management
- The particulate debris of the inhalation is the more damaging of the two. Particles are recognized as foreign material. The immune response initiates
phagocytosis-inducing free radical formation and the release of proteases from
neutrophils. This further fuels the systemic inflammatory response, resulting in
increased capillary permeability. Experimental smoke inhalation to a single lung
caused bilateral lung damage providing further evidence that it is the exaggerated
host defense to particulate matter which causes much of the pulmonary damage.
- The gaseous phase includes the asphyxiants carbon monoxide and cyanide which
will be dealt with separately. Other products include aldehydes, nitrogen dioxide, hydrogen chloride, ammonia and phosgene; all of which may lead to pulmonary edema. Soluble vapors, such as acrolein, sulfur dioxide, ammonia and
hydrogen chloride cause injury to the upper airway. Chlorine and isocyanates,
with intermediate solubility, cause upper and lower respiratory tract injury.
Phosgene and oxides of nitrogen have low water solubility and cause diffuse
parenchymal injury. Paradoxically, some fire retardants, which reduce but do
not completely inhibit combustion, have been associated with grand mal seizures and death in laboratory experiments on rats. Hence, these may act as
chemical asphyxiants, particularly in an enclosed environment.
ManagementEarly
57
Humidified OxygenMany smoke inhalation victims will require this alone,

but, as symptoms can be slow to develop, they should continue to be monitored closely. Supplemental oxygen is the mainstay of treatment of carbon
monoxide poisoning and humidification helps to loosen secretions and therefore aid expectoration.
IntubationApproximately 50% of all patients with smoke inhalation require
endotracheal intubation and most of these will have co-existent burns. Intubation is indicated by the need to support ventilation and to protect the airway of the unconscious patient. It is the specific case of thermal injury to the
upper airway that requires special attention. The upper airway, and in particular the larynx, is an excellent absorber of heat. This protects the lower airway
from significant thermal damage, with the exception of steam inhalation. The
absorption of heat is the main contributor to upper airway and laryngeal swelling, which can precipitate acute airway obstruction. If there are signs suggestive of significant upper airway injury (voice changes, stridor, and air hunger),
a definitive airway should be secured immediately. The conscious patient is able
to protect his/her own airway effectively, and removal of these valuable protective reflexes by sedation or excessive analgesia should be avoided if at all
possible. Direct vision of the laryngeal inlet in the spontaneously breathing
patient is the safest option. Either direct laryngoscopy, or fiberoptic bronchoscopy with local anesthesia or inhalational induction may be used. The airway is
maintained, as the patient self ventilates, and the risk of losing the airway is
diminished. In burns, suxamethonium causes refractory hyperkalemia after
24-48 h in burns but can be used in the acute setting. Nondepolarizing agents
should be used with great caution as there is a risk of the airway being lost.
The largest compatible endotracheal tube should be used to facilitate suctioning
and/or bronchoscopy. Swelling of the face generally worsens during the resuscitation and acute phase, and the endotracheal tube should be left uncut to
avoid losing the end of the endotracheal tube into the oropharynx as the
Inhalation Injury
597
face swells. The tube should be well secured, though ties should be loose
enough to allow for the facial swelling, and re-evaluated regularly.
The cuff of the endotracheal tube should be filled with enough air to avoid a
leak, and should be reassessed regularly. The swelling that occurs at the damaged
laryngeal inlet/upper trachea may increase the pressure on already compromised
tracheal mucosa and result in tissue necrosis. Regardless of the method chosen,
the most experienced person available should be in charge of the intubation.
OxygenationIf significant CO poisoning is suspected/proved, the patient
should be ventilated on 100% oxygen for at least 48-72 hrs to facilitate
maximal dissociation of carboxyhemoglobin from hemoglobin. There are risks
of prolonged high oxygen concentration, such as compromise of the already
impaired mucociliary mechanism and absorption atelectasis but they are outweighed by the risk of long term sequelae from carboxyhemoglobin poisoning.
Hyperbaric treatment is effective in rapidly reducing the carbon monoxide
levels and speeding the dissociation of carbon monoxide from cytochrome
c oxidase but has not been shown to improve outcome in randomized controlled trials and is associated with risks, both to patients and staff. It is used
in some centers.
VentilationThe recently introduced high frequency, flow interrupted
ventilator, which results in pulsatile flow, has become popular and may reduce
mortality and the incidence of barotrauma and ventilator associated pneumonia.
There may be a reduction in barotrauma associated with open lung ventilation
strategy (tidal volume 6-8 ml/kg) and optimum positive end expiratory pressure.
This modality, or pressure limited ventilation, should be instituted early to
limit the effects of air trapping and barotrauma.
Fluid resuscitationThe presence of inhalation injury necessitates an increased
fluid requirement over and above that calculated for the cutaneous burn.
However, it is difficult to quantify inhalation injury and hence the exact volume
needed. At least a 30% increase fluid requirement is required. Frequently even
more is required. Paradoxically, there is an increased risk of pulmonary edema
in smoke inhalation, if fluid resuscitation is insufficient. As with all burns,
fluid resuscitation is calculated by a chosen formula (e.g., Parkland formula),
but this should only be used as a framework. If the clinical indicators of resuscitation indicate hypovolemia, e.g., hypotension, tachycardia, reduced urine
output or developing lactic acidosis, further fluid should be administered or
causes for failure of fluid resuscitation should be considered.
DrugsSteroids have been shown to increase mortality in a randomized trial
in inhalation injury. Antibiotics should only be used for clinically suspected
or proven infections. Prophylactic antibiotics merely select out resistant
organisms, which frequently become problematic. Beta agonists should be
used for persistent wheeze, though frequently they are ineffective, as the wheeze
is related to particulate matter and chemical irritants.
Oxygen should be humidified, and this can be supplemented with nebulised
saline prephysiotherapy/bronchoscopy. There is also data showing that
nebulised heparin and N-acetylcysteine reduces morbidity and mortality in
inhalation injury.
ECMO-extracorporeal membrane oxygenation has been shown to be of some
benefit in those with smoke inhalation alone. Results in those with concomitant
burn injury have been thoroughly disappointing.
57
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Trauma Management
Carbon Monoxide Poisoning

Carbon monoxide (carboxyhemoglobin) is formed from combustion of carbon
at low oxygen tension. carboxyhemoglobin causes tissue hypoxia in a number of
ways:
Carboxyhemoglobin binds to hemoglobin with 250 times the affinity of oxygen
to hemoglobin. Thus the oxygen carrying capacity of the blood is severely
reduced even with small concentrations of carboxyhemoglobin. An environmental
carboxyhemoglobin concentration of 0.1% produces approximately equal
concentrations of O2HB and COHB.
Carboxyhemoglobin induces a leftward shift in oxygen dissociation curve,
facilitating oxygen uplift at the lungs, but making delivery of oxygen at the
tissues more difficult.
Carboxyhemoglobin binds not only to Fe in hemoglobin, but also to myoglobin
and the cytochrome system. Thus, even when all the carboxyhemoglobin has
been converted to oxyhemoglobin, the tissue is still unable to utilize the oxygen.
Significant carboxyhemoglobin poisoning causes myocardial dysfunction,
further reducing oxygen delivery to tissue
Treatment
Remove from environment
Provide maximal supplemental oxygenThe half life of carboxyhemoglobin
is reduced significantly with supplemental oxygen and more so with hyperbaric
oxygen (Table 57.2)
As carboxyhemoglobin concentrations increase as more smoke is inhaled, the
carboxyhemoglobin concentration can be used as an approximation of degree
of smoke inhalation. The elimination of carboxyhemoglobin is predictable( if
inspired oxygen is known), hence a nomogram can be used to extrapolate
carboxyhemoglobin levels to the time of injury, and this level may be used as
a predictor of outcome (Fig. 57.1).
Supportive therapy
Cyanide
Thermal decomposition of all nitrogen contained in both natural and synthetic
polymers may result in the production of the histotoxic poison, cyanide. Cyanide has a
high affinity for ferric iron resulting in the inhibition of a number of metabolic processes, most importantly oxidative phosphorylation. Cyanide combines specifically with
cytochrome AA 3, reducing electron transport, inhibits mitochondrial oxygen
utilization and hence cellular respiration. This results in anaerobic metabolism with
the production of lactic acidosis. The toxicity of cyanide is synergistic with
concomitant poisoning with carboxyhemoglobin. Exhaled breath detectors and
Table 57.1. Variations in carboxyhemoglobin concentrations
57
Environment
Carboxyhemoglobin concentration
Endogenous production
City dweller
Heavy smoker
0.3-0.8%
1-5%
5-10%
599
Inhalation Injury
Table 57.2. Carboxyhemoglobin half life and ambient oxygen tensions

Breathing medium
Half life (minutes)
Room air (21% oxygen)

100% normobaric oxygen
100% oxygen-3 atm
320
90
23
Fig. 57.1. Nomogram for estimation of initial level of carboxyhemoglobin;

Reprinted with permission from: Clarke et al, Lancet 1981; 1332-1335.
57
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Trauma Management
gas chromatography methods can both reliably detect cyanide, but are not used
routinely. There is no rapid laboratory assay for blood cyanide.
A high level of clinical suspicion is justified if a smoke inhalation is diagnosed
combined with an rising lactate, which cannot be explained by hypovolemia or
concomitant carboxyhemoglobin poisoning. A high mixed venous oxygen may
also be present, indicating the failure of the cells to uptake oxygen.
Treatment
Supportive
100% oxygen and endotracheal intubation if indicated, with appropriate level
of monitoring.
Intravenous fluid and consider NaHCO3 for presumed/proven metabolic acidosis.
Specific Antidotes
All the specific antidotes carry some risk, and this should be considered when
administering them on a presumptive diagnosis alone.
Administration of sodium or amyl nitrates, inducing oxidation of hemoglobin to methemoglobin, which provides an alternative substrate for the cyanide. Thus the cytochrome oxidase is restored, at the expense of reducing
the oxygen transport capacity, which itself can result in hypoxia. Hyperbaric
oxygen has been used in combined carboxyhemoglobin/cyanide poisoning,
but also in isolated cyanide treated with sodium nitrate, where the dissolved
plasma oxygen compensates for the reduced oxygen carrying capacity of the
methemoglobinaemia.
Agents, such as cobalt EDTA or hydroxycobalamin, chelate the cyanide, and
the resultant compounds are eliminated by renal excretion. Cardiovascular
instability and anaphylaxis can occur with cobalt EDTA. Hydroxycobalamin
is safer, though doses of between 70 and 150 mg/kg are required.
The mitochondrial enzyme rhodanase catalyses cyanide, complexing it with
sulfur to produce the less toxic thiocyanate molecule. The rate-limiting step is
the endogenous sulfur supply. Administration of sodium thiosulphate provides a
sulfur bank and results in the formation of the relatively innocuous thiocyanate.
However, the reaction is slow and produces a problematic osmotic diuresis. It
is the safer of the nonchelating agents.
Conclusions
Inhalation injury is a major contributor to mortality in burn victims. The injury is
a composite of hypoxia, thermal damage, particulate inhalation and chemical asphyxiation. Whilst most deaths occur in the prehospital setting, there is a large scope for
treatment optimization in the emergency rooms and ICU. The mainstay of treatment
is supportive, together with appropriate investigation and monitoring. However, novel
therapies, including high frequency ventilatory strategies and nebulization of heparin
and NAC are beginning to improve the outcome. The optimum method to reduce
morbidity and mortality from this challenging condition, however, is prevention. This
requires education and utilization of relatively cheap and accessible smoke detectors.
57
Inhalation Injury
601
Reference
1.
2.
3.
4.
5.
Kinsella J, Rae CP. Smoke Inhalation and airway injury. Ballieres Clinical
Anaesthesiology Balliere Tindall 1997; 385-406.
Desai MH, Mlcak R, Richardson J et al. Reduction in mortality in paediatric
patients with inhalation injury with aerosolized Heparin/ Acetylcystine therapy. J
Burn Care and Rehab 1998;19 (3); 210-212.
Thompson PB, Herndon DN, Traber DL et al. Effect of mortality of inhalation
injury. J Trauma 1986; 26:163-165.
Cioffi WG, deLemos RA, Coalson JJ, et al. Decreased pulmonary damage inn
primates with inhalation injury treated with high-frequency ventilation. Ann Surg
1991; 218:328-335.
Prien T, Traber DL. Toxic smoke compounds and inhalation injurya review.
Burns 1988; 14(6):451-460.
57
CHAPTER 58
Management
of the Potential Organ Donor Patient
Bradley J. Roth
The worldwide shortage of viable organs for transplantation makes identification
and optimal management of potential donors essential. The key to successful
management of the potential organ donor consists of three steps:
1. Recognizing and continued aggressive hemodynamic monitoring of those
patients that may have suffered a fatal head injury.
2. Understanding the legal and medical steps required to declare brain death.
3. Understanding the rapid hemodynamic changes which occur with brain death
and quickly correcting the multiple physiologic abnormalities.
The Physiological Consequences of Traumatic Brain Death

Secondary to Trauma
In the setting of fatal head injury and brain death, several physiologic changes
result in significant instability:
1. Increased catecholamine release and an autonomic storm prior to herniation
makes the neurotrauma patient less likely to manifest hypovolemic shock with
hypotension as early as other trauma patients.
2. Most neurotrauma patients will have a total body (intravascular and extravascular) fluid deficit secondary to mannitol and other diuretics.
3. Up to 85% of patients with severe intracranial injuries will develop diabetes
insipidus (DI) resulting in further fluid loss.
4. Thromboplastin release secondary to severe head injury results in a significant
incidence of disseminated intravascular coagulopathy (DIC).
5. A scalp laceration, which may be associated with head trauma, can be a source
of significant hemorrhage.
6. During the autonomic storm that is associated with herniation, many patients
develop neurogenic pulmonary edema, resulting in hypoxia and left ventricular
dysfunction.
7. Once herniation is completed and mid-brain death occurs, autonomic vasomotor activity is lost and severe distributive shock occurs.
8. In addition to the above effects, brain herniation also causes an intercellular
metabolic dysfunction related to the processing of triiodothyronine (T3).
If all of the above are not corrected rapidly the patient will progress into irreversible
cellular dysfunction, hypoxia, shock, and cardiac arrest. Patients who suffer brain
death from a non-traumatic etiology generally do not develop the rapid hemodynamic
changes seen in neurotrauma patients.
Bradley J. Roth, Defense Medical Readiness Training Institute, Joint Trauma Training
CenterBen Taub General Hospital, Houston, Texas
Management of the Potential Organ Donor Patient
603
Clinical Evaluation for Brain Death

Definition: Death due to neurologic failure (brain death) is defined as an
irreversible state in which there is no neurologic function of the brain and brain stem.
Two licensed physicians should independently perform the following neurologic
examination. The examining physicians should document their findings in the patient
record. The criteria for documenting brain death may vary depending on hospital
policy or state regulation. Also, the requirements for children may differ from those
for adults.
Criteria
All of the following must be true:
normothermia (core temperature > 95 F)
absence of pharmacologic effect (negative toxicology)
Barbiturate level < 5. Other levels (if present) must be individually evaluated to
determine if they are contributory to decreased neurologic function. Trace levels do not absolutely rule out the ability to determine brain death. Check with
your individual lab.
electrolytes (ranges for normal neurological function)

Sodium 125 - 160, potassium 3 - 7, magnesium 1 - 4, phosphorus 1 - 8, glucose
50 - 400
absence of neurologic function of the brain or brain stem.

- negative corneal reflex
- absent papillary reflex
- absent oculocephalic reflex (negative dolls eyes)
- absence of response to cold caloric stimulation (direct instillation of 60 cc
iced solution into each ear canal fails to cause ocular motion)
- no spontaneous respirations after an apnea test.
(See apnea test below)
Spinal reflexes may be present, but do not change the status of the patient if
brain stem function is absent.
Apnea Test
Patient should have ventilator adjusted resulting in normal pH and PaCO2,
with 97-100% saturation.
Preoxygenate for 5-10 minutes with 100% FiO2.
Disconnect patient from ventilator and place a catheter down the length of
the endotracheal tube. The catheter should be connected to 100% O2 at 12-15
liters/minute. (This continuous supply of oxygen ensures the patient is oxygenated but will not ventilate the patient adequately.) Continue to monitor
the pulse oximeter during the test. If the SaO2% declines below 90% an ABG
should be obtained and the patient placed back on the ventilator.)
Observe the patient for approximately 10 minutes for respiratory effort.
The test is stopped when the ABG PaCO2 > 60 mm Hg and rises 20 mm Hg
above baseline.
The test should be terminated early and the patient placed back on the ventilator if spontaneous respiration is noted, the oxygen saturation is < 90%, and/
or the patient becomes hemodynamically unstable.
The apnea test is a clinical determination of brain death. Alternative methods
such as nuclear flow studies may be used in cases where the clinical evaluation is
58
604
58
Trauma Management
impractical; however, the clinical determination alone is sufficient to determine death

based upon neurologic function. If the patient is too hemodynamically unstable to
perform an apnea test, a nuclear flow study should be able to determine brain viability.
Serial EEGs may take too long and result in loss of the potential donor secondary to
cardiac failure.
Management Protocol for the Potential Organ Donor

This protocol was developed to manage trauma patients in an ICU setting or on
a ward when an ICU bed is not immediately available. When the following protocol
is adhered to closely a 90% success rate has been achieved (patient able to qualify for
donation). The management protocol should be followed as a bridge from trauma
service/ICU care until the regional organ procurement agency has received consent
to manage the care of the patient or a decision to withhold care is made. The T-4
Protocol that follows is part of the resuscitation protocol.
Never discuss organ donation with the family, but rather call the local regional
organ procurement agency. The likelihood that a family member will donate organs
is significantly increased when specialists from an organ procurement agency, rather
than the primary care team, speak to the family.
Prior to starting the protocol all patients should be evaluated by a neurosurgeon.
The neurosurgeons opinion should be that the patients injury is 1) nonsurvivable,
2) would not benefit by neurosurgical intervention, 3) but the patient requires continued resuscitation by the Trauma or Critical Care Services.
The following are common problems usually encountered during resuscitation:
DIC: If a patient has clinical signs of DIC, transfuse immediately with 4-6
units of FFP. Delaying transfusion while waiting for lab results with uncontrolled hemorrhage is not indicated. Maintain Hct > 30 with PRBC.
DI: If patient is normotensive, serum sodium > 148 and urine output (UOP)
> 500cc/hr, give 1-2 micrograms of DDAVP IVP (q 2-8 hours as needed) and
replace UOP cc for cc with 1/2 NS or D5W every hour for UOP > 200
(example: for UOP of 1000 cc replace with 800 cc of 1/2 NS). In some patients
a DDAVP drip maybe helpful. A common error is to assume that a high UOP is
from DI, when it is in fact from earlier doses of furosemide and/or mannitol.
Tachycardia and hypertension: This commonly occurs prior to complete
herniation and should not be treated unless instructed by the neurosurgery
critical care team. Use only short acting agents.
Neurogenic pulmonary edema: Increase ventilator support as needed. With
severe problems of oxygenation alternative modes of ventilation may have to
be considered (inverse I:E ratio high frequency or percussinator ventilation).
Hypokalemia and/or hyperglycemia: Use sliding scales as needed.
Hypothyroid: Many patients have a T-3/T-4 abnormality and require additional
thyroxin. Start patients on thyroxin protocol (attached: T-4 Donor Protocol)
once declared brain dead or as soon as they fail to have spontaneous respirations
via an apnea test.
Aspiration: Following trauma that results in a decreased mental status, patients
often aspirate. These patients should have their airway cleared with bronchoscopy as soon as possible.
Cardiac arrest: Follow ACLS guidelines.
605
Management of the Potential Organ Donor Patient

Patient Evaluated in ER
A
S
A
P
1. Labs obtained: ABG/serum lactate/

CBC/PT/PTT/lytes
2. Transfuse to maintain Hct > 30
3. Bolus 1 liter NS
4. Control active bleeding
5. Maintain MAP > 70 with fluid bolus/
dopamine
6. Place large trauma central line
7. Transfer to ICU as quickly as possible
8. Protect against hypothermia
YES
Patient MAP > 70

NO
Continue to fluid resuscitate as needed, and correct lab abnormalities

Caution: Patients may go from hypertension to hypotension rapidly!
(End points of resuscitation should include normalization of base
deficit/lactate, CVP and/or PAOP between 8-15, and minimal use
of pressors)
Rules of 100s: SBP > 100 mm Hg, UOP > 100, PaO2 > 100.
Maintenance fluid: Early NS or LR; then adjust as indicated.
1. Continue to fluid resuscitate with 5% albumin and NS

(Continue with this protocol until MAP > 70)
2. Double the dose of dopamine q5 minutes to maintain MAP > 70
3. Once dopamine is at 20 g/kg/min, if MAP < 70, start epinephrine drip.
4. Double epinephrine drip q5 minutes and bolus over 20 minutes with 100 cc
of 25% albumin in 1 liter NS.
5. Is CVP > 12 and/or PAOP (wedge) > 16?
NO: Continue to bolus with above NS/albumin solution.
YES: Does the patient have clinical symptoms and laboratory values
suggestive of DI (diabetes insipidus)?
-UOP > 600 cc/hour and serum sodium > 150?
NO: Consider starting norepinephrine or neosynephrine if CI > 4
YES: Start vasopressin at 1-8 units/hour and replace UOP over 200cc
with 1/2 NS cc for cc every hour (Norepinephrine, neosynephrine, and
vasopressin should not be used if SVRI > 1100)
T-4 Donor Protocol

This is one example of a thyroxin/tri-iodothyronine supplementation Your local
organ procurement agency may follow a different protocol.
Pretreatment:
- Hydrate donor to a minimum central venous pressure >7
- Transfuse with PRBC to obtain and maintain hemoglobin >10 and/or hematocrit >30
- Correct electrolyte abnormalities
Prerequisite:
Donor is requiring a combined vasopressor need greater than 15 mcg per minute
58
606
Trauma Management
(all vasopressors combined including dopamine) to maintain a systolic pressure
of 100 after the pretreatment is completed.
58
T-4 Protocol:
Administer IV boluses of the following in rapid succession:
1 amp of 50% dextrose IVP
2 grams of methylprednisolone IVPB
20 units regular insulin IVP
20 mcg Thyroxin (T-4) IVP
Start a drip of 200 mcg T-4 in 500cc Normal Saline (.4 mcg/cc). Administer at
25 cc (10 mcg) per hour initially. Reduce levels of other pressors as much as
possible and then adjust T-4 as necessary to maintain desired pressure.
- Donors > 100 lbs give above dose
- Donors 50-75 lbs give 13 cc/hr = 5.2 mcg/hr
- Donors 75-100 lbs give 19 cc/hr = 7.6 mcg/hr
After 30 to 60 minutes the donor will usually become tachycardic with an increase in temperature and blood pressure.
Monitor K+ (serum potassium) levels carefully. Serum potassium levels usually
decrease and require aggressive replacement.
Note: The opinions or assertions contained herein are the private views of the
author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
References
1.
2.
3.
4.
5.
6.
7.
8.
Jonas M, Oduro A. Management of the Multi-Organ Donor, In: The Multi-organ

Donor, Selection and Management, Ed: Higgins RS, Sanchez JA, Lorber MI,
Baldwin JC. Blackwell Science, Inc. Malden , MA. 123-139, 1997.
Novitzky D, Cooper DK, Reichart B, et. al. Hemodynamic and metabolic responses to hormonal therapy in brain dead potential organ donors. Transplantation 1987;43:852-854.
Novitzky D, Cooper DK, Chaffin JS, et al. Improved cardiac allograft function
following triiodothyronine therapy to both donor and recipient. Transplantation
1990;49:311-316.
Bittner HB, Kendall SH, Chen EP, Van Trigt P. Endocrine changes and metabolic
responses in a validated canine brain death model. J Crit Care 1995;10:56-63.
Mertes PM, Abassi KE, Jaboin Y, et al. Changes in hemodynamic and metabolic
parameters following induced brain death in the pig. Transplantation 1994;
58:414-418.
Chen HI. Hemodynamic mechanisms of neurogenic pulmonary edema. Biol Signals 1995;4:186-192.
Novitzky D, Cooper DK, Morrell D, Isaacs S. Changes from aerobic to anaerobic
metabolism after brain death, and reversal following triiodothyronine therapy. Transplantation 1988;45:32-36.
Wijdicks EM. Determining brain death in adults. Neurology 1995;45:1003-1011.
CHAPTER 1
CHAPTER 59
Hypothermia in Trauma Patients

Thomas V. Berne
Etiology in Trauma Patients
Environmental
Injury occurring outdoors in a cool or cold ambient temperature, particularly
if immersion occurs or there is exposure to wind
Additional loss of heat occurs in the hospital particularly when a patient is
undressed and uncovered in a cool room
Administration of Cold Fluid or Blood

Crystalloids are often kept at room temperature (22o C.) and infused rapidly
for the treatment of hypovolemia
Blood stored at 4 o C is rapidly infused for the treatment of major hemorrhage
Ventilation with cool dry gas
Physiology
Definitions and mortality in trauma cases
Hypothermia is considered to be present if core body temperature falls
below 35C.
If core body temperature falls below 34oC., it has reached a serious level with
mortality in trauma patients reported from 16-60%
If core body temperature falls below 32oC., it has reached a critical level, with
mortality rates between 85-100%
Responses
37-35C: hyperdynamic, shivering and vasoconstriction
35-33C: confusion, severe shivering
33-30 C: bradycardia, falling cardiac output, cardiac irritability,
hypoventilation, hypotension, cold diuresis, muscle rigidity
Below 30C: loss of consciousness and reflexes, flaccidity, hypotension, acidosis, widening of QRS complexes, prolonged PR and QT intervals, T-wave
inversion, Osborne J waves (a hump immediately following the QRS complex) appears below 28C.
Atrial fibrillation, ventricular fibrillation, fatal arrhythmias and then asystole
at temperatures around 22C
Oxyhemoglobin dissociation curve shifts to the left, PO2 and PCO2 falls
4%-5% per each degree of temperature reduction. ABGs are difficult to
interpret because they are corrected to 37C in the lab
Coagulopathy develops progressively as temperature falls because both platelets
Thomas V. Berne, Department of Surgery, Los Angeles County University of Southern
California Medical Center, Los Angeles, California, U.S.A.
608
Trauma Management
and clotting factors do not function normally. Again, tests run at 37C maybe
misleading.
Prevention and Treatment
59
Emergency Department/Radiology Department

Maintain ambient temperature above 80F.
After removing trauma victims clothing to do complete examination, then
cover with blankets (preferably warm). Use reflective garments, particularly to
cover the scalp.
Warm all IV fluids (keep Ringers-Lactate stored in an incubator at 37C).
Institute these measures as soon as possible if a serious injury has occurred;
hypothermia is much easier to prevent than treat.
Operating Room
Continue measures mentioned above.
Cover appropriate parts of the body with a warm airflow blanket (e.g., Bair
HuggerTM).
Have heating blanket under the patient.
Lavage operative cavity with warm saline (40C, kept in incubator in O.R.
suite). Copious irrigation allowing contact to high blood flow viscera (i.e.,
bowel, liver, lungs). Apply directly to a cold asystolic heart.
Humidification and warming of inhaled anesthetic gas
Intensive Care Unit

Same as E.R./Radiology and O.R.
Active core rewarming should be considered for critical hypothermia
Most efficient method for trauma patients is extracorporeal arteriovenous or
venovenous rewarming, using the heat exchanger from the rapid blood infusion set
Hemodialysis utilizing a heat exchanger is equally efficacious
More rapid rewarming is possible with cardiopulmonary bypass, but requires
heparinization and cannulation is more difficult (operative)
Peritoneal dialysis and pleural irrigation are also used but much slower than
extracorporeal methods
Infusion of crystalloids (Ringers Lactate or Saline) at 40C. can be helpful as
patients are often hypovolemic
Value of Hypothermia
Because metabolic rates drop in hypothermic organs, its is postulated there may
be some benefit to individual organs such as the brain, heart, kidneys, etc. It is
difficult to utilize this potential benefit clinically without incurring the deleterious
effects previously discussed.
Potentially, total circulatory arrest could be employed along with profound
hypothermia to allow for the repair of otherwise lethal injuries in a bloodless
field. Although possible in laboratory animals, it will be difficult to translate to
the uncontrolled environment in which we encounter such seriously injured
trauma (e.g., battlefield patients). When repairing renal or hepatic vascular
injuries, surface cooling or even intra-arterial cooling (if organ preservation
solution is available) can be used to extend the safe ischemic period.
Mild hypothermia may be useful in the Intensive Care Unit management of
head injuries.
Hypothermia in Trauma Patients
609
References
1.
2.
3.
4.
5.
Gentilello LM, Cobean RA, Offner PJ et al. Continuous arteriorenous rewarming:

Reversal of hypothermia in critically ill patients. J Trauma 1992; 32:316-327.
Jurkovich, GJ Greiser, WB Luterman A et al. Hypothermia in trauma victims: An
ominous predict of survival. J Trauma 1987; 1019-1024.
Kim SH, Stezoski SW, Safar P et al. Hypothermia, but not 100% oxygen breathing, prolongs survival time during lethal uncontrolled hemorrhagic shock in rats. J
Trauma 1998; 44:485-491.
Valeri CR, Casiday G, Khuri S et al. Hypothermia-induced reversible platelet dysfunction. Ann Surg 1987; 205:175.
Peng RY, Bongard FS. Hypothermia in trauma patients. J Am Coll Surg 1999;
685-694.
59
CHAPTER 60
Trauma Scores
D. Bowley and Ken Boffard
Introduction
Estimates of the severity of injury or illness are fundamental to the practice of
medicine. The earliest known medical text, the Smith Papyrus, classified injuries
into three grades, treatable, contentious and untreatable.
The Glasgow Coma Scale (GCS), devised in 1974, was one of the first numerical scoring systems (Table 60.1). The GCS has been incorporated into many
later scoring systems, underscoring the importance of head injury as a triage and
prognostic indicator.
Modern trauma scoring methodology uses a combination of an assessment of
the severity of anatomical injury with a quantification of the degree of physiological derangement to arrive at scores that correlate with clinical outcomes.
Trauma scoring systems are designed to facilitate prehospital triage, identify
trauma patients suitable for quality assurance audit, allow accurate comparison
of different trauma populations and organize and improve trauma systems.
Physiological Scoring Systems

Introduced by Champion et al, the Revised Trauma score (RTS) evaluates
blood pressure, Glasgow Coma Scale and respiratory rate to provide a scored
physiological assessment of the patient.
The difference between RTS on arrival and best RTS after resuscitation will give
a reasonably clear picture of prognosis. By convention the RTS on admission is
the one documented.
The RTS (nontriage) is designed for retrospective outcome analysis. Weighted
coefficients are used, which are derived from trauma patient populations and
provide more accurate outcome prediction that raw RTS (Table 60.2). Since a
severe head injury carries a poorer prognosis than a severe respiratory injury,
the weighting is therefore heavier. The RTS therefore varies from 0 (worst) to
7.8408 (best). The RTS is the most widely used physiological scoring system
in the trauma literature.
The Pediatric Trauma Score (PTS) (Table 60.3) has been designed to facilitate
triage of children. The PTS is the sum of six scores, and values range from 6
to +12, with a PTS of <8 being recommended as a trigger to send to a trauma
center. The PTS has been shown to accurately predict risk for severe injury or
mortality, but is not significantly more accurate than the RTS and is a deal
more difficult to measure.

D. Bowley, Johannesburg Hospital, Johannesburg, South Africa
Ken Boffard, Johannesburg Hospital, Johannesburg, South Africa
611
Trauma Scores
TAble 60.1. The Glasgow coma scale

Parameter
Eye opening
Motor response
Verbal response
Response
Score
Nil
To pain
To speech
Spontaneously
1
2
3
4
Nil
Extensor
Flexor
Withdrawal
Localizing
Obeys command
1
2
3
4
5
6
Nil
Groans
Words
Confused
Orientated
1
2
3
4
5
Table 60.2. Revised trauma score (RTS). The values for the three parameters are
summed to give the raw RTS. Weighted values are summed for the RTS.
Clinical Parameter
Respiratory rate
(Breaths per minute)
Systolic blood
pressure
Glasgow Coma
Scale
Category
Score
x weight
10-29
> 29
5-9
1-4
0
4
3
2
1
0
0.2908
> 89
76-89
50-75
1-49
0
4
3
2
1
0
0.7326
13-15
9-12
6-8
4-5
3
4
3
2
1
0
0.9368
Anatomical Scoring Systems

The Abbreviated Injury Scale (AIS) was developed in 1971. The AIS grades
each injury by severity from 1 (least severe) to 5 (survival uncertain), within
six body regions (head/neck, face, chest, abdominal/pelvic contents, extremities and skin/general. The AIS has been periodically upgraded and AIS-90 is
currently being revised.
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Trauma Management
Table 60.3. Pediatric trauma score (PTS). The values for the six parameters are
summed to give the overall PTS.
Clinical Parameter
Category
Size (kg)
> 20
10-20
< 10
2
1
-1
Airway
Normal
Maintainable
Unmaintainable
2
1
-1
> 90
50-90
< 50
2
1
-1
Awake
Obtunded / LOC
Coma / decerebrate
2
1
-1
Open wound
None
Minor
Major/penetrating
2
1
-1
Skeletal
None
Closed fracture
Open/multiple fractures
2
1
-1
60
Systolic blood pressure

(mmHg)
Score
Table 60.4. ISS body regions

Number
Region
1
2
3
4
5
6
Head & Neck

Face
Thorax
Abdomen
Extremities
External
In 1974, Baker et al created the Injury Severity Score (ISS) to relate AIS scores
to patient outcomes. ISS body regions are listed in Table 60.4. The ISS is
calculated by summing the square of the highest AIS scores in the three most
severely injured regions. ISS scores range from 1-75 (since the highest AIS
score for any region is 5). By convention an AIS score of 6 for any region
(defined as a nonsurvivable injury) becomes an ISS of 75.
The ISS only considers the single, most serious injury in each region, ignoring
the contribution of injury to other organs within the same region. Diverse
injuries may have identical ISS but markedly different survival probabilities
(ISS of 25 may be obtained with isolated severe head injury or by a combination of lesser injuries across different regions). Also, ISS does not have the power
to discriminate between the impact of similarly scored injuries to different
Trauma Scores
613
organs and therefore cannot identify, for example, the different impact of
cerebral injury over injury to other organ systems. In response to these limitations, in 1997, the ISS was modified to become the New Injury Severity Score
(NISS) as the simple sum of the squares of the three highest AIS scores regardless of body region. NISS is able to predict survival outcomes better than ISS.
The Anatomic Profile (AP) was introduced in 1990 to overcome some of the
limitations of the ISS. AIS scoring is used, but four body regions were chosen
(head/brain/spinal cord, thorax/neck, all other serious injury and all nonserious
injury). The AP score is the square root of the sum of the squares of all the AIS
scores in a region, thus enabling the impact of multiple injuries within that
region to be recognized. Component values for the four regions are summed
to constitute the AP score. A modified Anatomic Profile (mAP) has recently
been introduced which is a four number characterization of injury, the four
component scores are the maximum AIS score and the square root of the sum
of the squares of all AIS values for serious injury (AIS 3) in specified body
regions (Table 60.5). This leads to Anatomic Profile Score, the weighted sum
of the four mAP components. The coefficients are derived from logistic
regression analysis of admissions to four Level 1 trauma centers (the controlled
sites) in the Major Trauma Outcome Study.
A limitation of the use of AIS-derived scores is their cost. International
Classification of Disease (ICD) taxonomy is a standard used by most hospitals
and other health care providers to classify clinical diagnoses. Computerized
mapping of ICD-9CM rubrics into AIS body regions and severity values has
been used to compute ISS, AP and NISS scores. Despite limitations, ICD-AIS
conversion has been useful in population-based evaluation when AIS scoring
from medical records is not possible.
Severity scoring systems have also been directly derived from ICD coded
discharge diagnoses. Most recently the ICD-9 Severity Score (ICISS) has been
proposed, which is derived by multiplying survival risk ratios associated with
individual ICD diagnoses. Neural networking has been employed to further
improve ICISS accuracy. ICISS has been shown to be better than ISS and to
outperform TRISS in identifying outcomes and resource utilization. However,
modified-AP scores, AP and NISS appear to outperform ICISS in predicting
hospital mortality.
There is some confusion as to which anatomic scoring system should be used.
However currently, NISS should probably be the system of choice for AIS-based
scoring.
Organ Injury Scaling (OIS) is a scale of anatomic injury within an organ
system or body structure. The goal of OIS is to provide a common language
between trauma surgeons and facilitate research and continuing quality
improvement. It is not designed to correlate with patient outcomes. The OIS
tables can be found on the American Association for the Surgery of Trauma
(AAST) web site. Additional information and guidance can be found at the
Eastern Association for the Surgery of Trauma website.
Moore and colleagues facilitated identification of the patient at high risk of
postoperative complications when they developed the Penetrating Abdominal
Trauma Index (PATI) scoring system. In a group of 114 patients with gunshot
wounds to the abdomen they showed that a PATI score > 25 dramatically
increased the risk of postoperative complications (46% of patients with a PATI
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Trauma Management
Table 60.5. Component definitions of the modified anatomic profile
60
Component
Body region
AIS severity
mA
Head/brain
3-6
Spinal cord
3-6
mB
Thorax
3-6
Front of neck
3-6
mC
All other
3-6
mA, mB, mC scores are derived by taking the square root of the sum of the squares
for all injuries defined by each component
score of > 25 developed serious postoperative complications compared to 7%

of patients with a PATI of < 25). Further studies have validated the PATI
scoring system.
Outcome Analysis Systems

For head-injured patients it was found that the level of coma on admission or
within 24 hours expressed by the Glasgow coma scale correlated with outcome.
The Glasgow outcome scale was an attempt to quantify outcome parameters
(Table 60.6) for head-injured patients. The grading of depth of coma and neurological signs was found to relate strongly to outcome, but the accuracy
of individual signs limits their use in predicting outcomes for individuals
(Table 60.7).
In 1982 the American College of Surgeons Committee on Trauma began the
ongoing Major Trauma Outcome Study (MTOS), a retrospective, multi-center
study of trauma epidemiology and outcomes.
MTOS uses Trauma Score and Injury Severity Score Analysis (TRISS)
methodology to estimate the probability of survival, or P(s), for a given trauma
patient. P(s) is derived according to the formula: P(s) = 1/(1 + e-b), where e is
a constant (approximately 2.718282) and b = b0 + b1(RTS) + b2(ISS) +b3(age
factor). The b coefficients are derived by regression analysis from the MTOS
database (Table 60.8).
The P(s) values range from zero (survival not expected) to 1.000 for a patient
with a 100% expectation of survival. Each patients values can be plotted on a
graph with ISS and RTS axes (Fig. 60.1) The sloping line represents patients
with a probability of survival of 50%, these PRE charts (from PREliminary)
are provided for those with blunt or penetrating injury and for those above or
below 55 years of age. Survivors whose coordinates are above the P(s)50
isobar and nonsurvivors below the P(s)50 isobar are considered atypical
(statistically unexpected) and such cases are suitable for focused audit.
In addition to analyzing individual patient outcomes, TRISS allows comparison
of a study population with the huge MTOS database. The Z-statistic identifies
if study group outcomes are significantly different from expected outcomes as
predicted from MTOS. Z is the ratio: (A-E)/S, where A = actual number of
survivors, E = expected number of survivors and S = scale factor that accounts
615
Trauma Scores
Table 60.6. Glasgow outcome scale

i.
ii.
iii.
iv.
v.
Death (D)
Persistent vegetative state (PVS)
Severe disability (SD)
Moderate disability (MD)
Good recovery (GR)
60
Table 60.7. Outcome related to signs in the first 24 hours of coma after injury.
Outcome scale as described by Glasgow group.
Dead or vegetative, %
Moderate disability
or good recovery, %
reacting
nonreacting
39
91
50
4
Eye movements
intact
absent / bad
33
90
56
5
Motor response
Normal
Abnormal
36
74
54
16
Pupils:
Fig. 60.1. PRE Chart. L = survivors, D = nonsurvivors.
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Trauma Management
Table 60.8. Coefficients from major trauma outcome study database.

Blunt
bo = -1.2470
b1 = 0.9544
b2 = -0.0768
b3 = -1.9052
Penetrating
-0.6029
1.1430
-0.1516
-2.6676
60
Table 60.9. Coefficients derived from MTOS data for the ASCOT probability of
survival, P(s).
Type of injury
k-Coefficients
Blunt
Penetrating
k1
-1.157
-1.135
k2 (RTS GCS value)
0.7705
1.0626
k3 (RTS SBP value)
0.6583
0.3638
k4 (RTS RR value)
0.281
0.3332
k5 (AP head region value)
-0.3002
-0.3702
k6 (AP thoracic region value)
-0.1961
-0.2053
k7 (AP other serious injury value)
-0.2086
-0.3188
k8 (age factor)
-0.6355
-0.8365
for statistical variation. Z may be positive or negative, depending on whether

the survival rate is greater or less than predicted by TRISS. Absolute values of
Z > 1.96 or < -0.96 are statistically significant (P < 0.05).
The so-called M-statistic is an injury severity match allowing comparison of
the range of injury severity in the sample population with that of the main
database (i.e., the baseline group). The closer M is to 1, the better the match,
the greater the disparity, the more biased Z will be. This bias can be misleading, for example, an institution with a large number of patients with lowseverity injuries can falsely appear to provide a better standard of care than
another institution that treats a higher number of more severely injured patients.
The W-statistic calculates the actual numbers of survivors greater (or fewer)
than predicted by MTOS, per 100 trauma patients treated. The Relative Outcome Score (ROS) can be used to compare W-values against a perfect outcome of 100% survival. The ROS may then be used to monitor improvements in trauma care delivery over time.
TRISS has been used in numerous studies. Its value as a predictor of survival/
death has been shown to be from 75-90% as good as a perfect index, depending on the patient data set used. However, TRISS methodology does have
major limitations, it is costly and labor intensive and also maybe inaccurate in
some subgroups of patients, especially in severe trauma.
A Severity Characterization of Trauma (ASCOT), introduced by Champion
Trauma Scores
617
et al in 1990, is a scoring system that uses the Anatomic Profile to characterize

injury in place of ISS. Different coefficients are used for blunt and penetrating injury and the ASCOT score is derived from the formula: P(s) = 1/(1 + e-k).
The ASCOT model coefficients are shown in figure 10. ASCOT has been
shown to outperform TRISS, particularly for penetrating injury.
Summary
Trauma scoring systems and allied methods of analyzing outcomes after trauma
are steadily evolving and have become increasingly sophisticated over recent years.
Trauma scoring systems are designed to facilitate prehospital triage, identify
trauma patients whose outcomes are statistically unexpected for quality assurance analysis, allow accurate comparison of different trauma populations and
organize and improve trauma systems. They are vital for the scientific study of
the epidemiology and the treatment of trauma and may even be used to define
resource allocation and reimbursement in the future.
Trauma scoring systems that measure outcome solely in terms of death or
survival are at best blunt instruments. Despite the existence of several scales
(Quality of Well-being Scale, Sickness Impact Profile etc.) further efforts are
needed to develop outcome measures that are able to evaluate the multiplicity
of outcomes across the full range of diverse trauma populations.
Despite the profusion of acronyms, scoring systems are a vital component of
trauma care-delivery systems. The effectiveness of well-organized, centralized,
multidisciplinary trauma centers in reducing the mortality and morbidity of
injured patients is well documented. Further improvement and expansion of
trauma care can only occur if developments are subjected to scientifically rigorous evaluation. Thus, trauma scoring systems play a central role in the provision of trauma care today and for the future.
References
1.
2.
3.
4.
5.
6.
7.
8.
American Association for the Surgery of Trauma web site. www.aast.org

Boyd CR, Tolson MA, Opes WS. Evaluating trauma care: The TRISS method. J
Trauma 1987; 27:370-377.
Champion HR, Sacco WJ, Copes WS et al. A revision of the trauma score. J Trauma
1989; 29(5):623-629.
Champion HR, Copes WS, Sacco WJ et al. Improved predictions from a severity
characterization of trauma (ASCOT) over Trauma and Injury Severity Score
(TRISS): Results of an independent evaluation. J Trauma 1996; 40(1):42-48.
Eastern Association for the Surgery of Trauma website. www.east.org
Moore EE, Dunn EL, Moore JB et al. Penetrating Abdominal Trauma Index. J
Trauma 1981; 21(5):439-444.
Osler T, Baker SP, Long W. A modification of the Injury Severity Score that both
improves accuracy and simplifies scoring. J Trauma 1997; 43(6):922-926.
Tepas JJ 3rd, Ramenofsky ML, Mollitt DL et al. The Pediatric Trauma Score as a
predictor of injury severity: an objective assessment. J Trauma 1988; 28(4):425-429.
60
CHAPTER 61
Crush Syndrome
Gail T. Tominaga
Crush Injuries
Mechanism
Crush injuries are caused by continuous prolonged pressure on the body.
The major factor in producing crush injury is the length of time the pressure
is applied. The shortest duration reported in the literature is one hour.
Patients who survive to reach medical attention have crush injuries to the
extremities and not the torso. The prolonged pressure required to cause this
syndrome usually causes immediate death if applied to the torso.
Crush injuries occur in disaster situations, such as earthquakes, bombings,
train accidents and mine accidents. Prolonged extrication of victims is the
rule rather than the exception.
Following extrication, the patient usually suffers no pain and has no physical
complaints. Main complaints are emotional.
Immediately following extrication, a severe neurologic deficiency, mainly flaccid
paralysis of the injured limb, may be present. Sensory loss to pain and touch is
seen in a patchy pattern.
Limb edema is initially not present. Gross edema takes time to develop and
can progress to marked edema.
Distal pulses are present even in the presence of gross edema. Investigation for
additional injuries is warranted if pulses are not demonstrated.
After extrication, the patient becomes severely hypovolemic, which may develop into severe hypovolemic shock and death.
The skin and subcutaneous layers are not injured, but the underlying muscles
are severely damaged. The involved muscles bleed profusely when cut which
may be misleading.
Associated injuries may be present due to the mechanism of injury, i.e., entire
body trapped under a collapsed building.
Pathophysiology
Continuous pressure causes muscle damage resulting in loss of the muscle
cells ability to control fluids. This causes an influx of fluid into the muscles
resulting in edema and elevation in compartment pressure.

Gail T. Tominaga, John A. Burns School of Medicine, The Queens Medical Center,
Honolulu, Hawaii, U.S.A
Crush Syndrome
619
Differential Diagnosis
Crush injury is differentiated from arterial occlusion by the lack of damage to
the skin and the presence of pulses.
Direct pressure injuries (i.e., being run-over by a tire of an automobile) can be
differentiated by the presence of skin and subcutaneous tissue injury with
undamaged muscle.
Elevation of pressure in compartment syndrome causes occlusion of venous
drainage from the compartments, which further elevates the pressure eventually causing muscle injury. In crush injuries, the muscle injury causes edema,
which then leads to elevation of compartment pressures.
The flaccid paralysis from crush injury is not related to the distribution of
nerves in the affected limb. Their symptoms may mimic spinal cord injury.
Normal anal sphincter tone may help exclude the presence of an acute spinal
cord injury.
Treatment
Treatment is aimed at prevention of the crush syndrome.
Treatment of closed crush injuries is conservative. They should not be routinely explored since the intact skin acts as a barrier against infection.
The use of fasciotomies is controversial. Routine use should not be advocated.
Fasciotomies will not reverse muscle necrosis in the absence of compartment
syndrome.
If compartment pressures are elevated (greater than 40 mm Hg), fasciotomies
should be performed. At the time of fasciotomy, extensive resection of all dead
muscle should be performed at the first operation. Dead muscle can not be
identified by lack of bleeding. Identification of dead muscle is by its reaction
to direct physical or electrical stimulation.
Open crush injuries have a greater potential for bacterial contamination and
should be widely debrided.
Outcome
There is little data on functional outcome of limbs suffering from crush injury.
Both open and closed crush injuries have a risk of developing local myonecrosis
and compartment syndrome.
Following the acute phase, there is a recuperation of the sensory loss accompanied by a transient period of paresthesia with severe pain. Sensation can
recover but may take up to one year.
Infection and recurrent bleeding often complicate fasciotomies. Outcome may
be better in limbs not treated by fasciotomy.
Crush Syndrome
Crush syndrome refers to the systemic manifestations of muscle necrosis including myoglobinuric renal failure, shock, and the cardiac sequelae of acidosis and
hyperkalemia. It is also referred to as traumatic Rhabdomyolysis. It is a life and
limb threatening condition.
Crush Syndrome was first applied to the ischemia-induced syndrome of
myonecrosis, myoglobinuria, and renal failure seen during the London Blitz
in World War II.
61
620
Trauma Management
The severity of the clinical manifestations is proportional to the amount of
injured muscle.
There is frequently a delay in diagnosis following admission. This results from:
- failure to suspect the diagnosis
- preoccupation with other overwhelming injuries or medical problems
- presence of a comatose patient or a patient with altered sensorium who cannot
complain of pain or who has an unreliable examination
61
Extrication of survivors and decompression of injured limbs may paradoxically accelerate the development of shock and hemoconcentration.
Crush syndrome manifests with the systemic signs and symptoms resulting
from the products of devitalized tissue entering the circulation. These include:
- Hyperkalemia, which may occur within the first hour and can increase to dangerous levels leading to arrhythmias and death.
- Dangerous degrees of hyperphosphatemia, hypocalcemia, hyperuricemia, and
metabolic acidosis which may present just hours after extrication.
- Hemoconcentration and thrombocytopenia, which may suggest the onset of
diffuse intravascular coagulation.
The first urine specimen may appear dark due to myoglobin in the urine. This
can be mistaken for hematuria.
Pathophysiology
The membranes of the injured muscles lose their integrity and become permeable. Water enters the cell freely resulting in severe muscle edema. Massive
uptake of extracellular fluid (ECF) by the swelling of crushed muscle can
occur. Within hours, the entire 14L of ECF can be sequestered in the crushed
injured muscles resulting in hypovolemic shock and death.
Penetration of calcium into the muscle after crush injury activates autolytic
enzymes and interferes with mitochondrial integrity leading to muscle cell
anoxia and acidosis.
Efflux of potassium into the extracellular fluid can cause cardiac arrest within
2 hours of extrication.
Myoglobin, phosphate, creatine phosphokinase, and purines efflux from the
damaged muscle cell into the ECF.
The synergistic combination of hyperkalemia and hypocalcemia cause cardiovascular suppression, which sensitizes the kidney to the nephrotoxic metabolites
leaking from the crushed muscle. Myoglobin also chelates renal vasodilatory
nitric oxide which intensifies renal vasoconstriction contributing to acute renal
failure.
There is increased production of muscular nitric oxide accompanied by
muscular vasodilation and hyperperfusion of the injured limb leading to
aggravation of hemodynamic shock.
Diagnosis/Clinical Investigations
The diagnosis should be suspected in any patient with a history of prolonged
immobilization and blunt trauma/crush.
Hyperkalemia, hypocalcemia, hyperphosphotemia, and metabolic acidosis
appear before azotemia and within hours of extrication.
Crush Syndrome
621
Myoglobinemia, elevated creatine phosphokinase and urine microscopy demonstrate heme pigment without red blood cells in the urine sediment when
Rhabdomyolysis is present. Hemoglobinuria may or may not be present.
The diagnosis should be suspected in any patient requiring massive fluid
resuscitation following soft tissue trauma.
Immediate medical management should be directed at the hypovolemic shock.
Intravascular fluid volume should be rapidly replaced with crystalloid and
should begin as soon as one of the trapped limbs is freed during extrication.
Once the patient is fully extricated, blood pressure and urine output should
be closely monitored.
Management and Treatment

Early, aggressive fluid resuscitation with isotonic saline is imperative. Whole
blood should not be used since these patients are already hemoconcentrated.
Maintenance of a high urine output, of at least 100-200 mL/hr, will help prevent
renal failure.
Massive fluid resuscitation (10-20 L/day) is often required.
After adequate volume replacement and documentation of urine flow, mannitol
alkaline diuresis should be instituted.
Mannitol should not be given to anuric patients. Once urine flow is documented,
mannitol diuresis should be instituted. A 20% solution of mannitol at a rate
of 1-2 g/kg body weight should be administered over 4 hours. Mannitol doses
should be titrated to urine output but doses above 200 g/day should be avoided.
Intravenous mannitol doses greater than 200 g/day can cause acute renal failure
that is reversible by hemodialysis. The urine should be tested frequently for
the presence of myoglobin.
Maintaining an alkaline urine (pH > 6.5) by infusing sodium bicarbonate IV
(1-2 mEq/kg/hr) to increase the urine solubility of myoglobin and hemoglobin may reduce the likelihood of precipitation and occlusion of renal tubules
by these pigments. Myoglobin is not a direct toxin. In the presence of aciduria,
myoglobin is converted to ferrihemate which is toxic to renal cells.
If bicarbonate administration produces metabolic alkalosis (pH > 7.45),
acetazolamide (500 mg IV) should be administered until urinary myoglobin disappears. Acetazolamide will correct metabolic alkalosis and increase
urinary pH.
Massive volume replacement and mannitol diuresis may not be tolerated well
by geriatric patients or patients with limited cardiac function. Closer hemodynamic monitoring with a pulmonary artery catheter, gentler resuscitation,
and diuresis with furosemide may be needed.
Electrolyte abnormalities should be corrected except for hypocalcemia.
Supplemental calcium should not be administered unless there is a danger of
hyperkalemic arrhythmia.
Complications
If intravenous volume replacement is inadequate or is delayed for more than
six hours, acute renal failure will develop.
61
622
Trauma Management
Outcome
61
There is high mortality in patients with crush syndrome who are not adequately
fluid resuscitated.
Deaths within the first hours of injury are due to shock and hyperkalemia.
Late deaths (7-12 days) are caused by myoglobinuric acute renal failure or
multiple organ failure.
Patients who survive the crush syndrome and acute renal failure usually recover completely.
Patients with associated truncal injuries (i.e., abdominal injuries) have a higher
mortality rate when compared to those without truncal involvement.

In crush injuries, the lack of complaints by the conscious patient may be
misleading. In the comatose patient, the presence of other injuries and lack of
adequate history may delay diagnosis of crush injuries. There must be a high
index of suspicion for early diagnosis and treatment.
Nonviable tissue may be present below deceptively normal appearing skin
and dermis and must be debrided prior to closure of any open crush injury.
Patients sustaining crush injuries can be deceptively stable only to deteriorate
within hours of extrication.
Inadequate debridement of open wounds can occur since the injured muscle
in crush injuries bleeds when cut. The muscle must be stimulated electrically
or manually to determine viability.
The amount of crystalloid fluid resuscitation is often underestimated due to
the underestimation of underlying muscle damage.
References
1.
2.
3.
4.
5.
Oda J, Tanaka H, Yoshioka T et al. Analysis of 372 patients with Crush syndrome
caused by the Hanshin-Awaji earthquake. J Trauma 1997; 42(3):470-476.
Better OS. Rescue and salvage of casualties suffering from the crush syndrome
after mass disasters. Military Medicine 1999; 164:366-369.
Reis ND, Michaelson M. Crush injury to lower limb: treatment of the local injury.
J Bone Joint Surg Am 1986; 68A:414-416.
Abassi ZA, Hoffman A, Better OS. Acute renal failure complicating muscle crush
injury. Seminars in Nephrology 1998; 18(5):558-565.
Rubenstein I, Abassi Z, Milman F. Involvement of nitric oxide system in experimental muscle crush injury. J Clin Invest 1998; 101:1325-1333.
CHAPTER 1
CHAPTER 62
Anesthesia of the Traumatized Patient

Michael J Sullivan and Earl Moore-Jefferies
Introduction
Death of patients secondary to trauma occurs in a tri-modal distribution. The
first peak of mortality starts from the time of injury up to one hour after the
injury. More than fifty percent of trauma deaths occur in this phase. Even
with the provision of immediate medical care, death occurs. The injury
sustained is so severe that internal compensatory mechanisms coupled with
medical intervention are overwhelmed.
The second peak occurs from one hour up to four hours after injury.
Physiologic reserve and medical intervention sustain life until compensatory
mechanisms are exhausted and mortality ensues.
The third peak of mortality is seen one to five weeks after initial insult. A
secondary insult occurs such as sepsis or organ dysfunction becomes organ
failure.
This chapter presents a framework for the anesthetic management of traumatized patients. Aggressive and appropriate anesthetic care can reduce the
incidence of intraoperative mortality and postoperative complications.
Airway
Airway management in the trauma patient is always first! Provide supplemental
oxygen while assessing the patient. Surgical establishment of the airway is an
option that should be entertained early. It is best not to wait until every method
of tracheal intubation is tried and unsuccessful before surgical intervention is
considered.
Assessment of the airway is done prior to direct laryngoscopy in the hope that
a preintubation exam will prognosticate the ease or difficulty in viewing the
glottis during direct laryngoscopy. As the view of the glottis is the central
point of airway management, the Cormack-Lehane scoring system grades the
view of the glottis during laryngoscopy from one to four. A grade 1 score
represents full visualization of the glottis, grade 2 is a partial view, grade 3 is
epiglottis only, and grade 4 indicates that no laryngeal structures are seen.
A short neck is associated with difficulty in visualizing the glottis. A receding
mandible, defined as the inability to place three fingerbreadths between the
mandibular symphysis and the hyoid bone, limits the space available to displace
the tongue. Prominent upper incisors and/or a small mouth limit the viewing
size available when a laryngoscope and endotracheal tube are placed in the
oropharynx. Limited jaw opening can prevent placement of the laryngoscope
in the mouth. Limited range of motion of the cervical vertebra prevents alignment of the neck to facilitate viewing the glottis.
Michael J. Sullivan, LAC + USC Keck School of Medicine, Los Angeles, California, U.S.A.
Earl Moore-Jefferies, LAC + USC Keck School of Medicine, Los Angeles, California, U.S.A.
624
Trauma Management
Traumatic facial and laryngeal injury can add to the aforementioned problems.
Any disease process that manifests as swelling or edema of the lips, tongue,
pharyngeal tissues and epiglottis may create a difficult airway. Failed intubation
attempts traumatize the oropharyngeal tissue, increasing secretions, and produce swelling. Fractures of the mandible usually do not increase the difficulty
for intubation. The mandible can be displaced to facilitate viewing of the
glottis. Any displacement of the jaw should be accomplished after induction
of anesthesia, as it is painful.
The Pediatric Airway

There are several differences in head and neck anatomy that make visualization
of the glottis technically more difficult.
62
- A small child may have a prominent occiput bringing the mouth to a position
too far anterior to the larynx. A shoulder roll compensates for the increased
occiput size of the pediatric head. Readily available materials may be used: a
towel, hospital gown or intravenous fluid bag.
- The infant has a relatively large tongue in relationship to the size of the
oropharynx. This increases the risk of a lax tongue causing obstruction and
thereby requires more technical expertise.
- The larynx is higher in the neck creating a more acute angle between the
oropharynx and the larynx. To compensate for this anatomical difference, straight
blades are more useful than the curved blades. Gentle external pressure on the
thyroid cartilage displaces the larynx posterior aiding in visualization.
- The epiglottis is short, stubby, and soft, obstructing the view of the vocal cords.
The narrowest part of the infant larynx is below the level of the vocal cords. The
endotracheal tube may pass through the vocal cords only to meet resistance. If
this occurs, change the tube size to one size smaller.
- Uncuffed endotracheal tubes are preferred for children less than 10 years of age.
A leak should be present around the tube at peak airway pressures greater than
20 mmHg.
Many aids are available for definitive airway management: estimation of the
infants weight; calculation of medication of doses; endotracheal tube size;
and the distance the tube should be inserted. The following are guidelines.
- The weight can be estimated for a child from one to ten years old by: [Patients
age x 2] + 9 = weight in kilograms. Using this formula the weight is estimated to
be 11 kilograms. A one year old generally weighs about 10 kilograms.
- Endotracheal tube size is calculated by [age + 16] / 4 = endotracheal tube size.
Endotracheal tube sizes that are one size larger (5.5) and one size smaller (4.5)
have to be immediately available. The distance of endotracheal tube insertion is
roughly three times the tube size; a size 5.0 endotracheal tube would be inserted
to a distance of 15 mm measured from the lips.
Basic Airway Management

Initial interventions include basic airway maneuvers. A variety of objects can
mechanically cause partial or complete airway obstruction; the tongue, vomitus,
blood, dentures, swollen or distorted tissues, and foreign bodies are common
causes. Clearing of these objects with suction re-establishes the airway.
Positioning of a patient on their side facilitates external drainage of secretions,
vomitus, or blood instead of pooling in the oropharynx in a supine patient.
625
Reflex clenching of the jaw and cervical spine precautions may hinder the
ability to place the patient on his side and clear the airway.
Available and working suction is absolutely essential. Several types of suction
catheters are available. Suctioning techniques are to remove any foreign objects
in the oropharynx while minimizing the trauma to the delicate tissues of the
oropharynx.
Lax pharyngeal musculature and tongue occlusion can be managed with one
of three maneuvers. For all techniques the patient is assumed to be in the
supine position.
- The first is the neck lift-head tilt. Suspected cervical spine injury is a contraindication to this technique. One hand is placed on the back of the neck and the
other is placed on the forehead, an upward movement of the hand on the neck
with a downward motion of the hand on the forehead opens the mouth and
relieves the airway obstruction.
- The chin lift maneuver can be used with possible cervical spine injury. The
thumb is placed just below the border of the lower lip and several fingers of the
same hand are placed on the volar surface beneath the patients chin. As the
mandible is gently lifted by the fingers, the mouth is opened by downward
traction on the lower lip.
- In the jaw thrust maneuver, usually the index and middle finger are placed on
the section of the mandible that is superior to the angle of the mandible and
inferior to the ear. Forward displacement of the mandible is done and opening
the mouth is achieved with downward displacement of the lower lip by the
thumbs (Table 62.1).
- Bag-mask assisted ventilation or complete bag-mask ventilation can be used in
conjunction with the chin lift or jaw thrust maneuver. A tight mask seal can be
accomplished with minimal pressure.
Two adjunctive artificial airways that improve assisted ventilation are the
oropharyngeal and nasal pharyngeal airway devises.
The oropharygeal airway is shaped like a question mark. ? The nasal pharyngeal airway is a soft tube that is flared at one end. The nonflared end is
inserted into the nare and the entire length of the tube is advanced until the
flared end rests at the nasal opening. Surgical gel lubrication facilitates this
placement. The tube should always be inserted so the direction of advancement is parallel to the hard and soft palate. Occasionally resistance is met
when about one-third of the tube has been inserted. Maintain constant
forward pressure but do not force the tube past the obstruction, after several
seconds the tube will then advance into the proper position.
Intubation Techniques
Direct Laryngoscopy
Two basic blades are used, the curved Macintosh blade or the straight Miller
blade. They come in sizes one through four, the larger the numerical designation, the larger the blade. Usually size three or four blades are used for
adult patients.
Endotracheal tube size is also given a numerical description, ranging from size
3-8 in half size increments, the number is the internal diameter in millimeters
of the tube The larger the tube number the larger the tube size. Averaged sized
62
626
Trauma Management
Table 62.1. Basic airway management

Suction the oropharynx of secretions
Give supplemental oxygen
Relieve pharyngeal tissue obstruction
Neck lift-head tilt-contraindicated in suspected cervical injury
Chin lift
Jaw thrust
Placement of oral airway or nasal trumpet
Bag mask assisted ventilation
62
adult women need a 7.0-7.5 mm tube and averaged sized adult males need a
7.5-8.0 mm sized tube.
Proper positioning is having the bed at a good height and the patient in the
sniff position, neck flexion and head extension (provided there is no
suspicion of C-spine trauma). The following steps are for the novice
laryngoscopist and can be modified or deleted as proficiency improves. The
clinical scenario is of an ideal patient for intubation.
- An induction agent is given and the laryngoscopist is standing at the head of the
bed. The patient enters the anesthetized state and becomes apneic.
- Bag-mask ventilation with chin lift now easily supports ventilation.
- The muscle relaxant is given and after the appropriate time interval, the patients
muscles are lax.
- The following is for the Macintosh blade: Step one is opening the mouth as
wide as possible using the finger and thumb of the right hand pushing on the
premolars. Second, position the tip of laryngoscope blade at the tip of the tongue.
Insert the blade in the right side of the mouth sliding the blade over the right
side of the tongue. As the blade pushes the tongue to the left and out of the field
of vision, rotate the handle so that it points to the umbilicus instead of the
nipple. Continue to insert the blade until the handle gently touches the lower
lip. The blade will come to rest in the proper position in the vallecula anterior to
the epiglottis. The handle should now be parallel to the floor, pointing to the
patients umbilicus and inserted into the mouth the length of the blade. The
right hand can be removed from the teeth. Keeping the handle parallel to the
floor and midline, dislocate the jaw by pushing the handle away from oneself
and shortening the distance between the end of the handle and the umbilicus
The next motion is to lift the handle up while keeping it parallel to the floor. If
visualization of the vocal cords is still not optimal continue to lift the laryngoscope in the vertical direction. The head may be lifted up off the occipital
towels. The head will not slip and fall off of the blade and the vocal cords will
come into view. The endotracheal tube can now be placed in the trachea.
Rapid Sequence Induction

This is a specific technique combining pharmacologic agents and direct
laryngoscopy in the trauma patient to prevent aspiration of gastric contents.
Trauma patients are considered to have full stomachs.
- Preoxygenation is essential. It increases the time a patient can tolerate apnea
while the laryngoscopist attempts to secure the airway. Causes of failure to
preoxygenate are insufficient time of preoxygenation and failure to breath 100%
627
oxygen through a sealed system. Several methods of preoxygenation are

advocated. The traditional method is 100% oxygenation over 3-5 minutes. If
shortening the time for preoxygenation is required to prevent further morbidity,
four deep breaths over 30 seconds is the standard method. Patients have been
shown to desaturate faster with this method. An eight deep breath in 60 seconds
technique may be superior to the 4 breaths or 3-5 minute method.
- Cricoid pressure is applied as an induction agent is given. The cricoid cartilage
is a circular and rigid ring. An assistant exerts pressure on the cricoid cartilage
causing it to occlude the esophagus. Cricoid pressure is maintained until the
cuff of the endotracheal tube is inflated and the endotracheal tube is verified to
be in the trachea. The lungs may be ventilated with cricoid pressure applied if
the need arises. Occlusion of the esophagus with cricoid pressure occurs even
with the presence of a nasogastric tube (Table 62.2).
Induction with an intravenous agent is given according to the patients cardiovascular status. In a hypotensive patient, sodium thiopental and propofol
can be safely used, although etomidate or ketamine may support blood pressure better. Succinycholine, a rapid acting muscle relaxant, is immediately
given after an induction agent. Give the full dose of muscle relaxant. If
succinycholine is contraindicated, a high dose of a short acting nondepolarizing
neuromuscular blocking drug can be used. Once the patient is induced,
placement of an endotracheal tube is performed (Table 62.3).
The Laryngeal Mask Airway

The Laryngeal Mask Airway (LMA) is an airway management device intended
as an alternative to face mask use. It is inserted without instrumenting the
oropharynx, nor with the requirement of visualizing the vocal cords. It can
provide a clear airway and be inserted with minimal stimulation if the
pharyngeal reflexes are sufficiently depressed.
The person performing the LMA insertion is positioned at the head of the
patient. The patients head is positioned with the neck flexed and the head
extended. Anesthetic induction is performed to blunt protective airway reflexes.
A black line runs the length of the airway tube along the greater curve portion
for orientation. This black line is orientated toward the upper lip. Place the
tip of the mask against the hard palate.
Advance the LMA along the hard palate toward the soft palate directing the
force of the index finger into the hard palate and the movement of the hand
into the mouth. Continue to advance the LMA until resistance is felt. Using
the other hand grasp the proximal end of the breathing tube section to stabilize
the LMA and remove the insertion hand out to the patients mouth. This will
prevent displacement of the LMA. Inflate the cuff with just enough pressure
to obtain a seal. The LMA may appear to back out of the patients mouth with
cuff inflation; this is the tube settling into position in the hypopharynx.
Operating Room Preparation

Preoperative preparation of the operating room is essential. Presetting
the ventilator for a standard 70 kg patient, a tidal volume 700 ccs at a rate 10
breaths per minute, with an I:E ratio of 1:2 will temporarily ventilate a small
female to a large male safely.
Many acutely injured patients are hypovolemic. Equipment and supplies to
rapidly place large bore peripheral intravenous lines, (14 gauge or 16 gauge
62
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Trauma Management
Table 62.2. Rapid sequence induction

Preparation
Operating room prepared:
Airway equipment prepared:
62
Monitors:
Assistant:
Position:
Procedure
Preoxygenation:
Medications for induction, paralysis,

sedation, analgesia
Resuscitation fluids available with
infusion devices
Ventilation machine/anesthetic machine
checked
Suction
Bag mask ventilation
Oropharyngeal/nasopharyngeal airways
Laryngoscope handle and blades
Endotracheal tubes
Electrocardiographic
Pulse oximetry
Automatic noninvasive blood pressure
cuff
Dedicated person to assist laryngoscopist
during tracheal intubation
Patient positioned with neck flexed and
head extented
Four deep breaths over 30 seconds, eight
deep breaths over 60 seconds, or three
to five minutes of normal respirations, all
at an FiO2 of 1.0 ( 100% oxygen )
Applied by assistant at induction of
anesthesia
Intravenous medication to anesthetize
the patient
Facilitate endotracheal intubtion
Cricoid pressure:
Induction:
Muscle paralysis:
Table 62.3. Induction medications

Drug
Intravenous Dose
mg/kg
Onset
min
Clinical
Action (min)
Thiopental
Etomidate
Ketamine
Propofol
Muscle Relaxants
Depolarizing
Succinycholine
Nondepolarizing
Rocuronium
Atracurium
Vecuronium
Mivacurium
3-5 mg/kg
0.3-0.4 mg/kg
1-2 mg/kg
2 mg/kg
<1
<1
<1
<1
5-10
3-5
5-20
8
1-2 mg/kg
<1
2-5
0.6-1mg/kg
0.5 mg/kg
0.08-1.0mg/kg
0.2
1-3
2-3
2-3
1-2
10-30
20-40
30-40
15-20
629
angiocatheter) and central lines are mandatory. Have rapid fluid warmers to
attach to these catheters. After successful venous cannulation comes arterial
catheterization. Arterial catheters, pressure tubing and pressure transducers
should be ready. A second pressure transducer for central venous pressure
monitoring is recommended. If technical ability allows, time permits, and it is
clinically indicated, a pulmonary artery catheter is valuable. Understand that
a Swan Ganz catheter is not a therapeutic measure and that the optimal use of
a pulmonary artery catheter is before organ failure begins.
Warm the operating room and/or the patient. Hypothermia increases the risk
of infection, bleeding complications, cardiac dysfunction, adverse therapeutic
drug effects, increases protein catabolism, increases postoperative recovery time,
and increases mortality. Mortality in trauma is related to temperature. Up to
100% mortality is seen with core body temperature less than 32Celsius. Alert
the blood bank if they are not automatically notified that blood products may
be necessary.
Intraoperative Monitoring
Clinical, monitored, and laboratory variables are useful markers of the success
of resuscitation of the traumatized patient. Vital signs by paramedics at the
scene of injury or vital signs recorded in the emergency department are a
starting point.
In the operating room, noninvasive monitors are rapidly applied: electrocardiographic leads are placed, pulse oximetry, a blood pressure cuff, and a skin
temperature probe.
Foley catheterization of the bladder will allow quantification of urine output.
Cannulation of an artery will provide instantaneous awareness of blood pressure along with the ability to sample blood for arterial blood gases.
Central venous catheters provide the ability to measure central venous pressure,
place a pulmonary artery catheter, and administer resuscitative fluids. No
anatomical disruption should be present between the access site and the right
atrium or the fluids will leak out the injury site and not perfuse the vasculature.
This may occur with abdominal injury and femoral vein access.
Other monitors are an esophageal temperature probe, which is also an
esophageal stethoscope, a naso- or orogastric tube, and a precordial stethoscope.
Markers of Resuscition
Vital Signs
Altered vital signs are nonspecific but sensitive for shock. Pain, anxiety, temperature, therapeutic medications, and illicit drugs can influence them. Some
patients have physiologic reserves that allow them to maintain vital signs in
the normal range until terminal cardiovascular collapse. Vital signs still are
the most commonly used parameters in assessing adequacy of resuscitation.
In certain patients the normalization of vital signs is all that is needed. A
decrease in heart rate, an increase in blood pressure, a decrease in the FiO2
needed to maintain an adequate PaO2 , an increase in urinary output, and
longer time intervals between therapeutic interventions signals a movement
toward normal homeostasis. Clinically this can be described as pulse less
than 100 bpm, pulse pressure greater than 30 mmHg, urine output greater
than 0.5-1.0 ml/kg, absence of metabolic acidosis, and minimal effects of
positive pressure ventilation.
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Trauma Management
Base Deficit
Easily calculated from arterial blood gas analysis, base deficit is the sum of all
metabolic acids including lactate caused by hypoperfusion and ischemia. Base
deficit can be an accurate predictor of mortality in multiple trauma patients.
The magnitude of the initial base deficit has been a reliable early indicator of
the severity of the volume deficit. The amount of fluid required for resuscitation
was greater in patients with the more severe base deficit than in patients with
a less severe base deficit. Base deficit is easy to use and obtain from a arterial
blood gas. Its limitations are that the use of bicarbonate during resuscitation and
any pre-existing medical conditions that result in chronic elevations or reductions in bicarbonate levels falsely skew the results.
62
Arterial Blood Gas

Arterial blood gas analysis reveals information on the global acid base status,
efficiency of oxygenation and ventilation, and hemoglobin and hematocrit.
Normalization of each of these parameters suggests that resuscitation is reversing
the shock state. A decreasing pH in the trauma patient is generally due to
metabolic acidosis secondary to hypoperfusion or a respiratory acidosis
secondary to underventilation. Fluid replacement and increasing the minute
respiration will correct this. Improvement of oxygenation is manifested by an
adequate pa02 with a decreasing FiO2 level.
Serum Lactate
Lactate levels are a marker for anaerobic metabolism. The amount of lactate
produced is believed to correlate with the total oxygen debt, the magnitude of
hypoperfusion, and the severity of shock. High serum lactate levels have been
associated with high mortality among critically ill patients. However lactate as
a marker has its limitations. Some patients experience a resolution of their
lactic acidosis but it is not always accompanied by improvement in systolic
blood pressure or survival. Lactate is cleared by the liver, therefore liver injury
or hepatic disease can decrease lactate clearance leading to high levels not
associated with ongoing tissue hypoxia. Tissues that are not perfused during true
ischemia do not contribute to lactate levels that are measured in the laboratory.
Lactate offers no information on regional distribution of tissue hypoxia and
blood flow.
Oxygen Transport Parameters

The critical molecule that is transported by the cardiovascular system is oxygen.
It has been found that the total oxygen debt and the rate of accumulation of
the debt are both critical determinants of survival. Arterial-venous oxygen
content difference along with cardiac output can be measured with a pulmonary
artery catheter and an arterial line.
Gastrointestinal Tonometry
Stomach mucosa is used to assess tissue perfusion. A tonometer is a nasogastric
tube that has a fluid filled balloon distally. It measures the partial pressure of
carbon dioxide in the gastrointestinal mucosa by allowing the equilibration
of the partial pressure of carbon dioxide in the fluid filled balloon with
that of gastric mucosa. Assuming that excess production of CO2 occurs during
hypoxia, an increasing value of CO2 should reflect tissue hypoperfusion. Because
631
the gut is highly susceptible to hypoperfusion, changes in pH may be an early

indicator of concurrent global hypoperfusion and impending shock.
Choice of Marker
All of the clinical and laboratory markers of hypovolemic shock and adequacy
of resuscitation have utility and limitations as tools to help us manage and
treat patients. In the very dynamic situation of resuscitating a patient, no one
marker can achieve the goal of telling us our patients are in this much shock
and needs this much resuscitation in this much time or these organs are going
to die and take the entire organism with it. The best we can do is use a
combination of markers and look for patterns that support our observations
that the patient is getting better or is not getting better.
Resuscitation
Fluid Therapy
There is much passion involved in any discussion about appropriate fluid
replacement. Successful resuscitations have been accomplished with every
intravenous fluid available. Ultimately it is up to the clinician to decide the
most advantageous use of each fluid.
Crystalloid solutions are water with cations and anions, with or without glucose,
in various concentrations and osmolarities to mimic the water and salt milieu of
the human body. They are the least expensive of the various solutions, are not
allergenic, immunogenic, or toxic. They equilibrate across all solute compartments quickly and have an intravascular half-life of about 15 minutes. Three
times the amount of crystalloid is given for the amount of blood lost. These are
usually the first fluids administered for resuscitation in acute hypovolemia shock.
They rapidly restore volume, urinary output, and keep blood viscosity low.
Colloids that are used in clinical practice contain a large macromolecular moiety
in iso-osmotic saline. The common moieties are; albumin, polypeptide gelatin,
dextran, or hydroxyethylstarch. The colloid moiety had a higher water binding
capacity than does the Na cation in crystalloid solutions and can retain a large
fraction of infused fluid in the vascular space. The increase in the plasma volume
persists for longer periods with the infusion of colloids. The blood loss volume is
replaced in a one to one ratio with colloid solutions. They can have allergenic,
coagulopathic or immunogenic reactions. The synthetic colloids and processed
albumin and protein fractions have minimal if any risk of infection.
Volume loss can be corrected with either crystalloid or colloids. Only blood
and blood products can correct defects in either oxygen carrying capacity or
coagulation. Current practice is a one-to-one ratio of replacement for each
volume of blood lost. The benefit of transfusion is the restoration of
intravascular volume and oxygen carrying capacity. The risks of transfusion
ranges from an allergic reaction to a fatal hemolytic transfusion reaction.
Infectious risks range from hepatitis B to HTLV I and II (Table 62.4).
Massive Transfusion
- Complications unique to massive transfusions are coagulopathy, hypothermia
and metabolic derangements. Massive transfusion is the replacement of more
than one blood volume within several hours.
- Coagulopathy can occur when replacement fluids (crystalloids, colloids or
PRBCs) dilute platelets or protein factors below a level at which they can
62
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Trauma Management
Table 62.4. Risks per unit of blood that are negative in laboratory testing
Minor allergic reactions
Bacterial infection ( platelets)
Viral hepatitis
Hemolytic transfusion reaction
HTLV I/II infection
HIV infection
Acute lung injury
Anaphylactic shock
Fatal hemolytic reaction
Graft vs host disease
Immunosupression
62
1:100
1:2,500
1:5,000
1:6,000
1:200,000
1:420,000
1:500,000
1:500,000
1:600,000
rare
unknown
HTLV = human T-cell leukemia-lymphoma virus; HIV = human immunodeficiency

virus source: Klein H. G. Allogeneic transfusion risks in the surgical patient. Am J
Surg. 170(suppl 6A):21-26, 1995
function. Clinically this is recognized by microvascular bleeding, oozing, or no

clot formation at wound, surgical or invasive catheter puncture sites. There is
no single laboratory coagulation test that will give complete information on
homeostatic function during massive transfusion. PT, PTT and thrombin time
have not reliably predicted perioperative bleeding. Dilutional coagulopathy is
more commonly due to a thrombocytopenia than a coagulation factor deficit.
- Platelet transfusion is recommended with platelet counts less than 50 x 109/liter
and clinical evidence of bleeding. If there is any evidence of prior platelet dysfunction, platelets are given with intermediate platelet counts of 50-100 x 109/
liter. Other authors believe that intraoperative bleeding occurs at platelet counts
below 100 x 109/liter which occurs at about 10 units of transfused blood. Both
schools believe that platelets should generally be given before giving FFP.
- For normal hemostasis to occur about 20% of factor V and 30% of factor VIII
need to be present. Percentages below this level usually do not occur until greater
than one blood volume has been replaced. In the clinical setting when PT and
PTT can not be obtained in a timely fashion, with evidence of bleeding and
with replacement of one blood volume FFP can be given. The risks of a transfusion reaction are equal for FFP and red blood cells. Generally two units will
correct most coagulopathies.
- Metabolic problems associated with massive transfusions are citrate toxicity,
hypocalcemia, hyperkalemia, hypothermia, and acidosis.
Citrate toxicity is secondary to the administration of large quantities of citrated
blood components. This can acutely lower the serum calcium level. The liver
quickly metabolizes citrate, however in states of shock, liver function is impaired and citrate may not be cleared as rapidly. Citrate induces hypocalcemia
causing hypotension, narrowing of the pulse pressure, increased cardiac filling
pressures, gross muscle tremors and prolonged QT interval on electrocardiogram. All of these signs, except prolonged QT interval, are seen in shock regardless of calcium level and therefore not specific for hypocalcemia in the situation
it is most likely to be encounteredmassive transfusions. Exogenous calcium is
given when the measured ionized calcium level is low or falling in the face of
ongoing blood transfusions.
633
Hyperkalemia is seen with massive transfusions that require blood replacement

in a short amount of time. The older the unit of red cells the higher the potassium level in the stored blood. Potassium leaves viable erythrocytes and increases the concentration in plasma of stored blood. After 21 days of storage
plasma potassium concentrations approach 25-30 mEq/liter. Massive transfusions that occur over 8 hours may never need treatment for hyperkalemia because the potassium can redistribute to the intracellular space. Current rapid
infusion technology allows blood infusion of 100 ml/min per machine. If two
rapid transfusion devises are being used simultaneously acute hyperkalemia can
occur. The best intraoperative clinically useful marker for acute hyperkalemia is
the electrocardiogram. Peaking of the T waves signifies a potassium level that is
clinically significant. Laboratory values of potassium may not be significantly
high but the associated hypocalcemia narrows the range of safety for potassium
levels. Treatment of hyperkalemia ranges from surgical control of hemorrhage,
administering calcium, hyperventilation, administration of bicarbonate, insulin and glucose, and rarely the administration of epinephrine.
- Hypothermia occurs in massive transfusions for multiple reasons, environmental exposure prior to arrival, low ambient operating room temperatures, large
exposed wound surfaces, anesthetic drugs, and infusion of fluids below body
temperature. Warming blood prior to infusion is essential to combat intraoperative hypothermia.
- Infusing stored blood is infusing an acid load. The pH of stored blood is 6.66.9 due to the slow accumulation of carbon dioxide and lactic acid from erythrocyte metabolism and the citric acid in the anticoagulant. With normal tissue
perfusion this acid load is rapidly metabolized and lactate and citrate are converted to bicarbonate in the liver. This alkalization is variable depending upon
the functional status of the liver and is rarely a problem in massive transfusions.
Options in Emergent Transfusions

The universal donor blood Type O Rh-negative red blood cells can be given
immediately without laboratory verification of compatibility. If two units or
less of this type of blood is administered, the patients own blood type still can
be given subsequently. With larger transfused amounts of universal donor
blood administered, transfusing the patient with their own type and crossed
matched blood can lead to transfusion reactions.
The second option is type specific red blood cells. Typing looks at the ABO
and Rh blood antigens. ABO and Rh compatible blood can be selected from
the stock and issued within 5-10 minutes. Delays in receiving type specific
blood are usually due to transportation of specimens and red blood cells between the laboratory and the patient. Type specific blood is safe and has a very
low potential for a transfusion reaction. Groups at higher risk are previously
transfused patients and multiparious woman. They may harbor undetected
antibodies.
A third option is Type O Rh-positive red blood cells when blood is needed
immediately. Men and women past child-bearing age or who have undergone
a hysterectomy can receive Rh-positive blood. This increases the pool of
universal donor blood available for transfusion. This blood should be considered
when the above two options are not available.
Type and crossed matched blood takes at least 45 minutes to check compatibility. Both ABO and all other red cell antigens can be tested.
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Trauma Management
In acute hypovolemic shock situations intraoperative blood cell salvage can be

utilized to decrease the amount of blood bank blood units transfused. With
massive blood loss both blood salvaged and typed blood may need to be given.
Anesthesia and Analgesia
62
Patients may present in such extremis that none to minimal anesthetic medications are needed. In this situation usually a medication that will blunt intraoperative recall, such as a benzodiazipine is given. As resuscitation improves
hemodynamics other medications to blunt pain are given, such as opoids. The
most common are alfenta, fentanyl, sufenta, and morphine (Table 62.5). The
placement of an endotracheal tube allows control of the sided effect of respiratory depression. In special circumstances, regional anesthesia can be used
alone or in combination with a general anesthetic. An example is the operative repair of a traumatic knee injury where neuro-axis anesthesia is combined
with a general anesthetic.
The measurement of pain and the amount of analgesic medication needed to
alleviate this pain in an anesthetized, traumatized patient is a best guess. Acute
pain, like acute trauma, activates the same sympatho-adrenal response systems.
Increased heart rate, increased blood pressure, increased respiratory rate, and
increased anxiety are present. Other medications can be used in conjunction
with opoids for pain control. Benzodiazipines will act in conjunction with opoids
in achieving sedation and analgesia (Table 62.6). Ketamine, intravenous
nonsteroidals, and even rectal acetomenaphin has analgesic properties.
Conclusion
Anesthesia of the traumatized patient involves having an operating room prepared with the necessary airway, venous access, and monitoring equipment. Management of the airway, fluid resuscitation, and analgesia are paramount to improve
successful outcome after an acute injury that requires operative repair.
Table 62.5. Intravenous opoid analgesia

Drug
Intravenous Dose
mg/kg
Per dose titration

mg
Demerol
Morphine
Fentanyl
0.1-1.0 mg/kg
0.1 mg/kg
0.004-0.02 mg/kg
(4-20 g/kg )
0.005-0.010 mg/kg
(5-10 g/kg)
0.008-0.020 mg/kg
(8-20 g/kg)
25 mg increments
2-4 mg
0.025 mg
(25 g/kg)
0.005 mg
(5 g)
0.05 mg
(50 g/kg)
Sufentanyl
Alfentanyl
Table 62.6. Amnestics

Drug
Diazepam
Midazolam
Lorazepam
Intravenous dose
Titrate
1-2 mg
0.5-1 mg
0.2-0.4 mg
Onset (min)
Clinical Action (min)
2-3
<1
2-3
15-60
20-30
30-240
635
References
1.
2.
3.
4.
5.
Mallampati SR, Gatt SP, Gugino LD et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32:429-434.
Eckenhoff JE. Some anatomic considerations of the infant larynx influencing
endotrachel anesthesia. Anesthesiology 1951; 12:401.
Brain AIJ. The laryngeal maska new concept in airway management. Br J Anaesth
1983; 55:801-804.
Jurkovich G, Greiser W, Luterman A et al. Hypothermia in trauma victims: an
ominous predictor of survival. J Trauma 1987; 27:1019-1024.
Davis JW, Shackford SR et al. Base deficit as a guide to volume resuscitation. J
Trauma 1990; 28:1464-1467.
62
CHAPTER 63
Transfusion Therapy
Gay Wehrli and Ira A. Shulman
Background for Transfusion
Definitions
Group: refers to a persons blood group, including A, B, O, or AB.
Type: refers to a persons blood type, either positive or negative, for the presence
or absence of the Rh(D)-antigen respectively.
Expected Antibody: an antibody, which occurs naturally, unstimulated
- Group O people have anti-A, anti-B, and anti-AB
- Group A people have anti-B
- Group B people have anti-A
Unexpected Antibody: an antibody, formed due to alloimmunization (exposure

to a foreign antigen). Alloimmunization may occur during pregnancy or
transfusion.
Screen for Antibodies: the test used to look for unexpected antibodies in the
patients serum, tests for 18 specific antibodies required by the FDA, and
hundreds of other antibodies, not required by the FDA.
Panel: if the screen for antibodies is positive it is followed with an antibody
identification work up, called a panel to ensure the antibody identification.
Crossmatch: the patients serum is tested with the donor red blood cells (RBCs)
to detect incompatibility and to prevent transfusion reactions due to antibodies
present in the recipients serum.
Group Specific: refers to a blood product, which is the same ABO group as
the intended recipient.
Type Specific: refers to a blood product, which is the same Rh(D)-antigen
type as the intended recipient.
Antigen negative: refers to a blood product known to lack a specific antigen,
the absence of a specific antigen may be indicated on the products label.
Uncrossmatched Release: refers to a blood product, which is dispensed for use
prior to completing pretransfusion compatibility testing. Requires a clinicians
approval prior to transfusion, indicating knowledge of incomplete testing.
Leukocyte Reduced: indicates white blood cells (WBCs) have been removed
from a blood product to a count of < 5x106. Typically used to prevent nonhemolytic febrile transfusion reactions. Also used to decrease the risk of
cytomegalovirus (CMV) transmission when patients are at risk for CMV.
Irradiated: indicates the blood product has been irradiated to inhibit WBC
replication. Typically used to prevent graft versus host disease in an immunosuppressed patient at risk for graft versus host disease.
Gay Wehrli, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A.
Ira A. Shulman, Department of Pathology, University of Southern California, Los Angeles,
California, U.S.A., E-mail: ishulman@usc.edu
Transfusion Therapy
637
Massive transfusion: when the patients blood volume is replaced or exceeded

within a 24-hour period.
Blood Bank and Transfusion Medicine Service

Pretransfusion compatibility testing is done to prevent ABO incompatible transfusions, which can be fatal, although, access to blood components must not be
delayed in a life or death situation.
Timing for Testing (after receiving a patients properly labeled

blood sample)
ABO Group and Rh type determination: 10-15 minutes
ABO Group, Rh type determination, and screen for antibodies: 30-60 minutes
If an unexpected RBC antibody is identified in the screen for antibodies, an
antibody panel: 90 minutes
- The turn around time to identify the antibody may be extended from hours to
days depending on the specificity of the antibody.
Timing for Preparation and Availability of Blood Products

(after receiving a patients blood sample)
Uncrossmatched, group specific blood: 15-20 minutes

Crossmatch compatible blood: 35-45 minutes
Frozen plasma: 20-30 minutes
Cryoprecipitate: 5-10 minutes
Frozen RBCs (typically used when a patient has an unusual antibody requiring a rare donor RBC unit): 60-90 minutes to prepare for transfusion, but
hours to days to obtain from blood center.
Standard Operating Procedures (SOPs)

SOPs are created by the blood banking and transfusion medicine service in
conjunction with other departments, which will use the SOP to provide steps
taken to rapidly provide blood components during an emergency situation.
Personnel responsible for following these SOPs, including laboratory technologists, nurses and physicians, require adequate training and competency
in the procedures.
The SOPs should address patients suddenly needing blood during an existing
hospitalization as well as patients brought to the hospital needing acute, emergent treatment.
Following SOP guidelines minimizes the risk of patient misidentification, specimen mislabeling, administering the wrong unit of blood, undue delay providing blood for transfusion, and/or an ABO incompatible transfusion.
Emergency Transfusion
Complete pretransfusion patient testing may be waived in a dire emergency
where uncrossmatched RBC units are dispensed immediately for the unstable
patient.
The RBC unit is labeled to indicate: Emergency Blood Release. Blood issued
without complete compatibility testing. (Or some similar wording.)
The Food and Drug Administration (FDA) mandates that physicians requesting
an emergency, uncrossmatched transfusion, document the blood was needed
before compatibility testing could be completed.
63
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Trauma Management
Requiring written documentation by the requesting physician prior to an emergency transfusion may be inappropriate, because this could lead to delays in
blood availability.
Administration of Blood Products

Pretransfusion Clerical Checks
Check the physicians order to transfuse.
Check for a completed and signed informed consent to transfuse (in the emergent situation this may not be feasible to obtain).
Properly identify the patient.
Properly identify the blood product to be transfused.
Confirm that the identity of the patient and blood product match each other.
Emergency Alias Names
63
A system should exist to assign temporary identification for an unidentified

patient, such as an alias name and medical record number.
The Los Angeles County + University of Southern California Medical Center
has created a successful mechanism to achieve this goal.
The Department of Medical Records generates an extensive list of male and
female aliases.
- Each alias consists of a unique medical record number (MRUN) and an alias
name:
The MRUN consists of seven digits (using the numbers 0 through 9).
MRUNs are never recycled.
The last name is an alphanumeric number from one to ninety-nine. These
last names are cycled (i.e., after one through ninety-nine are used, the list
goes back to one).
The surname is a generic male or female name. Twenty male and twenty
female names are used. Each of the twenty names begins with a different
letter and is used in alphabetical order. These names are also cycled.
The combination of ninety-nine last names and twenty surnames provides
1,980 male alias names and 1,980 female alias names.
The list of male and female alias MRUNs with assigned names is given to the
Emergency Department administration.
- The administration creates packets for each alias. The packets are labeled on the
outside with the alias MRUN and assigned name using red ink for female aliases
and black ink for male aliases.
- The packets consist of the patient identification (I.D.) plate, which includes the
MRUN, gender (M for male or F for female), alphanumeric last name, and
surname. All documentation for the patient will be imprinted with this I.D.
plate.
- Additionally each packet contains a patient chart including all of the following,
which are prelabeled using the I.D. plate:
Two patient identification arm bands
Paper tie-on, identification tag
Physical exam sheet
General consent form
Four labels for blood tubes
Transfusion Therapy
639
Radiology request and record sheet

Blood bank request sheet
The patient should continue to use the alias name until the patient has been
stabilized and a correct identity has been determined. When both of these
have occurred, the name change should be made through the Department of
Medical Records. The patients MRUN should not change unless the patient
has a historical MRUN, which should be referenced.
- Permanent records should be maintained of all patient aliases (MRUN and
name) used with corresponding true identities if known.
Intravenous (IV) Line and Timing of Transfusion

Transfusion of any blood product should begin within 30 minutes from the
time it was dispensed from the Blood Bank, unless the blood is stored in an
authorized and properly monitored refrigerator (or cooler), in compliance with
federal, state and local regulations and hospital policy.
The transfusion may occur as fast as the patient tolerates the volume.
Transfusion of any blood product should not exceed 4 hours.
18 gauge catheters are most commonly used.
- Smaller catheters will slow the flow rate.
- Smaller catheters may damage the RBCs.
Solutions Used with Transfusion

0.9% Sodium Chloride, USP (NaCl) may be used with the transfusion of
blood products.
Plasma or albumin is an acceptable alternative to use with the transfusion of
blood products.
Do not add 5% dextrose solutions to the blood container because this may
cause osmotic hemolysis of RBCs.
Do not add Lactate Ringers solution to the blood container because this may
cause RBC clotting.
Do not add medication through the IV line to be used for transfusion.
Blood Filters
Standard (170 micron) filters are used for all blood products to prevent transfusion of clotted blood and other debris.
Leukocyte reduction filters are used to decrease the WBC content of red blood
cell and platelet products (see definition for leukocyte reduced).
Blood Warmers
Blood warmers are used to increase the temperature of the unit of blood at the
time of transfusion.
- The cold temperatures may reduce the temperature of the sinoatrial (SA) node
placing the patient at risk of ventricular arrhythmias.
Blood may be warmed to 42C.

Indications for use of blood warmers:
-
Massive transfusion, > 100 cc/minute for 30 minutes.

Adults being transfused at a rate > 50 cc/kg/hour.
Children being transfused at a rate > 15 cc/kg/hour.
When administering blood rapidly through a central line.
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Trauma Management
Patient Monitoring During Transfusions

The patient needs to be monitored immediately before, during, and up to
several hours following the transfusion.
Documentation of the transfusion must include:
- Date and time when transfusion begins and ends.
- Vital signs including blood pressure (BP), temperature (T), respiratory rate (RR),
heart rate (HR) before, during (every 15-30 minutes), and after the transfusion.
- Premedication and/or medication during or following the transfusion, which is
related to the transfusion.
- Product type and amount of product transfused.
- Signs and symptoms, which occur before, during, or following the transfusion.
- Transfusion reactions (see Acute Transfusion Reaction section).
Emergency Transfusion of Blood Components
63
Whole Blood
Volume: 450-500 cc
Components: RBCs, plasma, WBCs, platelets
- The platelets become nonviable after one day of product storage at 4C. The
WBCs disintegrate over the storage period of the product, so that by the end of
storage, 50% of the WBCs remain.
Indication: to increase the oxygen carrying capacity of a patient with acute

hypovolemia.
Expected effect: hematocrit increases 3% (hemoglobin increases 1 g/dL).
- However, since whole blood is only given to bleeding patients, the increment is
rarely achieved.
Group and type requirements:

- First choice: crossmatch compatible whole blood.
- Second choice: group specific, uncrossmatched whole blood.
Whole blood contains a significant amount of plasma with the naturally
occurring antibodies.
Using uncrossmatched, group specific whole blood carries the greatest risk
of any uncrossmatched transfusion.
- The risk lies in clerical error, where a patient receives the wrong unit of
whole blood leading to a hemolytic transfusion reaction due to the
transfusion of incompatible red cells or to the transfusion of naturally
occurring, but incompatible antibodies.
Packed Red Blood Cells (PRBCS)

Volume: 300 cc
Components: RBCs, small amount of plasma, WBCs
- The platelets become nonviable after one day of product storage at 4C. The
WBCs disintegrate over the storage period of the product, so that by the end of
storage, 50% of the WBCs remain.
Indication: to increase the oxygen carrying capacity of a patient.

Expected effect: hematocrit increases 3% (hemoglobin increases 1 g/dL).
- However, when given to bleeding patients, the increment is rarely achieved.
Group and type requirements:

- First choice: crossmatch compatible pRBCs.
- Second choice: group specific, uncrossmatched pRBCs.
Transfusion Therapy
641
- Third choice: O negative, uncrossmatched pRBCs. These become the first choice
in the emergent situation until group specific, uncrossmatched or crossmatch
compatible pRBCs are available.
Group O, Rh-negative pRBCs carries a low (but not a zero) risk of hemolytic
transfusion reaction.
There is essentially no risk of the group O Rh-negative transfused pRBCs
being hemolyzed by a recipients anti-A, anti-B, or anti-AB since group O
RBCs lack A and B antigens.
The nominal amount of anti-A, anti-B, and anti-AB contained in the plasma
of group O pRBC will typically be diluted out once transfused. Therefore
there is essentially no risk that the recipients own red cells will be hemolyzed by the expected antibodies found in the pRBC unit.
The hemolysis risk of transfusing uncrossmatched O Rh-negative pRBCs
lies in unexpected alloantibodies (e.g., Rh, Kell, Kidd, or Duffy), that are
not detected in the patient until the screen, and/or panel for unexpected
antibodies is completed.
Using group O Rh-negative pRBCs in the emergent situation is preferable
to Rh-positive.
If there is a shortage of O Rh-negative units, females with childbearing potential should be given preference for these units.
Patients with anti-D will also require Rh-negative units.
A male patient or female patient with no childbearing potential may receive
Rh-positive units.
If no Rh-negative units are available, Rh-positive units may be used, however, consideration should be given to administering IV anti-D to prevent
alloimmunization in the Rh-negative patient.
- IV anti-D will coat D-antigen positive RBCs thus preventing the recipients
immune system from responding to the presence of transfused D-antigen
positive red cells and thus preventing alloimmunization.
Should group O pRBC units be used in the emergent situation,
crossmatching must be performed as soon as possible, to detect unanticipated incompatibility.
Fresh Frozen Plasma (FFP), Solvent-Detergent Treated Plasma

(SD-Plasma), and Donor Retested Plasma (DR-Plasma)
Volume:
FFP
DR-Plasma
SD-Plasma
Components: plasma-containing
plasma) and complement.
180 cc - 300 cc
180 cc - 300 cc
200 cc
coagulation factors (1 IU of factor/mL of
- There are reduced amounts of factors V, VIII, VIII:C because these are labile.
Indications:
- To replace clotting factors in a patient undergoing massive transfusion.
- Bleeding patients with a clotting factor deficiency, when factor concentrates are
not available.
- Patients taking Coumadin who are bleeding.
Expected effect: increase factor levels by 20% if administered at a dose and

rate indicated below
Group and type requirements (crossmatching is not required):
63
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Trauma Management
- Group specific plasma.
Group A patients may receive group A or AB plasma.
Group B patients may receive group B or AB plasma.
Group AB patients may receive group AB plasma.
Group O patients may receive group A, B, AB or O plasma.
- Rh type does not have to be considered.
Dose: 10-20 mL/kg body weight (a standard dose would be 4-6 units in an
adult).
Cryoprecipitate
Volume: 15cc
Components: plasma containing fibrinogen (> 150 mg), fibronectin, and factor VIII:C (> 80 IU), factor XIII, and vonWillebrands factor (Factor VIII:vWF)
Uses:
63
- To replace fibrinogen.
- Second line treatment for vonWillebrands disease or Hemophilia A (factor
concentrates are the first line treatment).
Expected effect: fibrinogen increases 5 mg/unit (an average adult dose is 10

units, which would increase the fibrinogen level by 50 mg).
- However, when given to a patient with a consumptive coagulopathy such as
disseminated intravascular coagulation (DIC), this increment is rarely achieved.

- Group specific plasma is preferred.
Group A patients may receive group A or AB plasma.
Group B patients may receive group B or AB plasma.
Group AB patients may receive group AB plasma.
Group O patients may receive group A, B, AB or O plasma.
- Rh type does not have to be considered.
Dose: 1-2 units/10 kg body weight (a standard dose would be 10 units in an

adult).
Platelet Concentrate and Platelets, Pheresis

Volume:
Platelet concentrate 40 - 70 cc
Platelets, pheresis 100 - 500 cc
Components:
- Platelet concentrate contains plasma, > 5.5 x 1010 platelets, white blood cells,
and < 0.5 cc RBCs
- Platelet pheresis contains plasma, > 3 x 1011 platelets, white blood cells, and < 2 cc
RBCs.
Use: for bleeding patients with low platelet counts or for bleeding patients
with normal platelet counts but abnormal functioning platelets.
Expected effect:
- Platelet concentrate increases the platelet count by 5-10 x 103/uL
- Platelet pheresis increases the platelet count by 30-60 x 103/uL

- Group specific platelets are preferred.
Group A patients may receive group A or AB platelets; use group O or B as
last resort.
Group B patients may receive group B or AB platelets; use group O or A as
last resort.
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643
Group AB patients may receive group AB platelets; use group O, A, or B as

last resort.
Group O patients may receive group A, B, AB or O platelets.
- Rh type specific platelets are preferred.
Dose:
- Platelet concentrate: 1 unit/10 kg body weight (average adult dose is 5-7 units).
- Platelet pheresis: 1 unit/50 kg body weight
Acute Transfusion Reactions

Steps to Take in the Event of a Transfusion Reaction
Step 1: Discontinue the transfusion.
Step 2: Continue IV fluids (0.9% NaCl).
Step 3: Check and document vital signs and the amount of blood product
transfused.
Step 4: Perform a clerical check (ensure the patient identity and blood product identity match).
Step 5: Notify the physician caring for the patient.
Step 6: Notify the Blood Bank.
Step 7: Collect and correctly label a red top tube and purple top tube of blood.
Step 8: Send the samples collected in step 7 and the remainder of the blood
product (or empty blood product) with the tubing (but without the needle)
to the Blood Bank.
Mild Allergic Reaction

Signs and Symptoms: localized hives and/or pruritis.
Actions to Take:
- Follow steps 1-5.
- Administer the following as clinically indicated:
Antihistamine (e.g., diphenhydramine 25-50mg PO/IM/IV q6h).
- The transfusion may be continued if the signs and symptoms improve within
30 minutes.
Moderate to Severe Allergic Reaction

Signs and Symptoms: hives, shortness of breath, wheezing, hypotension, and/
or anaphylaxis.
Actions to Take:
- Follow steps 1-8.
Antihistamine (e.g., diphenhydramine 25-50 mg PO/IM/IV q6h).
Epinephrine (e.g., 0.3-0.5 mg {0.3-0.5 ml of 1:1000 solution} SQ q20 min).
Vasopressor (e.g., dopamine 400 mg in 250 ml D5W at 2-20 ug/kg/min).
Corticosteroids (e.g., methylprednisolone 125 mg IV q6h).
Febrile Reaction
Signs and Symptoms: increase of temperature 1.8F with or without chills.
Actions to Take:
- Follow steps 1-8.
Antipyretic (e.g., acetaminophen 325-650 mg PO/PR q4h).
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Volume Overload Reaction

Signs and Symptoms: shortness of breath, pulmonary edema, and/or
hypertension.
Actions to Take:
- Follow steps 1, 3, 4 and 5.
Diuretic (e.g., furosemide 1mg/kg body weight or 20-80 mg IV).
Septic Reaction
Signs and Symptoms: chills, fever, hypotension, and/or nausea and vomiting.
Actions to Take:
63
- Follow steps 1-8.

Antibiotic (review gram stain and culture results of blood product to determine which antibiotic to administer).
Acute Hemolysis
Signs and Symptoms: shortness of breath, anxiety, pain at infusion site, chest
and flank pain, shock, renal failure, and/or bleeding.
Actions to Take:
- Follow steps 1-8.
Vasopressor (e.g., dopamine 400 mg in 250 ml D5W at 2-5 g/kg/min).
Diuretic (e.g., furosemide 1mg/kg body weight or 20-80 mg IV).
- Maintain airway.
- Maintain renal blood flow and diuresis (see above for diuretic).
- Monitor coagulation and watch for DIC.
Request the following labs:
- CBC (Complete Blood Count)
- PT (Prothrombin Time)
- PTT (Partial Thromboplastin Time)
- Fibrinogen Level
- D-Dimer Test for Fibrin Derivatives (Cross-Linked Fibrin Derivatives) or
- FDP (Fibrin Degradation Products)
Transfusion Related Acute Lung Injury (TRALI)

Signs and Symptoms: chills, fever, shortness of breath, respiratory failure, and/
or noncardiogenic pulmonary edema.
Actions to Take:
- Follow steps 1-8.
- Administer oxygen.
- Intubate (mechanical ventilation) if necessary.
Risk of Transfusion Transmitted Viruses

Transfusion Risks Per Unit of Blood
The risk of transfusion transmitted human immunodeficiency virus (HIV) is
1/200,000-2,000,000 units.
The risk of transfusion transmitted hepatitis B virus (HBV) is 1/30,000250,000 units.
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645
The risk of transfusion transmitted hepatitis C virus (HCV) is 1/30,000150,000 units.

These risks will continue to decline with the advent of new testing to detect
the viruses.
References
1.
2.
3.
4.
5.
6.
Goodnough LT, Brecher ME, Kanter MH et al. Medical progress: Transfusion

medicine (First of Two Parts)Blood transfusion. N Eng J Med 1999; 340:438-447.
In: Harmening DH, ed. Modern blood banking and transfusion practices. 4th ed.
Philadelphia: F.A. Davis Company 1999.
In: Menitove JE, ed. Standards for blood banks and transfusion services. 19th ed.
Bethesda: American Association of Blood Banks, 1999.
In: Rossi EC, Simon TL, Moss GS et al, eds. Principles of transfusion medicine.
2nd ed. Baltimore: Williams and Wilkins, 1996.
In:Triulzi DJ, ed. Blood transfusion therapy. 6th ed. Bethesda: American Association of Blood Banks, 1999.
Vengelen-Tyler V, ed. Technical manual. 13th ed. Bethesda: American Association
of Blood Banks, 1999.
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CHAPTER 64
Venous Thromboembolism After Injury

George C. Velmahos
Definition
Venous thromboembolism (VT) consists of two clinical entities that have the same
pathophysiology, deep venous thrombosis (DVT) and pulmonary embolism (PE).
Incidence
The incidence of DVT varies widely among studies according to type and
severity of trauma, age, method of prophylaxis, and intensity of surveillance.
Overall, the incidence is approximately 12% of trauma patients who require
admission to the hospital.
The incidence of PE is 1.5%. Between one-fifth and one-third of patients
who develop PE after trauma die from it.
Location of Thrombi
Any vein in the human body may clot. Our knowledge of the most common
sites of thrombosis is limited by the accessibility of these sites for diagnostic
evaluation and our aggressiveness in suspecting and evaluating DVT.
The majority of thrombi are formed in the lower extremities, although the
upper extremities may account up to 20% of DVT found after trauma.
The majority of lower-extremity thrombi are located proximally (above the
knee) rather than distally. This may be related to easier accessibility of femoral
veins compared to below-the-knee veins for instrumentation and evaluation.
The precise incidence of pelvic vein thrombosis is not known.
PE can originate from any vein but is suspected to occur more frequently after
dislodgment of clot from proximal lower extremity veins. Autopsy studies
have shown that upper extremity or neck veins can be sources of PE.
Clinical symptoms and signs are extremely unreliable and carry a sensitivity
and specificity of 30% for detecting DVT. The sensitivity and specificity of
clinical symptomatology for PE is even lower.
The most common symptoms are pain, tenderness on palpation and swelling.
Homans sign is positive when pain is elicited at the calf upon forced dorsiflexion of the toes. It is also both insensitive and nonspecific.
The condition that describes the marked swelling and cyanosis following complete iliofemoral venous thrombosis is phlegmasia cerulea dolens. It is associated with generalized obstruction of the extremity venous system, including
the deep and superficial components. The obstruction to venous outflow may
compromise the arterial blood inflow and lead to venous gangrene.
Trauma Management, edited by Demetrios Demetriades and Juan Asensio.
647
The symptoms and signs of PE, like those of DVT, are unreliable.
Dyspnea and tachypnea are the most commons signs. Tachycardia, pleuritic
pain, hemoptysis and fever are additional elements of the clinical presentation.
Many patients will have DVT or PE with no symptoms or will be unable to
verbalize them.
Diagnosis of DVT
Contrast venography is considered the gold standard for diagnosis of DVT.
Intraluminal defects or acute termination of the opaque contrast column are
considered pathognomonic findings. However, the test has the following
limitations:
- It requires transport to the radiology department and therefore is unsuitable for
many critically ill patients.
- It is associated with local complications such as pain, thrombosis and chemical
cellulitis, and systemic complications such as anaphylactic reactions, renal and
cardiac dysfunction.
- It is associated with a low but real false-positive and false-negative rate (approximately 5%).
- It may not offer adequate visualization of the inferior vena cava and pelvic veins.
Impedance plethysmography is a noninvasive method that measures changes

in blood volume in the leg. The sensitivity and specificity of the test is debated. Its main disadvantage is that it cannot provide information on the
precise location and extent of the thrombus. False positives and false negatives
may be produced by multiple technical (skin movement, incorrect position of
the tourniquet) or pathophysiologic causes (muscle tension, increased central
venous pressure, venoconstriction, arterial insufficiency). Its use is limited.
Duplex ultrasonography is currently the most frequently used test (Fig. 64.1A,
64.1B). Normal blood flow in the veins is spontaneous and phasic with respirations, can be augmented by elevating the lower extremity or by manual
compression, and can be interrupted by performing the Valsalva maneuver. In
the absence of the above characteristics, venous blood flow is abnormal and a
thrombosis is diagnosed. The advantages of the test are:
- It is noninvasive and associated with almost no complications.
- It can be performed at the bedside and repeated frequently (Fig. 64.2).
The disadvantages of the test are:

- It is operator-dependent.
- It offers poor visualization of the veins below the knee and above the inguinal
ligament.
- Although its sensitivity and specificity range from 80-100% in nontrauma patients, these values have never been studied in the trauma population.
D-dimers are products of degradation of the clot. In the presence of VT (DVT

or PE), the blood levels of D-dimers are high. Although the experience with
this test in trauma patients is still limited, studies show that if the levels are
normal, VT can be safely excluded. If the levels are abnormal, further evaluation is necessary because of a significant number of falsely positive tests.
Diagnosis of PE
The gold standard for PE diagnosis is pulmonary angiography (Fig. 64.3). The
sensitivity and specificity of the test is over 95%, but it is invasive and associated
with contrast-, transport-, catheter-, and access-site-related complications.
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64
Fig. 64.1A. Partial jugular vein thrombosis around central line. Observe the freefloating tail of the clot.
Fig. 64.B. The same patient showing the partial thrombosis in a different view.
Ventilation and perfusion (V/Q) scan is a test that has much lower accuracy
but is not associated with major complications. A V/Q mismatch suggests the
presence of PE. The interpretation of a V/Q scan offers a high, intermediate,
low or no probability for PE. High or low probability V/Q scans are associated with a rate of 15% of false-positive or false-negative results respectively.
PE exists in 70% of intermediate-probability scans.
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Fig. 64.2. Almost complete subclavian vein thrombosis. Central lines are usually
the cause. It is frequently missed because the upper extremities are not evaluated
as regularly as the lower extremities for deep venous thrombosis. Although the
exact significance of upper extremity venous thrombosis is unknown, there is documentation in the literature of pulmonary embolism originating from upper extremity and neck veins.
Fig. 64.3. Angiography is very sensitive in detecting small pulmonary emboli. One
such embolus is detected at the distal end of a secondary branch of the pulmonary
artery.
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Trauma Management
CT angiography is a recently developed technique that outlines the pulmonary vascular tree by thin cuts of the pulmonary fields during simultaneous
contrast injection. Helical CT technology is required with special software for
reconstruction of the images. The accuracy of CT angiography in diagnosing
PE is reported to be higher than 90% but there have been no studies in trauma
patients (Fig. 64.4A, 64.4B).
The estimation of the late pulmonary dead space fraction (Fdlate) is a new
method that has been successfully tested for the bedside diagnosis of PE in a
limited number of patients. It requires a special respiratory monitor to obtain
the CO2 expirogram.
Duplex venous scanning is completely unreliable for the diagnosis of PE. False
negatives are over 50%. A peripheral venous clot may be absent in the presence
of PE for various reasons. The origin of the clot may be a vein not subjected to
scanning, a clot may exist but is not identified by Duplex, or the clot may
have traveled to the lungs.
At this time, a V/Q scan is the screening test of choice. In most centers, a
pulmonary angiogram is reserved only for equivocal cases. However, the
inaccuracy of the former test and invasiveness of the latter make the diagnosis
of PE difficult. If CT angiography proves to be a reliable tool, it may become
the test of choice.
Fig. 64.4A. CT angiography is emerging as a new, more convenient and less invasive
tool for the evaluation of possible pulmonary embolism. Its reliability in critically
injured patients has not yet been established, particularly in the presence of significant
intrathoracic pathology. This patient had a CT angiogram that was reported as negative
for pulmonary embolism.
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Fig. 64.4B. Pulmonary arteriography, done immediately after the CT angiogram, showed
the presence of multiple emboli. One of these emboli is shown in this view.
Rationale for VT Prophylaxis

Trauma patients are at increased risk for VT. The posttraumatic activation of
the inflammatory cascade affects coagulation mechanisms and distorts the
balance between clot formation and lysis.
PE is a potentially lethal disease. Most of the patients who die from PE do so
within 30 minutes of the event, before therapy becomes effective.
DVT is highly morbid, with 30-50% of patients suffering the long-term
sequelae of postphlebitic syndrome.
Patients at High Risk for VT

All trauma patients are at risk for VT. The following criteria have been found
to increase the already high risk:
- Spinal cord injury
- Spinal fractures
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-
Head injuries
Long bone fractures
Age more than 55
Major abdominal and particularly pelvic operations
Venous injury
Methods of Prophylaxis
The methods of prophylaxis can be grouped as pharmacological and mechanical. The most frequently used pharmacological methods are: low-dose
heparin (LDH), low-molecular-weight heparin (LMWH) and Coumadin. The
most frequently used mechanical methods are: calf-length or thigh-length sequential compression devices (SCD), arteriovenous foot pumps (AFP), and
vena caval filters (VCF).
LDH is the drug that has been used for the longest time.
- It may be given in four forms:
64
5,000 units subcutaneously 12-hourly

5,000 units subcutaneously 8-hourly
weight-adjusted dose subcutaneously
weight-adjusted dose intravenously (1-2 units/kg/hour)
There is little evidence that any dosing scheme is better than another.
- It has been shown to decrease VT rates significantly among nontrauma, especially elective general surgery and orthopedic, patients.
- It is inexpensive and therefore, cost-effectiveness can be established easily.
- It is associated with complications such as bleeding (3%), thrombocytopenia
(1%), and allergic reactions.
LWMH has a mean molecular weight of 4,000 to 5,000 daltons (compared

with 12,000-16,000 daltons of unfractionated heparin).
-
It binds only to Xa and not to antithrombin III, as unfractionated heparin does.

It has better bioavailability and a longer half-life than unfractionated heparin.
It is more expensive than LDH.
It is given subcutaneously once or twice daily in a fixed or weight-adjusted dose.
Coumadin is used for prophylaxis mostly in elective surgery. Its use in the
acute posttraumatic phase is limited because:
- it is associated with bleeding,
- coumadins anticoagulant effect cannot be easily reversed,
- the enteral absorption may be unpredictable in patients with posttraumatic hemodynamic alterations.
SCD and AVF prevent VT by a mechanical (intermittent compression of the

veins by simulation of the muscle pump) and a fibrinolytic effect (release of
tissue plasminogen activator). They are associated with no complications.
However, they cannot be applied in patients with extremity injuries or operations. Patients low compliance due to perceived local discomfort or system malfunction may account for failure rates up to 50% of adequate VT prophylaxis.
VCF offers mechanical interruption of the flow of clots travelling from peripheral veins to the pulmonary circulation. There are multiple designs but the
Greenfield filter is the most popular. VCF prevent only PE, not DVT. Associated
complications occur in 7% of patients and consist of malplacement, migration,
vessel perforation, IVC thrombosis and access-site-related problems such as
bleeding and thrombosis. The long-term results in trauma patients are not known.
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Comparison of Safety and Efficacy of Prophylactic Methods

A complete meta-analysis of all up-to-date literature evidence revealedcontrary to common beliefsthat there is no difference in safety and efficacy
between the different methods of VT prophylaxis.
Because the available data is limited and of poor quality, such differences may
exist and could be proven with better trial design and larger sample sizes.
The most promising drug seems to be LMWH. In two prospective randomized controlled trials, it outperformed LDH in preventing DVT. Its cost-effectiveness is still unknown.
There is no evidence suggesting superior safety of any of the pharmacological
methods.
Combination methods have not been proven to be better than single methods.
Pitfalls in Prophylaxis
The belief that VT is a disease that does not occur early after trauma. About
6% of all PEs occur within the first 24 hours, and 12% within the first 48
hours. Prophylaxis should be started as early as possible.
Prescription of SCD without strict monitoring. Frequently the device is not
functioning or simply not worn. The protective effect of SCD dissipates within
minutes after it is removed. Nurses and patients should be trained accordingly.
Exclusion of the possibility of VT because the patient is receiving adequate
prophylaxis. Among critically injured patients, 13% develop VT despite
thromboprophylaxis. Patients at high risk should be screened routinely by
Duplex scan.
Reliance on clinical symptomatology to diagnose VT. The majority of patients will have atypical or no symptoms. A low level of suspicion should be
maintained. Patients at high risk should be screened routinely (once or twice
weekly).
Selection of Patients who Need Prophylaxis

Patients with any of the above-mentioned high-risk criteria should be considered for prophylaxis.
Patients with ongoing bleeding, serious posttraumatic coagulopathies, or significant intracranial hemorrhage should not receive pharmacological prophylaxis until the bleeding is controlled, the coagulopathy corrected, or 3-5 days
have passed from the head injury.
Such patients should be considered for early placement of VCF by balancing
the risks and benefits. Additional patients to be considered for VCF are those
with multiple long-bone and/or pelvic fractures or with lifelong VT risk due
to permanent neurologic deficits that will not allow proper mobilization (spinal-cord or severe brain injuries).
Patients with minor to moderate trauma receive the best prophylaxis if they
are encouraged to walk. The practice of keeping potentially ambulatory patients in bed in order to wear SCDs should be condemned.
Treatment of VT
The standard treatment of VT is intravenous unfractionated heparin titrated
to prolong the APTT to 1.5-2 times normal for the first 5-7 days. In patients
who can tolerate oral intake, coumadin is started almost simultaneously and
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64
continued for 3-6 months after the heparin is discontinued on the fifth to
seventh day. Trauma patients with VT are likely to be severely injured, cannot
be fed orally, and must have intravenous heparin for longer periods of time.
New evidence suggests that LMWH is equally or more effective and safe
than LDH at a dose of 1 mg/kg or an equivalent of 200-250 anti-Xa IU/kg
subcutaneously 12-hourly. It is proposed that coagulation parameter monitoring is not necessary.
A VCF can be inserted if there are contraindications to full anticoagulation,
or if recurrence is noted despite therapeutic levels of anticoagulation.
Thrombolysis by r-tPA (recombinant tissue plasminogen activator) or urokinase is associated with high rates of bleeding. Trauma or surgery within 10
days are contraindications to thrombolysis. Resolution of clot should be expected in 70% of the cases. No proven benefit is found between bolus versus
continuous doses or systemic versus local infusion of thrombolytic agents.
Embolectomy by surgical removal of clot from the pulmonary artery is reserved for patients who manifest severe hemodynamic instability with no improvement by other therapies. It is an operation with very high mortality and
is practiced very rarely in trauma patients.
Pitfalls in Therapy
Inadequate coagulation parameter monitoring during heparin anticoagulation.
An APTT level of less than 1.5 normal is associated with high rates of recurrence. A level of more than 2.5 normal is associated with high rates of bleeding.
Failure to initiate therapy for PE before definitive diagnosis is made, if suspicion is high and contraindications to therapy do not exist. Most patients who
will die from PE will do so within the first hour. If the patient survives the
initial event, the focus should be shifted towards preventing a recurrence by
starting early therapy. Definitive diagnosis may be time-consuming. Treatment should be started while diagnosis is pursued and then discontinued if
the tests are negative for PE.
Exclusive reliance in IVC filters to treat PE of unknown origin. Although the
majority of PEs will originate in the lower extremities, some clots will be dislodged from the upper torso or upper extremities.
References
1.
2.
3.
4.
5.
Velmahos GC, Kern J, Chan L et al. Prevention of venous thromboembolism after

injury: An evidence-based report. Part I. J Trauma, in press.
Velmahos GC, Kern J, Chan L et al. Prevention of venous thromboembolism after
injury. An evidence-based report. Part II. J Trauma, in press.
Velmahos GC, Nigro J, Tatevossian R et al. Inability of an aggressive policy of
thromboprophylaxis to prevent deep venous thrombosis in critically injured patients:
Are current methods of DVT prophylaxis insufficient? J Am Coll Surg 1998;
187:529-533.
Geerts WH, Jay RM, Code KI et al. A comparison of low-dose heparin with lowmolecular-weight heparin as prophylaxis against venous thromboembolism after
major trauma. N Engl J Med 1996; 335:701707.
Venous thromboembolism: An evidence-based atlas. Hull RD, Raskob GE, Pineo
GF, eds. New York: Futura Publishing Company, Inc., 1996.
CHAPTER 1
CHAPTER 65
Trauma Program Manager

Kathleen E. Alo and Pamela M.Griffith
The role of the Trauma program manager (TPM) is multi-facetted and
encompasses a wide variety of distinct functions. In the past the role has been
titled Trauma Nurse Coordinator. An overview of the TPM role is highlighted.
However, due to the specific needs of our readers, the greatest focus of this
chapter is on the trauma Performance improvement functions of this role.
For success, it is suggested that a TPM be flexible, self-motivated, self-directed,
assertive, goal-directed, diplomatic, tenacious, an analytical thinker, able to
communicate well, work independently, and have strong interpersonal skills.1,2,3
The 1999 American College of Surgeons resource document describes the
TPM as Fundamental to the development, implementation and evaluation
of the trauma program. 4
Non-heading terms in this Chapter, which are bolded, are defined in the final
section, Performance improvement Glossary.
Overview of Operational Functions of TPM

There are 10 distinct functions performed or overseen by the TPM. These
functions are implemented differently within each Trauma Centerspecifically tailored to the needs of that institution.
1. Clinical Activities
Monitoring trauma care across continuum of care, policy and procedure development, clinical practice guidelines, clinical care resource evaluation, case management.
2. Program Administration
Managing operational, administrative, financial aspects of the program. Supervising, hiring and firing trauma program staff. Evaluating and setting trauma
care prices, assisting with hospital and/or physician billing.
3. Trauma Registry
Supervising or performing trauma patient data collection, coding and scoring.
Designing and validating database, designing and analyzing trauma reports for
performance improvement, research, resource planning, epidemiology and injury
prevention.
4. Consultant/Liaison
Stabilizing complex network of caregivers as a liaison with numerous surgical
and nonsurgical departments, as well as, extra-facility agencies, trauma system
administrators, and prehospital care organizations and providers.

Kathleen E. Alo, Los Angeles County / USC Medical Center, Los Angeles, California, U.S.A.
Pamela M. Griffith, Childrens Hospital Los Angeles, Los Angeles, California, U.S.A.
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Trauma Management
5. Trauma System Evaluation / Design
Trauma system designing, planning, implementation and evaluation at the local,
regional and national levels. Facilitating appropriate regulations and legislation
regarding trauma care and systems.
6. Education
Providing trauma care education for trauma center staff, as well as inter-facility
and regional professional staff. Conducting individual case reviews, community
education, and participating in offering and/or instructing in ATLS, PALS, and
other provider training.
7. Research
Facilitate trauma research topic selection, protocol design, analysis and documentation and distribution of findings. Providing data and data analysis for
basic and clinical trauma related research.
8. Injury Prevention
Directing and conducting community health education and injury prevention
programs. These may occur at many different locations including local schools,
retirement areas, hospital foundations, and community, religious or social groups.
9. Survey Coordination
Plan and coordinate hospitals overall preparedness to demonstrate compliance
with all trauma care standards. Assure completion of presurvey packet. Gather
all supporting documentation to achieve and maintain trauma center designation.
10. Performance improvement
Monitors patient care and system issues. Develops quality indicators, conduct
audits, evaluates trends and events while maintaining confidentiality, outlining
and following through on appropriate corrective actions. Works to improve
clinical outcomes.
Process of Trauma Performance Improvement

Trauma Performance improvement (PI) programs should provide a structured
approach to continually improving trauma care. A primary objective is to
reduce inappropriate variation and undesired outcomes in care.4 The complete
process must be well documented (Fig. 65.1). The following components are
important in every trauma PI effort:
1. Identification of Trauma Patients
In an optimal system, all injured patients would be included in your trauma
performance improvement program. If this is not practical, at least all of the
most severely injured patients should be included.
2. Identification of Issues
Concurrent ReviewReview of patient care while it being delivered
Retrospective ReviewReview of patient care after discharge
TrendingReview of care issue in multiple patients over time
3. Trauma PI Indicators
- A trauma PI indicator or audit filter is one method intended to identify
cases for which a review of the clinical care is needed. The review may examine
the care in a peer review setting or as a system root cause analysis evaluation.
- Indicators should stimulate curiosity and creativity in developing meaningful discussions and opportunities to improve care. Variety is important, as
the PI program must address issues across the continuum of care.
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Fig. 65.1. Trauma performance improvement process.
Adult and Pediatric Focus

A comprehensive program includes specific indicators for both the adult
and pediatric population. In addition, the pediatric population should be
summarized and analyzed separately in order to address needs specific needs
of this specialized population.
Primary Outcomes
A thorough mortality review is necessary on all patients who expire from
injury in the Trauma Center.
Functional Outcome Measures
A variety of scoring systems that quantifies the patients ability to independently perform activities of daily living and reintegrate into society. For example, Functional Independence Measures Score (FIMS).
Sample Indicators
The following table reflects a wide range of potential indicators. The list is
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Table 65.1. Sample trauma quality indicators/audit filters
65
All Trauma Deaths

Major Complications
All Trauma Transfers
Delay in Diagnosis
Error in Diagnosis
Error in Technique
Scene Time > 20 Minutes
Absence of Paramedic Report on Medical Record for EMS Patients
No Trauma Team Activation for Qualifying Patient
Not Met by Trauma Surgeon on ED Arrival
GCS < 14 without CT Head within 2 hours of ED Arrival
GCS < 8 Leaving the ED without a Mechanical Airway
GSW Abdomen Who is Managed Non-operatively
Abdominal Injuries and Sys BP<90, Undergoing Ex Lap > 1 After Arrival
Ex Lap > 4(-6) after ED Arrival
EDH or SDH Receiving Crainiotomy > (2-)4 hours After Arrival (Excludes ICP
monitoring)
Open Long Bone Fxs with > (6-)8 hours Between Arrival and Debridement (Exc
Low Velocity GSWs)
Abdominal, Thoracic Vascular, or Cranial Surgery > 24 hours After Arrival
Admitted to a Non-Surgical Service (Exclude Isolated Ortho/Neuro).
ICU Stay 2 times Average Trauma ICU LOS
Uplanned Return to the OR with in 48 hours of Initial Procedure
Re-intubation within (24-)48 hours of Extubation
Deep vein thrombosis, Pulmonary embolism, Decubitus
Non-admitted Trauma Pt Returns within 72 hours and is Admitted
ED Arrival to Disposition Time > 2 hours
Non-Compliance with Hospital Criteria for Trauma Center Designation
Transferred from Another Facility After > 6 hours
Absence of Sequential ED Neurologic Eval on pts with Skull Fx, Intercranial, or
Spinal cord injury
Absence of Hourly Documentation on Trauma Patients Until Disposition
Adults with Non-fixated Femoral Diaphyseal Fractures
Adults Receiving Platelets of FFP Within 24 hours of Arrival (after receiving 8 units
of blood)
Blunt Head Injury with Field GCS =14 with Abnormal Head CT & Craniotomy
Pediatric Blunt Trauma Undergoing Abdominal Surgery
Lower Extremity Injuries Who Develop Compartment syndrome
Chest Injuries Developing Empyema
4.
5.
6.
7.
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not complete but is meant to be a guide illustrating the variety of possible

filters (Table 65.1).
Reviews
- Multi-Disciplinary Peer ReviewDetailed review of individual patients care
across the trauma care continuum among peers.
- System Root-Cause AnalysisDetailed review of the problem, including
all steps and related processes potentially affecting the issue.
Conclusions
Consensus evaluation as to whether an opportunity for improvement exists. A
causative factor should be determined, to assist in planning appropriate corrective actions, whenever possible. These factors are generally knowledge, system
or performance / behavioral deficits.
Corrective Actions
An action is only necessary if an opportunity for improvement exists. Must
correspond with identified causative factor. May include, education, counseling, change in protocol, resource enhancement, refer to another area for further
review and disciplinary action.
Follow-up and Loop Closure
Assure the corrective action has been completed and has accomplished the desired effect. If desired effect did not occur, additional actions may be required,
until improvement is achieved.
Principles of Performance Improvement

Program must address the injured patients ongoing needs and required services across the continuum of care
Multi-Disciplinary Approach
- Relationship between Disciplines
Should include General Surgery, Neurologic Surgery, Orthopedic Surgery,
Emergency Medicine, Prehospital Care, Anesthesia, Critical Care, Pediatrics, Radiology, Nursing, Respiratory Care, Laboratory and Blood Bank,
Infection Control, Physical Therapy, Hospital, Administration, Pathology
and any other involved service.
- Relationship with Individuals
Objective, nonsectarian interaction regardless of domain and patients
physical location
Process and Outcome Measures should be utilized in trauma PI plan.

- Process measures evaluate appropriateness, availability, efficiency, timeliness
and continuity of care
- Outcome measures evaluate the quality, value, safety, respect, caring, effectiveness and efficacy of care
ExamplesTable 65.2.
- Focus on various Dimensions of Performance
Causes of variance in process and outcome should be evaluated and documented clearly on each case reviewed
- Three potential causes of variance include (one or more):
Knowledge Deficit
- A major causative factor
- Corrective actions should be educationally based and NOT PUNITIVE
System Deficit
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Trauma Management
Table 65.2. Process vs. outcome measures

Process
Outcomes
Timeliness of Radiological Films

Availability of Call-panel
Errors in Judgement
Errors or Missed Diagnosis
Readmission to Hospital
Unplanned Returns to the OR
Errors in Technique
Morbidity
Mortality
Length of Stay (LOS)
Cost
Splenic Salvage
Functional Outcome Measures
Patient Satisfaction
65
- A major causative factor

- Corrective actions usually require task forces, or PI teams
- May require root-cause analysis
- Hospital Administration may need to be involved
Performance or Behavioral Deficit
- An infrequent causative factor
- Corrective actions should be handled individually
- Documentation should be considered in the credentialing, privileging,
and competency evaluation process
Mortality reviews should also evaluate and come to a conclusion regarding
preventibility
- Include only one of the three potential conclusions:
Nonpreventable
Potentially Preventable
Preventable
- Every death deemed preventable or potentially preventable should have
corrective action(s) aimed at averting mortality in similar cases
Responsibility and Accountability for PI

- Ultimate responsibility rests with the hospitals governing body
Integration with hospital organizational structure is essential
- Specific Authority must be designated through the Trauma Director
- Day-to-day operational responsibility rests with the TPM
Performance improvement Setting

- Trauma Center
Hospital-specific PI issues
Filters, peer reviews, focused reviews, trending, outcomes
i.e., Timeliness to the OR
- State or Regional Trauma System
Review of issues across a multi-center trauma system
Trending, filters, analysis of system-wide issues
i.e., Evaluation of field triage criteria
- Benchmarking
Compare local or regional measures with those from other similar Trauma
Centers, and systems.
Utilization of the Trauma Registry

The Trauma Registry is the core of a trauma program. It is the objective
reflection of care given to injured patients. Analysis of trauma data is the
661
basis of clinical decision-making, hospital policy, and the foundation for

research, prevention, and legislative advocacy.
The hospitals trauma registry should be incorporated into larger databases
regionally and nationally, in order to capitalize on its full potential. Uses of
the trauma registry include:
- Epidemiology of Injury
Identification of Injury-related Public Health Issues
Influences Development of Injury Prevention Program
- Performance improvement
Trauma Care Assessment
Trauma System Evaluation
Institutional Benchmarking
- Program Resource Needs Assessment
- Research
Basic and Clinical
Outcomes Related
Performance Improvement Glossary

Appropriateness
Availability
Continuity
Continuum
of Care
Cost of injury
Dimensions
of Performance
Effectiveness
Efficacy
Efficiency
Filter/Indicator
Morbidity
Mortality
The degree to which the care and services provided are

relevant to an individuals clinical needs, given the current
state of knowledge.5
The degree to which appropriate care is available to meet
an individuals needs. 5
The degree to which the care of individuals is coordinated
among practitioners, among organizations, and over time. 5
The phases of injury intervention, from a traumatic incident through each phase of care concluding with rehabilitation and reintegration into society.
Injury and trauma care results in unintended costs to the
individual, the healthcare system, and society at large
(Table 65.3).
Nine definable, measurable, and improvable attributes of
organization performance related to doing the right things
right 5 (appropriateness, availability and efficacy) and
doing things well (timeliness, effectiveness, continuity,
safety, efficiency, and respect and caring).
The degree to which care is provided in the correct manner, given the current state of knowledge, to achieve the
desired or projected outcome(s) for the individual. 5
The degree to which the care of the individual has been
shown to accomplish the desired or projected outcomes. 5
The relationship between the outcomes (results of care)
and the resources used to deliver care. 5
A measure used to determine, over time, an organizations
performance of functions, processes, and outcomes. 5
The rate, proportion or incidence of disease in an area, locality, nation, or region. For instance, complications rate.
The proportion of deaths to an area, locality, nation, or
region. For instance, deaths rate.
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Trauma Management
Table 65.3. Cost of injury
65
Individual costs
Societal costs
Health system costs
Co-Payments
Self &/or Under-Insured
Loss of Life
Quality of Life
Health Insurance
Costs
Mortality Rate
Morbidity Rate
Unreimbursed Hospital
/ MD Costs
Cost Shifting
Healthcare Resource
Availability
Functional Outcome
Years of Productive
Life Loss
Performance
To measure, evaluate and improve functions, processes and
Improvement (PI) outcomes of health care delivery. Similar terms include quality assurance, quality management, quality improvement,
total quality management, organization wide performance
improvement. 5
Quality of Care
The degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. 5
Quality of Life
A individuals belief in the ability to utilize the characteristics and attributes both physical and nonphysical that constitute the basic value of a persons own life.
Respect and Caring The degree to which those providing services do so with
sensitivity for the individuals needs, expectations, and individual differences, and the degree to which the individual
or a designee is involved in his or her own care decisions. 5
Safety
The degree to which the risk of an intervention (for example, use of a drug or a procedure) and risk in the care
environment are reduced for a patient and other persons,
including health care practitioners. 5
Timeliness
The degree to which care is provided to the individual at
the most beneficial or necessary time. 5
Value
The quality of a service or object, which is thought of as
being more or less desirable, useful, estimable, important
etc. Often considered as the degree of worth.
References
1.
2.
3.
4.
5.
Beachley M, Snow S; Trimble P. Developing trauma care systems: the trauma nurse
coordinator. J Nsg Admin 1988; Vol 18(7,8):34-42.
Blansfield JS. The career spectrum in emergency nursing: trauma nurse coordinator. J Emerg Nsg 1996; Vol. 22(6):486-488.
Flint CB. The role of the trauma coordinator: A position paper. J Trauma 1988;
Vol. 28(12):1673-1675.
American College of Surgeons. Resources for Optimal Care of the Injured patient.
Chicago, IL: ACS 1998; 5:23-25, 16:69-76.
Joint Commission: Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint
Commission on Accreditation of Healthcare Organizations 1999:281-307.
CHAPTER 1
CHAPTER 66
Fat Embolism
George Androulakis and Demetrios Demetriades
Definition
Fat embolism is a recognized serious complication characterized by pulmonary
or central nervous system dysfunction or both. It results from fat microemboli to
the skin, lungs, brain and other tissues usually after long bone or pelvic fractures or
orthopedic procedures that require intramedullary manipulation.
First described by Zenker in 1861, while its clinical manifestations have been
recognized for more than 100 years.
Since 1861 more than 2.000 reports and articles have been published on the
process of fat embolization.
Incidence
There is evidence that marrow fat embolization occurs in almost all patients who
sustain a long bone or pelvic fracture and it refers to the presence of fat globules in
the lung parenchyma and peripheral circulation. Still, only a minority, 1-5% of
these patients develop clinical symptoms related to the so called fat embolism syndrome. Thus petechial rash, thrombocytopenia, pulmonary distress and mental disturbances with an onset of 12-48h after a fracture.
Pathophysiology
There are two main theories on the pathogenesis of the fat embolism syndrome:
the mechanical theory and the biochemical theory.
a) Mechanical Theory
When a bone fractures, the disruption of fat cells and venous sinusoids allow
fat to enter the venous circulation. Spongiosa bone particles and larger fat
globules block the smallest branches of the pulmonary vasculature, while small
fat droplets, push through the lung capillaries and enter the systemic circulation and embolize other organs. Major systemic embolization has also been
ascribed to the migration of these globules to the pulmonary veins through
pulmonary precapillary shunts.
b) Biochemical Theory
The current biochemical theory is based on the fact that fatty acids, whether
freely circulating or formed within the pulmonary system, cause endothelial
damage and are directly toxic to pneumocytes. Capillary leakage, perivascular
bleeding, platelet adhesion and clot formation are considered to be the main
factors responsible for tissue damage and organ dysfunction.
George Androulakis, University of Athens, Athens, Greece
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Trauma Management
Fig. 66.1. MRI of brain fat embolism. Note the high-intensity areas on the T2-weighted
images.
66
The origin of the free fatty acids may be twofold. In the first case, free fatty acids
are mobilized from the fracture site by the lysis of triglycerides. When formed in
excess, they are only partly bound to albumin. These fatty acids are then carried
along with the venous circulation, and enter the pulmonary capillary bed where
they have a direct toxic effect on the endothelial cells and pneumocytes.
- In the second case, the high levels of circulating free fatty acids, observed
after major injuries, are assumed to be associated with the increased release
of catecholamines, the latter induce lipolysis which lead to high levels of free
fatty acids.
Clinical Manifestations
Many patients with fat embolism remain asymptomatic. Signs and symptoms
may include:
Respiratory symptoms, characterized by tachypnoea, dyspnea and sometimes
cyanosis, accompanied by a decrease in pO2. Pulmonary signs are present in
about 75% of fat embolism patients; a minority (10%) develop respiratory
insufficiency that requires mechanical ventilation.
Cerebral manifestations, unrelated to head injury. These occur in more than
80% of cases. The patients may show a wide range of clinical symptoms, such
as confusion, drowsiness, lethargy, convulsions and coma. Occasionally cerebral manifestations may be the only symptoms of FES.
Petechial rash on the mucous membranes and skin on the anterior part of the
thorax and neck. This is observed in more than 50% of fat embolism patients.
The clinical signs usually do not appear until at least 6-12h have elapsed following the accident. Major signs appear in 60% of the patients within 24h and in 85%
of the patients within 48 h. Earlier clinical manifestation is possible, but rare. Onset
after 72h has also been described in exceptional cases. Occasionally, the clinical
Fat Embolism
665
symptoms of a late-developing fat embolism syndrome imitate those of massive

thromboembolism of the pulmonary artery.
Several minor symptoms may accompany the main clinical picture of this
syndrome. The most important ones are: early fever, an unexplained anemia
and thrombocytopenia from day 1 onwards, retinal changes, jaundice, renal
function tachycardia.
Respiratory System
The pulmonary manifestations start with hypoxia-induced tachypnea and
subsequent hyperventilation.
Moderate to severe cyanosis may be present. If respiratory insufficiency is
combined with progressive anemia, cyanosis may be absent.
Chest radiographs show multiple bilateral diffuse infiltrates called the snow
storm appearance, especially in the upper and middle parts of the lungs.
Pulmonary function usually recovers completely within 1 week.

An initial symptom-free interval of about 24h is common.
The first clinical symptoms may include delirious restlessness, somnolence or
confusion. As the pathophysiological process progresses, stupor and even complete loss of consciousness (coma) may develop.
Severe cerebral involvement has been described in patients with little or no
pulmonary involvement.
In the majority of cases, there is complete cerebral recovery.
In patients with multiple skeletal injuries who are also suffering from craniocerebral injuries, the origin of the neurological signs and symptoms is often
difficult to establish. An initial symptom-free interval may help to make a
differential diagnosis.
b) Petechial Rash
Petechiae are present in about 50-60% of cases, and they often appear after an
interval of 24-28h. They are most frequently found in both axillae, on the anterior side of the chest and neck, around the navel, the conjunctivae and the mucous
membranes of the mouth. The anatomical substrates of the petechiae are similar
to those observed in the brain, lungs, eyes and other organs involved in the pathological process. Microscopic examination may reveal small droplets of fat that are
obstructing capillaries and are surrounded by small perivascular hemorrhages.
Diagnosis
The diagnosis of fat embolism is usually an exclusion diagnosis. The diagnostic
criteria are based on the classic Gurd criteria. Gurds criteria, are divided into major
and minor criteria:
Major Criteria
- Hypoxemia with no other clear cause
- CNS depression
- Axillary or subconjunctival petechiae
Minor Criteria
-
Tachycardia (more than 110 beats/min)

Pyrexia (temperature more than 38.5C)
Retinal changes on fundoscopic exam (fat or petechiae)
Unexplained anemia
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Trauma Management
- Unexplained thrombocytopenia
- Fat globules in the sputum or urine
At least one of the major criteria and three minor criteria or two major and two
minor criteria are required for the diagnosis of FES.
Radiological Diagnosis
66
a) Chest RadiographsThe chest radiograph findings of FES tend to lag at least

12-24 hours behind the clinical, blood gas, and platelet changes. The clinical
and arterial blood gas (ABG) changes usually become clinically obvious at
least 12-24 hours before any radiologic abnormalities appear. When radiographic changes become apparent, they resemble those of other types of acute
respiratory distress syndrome (ARDS) and include early congestion and diffuse
infiltrates. If the radiologic changes occur before clinical respiratory changes,
one should suspect pulmonary contusion.
b) Computed Tomography Scan and Magnetic Resonance Imaging of the Head
Before it is assumed that the neurologic changes occurring after major trauma
are the result of FES, a computed tomography (CT) scan of the head is needed
to rule out space-occupying lesions. In FES the brain CT usually shows no
abnormality. Differentiating the changes of FES from diffuse axonal injury
may be very difficult.
A magnetic resonance imaging (MRI) scan is usually diagnostic and shows
scattered spotty high-intensity areas on T2 weighted images or low-intensity
areas on T1 weighted images involving the cerebral white matter, corpus
callosum and basal ganglia.
Therapy
Prophylaxis:
Modified surgical techniques, such as unreamed rodding, have been described
to reduce the bone marrow release into the circulation significantly and therefore minimize the risk for developing FES, although other studies challenged
this recommendation.
The early adequate administration of analgesia to limit the sympathomimetic
response to injury in order to avoid increased liberation of free fatty acids by
accelerated lipolysis may be useful, although not proven.
Heparin alcohol, bile salts, or steroids have all been used without any proven
benefit.
Outcome
The reported overall mortality ranged from 10-20% in the 1970s to 5-10%
today. Mortality is related to the severity of FES and to associated injuries.
Conclusions
FES remains a diagnosis of exclusion based on clinical criteria.
Clinical apparent FES is unusual.
Early intramedullary fixation, especially with the unreamed technique, does
not increase the incidence of FES.
The management of FES remains primarily supportive, with only a small
number of patients requiring advanced, aggressive critical care.
Fat Embolism
667
References
1.
2.
3.
4.
5.
Wilson RF, Georgiadis GM. Fat embolism syndrome. In: Wilson RF, Walt AJ, eds.
Management of trauma: pitfalls and practice. 2nd ed. Philadelphia: Williams &
Wilkins, 1996:703-725.
Gurd AR. Fat embolism: an aid to diagnosis. J Bone Joint Surg Br 1970; 52:732-744.
Ten Duis H.J. The fat embolism syndrome. Injury 1997; 28:77-85.
Bulger EM, Smith GD, Maier RV et al. Arch Surg 1997;132:435-439.
Hofmann S, Huemer G, Salzer M. Pathophysiology and management of the fat
embolism syndrome. Anaesthesia 1998; 53:35-37.
66
CHAPTER 67
Alcohol, Illicit Drugs and Trauma

Howard Belzberg
Principles of Management
Every trauma patient presents with the possibility that acute or chronic drug
or alcohol use will complicate his or her hospital course.
Alcohol and drugs are among the most common underlying causes of both
accidental and intentional injury.
The consequences of pretrauma drug and alcohol use are extremely variable.
Some investigators have found that, for a given severity of injury, patients
with positive alcohol levels seem to have a lower mortality. Others have found
no influence, or a higher mortality. Some investigators have found that greater
resuscitation volumes were required in patients with alcohol in their systems
at the time of trauma, or that catecholamine response in trauma patients was
blunted by alcohol.
The underlying disease processes associated with chronic abuse may not be
the same as the acute impact of drugs or alcohol.
The following elements associated with drug or alcohol use must be considered in the development of the therapeutic and monitoring plan:
-
acute intoxication
chronic intoxication
tolerance
habituation
addiction/withdrawal/abstinence syndromes
comorbidities associated with a particular drug or alcohol
Alcohol
Alcohol is by far the most commonly abused substance. As many as 52% of a
recent series of severe trauma victims were positive for alcohol on admission
to the hospital.
Respiratory Problems
- Altered mental status, especially episodes of stupor and coma, put
alcohol-intoxicated patients at high risk of aspiration.
Cardiovascular Problems
- Cardiomyopathy is present in as many as one-third of chronic alcohol abusers.
In many of these cases, the cardiac compromise may be subclinical, with symptoms developing when the patient is stressed by trauma or surgery.
- Arrhythmias are a common manifestation of alcohol-related cardiac compromise. Atrial fibrillation, atrial flutter and premature ventricular contractions
(PVCs) are frequently observed.

Howard Belzberg, LAC + USC Medical Center, Los Angeles, California, U.S.A.
669
- Acute alcohol ingestion leads to reduced vascular reactivity and potential

hypotension.
- General anesthesia may exacerbate this hypotension, or paradoxically cause
hypertension due to increased metabolism of anesthetic agents due to enzyme
induction.
Liver Problems
- Cirrhosis is a serious consequence of alcohol abuse and may affect the outcome
after trauma.
Coagulation Problems
- Both coagulation and fibrinolysis are altered by alcohol consumption. Platelets
are reduced due to suppression of megakaryocyte maturation. Platelet aggregation
in response to various stimuli including collagen and adrenaline is inhibited by
alcohol consumption.
- The clinical manifestation of these abnormalities is a prolonged bleeding time.
Renal Function Problems

- Alcohol reduces the secretion of antidiuretic hormone, which induces a
significant diuresis, primarily of free water.
- There is also an increase in excretion of magnesium and phosphate, which often
leads to metabolic complications.
Acid-Base and Electrolytic Problems

- A variety of acidosis problems are associated with acute and chronic alcohol
ingestion.
- Most common is lactic acidosis.
- Alcoholic keto-acidosis may be induced due to accumulation of metabolites
such as beta-hydroxybutyrate.
- Magnesium deficiency is common in the alcoholic patient, often requiring
major replacement. While magnesium levels are widely available, the intracellular nature of this ion leads to difficulty in evaluating the total body magnesium.
Thus, low serum levels of magnesium (< 2 mg) are likely to be associated with
hypomagnesemia, while apparently normal levels do not necessarily ensure
adequate magnesium stores.
- Phosphorus deficiency is common among alcoholics, ranging from 2.5-30.4%.
It becomes an emergency at levels below 1.1 mg/dl, potentially inducing
Rhabdomyolysis, hemolysis or respiratory muscle failure. Phosphorus deficiency can be caused by the malnutrition and endocrine abnormalities associated with alcohol abuse.
Nutritional Problems
- Thiamine deficiency and B6 deficiency are common in alcohol abusers, and are
associated with both poor nutritional intake and absorption abnormalities.
Withdrawal or Abstinence Syndromes

- The abstinence syndrome is characterized by progression through tremulousness
to hallucinosis to delirium tremens.
- Alcohol withdrawal is the most complex of the abstinence syndromes. The
spectrum of symptoms ranges from intoxication, coma, blackouts, rum fits or
withdrawal seizures, tremulousness and hallucinations to delirium tremens.
- The full-blown delirium-tremens syndrome is characterized by confusion,
hallucinations, agitation, sleeplessness and profound hyperactivity of the autonomic nervous system manifested by tachycardia, diaphoresis, fever and
occasional vascular collapse.
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Trauma Management
Principles of Treatment for the Chronic Alcohol User

Therapy for alcohol intoxication, complications and withdrawal symptoms
must be individualized.
Symptoms and physiologic complications must be identified and treated
aggressively.
Specific electrolyte and acid-base disturbances should be corrected.
- Dehydration should be anticipated and treated with infusion of normal saline.
- Initially, glucose solutions should be avoided due to the risk of inducing neurologic deterioration due to Wernicke-Korsakoff syndrome.
- The saline solution should have multiple vitamins, especially B vitamins, and
thiamine (50 mg per liter) added once hypovolemia has been controlled.
- Magnesium deficiency should be treated with 2 grams of magnesium per
liter of intravenous fluids. A total of 8 grams should be administered to
ensure adequate stores.
- Replacement of phosphorus can usually be achieved with oral supplementation. Extremely low levels of phosphorus may be treated with intravenous
phosphorus salts at a dose of 1 mmole per kilogram of body weight, administered
over 24 hours. Care should be taken to avoid hypocalcemia associated with the
administration of phosphorus, and potassium replacement should be performed.
- The ketoacidosis associated with acute alcohol intoxication is best treated with
volume expansion and low-dose glucose administration after vitamin therapy.
- The administration of glucose may increase the utilization of phosphorus, causing
a reduction below initial levels. Therefore, close monitoring and replacement of
phosphorus should be performed.
67
Treatment of Cardiac Rhythm/Contractility

-
Support for inadequate cardiac contractility should be provided aggressively.

Vitamin replacement may reverse some of the underlying pathology.
Digitalization should be considered early if contractility is impaired.
Aggressive hemodynamic monitoring and support with inotropes should be
provided as needed. However, in most cases, there is an excess of catecholamines circulating due to increased sympathetic tone.
- Tachyarrythmias are most commonly due to sympathetic stimulation; treatment is with beta-blockers (propranolol) or false neurotransmitters (clonidine).
Treatment of Abstinence Syndrome

- Treatment of abstinence syndrome is not standardized.
- Mild symptoms are effectively treated with mild sedation using benzodiazepam
or chlorpromazine.
- More severe symptoms require higher doses and combination therapy, including
haloperidol, benzodiazepam, with or without clonidine. Therapy using these
agents must be titrated to effect, occasionally requiring dosages sufficient to
require ventilatory support.
- Alternatively, the use of an alcohol infusion will reverse the neurologic and hemodynamic effects of the withdrawal syndrome. A 10% solution of ETOH should
be titrated to achieve a trace level of alcohol in the blood.
Treatment of Neurologic Problems

- Thiamin, B vitamins, electrolyte replacement with magnesium, phosphorus and
potassium, and sedation are the major therapies for the neurologic complications.
671
- Alcohol withdrawal seizures occur as the alcohol level is decreasing in a given

patient. Treatment for these seizures is symptomatic, with benzodiazepam or
barbiturates.
- Long-term therapy of alcohol withdrawal seizures is not indicated.
Cocaine
Cocaine is one of the most commonly abused substances in trauma victims. In a
recent review, evidence of cocaine use was found in 26.7% of all New York City
residents sustaining fatal injuries. One-third of deaths after cocaine use were the
direct result of the drugs effects, but two-thirds of the deaths resulted from
traumatic injuries from homicides, suicides, traffic accidents and falls.
Neurologic Effects
- Dopaminergic and neuroadrenergic pathways in the central nervous system
probably mediate the effects of cocaine.
- Euphoria is followed rapidly by despair. Repeated doses often lead to return of
the euphoric state and are at the core of the binge-type abuse pattern. Ultimately, the increased use of cocaine may lead to a state of excited delirium
associated with hyperthermia, agitation and often vascular collapse and death.
- There is a high incidence of hemorrhagic and ischemic strokes, as well as
ruptured aneurysms.
Cardiovascular Effects
- Initial effects are vagotonic, inducing a transient bradycardia. In some chronic
abusers of cocaine, there is a persistent suppression of the tachycardic response
to stress. In most cases, the vagolytic episode is rapidly replaced by a sympathetic stimulation induced by reduced reuptake of catecholamines. This is
often complicated by severe hypertension, tachycardia and chest pain.
Respiratory Effects
- Respiratory arrest is an occasional complication of cocaine abuse.
- The underlying pathology may be bronchiolitis obliterans with organizing
pneumonia, interstitial pneumonitis, or pneumothorax with or without pneumomediastinum.
Hematological Effects
- Disseminated intravascular coagulation occurs in severe cases of cocaine overdosage.
Abstinence Syndrome
- Although there is a high level of desire to continue cocaine use in an effort to
regain the euphoria and avoid the depression associated with cessation of cocaine
use, there is not a clear withdrawal syndrome as in opiates or alcohol abuse.
Treatment of Cocaine Use

Treatment of neurologic problems
- Agitation is the most common presenting problem. It is best treated with
benzodiazepines.
- Seizures are typically solitary and require only protective therapy. Status
epilepticus should be treated with intravenous benzodiazepines followed with
phenytoin.
67
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Trauma Management
Table 67.1. General approach to acute drug and alcohol toxicity

1.
2.
3.
4.
5.
6.
7.
When In
Protect Airway
Ventilatory Support
Support Circulation with Volume
Control Hypotension with Dopamine
Control Agitation with Benzodiazepines
Control Hypertension with Calcium Channel Blockers
Encourage Urine Flow with Mannitol and Bicarb
Doubt Try Naloxone
There are many agents recommended to reduce the desire for cocaine use and
the emotional and psychological effects of chronic cocaine use. In particular,
antidepressants and dopamimetic agents may reduce the dysphoria and
depression associated with discontinuing cocaine use.
Treatment of Cardiovascular Function
67
- There are several unique features of treating the hypertensive, arrhythmic and
ischemic cardiac complications associated with cocaine.
- Beta-blockers, although they may be effective, should be avoided because of the
possibility of rebound hypertension due to unopposed alpha effect.
- Nitrates, either sublingual or intravenous, are effective in lowering the blood
pressure, reducing cardiac ischemia and limiting the size of infarctions.
- If nitrates fail, phentolamine or calcium channel blockers are preferred, especially if chest pain is persistent.
- Aspirin and thrombolytics may be used for coronary occlusion; however, the
risk of intra-cranial bleed must be excluded prior to such therapy.
- Arrythmias are best controlled with calcium channel blockers.
Treatment of Hyperthermia
- Acute cocaine intoxication may induce hyperthermic crisis. Treatment should
be initiated immediately with surface-cooling measures.
- Calcium channel blockers are also effective in the treatment of cocaine-induced
hyperthermia.
Opiates
The opiates include a large number of substances, some of which are used for
clinical purposes, and some of which are purely illicit. Specific agents include
opium, morphine, codeine, fentanyl, heroin (also known as smack, scag, junk
and other names) and methadone. There are many combinations and various
other preparations available legally and illegally.
The physiologic damage associated with opiates, unlike alcohol, is limited,
with relatively few systemic complications. However, there are severe physiologic
consequences to the cessation of opiate use once tolerance and addiction have
been established.
Acute opiate intoxication is the most life-threatening complication with this
category of drugs. Direct depression of respiratory centers may lead to cardiopulmonary arrest. The specific antidote for opiate intoxication is naloxone.
Naloxone treatment must be titrated to ensure three effects:
- Dosage
Most patients will respond to .8-1.2 mg; however, larger or repeated doses may
be required.
673
- Duration
Some of the opiate preparations may have a protracted half-life, and a single
injection of naloxone may not provide reversal of adequate duration. Typically,
naloxone will have a duration of action of 1-2 hours while many of the opiate
preparations may have a duration of action of 3-6 hours. In these cases, a continuous intravenous infusion may be required.
- Withdrawal
Acute withdrawal symptoms may be precipitated by the use of naloxone. Care
must be taken to provide adequate symptomatic therapy for withdrawal syndrome.
The physiologic damage associated with opiates, unlike alcohol, is limited,

with relatively few chronic systemic complications. The most significant medical
issues in chronic opiate abuse are secondary complications including:
-
Malnutrition
Infections and sexually transmitted diseases (hepatitis B and C, AIDS)
Bacterial endocarditis, skin and soft tissue infections, tuberculosis
Complications of injection and impurities (thrombophlebitis, pulmonary
fibrosis, talcosis, pulmonary vascular abnormalities, bullous disease, especially
of the upper lung fields)
There are severe physiological consequences to the cessation of opiate use

once tolerance and addiction have been established.
- The abrupt discontinuation of opiates precipitates a withdrawal syndrome, which
is typically no more severe than a serious bout of influenza.
- The symptoms of nausea, vomiting and anxiety can be treated with combinations
of benzodiazepam and clonidine.
- In severe cases or in the presence of unstable medical conditions, methadone
may be used to replace the opiate, with a reduced euphoria component.
References
1.
2.
3.
4.
5.
OConnor PG, Samet JH, Stein MD. Management of hospitalized intravenous

drug users: Role of the internist. Am J Med 1994; 96(6):551-558.
Spies CD, Dubisz N, Neumann T et al. Therapy of alcohol withdrawal syndrome
in intensive care unit patients following trauma: Results of a prospective, randomized trial. Crit Care Med 1996; 24(3):414-422.
Spies CD, Rommelspacher H. Alcohol withdrawal in the surgical patient: Prevention and treatment. Anesthesia & Analgesia 1999; 88(4):946-954.
Cornwell EE III, Belzberg H, Velmahos G et al. The prevalence and effect of alcohol and drug abuse on cohort-matched critically injured patients. Am Surgeon
1998; 64:461-465.
Li G, Keyl P, Smith GS et al. Alcohol and injury severity: Reappraisal of the continuing controversy. J Trauma 1997; 42(3):562-569.
67
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INDEX
Index
Abdominal compartment 310, 362,

363, 368, 369, 374, 376-379
Abdominal compartment syndrome
(ACS) 310, 362, 363, 368, 369,
374, 376-379, 579, 662
Abdominal trauma 30, 38, 209
Acidemia 71, 372, 373, 378
Adrenal insufficiency 567, 570-573,
575
Advanced Trauma Life Support
(ATLS) 16, 28, 70, 82, 201, 225,
231, 273, 283, 357, 417, 483, 484,
491, 493, 546, 550, 656
Alcohol 22, 51, 76, 125, 210, 321, 389,
426, 506, 510, 554, 567, 594, 666,
668, 669, 670, 671, 672, 673
Alcohol abuse 669, 671
Ankle injury 51, 127, 141, 415, 421,
423
Anticonvulsants 88, 568
Aorta 27, 70, 192, 197, 199, 205,
221-227, 229-233, 235, 258, 260,
262, 263, 265, 268, 271, 274, 275,
277, 310, 358-362, 380, 385, 394,
399, 485, 502, 519, 548
Audit filters 659
Caliber 84, 266, 269, 311, 417, 533,

536, 537, 539, 541-543
Carotid artery 128, 135-140, 199,
222, 230, 233, 253, 512, 514
Catheterization 73, 123, 290, 344,
476, 505, 584, 629
Celiac axis 358-360
Chest trauma 7, 194, 199, 200,
210-212, 217, 220, 238, 254, 265,
485, 494
Chest tube 18, 27, 192, 195, 196, 198,
199, 213, 217, 218, 220, 250, 269,
270, 290, 485, 497, 530, 550
Chest wall injury 212
Child abuse 489-491, 554
Cirrhosis 669
Clavicle 21, 127, 135, 141, 143, 144,
148-150, 172, 173, 177-182, 190,
232, 258
Clindamycin 57
Coagulopathy 22, 64, 75, 310, 370,
373, 378, 379, 417, 453, 503, 505,
520, 523, 579, 602, 607, 631, 632,
642, 653
Colon injury 340, 347
Colostomy 340, 345, 347
Compartment syndrome 24, 310,
362, 363, 368, 369, 374, 376-379,
405-410, 412, 414, 416, 418, 425,
441, 442, 579, 619, 659
Consciousness 5, 21, 25, 54, 85-90,
96, 122, 123, 193, 284, 575, 594,
607, 665
Cost of injury 661, 662
Cytomegalovirus (CMV) 636
B
Basilar skull fracture 22, 93, 97-99
Bile duct trauma 391
Bladder injury 380, 382, 400
Bladder pressures 366, 368, 375
Bladder trauma 400, 401
Blast effect 350, 351
Blast injuries 544-546, 551
Blast lung injury 546, 550, 552
Brachial plexus injury 171, 178, 179,
183, 184
Brain death 87, 88, 602, 603, 606
D
Damage control operations 364, 370,
373
Deep vein thrombosis (DVT) 323,
418, 477, 519, 646, 647, 651-654,
659
675
Index
E
Elbow dislocation 51
Empyema 191, 192, 198, 199, 217,
220, 253, 529, 659
Endotracheal intubation 5, 6, 13, 18,
41, 52, 65, 68, 73, 78, 131, 160,
169, 212, 231, 273, 467, 494-496,
572, 596, 600
Enteral nutrition 582-584
Epidural hematoma 85, 87, 93
Esophageal injury 249-251, 253, 265
Explosions 425, 544, 545, 550, 551
Extremity fracture 378
F
Fasciotomy 408-412, 416, 418, 424,
425, 441, 442, 619
Fat embolism 663-665, 667
Femur fracture 8, 446, 509
Flail chest 19, 22, 51, 187, 188, 189,
190, 194, 212, 223, 493
Foreign bodies 17, 128, 343, 346, 347,
379, 414, 419, 421, 430, 624
G
Gallbladder trauma 389, 391
Gelfoam 23, 506, 508, 511
Glasgow Coma Score (GCS) 6, 8, 9,
18, 21, 26, 87-90, 122, 127, 480,
483-494, 610, 617, 659
Growth hormone 40, 575
H
Hematuria 284, 293, 299, 348, 349,
351, 354, 395, 452, 485, 486, 620
Hemothorax 21, 25, 69, 74, 127, 141,
191, 195, 196, 199, 212, 213,
214, 217-220, 229, 234, 246, 250,
254, 380, 485, 529, 546
Heparin 138, 226, 417, 519, 597, 600,
601, 652-654, 666
Hepatic artery 294, 303, 309, 310,
359, 391
Hepatic trauma 388
Hepatitis 389
Hypercalcemia 573-575
Hyphema 98
Hypocalcemia 620, 621, 632, 633,
670
Hypokalemia 567, 575, 604
Hypomagnesemia 669
Hypotension 19, 43-47, 49, 51, 58-62,
69, 70, 76-78, 80-82, 88, 135,
141, 152, 196, 200, 212, 286,
290, 305, 316, 357, 363, 364,
366, 368, 371, 378, 395, 398,
409, 410, 413, 416, 440, 462,
467, 475, 482, 483, 485, 493,
497, 504, 528, 545, 570, 573,
579, 597, 602, 604, 607, 632,
643, 644, 669, 673
Hypothermia 22, 75, 310, 312, 364,
365, 373, 417, 453, 494, 497,
566, 571, 579, 604, 607-609, 629,
631-633, 635
Hypovolemia 11, 72, 81, 89, 200, 226,
304, 312, 362, 366, 371, 385,
398, 399, 464, 494, 588, 597,
600, 607, 631, 640, 670
I
Iliac vessels 342
Intercostal nerve block 51, 187
Intraabdominal pressure 312, 363, 364
Intracranial hematoma 87, 291
Intracranial hypertension 90, 483
Index
Diabetes insipidus 575, 576, 602, 604

Diabetes mellitus 563-566
26, 27, 29, 240, 241, 284, 286,
287, 290-292, 296, 297, 316, 330,
337, 342, 347, 381, 382, 547, 551
Diaphragm injury 244
Disseminated intravascular coordination (DIC) 602, 604, 642, 644
Duodenal injury 330, 333-335, 337,
338, 392
676
Intracranial pressure (ICP) 8, 40, 41,
43, 46-48, 52, 54-63, 86, 88-90,
92, 126, 363, 483, 528, 659
Intracranial pressure monitoring 89
Index
L
Laparoscopy 239, 242, 244, 245, 246,
247, 248, 261, 284, 290, 299, 300,
301, 527-531
Laparotomy 27, 29, 31, 36, 201, 238,
239, 242, 244-247, 261, 286-288,
290-292, 299-302, 310, 317, 343,
344, 346, 350, 356, 358, 366-368,
370, 373, 374, 376, 379, 381, 385
Le Fort fractures 100
Liver injury 288, 305, 306, 313, 388,
389, 391, 630
Loop closure 659
Lung injury 188, 191, 197, 212, 214,
217, 219, 220, 254, 546, 550, 552,
633, 644
Trauma Management
O
Organ donation 604
Osteoporosis 492
Oxygen saturation 71, 73, 76, 81, 213,
226, 480, 496, 595, 603
Pancreatitis 323, 332, 338, 563, 566,

567
Pelvic fracture 8, 12, 23, 24, 27, 222,
291, 306, 343, 345, 351-353, 376,
400, 451-453, 457, 485, 498, 508,
510, 511, 519
Pelvic injury 342
Performance improvement 655, 656,
659, 660-662
Pericardial tamponade 20, 69, 72, 73,
81, 218, 271, 272
Pericardial window 529
Peroneal compartment 442
Peroneal nerve 406
M
Pneumothorax 7, 19, 20, 22, 27, 40,
52, 72-74, 80, 127, 128, 177, 186,
Mandibular fracture 100, 109
191, 195-197, 212, 213, 215, 217,
Median nerve 51, 176
218, 220, 250, 254, 256, 257, 260,
Mesenteric injury 380, 394
287, 380, 394, 485, 519, 528-530,
Mesenteric vessels 326, 331, 359
550, 582, 584, 671
Mesh closure 376, 377
Popliteal artery 409, 420, 423, 444,
Methylprednisolone 468, 606, 643
501
Mortality review 657
Portal vein 310, 311, 356, 359, 362,
Multiple organ dysfunction syndrome
364, 388, 391
374, 577, 579
Pregnancy 25, 29, 286, 291, 468,
Myoglobinuria 49, 73, 407, 442, 619
496-498, 500, 503, 636
Presacral drainage 340, 345, 347
N
Pringle maneuver 309, 310
Pulmonary artery pressure 75, 78
Nerve block 51, 187
Pulmonary contusion 19, 25, 191,
Nerve grafting 171, 179, 180
194, 212-214, 217, 218, 220, 254,
Nerve injury 21, 130, 160, 171, 172,
257, 316, 485, 666
174, 177, 180, 227, 413, 426, 429,
Pulmonary
embolism 418, 515, 516,
545
519, 646, 648, 651, 659
Nerve repair 179, 180, 182
Pulmonary injury 173, 182, 191, 193,
Nerve transfer 179, 180, 183, 184
199, 220, 226, 580
Neurogenic shock 20, 27, 76, 462, 464,
473, 475
Q
Nutrition 111, 312, 566, 567, 574,
575, 581, 582-584
Quality improvement 613, 662
R
Rectal injury 23, 340, 341, 343, 344,
345, 346, 347
Renal trauma 288, 395, 397
Resuscitation 3, 4, 5, 8, 11, 13, 14, 17,
20, 25, 28, 41, 51, 62, 66, 69,
72-76, 80, 82, 158, 195, 205, 210,
218, 220, 224, 226, 230-233, 236,
271, 273, 276, 288, 292, 311, 317,
320, 342, 344, 356, 365, 371, 385,
388, 394, 417, 425, 438, 453, 480,
482, 483, 491, 493, 498, 500, 563,
578, 580, 588, 589, 592, 596, 597,
604, 610, 621, 622, 629-631, 634,
635, 668
Retina 96
Retrograde urethrogram 295, 353,
400, 452
Retroperitoneal hematoma 287, 330,
342, 350, 357, 382, 453, 511, 519
Rhabdomyolysis 40, 73, 575, 584, 592,
619, 621, 669
Rib fracture (s) 174, 186, 257, 269,
485, 494
S
Saphenous vein cutdown 19
Scoop and run 201, 550
Sepsis 16, 56, 69, 71, 77, 92, 227, 241,
247, 312, 314, 332, 338, 343, 345,
347, 468, 525, 567, 582, 584, 623
Shock 4, 7, 8, 9, 11-13, 18-20, 24, 26,
27, 39, 58, 69-73, 75-82, 92, 127,
195, 196, 200, 209, 212, 218, 239,
315-317, 341, 342, 345, 357, 363,
370-372, 374, 378, 380, 385, 394,
395, 398, 399, 414, 425, 462, 464,
473, 475, 480, 482, 497, 544, 545,
550, 567, 570, 573, 575, 578, 602,
609, 618-622, 629-634, 644
Skull fracture 22, 85, 93, 97, 98, 99,
485, 489, 546, 575
Small bowel injury 284
Spinal cord injury 20, 21, 23, 40, 69,
76, 458, 461, 463, 464, 467, 469,
475, 476, 478, 483, 519, 574, 619,
651, 659
Splenic trauma 292, 318, 385

Splinting 13, 51, 107, 112, 182, 430,
431
Sternal fracture 190, 258, 260
Stress ulceration 589
Subarachnoid hemorrhage 72, 90, 92
Subdural hematoma 84, 91
Systemic inflammatory response
syndrome (SIRS) 582
T
Tachycardia 2, 11, 19, 20, 40, 55, 57,
59, 60, 69, 74, 76, 78, 80-82, 89,
196, 200, 212, 305, 316, 363,
364, 398, 477, 497, 505, 528,
568, 569, 597, 604, 647, 665,
669, 671
Tension pneumothorax 7, 19, 20, 22,
72, 74, 80, 195, 196, 212, 213,
215, 220, 256, 528-530, 550
Terrorist acts 544
Tetanus 102, 417, 426, 498, 499
Thoracostomy 7, 14, 19, 20, 25, 141,
195, 198, 206, 212, 213, 217,
220, 240, 244, 246, 483, 528, 530
Thoracotomy 27, 143, 191, 192,
196-199, 204-207, 210, 212, 214,
217-220, 226, 231, 232, 234, 235,
238, 246, 250, 251, 271-276, 278,
279, 356, 358, 438, 530
Thrombocytopenia 82, 519, 572, 620,
632, 652, 663, 665, 666
Thyroid emergencies 570
Total parenteral nutrition (TPN)
580, 582, 584
Traction injuries 172
Traction injury 234
Transfusion 75, 77, 78, 312, 320, 322,
323, 373, 378, 453, 498, 505,
578, 604, 631, 632, 633, 636-641,
643-645
Trauma nurse coordinator 655, 662
Trauma program manager 655
Tube thoracostomy 19, 20, 195, 198,
212, 217, 220
Index
677
Index
678
Trauma Management
Vein injury 424

Vena cava filters 515, 516, 526
Vena cava injury 309
Ventilation 4, 5, 7, 9, 11, 13, 18, 19, 23,
41, 52, 54, 55, 62-65, 70, 77, 78,
79, 191, 205, 272, 363, 375, 376,
395
Vertebral artery 92, 128, 152, 154-156
Ureteral injury 526

Urethral injury 353, 400, 402, 452
Index
V
Vaccination status 417
Vascular injury 22, 24, 73, 74, 101,
133, 135, 141, 143, 152, 173, 177,
179, 182, 183, 199, 230, 254, 273,
321, 356, 357, 398, 405, 413-415,
418, 421, 422, 424, 425, 440, 442,
443, 474, 511, 512, 546

Trauma Management

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v a d e m e c u m

Demetrios Demetriades, M.D., Ph.D., F.A.C.S.

Juan A. Asensio, M.D., F.A.C.S.

Library of Congress Cataloging-in-Publication Data

Emergency Room Care

3. Ultrasound in Trauma ................................................................ 29

4. Analgesia and Sedation in Trauma .............................................. 39

5. Emergency Airway Management in the Trauma Patient ............. 54

6. Shock and Resuscitation ............................................................. 69

8. Maxillofacial Trauma .................................................................. 94

10. Penetrating Injuries of the Neck ............................................... 127

11. Carotid Artery Injuries ............................................................. 135

12. Subclavian and Axillary Vascular Injuries .................................. 141

13. Vertebral Artery Injuries .......................................................... 152

14. Laryngotracheal Injuries ........................................................... 157

15. Traumatic Brachial Plexus Injuries ............................................ 171

17. Penetrating Chest Injuries: Evaluation and Management .......... 195

18. Cardiac Injuries ........................................................................ 200

19. Lung Injuries ............................................................................ 212

20. Blunt Aortic Trauma ................................................................ 221

21. Penetrating Thoracic Vascular Injuries ...................................... 229

22. Diaphragm Injuries .................................................................. 237

23. Esophageal Injury ..................................................................... 249

24. CT Scan in Chest Trauma ........................................................ 254

25. Emergency Department Thoracotomy ..................................... 271

27. Evaluation of Penetrating Abdominal Trauma .......................... 293

28. Hepatic Injuries and Bile Duct Injuries .................................... 303

29. Splenic Injuries ......................................................................... 314

30. Pancreatic Injuries .................................................................... 326

31. Duodenal Injuries ..................................................................... 333

32. Colon/Rectal Injuries ................................................................ 340

33. Genitourinary Tract Trauma ..................................................... 348

34. Abdominal Vascular Injury ....................................................... 356

35. Abdominal Compartment Syndrome ........................................ 363

36. Damage Control Operations .................................................... 370

37. CT Scan in Abdominal Trauma ................................................ 380

39. Penetrating Extremity Injury .................................................... 413

40. Popliteal Vessel Injuries ............................................................. 420

41. Hand Trauma ........................................................................... 426

43. Pelvic Fractures and the General Surgeon ................................. 450

44. Spinal Injuries .......................................................................... 458

46. Geriatric Trauma ...................................................................... 492

47. Trauma in Pregnancy ................................................................ 496

48. Interventional Radiology in the Care

49. Minimally Invasive Surgery in Trauma ..................................... 527

50. Ballistics of Gunshot Injuries .................................................... 532

51. Blast Injuries ............................................................................. 544

52. Forensics for Trauma Care Givers ............................................. 553

53. Endocrine Problems in Trauma ................................................. 563

54. MOF Failure: MOF Syndrome ................................................. 577

55. Surgical Nutrition ..................................................................... 581

56. Acute Burn Injury ..................................................................... 585

57. Inhalation Injury ...................................................................... 594

59. Hypothermia in Trauma Patients ............................................. 607

60. Trauma Scores .......................................................................... 610

61. Crush Syndrome ....................................................................... 618

62. Anesthesia of the Traumatized Patient ...................................... 623

63. Transfusion Therapy ................................................................. 636

64. Venous Thromboembolism After Injury ................................... 646