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(BQ) Part 1 book The trauma manual - trauma and acute care surgery has contents: Introduction to trauma care, airway management and anesthesia, physiologic response to injury, damage control surgery, nutritional intervention, interventional radiology,... and other contents.
d te ni -U r9 tahir99 - UnitedVRG vip.persianss.ir Trim: 5.25in × 8.375in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 THE TRAUMA MANUAL: TRAUMA AND ACUTE CARE SURGERY r9 -U ni te dV R G Fourth Edition hi LWBK1111-fm Top: 0.249in ta P1: tahir99 - UnitedVRG vip.persianss.ir i 19:44 Trim: 5.25in × 8.375in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 19:44 ni te dV R G LWBK1111-fm Top: 0.249in hi r9 -U This page intentionally left blank ta P1: tahir99 - UnitedVRG vip.persianss.ir ii Trim: 5.25in × 8.375in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 THE TRAUMA MANUAL: TRAUMA AND ACUTE CARE SURGERY Fourth Edition R G Editors ni te Mark M Ravitch Professor Chief, Trauma and General Surgery Department of Surgery University of Pittsburgh School of Medicine Pittsburgh, PA dV Andrew B Peitzman, MD Donald M Yealy, MD -U Professor and Chair of Emergency Medicine University of Pittsburgh/University of Pittsburgh Physicians Pittsburgh, PA Timothy C Fabian, MD r9 Harwell Wilson Alumni Professor and Chairman Department of Surgery University of Tennessee Health Science Center Memphis, TN hi LWBK1111-fm Top: 0.249in Michael Rhodes, MD ta P1: Professor of Surgery Thomas Jefferson University Chair, Department of Surgery Christiana Care Health Systems Wilmington, DE C William Schwab, MD Professor of Surgery Department of Surgery Perelman School of Medicine University of Pennsylvania Division of Traumatology, Surgical Critical Care & Emergency Surgery Hospital of the University of Pennsylvania Philadelphia, PA tahir99 - UnitedVRG vip.persianss.ir iii 19:44 Trim: 5.25in × 8.375in LWBK1111-fm Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 Acquisitions Editor: Brian Brown Product Manager: Brendan Huffman Production Manager: Bridgett Dougherty Senior Manufacturing Manager: Benjamin Rivera Marketing Manager: Lisa Lawrence Design Coordinator: Teresa Mallon Production Service: Aptara, Inc ©2013 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com R G All rights reserved This book is protected by copyright No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright dV P1: ni te Printed in China -U Library of Congress Cataloging-in-Publication Data available upon request ISBN-13: 978-1-4511-1679-3 ISBN-10: 1-4511-1679-3 ta hi r9 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 2232300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 tahir99 - UnitedVRG vip.persianss.ir iv 19:44 Trim: 5.25in × 8.375in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 r9 -U ni te dV R G This book is dedicated to those who have given their lives, and those who daily risk their lives, in the care of the injured hi LWBK1111-fm Top: 0.249in ta P1: tahir99 - UnitedVRG vip.persianss.ir v 19:44 P1: Trim: 5.25in × 8.375in LWBK1111-fm Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 19:44 This page intentionally left blank tahir99 - UnitedVRG vip.persianss.ir vi P1: Trim: 5.25in × 8.375in LWBK1111-fm Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 Contributors Michel B Aboutanos, MD, MPH, FACS Professor of Surgery Director, International Trauma System Development Program Division of Trauma, Critical Care & Emergency Surgery Department of Surgery Virginia Commonwealth University Medical Center Richmond, VA Syed M Faisal Alam, MD Vascular Surgery Fellow Division of Vascular and Endovascular Surgery Department of Surgery The University of Tennessee Health Science Center Memphis, TN Louis H Alarcon, MD Medical Director, Trauma Surgery Associate Professor of Surgery and Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, PA Darwin Ang, MD, PhD, MPH Associate Professor of Surgery Trauma Medical Director, Ocala Regional Director of Research USF/HCA Trauma Network University of South Florida Tampa, FL Derek C Angus, MD, MPH, FRCP Chair, Department of Critical Care Medicine The Mitchell P Fink Endowed Chair in Critical Care Medicine Professor of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, PA Juan A Asensio, MD, FACS, FCCM, FRCS Professor of Surgery Department of Surgery University of Miami Miller School of Medicine Director, Trauma Clinical Research, Training and Community Affairs Department of Surgery University of Miami Miller School of Medicine Miami, FL Vishal Bansal, MD, FACS Assistant Professor of Surgery Division of Trauma, Burns and Surgical Critical Care University of California San Diego Health Sciences San Diego, CA Philip S Barie, MD, MBA, FIDSA, FCCM, FACS Professor Departments of Surgery and Public Health Weill Cornell Medical College Chief Preston A (Pep) Wade Acute Care Surgery Service New York-Presbyterian Hospital/Weill Cornell Medical Center New York, NY Tiffany K Bee, MD Associate Professor of Surgery The University of Tennessee Health Science Center Memphis, TN Matthew V Benns, MD Assistant Professor of Surgery School of Medicine University of Louisville Louisville, KY Timothy R Billiar, MD, FACS George Vance Foster Professor and Chairman Department of Surgery University of Pittsburgh School of Medicine Pittsburgh, PA Thane A Blinman, MD Associate Director of Trauma Division of General, Thoracic and Fetal Surgery The Children’s Hospital of Philadelphia Philadelphia, PA Deanna M Blisard, MD Department of Critical Care Medicine and Surgery University of Pittsburgh Medical Center Pittsburgh, PA Amir Blumenfeld, MD, MHA Former Chief, Trauma Branch Israeli Defense Forces Israel vii tahir99 - UnitedVRG vip.persianss.ir 19:44 P1: Trim: 5.25in × 8.375in LWBK1111-fm viii Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 Contributors Charles C Branas, PhD Professor of Epidemiology Perelman School of Medicine University of Pennsylvania Philadelphia, PA Benjamin Braslow, MD, FACS Associate Professor of Surgery Division of Trauma, Emergency General Surgery & Surgical Critical Care Section Chief of Emergency General Surgery Department of Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, PA Susan Miller Briggs, MD, MPH Associate Professor of Surgery Harvard Medical School Director, International Trauma and Disaster Institute Massachusetts General Hospital Boston, MA L.D Britt, MD, MPH, FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon) Brickhouse Professor and Chairman Eastern Virginia Medical School Department of Surgery Norfolk, VA Joshua B Brown, MD General Surgery Resident Department of Surgery University of Pittsburgh Medical Center Pittsburgh, PA Jodie A Bryk, MD Chief Internal Medicine Resident University of Pittsburgh School of Medicine Pittsburgh, PA Christopher H Byrne, MD Assistant Professor of Surgery Department of Surgery The University of Tennessee Health Science Center Memphis, TN Asim F Choudhri, MD Assistant Professor of Radiology and Neurosurgery The University of Tennessee Health Science Center Memphis, TN Director of Neuroradiology Le Bonheur Neuroscience Institute Le Bonheur Children’s Hospital Memphis, TN William L Chung, DDS, MD Associate Professor Department of Oral & Maxillofacial Surgery University of Pittsburgh Medical Center Pittsburgh, PA Mark Cipolle, MD, PhD Medical Director, Trauma Program Christiana Care Health System Wilmington, DE Mitchell J Cohen, MD Associate Professor of Surgery Division of General Surgery Director of Acute Care Research San Francisco Injury Center University of California San Francisco, CA Raul Coimbra, MD, PhD, FACS The Monroe E Trout Professor of Surgery Executive Vice-Chairman, Department of Surgery Chief Division of Trauma, Surgical Critical Care, and Burns UC San Diego Health System San Diego, CA David C Cone, MD Professor and EMS Section Chief Department of Emergency Medicine Yale University School of Medicine New Haven, CT Michael W Cripps, MD Assistant Professor of Surgery UT Southwestern Medical Center Dallas, TX Martin A Croce, MD Professor of Surgery Chief, Trauma and Surgical Critical Care The University of Tennessee Health Science Center Memphis, TN tahir99 - UnitedVRG vip.persianss.ir 19:44 P1: Trim: 5.25in × 8.375in LWBK1111-fm Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 Contributors Frederick J Denstman, MD Section, Colon and Rectal Surgery Christiana Care Health System Wilmington, DE Jennifer M DiCocco, MD General Surgery Chief Resident Department of Surgery The University of Tennessee Health Science Center Memphis, TN Soumitra R Eachempati, MD, FACS, FCCM Professor of Surgery and Public Health Weill Cornell Medical College Chief, Trauma Services and Surgical Intensive Care Unit New York-Presbyterian Hospital New York Weill Cornell Center New York, NY Philip A Efron, MD Assistant Professor of Surgery and Anesthesiology Co-director, Laboratory of Inflammation Biology and Surgical Science Associate Director, Trauma ICU Program Director, Surgical Critical Care Residency Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care College of Medicine University of Florida Gainesville, FL Timothy C Fabian, MD Harwell Wilson Alumni Professor and Chairman Department of Surgery University of Tennessee Health Science Center Memphis, TN David V Feliciano, MD Professor Department of Surgery Emory University School of Medicine Surgeon-in-Chief Department of Surgery Grady Memorial Hospital Atlanta, GA John Fildes, MD, FACS, FCCM Professor and Vice Chair Department of Surgery Chief, Division of Acute Care Surgery University of Nevada School of Medicine Las Vegas, NV ix Abe Fingerhut, MD Hippokration Hospital and Medical School Athens, Greece Gerard Fulda, MD, FACS, FCCM Director, Surgical Critical Care and Surgical Research Christiana Care Health Systems Associate Professor of Surgery Jefferson Medical College Newark, DE Gary N Galang, MD Vice Chairman for Operations UPMC Rehabilitation Institute UPMC Mercy Hospital Pittsburgh, PA Frederick Giberson, MD, MS Assistant Professor of Surgery Jefferson Medical College Program Director, General Surgery Christiana Care Health Services Newark, DE Steven P Goldberg, MD Assistant Professor of Surgery Division of Pediatric Cardiothoracic Surgery The University of Tennessee Health Science Center Le Bonheur Children’s Hospital Memphis, TN Daniel J Grabo, MD Division of Traumatology, Surgical Critical Care and Emergency Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, PA Vicente H Gracias, MD Professor of Surgery Department of Surgery Chief Trauma, Emergency Surgery, Surgical Critical Care UMDNJ-Robert Wood Johnson Medical School New Brunswick, NJ Francis X Guyette, MD, MPH Assistant Professor, Department of Emergency Medicine Medical Director, STAT MedEvac Pittsburgh, PA tahir99 - UnitedVRG vip.persianss.ir 19:44 P1: Trim: 5.25in × 8.375in LWBK1111-28 342 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 The Trauma Manual: Trauma and Acute Care Surgery ii Subclavian artery a) Presentation Superior mediastinal hematoma or neck hematoma Proximal injuries can present with massive left hemothorax b) Exposure The proximal subclavian artery is accessed by a median sternotomy An infra- or supraclavicular extension is used to gain distal control with or without removal of the clavicle c) Technique Primary repair or interposition graft with PTFE If possible based on patient stability, an endovascular stent is an excellent option iii Pulmonary hilum a) Presentation Massive hemothorax on the side of injury b) Exposure Anterolateral thoracotomy on the side of injury Control can also be gained initially through a median sternotomy c) Technique Control of hilar hemorrhage can be accomplished initially by manual compression Quick dissection of the inferior pulmonary ligament aids in the isolation and identification of the bleeding site Exsanguinating hemorrhage can then be definitively stopped by placing a clamp across the entire hilum 1) Intrapericardial control of hilar vessels is used for proximal injury to the pulmonary artery or vein, if necessary Primary repair is desirable; however, lobectomy should be considered early if bleeding is not easily controlled 2) With the advent of stapled pulmonary tractotomy and stapled pneumonectomy, approximately 85% of pulmonary injuries will be spared resection 3) Pneumonectomy is rarely required to stop hilar bleeding and carries high postoperative morbidity and mortality iv Intercostal arteries a) Presentation Hemothorax or subcutaneous hematoma b) Exposure Thoracotomy on the side of injury c) Technique Simple ligation proximal and distal to the injury v Internal mammary artery a) Presentation Hemothorax, superior or middle mediastinal hematoma b) Exposure Median sternotomy or anterolateral thoracotomy c) Technique Simple ligation proximal and distal to the injury Bilateral internal mammary artery ligation can be performed safely in most patients vi Azygos and hemiazygos veins a) Presentation Hemothorax b) Exposure Thoracotomy on the side of hemothorax c) Technique Suture ligation proximal and distal to injury Take care to avoid inadvertent injury to the thoracic duct on the left Diaphragmatic injury a Blunt trauma Diaphragmatic injury from blunt forces is classically large, radial, and located posterolaterally The left hemidiaphragm is involved in 65% to 80% of cases Diaphragmatic ruptures are markers for associated intraabdominal injuries b Penetrating trauma Wounds are smaller but tend to enlarge over time Left-sided injuries still predominate These injuries required operative repair when diagnosed as they not heal spontaneously and can produce herniation or strangulation of hollow viscera as late sequelae c Diagnosis i Diagnosis can be difficult; therefore, a high index of suspicion based on mechanism is required a) Rapid deceleration or direct crush to the upper abdomen b) Severe chest trauma, lower rib fractures c) Penetrating injuries to the chest and upper abdomen 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 Top: 0.249in LWW-Peitzman-educational Gutter: 0.498in September 19, 2012 Chapter 28 r Thoracic Injuries 343 ii CXR is diagnostic in only 25% to 50% of cases of blunt trauma Possible findings include: a) Hemidiaphragmatic elevation or lower lobe atelectasis b) Nasogastric tube in left hemithorax c) Stomach, colon, or small bowel herniated into chest d) In penetrating trauma and small defects, the diaphragm appears normal e) Positive pressure can tamponade visceral herniation and make the CXR appear normal After extubation, herniation may become apparent on CXR iii Right hemidiaphragm tears are less likely to be diagnosed by CXR because of the presence of the liver in the defect iv CT scan may miss diaphragmatic injury in the absence of gross hollow visceral herniation v Diagnostic peritoneal lavage (DPL) yields false-negative results in 25% to 34% of diaphragmatic injuries If an ipsilateral chest tube is present, DPL fluid may be observed exiting the chest tube, although this finding is rare vi Direct visualization of the injury by laparotomy, laparoscopy, or thoracoscopy remains the standard for diagnosis d Treatment i Diaphragmatic tears require repair ii Acute repair is accomplished via laparotomy, in most cases, with nonabsorbable, interrupted horizontal mattress sutures iii Thoracotomy may be needed to reduce large defects in chronic herniation iv Prosthetic material or flaps are rarely needed to close the defect v The mortality rate is 25% to 40% because of the severity of associated injuries Esophageal injury a Most injuries result from penetrating trauma Blunt injury is rare (50% Sternal fractures Of these, 40% will have associated rib fractures and 25% will have associated long-bone injury Fractures of ribs to a The main clinical issues are pain and restriction of ventilation with impair- ment of both static and dynamic compliances b Search for pulmonary contusion and BCI c Provide adequate pain relief by epidural anesthesia, PCA, or intercostal nerve blocks Fractures of ribs to 12 A 10% risk exists of associated hepatic (right- sided fractures), and a 20% risk of splenic (left-sided fractures), or renal injuries VII EMERGENCY THORACIC PROCEDURES A Tube thoracostomy (Fig 28-6) The usual insertion site is the fifth intercostal space at the anterior to mid-axillary line Identify the space between the pectoralis major anteriorly and the latissimus dorsi posteriorly (Fig 28-6A) Do not insert tubes through traumatic wounds Use a large caliber chest tube (≥36 to 40 Fr) to ensure adequate drainage of the pleural space Administer a single dose of prophylactic antibiotics such as cefazolin or cefoxitin Prepare and drape the chest Anesthetize the site locally with 1% lidocaine (10 to 20 mL), including the skin, periosteum, subpleural space, and pleura Except under the most life-threatening circumstances, proper local anesthesia must be used to minimize patient discomfort Commence with to cm horizontal skin incision below the selected interspace and continue the incision down to the chest wall (Fig 28-6B) With a large curved Kelly clamp, carefully puncture the parietal pleura just above the rib, avoiding the neurovascular bundle coursing along the inferior border Spread the intercostal muscles Remove the clamp and insert a finger into the pleural space to confirm appropriate position and to clear any adhesions that may be present (Fig 28-6C) Use the clamp or a finger as a guide to advance and position the tube into the pleural space Guide the tube posteriorly and toward the apex of the pleural space (Fig 28-6D–F) If correctly placed, the tube should “fog” with expiration After placement, run a finger along the tube to confirm proper placement Confirm that all of the holes are within the pleural space Rotating the tube 360 degrees ensures that it is not kinked in the chest 10 Connect the tube to an underwater-seal apparatus and apply at 20 cm of water suction For known hemothoraces, use an autotransfusion reservoir 11 Secure tube with 0-silk sutures Tape all tube connections to prevent separation 12 Obtain a CXR to confirm proper placement B Pericardiocentesis (Fig 28-7) Indications 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 346 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 The Trauma Manual: Trauma and Acute Care Surgery Figure 28-6 Steps for chest tube insertion (Figures A–F) (From Trunkey DD, Guernsey JM Surgical procedures In: Blaisdell FW, Trunkey DD, eds Trauma Management—Cervicothoracic Trauma New York, NY: Thieme Medical Publishers; 1986:310, with permission.) (continued ) a Acute distension of the pericardial sac with as little as 75 to 100 mL of blood can produce cardiac tamponade Withdrawal of this fluid is lifesaving However, it is difficult to aspirate fluid, especially if it accumulates posteriorly Similarly, clot cannot be aspirated b When used for diagnosis, pericardiocentesis can produce false-negative results in 50% to 60% of cases because of pericardial blood clotting or needle misplacement c In acute cardiac tamponade, pericardiocentesis can be used as a temporizing maneuver until definitive pericardiotomy is possible d Pericardiocentesis is rarely indicated in a level I trauma center Technique a A 16 or 18 gauge long (6 ) needle is connected to a 30 mL syringe The needle is introduced at the left xiphisternal junction (Larrey’s point) and directed toward the left shoulder and at a 45-degree angle to the skin Back pressure is placed on the plunger of the syringe as the needle is advanced b Blood (30 mL) is withdrawn and the clinical situation is reassessed If no improvement is noted, aspiration is repeated 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 Chapter 28 r Thoracic Injuries 347 Figure 28-6 (Continued ) Complications a Iatrogenic coronary artery injury, myocardial laceration, pneumothorax, hemothorax, and mediastinal hematoma can occur b False-positive return can occur when the ventricle or a hemothorax is inad- vertently entered C Pericardial window (Fig 28-8) Sub-xiphoid pericardial window should be considered in the patient who is at risk of cardiac injury but who has maintained adequate vital signs As mentioned, pericardial tamponade is rapidly fatal If the patient is in extremis or hypotensive, prompt left anterolateral thoracotomy is indicated However, in a more stable patient with a parasternal penetrating wound suggestive of possible cardiac injury, a sub-xiphoid pericardial window is safer and more definitive than pericardiocentesis Technique a Sub-xiphoid pericardial window is performed in the OR under general anesthesia b Prepare the patient from chin to midthighs before induction of general anesthesia in anticipation of acute hemodynamic decompensation c A 10 cm incision is made over the xiphoid process and extend cephalad and caudal the upper midline of the abdomen 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 348 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 The Trauma Manual: Trauma and Acute Care Surgery Figure 28-7 Pericardiocentesis (From Rich NM, Spencer FC Vascular Trauma Philadelphia, PA: WB Saunders; 1978:409, with permission.) Figure 28-8 Pericardial window 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 Chapter 28 r Thoracic Injuries 349 d Excision of the xiphoid process may facilitate the procedure The diaphrag- matic attachments immediately deep to the sternum should be freed by blunt dissection The diaphragm can then be retracted downward with Allis clamps Reverse Trendelenburg position helps to expose the pericardium A Kittner dissector can be used to mobilize the pericardial fat off the anterior surface of the pericardium The tense, fibrous, white pericardium is then identified e A to cm incision is made with scissors or knife on the anterior surface of the pericardium i If blood is found in the pericardial sac, the procedure should be rapidly converted to median sternotomy to perform cardiorrhaphy ii If no gross blood is aspirated, a catheter is placed to gently irrigate the pericardium with warm saline to obtain clots from the pericardial recesses D Emergency department thoracotomy (EDT) Enthusiasm for EDT has waned over the past several years since the overall mortality of patients receiving EDT is high Patients most likely to benefit from EDT are young, have isolated penetrating injury to the chest, preferably a cardiac wound with tamponade that can be easily released Patients with blunt injury, exsanguination below the diaphragm or associated head injury have very low survival rates Indications (Table 28.2) a EDT is indicated for patients who are in extremis or in cardiopulmonary arrest without vital signs, which is defined as a measurable blood pressure or pulse Patients should then be evaluated for when signs of life (SOL) were present and lost SOL include: i Spontaneous movements ii Pupillary response, eye movement iii Spontaneous respirations iv Electrical complexes >40/min on ECG b In patients with cardiopulmonary arrest from blunt trauma, EDT is indicated only if the patient has SOL on arrival to the hospital Patients who have SOL in the field and lose them in route are considered dead on arrival (DOA) c In patients with cardiopulmonary arrest from penetrating trauma, EDT is indicated if the patient had SOL in the field Patients with penetrating injury should receive EDT even if SOL are lost en route This expanded indication (compared with blunt trauma arrest) is specific because of the higher frequency of reparable lesions being present d Patients without SOL in the field, regardless of mechanism are DOA Technique a Perform a left anterolateral thoracotomy at the fifth intercostal space The incision begins at the left sternocostal margin, it is curvilinear and is extended to the latissimus dorsi posteriorly (Fig 28-9) In females, displace the breast cephalad to perform the skin incision in the inframammary crease Incise the intercostal muscles with scissors and insert a finochietto retractor Take care TABLE 28-2 Indications for Emergency Department Thoracotomy No measurable blood pressure or pulse Blunt mechanism Penetrating mechanism No SOL SOL field only SOL arrival No SOL SOL field only SOL arrival DOA DOA EDT DOA EDT EDT SOL, signs of life (eye movement, pupillary response, spontaneous respiration, electrical activity >40 complexes/min on electrogram); DOA, dead on arrival; EDT, emergency department thoracotomy 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 350 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 The Trauma Manual: Trauma and Acute Care Surgery Figure 28-9 EDT Extend the incision to the right side below the right nipple for easy access to the right chest (Adapted from Moore EE, Eiseman B, Van Way CW Critical Decisions in Trauma St Louis, MO: Mosby; 1984:524, with permission.) to insert the retractor with the “T” bar posteriorly near the bed; this will allow free access to extend the thoracotomy across the sternum to the right side if necessary (Fig 28-10) b The pericardium is opened anterior to the phrenic nerve This relieves tamponade and allows more effective internal compressions This should be done 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 Top: 0.249in LWW-Peitzman-educational Gutter: 0.498in September 19, 2012 Chapter 28 r Thoracic Injuries 351 Figure 28-10 A view into the left chest during EDT A clamp is shown on the descending aorta and a sharp pericardiotomy is shown proceeding cephalad anterior to the phrenic vessels (Adapted from Moore EE, Eiseman B, Van Way CW Critical Decisions in Trauma St Louis, MO: Mosby; 1984:529, with permission.) in the anterior portion of the pericardium in a caudal to cephalad plane, avoiding injury to the phrenic nerve The opening should extend from the cardiac apex to the root of the aorta c If the heart is not beating, perform internal massage with open hands spanning the left ventricle-–do not squeeze with one hand, as this can lead to ventricular injury If the heart is fibrillating, attempt internal cardioversion at 20 J followed by 30 J Cardioversion may be repeated after internal compression to perfuse the coronaries d If the myocardium is ruptured or injured, digitally occlude the injury Cardiorrhaphy should be performed with 2-0 sutures with horizontal mattress sutures i Although some surgeons recommend placing a balloon catheter into a cardiac injury, this maneuver should not be performed as the maneuver often exacerbates the injury ii If the wound is adjacent to a coronary artery, the cardiorrhaphy must not compromise the coronary artery The horizontal mattress sutures should be placed underneath the coronary artery to avoid coronary narrowing 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 352 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 The Trauma Manual: Trauma and Acute Care Surgery iii Atrial wounds can be controlled with a Satinsky partial occlusion clamp followed by repair with 2-0 horizontal mattress sutures e If the thoracic aorta is bleeding, compress and clamp with a partial occlusion vascular clamp Check for the possibility of a posterior injury f In cases of massive hemorrhage from the pulmonary parenchyma or the hilum, clamp the hilum This is best performed by releasing the inferior pulmonary ligament, passing a hand around the vascular structures, and safely guiding a vascular clamp to gently occlude the hilum g If no reparable thoracic injury is found, the patient is unlikely to survive With the chest open, clamp the descending thoracic aorta and continue open cardiac massage If this successfully restores a palpable carotid pulse in a short period of time, rapidly transport to the OR for repair of injuries below the diaphragm E Median sternotomy Advantage Provides excellent exposure of the heart and proximal great vessels, but not the posterior mediastinal structures The incision can be extended into the neck or supraclavicular are for more distal vascular control and repair (Fig 28-11) Figure 28-11 Extensions of the median sternotomy Supraclavicular and neck extensions are shown (dotted lines) (Adapted from Rutherford RB Atlas of Vascular Surgery: Basic Techniques and Exposures Philadelphia, PA: WB Saunders; 1993:235, with permission.) 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 Top: 0.249in LWW-Peitzman-educational Gutter: 0.498in September 19, 2012 Chapter 28 r Thoracic Injuries 353 Disadvantages Requires a sternal saw or Lebsche knife and usually takes more time to perform than left anterolateral thoracotomy; because of this, it is not recommended for EDT Also, access is limited to the esophagus and descending aorta Technique a The patient is placed supine on the OR table with both arms abducted to 90 degrees b The skin and subcutaneous tissues are incised from the sternal notch to inferior to the xiphoid c A plane on the posterior surface of the sternum is developed bluntly from above and below before division of the sternum with a sternal saw or Lebsche knife Begin this at the upper edge of the sternum, and lift the saw or knife and sternum as you proceed in the caudal direction (Procedure may also be performed from caudal to cephalad direction.) Stay in the center of the sternum to avoid injury to the costal cartilages and entry into either hemithorax d Bone wax may be required for cancellous bone bleeding e To facilitate exposure of the great vessels, this incision can be extended laterally into the neck, dividing sternocleidomastoid, platysma, strap, and anterior scalene muscles (protecting the phrenic nerve) f Further exposure of the second and third portions of the subclavian vessels can be enhanced by resection or division of the clavicle g Extension into the abdomen with a midline incision is easily accomplished F Left anterolateral thoracotomy Advantage Permits rapid access to the chest, especially for decompression of pericardial tamponade and for repair of the heart, left lung and hilum, or aorta This can be extended across the sternum (bilateral or clamshell thoracotomy) to access the right chest Left anterolateral thoracotomy is the best initial operative approach for unstable patients requiring resuscitation or when the location of the intrathoracic injury is unclear Disadvantage Poor access to the posterior mediastinum, distal subclavian vessels, and right chest Technique a The left arm should be fully extended over the patient’s head to provide extension of the incision on the posterior chest wall b An incision is made in the fifth intercostal space, from the sternal edge to the scapula c The muscles of the anterior chest wall are divided with electrocautery and the intercostal muscles are also sharply transected while avoiding injury to the neurovascular bundle d A Finochietto rib retractor is inserted with the “T” bar toward the back and opened widely e A thoracoabdominal incision can be carried out by performing a midline laparotomy We not recommend costal margin transection G Left or right posterolateral thoracotomy Advantages Provides excellent access to the hemithorax The left posterolateral thoracotomy permits access to the aorta and proximal left subclavian artery, the left lung, the left chest wall, and the distal esophagus The right posterolateral thoracotomy provides access to the trachea, the right lung, the right chest wall, and the proximal esophagus Disadvantages The lateral position for the posterolateral thoracotomy is time consuming and leaves little flexibility in gaining access to opposite hemithorax or abdominal structures, thus injuries elsewhere cannot be accessed Technique a Use the standard skin incision for elective thoracic surgery By varying the interspace entered, all regions of the thoracic cavity can be exposed 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 354 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 The Trauma Manual: Trauma and Acute Care Surgery Figure 28-12 Position for an urgent right posterolateral thoracotomy (From Champion HR, Robbs JV, Trunkey DD Trauma surgery (parts and 2) In: Dudley H, Carter D, Russell RCG, eds Rob and Smith’s Operative Surgery London: Butterworth; 1989:273, with permission.) b The patient is placed in full lateral decubitus position with the upper arm supported over the head, the lower arm extended and padded with an axillary roll, the lower leg is flexed, and the upper leg extended with padding between the knees The pelvis should be secured with adhesive tape and a sandbag (Fig 28-12) c Using the tip of the scapula as a landmark, the muscles of the lateral chest wall are divided down to and including the intercostal muscles In more stable patients requiring less exposure, sparing of the latissimus dorsi muscle is possible H Bilateral thoracotomy (clamshell thoracotomy) (Fig 28-13) Advantage Permits wide exposure to all structures in the chest Best incision for patients with multiple gunshot wounds that violate both pleural spaces, bilateral hemothoraces, and superior mediastinal hematomas Disadvantage Large incision, extensive heat loss from wound, both internal mammary arteries are ligated Technique After the anterolateral thoracotomy, the sternum is divided transversely with heavy scissors, Lebsche knife, or sternal saw The sternal incision is opened with a Finochietto rib retractor The incision is extended through the fifth interspace as far into the contralateral chest as possible a Care is taken to ligate the internal mammary arteries on each side of the sternum Often these arteries will start to hemorrhage heavily with successful resuscitation and return of an adequate blood pressure 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 Top: 0.249in LWW-Peitzman-educational Gutter: 0.498in September 19, 2012 Chapter 28 r Thoracic Injuries 355 Figure 28-13 A view into the chest during a bilateral “clamshell” thoracotomy Note the excellent exposure of the heart and great vessels (Adapted from Moore EE, Eiseman B, Van Way CW Critical Decisions in Trauma St Louis, MO: Mosby; 1984:528, with permission.) Figure 28-14 The “taxi-hailing” position that allows for access to the abdomen and left chest (Adapted from Rutherford RB Atlas of Vascular Surgery: Basic Techniques and Exposures Philadelphia, PA: WB Saunders; 1993:223, with permission.) 19:32 P1: Trim: 5.25in × 8.375in LWBK1111-28 356 Top: 0.249in Gutter: 0.498in LWW-Peitzman-educational September 19, 2012 The Trauma Manual: Trauma and Acute Care Surgery I Other approaches include: Right thoracotomy can be useful for isolated right hemothorax It is also the incision of choice with high esophageal wounds and wounds to the trachea and tracheobronchial tree Thoracoabdominal incision is useful to expose the inferior thoracic and supraceliac aorta on the left side It is also indicated to gain control of the proximal thoracic inferior vena cava on the right side (Fig 28-14) AXIOMS ■ ■ ■ ■ Hemodynamic instability from a chest wound indicates a major vascular or cardiac injury that mandates immediate control of hemorrhage The choice of thoracic incision is determined by the expected anatomic injury, urgency with which surgical access is required, and the patient’s hemodynamic stability Diagnosis of transmediastinal penetration is based on clinical suspicion, trajectory of the missile, or CXR findings Suspect the presence of tamponade in the patient with persistent hypotension, acidosis, or base deficit, despite adequate blood and fluid resuscitation Suggested Readings Asensio JA, Arroyo H, Veloz W, et al Penetrating thoracoabdominal injuries: ongoing dilemma-which cavity and when? World J Surg 2002;26:539–543 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 Asensio JA, Chahwan S, Forno W, et al Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma J Trauma 2001;50:289–296 Asensio JA, Demetriades D, Murray J, et al Penetrating cardiac injuries: a prospective study of variables predicting outcomes J Am Coll Surg 1997;186:24–34 Asensio JA, Petrone P, Costa D, et al An evidenced based critical appraisal of emergency department thoracotomy Evidence-Based Surgery 2003;1:11–21 Biffl WL, Moore FA, Moore EE, et al Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion Am J Surg 1994;169:523–528 Demetriades D, Velmahos GC, Scalea TM, et al Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study J Trauma 2008;64:561–571 Fabian TC, Davis KA, Gavant ML, et al Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture Ann Surg 1998;227:666–676 Link MS Mechanically induced sudden death in chest wall impact (commotio cordis) Prog Biophys Mol Biol 2003;82:175–186 Maenza RL, Seaberg D, DiAmico F A meta-analysis of blunt cardiac trauma: ending myocardial confusion Am J Emerg Med 1996;14:237–241 Moon RM, Luchette FA, Gibson SW, et al Prospective, randomized comparison between epidural versus parenteral opioid analgesia in thoracic trauma Ann Surg 1999;229:684–692 Ott MC, Stewart TC, Lawlor DK, et al Management of blunt thoracic aortic injuries: endovascular stents versus open repair J Trauma 2004;56:565–570 Richardson JD, Flint LM, Snow NJ, et al Management of transmediastinal gunshot wounds Surgery 1981;90:671–676 Richardson JD, Miller FB, Carillo EH, et al Complex thoracic injuries Surg Clin North Am 1996;76: 725–748 Rozycki GS, Feliciano DV, Oschner MG, et al The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study J Trauma 1999;46:543–552 Velmahos GC, Baker C, Demetriades D, et al Lung-sparing surgery after penetrating trauma using tractotomy, partial lobectomy, and pneumonorrhaphy Arch Surg 1999;134:186–189 19:32 ... China -U Library of Congress Cataloging-in-Publication Data available upon request ISBN -1 3 : 97 8 -1 -4 51 1 -1 67 9-3 ISBN -1 0 : 1- 4 51 1 -1 67 9-3 ta hi r9 Care has been taken to confirm the accuracy of the. .. 22 M -1 6 AK-47 270 Winchester 30–0 40 55 12 3 15 0 15 0 1, 180 3,200 3,500 2,900 2, 910 12 4 1, 248 1, 725 2, 810 2,820 tahir99 - UnitedVRG vip.persianss.ir 12 :50 P1: Trim: 5.25in × 8.375in LWBK 111 1- 0 1 Top:... Gutter: 0.498in LWW-Peitzman-educational September 19 , 2 012 THE TRAUMA MANUAL: TRAUMA AND ACUTE CARE SURGERY r9 -U ni te dV R G Fourth Edition hi LWBK 111 1-fm Top: 0.249in ta P1: tahir99 - UnitedVRG