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for medical professionals
Trauma Surgery
Treatment of Acute Burns
Skin is a complex organ that protects humans from bacterial infection and minimizes fluid loss. It is composed of two structural layers: the epidermis which forms a barrier for fluid loss and the underlying dermis which is a thick collagenous structure that provides structural integrity to the skin.
19/01/2023
Acute Wound Care
Traumatic wounds are common in civilian and military conflict. Because of the unfortunate carnage of war, physicians have learned through a variety of conflicts methods to treat wounds to avoid death and to maximize disability.
14/01/2023
Crush Injury
Crush injury is caused by the static compression of body parts causing localized damage to skeletal muscle and nerves, most commonly involving the lower extremities. Skeletal muscle can withstand 2 hours of ischemia without permanent injury, 2-4 hours with some reversible cell damage, and may suffer irreversible necrosis by 6 hours of ischemia time
3/09/2022
Trauma Considerations for the Pregnant Patient
Trauma affects up to 10% of pregnancies and is the leading cause of nonobstetric maternal death. Major trauma during pregnancy is associated with up to 7% mortality of the pregnant person and 60-80% mortality of the fetus
2/09/2022
Pancreatic Injuries in Deployed/Austere Settings
Pancreatic injuries can present significant problems under the best of circumstances. In deployed or austere settings, they can be among the most difficult surgical challenges encountered. As part of the “surgical soul”, pancreatic injuries are commonly associated with concomitant injury to the duodenum as well as major abdominal vascular injury
25/08/2022
Liver Injury
Liver injuries are one of the most common injuries to occur after trauma. The liver’s large size and exposed position under the right costal margin make it one of the most regularly injured organs in blunt and penetrating abdominal trauma. The majority of liver injuries can be managed non-operatively, only the most severe injuries risk exsanguinating hemorrhage necessitating massive resuscitation protocols and emergent laparotomy.
18/08/2022
Trauma Laparotomy
Trauma laparotomy is a versatile procedure that allows for rapid access to all regions of the abdominal cavity. Trauma laparotomy must be performed in a systematic way to avoid delays or missing injuries.
11/08/2022
Neck Trauma
Any injury to the neck requires prompt evaluation as it can be potentially life threatening. Neck injuries are classified as blunt or penetrating, the latter of which refers to penetration of an object through the platysma muscle. Neck injuries are additionally categorized by anatomic zones that can help the provider with differential diagnosis, workup, and treatment.
10/08/2022
Ultrasound: Focused Assessment with Sonography for Trauma (FAST) Exam
Ultrasonography has become an increasingly important tool in the assessment of the trauma patient. Ultrasound performed as part of the initial examination of the trauma patient is known as the Focused Assessment with Sonography for Trauma (FAST) exam. When additional views are added to evaluate for pneumo- or hemothorax, it is called the extended FAST (E-FAST) exam. The primary purpose of the E-FAST exam is to identify pathologic fluid in the abdomen, pelvis or chest. FAST or E-FAST is typically included as an adjunct to the primary survey during the “C” or circulation portion of Advanced Trauma Life Support (ATLS) to assess for hemorrhage.
1/08/2022
Clinical Management of Acute Traumatic Spinal Cord Injury
Traumatic spinal cord injuries are debilitating and require prompt recognition and treatment to mitigate long-term outcomes, secondary damage, and complications.
27/06/2022
Geriatric Trauma Patient
With a rapidly aging population, increasing numbers of older adults sustain trauma. Most injuries are due to falls, but more older adults are also suffering from motor vehicle crashes, assaults, and burns. Age-related anatomic and physiologic changes alter older trauma patients’ clinical presentations and blunt their physiologic response to injury. As people age, their adaptive and homeostatic mechanisms change, contributing to a decreased physiologic reserve and reduced metabolic response to injury. Thus, seemingly minor injuries can be lethal and older injured patients are at greater risk for prolonged hospitalization, worsening disability, and functional dependence. Moreover, trauma is associated with increased mortality, relative to other non-injured older adults, for years after injury. Multidisciplinary and appropriate evaluation and management of older patients is necessary to improve clinical outcomes.
29/04/2022
Initial Evaluation of the Trauma Patient
Advanced Trauma Life Support (ATLS) was first developed in 1976 and is used globally as a framework for the systematic evaluation of trauma patients to optimize outcomes and reduce the risk of unidentified injuries(1). ATLS provides an easy-to-remember, algorithmic approach to the evaluation and initial management of the trauma patient, focusing on the greatest threat to life first, with the “ABCDE” approach to trauma management: Airway (with restriction of cervical spine motion), Breathing, Circulation (stop bleeding), Disability of neurologic status, and Exposure (undress) / Environment (temperature control). This chapter will outline the initial evaluation of the trauma patient using the ABCDE approach.
29/04/2022
Pelvic Binder Placement
Treatment for traumatic brain injury (TBI) is performed to prevent secondary injury to the brain following the initial injury. The prevention of secondary injury to the brain involves avoiding systemic events such as hypotension, hypoxia, or hyperthermia. The assessment and treatment of military TBI is similar to the treatment of civilian TBI with a greater focus on blast-induced TBIs. With limited resources during wartime, efficient triage and logistics of clinical care delivery take on greater importance. During wartime, many subspecialty surgeons may be tasked to assist with trauma care, outside their area of expertise. The purpose of this chapter is to describe the initial evaluation, management, and stabilization of moderate to severe TBI patients to a non-neurosurgeon surgical audience in a limited resource setting with a focus on prevention of secondary injury.
29/04/2022
The Initial Management of Moderate to Severe Traumatic Brain Injury
Treatment for traumatic brain injury (TBI) is performed to prevent secondary injury to the brain following the initial injury. The prevention of secondary injury to the brain involves avoiding systemic events such as hypotension, hypoxia, or hyperthermia. The assessment and treatment of military TBI is similar to the treatment of civilian TBI with a greater focus on blast-induced TBIs. With limited resources during wartime, efficient triage and logistics of clinical care delivery take on greater importance. During wartime, many subspecialty surgeons may be tasked to assist with trauma care, outside their area of expertise. The purpose of this chapter is to describe the initial evaluation, management, and stabilization of moderate to severe TBI patients to a non-neurosurgeon surgical audience in a limited resource setting with a focus on prevention of secondary injury.
29/04/2022
Management of Genitourinary Trauma
Trauma to the genitourinary system usually occurs as part of a multisystem trauma rather than as an isolated presentation. Injury to organs of the genitourinary system should be suspected based on the mechanism and the anatomic location of the trauma. The kidneys, ureters, and bladder are well protected within the retroperitoneum, making them relatively less prone to injury. Therefore, urological traumas are relatively rare, comprising about 10% of total abdominal traumas.
29/04/2022
Traumatic Colon Injuries
Colonic injuries may be caused by either penetrating or blunt trauma. Colonic injury from penetrating injury is far more common and often found at the transverse colon, in part due to its anterior position in the abdomen [1,2,3]. In a retrospective study of the primary mechanism of colonic injury in United States military personnel, gunshot wounds were responsible for over 50% of colorectal injury and explosion or blast injuries were responsible for 35% [4]. In civilians, gunshot wounds compromise the majority of colon injury mechanisms, followed by stab wounds [5].
29/04/2022
Craniomaxillofacial Trauma
Craniomaxillofacial trauma is a significant and complex issue to manage in wartime settings. Injuries of the facial skeleton are commonly sustained secondary to projectiles and munitions and may present with various hard and soft tissue defects that often require extensive secondary.1 Facial injuries should be immediately triaged and managed either acutely or secondarily depending upon the local craniofacial factors and the global injury burden of the patient.2 The patterns of facial injury sustained in a wartime setting differ from the civilian population with a higher propensity of mid- and upper facial injuries likely due to the combination of missile and blast injuries,3 however the morbidity and mortality from these injuries is similar.4 Additionally, many patients suffer a combination of bone and tissue loss that requires secondary management.5
29/04/2022
Rectal Injuries
ies to the rectum occur in up to 3% of civilian trauma and 5.1% in military-related trauma patients.1 Understanding the anatomy of the rectum is critical to guiding trauma management. The rectum is the most posterior visceral organ in the pelvis, initiating at the rectosigmoid junction and terminating in the anal canal. In male patients, the rectum lies posterior to the bladder and prostate, separated by the rectovesical pouch. In female patients, the rectum is posterior to the vaginal canal and uterus, separated by the pouch of Douglas (rectouterine pouch).
29/04/2022
Treatment of Life-threatening Injuries on Initial Survey (airway obstruction, tension PTX, hemothorax, cardiac tamponade)
Resuscitative thoracotomy, is performed on a patient in circulatory collapse with the objective of addressing reversible causes of cardiovascular collapse from cardiac tamponade or significant hypovolemia [1-5]. The goals are to release pericardial tamponade, control cardiac or intrathoracic hemorrhage, perform open cardiac massage, and temporarily occlude the descending thoracic aorta in the case of persistent hypotension until definitive operative intervention can be performed [1,2,5].
29/04/2022
Resuscitative Thoracotomy
Resuscitative thoracotomy, is performed on a patient in circulatory collapse with the objective of addressing reversible causes of cardiovascular collapse from cardiac tamponade or significant hypovolemia [1-5]. The goals are to release pericardial tamponade, control cardiac or intrathoracic hemorrhage, perform open cardiac massage, and temporarily occlude the descending thoracic aorta in the case of persistent hypotension until definitive operative intervention can be performed [1,2,5].
29/04/2022
Chest Tube Placement
Chest trauma in modern warfare occurs in 7-15% of cases [5-6]. Injuries sustained to the thorax require immediate attention as approximately one in six injuries carry an immediate mortality risk due to cardiac tamponade, massive hemothorax, or lung parenchymal or airway injury resulting in massive air leak [6]. The most common indications for chest tube placement are pneumothorax or hemothorax; however, important to note, there are no absolute contraindications, particularly given the life-threatening scenarios previously described [3, 7].
29/04/2022
Abdominal Vascular Trauma
Abdominal vascular injuries represent a grave threat to the victim of penetrating abdominal trauma, requiring expeditious diagnosis, judicious resuscitation and perioperative management, and swift surgical exposure and control. Early recognition and management of abdominal vascular injuries is paramount for improving patient survival.
12/04/2022
Tracheostomy
Tracheostomy is a procedure used to support patients with obstruction of their airway at the level of the larynx or above the it. Additionally, tracheostomy can be used to support patients with chronic respiratory problems or those who would require prolonged intubation with an endotracheal tube.
12/04/2022
Cricothyroidotomy
Cricothyroidotomy is a life-saving procedure that can be performed to establish a definitive airway in situations when oral intubation has failed or a provider is unable to perform the procedure. The cricothyroidotomy does not require many tools, but the procedure does require an understanding of the important landmarks in the neck. Although cricothyroidotomy is not commonly performed, knowledge of this procedure can help health care providers when their patients need an airway.
12/04/2022
Traumatic Small Bowel Injury
Approach to Blunt Abdominal Trauma Please see separate section for a more complete overview of blunt abdominal trauma. In summary, in a patient who underwent blunt abdominal trauma, Focused Abdominal Sonography for Trauma (FAST) should be performed as an adjunct to the primary survey. A hemodynamically unstable patient with a positive FAST should be taken […]
12/04/2022
Lower Extremity Fasciotomies
Acute compartment syndrome (ACS) of an extremity occurs when significant pressure builds up within a closed osteofascial space, which can result in irreversible damage to structures contained within the specific compartment. Fractures are the most common cause of compartment syndrome, but ischemia-reperfusion (after vascular injury), burns, prolonged immobilization, and crush injuries can also result in ACS. Diagnosing ACS early is critical in appropriately treating and reducing the risk of associated complications. While pain out of proportion to injury is the classic finding associated with ACS, early findings include paresthesias and pain on passive muscle stretch and late findings include loss of pulses or motor deficits. Although diagnosis is primarily clinical, intracompartmental pressures can be measured when findings are equivocal. 30 mmHg is often the threshold for fasciotomy. Once a diagnosis of ACS is suspected or confirmed, emergent fasciotomies need to be performed to relieve the compartmental pressure.
12/04/2022
Pelvic Fractures
Pelvic fractures resulting from blunt traumatic injury are often associated with significant hemorrhage. Early identification and intervention can be lifesaving.
12/04/2022
Management of Peripheral Vascular Trauma
The majority of wartime peripheral vascular trauma are due to explosive mechanisms which result in worse limb salvage rates compared to firearm injuries. Military data suggest that 10% battlefield deaths are secondary to extremity hemorrhage. The following describes assessment and management of peripheral vascular trauma for emergency scenarios in which a vascular or trauma surgeon is not available and without the availability of endovascular equipment or trained-providers. With vascular injuries, early recognition and intervention are essential to improve outcomes and functionality, avoid complications, and avert continued hemorrhage, limb loss and mortality.
12/04/2022
Thoracic Trauma
Traumatic thoracic injury currently accounts for approximately 6-10% of all injuries seen in trauma but carries a mortality of up to 80%. This is the case for both penetrating and blunt injury which, unlike the extremities, are not amenable to the rapid, life-saving intervention of tourniquet placement. In the modern era of trauma, high velocity projectiles, body armor and explosive blasts result in more significant injury with larger areas of tissue damage. Blast injuries are particularly devastating due to the multiplicity of concurrent mechanisms (blunt, penetrating, and thermal injuries) within a single event.1,2 The advancement and use of protective body armor and armored vehicles decreases the incidence of sudden death, thereby increasing the frequency of profound multi-trauma victims in need of life saving interventions.
12/04/2022
Upper Extremity Fasciotomies
Compartment syndrome occurs when pressures within fascial compartments exceed perfusion pressures, causing injury to the muscle, blood vessels, and nerves within the compartment. Although this condition most commonly occurs in the lower extremities, it can also occur in the upper extremities associated with ischemia, burn injuries, crush injuries, and bone fractures. If there is any concern that compartment syndrome is present or the patient could quickly develop undiagnosed compartment syndrome after prolonged ischemic time or electrical injuries, a fasciotomy should be performed. In this section, we focus specifically on upper extremity compartment syndrome, how to perform fasciotomies, and post-operative care.
12/04/2022
Venous Access
Obtaining venous access is crucial in the treatment of an acutely injured patient. Venous access allows for administration of medications, fluids, and blood products and facilitates drawing labs.
10/04/2022
Splenectomy
The spleen is an encapsulated, immunologic, solid organ located in the posterolateral left upper quadrant immediately beneath the diaphragm and lateral to the greater curve of the stomach and the tail of the pancreas. Its primary function is hematologic filtration and immunologic protection – particularly against encapsulated bacteria(1). In the trauma setting, the spleen and liver are the most commonly injured intra-abdominal organs following blunt trauma and the spleen is at risk for injury in penetrating trauma of the thoracoabdominal and abdominal regions(2). Initial evaluation of the spleen in the trauma setting can occur at bedside via the Focused Assessment with Sonography in Trauma (FAST) which can demonstrate a hypoechoic or black rim around the spleen in the left upper quadrant view or intra-abdominal free fluid in any view.
6/04/2022
Cardiac Trauma – Blunt and Penetrating
Traumatic injury to the heart can occur due to either penetrating or blunt force. Penetrating trauma is mostly due to gunshot or stab wounds to the chest.
16/05/2022
Duodenal Trauma
Duodenal injuries are uncommon and most often associated with penetrating injury1. Incidence is <2% with stab wounds and 10-11% with gunshot wounds2. It is rare that duodenal injuries are isolated and therefore it is essential to evaluate for associated injuries. Commonly injured organs include liver (16.9%), pancreas (11.6%), major vascular injuries (9%), small bowel, colon and urogenital system. The second portion of the duodenum is the most frequently injured (33%), followed by third and fourth (19.4%, 19%). Whereas, the first portion of duodenum is only injured 14.4% of the time.
25/03/2022