2. Editors William C. Wilson, MD, MA Clinical Professor
Director of Anesthesiology Critical Care Program Department of
Anesthesiology and Critical Care University of California, San
Diego School of Medicine La Jolla, California Director of Trauma
Anesthesia Associate Director Surgical Intensive Care Unit UC San
Diego Medical Center San Diego, California, U.S.A. Christopher M.
Grande, MD, MPH Executive Director International TraumaCare
(ITACCS) Baltimore, Maryland, U.S.A. David B. Hoyt, MD, FACS John
E. Connolly Professor and Chairman Department of Surgery University
of California, School of Medicine Irvine, California UC Irvine
Medical Center Orange, California, U.S.A. DK3592_FM.indd 2 1/4/07
1:08:22 PM
3. Volume 1 Associate Editors Raul Coimbra, MD, PhD, FACS
Professor of Surgery, Chief Division of Trauma, Burns and Critical
Care Department of Surgery, University of California San Diego La
Jolla California Director Surgical Intensive Care Unit UC San Diego
Medical Center San Diego, California, U.S.A. Jose A. Acosta, MD,
FACS Associate Professor of Surgery Division of Trauma and Critical
Care Department of Surgery Naval Medical Center San Diego San
Diego, California, U.S.A. Jonathan L. Benumof, MD Professor of
Anesthesiology Director of Airway Management Training Department of
Anesthesiology University of California San Diego La Jolla
California Chief Division of Airway Management UC San Diego Medical
Center San Diego, California, U.S.A. Richard P. Dutton, MD, MBA
Associate Professor of Anesthesiology Department of Anesthesiology
University of Maryland School of Medicine Director of Trauma
Anesthesiology R Adams Cowley Shock-Trauma Center Baltimore,
Maryland, U.S.A. DK3592_FM.indd 3 1/4/07 1:08:22 PM
4. Irving "Jake" Jacoby, MD, FACP, FACEP Clinical Professor of
Medicine & Surgery Department of Emergency Medicine UC San
Diego School of Medicine La Jolla California Team Leader, DMAT San
Diego CA-4 Attending Physician, Emergency Department Director UCSD
Hyperbaric Medicine Center UC San Diego Medical Center San Diego,
California, U.S.A. Catherine McCoy-Hill, RN, MSN, CCRN, CNS, ANP
Assistant Professor Director Critical Care Nursing Education School
of Nursing Azusa Pacific University Azusa, California, U.S.A.
Joseph F. Rappold, MD, FACS Associate Professor of Surgery
Director, Division of Trauma and Critical Care Department of
Surgery Naval Medical Center San Diego San Diego, California,
U.S.A. Past Naval Medical Commander Fallujah and Ramadi, Iraq
DK3592_FM.indd 4 1/4/07 1:08:22 PM
5. Volume 1 Section Editors Section A: Preparation and
Prehospital Care Irving "Jake" Jacoby, MD, FACP, FACEP Clinical
Professor of Medicine & Surgery Department of Emergency
Medicine UC San Diego School of Medicine La Jolla California Team
Leader, DMAT San Diego CA-4 Attending Physician, Emergency
Department Director UCSD Hyperbaric Medicine Center UC San Diego
Medical Center San Diego, California, U.S.A. Section B:
Resuscitation Suite / Trauma ED Management Richard P. Dutton, MD,
MBA Associate Professor of Anesthesiology Department of
Anesthesiology University of Maryland School of Medicine Director
of Trauma Anesthesiology R Adams Cowley Shock-Trauma Center
Baltimore, Maryland, U.S.A. Section C: Anesthetic Management and
Damage Control for Trauma Christopher M. Grande, MD, MPH Executive
Director International TraumaCare (ITACCS) Baltimore, Maryland,
U.S.A. DK3592_FM.indd 5 1/4/07 1:08:22 PM
6. Section D: Anesthetic and Surgical Considerations for
Specific Injuries William C. Wilson, MD, MA Clinical Professor
Director of Anesthesiology Critical Care Program Department of
Anesthesiology and Critical Care University of California, San
Diego School of Medicine La Jolla, California Director of Trauma
Anesthesia Associate Director Surgical Intensive Care Unit UC San
Diego Medical Center San Diego, California, U.S.A. Bruce Potenza,
MD, FACS Associate Professor of Surgery Director of Burns, Division
of Trauma, Burns and Critical Care Department of Surgery University
of California San Diego School of Medicine La Jolla California
Director UC San Diego Burn Unit UC San Diego Medical Center San
Diego, California, U.S.A. Section E: Special Conditions Associated
with Trauma Raul Coimbra, MD, PhD, FACS Professor of Surgery, Chief
Division of Trauma, Burns and Critical Care Department of Surgery,
University of California San Diego La Jolla California Director
Surgical Intensive Care Unit UC San Diego Medical Center San Diego,
California, U.S.A. DK3592_FM.indd 6 1/4/07 1:08:22 PM
7. TRAUMAEmergency Resuscitation Perioperative Anesthesia
Surgical Management edited by William C. Wilson, MD, MA Clinical
Professor Director of Anesthesiology Critical Care Program
Department of Anesthesiology and Critical Care University of
California, San Diego School of Medicine La Jolla, California
Director of Trauma Anesthesia Associate Director Surgical Intensive
Care Unit UC San Diego Medical Center San Diego, California, U.S.A.
Christopher M. Grande, MD, MPH Executive Director International
TraumaCare (ITACCS) Baltimore, Maryland, U.S.A. David B. Hoyt, MD,
FACS John E. Connolly Professor and Chairman Department of Surgery
University of California, School of Medicine Irvine, California UC
Irvine Medical Center Orange, California, U.S.A. New York London
Volume 1 DK3592_FM.indd 7 1/4/07 1:08:22 PM
8. Informa Healthcare USA, Inc. 270 Madison Avenue New York, NY
10016 2007 by Informa Healthcare USA, Inc. Informa Healthcare is an
Informa business No claim to original U.S. Government works Printed
in the United States of America on acidfree paper 10 9 8 7 6 5 4 3
2 1 International Standard Book Number10: 0824729196 (Hardcover)
International Standard Book Number13: 9780824729196 (Hardcover)
This book contains information obtained from authentic and highly
regarded sources. Reprinted material is quoted with permission, and
sources are indicated. A wide variety of references are listed.
Reasonable efforts have been made to publish reliable data and
information, but the author and the publisher cannot assume
responsibility for the validity of all materials or for the
consequences of their use. No part of this book may be reprinted,
reproduced, transmitted, or utilized in any form by any electronic,
mechanical, or other means, now known or hereafter invented,
including photocopying, microfilming, and recording, or in any
information storage or retrieval system, without written permission
from the publishers. For permission to photocopy or use material
electronically from this work, please access www.copyright.com
(http://www.copyright.com/) or contact the Copyright Clearance
Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923,
9787508400. CCC is a notforprofit organization that provides
licenses and registration for a variety of users. For organizations
that have been granted a photocopy license by the CCC, a separate
system of payment has been arranged. Trademark Notice: Product or
corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation with out intent to
infringe. Visit the Informa Web site at www.informa.com and the
Informa Healthcare Web site at www.informahealthcare.com
DK3592_FM.indd 8 1/4/07 1:08:22 PM
9. This book is dedicated to the trauma victims, as well as the
doctors, nurses, prehospital personnel, and other members of the
trauma team who tirelessly strive to provide optimum care for their
recovery.
10. Foreword From my recent perspective as the 17th surgeon
general of the United States, along with my prior experiences as a
trauma surgeon, combat experienced U.S. Army Special Forces medical
specialist, paramedic, police ofcer, and registered nurse, I have
witnessed numerous developments over the last three decades in the
elds of trauma and critical care. Despite these signicant advances,
trauma remains the chief cause of death and disability of
individuals between 1 and 44 years of age; hence, much work remains
to be done. Trauma is a worldwide phenomenon with profound public
health implications and numerous existent chal- lenges, including
the need for an increased emphasis on accident prevention;
overcoming barriers to care for the indi- gent, the elderly, and
rural populations; and streamlining and improving disaster response
effectiveness. This two-volume book provides comprehensive cover-
age of all realms of modern trauma management, including the
important aforementioned areas of care, which continue to impact
the outcomes for these vulnerable populations. Volume 1 focuses on
initial management and is divided into sections that mirror the
continuum of care, including prehospital, resuscitation suite, and
perioperative management. The prehospital section includes chapters
on trauma mechanisms, epidemiology, scoring and triage, and
transport. The authors acknowledge that optimal manage- ment
algorithms for this early phase of care can differ based on the
setting (urban/rural) and the prevailing geographical, political,
and nancial conditions. Hospital- based components of management
(e.g., primary survey, secondary survey, etc.) are meticulously
reviewed, including specic chapters on the critical elements of
care (e.g., airway management, uid therapy, etc.). The
perioperative section details the anesthetic and surgical
priorities, but surgical technical details are minimized in favor
of global management guidelines, which are important to all members
of the care team. Important trauma-related con- ditions are also
fully reviewed. Volume 2 encompasses the critical care management
of trauma and other surgical conditions. These topics are arranged
in sections according to organ systems, with each chapter dedicated
to a specic lesion or critical illness con- dition. Recent
evidence-based principles are fully character- ized, including the
management of abdominal compartment syndrome, tight glucose
control, adrenal suppression, and thromboembolism, etc. In
addition, chapters covering post- traumatic stress disorder, family
centered care, rehabilita- tion, and palliation at the end of life
provide a breadth of coverage not present in other trauma books.
Chapters in both volumes are co-authored by experts from
complimentary specialties, with surgeons, anesthesiol- ogists,
emergency medicine physicians, and pulmonologists involved
throughout. Specialty sections are written by medical or surgical
sub-specialists with extensive trauma and critical care experience.
Interdisciplinary collaboration is further evident with chapters
co-authored or edited by experienced nurses, pharmacists, and
social workers, as well as occupational, physical, and respiratory
therapists, among others. The editors are eminently qualied and
have suc- ceeded in producing an authoritative and comprehensive
book on trauma. Drs. Wilson, Grande, and Hoyt have each conducted
important research and have published and lectured extensively on
numerous trauma-related topics over the last two decades. They have
assembled a superb table of contents and an expert array of
contributors and associate editors. The editors have also insured
that rec- ommendations are evidence based where possible. Accord-
ingly, the novice will learn in depth about the scientic basis of
the guidelines provided here, and the expert will be updated on the
latest thinking in trauma management. In summary, this two-volume
book is an extremely valuable contribution because of the
importance of the subject, the fact that the topic has not been so
comprehen- sively covered in one book until now, and because of the
wisdom and insight of the editors. Vice Admiral Richard Henry
Carmona, MD, MPH, FACS 17th Surgeon General of the United States of
America v
11. Foreword The modern-day management of trauma is multidis-
ciplinary and requires teamwork. The specialists involved include
emergency physicians, anesthesiologists, radiol- ogists, surgeons,
toxicologists, and critical care specialists along with paramedics,
nurses, and technical staff. Those involved in the management of
trauma have a need for a comprehensive book that spans the entire
spec- trum of trauma management by all specialists, including
prehospital, perioperative, and critical care. This two- volume
book, edited by Wilson, Grande, and Hoyt, does precisely that.
Along with a superbly designed table of contents, the editors have
recruited a world-class group of contributors from all specialties
to write the chapters. The editors are abundantly qualied to
oversee a work of this magnitude in terms of academic and
intellectual strength, as well as in terms of clinical expertise.
Volume 1 covers the areas of prehospital, emergency department, and
perioperative management. Other impor- tant trauma-related
conditions (e.g., alcohol and drug intoxi- cation, burns, near
drowning, environmental conditions) and management of unique
populations of trauma patients (e.g., pediatric, geriatric, and
obstetric) are also reviewed by experts in this volume. In addition
to reviewing the key conditions, this volume contains clear
guidelines for medical and surgical decision making in the various
stages of care. In Volume 2, the critical care management of trauma
is reviewed. This volume proceeds in a logical systems-based
presentation of the conditions and complications commonly
encountered in a modern trauma or surgical intensive care unit. All
of the evidence-based measures recommended to improve outcomes in
critically ill patients are included. In addition, emerging topics
such as the remote evaluation and management of trauma and critical
illness are introduced. As the only book to cover the full spectrum
of trauma management, this two-volume set is strongly rec- ommended
for all students and clinically active physicians engaged in the
management of trauma and surgical critical care. Peter J. F.
Baskett, BA, MB, BCh, BAO, FRCA, FRCP, FCEM Consultant Anaesthetist
Emeritus, Frenchay Hospital and the Royal Inrmary, Bristol, U.K.
Editor-in-Chief, Resuscitation Past President, International Trauma
Anaesthesia and Critical Care Society vi
12. Foreword Three decades ago, as an impressionable resident
physician- in-training at the University of Washington in Seattle,
I was asked to respond with the citys emergency medical services
personnel on 9-1-1 emergency calls. Working out of the Harborview
Emergency-Trauma Center, I soon began to recognize how the outcomes
of those with severe injury are often determined, for better or for
worse, in the rst few minutes after injury. After accompanying
hundreds of patients from the incident scene, in the back of
ambulances, in the emergency centers, and in operating rooms and
inten- sive care units, I soon learned that a continuity of
optimized care must be stewarded by an integrated team of experts
from many disciplines. In turn, I have always stressed that an
interdependent chain of survival/recovery had to be created with
each link being strong and solidly connected to each other. I have
been fortunate to train, perform research, and provide care in all
of those arenas, and thus appreciate the tremendous expertise and
demands required of each team member at each and every link. This
two-volume book (edited by Wilson, Grande, and Hoyt) is, in many
ways, the rst book to examine that entire spectrum of trauma care.
Accordingly, as an emergency medicine physician originally trained
in surgical critical care and trauma fellowships to challenge
sacred cows with clinical trials, and as a prehospital care trauma
specialist who has since spent many a night responding to out-of-
hospital 9-1-1 incidents, I am now honored to write a foreword for
this book. For those of us who have come to understand the chain of
care and the impact of early decision making on long-term outcomes,
this book is a tremendous gift. Volume 1 discusses many of the
areas with which I am quite familiar, namely the initial treatment
priorities in prehospital care, the resuscitation suite, and the
periopera- tive period. These chapters are very current, including
recent citations emphasizing the need for only a few assisted
rescue breaths in conditions of severe circulatory impair- ment,
while also minimizing initial intravascular uid infusion in the
face of internal injuries resulting from penetrating trauma.
Associated conditions known to con- found initial trauma care are
also expertly reviewed. Volume 2 covers the critical care
management of trauma and the other emergency surgical conditions
commonly encountered in modern surgical intensive care units.
Recent evidence-based principles of care are provided for virtually
every condition for which such data exist. In addition, there are
chapters focusing on the patients transition to recovery following
the critical care period, including physical, occupational, and
psychological rehabili- tation. For example, it addresses screening
and treatment of posttraumatic stress disorder. Complementing the
breadth of material, the chapters are co-written by experts from
all of the relevant pivotal spe- cialties, ranging from
resuscitologists, emergency medicine doctors, anesthesiologists,
and orthopedists to the spectrum of surgeons, intensivists,
psychiatrists, and rehabilitation experts. In addition, the
co-authors hail from around the globe, emphasizing the
international appeal, perspective, and orientation of this
extremely inclusive, contemporary book. Finally, I should also say
that the editors are exception- ally well qualied for a book of
this magnitude. They are all experienced investigators, authors,
and international lecturers on the many topics covered. In summary,
this two-volume book should be considered as mandatory reading for
every clinician actively involved in the care and management of
trauma patients. Paul E. Pepe, MD, MPH, FACEP, FCCM Professor of
Surgery, Medicine, Public Health and Riggs Family Chair in
Emergency Medicine, University of Texas Southwestern Medical Center
and the Parkland Emergency Trauma Center Director, City of Dallas
Medical Emergency Services for Public Safety, Public Health, and
Homeland Security Dallas, Texas, U.S.A. vii
13. Foreword Physicians involved in the care of injured
patients come from many different disciplines and are sometimes
called traumatologists. Emergency medical services personnel,
emergency physicians, anesthesiologists, surgeons, intensi- vists,
and hospital administrators are all concerned with a broad spectrum
of trauma management. This two-volume book, edited by Wilson,
Grande, and Hoyt, joins relatively few such comprehensive books on
this subject and describes management of the trauma patient from a
multidisciplinary standpoint, and emphasizes the anesthesiologists
physio- logic perspective. Internationally, the anesthesiologist is
often the resus- citation or reanimation physician, with major
responsibil- ities in the ambulance and in the evaluation area of
hospitals, often without a specic trauma service. The table of
contents reects an international group of contributors assembled by
the editors to author the chapters. The editors have ensured
academic and intellectual strength and clinical expertise. They are
to be commended for achiev- ing such attention to detail in the rst
edition. Dr. William C. Wilson, a trauma anesthesiologist and
intensivist, is internationally recognized in the areas of trauma
airway management, respiratory gas exchange, thoracic anesthesia,
and monitoring. As editor-in-chief, Dr. Wilsons editorial
leadership is evident in the clear organiz- ation of the book,
uency of the writing, and balance of coverage. Dr. Christopher
Grande, a clinically active trauma anesthesiologist and
intensivist, is the executive director of International Trauma Care
(ITACCS). He has published extensively in the area of trauma
anesthesia and critical care for decades. Doctor Grandes editorial
inuence is evi- denced by the expert international coverage of many
topics. Dr. Hoyt is a world-renowned trauma surgeon and surgical
intensivist. He has been an active leader of numer- ous prestigious
surgical trauma organizations, including past president of the
American Association for the Surgery of Trauma and the Shock
Society, as well as chairman of the American College of Surgeons
Committee on Trauma. He is the current president of the Pan
American Trauma Society. Dr. Hoyts experience and wisdom are
reected in his careful editorial oversight of this comprehensive
two-volume treatise on trauma care. Volume 1 covers the areas of
prehospital care, resusci- tation, perioperative management, and
associated trauma conditions. It is logically organized, covering
the key conditions, and provides clear guidelines for medical and
surgical decision making, including global operative con-
siderations. However, by design, esoteric technical details of
surgical procedures are omitted in favor of general management
concepts and principles supported by recent literature. Other
important trauma-related conditions (e.g., alcohol and drug
intoxication, burns, near drowning, etc.) and management of unique
populations (e.g., pediatric, geriatric, and obstetric) are also
reviewed in Volume 1. Volume 2 covers the critical care management
of trauma and is a logical, systems-based presentation of the
problems commonly encountered in a modern intensive care unit. This
volume reviews medical conditions, the role of psychological
factors, the family, rehabilitation, and ethics. In addition,
emerging topics such as remote evalu- ation and management are
introduced. Because of the fundamental importance of the subject
matter along with the editorial review, this two-volume set
represents a compelling resource in the management of trauma and is
highly recommended for all clinicians with primary responsibility
for resuscitation and management of trauma patients. Kenneth L.
Mattox, MD, FACS Professor and Vice Chair Michael E. DeBakey
Department of Surgery Baylor College of Medicine Chief of Surgery
Ben Taub General Hospital Houston, Texas, U.S.A. viii
14. Preface OVERVIEWOF BOTH VOLUMES Trauma is the leading cause
of death in the young (ages 144) in the United States and the chief
reason for lost years of productive life among citizens living in
industrial- ized countries. Despite the enormous importance of the
subject matter, no single text has yet been published that fully
covers all phases of trauma management. The purpose of this book is
to bring together in one source a description of modern clinical
management prin- ciples for the care of the trauma patient. This
two-volume set, Trauma, Volume 1: Emergency Resuscitation,
Perioperative Anesthesia, Surgical Management and Trauma, Volume 2:
Critical Care, thoroughly encompasses the entire spectrum of trauma
management from the prehospital phase through critical care and
rehabilitation. A comprehensive table of contents, at the front of
each volume, encapsulates the organization of the entire book
(providing a macroscopic view), and also details the sections and
sub-headings within each chapter (providing a micro- scopic view).
The extensive index at the back of the book is organized to provide
expeditious referral to specic pages that cover the subject matter
of interest. The reader is encour- aged to utilize both the very
detailed table of contents and the index as needed to quickly
locate topics. Each chapter in this work incorporates important
features that greatly enhance information communication and
learning. The chapters are generously illustrated with gures and
tables to facilitate synthesis of important concepts. In addition,
key points are highlighted within the text and are summarized at
the end of each chapter for quick review. Care has been taken to
minimize redundancy by maximizing appropriate cross-referencing
throughout. Another useful aspect of each chapter is the Eye to the
Future section, which reviews emerging concepts and new research
ndings likely to impact clinical management. The contributors to
these volumes are both authorita- tive (having performed original
research and authored numerous publications on their subject
matter) and have extensive clinical experience. The authorship
considered as a whole is truly international, with contributors
from all continents. Furthermore, both civilian and military
consider- ations are reviewed whenever relevant. The majority of
chapters have multi-specialty co-authorship by experts in trauma
surgery, trauma anesthesiology, emergency medi- cine, and numerous
other medical and surgical specialties. In addition, chapters have
multidisciplinary involvement by experts in physical medicine,
rehabilitation, nursing, and pharmacy, among other disciplines. The
scientic soundness is further insured by the multiple layers of
editorial oversight; every chapter has been reviewed by at least
three experts in the eld (principal, associate and section
editors). The high level of scientic accuracy and the
reader-friendly nature of these two volumes are expected to
facilitate learning in order to improve the care provided to trauma
patients around the globe. VOLUME1 Volume 1 is divided into ve
sections and begins to tell the trauma story. Section A
(Preparation and Prehospital Care) provides the background
knowledge and prehospital con- cepts required to manage trauma
patients in both civilian and military settings. Section B
instructs the traumatologist on what must be accomplished and
accomplished quickly in the trauma resuscitation suite. Section C
explores the principles of anesthetic management for trauma,
including preoperative evaluation, preparation, and monitoring,
along with the decision-making processes employed for selecting
general or regional anesthetic techniques in trauma patients.
Section D details the perioperative anesthetic and surgical
priorities for specic injuries. This section focuses on the most
important areas of management in a systematic fashion, including
chapters on maxillofacial, brain, penetrat- ing neck,
cardiothoracic, and cervical and thoracic vertebral spine injuries,
along with abdominal, pelvic, and extremity trauma. Each organ
system receives specic focus as well as discussion within the
context of the overall management strategy for severely injured
patients. Section E surveys the numerous trauma-associated
conditions with important time-sensitive diagnostic and management
considerations. This section includes dis- cussions on the
management of intoxication due to alcohol, drugs, poisoning, and
envenomations. Anaphylaxis and allergy are discussed with specic
implications for the trauma patient. Burn injuries are extensively
reviewed, as are cold- and heat-related injuries, near-drowning,
and weapons of mass destruction. In addition, the less frequently
encountered trauma demographics (e.g., pediatrics, geria- trics,
obstetrics) each have their own dedicated chapters. Finally, the
pitfalls in trauma management and the elements constituting the
tertiary survey are fully described. The absolute necessity to
begin at the beginning when learning trauma management, including
the principles of prehospital care and initial resuscitation and
perioperative management concepts, makes this volume a must
reference for the serious traumatologist and all others involved in
this phase of the trauma story. William C. Wilson, MD, MA
Christopher M. Grande, MD, MPH David B. Hoyt, MD, FACS ix
15. Acknowledgments The editors would like to express gratitude
to our families and loved ones for their unwavering support during
the many years of planning and production of this book. Without
their sacrices, encouragement, and love, this two-volume book could
not have been completed. The associate editors and numerous section
editors have likewise sacriced time from their families and other
professional responsibilities during their dedicated work on this
important project. We cannot over express our gratitude for their
contributions, or for our delight in the superb job accomplished by
these gifted experts. Due to their diligence, this book has
achieved a level of editorial oversight seldom found in
multi-authored books. Essential to the production of this work was
the superb administrative assistance provided by Paul Hobson and
Bertha Englund. Paul, in particular, must be acknowl- edged for his
dedicated support, working weekends and late into many evenings
throughout the process of chapter formatting and editing. In
addition, the contributions made by Linda Kesselring, Jan Bailey,
and Sereyrathana Keng during the early stages of this project were
critical to the ulti- mate success of the book. The excellent
administrative support of Linda Collins throughout the project was
likewise essential. Also vital to the development of this book has
been the assistance of ITACCS (International TraumaCare), whose
membership has contributed numerous chapters, and whose leadership
has supported this project throughout its development. Finally, we
would like to acknowledge the expert assistance provided by our
publishers at Informa Health- care. The professionalism of this
organization has been superb, starting at the top with Sandra
Beberman, and throughout the publication process with the able
assistance of Vanessa Sanchez and Joe Stubenrauch. The
professionals at the Egerton Group (Joanne Jay and Paula Garber)
were likewise essential to the production of this book. In
particular, Mrs. Garber, editorial supervisor, must be commended
for providing excellent attention to detail, a strong work ethic,
and calm, kind leadership throughout the typesetting and nal
editing. Geoffrey Greenwood must also be acknowledged for helping
us initiate this project many years ago. Each of these individuals
has served to kindly and expertly assist our navigation through the
ardors of the publication process, and we are grateful to them all.
William C. Wilson, MD, MA Christopher M. Grande, MD, MPH David B.
Hoyt, MD, FACS xi
16. Contents Foreword Richard Henry Carmona . . . . v Foreword
Peter J. F. Baskett . . . . vi Foreword Paul E. Pepe . . . . vii
Foreword Kenneth L. Mattox . . . . viii Preface . . . . ix
Acknowledgments . . . . xi Contributors . . . . xxxiii SECTION A:
PREPARATION AND PREHOSPITAL CARE Section Editor: Irving Jake Jacoby
1. History of Trauma . . . . 1 Panna Sanga, Adolph H. Giesecke,
William C. Wilson, and Anne J. Sutcliffe B Introduction . . . . 1 B
Prehistory . . . . 2 B Early Civilizations, 3000 B.C. 200 A.D. . .
. . 2 Egyptians . . . . 2 Greeks . . . . 3 The Romans . . . . 4 B
Dark and Middle Ages and Middle Eastern Medical Advances, 2001500 .
. . . 6 B Renaissance Era, 1500 . . . . 8 B History of Analgesia
Through Antiquity (Through the 1700s) . . . . 12 B Epoch of
Inhalation Anesthesia, 1800 . . . . 12 The Mexican War of 1845 . .
. . 13 The American Civil War . . . . 14 B Discovery of Antiseptic
Strategies, 1848 . . . . 15 B Epoch of Regional Anesthesia, 1884 .
. . . 16 B Epoch of Intravenous Anesthesia and Antibiotics, 1934 .
. . . 17 B Epoch of Fluid Therapy for Trauma, 1950 . . . . 18 B
Epoch of Precision Monitoring and Resuscitation for Anesthesia and
Trauma, 1986 . . . . 19 B Epoch of Emergency Medical Services
(Current Era) . . . . 20 B Summary . . . . 21 Key Points . . . . 21
B References . . . . 22 2. Mechanisms and Epidemiology of Trauma .
. . . 25 Bruce Potenza and Jerry Nolan B Introduction . . . . 25 B
Mechanisms of Trauma . . . . 26 Precipitating Agents of Injury . .
. . 26 Biomechanical Forces Generated by Various Mechanisms . . . .
28 Blunt Trauma . . . . 28 Penetrating Trauma . . . . 28 Gunshot
Wounds (Combination of Penetrating and Blunt Biomechanics) . . . .
28 Thermal Injuries . . . . 29 Caustic ChemicalRelated Injury . . .
. 29 Electrical Injuries . . . . 30 Blast Injuries . . . . 30
Radiation Injury . . . . 31 Injury Intent . . . . 31 Intentional .
. . . 31 Unintentional . . . . 31 B Scope of Injury and Death Due
to Trauma . . . . 31 Injury Pyramid . . . . 32 Years of Productive
Life Lost and Disability Adjusted Life Years . . . . 33 Trauma Data
Base Organizations and Coding . . . . 33 B Demographic Factors . .
. . 34 Age-Specic Injury Mechanisms . . . . 34 Socioeconomic Status
. . . . 34 Gender . . . . 35 B Leading Mechanisms of Injury . . . .
35 Unintentional Injuries . . . . 35 Motor Vehicle Collisions . . .
. 35 Pedestrians Struck by a Motor Vehicle . . . . 36 Falls . . . .
36 Drowning . . . . 36 Bicycle . . . . 36 Fires and Burns . . . .
36 Intentional Injuries . . . . 36 Assault . . . . 37 Homicide . .
. . 37 Suicide . . . . 37 War-Related Injuries . . . . 37 B Public
Health Approach to Injury Prevention . . . . 37 B Eye to the Future
. . . . 39 B Summary . . . . 39 Key Points . . . . 40 B References
. . . . 40 3. Prehospital Care and Trauma Systems . . . . 43 Erika
Frischknecht Christensen, Charles D. Deakin, Gary M. Vilke, and
Freddy K. Lippert B Introduction . . . . 43 B Models of Prehospital
Trauma Care . . . . 43 Stafng Models of Prehospital Care . . . . 43
Background . . . . 43 United States and Canadian Model . . . . 43
Central European Model . . . . 44 Comparison of Prehospital Stafng
Models . . . . 44 Skill Levels and Training of Prehospital
Providers . . . . 45 Integration of Prehospital and In-Hospital
Systems . . . . 45 Communication Between Hospitals and Field Units
. . . . 46 Dispatch . . . . 46 On-Scene Communication . . . . 46 B
System Management Strategies . . . . 46 Overview of Management
Strategies . . . . 46 Prehospital Mortality Data Drives
Resuscitation Priorities . . . . 47 xiii
17. Organizational Inuences on the System of Prehospital Care .
. . . 47 Overview . . . . 47 Evidence for Scoop and Run . . . . 47
Evidence for Field Stabilization . . . . 47 Optimum Mode of
Transport . . . . 48 B Prehospital Management Priorities . . . . 48
Airway . . . . 48 Breathing . . . . 49 Circulation . . . . 49 B
Communication of Patient Information to the Trauma Team . . . . 50
Prearrival Report . . . . 50 Transfer of Care and Patient
Information . . . . 51 Mechanism . . . . 51 Injuries . . . . 51
Vital Signs . . . . 51 Treatment . . . . 51 B Trauma Center and
Trauma System Concepts . . . . 51 Background . . . . 51 Dening
Trauma Centers and Systems . . . . 51 Effectiveness of Trauma
Centers and Trauma Systems . . . . 54 B Eye to the Future . . . .
54 B Summary . . . . 55 Key Points . . . . 55 B References . . . .
56 4. Trauma Scoring and Triage . . . . 59 Daniela Levin, Costas
Bachtis, Jose A. Acosta, and Irving Jake Jacoby B Introduction . .
. . 59 B Trauma Scoring Denition and Categorization . . . . 59 B
Frequently Used Scoring Systems . . . . 60 Glasgow Coma Scale . . .
. 60 Trauma Score and Revised Trauma Score . . . . 61 Organ Injury
Scale . . . . 62 Abbreviated Injury Scale . . . . 62 Injury
Severity Score . . . . 62 Anatomical Prole . . . . 63 Pediatric
Scoring . . . . 63 Acute Physiological and Chronic Health
Evaluation . . . . 64 B Quality Assessment Systems . . . . 65
Trauma ScoreInjury Severity Score . . . . 65 A Severity
Characterization of Trauma . . . . 65 B Trauma Registries . . . .
66 Major Trauma Outcome Study . . . . 66 The Utstein Style:
Uniformity in Scoring . . . . 66 B Triage Denitions and General
Concepts . . . . 67 B Triage Applications . . . . 67 Use of
Disaster Medical Assistance Teams . . . . 67 Out-of-Hospital Triage
Principles . . . . 68 In-Hospital (Secondary) Triage . . . . 72 B
Limitations and Pitfalls of Triage . . . . 73 B Special Triage
Situations . . . . 74 Civilian Mass Casualty: START/JumpSTARTTM . .
. . 74 Nuclear Incidents . . . . 75 Biological Agent Release . . .
. 75 Chemical Agent Release . . . . 76 Pediatrics . . . . 78 War .
. . . 78 B Eye to the Future . . . . 78 B Summary . . . . 79 Key
Points . . . . 79 B References . . . . 79 5. Resuscitation Suite
and Operating Room Readiness . . . . 83 Sanjeev V. Chhangani, Peter
J. Papadakos, William C. Wilson, Wasif Ali, and Jose A. Acosta B
Introduction . . . . 83 B Physical Plan of Trauma Resuscitation
Suite . . . . 83 Equipment . . . . 84 Airway Cart . . . . 84
Procedure Cart . . . . 84 Monitors . . . . 84 Immobilization
Devices . . . . 85 Other Equipment . . . . 86 Pharmacologic Agents
. . . . 86 Communication . . . . 87 Preassigned Roles of Trauma
Team Members . . . . 89 Noise Level Expectations . . . . 89 ATLS
Training of Personnel . . . . 89 Laboratory Support . . . . 91
Blood Bank . . . . 91 Clinical Laboratory . . . . 91 Radiology . .
. . 91 Ultrasonography . . . . 91 B Intrahospital Transport . . . .
91 Pretransport Patient Evaluation . . . . 92 Transport Monitoring
. . . . 92 Data Management . . . . 92 Coordination of Care . . . .
93 B Physical Plan of Trauma Operating Room . . . . 93 Equipment .
. . . 94 Anesthesia Machine and Anesthesia Cart . . . . 94
Fluid-Warming Devices . . . . 94 Procedure and Invasive Line Carts
. . . . 94 Other Equipment . . . . 95 Pharmacologic Agents . . . .
95 Laboratory and Blood Bank Support Personnel . . . . 95
Additional Anesthesia Monitoring and Support Personnel . . . . 95 B
Military Resuscitation and Operating Room Considerations . . . . 96
B Eye to the Future . . . . 98 B Summary . . . . 98 Key Points . .
. . 98 B References . . . . 99 6. Trauma Team Performance . . . .
101 Paul Barach and Matthew B. Weinger B Introduction . . . . 101 B
Team Denition and Relevance in Trauma . . . . 101 Team Competence .
. . . 101 Team Member Conict Resolution . . . . 102 B Organization
of the Modern Trauma Team . . . . 102 The Trauma Team Leader . . .
. 102 Other Members of the Trauma Team . . . . 103 B Human Factors
in the Trauma Environment . . . . 103 xiv Contents
18. Sleep Deprivation and Fatigue . . . . 104 Stress and Job
Performance . . . . 104 Environmental Factors (e.g., Noise,
Clutter, Disorganization) . . . . 105 Interpersonal Communication .
. . . 105 B Keys to Expert Decision Making for Trauma . . . . 105
Correct Decision Making with Incomplete/Conicting Data . . . . 105
Situation Awareness . . . . 106 B Team Training Techniques . . . .
106 Traditional Team Training Exercises . . . . 106 Cross Training
. . . . 107 Team Model Training . . . . 107 Trauma Crew Resource
Management . . . . 107 Simulators for Trauma Team Training and
Assessment . . . . 108 Value of Realistic Patient Simulators . . .
. 108 Importance of Scenario Design . . . . 108 Components of a
Simulation-Based Training Course . . . . 108 B Evaluating Trauma
Team Performance . . . . 108 Paucity of Validated Competency
Assessment Metrics . . . . 109 Video Analysis of Trauma Care . . .
. 109 B Eye to the Future . . . . 109 Increased Emphasis upon
Computerized Simulation . . . . 109 Incorporating Military and
Aviation Industry Lessons . . . . 110 B Summary . . . . 110 Key
Points . . . . 111 B References . . . . 111 7. Transport of the
Trauma Patient . . . . 115 Jose A. Acosta, Maureen McCunn, William
Beninati, William C. Wilson, and Joseph F. Rappold B Introduction .
. . . 115 Overview . . . . 115 Transportation Guidelines . . . .
116 Determining Appropriateness of Transport . . . . 116 B
Prehospital and Interhospital Transport Modes . . . . 117 Ground
Travel . . . . 117 Rotary-Wing Transport . . . . 118 Fixed-Wing
Transport . . . . 118 Miscellaneous Modes of Transportation . . . .
118 B Preparation . . . . 120 Transport Team Members . . . . 120
Equipment . . . . 120 Safety Considerations . . . . 120 B Potential
Transport Complications . . . . 121 Hemodynamic Stability . . . .
122 Airway and Respiratory Compromise . . . . 124 Intracranial
Pressure Considerations . . . . 124 Physiological Stresses of
Flight . . . . 125 B Long-Range Air Transport Considerations . . .
. 126 Trapped Gas . . . . 126 Decompression Sickness/Air Embolism .
. . . 126 Casts/Compartment Syndrome . . . . 126 Damage
Control/Abdominal Compartment Syndrome . . . . 127 Burns . . . .
127 Infection Control . . . . 127 B Special Circumstances . . . .
128 Disaster/Mass Casualty . . . . 128 Contaminated Casualties . .
. . 128 Combat MEDEVAC and Transport . . . . 128 B Eye to the
Future . . . . 130 B Summary . . . . 132 Key Points . . . . 132 B
References . . . . 133 SECTION B: RESUSCITATION SUITE/TRAUMA ED
MANAGEMENT Section Editor: Richard P. Dutton 8. Primary Survey:
Initial Resuscitation Priorities . . . . 135 Eran Tal-Or, Koichi
Tanigawa, Andreas R. Thierbach, Herbert Kuhnigk, and Moshe
Michaelson B Introduction . . . . 135 B Airway Maintenance with
Cervical Spine Protection . . . . 135 Assessment . . . . 135 Basic
Airway Management . . . . 136 Supplemental Oxygen and Chin-Lift/
Jaw-Thrust Maneuvers . . . . 136 Oropharyngeal and Nasopharyngeal
Airways . . . . 137 Aspiration Precautions and Suction Devices . .
. . 137 Cervical Spine Precautions . . . . 137 Denitive Airway
Management . . . . 138 Rapid Sequence Induction . . . . 138
Alternative Emergency Airway Devices . . . . 139 Surgical Airway .
. . . 139 Conrmation of Tracheal Intubation . . . . 139 B Breathing
Assessment and Maintenance . . . . 140 Physical Examination . . . .
140 Inspection . . . . 140 Palpation/Percussion . . . . 141
Auscultation . . . . 141 Imaging Aids to Breathing Assessment . . .
. 141 Life-Threatening Thoracic Injuries . . . . 143 Tension
Pneumothorax . . . . 143 Massive Hemothorax/Tube Thoracostomy . . .
. 143 Sucking Chest Wounds . . . . 143 Flail Chest . . . . 143
Cardiac Tamponade/Pericardial Drainage . . . . 144 Mechanical
Ventilation in the Resuscitation Suite . . . . 144 B Circulation
Assessment and Hemorrhage Control . . . . 145 Assessment . . . .
145 Denition of Hemodynamic Stability . . . . 145 Circulation
Assessment Principles . . . . 145 Contents xv
19. Circulatory Depression from Nonhemorrhagic Causes . . . .
146 Management of Compensated Hemorrhagic Shock . . . . 147 Shock
Prediction and Prevention . . . . 147 Maintenance of Blood Pressure
and Tissue Perfusion . . . . 147 Management of Uncontrolled
Hemorrhagic Shock . . . . 147 Diagnostic Testing and Monitoring
Adjuncts . . . . 147 Hemoglobin Measurements . . . . 147 Invasive
Blood Pressure Monitoring . . . . 147 Central Venous Pressure . . .
. 147 Arterial Blood Gas and Base Decit . . . . 148 Lactate Level .
. . . 148 FAST Versus DPL Versus CT Scan . . . . 148 CT Scan . . .
. 148 B Disability . . . . 148 General Considerations . . . . 148
History . . . . 148 Mechanism of Injury . . . . 148 Patient History
. . . . 149 Physical Examination . . . . 149 Level of
ConsciousnessGlasgow Coma Scale . . . . 149 Pupil Examination . . .
. 149 Motor Examination . . . . 150 Sensory Function and Other
Symptoms . . . . 150 B Exposure/Environmental Control . . . . 150
Exposure . . . . 150 Environmental Control . . . . 150 B Eye to the
Future . . . . 150 B Summary . . . . 151 Key Points . . . . 151 B
References . . . . 152 9. Denitive Airway Management . . . . 155
William C. Wilson, Anushirvan Minokadeh, Jonathan L. Benumof,
Michael Frass, and Pedro Barbieri B Introduction . . . . 155 B
Equipment and Drug Preparation . . . . 155 Oxygen: Critical During
Trauma Airway Management . . . . 155 Treatment of Hypoxemia . . . .
156 Preoxygenation: Maximizing PaO2 During Apnea . . . . 156
Ventilation and Intubation Equipment . . . . 157 Suction Equipment
. . . . 158 Functioning Intravenous Catheter . . . . 158 Monitoring
and Endotracheal Tube Conrmation Devices . . . . 158 Vasopressors
and Inotropes . . . . 159 Portable Storage Unit for Trauma
Resuscitation . . . . 159 B Denition of the Difcult Airway . . . .
159 Historical Indicators of Airway Difculty . . . . 160
Pathologic/Anatomic Predictors of Airway Difculty . . . . 160 B
Airway Examination Principles . . . . 161 The 11-Step Airway Exam
of Benumof . . . . 161 Abbreviated Trauma Airway Exam . . . . 161 B
Conventional Trauma Airway Management . . . . 161 Patient
Preparation and Positioning . . . . 161 Mask Ventilation . . . .
163 Types of Masks Used for Ventilation . . . . 163 Mask
Ventilation Techniques . . . . 163 Oropharyngeal and Nasopharyngeal
Airways . . . . 163 Laryngeal Mask Airway . . . . 163 Rigid Direct
Laryngoscopy . . . . 164 In-Line Cervical Immobilization . . . .
165 Rapid Sequence Intubation (RSI) Principles . . . . 165 Modied
Rapid Sequence Intubation Techniques . . . . 167 B The Difcult
Trauma Airway . . . . 167 Awake Techniques (Cooperative/Stable
Patients) . . . . 167 Adjunts for Unstable, Uncooperative, or
Apneic Patients with Difcult Airways . . . . 168
Esophageal-Tracheal-Combitube . . . . 168 Laryngeal Mask Airway . .
. . 168 Rigid Bronchoscope . . . . 170 Surgical Airway Options . .
. . 171 Blind Intubation Techniques (Not Recommended with Stridor)
. . . . 173 Blind Nasal Intubation . . . . 173 Light Wand . . . .
175 Retrograde Wire . . . . 175 Regional Anesthesia in the Trauma
Patient with Known Difcult Airway . . . . 175 B Fiberoptic
Bronchoscopy: Techniques and Pitfalls . . . . 175 Patient Selection
. . . . 176 Patient Preparation . . . . 177 Positioning for
Fiberoptic Bronchoscopy . . . . 177 Intravenous Analgesia,
Sedation, and Antisialagogue . . . . 177 Local Anesthesia and
Vasoconstriction . . . . 177 Techniques of Fiberoptic Intubation .
. . . 178 Awake Nasal Technique . . . . 178 Oral Technique . . . .
180 B Difcult Airway Algorithms . . . . 181 The ASA Difcult Airway
Algorithm . . . . 181 Recognition of the Difcult Airway . . . . 181
Awake Limb of the ASA Difcult Airway Algorithm . . . . 183
Uncooperative/Unstable/Anesthetized Limb of the ASA Difcult Airway
Algorithm . . . . 183 ASA Difcult Airway Algorithm Modied for
Trauma . . . . 183 Five Common Trauma Difcult Intubation Scenarios
. . . . 184 Traumatic Brain Injury/Intoxication . . . . 184
Cervical-Spine Injury . . . . 185 Airway Disruption . . . . 185
Maxillofacial Trauma . . . . 188 Airway Compression . . . . 188 B
Emergency Intubation Complications . . . . 189 Failure to Intubate
or Ventilate . . . . 190 Unrecognized Esophageal Intubation . . . .
191 Direct Conrmation of Intratracheal Tube Position . . . . 191
Indirect Conrmation of Intratracheal Tube Position . . . . 191
End-Tidal CO2 Measurement . . . . 191 xvi Contents
20. Hemodynamic Compromise . . . . 191 Causes of Preinduction
Increases of Catecholamines . . . . 192 Causes of Hypotension
Following Induction and Intubation . . . . 192 Techniques to Limit
Hypotension Following Intubation . . . . 192 Aspiration of Gastric
Contents . . . . 192 Creating a C-Spine Injury in a Patient with an
Unstable Neck . . . . 192 B Eye to the Future . . . . 193 B Summary
. . . . 194 Key Points . . . . 194 B References . . . . 195 10.
Intravenous Access . . . . 197 Robert E. Johnstone, Joseph F.
Talarico, Edward E. Cornwell III, and Nelson Tang B Introduction .
. . . 197 B Determinants of Intravenous Flow Rate . . . . 197 B
Peripheral Intravenous Access . . . . 199 General Considerations .
. . . 199 Technique . . . . 199 B Central Venous Access . . . . 200
General Considerations . . . . 200 Complications . . . . 200
Internal Jugular Vein Catheterization . . . . 201 General . . . .
201 Advantages and Disadvantages . . . . 201 Complications . . . .
201 Technique 1: Middle Approach . . . . 202 Technique 2: Posterior
Approach (Alternate) . . . . 203 Subclavian Vein Catheterization .
. . . 203 General . . . . 203 Advantages and Disadvantages . . . .
203 Complications . . . . 203 Technique . . . . 204 Femoral Vein
Catheterization . . . . 204 General . . . . 204 Advantages and
Disadvantages . . . . 204 Complications . . . . 204 Technique . . .
. 204 B Saphenous Vein Cutdown . . . . 205 B Intraosseous Infusion
. . . . 205 B Intratracheal Administration of Drugs . . . . 206 B
Other Infusion Considerations . . . . 206 B Special Lines and
Maneuvers . . . . 207 Pringle Maneuver . . . . 208 Atriocaval
Shunts and Atrial Lines . . . . 209 Arterial Catheters . . . . 210
B Eye to the Future . . . . 210 B Summary . . . . 211 Key Points .
. . . 211 B References . . . . 211 11. Fluid Resuscitation Strategy
. . . . 215 Richard P. Dutton and Robert S. Howard B Introduction .
. . . 215 Early vs. Late Resuscitation . . . . 215 Recent Advances
and Controversies . . . . 215 B Physiology of Hemorrhage . . . .
216 Neuroendocrine Response to Hypotension . . . . 216 Cellular
Response to Ischemia . . . . 216 Hibernation vs. Apoptosis and
Necrosis . . . . 216 The No-Reow Phenomenon . . . . 216 Reperfusion
Injury . . . . 217 Organ System Response to Ischemia . . . . 217
Cardiovascular System . . . . 217 Gastrointestinal System . . . .
218 Hepatic System . . . . 218 Renal System . . . . 218 Central
Nervous System . . . . 218 Pulmonary System . . . . 218
Musculoskeletal System . . . . 218 Immune/Hematopoetic System . . .
. 219 B Basics of Management . . . . 219 Optimum Monitoring . . . .
219 Vital Signs . . . . 219 Laboratory Studies . . . . 220 Pressure
Measurement . . . . 220 Measures of Perfusion . . . . 220 Adequate
Intravenous Access . . . . 221 Warming . . . . 221 Availability of
Resuscitation Fluids and Blood Products . . . . 221 Personnel . . .
. 221 Control of Hemorrhage . . . . 222 Bleeding into the Chest . .
. . 222 Bleeding into the Abdomen . . . . 222 Bleeding into the
Retroperitoneum . . . . 222 Bleeding into Long Bone Compartments .
. . . 222 Bleeding Outside the Body . . . . 222 B Resuscitation
Fluid Choices . . . . 222 Crystalloids . . . . 222 Lactated Ringers
Solution . . . . 222 Normal Saline . . . . 223 Plasmalyte-Aw . . .
. 223 Colloids . . . . 223 Albumin . . . . 224 Gelatins . . . . 224
Starch Solutions . . . . 224 Dextrans . . . . 224 Crystalloids vs.
Colloids . . . . 224 Hypertonic Saline . . . . 225 Blood Products .
. . . 225 Packed Red Blood Cells . . . . 225 Plasma . . . . 225
Platelets . . . . 225 Blood Substitutes . . . . 226 Peruorocarbons
. . . . 226 Hemoglobin-Based Oxygen Carriers . . . . 226 B
Guideposts and Endpoints for Resuscitation . . . . 227 Perfusion
Targets for Early Resuscitation . . . . 227 Blood Pressure . . . .
227 Lactate and Base Decit . . . . 227 Central Venous and Pulmonary
Artery Pressure . . . . 227 Transesophageal Echocardiography . . .
. 227 End-Organ Perfusion . . . . 227 Perfusion Targets for Late
Resuscitation . . . . 227 B Controversies in Early Resuscitation .
. . . 228 Controlled Hypotension? . . . . 228 Wait and Resuscitate
or Go to the Operating Room? . . . . 228 Contents xvii
21. What Is the Appropriate Transfusion Threshold? . . . . 228
B Special Cases in Fluid Resuscitation . . . . 228 Elderly Patients
. . . . 228 Head-Injured Patients . . . . 228 Patients with Cardiac
Dysfunction . . . . 229 B Eye to the Future . . . . 229 Better
Monitors . . . . 229 Improved Hemorrhage Control . . . . 229 Better
FluidsBlunting Reperfusion Injury . . . . 229 Ringers Ethyl
Pyruvate Solution . . . . 229 Pentoxifylline . . . . 230 B Summary
. . . . 231 Key Points . . . . 231 B References . . . . 232 12.
Initial Circulation Assessment and Shock Prevention . . . . 235
Denzil W. Hawkinberry and Anushirvan Minokadeh B Introduction . . .
. 235 B Clinical Assessment . . . . 235 History . . . . 235
Examination . . . . 236 Mental Status . . . . 236 Pulses . . . .
236 Blood Pressure . . . . 236 Skin Color . . . . 237 Urine Output
. . . . 237 Capnography . . . . 238 Focused Assessment with
Sonography for Trauma . . . . 238 B Laboratory Based Assessment of
Circulation . . . . 239 Hematocrit and Hemoglobin . . . . 239 Blood
Gas Analysis . . . . 239 B Invasive Monitors in Circulatory
Assessment . . . . 240 Central Venous Catheter . . . . 240
Pulmonary Artery Catheter . . . . 241 B Prevention of Shock . . . .
241 Denition of Shock and Objectives for Prevention . . . . 241
When Oxygen Delivery Is Adequate, Shock Is Rare . . . . 241
Denition and Terminology of Oxygen Delivery . . . . 241 Response to
Initial Fluid Resuscitation . . . . 242 B Complications of Massive
Resuscitation . . . . 243 Dilutional Anemia . . . . 243 Dilutional
Coagulopathy . . . . 243 Electrolyte Abnormalities . . . . 243
Hypothermia . . . . 243 B Eye to the Future . . . . 244 B Summary .
. . . 244 Key Points . . . . 245 B References . . . . 245 13.
Resuscitative Thoracotomy . . . . 247 Jeffrey M. Farrier, Rohan
Lall, and Raul Coimbra B Introduction . . . . 247 B Denitions . . .
. 247 B Resuscitative Thoracotomy: Objectives . . . . 248 B
Emergency Thoracotomy: Indications . . . . 249 Accepted Indications
. . . . 249 Penetrating Thoracic Injury . . . . 249 Blunt Thoracic
Injury . . . . 249 Penetrating Nonthoracic Injury . . . . 250
Contraindications . . . . 250 B Technical Aspects . . . . 250 B
Complications . . . . 251 B Results and Outcomes . . . . 251 B Eye
to the Future . . . . 252 B Summary . . . . 252 Key Points . . . .
253 B References . . . . 253 14. Secondary Survey: Comprehensive
Trauma Evaluation . . . . 255 James I. Merlino, James D. Polk, Jose
A. Acosta, and William F. Fallon, Jr. B Introduction . . . . 255 B
Timing, Overview, and Decision Making . . . . 255 Comprehensive
Evaluation of the Trauma Patient . . . . 255 Timing of the
Secondary Survey . . . . 256 Decision Making/Prioritizing Injury
Management . . . . 256 Advanced Triage . . . . 256 Continuous
Reassessment . . . . 256 Elimination of Missed Injuries . . . . 257
B Patient History. . . . 257 Prehospital History . . . . 257
Mechanism of Injury . . . . 257 Past Medical/Surgical History . . .
. 258 Medications/Allergies . . . . 258 Social History . . . . 258
Review of Systems . . . . 258 B Physical Examination . . . . 259
Neurological . . . . 259 Head/Maxillofacial . . . . 259 Neck . . .
. 259 Chest . . . . 260 Abdomen . . . . 260
Pelvis/Perineum/Rectum/Vagina . . . . 260 Thoracolumbar Spine . . .
. 260 Extremities . . . . 260 Vascular Assessment . . . . 260 B
Adjuncts to the Secondary Survey. . . . 260 Additional Imaging . .
. . 260 Additional Laboratory Tests . . . . 260 Special Diagnostic
Procedures . . . . 261 B Continued Assessment and Planning . . . .
261 Overview . . . . 261 Input from Consultants . . . . 261
Diagnostics and Subsequent Imaging . . . . 261 B Missed Injuries .
. . . 261 The Importance of Missed Injuries . . . . 261 Strategies
for Reducing Missed Injuries . . . . 262 Patient Mental Status . .
. . 262 Documentation . . . . 262 The Tertiary Survey . . . . 262 B
Eye to the Future . . . . 262 B Summary . . . . 262 Key Points . .
. . 264 B References . . . . 264 xviii Contents
22. 15. Cervical Spine: Initial Evaluation and Management . . .
. 267 Tudor H. Hughes, Jose A. Acosta, Steven R. Garn, William C.
Wilson, and Alexandra K. Schwartz B Introduction . . . . 267 B
Epidemiology. . . . 267 B Anatomy. . . . 268 Divisions . . . . 268
Bony Elements . . . . 269 Ligamentous Support . . . . 270 B
Injuries to the Cervical Spine . . . . 270 Structural Types . . . .
270 Fractures . . . . 270 Ligamentous DisruptionPredicted by
Subluxation/Dislocation Pattern . . . . 271 Spinal Cord Injury
Without Radiographic Abnormality . . . . 272 Cervical Spine
Fractures and Dislocations Classied by Biomechanical Forces . . . .
272 Flexion Injuries . . . . 272 Flexion Rotation . . . . 276
Extension . . . . 276 Vertical Compression . . . . 277 B History
and Physical Exam . . . . 278 High-Risk Activities Associated with
C-Spine Injury . . . . 278 C-Spine Injuries Relationship to
Restraint Devices . . . . 278 Motor and Sensory Exam . . . . 279
Advanced Trauma Life Support Screening Approach . . . . 279 B
Radiographic Trauma Evaluation . . . . 279 Essential Views . . . .
279 Cross Table Lateral . . . . 280 Open-Mouth Odontoid View . . .
. 283 AnteriorPosterior View . . . . 283 Additional Views Relegated
to Stable Patient Situations . . . . 283 Swimmers View . . . . 283
Oblique Views . . . . 283 Flexion-Extension Lateral Views . . . .
283 Advanced Imaging Modalities . . . . 284 Computed Tomography . .
. . 284 Magnetic Resonance Imaging . . . . 285 B Airway Management
. . . . 285 B General Approach and Management Algorithms . . . .
286 Awake Patient . . . . 286 The National Emergency X-Radiography
Utilization Study . . . . 287 The Canadian Cervical Spine Rule
Study . . . . 287 National Emergency X-Radiography Utilization
Study and Canadian Cervical Spine Rule . . . . 288 Obtunded Patient
. . . . 288 B Eye to the Future . . . . 289 B Summary . . . . 289
Key Points . . . . 289 B References . . . . 290 16. Diagnostic
Imaging for Trauma . . . . 293 Mary L. Grebenc, David L. Levin, and
Susan Kaplan B Introduction . . . . 293 B Basic Concepts of
Diagnostic Imaging . . . . 293 Radiation Exposure . . . . 293
Patient Exposure . . . . 293 Exposure of Health Care Personnel . .
. . 293 Contrast Toxicity . . . . 294 B Initial Screening of the
Trauma Patient . . . . 294 Screening Studies in the Trauma
Resuscitation Suite . . . . 294 Radiographs . . . . 294 Abbreviated
Contrast Studies . . . . 296 Ultrasonography . . . . 296 Imaging
Studies in the Operating Room . . . . 296 Imaging Studies in the
Radiology Suite . . . . 296 B Imaging for Specic Pathological
Conditions . . . . 297 Head Trauma . . . . 297 Anatomy . . . . 297
Diagnostic Imaging . . . . 297 Common Traumatic Brain Injuries . .
. . 297 Spine and Spinal Cord Trauma . . . . 299 Anatomy . . . .
299 Diagnostic Imaging . . . . 300 Cervical Spine Trauma . . . .
301 Thoracolumbar Spine Trauma . . . . 302 Thoracic Trauma . . . .
303 Evaluation of the AP Chest Radiograph . . . . 303 Aortic Injury
and Mediastinal Hematoma . . . . 303 Pneumothorax and
Pneumomediastinum . . . . 304 Hemothorax . . . . 305 Pulmonary
Contusion . . . . 305 Rib Fractures . . . . 305 Cardiac Injuries .
. . . 305 Tracheobronchial Injury . . . . 306 Esophageal Injury . .
. . 307 Diaphragmatic Injury . . . . 307 Imaging of Nonacute Trauma
. . . . 308 Abdominal Trauma . . . . 309 Anatomy . . . . 309
Focused Assessment with Sonography for Trauma . . . . 309 Computed
Tomography . . . . 310 Diagnostic Peritoneal Lavage . . . . 312
Specic Injuries . . . . 312 Pelvic Trauma . . . . 315 Anatomy . . .
. 315 Classication of Pelvic Fractures . . . . 316 Diagnostic
Imaging of Pelvic Trauma . . . . 316 Organ Injury in Pelvic Trauma
. . . . 317 Extremity Trauma . . . . 317 Anatomy . . . . 317
Diagnostic Imaging . . . . 317 Upper Extremity . . . . 317 Lower
Extremity . . . . 317 Complications of Extremity Injuries . . . .
318 Trauma in Pregnancy . . . . 318 Pediatric Trauma . . . . 318
Spinal Injury . . . . 318 Long-Bone Injuries . . . . 319 Child
Abuse . . . . 319 B Eye to the Future . . . . 319 B Summary . . . .
320 Key Points . . . . 320 B References . . . . 321 SECTION C:
ANESTHETIC MANAGEMENT AND DAMAGE CONTROL FOR TRAUMA Section Editor:
Christopher M. Grande 17. Preoperative Evaluation, Preparation, and
Monitoring . . . . 325 Beverly J. Newhouse and Carla St. Laurent B
Introduction . . . . 325 Contents xix
23. B Preoperative Evaluation . . . . 325 Prehospital
Information Sources . . . . 325 Triage to Operating Room vs. Trauma
Resuscitation Suite . . . . 326 Priorities During the Primary
Survey . . . . 326 Information Garnered During the Secondary Survey
. . . . 327 Systematic Review of Potential High-Risk Injuries . . .
. 328 Airway Injury . . . . 329 Maxillofacial Trauma . . . . 329
Head Injury . . . . 329 Cervical Spine Injury . . . . 330 Chest
Injury/Aspiration . . . . 330 Abdominal, Retroperitoneal, and
Pelvic Injury . . . . 331 Extremity Injury . . . . 331 Burn Injury
. . . . 331 B Preoperative Preparation . . . . 332 Preparation of
the Trauma Patient . . . . 332 Preparation of the Operating Room .
. . . 332 Selecting a General vs. Regional Anesthetic . . . . 333 B
Monitoring Considerations . . . . 333 Monitoring Standards . . . .
333 Neurological Monitoring . . . . 333 Respiratory Monitoring . .
. . 335 Hemodynamic Monitoring . . . . 338 Electrocardiogram
Monitoring . . . . 341 Urine Output . . . . 341 Temperature
Monitoring and Warming Devices . . . . 341 Hematological Monitoring
. . . . 342 Neuromuscular Blockade Monitoring . . . . 343 Fetal
Monitoring . . . . 344 B Eye to the Future . . . . 345 Auditory
Evoked Potential Index . . . . 345 Sublingual Capnometry . . . .
345 Noninvasive Blood Hemoglobin Measurement . . . . 345
Noninvasive Pulmonary Gas Exchange Parameters . . . . 345
Noninvasive Cardiac Output Monitoring . . . . 345 Continuous
Noninvasive Blood Pressure Monitoring . . . . 345 Continuous
Arterial Blood Gas Analysis . . . . 346 B Summary . . . . 347 Key
Points . . . . 347 B References . . . . 347 18. Ongoing
Resuscitation Endpoints and Strategies . . . . 353 Lewis J. Kaplan
and Heatherlee Bailey B Introduction . . . . 353 B Cellular
Physiology of Hypoperfusion . . . . 353 Mitochondria as the
Powerhouse of the Cell . . . . 353 Aerobic vs. Anaerobic
Respiration . . . . 354 B Goals of Resuscitation . . . . 354
Limited Resuscitation Concept . . . . 354 Trauma Resuscitation
Priorities . . . . 355 Damage Control Surgery and Operative
Resuscitation . . . . 355 Surgical Intensive Care Unit:
Resuscitation Completion . . . . 355 B Hypothermia . . . . 355
Known Benets and Role in Metabolic Preservation . . . . 355
Potential Problems . . . . 356 Induced Hypothermia, Following
Trauma . . . . 356 B Review of Resuscitation Endpoints . . . . 356
Physical Exam . . . . 356 Biochemical Markers . . . . 356 AcidBase
Correlation with Survival . . . . 357 Lactate as an Arbiter of
Hypoperfusion . . . . 357 Strong Ion Gap (SIG) Correlation with
Trauma Mortality . . . . 357 Limitations of Using Volume
Requirements as Resuscitation Endpoints . . . . 357 Pulmonary
Artery Catheters and Surrogates . . . . 358 Transesophageal
Echocardiography . . . . 359 Esophageal Doppler Monitoring (Cardiac
Output) . . . . 359 End Tidal CO2 (PET CO2) . . . . 359
Tissue-Specic Endpoints of Resuscitation . . . . 359 Near-Infrared
Spectroscopy . . . . 359 Sublingual Capnometry . . . . 360 Gastric
Tonometry . . . . 360 B Blunt vs. Penetrating Trauma . . . . 360 B
Best Indicators of Resuscitation Success . . . . 360 B Eye to the
Future . . . . 361 B Summary . . . . 361 Key Points . . . . 361 B
References . . . . 361 19. General Anesthesia for Trauma . . . .
365 Cheryl Hilty, Anushirvan Minokadeh, and William C. Wilson B
Introduction . . . . 365 B Review of Trauma Condition Dictates
Anesthetic Management . . . . 365 Airway (with Spinal Cord
Protection) . . . . 365 Breathing . . . . 365 Circulation (with
Hemorrhage Control) . . . . 366 Disability (Assume Unstable
Cervical Spine) . . . . 366 Exposure and Environmental
Considerations . . . . 366 Full StomachConsiderations (Increased
Risk for Emesis and Aspiration) . . . . 367 Drug Intoxication
Considerations . . . . 367 Suspicion of Occult Injuries . . . . 367
Continued Reassessment . . . . 367 B Induction of Anesthesia . . .
. 367 Preoxygenation . . . . 367 Choice of Induction Drugs . . . .
367 Etomidate . . . . 368 Ketamine . . . . 369 Propofol . . . . 370
Thiopental . . . . 371 Neuromuscular Blockade Drug Selection . . .
. 372 Succinylcholine . . . . 372 Rocuronium . . . . 373 Management
of Patients Hemodynamically Unable to Tolerate General Anesthesia .
. . . 373 Scopolamine and Other Belladonna Alkaloids . . . . 373
Titration of Other Agents . . . . 374 B Maintenance of General
Anesthesia . . . . 374 Inhalation Drugs . . . . 374 Nitrous Oxide .
. . . 374 Volatile Anesthetics . . . . 375 xx Contents
24. Intravenous Agents (Total Intravenous Agents) . . . . 376
Opioid-Based Techniques . . . . 376 Other TIVA Infusion Drugs . . .
. 377 Neuromuscular Blocking Drugs . . . . 377 B Emergence and
Postoperative Planning . . . . 377 Extubation Considerations . . .
. 377 Conditions Suitable for Tracheal Extubation . . . . 377
Conditions Dictating Retention of Endotracheal Tube . . . . 377
Postoperative Sedation and Analgesia . . . . 378 B Transfer of Care
. . . . 378 Transport . . . . 378 Report to Critical Care Team . .
. . 379 B Eye to the Future . . . . 379 Xenon . . . . 379 Hydrogen
Sulde . . . . 379 B Summary . . . . 380 Key Points . . . . 380 B
References . . . . 381 20. Regional Anesthesia for Trauma . . . .
385 Daniel Wambold, Edward R. Mariano, and Andrew D. Rosenberg B
Introduction . . . . 385 B Risks and Benets of Regional Anesthesia
. . . . 385 B Historical Use of Regional Anesthesia in War Zones .
. . . 386 B Determining Appropriateness of Regional Anesthesia for
Trauma . . . . 387 B Techniques for Identifying Peripheral Nerves
for Blockade . . . . 388 Surface Electrical Stimulation for Nerve
Localization . . . . 388 Insulated Needle: Nerve StimulatorMediated
Nerve Localization . . . . 388 B Peripheral Nerve Blocks of the
Upper Extremity . . . . 389 General Considerations and Brachial
Plexus Anatomy . . . . 389 Interscalene Block . . . . 390 Clinical
Applications . . . . 390 Side Effects/Complications . . . . 390
Technique: Method of Winnie . . . . 390 Infraclavicular Block . . .
. 391 Clinical Applications . . . . 391 Side Effects/Complications
. . . . 391 Raj Technique . . . . 391 Coracoid Technique . . . .
392 Axillary Block . . . . 392 Clinical Applications . . . . 392
Side Effects/Complications . . . . 392 Technique . . . . 393 Elbow
and Wrist Blocks . . . . 393 Elbow Blocks . . . . 393 Wrist Blocks
. . . . 394 Intravenous Regional Anesthesia (Bier Block) . . . .
395 Clinical Applications . . . . 395 Side Effects/Complications .
. . . 395 Technique . . . . 395 B Peripheral Nerve Blocks of the
Lower Extremity . . . . 395 General Considerations and Anatomy . .
. . 395 Femoral Nerve Block . . . . 396 Clinical Applications . . .
. 396 Effects/Complications . . . . 396 Technique . . . . 396
Lateral Femoral Cutaneous Nerve Block . . . . 397 Clinical
Applications . . . . 397 Side Effects/Complications . . . . 397
Technique . . . . 397 Fascia Iliaca Block . . . . 397 Clinical
Applications . . . . 397 Side Effects/Complications . . . . 397
Technique . . . . 397 Sciatic Nerve Blocks . . . . 397 Clinical
Applications . . . . 397 Side Effects/Complications . . . . 398
Techniques . . . . 398 Ankle Block . . . . 400 Clinical
Applications . . . . 400 Side Effects/Complications . . . . 400
Technique . . . . 400 B Eye to the Future . . . . 401 B Summary . .
. . 402 Key Points . . . . 402 B References . . . . 402 21. Damage
Control . . . . 405 Rao R. Ivatury and Ajai K. Malhotra B
Introduction . . . . 405 B Patient Selection . . . . 405 B Stages
of Damage Control . . . . 405 Stage I: Limited Operation (Control
of Hemorrhage and Contamination) . . . . 405 Stage II:
Resuscitation (Restoration of Physiologic Homeostasis) . . . . 406
Stage III: Re-operation (Removal of Packs, Denitive Repair) . . . .
406 B Damage Control (Stage I) Operative Priorities for
Thoracic,Abdominal,andExtremityInjuries . . . . 406 Thoracic
Considerations . . . . 406 Pulmonary Hemorrhage . . . . 406 Cardiac
Hemorrhage . . . . 406 Aorta and Great Vessels . . . . 406
Abdominal Considerations . . . . 407 Liver Hemorrhage . . . . 407
Splenic Hemorrhage . . . . 407 Pancreatic Injuries . . . . 407
Contamination Control from the Gastrointestinal Tract . . . . 408
Renal Hemorrhage . . . . 408 Urinary Collecting System Injuries . .
. . 408 Internal Reproductive Organ Injuries . . . . 408 Hemorrhage
from Major Abdominal Vessels . . . . 408 Diffuse Abdominal Bleeding
. . . . 408 Extremity Injuries . . . . 408 Temporary Closure
Principles . . . . 409 B Resuscitation Considerations in the
Surgical Intensive Care Unit (Stage II) . . . . 409 Shock
(Metabolic Acidosis) and Resuscitation Endpoints . . . . 409
Hypothermia . . . . 411 Coagulopathy . . . . 411 Unplanned
Interventions: Emergent Surgery and/or Angiography . . . . 411 B
Re-operation: Removal of Packs, Washout, Denitive Repair . . . .
412 General Considerations . . . . 412 Operative Strategies for the
Difcult-to-Close Abdomen . . . . 412 Contents xxi
25. B Cumulative Experience: Supporting Damage Control . . . .
413 B Too Much, Too Often: The Criticism of Damage Control . . . .
413 B Eye to the Future . . . . 414 B Summary . . . . 414 Key
Points . . . . 414 B References . . . . 415 SECTION D: ANESTHETIC
AND SURGICAL CONSIDERATIONS FOR SPECIFIC INJURIES Section Editors:
William C. Wilson and Bruce Potenza 22. Maxillofacial Injuries . .
. . 417 John T. Moloney B Introduction . . . . 417 Historical
Management Review . . . . 417 Epidemiology . . . . 417 B Anatomy of
Maxillofacial Structures . . . . 418 Normal Anatomy of the Face . .
. . 418 Anatomy of the Base of the Skull . . . . 418 B Mechanisms
of Injury and Injury Patterns . . . . 419 Blunt . . . . 419
Penetrating . . . . 420 B Forces Involved . . . . 420 B Common
Maxillofacial Injuries . . . . 420 Mandible . . . . 420 LeFort
Fractures . . . . 420 LeFort I . . . . 420 LeFort II . . . . 421
LeFort III . . . . 421 Nose . . . . 421 Nasoethmoidal Fracture . .
. . 421 Zygoma . . . . 421 Orbit Injuries . . . . 421 Fractured
Base of Skull . . . . 422 Signs . . . . 423 B Associated Injuries .
. . . 423 Head Injury . . . . 424 Cervical Spine . . . . 424 Eyes .
. . . 424 Intraocular Pressure . . . . 424 Anesthesia and
Intraocular Pressure . . . . 425 Intraocular Air . . . . 426
Oculocardiac Reex . . . . 426 Ears . . . . 426 Blast Injuries and
Associated Injuries . . . . 426 Barotrauma . . . . 427 Other . . .
. 427 B Resuscitation . . . . 427 B Assessment . . . . 427 Clinical
Signs . . . . 427 X Ray/Orthopantomogram and Computed Tomography .
. . . 427 B Airway Management . . . . 427 Urgent/Semiurgent . . . .
427 Elective . . . . 428 Nasotracheal Intubation . . . . 428
Tracheostomy . . . . 428 Submental Intubation . . . . 428 Teeth
Wiring/Banding Issues . . . . 429 B Airway Evaluation . . . . 429
Awake vs. Asleep . . . . 429 Methods to Facilitate Tracheal
Intubation . . . . 429 Fiberoptic Bronchoscope . . . . 429 Bullard
Laryngoscope . . . . 429 Cricothyroidectomy vs. Tracheostomy . . .
. 429 B Antibiotics . . . . 429 B Eye to the Future . . . . 429 B
Summary . . . . 430 Key Points . . . . 430 B References . . . . 430
23. Traumatic Brain Injury . . . . 433 Gus G. Atkins and John C.
Drummond B Introduction . . . . 433 B Resuscitation of the
Head-Injured Trauma Patient . . . . 433 Initial Brain Resuscitation
Priorities: Airway, Breathing, and Circulation, then Intracranial
Pressure . . . . 433 Determining Need for Immediate Intubation . .
. . 433 Cervical Spine Uncertainty Is Common Following Traumatic
Brain Injury . . . . 434 Rapid Sequence Induction Drugs in
Traumatic Brain Injury . . . . 434 B Management of the Head-Injured
Trauma Patient During Surgery and the Perioperative Period . . . .
435 Intracranial Pressure Monitoring . . . . 435 Patients
Undergoing Craniotomy . . . . 436 Nonneurological Surgery in the
Traumatic Brain Injury Patient . . . . 436 Blood Pressure
Management . . . . 437 Fluid Management . . . . 439 Hypertonic
Crystalloids . . . . 439 Colloidal Solutions . . . . 439 Blood
Glucose Management . . . . 440 CO2 Management . . . . 440 Choice of
Anesthetic Agents . . . . 441 Jugular Venous Saturation Monitoring
. . . . 442 Hypothermia . . . . 442 B Eye to the Future . . . . 442
B Summary . . . . 443 Key Points . . . . 443 B References . . . .
444 24. Penetrating Neck Trauma . . . . 447 Vance E. Shearer and
Randall S. Friese B Introduction . . . . 447 B History . . . . 447
B Anatomy . . . . 447 B Prevalence . . . . 449 B Evaluation . . . .
449 Primary Survey . . . . 449 Secondary Survey . . . . 449
Diagnostic Work-Up . . . . 450 Radiologic Evaluation . . . . 451
Plain Films . . . . 451 Arteriography . . . . 451 Computed
Tomography . . . . 451 Duplex Ultrasound . . . . 451
FluoroscopyEsophagogram . . . . 452 Endoscopic Evaluation . . . .
452 Laryngoscopy/Bronchoscopy . . . . 452
Pharyngoscopy/Esophagoscopy . . . . 452 Exploration: Indications
for Surgery Are Controversial . . . . 452 Decision MakingWhich
Patients Require Neck Exploration? . . . . 452 xxii Contents