Manual of Definitive Surgical Trauma Care : Incorporating Definitive Anaesthetic Trauma Care

Developed for the International Association for Trauma Surgery and Intensive Care (IATSIC), the Manual of Definitive Surgical Trauma Care 6e is ideal for training all surgeons and anaesthetists who manage trauma on an infrequent basis. The Manual is updated every 4 years and reflects the most recent developments in patient management based on new evidence-based information. Its focus is on the importance of the multidisciplinary care of the trauma surgical patient. This sixth edition has evolved, and the all-important section on the Non-Technical Skills which are required has been expanded. A significant number of the original guidelines in trauma have been archived, as they are no longer pertinent or have been superseded. The increasing (and occasionally harmful) role of non-operative management (NOM) has been recognized. The 'Military Environments' and 'Austere Environments' chapters have been substantially revised to reflect current multinational combat experience, and broadened to reflect modern asymmetrical conflicts and the increased need for humanitarian intervention including military peacekeeping in which only one side wears a uniform. Military weapons are used in major cities against the civilian population. More recently, urban, non-military populations have been the targets and victims of heavy military combat including use of ultra-sophisticated weaponry. Each situation carries its own spectrum of injury and responsibility of care. Including website access to a selection of videos which provide an anatomic overview of surgical approaches, this resource provides a gold standard educational and training resource to help prepare the relatively fully trained surgeon to manage the difficult injuries that might present to a major trauma centre. Cover Half Title Title Page Copyright Page Dedication Contents Video Contents Preface About the Editors Board of Contributors Contributors Emeritus Part 1: TRAUMA SYSTEM AND COMMUNICATION PRINCIPLES 1. Introduction 1.1. Injury Prevention 1.2. Safe Trauma Care 1.2.1. Individual Factors 1.2.1.1. Individual: Leadership 1.2.1.2. Trauma Team 1.2.1.3. Team: Training 1.2.2. Institutional Factors 1.2.2.1. Dedicated Trauma Service 1.2.3. Performance Improvement Activities 1.2.4. Regional Activities 1.2.5. National Activities 1.2.6. Global Activities 1.3. Sustainable Trauma Care 1.3.1. Workforce Training and Development 1.4. Surgical Trauma Training Beyond Initial Care 1.4.1. Non-Technical Skills for Surgeons (NOTSS) 1.4.2. The Advanced Trauma Operative Management (ATOM®) Course 1.4.3. The Advanced Surgical Skills for Exposure in Trauma (ASSET®) Course 1.4.4. The Definitive Surgical Trauma CareTM (DSTC) Course 1.4.5. The Definitive Anaesthetic Trauma CareTM (DATC) Course 1.5. Conclusion 2. Non-Technical Skills in Major Trauma: The Role of Crew Resource Management (CRM) and Communication 2.1. Overview 2.2. The Avoidance of Errors 2.2.1. The ‘Swiss Cheese’ Theory 2.3. Communication in the Trauma Setting 2.3.1. Initial Handover 2.3.2. Communication in Resuscitation and Ongoing Management 2.3.3. Damage Control Decision-Making 2.4. Leadership in Trauma Care 2.4.1. Situational Awareness 2.4.2. Role Allocation 2.4.3. Decision-Making 2.4.4. Leadership 2.4.5. Communication 2.5. A Six-Step Approach to Perioperative Communication in Trauma 2.6. Potential Errors Related to Each Behavioural Theme 2.7. Summary Part 2: PHYSIOLOGY AND THE BODY’S RESPONSE TO TRAUMA 3. Resuscitation Physiology 3.1. Metabolic Response to Trauma 3.1.1. Definition of Trauma 3.1.2. Initiating Factors 3.1.2.1. Hypovolaemia 3.1.2.2. Inflammation 3.1.2.3. The Consequences of the Pro- and Anti-Inflammatory Responses 3.1.2.4. Coagulation and Inflammation 3.2. Hormonal Mediators 3.2.1. Hypothalamus–Pituitary Axis 3.2.2. Adrenal Hormones 3.2.3. Pancreatic Hormones 3.2.4. Renal Hormones 3.2.5. Other Hormones 3.3. Effects of the Various Mediators 3.3.1. Hyperdynamic State 3.3.2. Water and Salt Retention 3.3.3. Effects on Substrate Metabolism 3.3.3.1. Carbohydrates 3.3.3.2. Fat 3.3.3.3. Amino Acids 3.3.3.4. The Gut 3.4. The Anabolic Phase 3.5. Clinical and Therapeutic Relevance 3.6. Shock 3.6.1. Definition of Shock 3.6.2. Classification of Shock 3.6.2.1. Hypovolaemic Shock 3.6.2.2. Cardiogenic Shock 3.6.2.3. Decreased LV Filling Pressures 3.6.3. Distributive (Inflammatory) Shock 3.6.4. Neurogenic Shock 3.6.4.1. Clinical Presentation 3.6.5. Measurements in Shock 3.6.5.1. Cardiac Output 3.6.5.2. Indirect Measurement of Flow 3.6.5.3. Direct Measurements 3.6.5.4. Non-Invasive Cardiac Monitoring 3.6.5.5. Invasive Haemodynamic Monitoring 3.7. Endpoints in Shock Resuscitation 3.7.1. Post-Shock and Multiple Organ Failure Syndromes 3.7.2. Management of the Shocked Patient 3.7.2.1. Oxygenation 3.7.2.2. Airway Indications for Intubation 3.7.2.3. Breathing Indications for Intubation 3.7.2.4. Breathing Indications for Ventilation 3.7.2.5. Circulatory Indication for Intubation 3.7.2.6. Disability Indications for Intubation 3.7.2.7. Environmental Indication for Intubation 3.7.3. Fluid Therapy for Volume Expansion 3.7.3.1. Hypotensive Resuscitation 3.7.4. Route of Administration 3.7.4.1. Intravenous Devices 3.7.4.2. Intraosseous Devices 3.7.5. Pharmacologic Support of Blood Pressure 3.7.5.1. Norepinephrine (Noradrenaline) 3.7.5.2. Epinephrine (Adrenaline) 3.7.5.3. Dopamine 3.7.5.4. Dobutamine 3.7.6. Prognosis in Shock 3.7.6.1. Recommended Protocol for Shock 4. Transfusion in Trauma 4.1. Indications for Transfusion 4.1.1. Oxygen-Carrying Capacity 4.2. Transfusion Fluids 4.2.1. Colloids 4.2.1.1. Starches 4.2.1.2. Albumin 4.2.2. Blood 4.2.2.1. Fresh Whole Blood 4.2.2.2. Stored Whole Blood 4.2.2.3. Packed Red Blood Cells 4.2.2.4. Synthetic Blood and Blood Products 4.2.3. Component Therapy (Platelets, Fresh Frozen Plasma [FFP], and Cryoprecipitate) 4.2.3.1. Platelets 4.2.3.2. Plasma: FFP or Freeze-Dried Plasma (FDP) 4.2.3.3. Cryoprecipitate 4.2.3.4. Fibrinogen Concentrate 4.3. Effects of Transfusing Blood and Blood Products 4.3.1. Metabolic Effects 4.3.2. Hyperkalaemia 4.3.3. Coagulopathy of Trauma 4.3.4. Other Risks of Transfusion 4.3.4.1. Transfusion-Transmitted Infections 4.3.4.2. Haemolytic Transfusion Reactions 4.3.4.3. Immunological Complications 4.3.4.4. Factors Implicated in Haemostatic Failure 4.4. Adjuncts to Enhance Clotting 4.4.1. Prothrombin Complex Concentrate (PCC) 4.4.2. Tranexamic Acid (TXA) 4.4.3. Desmopressin (DDAVP) 4.4.4. Recombinant Activated Factor VIIA 4.5. Monitoring the Coagulation Status 4.5.1. Traditional Assays 4.5.2. Viscoelastic Haemostatic Assays (VHAs): Thromboelastography (TEG) and Rotary Thromboelastomerography (RoTEM) 4.6. Autotransfusion 4.7. Massive Haemorrhage and Massive Transfusion Protocols (MHPS/MTPS) 4.7.1. Definition 4.7.2. Massive Transfusion Protocol 4.8. Local Haemostatic Adjuncts 4.8.1. Overview 4.8.2. Tissue Adhesives 4.8.2.1. Fibrin 4.8.2.2. Patches 4.8.3. Local Haemostatic Adjuncts 4.8.3.1. Chitosan (Celox [Meditrade, Crewe, UK]) and Hemcon (Hemcon Medical Technologies, Portland, or, USA) 4.8.3.2. Mineral Zeolyte (Quikclot® [Z-Medical, Wallingford, CT, USA]) 5. Pre-Hospital and Emergency Trauma Care 5.1. Resuscitation in the Pre-Hospital Setting and Emergency Department 5.2. Management of Major Trauma 5.2.1. Resuscitation 5.2.1.1. Civilian Pre-Hospital Tourniquet Use 5.2.1.2. Primary Survey 5.2.1.3. Secondary Survey 5.2.2. Management of Penetrating Trauma 5.3. Emergency Department Surgery 5.3.1. Head Trauma 5.3.2. Chest Trauma 5.3.3. Abdominal Trauma 5.3.4. Pelvic Trauma 5.3.5. Long Bone Fractures 5.3.6. Peripheral Vascular Injuries 5.4. Summary 5.5. Anaesthesiological Considerations 6. Damage Control 6.1. Introduction 6.2. Damage Control Resuscitation 6.2.1. Overview 6.2.2. Goals 6.2.2.1. Permissive Hypotension 6.2.2.2. Minimize the Use of Crystalloid and Non-Blood Products 6.2.2.3. Blood Product Administration with a Balanced Ratio of Packed Red Blood Cells (PRBCS), Fresh Frozen Plasma (FFP), and Platelets 6.2.2.4. Tranexamic Acid (TXA) 6.2.2.5. Goal-Directed Haemostasis 6.2.2.6. Avoid Hypothermia 6.2.2.7. Restoration of Normocalcaemia 6.2.3. Massive Transfusion/Haemorrhage Protocol (MTP/MHP) 6.3. Damage Control Surgery 6.3.1. Overview 6.3.2. Lethal Triad and Deadly Diamond 6.3.2.1. Hypothermia 6.3.2.2. Acidosis 6.3.2.3. Coagulopathy 6.3.2.4. Hypocalcaemia 6.3.3. Damage Control in the Thorax 6.3.4. Damage Control in the Abdomen 6.3.4.1. Stage 1: Patient Selection 6.3.4.2. Stage 2: Operative Haemorrhage and Contamination Control 6.3.4.3. Stage 3: Physiological Restoration in the ICU 6.3.4.4. Stage 4: Definitive Surgery 6.3.4.5. Stage 5: Abdominal Wall Closure 6.3.5. Planned Hernia 6.3.6. Outcomes 6.4. Damage Control Orthopaedics (DCO) Part 3: ANATOMICAL AND ORGAN SYSTEM INJURY 7. The Neck 7.1. Overview 7.2. Management Principles: Penetrating Cervical Injury 7.2.1. Initial Assessment and Definitive Airway 7.2.2. Control of Haemorrhage 7.2.3. Injury Location 7.2.4. Mechanism 7.2.5. Frequency of Injury 7.2.6. Use of Diagnostic Studies 7.2.6.1. Computed Tomography Scanning with Contrast: CT Angiography 7.2.6.2. Angiography 7.2.6.3. Other Diagnostic Studies 7.3. Management 7.3.1. Mandatory versus Selective Neck Exploration 7.3.2. Management Based on Anatomical Zones 7.4. Access to the Neck 7.4.1. Position 7.4.2. Incision 7.4.3. Surgical Access 7.4.3.1. Access to the Great Vessels 7.4.3.2. Zone I 7.4.3.3. Zone II 7.4.3.4. Zone III 7.4.3.5. Access to the Aerodigestive Tract 7.4.4. Priorities 7.4.4.1. Carotid Artery 7.4.4.2. Tracheal Injuries 7.4.4.3. Pharyngeal and Oesophageal Injuries 7.4.5. Midline Visceral Structures 7.4.6. Root of the Neck 7.4.7. Collar Incisions 7.4.8. Vertebral Arteries 8. The Chest 8.1. Overview 8.2. The Spectrum of Thoracic Injury 8.2.1. Immediately Life-Threatening Injuries 8.2.2. Potentially Life-Threatening Injuries 8.3. Pathophysiology of Thoracic Injuries 8.3.1. Paediatric Considerations 8.4. Applied Surgical Anatomy of the Chest 8.4.1. The Chest Wall 8.4.2. The Chest Floor 8.4.3. The Chest Contents 8.4.3.1. Tracheobronchial Tree 8.4.3.2. Lungs and Pleurae 8.4.3.3. Heart and Pericardium 8.4.3.4. The Aorta and Great Vessels 8.4.3.5. Oesophagus 8.4.3.6. Thoracic Duct 8.5. Diagnosis 8.6. Management of Specific Injuries 8.6.1. Damage Control in the Chest 8.6.2. Open Pneumothorax 8.6.3. Tension Pneumothorax (Haemo- or Pneumothorax) 8.6.4. Massive Haemothorax 8.6.5. Retained Haemothorax 8.6.6. Tracheobronchial Injuries 8.6.7. Oesophageal Injuries 8.6.8. Diaphragmatic Injuries 8.6.9. Pulmonary Contusion (PC) 8.6.10. Flail Chest (FC) 8.6.11. Fixation of Multiple Fractures of Ribs, 8.6.12. Pulmonary Laceration 8.6.12.1. Air Embolism 8.6.13. Cardiac Injuries 8.6.14. Injuries to the Great Vessels 8.7. Chest Drainage 8.7.1. Drain Insertion 8.7.2. Drain Removal 8.8. Surgical Approaches to the Thorax 8.8.1. Anterolateral Thoracotomy 8.8.1.1. Technique 8.8.1.2. Closure 8.8.2. Median Sternotomy 8.8.2.1. Technique 8.8.2.2. Closure 8.8.3. The ‘Clamshell’ Thoracotomy 8.8.4. Posterolateral Thoracotomy 8.8.5. ‘Trapdoor’ Thoracotomy 8.9. Emergency Department Thoracotomy 8.9.1. History 8.9.2. Objectives 8.9.3. Indications and Contraindications 8.9.4. Results 8.9.5. When to Stop an Emergency Department Thoracotomy 8.9.6. Technique 8.9.6.1. Instrument Requirements 8.9.6.2. Approach 8.10. Surgical Procedures 8.10.1. Pericardial Tamponade 8.10.2. Cardiac Injury 8.10.3. Pulmonary Haemorrhage 8.10.4. Pulmonary Tractotomy 8.10.5. Lobectomy or Pneumonectomy 8.10.6. Thoracotomy with Aortic Cross-Clamping 8.10.7. Aortic Injury 8.10.8. Tracheobronchial Injury 8.10.9. Oesophageal Injury 8.11. Summary 8.12. Anaesthesia for Thoracic Trauma 8.12.1. Penetrating Thoracic Injury 8.12.2. Blunt Thoracic Injury 8.12.2.1. Contained Large Vessel Rupture or Aneurism 8.12.2.2. Pulmonary Contusion 8.12.2.3. Large Airway Disruption 8.12.2.4. Flail Chest 8.12.2.5. Diaphragmatic Injury 8.12.3. Anaesthetic Management of Thoracic Injury 9. Abdomen 9.1. The Trauma Laparotomy 9.1.1. Overview 9.1.1.1. Difficult Abdominal Injury Complexes 9.1.1.2. The Retroperitoneum 9.1.1.3. Non-Operative Management OP Penetrating Abdominal Injury 9.1.2. The Trauma Laparotomy 9.1.2.1. Preoperative Adjuncts 9.1.2.2. Draping 9.1.2.3. Incision 9.1.2.4. Initial Procedure 9.1.2.5. Perform the Trauma Laparotomy 9.1.2.6. Perform Definitive Packing 9.1.2.7. Specific Routes of Access 9.1.2.8. Specific Organ Techniques 9.1.3. Closure of the Abdomen 9.1.3.1. Principles of Abdominal Closure 9.1.3.2. Choosing the Optimal Method of Closure 9.1.4. Temporary Closure 9.1.5. The Open Abdomen 9.1.6. Primary Closure 9.1.7. Specific Tips and Tricks 9.1.7.1. Headlight 9.1.7.2. Stirrups and Lithotomy Position 9.1.7.3. Table Tilt 9.1.7.4. Be Flexible – Move! 9.1.7.5. Pericardial Window 9.1.7.6. Washout 9.1.7.7. Drains 9.1.7.8. Stomas 9.1.8. Two Catheters: Bladder Injury 9.1.9. Early Tracheostomy 9.1.10. Briefing for Operating Room Scrub Nurses 9.1.11. Summary 9.2. Abdominal Vascular Injury 9.2.1. Overview 9.2.2. Retroperitoneal Haematoma 9.2.2.1. Central Haematoma 9.2.2.2. Lateral Haematoma 9.2.2.3. Pelvic Haematoma 9.2.3. Surgical Approach to Major Abdominal Vessels 9.2.3.1. Incision 9.2.3.2. Medial Visceral Rotations 9.2.3.3. Aorta 9.2.3.4. Coeliac Axis 9.2.3.5. Superior Mesenteric Artery 9.2.3.6. Inferior Mesenteric Artery 9.2.3.7. Renal Arteries 9.2.3.8. Iliac Vessels 9.2.3.9. Inferior Vena Cava (IVC) 9.2.3.10. Portal Vein 9.2.4. Shunting 9.3. Bowel, Rectum, and Diaphragm 9.3.1. Overview 9.3.2. Diaphragm 9.3.3. Stomach 9.3.4. The Duodenum 9.3.5. Small Bowel 9.3.5.1. The Stable Patient 9.3.5.2. The Unstable Patient 9.3.6. Large Bowel 9.3.6.1. The Stable Patient 9.3.6.2. The Unstable Patient 9.3.7. Rectum 9.3.8. Mesentery 9.3.9. Adjuncts 9.3.9.1. Antibiotics 9.4. The Duodenum 9.4.1. Overview 9.4.2. Mechanism of Injury 9.4.2.1. Penetrating Trauma 9.4.2.2. Blunt Trauma 9.4.2.3. Paediatric Considerations 9.4.3. Diagnosis 9.4.3.1. Clinical Presentation 9.4.3.2. Serum Amylase and Serum Lipase 9.4.3.3. Diagnostic Peritoneal Lavage/Ultrasound 9.4.3.4. Radiological Investigation 9.4.3.5. Diagnostic Laparoscopy 9.4.4. Duodenal Injury Scale 9.4.5. Management 9.4.6. Surgical Approach 9.4.6.1. Intramural Haematoma 9.4.6.2. Duodenal Laceration 9.4.6.3. Repair of the Perforation 9.4.6.4. Complete Transection of the Duodenum 9.4.6.5. Duodenal Diversion 9.4.6.6. Duodenal Diverticulation 9.4.6.7. Pyloric Exclusion 9.4.6.8. Pancreaticoduodenectomy (Whipple’s Procedure) 9.5. The Liver and Biliary System 9.5.1. Overview 9.5.2. Resuscitation 9.5.3. Diagnosis 9.5.4. Liver Injury Scale 9.5.5. Management 9.5.5.1. Non-Operative Management (NOM) 9.5.5.2. Subcapsular Haematoma 9.5.5.3. Operative (Surgical) Management 9.5.6. Surgical Approach 9.5.6.1. Incision 9.5.6.2. Initial Actions 9.5.6.3. Techniques for Temporary Control of Haemorrhage 9.5.6.4. Mobilization of the Liver 9.5.6.5. Hepatic Isolation 9.5.7. Perihepatic Drainage 9.5.8. Complications 9.5.9. Injury to the Retrohepatic Vena Cava 9.5.10. Injury to the Porta Hepatis 9.5.11. Removal of Packs (Aim for 36–49 Hours) 9.5.12. Injury to the Bile Ducts and Gallbladder 9.6. Pancreas 9.6.1. Overview 9.6.2. Anatomy 9.6.3. Mechanisms of Injury 9.6.3.1. Blunt Trauma 9.6.3.2. Penetrating Trauma 9.6.4. Diagnosis 9.6.4.1. Clinical Evaluation 9.6.4.2. Serum Amylase and Serum Lipase 9.6.4.3. Ultrasound 9.6.4.4. Diagnostic Peritoneal Lavage (DPL) 9.6.4.5. Computed Tomography (CT) 9.6.4.6. Endoscopic Retrograde Cholangiopancreatography (ERCP) 9.6.4.7. Magnetic Resonance Cholangiopancreatography (MRCP) 9.6.4.8. Intraoperative Pancreatography 9.6.4.9. Operative Evaluation 9.6.5. Pancreas Injury Scale 9.6.6. Management 9.6.6.1. Non-Operative Management 9.6.6.2. Operative Management 9.6.7. Surgical Approach 9.6.7.1. Incision and Exploration 9.6.7.2. Pancreatic Injury: Surgical Decision-Making 9.6.8. Adjuncts 9.6.8.1. Somatostatin and its Analogues 9.6.8.2. Nutritional Support 9.6.9. Pancreatic Injury in Children 9.6.10. Complications 9.6.10.1. Early Complications 9.6.10.2. Late Complications 9.6.11. Summary of Evidence-Based Guidelines 9.7. Spleen 9.7.1. Overview 9.7.2. Anatomy 9.7.3. Diagnosis 9.7.3.1. Clinical 9.7.3.2. Ultrasound 9.7.3.3. Computed Tomography (CT) Scan 9.7.4. Splenic Injury Scale 9.7.5. Management 9.7.5.1. Non-Operative Management (NOM) 9.7.5.2. Operative Management 9.7.6. Surgical Approach 9.7.6.1. Spleen Not Actively Bleeding 9.7.6.2. Splenic Surface Bleed Only 9.7.6.3. Minor Lacerations 9.7.6.4. Mesh Splenorrhaphy and Partial Splenectomy 9.7.6.5. Splenectomy 9.7.6.6. Drainage 9.7.7. Perioperative Considerations 9.7.7.1. Haemostatic Resuscitation 9.7.7.2. Repeat Imaging 9.7.7.3. Mobilization 9.7.7.4. Return to Normal Activities 9.7.7.5. Venous Thromboembolism (VTE) Prophylaxis 9.7.8. Outcomes 9.7.9. Vaccination and Prevention of OPSI 9.8. The Urogenital System 9.8.1. Overview 9.8.2. Renal Injuries 9.8.2.1. Diagnosis 9.8.2.2. Renal Injury Scale 9.8.2.3. Management 9.8.2.4. Surgical Approach 9.8.2.5. Adjuncts 9.8.2.6. Postoperative Care 9.8.3. Ureteric Injuries 9.8.3.1. Diagnosis 9.8.3.2. Surgical Approach 9.8.3.3. Complications 9.8.4. Bladder Injuries 9.8.4.1. Diagnosis 9.8.4.2. Management 9.8.4.3. Surgical Approach 9.8.5. Urethral Injuries 9.8.5.1. Diagnosis 9.8.5.2. Management 9.8.5.3. Ruptured Urethra 9.8.6. Injury to the Scrotum 9.8.6.1. Diagnosis 9.8.6.2. Management 9.8.7. Gynaecological Injury and Sexual Assault 9.8.7.1. Management 9.8.7.2. Guideline 9.8.8. Injury of the Pregnant Uterus 10. The Pelvis 10.1. Anatomy 10.2. Classification 10.2.1. Tile’s Classification 10.2.1.1. Type A: Completely Stable 10.2.1.2. Type B: Vertically Stable but Rotationally Unstable 10.2.1.3. Type C: Wholly Unstable in Rotational and Vertical Planes 10.2.1.4. A Jumper’s Fracture 10.2.1.5. Acetabular Fractures 10.2.1.6. Fracture Combinations 10.2.2. Young and Burgess Classification 10.2.2.1. Anteroposterior Compression (APC) (Types 1, 2, and 3) 10.2.2.2. Lateral Compression (LC) (Types 1, 2, and 3) 10.2.2.3. Vertical Shear (VS) 10.2.2.4. Combined Mechanism (CM) 10.3. Clinical Examination and Diagnosis 10.4. Resuscitation 10.4.1. Haemodynamically Normal Patients 10.4.2. Haemodynamically Stable Patients (Transient Responders) 10.4.3. Haemodynamically Unstable Patients (Non-Responders) 10.5. External Fixation 10.5.1. Iliac-Crest Route 10.5.2. Supra-Acetabular Route 10.5.3. Pelvic C-Clamp 10.6. Laparotomy 10.7. Extraperitoneal Pelvic (EPP) Packing 10.7.1. Technique of Extraperitoneal Packing 10.8. Associated Injuries 10.8.1. Head Injuries 10.8.2. Intra-abdominal Injuries 10.8.3. Bladder and Urethral Injuries 10.8.4. Urethral Injuries 10.8.5. Anorectal Injuries 10.8.6. Vaginal Injuries 10.9. Open Pelvic Fractures 10.9.1. Diagnosis 10.9.2. Surgery 10.10. Summary 11. Extremity Trauma 11.1. Overview 11.2. Management of Severe Injury to the Extremity 11.2.1. Life-Saving 11.2.2. Limb-Saving 11.3. Management of Vascular Injury of the Extremity 11.3.1. Shunts 11.3.2. Chemical Vascular Injuries 11.4. Crush Syndrome 11.5. Management of Open Fractures 11.5.1. Severity of Injury (Gustilo Classification) 11.5.2. Sepsis and Antibiotics 11.5.3. Venous Thromboembolism 11.5.4. Timing of Skeletal Fixation in Polytrauma Patients 11.5.4.1. Respiratory Insufficiency 11.5.4.2. Head Injury 11.6. Life-Threatening Limb Trauma: Life Versus Limb 11.6.1. Scoring Systems 11.6.1.1. Mangled Extremity Syndrome Index (MESI) 11.6.1.2. Predictive Salvage Index System 11.6.1.3. Mangled Extremity Severity Score (MESS) 11.6.1.4. Nisssa Scoring System 11.7. Compartment Syndrome 11.8. Fasciotomy 11.8.1. Lower Leg Fasciotomy 11.8.1.1. Two-Incision, Four-Compartment Fasciotomy 11.8.1.2. Single-Incision Fasciotomy 11.8.1.3. Fibulectomy 11.8.1.4. Subcutaneous Fasciotomy 11.8.2. Upper Leg 11.8.3. Upper and Lower Arm 11.9. Complications of Major Limb Injury 11.10. Summary 12. Head Trauma 12.1. Introduction 12.2. Injury Patterns and Classification 12.2.1. Severity 12.2.2. Pathological Classification of TBI 12.2.2.1. Blunt Head Trauma 12.2.2.2. Penetrating Head Trauma 12.2.2.3. Blunt Cerebrovascular Injury (BCVI) 12.3. Physiological Parameters in TBI 12.3.1. Mean Arterial Pressure (MAP) 12.3.2. Intracranial Pressure 12.3.3. Cerebral Perfusion Pressure 12.3.4. Cerebral Blood Flow 12.4. Pathophysiology of TBI 12.5. Management of TBI 12.6. CPP Threshold 12.7. ICP Monitoring 12.7.1. ICP Monitoring Devices 12.7.1.1. CSF Drainage 12.7.2. ICP Management: Do’s and Don’t’s 12.7.2.1. Hyperventilation 12.7.2.2. Osmotherapy (Mannitol and Hypertonic Saline) 12.7.2.3. Barbiturates and Propofol 12.7.2.4. Steroids 12.8. Imaging 12.9. Indications for Surgery 12.9.1. Burr Holes and Emergency Craniotomy 12.9.1.1. Emergency Burr Hole Craniotomy 12.9.1.2. Emergency Craniotomy 12.10. Adjuncts to Care 12.10.1. Infection Prophylaxis 12.10.2. Seizure Prophylaxis 12.10.3. Nutrition 12.10.4. Deep Vein Thrombosis (DVT) Prophylaxis 12.10.5. Steroids 12.11. Paediatric Considerations 12.12. Pearls and Pitfalls 12.13. Summary 13. Burns 13.1. Overview 13.2. Burns Pathophysiology 13.3. Anatomy 13.4. Special Types of Burn 13.4.1. Chemical Burns 13.4.2. Electrical Injury 13.5. Depth of the Burn 13.5.1. Superficial Burn (Erythema) 13.5.2. Superficial Partial Thickness 13.5.3. Deep Partial Thickness 13.5.4. ‘Indeterminate’ Partial-Thickness Burns 13.5.5. Full Thickness 13.6. Total Body Surface Area Burned (TBSA) 13.7. Management 13.7.1. Safe Retrieval 13.7.2. First Aid 13.7.3. Initial Management 13.7.3.1. Airway 13.7.3.2. Inhalational Toxicity 13.7.3.3. Analgesia 13.7.3.4. Intravenous Access 13.7.3.5. Emergency Management of the Burn Wound 13.7.3.6. Fluid Resuscitation 13.7.3.7. Associated Injuries 13.7.4. Escharotomy and Fasciotomy 13.7.5. Definitive Management 13.7.5.1. ‘Closing’ the Burn Wound 13.7.5.2. Technique of Excision and Split-Skin Grafting (SSG) 13.7.5.3. Tumescent Technique 13.7.5.4. Wound Coverage 13.7.5.5. Burn Wound Excision and Closure 13.7.6. Assessing and Managing Airway Burns 13.7.6.1. Upper Airway 13.7.6.2. Lower Airway 13.7.7. Tracheostomy 13.8. Special Areas 13.8.1. Face 13.8.2. Hands 13.8.3. Perineum 13.8.4. Feet 13.9. Adjuncts in Burn Care 13.9.1. Nutrition in the Burned Patient 13.9.1.1. Paediatric Burn Nutrition 13.9.2. Ulcer Prophylaxis 13.9.3. Venous Thromboembolism Prophylaxis 13.9.4. Vitamin C 13.9.5. Anabolic Steroids 13.9.6. Antibiotics 13.9.7. Other Adjuncts 13.10. Palliative Care for Burns 13.11. Summary 14. Special Patient Situations 14.1. Paediatric Trauma 14.1.1. Introduction 14.1.2. Injury Patterns 14.1.3. Pre-Hospital 14.1.4. Resuscitation Room 14.1.4.1. Airway 14.1.4.2. Breathing 14.1.4.3. Circulation 14.1.4.4. Disability 14.1.4.5. Cardiac Arrest 14.1.5. Specific Organ Injury 14.1.5.1. Head Injury 14.1.5.2. Thoracic Injury 14.1.5.3. Abdominal Injury 14.1.5.4. Genitourinary Injury 14.1.5.5. Pelvic Injury 14.1.5.6. Spine Injury 14.1.5.7. Suspected Non-Accidental Injury (NAI) 14.1.6. Analgesia 14.1.7. Anaesthesiology in Children 14.2. Trauma in the Elderly 14.2.1. Definition of ‘Older’ and Susceptibility to Trauma 14.2.2. Access to Trauma Care 14.2.3. Physiology 14.2.3.1. Respiratory System 14.2.3.2. Cardiovascular System 14.2.3.3. Nervous System 14.2.3.4. Renal 14.2.3.5. Musculoskeletal 14.2.3.6. Influence of Comorbid Conditions 14.2.4. Multiple Medications: Polypharmacy 14.2.5. Analgesia 14.2.6. Anticoagulants 14.2.7. Decision to Operate 14.2.8. Outcome 14.2.9. Anaesthetic Considerations in the Elderly 14.3. Trauma in Pregnancy 14.3.1. Evaluation 14.4. Non-Beneficial (Futile) Care Part 4: MODERN THERAPEUTIC AND DIAGNOSTIC TECHNOLOGY 15. Minimal Access Surgery in Trauma 15.1. Laparoscopy 15.1.1. Screening/Diagnostic Laparoscopy 15.1.1.1. Blunt Trauma 15.1.1.2. Penetrating Trauma – Stab Wounds 15.1.1.3. Penetrating Trauma – Gunshot Wounds 15.1.2. Diagnostic Laparoscopy 15.1.3. Non-Therapeutic Laparoscopy 15.1.4. Therapeutic Laparoscopy 15.1.5. Technique 15.1.6. Risks 15.1.7. Applications 15.1.7.1. Bowel Injury 15.1.7.2. Splenic Injury 15.1.7.3. Liver Injury 15.1.7.4. Diaphragmatic Injury 15.1.7.5. Bladder Injury 15.2. Video-Assisted Thoracoscopic Surgery 15.2.1. Technique 15.2.2. Applications 15.2.3. Summary 15.3. Resuscitative Endovascular Balloon Occlusion of the Aorta (Reboa) 15.3.1. Anatomy 15.3.2. Physiology 15.3.3. Insertion Technique 15.3.4. Monitoring 15.3.5. Total, Partial, and Intermittent Occlusion, and Targeted Blood Pressure 15.3.6. Perioperative and Postoperative Care 15.3.7. Indications 15.3.8. Contraindications 15.3.9. Complications 15.3.10. Summary 16. Imaging in Trauma 16.1. Radiation Doses and Protection from Radiation 16.2. Principles of Trauma Imaging 16.2.1. Extended Focused Assessment by Sonography for Trauma (eFAST) 16.2.2. Indications and Results 16.2.2.1. Penetrating Thoracic Trauma 16.2.2.2. Blunt Thoracic Trauma 16.2.2.3. Penetrating Abdominal Trauma 16.2.2.4. Blunt Abdominal Trauma 16.2.2.5. Pelvic Trauma 16.2.3. Other Applications of Ultrasound in Trauma 16.2.4. Training 16.3. Pitfalls and Pearls 16.4. Low-Dose X-Ray (Lodox®) 16.5. CT in Trauma 16.5.1. Pan CT 16.5.2. CT Angiography 16.5.3. CT in Specific Body Regions 16.5.3.1. CT of the Neck 16.5.3.2. CT of the Chest 16.5.3.3. CT of the Abdomen 16.5.3.4. CT Angiography of the Limbs 16.6. Catheter-Directed Angiography (CDA) 16.6.1. Diagnostic 16.6.2. Therapeutic 16.7. Retained Weapons 16.8. Summary Part 5: SPECIALIZED ASPECTS OF TOTAL TRAUMA CARE 17. Critical Care of the Trauma Patient 2024 17.1. Introduction 17.2. Phases of ICU Care 17.2.1. Resuscitative Phase (First 24 Hours Post Injury) 17.2.1.1. ‘Traditional’ Endpoints of Resuscitation 17.2.1.2. Post-Traumatic Acute Lung Injury 17.2.1.3. Respiratory Assessment and Monitoring 17.2.1.4. Mechanical Ventilation (MV) 17.2.1.5. Ventilatory Mode (Actual Mode is Unimportant) 17.2.2. Early Life Support Phase (24–72 Hours Post Injury) 17.2.2.1. Priorities 17.2.3. Prolonged Life Support (> 72 Hours Post Injury) 17.2.3.1. Respiratory Failure 17.2.3.2. Infectious Complications 17.2.3.3. Non-Infectious Causes of Fever 17.2.3.4. Percutaneous Tracheostomy 17.2.3.5. Weaning From Ventilatory Support 17.2.3.6. Extubation Criteria (‘SOA2P’) 17.2.4. Recovery Phase (Transition from the ICU) 17.3. Extracorporeal Membrane Oxygenation (ECMO) 17.3.1. Overview 17.3.2. Modes of ECMO 17.3.2.1. Veno-Venous ECMO (VV-ECMO) 17.3.2.2. Veno-Arterial ECMO (VA-ECMO) 17.3.2.3. Arteriovenous ECMO (AV-ECMO), More Commonly Termed Extracorporeal Carbon Dioxide Removal (ECCO2R) 17.3.3. ECMO Exclusion Criteria 17.4. Coagulopathy of Major Trauma 17.4.1. Management 17.5. Hypothermia 17.6. Multisystem Organ Dysfunction Syndrome 17.7. Systemic Inflammatory Response Syndrome (SIRS) 17.8. Sepsis 17.8.1. Definitions 17.8.1.1. Sepsis 17.8.1.2. Septic Shock 17.8.2. ‘Surviving Sepsis’ Guidelines 17.9. Antibiotics 17.9.1. Criteria 17.10. Abdominal Compartment Syndrome (ACS) 17.10.1. Introduction 17.10.2. Definition 17.10.3. Pathophysiology 17.10.4. Effect of Raised IAP on Individual Organ Function 17.10.4.1. Cardiovascular 17.10.4.2. Respiratory 17.10.4.3. Visceral Perfusion 17.10.4.4. Renal 17.10.4.5. Intracranial Pressure 17.10.5. Measurement of IAP 17.10.5.1. Measurement of Abdominal Perfusion Pressure (APP) 17.10.6. Management 17.10.6.1. Prevention 17.10.6.2. Treatment 17.10.6.3. Reversible Factors 17.10.7. Surgery for Raised IAP 17.10.7.1. Tips for Surgical Decompression for Raised IAP 17.10.8. Management Algorithm 17.11. Acute Kidney Injury 17.12. Rhabdomyolysis 17.13. Metabolic Disturbances 17.14. Nutritional Support 17.14.1. Access for Enteral Nutrition 17.14.1.1. Simple 17.14.1.2. More Complicated, Longer Term 17.14.2. Monitoring Nutritional Support 17.15. Prophylaxis in the ICU 17.15.1. Stress Ulceration 17.15.2. Deep Venous Thrombosis and Pulmonary Embolus 17.15.3. Tetanus Prophylaxis 17.15.4. Line Sepsis 17.16. Pain and Delirium Control 17.16.1. Pain Control 17.16.2. Delirium 17.17. ICU Tertiary Survey 17.17.1. Evaluation for Occult Injuries 17.17.2. Assess Comorbid Conditions 17.17.3. ICU Summary 17.18. Family Contact and Support 18. Trauma Anaesthesia 18.1. Introduction 18.2. Planning and Communicating 18.3. Damage Control Resuscitation (DCR) 18.3.1. Limited Fluid Administration 18.3.2. Targeting Coagulopathy 18.3.3. Prevent and Treat Hypothermia 18.4. Damage Control Surgery 18.4.1. Anaesthetic Procedures 18.4.1.1. Airway 18.4.1.2. Breathing 18.4.1.3. Circulation 18.4.1.4. Vascular Access 18.4.2. Monitoring 18.5. Anaesthesia Induction in Hypovolaemic Shock 18.5.1. Introduction 18.5.2. Drugs for Anaesthesia Induction 18.5.2.1. Ketamine 18.5.2.2. Propofol 18.5.2.3. Etomidate 18.5.2.4. Thiopental 18.5.2.5. Midazolam 18.6. Battlefield Anaesthesia 18.6.1. Damage Control Anaesthesia in the Military Setting 18.6.2. Battlefield Analgesia 19. Austere Environments 19.1. Definition 19.2. Overview 19.3. Infrastructure and Team Composition 19.3.1. Location 19.3.2. Hospital Structures 19.3.2.1. Water Supply 19.3.2.2. Energy 19.3.2.3. Waste Disposal 19.3.2.4. Sterilization Department 19.3.2.5. Surgical Equipment 19.3.2.6. Blood Bank 19.3.3. Health Protection of the Deployed Surgical Team 19.3.3.1. Vector-Borne Disease 19.3.3.2. Enteric Illness 19.3.3.3. Road Trauma 19.3.3.4. Physical, Sexual, and Mental Health 19.4. Caseload and Surgical Techniques to Have in Mind 19.4.1. Caseload 19.4.2. Bleeding Control 19.4.3. Control of Contamination 19.4.4. Treatment of Wounds 19.4.4.1. Delayed/Neglected Wounds 19.4.4.2. War Wounds 19.4.5. Amputations 19.4.6. Stabilization of Fractures 19.4.7. Obstetrics 19.4.8. Anaesthesia 19.5. Postoperative Care and Documentation 19.6. Summary 20. Military Environments 20.1. Introduction 20.2. Injury Patterns 20.3. Military Trauma Systems 20.3.1. The Echelons of Medical Care 20.3.1.1. Role 1 20.3.1.2. Role 2 20.3.1.3. Role 3 20.3.1.4. Role 4 20.3.2. Incident Management and Multiple Casualties 20.3.2.1. Confirm 20.3.2.2. Clear 20.3.2.3. Cordon 20.3.2.4. Control 20.3.3. Incident Command and Control 20.3.3.1. Safety 20.3.3.2. Communication 20.3.3.3. Assessment 20.3.3.4. Triage 20.3.3.5. Treatment 20.3.3.6. Transport 20.4. Triage 20.4.1. Source and Aim of Triage 20.4.2. Forward Surgical Teams and Triage 20.4.3. Forward Surgical Team Decision-Making 20.4.4. Selection of Patients for Surgery 20.5. Mass Casualties 20.6. Evacuation 20.7. Resuscitation 20.7.1. Overview 20.7.2. Damage Control Resuscitation (DCR) 20.7.3. Damage Control Surgery (DCS) in the Military Setting 20.8. Battlefield Analgesia 20.9. Battlefield Anaesthesia 20.9.1. Induction of Anaesthesia 20.9.2. Maintenance of Anaesthesia 20.10. Critical Care 20.11. Translating Military Experience to Civilian Trauma Care 20.11.1. Leadership 20.11.2. Front-End Processes 20.11.3. Common Training 20.11.4. Governance 20.11.5. Rehabilitation Services 20.11.6. Translational Research 20.12. Summary 21. Ballistics and Blast Injuries 21.1. Definition 21.2. The Science 21.2.1. Kinetic Energy 21.2.2. Wounding Energy 21.3. Bullets 21.3.1. Internal Ballistics 21.3.2. External Ballistics 21.3.3. Terminal Ballistics 21.3.4. Wound Ballistics 21.3.4.1. Pistol/Low-Energy Bullets 21.3.4.2. Rifle/High-Energy Bullets 21.3.5. Antibiotics 21.3.5.1. Bacterial Contamination – General: Gram-Negative Cover 21.3.5.2. Bacterial Contamination – Abdominal Cavity 21.3.5.3. Tetanus Toxoid If Not Previously Received 21.3.6. General Treatment Principles 21.4. Shotgun Injuries 21.5. Blast Injury 21.5.1. Primary Blast Injury 21.5.2. Secondary Blast Injury 21.5.3. Tertiary Blast Injury 21.5.4. Quaternary Blast Injury 21.5.5. Quinary Blast Injury 21.5.6. Diagnosis and Management of Blast Injuries 21.5.6.1. Rupture of the Tympanic Membrane 21.5.6.2. Blast Lung Injury (BLI) 21.5.6.3. Intra-abdominal Injuries 21.5.6.4. Other Injuries 21.5.6.5. E Developed for the International Association for Trauma Surgery and Intensive Care (IATSIC), the Manual of Definitive Surgical Trauma Care 6e is ideal for training all surgeons and anaesthetists who manage trauma on an infrequent basis. The Manual is updated every four years and reflects the most recent developments in patient management based on new evidence-based information. Its focus is on the importance of the multi-disciplinary care of the trauma surgical patient. This sixth edition has evolved, and the all-important section on the Non-Technical Skills which are required has been expanded. A significant number of the original guidelines in trauma have been archived as they are no longer pertinent or have been superseded. The increasing (and occasionally harmful) role of non-operative management (NOM) has been recognised. The Military Module, and Trauma under Austere Conditions Sections, have been substantially revised to reflect current multinational combat experience, and broadened to reflect modern asymmetrical conflicts and the increased need for humanitarian intervention including military peacekeeping in which only one side wears a uniform. Military weapons are used in major cities against the civilian population. More recently, urban, non-military populations have been the targets and victims of heavy military combat including use of ultra-sophisticated weaponry. Each situation carries its own spectrum of injury and responsibility of care. Including website access to a selection of videos which provide an anatomic overview of surgical approaches, this resource provides a gold standard educational and training resource to help prepare the relatively fully trained surgeon to manage the difficult injuries that might present to a major trauma centre.