Trauma Centers and Acute Care Surgery: A Novel Organizational and Cultural Model (Updates in Surgery)

This book offers an overview of acute care surgery around the world, focusing on the four main branches of this novel subdiscipline: trauma, general emergencies, critical care, and rescue surgery. The book’s primary goal is to provide a general view of acute care surgery, while addressing the most important issues in depth. The content is divided into three parts, the first of which is dedicated to the general organization of trauma centers, including the composition of modern trauma teams. Protocols of activation and action for the trauma team, as well as damage control procedures both in the emergency room and in the surgical theatre, are described. The book also addresses the development of a trauma registry, together with the quality assessment process that can be applied. In turn, the second part describes the principal protocols for making diagnoses, with special attention to circumstances such as unstable hemodynamics, neurological deterioration, normal vital signs, and penetrating injuries. The book subsequently deals with the most important aspects of trauma to the abdomen, chest, and pelvis, with notes on both surgical and intensive care issues. Practical descriptions of how to treat principal injuries to various organs are also provided. Finally, the third part of the book is dedicated to the most frequent general surgical emergencies and rescue surgical approaches, and includes information on diagnostic support with point of care ultrasound and endoscopic advanced techniques. Presenting cutting-edge strategies, this book will be of interest to professionals involved in surgical and intensive care for emergency conditions, such as colonic perforations, obstructions, acute pancreatitis, biliary tree stones, and caustic injuries. Foreword Preface Contents Contributors Part I: Acute Care Surgery: Concept and Organization 1: A Tale of Two Cities: The Development of Trauma and Acute Care Surgery Between Baltimore and Milan 1.1 Origins and Development of a Partnership 1.2 The US Trauma System Development 1.3 Trauma System Models References 2: Organization and Training in Trauma and Acute Care Surgery in Italy 2.1 History 2.2 Organization 2.2.1 Trauma System 2.2.2 Pre-hospital Triage 2.2.3 Epidemiology 2.2.4 Trauma Services 2.2.5 Model of Acute Care Surgery 2.3 Training 2.4 Conclusions References 3: The Development of a Regional Trauma Registry 3.1 The Beginning of Standards in Trauma Care 3.2 Birth and Development of Trauma Networks in England 3.3 Birth and Development of the Trauma Network in Germany 3.4 RITG: Italian Severe Trauma Registry 3.5 First Lombardy Trauma Registry Appendix: Birth of the Utstein Style References 4: Quality Assessment in Acute Care Surgery 4.1 The Impact of Emergency and Trauma Surgery 4.2 Quality Improvement Concepts and Key Performance Indicators 4.3 Emergency Surgery Key Performance Indicators 4.4 Trauma Quality Indicators 4.5 Conclusion References Part II: Principles of Trauma Care 5: Diagnostic Protocols in Trauma Care 5.1 Introduction 5.2 Trauma Series 5.3 Diagnostic Protocols 5.3.1 Hemodynamically Stable Patient Without Neurological Impairment 5.3.2 Hemodynamically Stable Patient with Neurological Impairment 5.3.3 Patient with Altered Vital Signs 5.4 Pediatric Patient 5.5 Pregnant Patient References 6: Damage Control Surgery: An Update 6.1 Introduction 6.2 Indication for DCS 6.3 Steps of Damage Control Surgery 6.3.1 DCS Part 0: Recognition of Injuries and Goal-Directed Hemostatic Resuscitation Without Delaying Surgery 6.3.2 DCS Part 1: Abbreviated Surgery, Prioritizing Physiology over Anatomy 6.3.2.1 Operating Room Set-Up 6.3.2.2 Patient Position 6.3.2.3 Surgical Incisions for Torso Injuries 6.3.2.4 Hemorrhage Control 6.3.2.5 Contamination Control 6.3.3 DCS Part 2: Dynamic Intraoperative Reassessment of Physiology 6.3.4 DCS Part 3: Continued Physiological Restoration in the Intensive Care Unit 6.3.5 DCS Part 4: Definitive Reconstruction 6.4 Damage Control for Extra-Abdominal Injuries 6.4.1 DCS for Neurosurgical Injuries [20, 21] 6.4.2 DCS for Maxillo-Facial Injuries [22] 6.4.3 DCS for Neck Injuries [23] 6.4.4 DCS for Thoracic Injuries [24–26] 6.4.5 DCS for Orthopedic Injuries [27] 6.4.6 DCS for Extremity Vascular Injuries [28, 29] 6.5 Resuscitative Endovascular Balloon for the Occlusion of the Aorta 6.5.1 Technique of Insertion 6.5.2 Complications 6.5.3 Evidence References 7: Damage Control Resuscitation and Massive Transfusion 7.1 Introduction 7.2 Damage Control Resuscitation 7.3 Massive Transfusion Protocols 7.4 Prediction of Massive Transfusion and Activation of Massive Transfusion Protocols 7.4.1 Scoring Systems 7.4.2 The ATLS Classification of Hypovolemic Shock 7.4.3 Laboratory Parameters 7.5 Cessation of Massive Transfusion 7.6 Outcome of Massive Transfusion 7.7 Risks and Harmful Effects of Blood Product Transfusions 7.8 Refining Strategies for Massive Hemorrhage References 8: Definitive Care of Abdominal Solid Organ Injuries 8.1 Introduction 8.2 Definitive Care of Liver Injuries 8.2.1 Angioembolization 8.2.2 Endoscopic Retrograde Cholangiopancreatography 8.2.3 Mesh Wrapping 8.2.4 Liver Resection 8.2.5 Liver Transplantation 8.3 Definitive Care of Traumatic Kidney Injuries 8.3.1 Endovascular Repair 8.3.2 Surgical Repair 8.4 Definitive Care of Pancreatic Injuries 8.5 Definitive Care of Splenic Injuries 8.5.1 Non-operative Management 8.5.2 Operative Management 8.6 Conclusions References 9: Trauma to the Chest: The Role of the Trauma Surgeon 9.1 Introduction 9.2 Preparation for Thoracic Damage Control Surgery 9.2.1 Patient Position/Preparation 9.2.2 Operating Room Setup 9.3 Surgical Incisions 9.3.1 Anterolateral Thoracotomy 9.3.2 Clamshell Thoracotomy 9.3.3 Median Sternotomy 9.3.4 Trapdoor (“Book”) Incision 9.3.5 Posterolateral Thoracotomy 9.4 Procedures: Tips and Tricks 9.4.1 Tube Thoracostomy 9.4.2 Decompressive Thoracotomy 9.4.3 Emergency Department Thoracotomy 9.4.4 Packing 9.4.5 Temporary Damage Control Thoracic Closure 9.5 Specific Injuries 9.5.1 Lung 9.5.2 Heart 9.5.3 Vessels 9.5.4 Trachea 9.5.5 Esophagus 9.6 Postoperative Care and Complications 9.7 Conclusion References 10: Abdominopelvic Trauma 10.1 Introduction 10.2 General Management Strategies 10.2.1 Diagnosis 10.2.2 Non-operative Management 10.2.3 Thromboprophylaxis, Feeding and Mobilization 10.3 Liver Trauma 10.3.1 Specific Non-operative Management Aspects 10.3.2 Operative Management 10.3.3 Complications 10.4 Splenic Trauma 10.4.1 Specific Diagnostic Procedures and Non-operative Management Aspects 10.4.2 Operative Management 10.4.3 Follow-Up in Non-operative Management 10.4.4 Infection Prophylaxis in Asplenic and Hyposplenic Patients 10.5 Kidney Trauma 10.5.1 Specific Diagnostic Procedures 10.5.2 Specific Non-operative Management and Angiography/Angioembolization Aspects 10.5.3 Operative Management 10.5.4 Renal Artery Injuries 10.5.5 Follow-Up in Non-operative Management 10.6 Pelvic Trauma 10.6.1 Specific Anatomical and Physiological Aspects 10.6.2 Classification 10.6.3 Specific Diagnostic Procedures 10.6.4 Management Strategies 10.6.4.1 Pelvic Binders 10.6.4.2 Resuscitative Endovascular Balloon Occlusion of the Aorta 10.6.4.3 Preperitoneal Pelvic Packing and/or Laparotomy 10.6.4.4 External Pelvic Fixation 10.6.4.5 Angioembolization 10.6.5 Definitive Surgical Fixation References Part III: Emergency General Surgery 11: The Open Abdomen: Indications and Techniques 11.1 Introduction 11.2 Indications 11.3 Classification 11.4 Systemic Management 11.5 Abdominal Management 11.6 The Closure Path 11.7 Management of Enteric Fistula 11.8 Conclusion References 12: Enteroatmospheric Fistula: A Challenge of Acute Care Surgery 12.1 Introduction 12.1.1 Definition 12.1.2 Epidemiology and Costs 12.1.3 Classification 12.2 Clinical Assessment 12.2.1 Prevention 12.2.2 Metabolic and Nutritional Evaluation 12.2.3 Sepsis 12.2.4 Anatomy of Fistulas: Clinical and Radiological Evaluation 12.3 Systemic Approach and Treatment 12.3.1 Sepsis Control 12.3.2 Nutritional Support 12.4 Local Control 12.4.1 Fistula Management 12.4.2 Definitive Surgery 12.5 Conclusion References 13: Operative Endoscopy in Gastrointestinal and Biliopancreatic Acute Care Surgery 13.1 Gastrointestinal Endoscopy 13.1.1 Upper Gastrointestinal Dehiscence/Perforations 13.1.2 Lower Gastrointestinal Dehiscence/Perforations 13.2 Biliopancreatic Endoscopy 13.2.1 Acute Cholangitis 13.2.2 Acute Cholecystitis 13.2.3 Acute Pancreatitis and Pancreatic Pseudocysts 13.2.4 Postoperative and Traumatic Biliary Fistulas 13.2.5 Postoperative and Traumatic Pancreatic Fistulas References 14: Point-of-Care Ultrasound in Acute Care Surgery: A Strategic Tool 14.1 Introduction 14.2 Trauma 14.3 Acute Cholecystitis and Biliary Emergencies 14.4 Acute Appendicitis 14.5 Acute Colonic Diverticulitis 14.6 Small Bowel Obstruction 14.7 Bowel Perforation 14.8 Postoperative Complications 14.9 Hemodynamics Assessment and Shock References 15: Large Bowel Emergencies 15.1 Large Bowel Perforation 15.1.1 Diagnosis 15.1.2 Perforated Colorectal Cancer 15.1.3 Perforated Diverticulitis 15.1.4 Inflammatory Bowel Disease, Toxic Colitis and Toxic Megacolon 15.2 Large Bowel Obstruction 15.2.1 Colorectal Cancer 15.2.2 Malignant Intussusception 15.2.3 Volvulus 15.3 Hemorrhage 15.4 Ischemic Colitis 15.5 Principles of Therapy of Left Colonic Obstruction 15.5.1 Colostomy 15.5.2 Hartmann’s Procedure 15.5.3 Primary Resection and Anastomosis 15.5.4 Colonic Stents 15.6 Conclusions References 16: Biliary Emergencies 16.1 Background 16.2 Acute Calculous Cholecystitis 16.2.1 Diagnosis 16.2.2 Imaging 16.2.3 Classification 16.2.4 Common Bile Duct Stones Associated with Acute Calculous Cholecystitis 16.2.5 Surgical Therapy 16.2.5.1 Tokyo Guidelines 16.2.5.2 World Society of Emergency Surgery Guidelines 16.2.6 Biliary Drainage 16.2.7 Antibiotic Therapy 16.3 Acute Cholangitis 16.3.1 Diagnosis 16.3.2 Imaging 16.3.3 Classification 16.3.4 Therapy References 17: Management of Infected Necrosis in Severe Acute Pancreatitis 17.1 Introduction 17.2 Incidence of Infected Necrosis 17.3 Diagnostics 17.4 Treatment 17.4.1 Antibiotics 17.4.2 Percutaneous Drainage 17.4.3 Endoscopic Interventions 17.4.4 Open Surgery 17.5 Choice of Surgical Tactics References 18: Source Control in Abdominal Sepsis 18.1 Introduction 18.2 Source Control 18.3 Relaparotomy Strategies 18.4 Conclusion References 19: Laparoscopy and Minimally Invasive Surgery Techniques in Acute Care Surgery 19.1 Introduction 19.2 Contraindications 19.3 Diagnostic Laparoscopy 19.4 Acute Appendicitis 19.5 Acute Calculous Cholecystitis 19.6 Perforated Peptic Ulcer 19.7 Small Bowel Obstruction 19.8 Acute Diverticulitis 19.9 Abdominal Trauma 19.10 Establishing or Building an Acute Care MIS Program References 20: Emergency Management of Caustic Injuries 20.1 Introduction 20.2 Epidemiology 20.3 Corrosive Agents 20.4 Emergency Management 20.4.1 Pre-hospital Management 20.4.2 In-hospital Management 20.4.3 Severity Assessment of Caustic Damage 20.4.3.1 Clinical Presentation 20.4.3.2 Laboratory Studies 20.4.3.3 Computed Tomography 20.4.3.4 Endoscopy 20.4.4 Non-operative Treatment 20.4.5 Emergency Surgery 20.4.5.1 Esophagogastrectomy 20.4.5.2 Gastrectomy 20.4.5.3 Extended Resections 20.4.5.4 Tracheobronchial Necrosis 20.4.5.5 Results of Emergency Surgery 20.5 Conclusion References Correction to: Trauma Centers and Acute Care Surgery Correction to: O. Chiara (ed.), Trauma Centers and Acute Care Surgery, Updates in Surgery, https://doi.org/10.1007/978-3-030-73155-7