Atlas of Trauma/ Emergency Surgical Techniques E-Book

-

English
350 Pages
Read an excerpt
Gain access to the library to view online
Learn more

Description

Atlas of Trauma/Emergency Surgical Techniques, a title in the Surgical Techniques Atlas Series, presents state-of-the-art updates on the full range of trauma and emergency surgical techniques performed today. Drs. Cioffi and Asensio, along with numerous other internationally recognized general surgeons, offer you step-by-step advice along with full-color illustrations and photographs to help you expand your repertoire and hone your clinical skills.
  • Easily review normal anatomy and visualize the step-by-step progression of each emergency surgery procedure thanks to more than 330 detailed anatomic line drawings and clinical photographs.
  • Avoid complications with pearls and pitfalls from the authors for every surgical technique.
  • Master the key variations and nuances for a full range of emergency techniques. A highly formatted approach provides step-by-step instructions with bulleted "how-to" guidance for each procedure.

Subjects

Informations

Published by
Published 10 July 2013
Reads 0
EAN13 9780323187992
Language English
Document size 2 MB

Legal information: rental price per page 0.0611€. This information is given for information only in accordance with current legislation.

Report a problem

Atlas of
Trauma/Emergency
Surgical Techniques
A Volume in the Surgical Techniques Atlas
Series
William G. Cioffi, MD, FACS
Professor and Chairman, Department of Surgery, The Warren Alpert Medical School of
Brown University, Providence, Rhode Island
Surgeon-in-Chief, Rhode Island Hospital, Providence, Rhode Island
Juan A. Asensio, MD, FACS, FCCM, FRCS (England)
Professor of Surgery, Vice-Chairman, Department of Surgery, New York Medical
College
Chief, Division of Trauma Surgery and Acute Care Surgery
Director, Joel A. Halpern Trauma Center
Director, International Medicine Institute
Co-Director, Research Institute, Westchester Medical Center University Hospital,
Valhalla, New York
Charles A. Adams, Jr. MD, FACS, FCCM
Associate Professor of Surgery, The Warren Alpert Medical School of Brown
University, Providence, Rhode Island
Chief, Division of Trauma and Surgical Critical Care, Rhode Island Hospital,
Providence, Rhode Island
Michael D. Connolly, MD
Assistant Professor of Surgery, The Warren Alpert Medical School of Brown University,
Providence, Rhode Island
Division of Trauma and Surgical Critical Care, Rhode Island Hospital, Providence,
Rhode Island
Walter L. Biffl, MDAssociate Director of Surgery, Assistant Director of Patient Safety and Quality, Denver
Health Medical Center, Denver, Colorado
Professor of Surgery, University of Colorado–Denver, Denver, Colorado
Gregory J. Jurkovich, MD
Director of Surgery, Denver Health Medical Center, Denver, Colorado
Bruce M. Rockwell Distinguished Professor and Vice-Chairman, Department of
Surgery, University of Colorado School of Medicine, Denver, Colorado
L.D. Britt, MD, MPH, DSc (Hon) FACS, FCCM,
FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon),
FRCSI (Hon), FCS(SA) (Hon)
Brickhouse Professor and Chairman, Department of Surgery, Eastern Virginia Medical
School, Norfolk, VirginiaTable of Contents
Cover image
Title page
Series page
Copyright
Contributors
Foreword
Preface
Chapter 1: Intracranial Pressure Monitoring and Ventriculostomy
Indications For Intracranial Pressure Monitoring
Clinical Anatomy
Preoperative Considerations
Type Of Monitoring Device
Cranial Access
Complications
Section I: Neck
Chapter 2: Neck Exploration
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative CarePearls And Pitfalls
Chapter 3: Surgical Airways: Tracheostomy and Cricothyroidotomy
Percutaneous Tracheostomy With The Ciaglia Blue Rhino
Open Tracheostomy
Cricothyroidotomy
Needle Cricothyroidotomy
Section II: Chest
Chapter 4: Resuscitative Thoracotomy, Anterolateral and Posterolateral Thoracotomy,
and Thoracotomy Decortication and Pleurodesis
Emergency Department Resuscitative Thoracotomy
Anterolateral And Posterolateral Thoracotomy
Video-Assisted Thoracoscopy For Removal Of Retained Hemothoraces And
Decortication
Open Thoracotomy Decortication And Pleurodesis
Chapter 5: Anterior Approach For Stabilization of Fractures of The Lower Thoracic and
Upper Lumbar Spine (T11-L2)
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 6: Cardiac Injuries
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 7: Thoracic Vascular Exposure and ReconstructionResuscitative Thoracotomy
Exigent Thoracotomy
Planned Thoracotomy
Summary
Chapter 8: Tracheal Injury and Repair
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 9: Pulmonary Injuries
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 10: Subxiphoid Pericardial Window
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 11: Surgical and Operative Management of Esophageal Injuries
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And PitfallsSection III: Abdomen
Chapter 12: Abdominal Closure Techniques
Surgical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Steps
Pearls And Pitfalls
Chapter 13: Duodenal Injury Repairs
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 14: Liver Injuries: Repair Techniques
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 15: Splenectomy and Splenorrhaphy
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 16: Pancreatic Injury: Repair and Resection Techniques
Clinical AnatomyPreoperative Considerations
Operative Steps
Injury Management
Postoperative Care
Pearls And Pitfalls
Chapter 17: Cholecystectomy and Common Bile Duct Exploration
Clinical Anatomy
Preoperative Considerations
Operative Steps (Laparoscopic Approach)
Postoperative Care
Pearls And Pitfalls
Chapter 18: Kidney Trauma (Parenchymal and Vascular Injuries): Repair and
Nephrectomy
Clinical Anatomy
Preoperative Considerations
Operative Steps
Chapter 19: Bladder and Ureteral Repair
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 20: Gastroduodenal Operations For Upper Gastrointestinal Bleeding and
Perforation
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative CarePearls And Pitfalls
Chapter 21: Incarcerated Hernia Repair—Posterior Preperitoneal Approach
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 22: Rectal Trauma
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Section IV: Abdominal Vascular
Chapter 23: Abdominal Vascular Injuries
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 24: Acute Mesenteric Ischemia
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care, Management, And Reoperation
Pearls And Pitfalls
Section V: Extremities and PelvisChapter 25: Vascular Injuries of The Upper and Lower Extremities
Preoperative Considerations
Operative Steps
Pearls And Pitfalls
Chapter 26: Upper and Lower Extremity Fasciotomy
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 27: Upper and Lower Extremity Amputation
Upper Extremity Amputations
Lower Extremity Amputations
Section VI: Bedside Procedures
Chapter 28: Bedside Placement of Inferior Vena Cava Filter
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
Chapter 29: Gastrostomy and Jejunostomy—Percutaneous Approach
Clinical Anatomy
Preoperative Considerations
Operative Steps
Postoperative Care
Pearls And Pitfalls
IndexSeries page
Other Volumes in the Surgical Techniques Atlas Series
Atlas of Endocrine Surgical Techniques
Edited by Quan-Yang Duh, MD, Orlo H. Clark, MD, and Electron Kebebew, MD
Atlas of Breast Surgical Techniques
Edited by V. Suzanne Klimberg, MD
Atlas of Surgical Techniques for the Upper Gastrointestinal Tract and Small
Bowel
Edited by Jeffrey R. Ponsky, MD, and Michael J. Rosen, MD
Atlas of Thoracic Surgical Techniques
Edited by Joseph B. Zwischenberger, MD
Atlas of Pediatric Surgical Techniques
Edited by Dai H. Chung, MD, and Mike Kuang Sing Chen, MD
Atlas of Cardiac Surgical Techniques
Edited by Frank W. Sellke, MD, and Marc Ruel, MD
Atlas of Minimally Invasive Surgical Techniques
Edited by Ashley Vernon, MD, and Stanley W. Ashley, MD
Atlas of Surgical Techniques for Colon, Rectum, and Anus
Edited by James W. Fleshman, MDCopyright
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF TRAUMA/EMERGENCY SURGICAL TECHNIQUES  ISBN:
978-1-41604016-3
Copyright © 2014 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher. Details
on how to seek permission, further information about the Publisher's permissions
policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright
by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds,
or experiments described herein. In using such information or methods they
should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are
advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to
verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors,contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Atlas of trauma : emergency surgical techniques / editors, William G. Cioffi … [et  al.].
   p. ; cm.—(Surgical techniques atlas series)
 Includes bibliographical references and index.
 ISBN 978-1-4160-4016-3 (hardcover : alk. paper)
 I. Cioffi, William G. II. Series: Surgical techniques atlas series.
 [DNLM: 1.  Wounds and Injuries—surgery—Atlases. 2.  Emergencies—Atlases.
3.  Surgical Procedures, Operative—methods—Atlases.  WO 517]
 RD93.8
 617.10022 ′2–dc23
   2013013469
Publishing Manager: Michael Houston
Content Development Specialist: Lauren Boyle
Publishing Services Manager: Patricia Tannian
Project Manager: Amanda Mincher
Manager, Art and Design: Steven Stave
Printed in China
Last digit is the print number:  9  8  7  6  5  4  3  2  1  Contributors
Darwin Noel Ang, MD, PhD, MPH, Associate Professor, Department of Surgery
University of South Florida
Ocala, Florida
Director of Trauma Services
Ocala Regional Medical Center
Director of Research
USF/HCA Trauma Network
Ocala, Florida
David P. Blake, MD, MPH, FACS, DMCC, Colonel, United States Air Force Medical
Corps
Master Clinician/Surgical Intensivist
633d Surgical Operations Squadron
Joint Base Langley-Eustis, Virginia
Assistant Professor, Department of Surgery
Uniformed Services University of the Health Sciences School of Medicine
Bethesda, Maryland
Hassan Adnan Bukhari, MD, Assistant Professor, Department of Surgery
Umm Al-Qura University
Saudi Arabia
Consultant, General Surgery, Trauma Surgery, and Surgical Critical Care
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Clay Cothren Burlew, MD, Director, Surgical Intensive Care Unit
Program Director, Surgical Critical Care Fellowship
Program Director, Trauma and Acute Care Surgery Fellowship
Denver Health Medical Center
Associate Professor
University of Colorado School of Medicine
Denver, Colorado
Jose Ceballos, MD, FACS, Formerly, Professor Asensio's International Visiting
Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Zara Cooper, MD, MSc, Assistant Professor, Department of Surgery
Harvard Medical SchoolAssociate Surgeon
Brigham and Women's Hospital
Boston, Massachusetts
Heather L. Evans, MD, MS, FACS, Assistant Professor, Department of Surgery
University of Washington
Director of Surgical Infectious Disease
Harborview Medical Center
Seattle, Washington
Takashi Fujita, MD, DMedSc, FACS, Associate Professor
Trauma and Resuscitation Center
Teikyo University
Tokyo, Japan
Formerly, Dr. Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Luis Manuel García-Núñez, MD, FACS, FAMSUS, Lieutenant Colonel, Mexican
Army
Department of Defense, General Surgery, Trauma Surgery, and Surgical Critical Care
Formerly, Dr. Asensio’s International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Assistant Professor
Department of Surgery
Military School of Health
Graduated Professionals
University of Army and Air Force
Director of Emergency Department
Military Central Hospital
México City, México
A. Alejandro Gigena, MD, Attending Physician, Trauma and General Surgery
Sanatorio Güemes
Buenos Aires, Argentina
Attending Physician, Thoracic Surgery
Swiss Medical Group
Buenos Aires, Argentina
Assistant Profesor of Anatomy
Universidad de Buenos Aires
Buenos Aires, Argentina
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Juan Manuel Sánchez González, MD, General Surgeon
Hospital Nuestra Señora de CandelariaSanta Cruz de Tenerife, Spain
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Rubén Gonzalo Gonzalez, MD, Resident Physician in General Surgery (5°)
Hospital Universitario Central de Asturias
Universidad de Oviedo
Asturias, España
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Daithi S. Heffernan, MD, AFRCSI, Assistant Professor of Surgery
The Warren Alpert Medical School of Brown University
Division of Trauma and Surgical Critical Care
Rhode Island Hospital
Providence, Rhode Island
Tamer Karsidag, MD, FACS, FEBS, Associated Professor, General Surgery
Department
Istanbul University, Faculty of Medicine
Istanbul, Turkey
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Jeffry L. Kashuk, MD, FACS, Director of Surgical Research and Academic
Development
EM Care—Acute Care Surgery Division
Dallas, Texas
Fernando J. Kim, MD, FACS, Chief of Urology
Denver Health Medical Center
Director of Minimally Invasive Urological Oncology
Tony Grampsas Cancer Center
Associate Professor of Surgery
University of Colorado Health Sciences Center
Denver, Colorado
International Editor of International Braz J Urol
Matthew S. Kozloff, MD, FACS, Attending Surgeon
Desert Regional Medical Center
Palm Springs, California
Meryl Singer Livermore, MD, Assistant Professor, Orthopedics
University of Colorado
Orthopedics, Hand, and Microvascular Surgery
Denver Health Medical CenterDenver, Colorado
Sarah D. Majercik, MD, MBA, FACS, Division of Trauma and Surgical Critical Care
Intermountain Medical Center
Murray, Utah
Corrado P. Marini, MD, FACS, Professor of Surgery
New York Medical College
Chief of Surgical Critical Care
Co-Director of the Joel A. Halpern Trauma Center
Co-Director of the Research Institute
Westchester Medical
Center, University Hospital
Valhalla, New York
Federico N. Mazzini, MD, Trauma and Emergency Surgery Attending
General Surgery Department
Hospital Italiano de Buenos Aires
Buenos Aires, Argentina
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Wilson R. Molina, Jr., MD, Attending Physician
Denver Health Medical Center
Assistant Professor, Division of Urology
Department of Surgery, SOM
University of Colorado
Denver, Colorado
Ernest E. Moore, MD FACS, FCCM, FACN, FACEP (Hon), FRCSEd (Hon), Vice
Chairman for Research
Department of Surgery
University of Colorado Denver
Editor, Journal of Trauma and Acute Care Surgery
Denver, Colorado
Michael J. Mosier, MD, FACS, Assistant Professor of Surgery
Vice Chair of Clinical Trials
Division of Trauma, Surgical Critical Care, and Burns
Loyola University Medical Center
Maywood, Illinois
Mamoun A.Y. Nabri, MBBS, FRCSI, FACS, Trauma Advisor, Ministry of Health
Riyadh, Saudi Arabia
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Thomas Ng, MD, FRCSC, FACS, Thoracic Surgeon
Rhode Island Hospital
Associate Professor of SurgeryThe Warren Alpert Medical School of Brown University
Providence, Rhode Island
Grant E. O'Keefe, MD, MPH, Professor of Surgery
Adjunct Professor of Neurological Surgery, Orthopedics, and Sports Medicine
Department of Surgery
University of Washington Medical Center
Harborview Medical Center
Seattle, Washington
Kagan Ozer, MD, Associate Professor
Department of Orthopedic Surgery
University of Michigan
Ann Arbor, Michigan
Alejandro J. Pérez-Alonso, MD, PhD, Master in Tissue Engineering
General and Digestive Surgeon
Hospital Universitario San Cecilio
Department of Experimental Surgery
University of Granada
Granada, Spain
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery, University of Miami
Miller School of Medicine
Miami, Florida
Patrizio Petrone, MD, MPH, Assistant Professor of Surgery
University of Buenos Aires School of Medicine
Attending Surgeon
HIGA-Güemes
Medical Advisor
Ministry of Health La Plata
Buenos Aires, Argentina
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Anthony J. Policastro, MD, FACS, Assistant Professor of Surgery
New York Medical College
Associate Director of Surgical Critical Care
Clinical Director of Trauma and Surgical Intensive Care Units
Westchester Medical Center, University Hospital
Valhalla, New York
Eva Iglesias Porto, MD, Attending Surgeon
General Surgery Department
Hospital Universitario Lucus Augusti
Lugo, Spain
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine,Miami, Florida
Gerd Daniel Pust, MD, Formerly, Professor Asensio's International Visiting
Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Pablo Menendez Sanchez, MD, PhD, General Surgeon
Hospital Gutierrez Ortega Ciudad
Real, Spain
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, Florida
Juan Manuel Verde, MD, Gastrointestinal and HPB Surgery
Clinicas Hospital
University of Buenos Aires
Buenos Aires, Argentina
Formerly, Professor Asensio's International Visiting Scholar/Research Fellow
Division of Trauma, Surgery, and Surgical Critical Care
DeWitt Daughtry Family Department of Surgery
University of Miami, Miller School of Medicine
Miami, FloridaForeword
“A picture is worth a thousand words.”
This atlas is for practicing surgeons, surgical residents, and medical students for
their review and preparation for surgical procedures. New procedures are developed
and old ones are replaced as technologic and pharmacologic advances occur. The
topics presented are contemporaneous surgical procedures with step-by-step
illustrations, along with the preoperative and postoperative considerations as well as
pearls and pitfalls taken from the personal experience and surgical practice of the
authors. Their results have been validated in their surgical practices involving many
patients. Operative surgery remains a manual art in which the knowledge, judgment,
and technical skill of the surgeon come together for the benefit of the patient. A
technically perfect operation is the key to this success. Speed in operation comes from
having a plan and devoting sufficient time to completion of each step, in order, one at a
time. The surgeon must be dedicated to spending the time to do it right the first time; if
not, there will never be enough time to do it right at any other time. Use this atlas,
study it for your patients.
“An amateur practices until he gets it right; a professional practices until she can't
get it wrong.”
Courtney M. Townsend, Jr., MD
B. Mark Evers, MDPreface
The Bridge Builder
An old man going a lone highway,
Came, at the evening cold and gray,
To a chasm vast and deep and wide.
Through which was flowing a sullen tide
The old man crossed in the twilight dim,
The sullen stream had no fear for him;
But he turned when safe on the other side
And built a bridge to span the tide.
“Old man,” said a fellow pilgrim near,
“You are wasting your strength with building here;
Your journey will end with the ending day,
You never again will pass this way;
You've crossed the chasm, deep and wide,
Why build this bridge at evening tide?”
The builder lifted his old gray head;
“Good friend, in the path I have come,” he said,
“There followed after me to-day
A youth whose feet must pass this way.
This chasm that has been as naught to me
To that fair-haired youth may a pitfall be;
He, too, must cross in the twilight dim;
Good friend, I am building this bridge for him!”
By Will Allen DromgooleThe poem “The Bridge Builder” highlights the necessity to formulate and transmit
new knowledge. This Atlas is our attempt as academic trauma and acute care
surgeons to pass our knowledge on to the current and future generations of trauma
and acute care surgeons that would follow in our path. It is our hope that the
knowledge contained in these pages will be used not only to save lives, but also to
teach others how to do the same. The authors dedicate this book to our families, to the
future generations of students, residents, fellows, and surgeons who continue to serve
as the pillars of our lives, and to this the most humane profession known to man.
William G. Cioffi and Juan A. AsensioC H A P T E R 1
Intracranial Pressure
Monitoring and
Ventriculostomy
Michael D. Connolly, Charles A. Adams, Jr. and William G. Cioffi
Traumatic brain injury (TBI) is a major source of morbidity and mortality in the United
States. TBI results in 1.1 million emergency department visits each year. Of these
patients, 235,000 require hospital admission, and 50,000 people will die of their TBI.
Furthermore, approximately 5.3 million people with TBI in the United States require
long-term assistance with activities of daily living.
The treatment of TBI requires immediate and aggressive intervention to prevent the
progression of secondary brain injury after trauma. The measurement of intracranial
pressure (ICP) is an integral part of monitoring patients with severe TBI. This
measurement is performed by placement of intraventricular or parenchymal monitors.
Indications for Intracranial Pressure Monitoring
Salvageable patients with severe TBI and an abnormality detected by computed
tomography (CT)
Hematoma
Contusion
Swelling
Herniation
Compressed basal cisterns
Salvageable patients with severe TBI and normal findings on CT with two or more
of the following:
Age older than 40 years
Unilateral or bilateral motor posturing
Systolic blood pressure
Clinical Anatomy
The cranial vault is a rigid, nonexpandable space with an average volume of 1.9
liters.
Approximate composition of skull volume ( Figure 1-1) is 80% brain, 10% blood,
and 10% cerebrospinal fluid (CSF).FIGURE 1-1
The cranium is composed of multiple bones that are held together at the cranial
sutures.
The sagittal and cranial suture lines compose the major landmarks for ICP monitor
placement.
Preoperative Considerations
Complete a primary and secondary survey.
Obtain a CT scan of the head.
Avoid or correct hypotension.
Avoid or correct hypoxia.
Correct coagulopathy with a goal international normalized ratio below 1.3.
Type of Monitoring Device
Ventriculostomy
Ventriculostomy is considered the “gold standard” for ICP monitoring.
Ventriculostomy allows measurement of ventricular pressure.
Ventriculostomy permits drainage of CSF.
Recalibration allows correction of measurement drift.
Placement is more difficult if the ventricles are compressed or displaced.
Intraparenchymal Bolt
Intraparenchymal bolt monitoring is usually performed if there are contraindications
to or difficulty in placement of ventriculostomy.
It should be placed intraparenchymally for most accurate pressure monitoring.
It cannot be recalibrated in vivo; therefore, it is susceptible to measurement drift.
Cranial Access
The patient is placed in the supine position. The frontal scalp is shaved and
prepared in sterile fashion.
Access may be into either lateral ventricle; the injured side is frequently selected.Place the drain on the nondominant, right side if there is no indication for side.
Make a sagittal incision 3  cm from midline and 1  cm anterior to the coronal suture.
This point is 3  cm from the midline approximately 10  cm above the nasion.
Consider a more lateral placement in a patient with midline shift ( Figure 1-2).
FIGURE 1-2
Ventriculostomy
Perform a twist drill hole through the skull.
Penetrate the dura with a scalpel or catheter passer.
Place the ventriculostomy catheter toward the ipsilateral medial canthus and the
external auditory meatus ( Figures 1-3 and 1-4).
FIGURE 1-3FIGURE 1-4
Pass the catheter gently through brain matter about 4 to 7  cm on the basis of
measured distance on the CT scan.
CSF return should be present; if not, reattempt passage of the catheter for a
maximum of three attempts. If the catheter is not able to be placed on the initial
side, placement on the contralateral side may be attempted.
Measure opening pressure.
Tunnel the catheter under the skin and remove it through a separate stab incision.
Suture incision closed and secure catheter.
Connect to CSF drainage system.
Intraparenchymal Bolt
Make a twist drill hole through the skull.
Incise the dura in cruciate fashion.
Screw bolt into skull.
Insert fiberoptic catheter into brain approximately 5 to 6  cm. Pull back slightly.
Verify pressure waveform on monitor.
Complications
Hemorrhage
The overall incidence of hemorrhage is 1.1%.
The incidence of significant hematoma requiring surgical evacuation is
0.5%.
Infection
Rates of colonization are 10% to 17%.
Malfunction
Malfunction occurs in 6% to 40% of devices.
Malposition
Approximately 3% of intraventricular catheters require repositioning.
Selected Readings
2007. Guidelines for the management of severe traumatic brain injury. Indications for
intracranial pressure monitoring. J Neurotrauma. 2007; 24(1 Suppl):S37.Langlois, JA, Rutland-Brown, W, Thomas, KE. Traumatic brain injury in the United
States: emergency department visits, hospitalizations, and deaths. Atlanta: Centers
for Disease Control and Prevention, National Center for Injury Prevention and
Control; 2004.S E C T I O N I
N e c kC H A P T E R 2
Neck Exploration
Walter L. Biffl
Most neck injuries requiring operative repair are the result of penetrating trauma. In the
setting of stab wounds or low-velocity gunshot wounds, tissue damage is usually
confined to the missile track. On the other hand, a high-velocity missile is associated
with a high incidence of significant injuries, and damage may be remote from the
missile track as a result of blast injury. Blunt trauma is an unusual but important cause
of injuries to the vessels of the neck. The skin may show minimal evidence of injury,
but there may be a life-threatening vascular or aerodigestive injury.
Clinical Anatomy
The major structures of concern are carotid and vertebral arteries, jugular veins,
trachea, and esophagus.
Zone I extends from the cricoid cartilage inferiorly ( Figure 2-1). Zone II lies
between the cricoid cartilage and the angle of the mandible. Zone III is above
the angle of the mandible.
FIGURE 2-1
Zone I includes the thoracic inlet, and wounds in this zone may injure the
brachiocephalic artery, left common carotid artery, or subclavian artery as well
as numerous veins and the aerodigestive structures. Proximal control of major
blood vessels may require a thoracic incision (see Chapter 7). The cervical esophagus lies posterior to the trachea, beginning at the level of the
cricoid cartilage. The recurrent laryngeal nerves are located in the
tracheoesophageal groove and are easily damaged by injury or careless surgical
dissection.
Preoperative Considerations
The initial evaluation should address the ABCs: airway, breathing, and circulation. A
patent airway may precipitously become obstructed by an expanding hematoma,
so it is always safest to control the airway early. It should be cautioned that
intubation in the setting of partial airway transection may result in complete
airway obstruction. Inability to secure the airway with an endotracheal tube
mandates a surgical airway (see Chapter 3).
The management of patients with penetrating neck trauma has been debated for
decades. Although presumptive neck exploration may be appropriate in some
circumstances, selective nonoperative management is practiced in most
centers. Indications for immediate surgery include hemodynamic instability and
significant external hemorrhage. The management of hemodynamically normal
patients is based on the anatomic level of injury (see Figure 2-1).
Because of technical difficulties of exposure and varying operative approaches, a
precise preoperative diagnosis is desirable for injuries in zones I and III.
Therefore, even if they are symptomatic, stable patients with injuries in these
zones should undergo diagnostic evaluation. Computed tomography scanning of
the neck and chest identifies the missile track, and further studies are based on
proximity to vascular or aerodigestive structures. Angioembolization may provide
definitive management of zone III vascular injuries.
Patients with zone II injuries who are symptomatic should undergo urgent operative
exploration. Signs and symptoms include active bleeding, expanding hematoma,
bruit, hemoptysis, hematemesis, significant subcutaneous emphysema,
hoarseness, dysphagia, and air bubbling from the wound. Those who are
asymptomatic may be managed expectantly on the basis of clinical examination
findings or may undergo further diagnostic evaluation.
The two most common causes of cervical esophageal injury are penetrating trauma
and perforation due to instrumentation. Blunt injuries of the esophagus are rare
and usually associated with laryngeal or tracheal trauma. Esophageal
perforation may be associated with a variety of signs and symptoms, but
asymptomatic perforations are common, especially after stab wounds. Contrast
studies and esophagoscopy are useful diagnostic tests and, when used
together, maximize the accuracy of diagnosis—particularly in the cervical
esophagus.
Operative Steps
Exposure
The patient should be positioned supine. If the injury is expected to be unilateral,
the head may be turned to the contralateral side. If bilateral exploration is
anticipated, the head should be maintained in a neutral position. Cervical
hyperextension should be used to facilitate exposure as long as there is no
cervical spine injury. The entire neck, chest, and upper abdomen should be
prepared as a sterile field.
If bilateral exploration is anticipated, a collar incision is made approximately two
fingerbreadths above the sternal notch. Adequate exposure is obtained bydeveloping superior and inferior skin flaps underneath the platysma. Additional
exposure is obtained by extending the incision upward or laterally.
For unilateral neck exploration, an incision is made along the anterior border of the
sternocleidomastoid from the head of the clavicle to the mastoid process (
Figure 2-2). A second oblique incision on the contralateral side of the neck may
be used for bilateral neck exploration.
FIGURE 2-2
Dissection
The platysma is incised and the sternocleidomastoid muscle retracted laterally to
expose the carotid sheath. The carotid sheath is opened, allowing examination
of the carotid artery and jugular vein ( Figure 2-3). Mobilization of the carotid
sheath contents often requires division of the facial vein. The ansa cervicalis
may be divided with impunity.FIGURE 2-3
Repair of a vascular injury requires proximal and distal control of the vessel, with
either vessel loops or vascular clamps. If an injury is near the carotid artery
bifurcation, vessel loops should be placed around the internal and external
carotid arteries. Distal dissection of the carotid artery is achieved by following
the anterior border of the sternocleidomastoid, with care taken to protect cranial
nerves.
The more cephalad portions of the carotid artery are better exposed if the digastric
muscle is divided. High internal carotid artery injuries sometimes require
additional exposure, which is accomplished by subluxation of the mandible (
Figure 2-4A) or mandibulotomy ( Figure 2-4B).FIGURE 2-4
For exploration of the trachea and esophagus, the carotid sheath is retracted
laterally and the trachea and thyroid are retracted medially. The middle thyroid
vein may be divided. It may be necessary to divide the isthmus of the thyroid
gland between clamps to completely visualize the anterior trachea. A suture
ligature can be placed on the divided isthmus. Alternatively, the thyroid can be
retracted superiorly.
Care is taken to avoid injury to the recurrent laryngeal nerves in examining the
posterior trachea and the esophagus. Identification of these nerves is especially
important if circumferential mobilization of the esophagus is performed. Access
to the retrovisceral space behind the esophagus is now possible. The wound
track is followed and the esophagus carefully examined for injury. Small injuries
can usually be demonstrated by filling the wound with saline and allowing air to
be injected into the cervical esophagus through the nasogastric tube. When the
distal esophagus is manually occluded and an injury is present, bubbles will
appear in the wound. Methylene blue may also be used in this circumstance.Repairs
Minor injuries to the jugular vein may be repaired with simple sutures, but venous
injuries in the neck may generally be controlled by ligation.
Control of arterial bleeding can be accomplished by gentle finger pressure as
proximal and distal control is secured with vascular tapes. Puncture wounds and
simple lacerations of the carotid artery are repaired by interrupted monofilament
sutures. Coaptation of the intima is important to minimize microemboli
originating at the repair site.
More complex injuries, especially close to the carotid bifurcation, may require
resection and end-to-end anastomosis with either running or interrupted sutures.
In some cases, loss of tissue may require a graft. The external carotid artery
may be substituted for the internal carotid artery ( Figure 2-5AB). The origin of
the internal carotid artery is carefully oversewn at the bulb to maintain a normal
contour. Prosthetic grafts are rarely used in the carotid system, but a
polytetrafluoroethylene graft may be helpful if the saphenous vein is too small to
be used in a common carotid artery injury.
FIGURE 2-5
When the internal carotid artery is injured and there is poor backflow, a temporary
shunt may be used while the repair is performed.
Injuries of the subclavian and vertebral arteries can be approached through a
supraclavicular incision located about 1  cm above the clavicle ( Figure 2-6). The
clavicular head of the sternocleidomastoid is divided and the subclavian vein
retracted inferiorly to expose the subclavian artery. The vertebral artery, internal
mammary artery, and thyrocervical trunk are preserved if possible ( Figure 2-7).