CHAPTER 6 - Trauma Jon M. Burch Reginald J. Franciose Ernest E.

Moore
Trauma or injury has been defined as damage to the body caused by an exchange with environmental energy that is beyond the body's resilience. Trauma remains the most common cause of death for individuals between the ages of 1 and 44 years, and the third most common cause of death for all ages. The U.S. government classifies accidental death under the following categories accidents and adverse effects! suicide, homicide, and legal intervention! and all other external causes. "ccidents and adverse effects account for a##roximately 1$$,$$$ deaths #er year, of which motor vehicle accidents account for nearly %$ #ercent. &omicides, suicides, and other causes are res#onsible for another %$,$$$ deaths each year. 'eath rates are a #oor indicator of the magnitude of the #roblem, however, because most injured #atients survive. (or exam#le, in 1)*% there were a##roximately 14$,$$$ trauma+related deaths, but %, million re#orted injuries and -. million hos#itali/ations. (or the same year the aggregate lifetime costs for all injured #atients was estimated to be 01%* billion. Trauma is a major #ublic health issue. 121T1"3 45"3U"T162 "2' 74SUS81T"T162 6( T&4 129U74' :"T142T Treatment of trauma #atients often begins in the field by emergency medical services ;4<S= #ersonnel and com#leted by rehabilitation s#ecialists. "lthough the "dvanced Trauma 3ife Su##ort ;"T3S= course of the "merican 8ollege of Surgeons 8ommittee on Trauma is directed at #rimary care #hysicians in rural communities, its format and basic tenets are sound for all #hysicians. The initial treatment of seriously injured #atients consists of a #rimary survey, resuscitation, secondary survey, diagnostic evaluation, and definitive care. The conce#ts are #resented in a se>uential fashion, but in reality they often #roceed simultaneously. The #rocess begins with the identification and treatment of conditions that constitute an immediate threat to life. The "T3S course refers to this as the #rimary survey or the "?8s+"irway, with cervical s#ine #rotection, ?reathing, and 8irculation. "ny life+threatening #roblem identified in the initial survey must be treated before advancing. "irway <anagement 4nsuring an ade>uate airway is the first #riority in the #rimary survey. 4fforts to restore cardiovascular integrity will be futile if the oxygen content of the blood is inade>uate. Simultaneously, all blunt+trauma #atients re>uire cervical s#ine immobili/ation until injury is ruled out. This can be accom#lished with a hard ;:hiladel#hia= collar or sandbags on both sides of the head ta#ed to the bac@board. Soft collars do not immobili/e the cervical s#ine. :atients who are conscious and have a normal voice do not re>uire further evaluation or early attention to their airway. 4xce#tions to this #rinci#le include #atients with #enetrating injuries to the nec@ and an ex#anding hematoma, evidence of chemical or thermal injury to the mouth, nares, or hy#o#harynx, extensive subcutaneous air in the nec@, com#lex maxillofacial trauma, or airway bleeding. These #atients initially may

have a satisfactory airway, but it may become obstructed if soft tissue swelling or edema #rogresses. 1n these cases, elective intubation should be #erformed before evidence of airway com#romise is a##arent. :atients who have an abnormal voice or altered mental status re>uire further airway evaluation. 'irect laryngosco#ic ins#ection often reveals blood, vomit, the tongue, foreign objects, or soft tissue swelling as sources of airway obstruction. Suctioning can offer immediate relief in many #atients. "ltered mental status is the most common indication for intubation because of the #atient's inability to #rotect the airway. 6#tions for airway access include nasotracheal, orotracheal, or o#erative intervention. 2asotracheal intubation can be accom#lished only in #atients who are breathing s#ontaneously and is contraindicated in the a#neic #atient. "lthough nasotracheal intubation fre>uently is used by #aramedics in the field, the #rimary use for this techni>ue in the emergency room is becoming limited to those few #atients re>uiring emergent airway su##ort who are #rohibitive candidates for #araly/ation. 6rotracheal intubation also can be #erformed in #atients with #otential cervical s#ine injuries #rovided that manual in+line cervical immobili/ation is maintained. The advantages of orotracheal intubation are the direct visuali/ation of the vocal cords, the ability to use larger+diameter endotracheal tubes, a##licability to a#neic #atients, and its familiarity to most #hysicians. The disadvantage of orotracheal intubation is that conscious #atients usually re>uire neuromuscular bloc@ade or dee# sedation. To a large extent, ra#id+se>uence induction of anesthesia with orotracheal intubation has become the standard in ex#erienced trauma centers with the availability of #ulse oximetry. The major advantage is ra#id, definitive airway control. The disadvantages include the inability to intubate, as#iration, and com#lications of the re>uired medications. Those who attem#t ra#id+se>uence induction must be thoroughly familiar with the details and contraindications of the #rocedure. :atients in whom attem#ts at intubation have failed or are #recluded because of extensive facial injuries re>uire a surgical airway. 8ricothyroidotomy ;(ig. A+1= and #ercutaneous transtracheal ventilation are #referred over tracheostomy in most emergency situations because of their sim#licity and safety. 6ne disadvantage of cricothyroidotomy is the inability to #lace a tube greater than A mm in diameter because of the limited a#erture of the cricothyroid s#ace. 8ricothyroidotomy also is contraindicated in #atients under the age of twelve because of the ris@ of damage to the cricoid cartilage and the subse>uent ris@ of subglottic stenosis. :ercutaneous transtracheal ventilation is accom#lished by inserting a large+ bore intravenous catheter through the cricothyroid membrane into the trachea and attaching it with tubing to an oxygen source ca#able of delivering %$ #si or more. " hole cut in the tubing allows for intermittent ventilation by occluding and releasing the hole. "de>uate oxygenation can be maintained for more than .$ min. ?ecause exhalation occurs #assively, ventilation is limited and carbon dioxide retention can occur. 4mergent tracheostomy has fallen into disfavor because of its technical difficulties! it may be necessary in cases of laryngotracheal se#aration or laryngeal fractures when cricothyroidotomy might cause further damage or result in the com#lete loss of the airway. ?reathing

6nce a secure airway is obtained, ade>uate oxygenation and ventilation must be assured. "ll injured #atients should receive su##lemental oxygen thera#y and be monitored by #ulse oximetry. The following conditions may constitute an immediate threat to life because of inade>uate ventilation ;1= tension #neumothorax, ;-= o#en #neumothorax, or ;.= flail chestB#ulmonary contusion. These diagnoses can be made with a combination of #hysical examination and chest x+ray. The diagnosis of tension #neumothorax is im#lied by the finding of res#iratory distress in combination with any of the following #hysical signs tracheal deviation away from the affected side! lac@ of or decreased breath sounds on the affected side! distended nec@ veins or systemic hy#otension! or subcutaneous em#hysema on the affected side. 1mmediate tube thoracostomy is indicated without awaiting chest x+ray confirmation ;(ig. A+-=. 1n tension #neumothorax the colla#sed lung acts as a one+way valve so that each inhalation allows additional air to accumulate in the #leural s#ace. The normal negative intra#leural #ressure becomes #ositive, de#ressing the i#silateral hemidia#hragm and forcing the mediastinal structures into the contralateral chest. The contralateral lung is then com#ressed, and the heart is rotated about the su#erior and inferior venae cavae, decreasing venous return and cardiac out#ut while distending the nec@ veins. "n unrecogni/ed sim#le #neumothorax can be converted to a tension #neumothorax if the #atient is #laced on a #ositive+#ressure mechanical ventilator. " tension #neumothorax also can develo# in a #atient who is breathing s#ontaneously. "n o#en #neumothorax or suc@ing chest wound occurs with full+thic@ness loss of the chest wall, #ermitting a free communication between the #leural s#ace and the atmos#here. This com#romises ventilation by two mechanisms. 1n addition to colla#se of the lung on the injured side, if the diameter of the injury is greater than the narrowest #ortion of the u##er airway, air #referentially moves through the injury site rather than the trachea and im#airs ventilation on the contralateral side. 6cclusion of the injury may result in converting an o#en #neumothorax into a tension #neumothorax. :ro#er treatment in the field involves #lacing an occlusive dressing over the wound, which is ta#ed on three sides. The occlusive dressing #ermits effective ventilation on ins#iration while the unta#ed side allows accumulated air to esca#e from the #leural s#ace, #reventing a tension #neumothorax. 'efinitive treatment re>uires wound closure and tube thoracostomy. (lail chest occurs when four or more ribs are fractured in at least two locations. :aradoxical movement of this free+floating segment of chest wall may be sufficient to com#romise ventilation. 1t is of greater #hysiologic im#ortance that #atients with flail chest fre>uently have an underlying #ulmonary contusion. :ulmonary contusion with or without rib fractures may com#romise oxygenation or ventilation to the extent that intubation and mechanical ventilation is re>uired. 7es#iratory failure in these #atients may not be immediate, and fre>uent reevaluation is warranted. The initial chest x+ray usually underestimates the degree of #ulmonary contusion, and the lesion tends to evolve with time and fluid resuscitation. 8irculation Cith a secure airway and ade>uate ventilation established, circulatory status is determined. " rough first a##roximation of the #atient's cardiovascular status is obtained by #al#ating #eri#heral #ulses. " systolic blood #ressure of A$ mm&g is re>uired for the carotid #ulse to be #al#able, ,$ mm&g for the femoral #ulse and *$

mm&g for the radial #ulse. "t this #oint in the #atient's treatment, hy#otension is assumed to be caused by hemorrhage. ?lood #ressure and #ulse should be measured at least every 1% min. 4xternal control of hemorrhage should be obtained before restoring circulating volume. <anual com#ression and s#lints fre>uently control extremity hemorrhage as effectively as tourni>uets and with less tissue damage. ?lind clam#ing should be avoided because of the ris@ to adjacent structures, #articularly nerves. The im#ortance of digital control of hemorrhage for #enetrating injuries of the head, nec@, thoracic outlet, groin, and extremities cannot be overem#hasi/ed. This should be done with a gloved finger #laced through the wound directly on the bleeding vessel a##lying only enough #ressure to control active bleeding. The surgeon #erforming this maneuver must then wal@ along beside the #atient on the way to the o#erating room for definitive treatment. Scal# lacerations through the galea a#oneurotica tend to bleed #rofusely! these can be tem#orarily controlled with 7ainey cli#s or a full+thic@ness large nylon continuous stitch. 1ntravenous access for fluid resuscitation is begun with two #eri#heral catheters, 1A+ gauge or larger in an adult. ?lood should be drawn simultaneously and sent for ty#ing and hematocrit measurement. ?ecause the flow of li>uid through a tube is #ro#ortional to diameter and inversely #ro#ortional to length, venous lines for volume resuscitation should be short with a large diameter. (or #atients re>uiring vigorous fluid resuscitation, sa#henous vein cutdowns at the an@le ;(ig. A+.= or #ercutaneous femoral vein catheter introducers are #referred. The sa#henous vein is reliably found 1 cm anterior and 1 cm su#erior to the medial malleolus. Short 1$+gauge catheters can be >uic@ly #laced even in an exsanguinating #atient with colla#sed veins. 5enous access in the lower extremities #rovides effective volume resuscitation in cases of abdominal venous injury, including the inferior vena cava. 9ugular and subclavian central venous introducers are less desirable for initial access in trauma #atients because #lacement can interfere with the wor@ of staff members #erforming other lifesaving #rocedures. Secondary central venous introducers should be #laced in the o#erating room in the event that vena caval cross+clam#ing is #erformed. 1n hy#ovolemic #ediatric #atients less than A years of age, #ercutaneous femoral vein cannulation is contraindicated because of the ris@ of venous thrombosis. 1f two attem#ts at #ercutaneous #eri#heral access are unsuccessful, interosseous cannulation should be #erformed in the #roximal tibia, or in the distal femur if the tibia is fractured ;(ig. A+4=. This is a safe emergency techni>ue! however, once alternative access has been established, the cannula should be removed because of the ris@ of osteomyelitis. 1nitial (luid 7esuscitation 1nitial fluid resuscitation is a 1+3 intravenous bolus of normal saline, lactated 7inger's solution, or other isotonic crystalloid in an adult, or -$ m3B@g of body weight lactated 7inger's solution in a child. 1n the United States crystalloid alone is used, whereas in other #arts of the world colloid is often added. This is re#eated once in an adult and twice in a child before administering red blood cells. The goal of fluid resuscitation is to reestablish tissue #erfusion. 8lassic signs and sym#toms of shoc@ are tachycardia, hy#otension, tachy#nea, mental status changes, dia#horesis, and #allor. 2one of these signs or sym#toms ta@en alone can #redict the #atient's organ #erfusion status, but

when viewed together they can hel# in evaluating the #atient's res#onse to treatment. :atients who have a good res#onse to fluid infusion, i.e., normali/ation of vital signs, clearing of the sensorium, evidence of good #eri#heral #erfusion ;warm fingers and toes with normal ca#illary refill= are #resumed to have ade>uate #erfusion. There are several caveats to @ee# in mind when ma@ing this #resum#tion. "lthough tachycardia may be the earliest sign of ongoing blood loss, individuals in good #hysical condition, #articularly trained athletes with a low resting #ulse rate, may manifest only a relative tachycardia. :atients on beta+bloc@ing medications may not be able to increase their heart rate in res#onse to stress. 1n children, bradycardia or relative bradycardia can occur with severe blood loss and is an ominous sign, often heralding cardiovascular colla#se. 8onversely, hy#oxia, #ain, a##rehension, and stimulant drugs ;e.g., cocaine, am#hetamines= #roduce a tachycardia unrelated to #hysiologic demands. &y#otension is not a reliable early sign of hy#ovolemia. 1n healthy #atients blood volume must decrease by .$ to 4$ #ercent before hy#otension occurs ;Table A+1=. Dounger #atients with good sym#athetic tone can maintain systemic blood #ressure with severe intravascular deficits until they are on the verge of cardiac arrest. 1n contrast, #regnancy increases circulating blood volume, and a relatively larger volume of blood loss must occur before signs and sym#toms become a##arent. "cute changes in mental status can be caused by hy#oxia, hy#ercarbia, or hy#ovolemia, or they may be an early sign of increasing intracranial #ressure ;18:=. "n abnormal mental status should #rom#t an immediate reevaluation of the "?8s and consideration of an evolving central nervous system injury. " deterioration in mental status may be subtle and may not #rogress in a #redictable fashion! for exam#le, a #reviously calm and coo#erative #atient may become anxious and combative as hy#oxia develo#s, or a #atient who is agitated and combative from drugs or alcohol may become somnolent if hy#ovolemic shoc@ develo#s. Urine out#ut is a >uantitative and relatively reliable indicator of organ #erfusion. "de>uate urine out#ut is $.% m3B@gBh in an adult, 1 m3B@gBh in a child, and - m3B@gBh in an infant less than 1 year of age. 6n the basis of the initial res#onse to fluid resuscitation, hy#ovolemic injured #atients may be #laced into three broad categories res#onders, transient res#onders, and nonres#onders. 1ndividuals who are stable or have a good res#onse to the initial fluid thera#y as evidenced by normali/ation of vital signs, mental status, and urine out#ut are unli@ely to have significant continuing hemorrhage, and further diagnostic evaluation for occult injuries can #roceed. "t the other end of the s#ectrum are nonres#onders with #ersistent hy#otension. This grou# re>uires immediate diagnosis and treatment to #revent a fatal outcome. :atients who res#ond transiently and then deteriorate #resent the most com#lex decision+ma@ing challenge. They usually are underresuscitated or have ongoing hemorrhage. 1n #atients with #enetrating trauma, the need for o#erative intervention for the control of hemorrhage usually is evident. ?lunt trauma #atients with multisystem injury, however, re>uire careful #lanning. 1t is in this grou# that the greatest number of #reventable deaths is li@ely to occur. :ersistent &y#otension 2onres#onders

The s#ectrum of disease in this category ranges from nonsurvivable multisystem injury to #roblems as sim#le as a tension #neumothorax. :ersistent hy#otension in these #atients usually is cardiogenic or a result of uncontrolled hemorrhage. "n evaluation of the #atient's nec@ veins and central venous #ressure ;85:= usually distinguishes between these two categories. 85: determines right ventricular #reload! in otherwise healthy trauma #atients, its measurement yields objective information regarding the #atient's overall volume status. 8entral venous catheters are ina##ro#riate for administering large volumes of fluid, but they are valuable for measuring 85:. " hy#otensive #atient with flat nec@ veins and a 85: less than % cm&-6 is hy#ovolemic and is li@ely to have ongoing hemorrhage. " hy#otensive #atient with distended nec@ veins or a 85: more than 1% cm&-6 is li@ely to be in cardiogenic shoc@. The 85: may be falsely elevated if the #atient is agitated and straining or fluid administration is over/ealous! isolated readings must be inter#reted with caution. 1n trauma #atients the differential diagnosis of cardiogenic shoc@ is indicated by ;1= tension #neumothorax, ;-= #ericardial tam#onade, ;.= myocardial contusion or infarction, and ;4= air embolism. Tension #neumothorax is the most fre>uent cause of cardiac failure. Traumatic #ericardial tam#onade is most often associated with #enetrating injury to the heart. "s blood lea@s out of the injured heart, it accumulates in the #ericardial sac. ?ecause the #ericardium is not acutely distendible, the #ressure in the #ericardial sac rises to match that of the injured chamber. This #ressure usually is greater than that of the right atrium! right atrial filling is im#aired, and right ventricular #reload is reduced. This leads to decreased right ventricular out#ut and increased 85:. 1ncreased intra#ericardial #ressure also im#edes myocardial blood flow, which leads to subendocardial ischemia and a further reduction in cardiac out#ut. This cycle may #rogress insidiously with injury of the venae cavae or atria, or #reci#itously with injury of either ventricle. Cith acute tam#onade, as little as 1$$ m3 of blood within the #ericardial sac can #roduce life+threatening hemodynamic com#romise. The usual #resentation is a #atient with a #enetrating injury in #roximity to the heart who is hy#otensive and has distended nec@ veins or an elevated 85:. The classic findings of ?ec@'s triad ;hy#otension, distended nec@ veins, and muffled heart sounds= and #ulsus #aradoxus are not reliable indicators of acute tam#onade. Ultrasound imaging in the emergency room using a subxi#hoid or #arasternal view is extremely hel#ful if the findings are clearly #ositive ;(ig. A+%=, but e>uivocal findings are common. 4arly in the course of tam#onade, blood #ressure and cardiac out#ut transiently im#rove with fluid administration, which may lead the surgeon to >uestion the diagnosisEor lull the surgeon into a false sense of security. 6nce the diagnosis of cardiac tam#onade is established, #ericardiocentesis should be #erformed ;(ig. A+A=. 4vacuation of as little as 1% to -% m3 of blood can dramatically im#rove the #atient's hemodynamic #rofile. :ericardiocentesis should be done even if the #atient stabili/es with volume loading because subclinical myocardial ischemia can lead to sudden lethal arrhythmias, and #atients with tam#onade can decom#ensate un#redictably. Chile #ericardiocentesis is being #erformed, #re#aration should be made for emergent trans#ort to the o#erating room. 4mergent #ericardiocentesis is successful in decom#ressing the tam#onade in a##roximately *$ #ercent of cases! most failures are a result of clotted blood within the #ericardium. 1f #ericardiocentesis is unsuccessful and the #atient remains severely hy#otensive ;systolic blood #ressure F,$ mm&g= or shows other signs of hemodynamic instability, emergency room

thoracotomy should be #erformed ;(ig. A+,=. This is best accom#lished using a left anterolateral thoracotomy and a longitudinal #ericardiotomy anterior to the #hrenic nerve, followed by evacuation of the #ericardial sac and tem#orary control of the cardiac injury. The #atient is then trans#orted to the o#erating room for definitive re#air ;(ig. A+*=. Myocardial contusion from direct myocardial im#act occurs in a##roximately one+ third of #atients sustaining significant blunt chest trauma. The diagnostic criteria for myocardial contusion include s#ecific electrocardiogram abnormalities, i.e., ventricular dysrhythmias, atrial fibrillation, sinus bradycardia, and bundle branch bloc@. Transient sinus tachycardia is not indicative of contusion. Serial cardiac en/yme determinations ;8:G+<? fraction= lac@ sensitivity and are not #redictive of com#lications under these conditions, and they are not recommended. Chile the diagnosis is common, acute life+threatening com#lications of ventricular arrhythmias and cardiac #um# failure occur in less than % #ercent and less than 1 #ercent, res#ectively, of #atients sustaining major blunt chest trauma. "rrhythmias are treated by #harmacologic su##ression. The management of cardiogenic shoc@ from cardiac #um# failure includes early #lacement of a Swan+Han/ #ulmonary artery catheter to o#timi/e fluid administration, inotro#ic su##ort, and urgent echocardiogra#hy to rule out se#tal or free wall ru#ture, valvular disru#tion, or #ericardial tam#onade. :atients with refractory cardiogenic shoc@ might re>uire #lacement of an intraaortic balloon #um# to decrease myocardial wor@ and enhance coronary #erfusion. "cute myocardial infarction is itself fre>uently the cause of motor vehicle accidents or other trauma in older #atients. Chile the ideal initial management is to #rovide o#timal treatment for the evolving infarction, decisions regarding lytic thera#y and emergent angio#lasty must be individuali/ed according to the #atient's other injuries. "ir embolism is a fre>uently overloo@ed lethal com#lication of #ulmonary injury. 1t occurs when air from an injured bronchus enters an adjacent injured #ulmonary vein and returns to the left heart. "ir accumulation in the left ventricle im#edes diastolic filling, and during systole it is #um#ed into the coronary arteries, disru#ting coronary #erfusion. The ty#ical scenario is a #atient with a #enetrating chest injury who a##ears hemodynamically stable but suddenly goes into cardiac arrest after being intubated and #laced on #ositive+#ressure ventilation. "ir emboli also have been described in conjunction with blunt thoracic trauma and can occur at any time when a #ulmonary venous injury is being mani#ulated. The #atient should be #laced in the Trendelenburg #osition to tra# the air in the a#ex of the left ventricle. 4mergency thoracotomy is followed by cross+clam#ing the #ulmonary hilum on the side of the injury to #revent further introduction of air. "ir is as#irated from the a#ex of the left ventricle with an 1*+gauge needle and %$+m3 syringe. 5igorous o#en cardiac massage is used to force the air bubbles through the coronary arteries. The highest #oint of the aortic root also is as#irated to #revent air from entering the coronary arteries or emboli/ing to the brain. The #atient should be @e#t in the Trendelenburg #osition and the hilum clam#ed until the #ulmonary venous injury is controlled. " state of #ersistent hy#otension and flat nec@ veins resulting from uncontrolled hemorrhage is associated with a high mortality. " ra#id search for the source or sources of hemorrhage, including visual ins#ection with @nowledge of the injury mechanism, abdominal ultrasound imaging, antero#osterior chest and #elvic x+rays,

usually indicates the regions of the body res#onsible for the blood loss. Ty#e 6 red blood cells ;6+negative for women of childbearing age= or ty#e+s#ecific red blood cells should be administered and the #atient ta@en directly to the o#erating room for ex#loration. (or #atients with a sustained systolic blood #ressure of less than ,$ mm&g, in s#ite of crystalloid and blood administration, emergency room thoracotomy should be considered. The clearest indication for this #rocedure is #enetrating chest trauma, and survival is re#orted as high as .$ #ercent. " small number of #atients with #enetrating abdominal trauma survive, but the role of emergency room thoracotomy in blunt abdominal trauma is controversial. The goal of emergency room thoracotomy for thoracic injuries is control of hemorrhage! for abdominal injuries the goal is to sustain central circulation and limit abdominal blood loss by clam#ing the descending thoracic aorta. 4very effort should be made to re#lace the aortic clam# to below the renal arteries within .$ min. 3onger clam#ing times #roximal to the abdominal viscera are seldom associated with survival. The decision to #erform an emergency room thoracotomy can be assisted by use of the algorithm in (ig. A+). Transient Responders &y#otensive #atients who transiently res#ond to fluid administration usually have some degree of active hemorrhage. Those with #enetrating injuries should be ta@en to the o#erating room for ex#loration. Those with multi#le blunt injuries constitute a diagnostic and thera#eutic dilemma. These #atients often re>uire so#histicated evaluation such as com#uted tomogra#hy ;8T= and angiogra#hy. 1t is during these diagnostic evaluations and the necessary trans#ortation that the greatest ha/ard exists, because monitoring is com#romised and the environment is subo#timal for dealing with acute #roblems. The surgeon must accom#any the #atient and be #re#ared to abort the examination if hy#otension recurs. 1f it does, the #atient should be given ty#e+s#ecific red blood cells and trans#orted immediately to the o#erating room to locali/e the hemorrhage. "n o#erating room should be immediately available when these #atients arrive in the emergency room. The traditional volume resuscitation ;described above= of #atients sustaining #enetrating torso trauma has been >uestioned. 1t has been assumed that any hy#otension is dangerous and must be treated, #referably with blood or crystalloid, but some have argued that hemostatic mechanisms fre>uently control hemorrhage initially, and increased venous and subse>uent arterial #ressure from fluid resuscitation can disru#t tenuous hemostasis. (urthermore, active bleeding increases as venous and arterial #ressure increases. 3aboratory studies su##ort these conce#ts. 1n a #ros#ective randomi/ed study of hy#otensive #atients who sustained #enetrating torso trauma and re>uired o#erative treatment, half the #atients received volume resuscitation and fluid was withheld in the others until the o#eration was begun, but there was no survival advantage for those resuscitated in the traditional fashion. Subgrou# analysis suggested a survival disadvantage for #ericardial tam#onade. :atients with #rofound hy#otension ;systolic blood #ressure F,$ mm&g= are at ris@ for sudden death. 8ontrolled hy#otension is the o#timal middle ground. Secondary Survey Chen the conditions that constitute an immediate threat to life have been attended to or excluded, the #atient is examined in a systematic fashion to identify occult injuries. S#ecial attention should be given to the #atient's bac@, axillae, and #erineum because injuries in these areas are easily overloo@ed. :atients should undergo digital rectal

examination to evaluate s#hincter tone and to loo@ for blood, #erforation, or a high+ riding #rostate. " (oley catheter should be inserted to decom#ress the bladder, obtain a urine s#ecimen, and monitor urine out#ut. Stable #atients at ris@ for urethral injury should undergo urethrogra#hy before catheteri/ation. Signs of urethral injury include blood at the meatus, #erineal or scrotal hematomas, or a high+riding #rostate. 1n the case of #ersistent hy#ovolemic shoc@, an initial attem#t at a (oley catheteri/ation should be made! if this is unsuccessful, a #ercutaneous su#ra#ubic cystostomy should be #laced. " nasogastric tube should be inserted to decrease the ris@ of gastric as#iration and allow ins#ection of the contents for blood suggestive of occult gastroduodenal injury. Selective radiogra#hs are obtained early in the emergency room evaluation. (or #atients with severe blunt trauma, antero#osterior chest and #elvic radiogra#hs should be obtained as soon as #ossible. (or #atients with truncal gunshot wounds, #osteroanterior and lateral radiogra#hs of the chest and abdomen are warranted. 1t is hel#ful to mar@ the entrance and exit sites of #enetrating wounds with metallic cli#s or sta#les so that the trajectory of the missile or blade can be estimated. <any trauma #atients cannot #rovide s#ecific information about the nature of their injury mechanism. 4mergency medical #ersonnel and #olice are trained to evaluate an injury scene and should be >uestioned. (or automobile accidents the s#eed of the accident, the angle of im#act ;if any=, the use of restraints, airbag de#loyment, condition of the steering wheel and windshield, the amount of intrusion, whether the #atient was ejected from the vehicle, and whether anyone was dead at the scene should all be ascertained. The #atient's #hysiologic condition in the field also is im#ortant. 5ital signs and mental status in the emergency room can be com#ared with those at the scene! im#rovement or deterioration #rovide critical #rognostic information. Mechanisms and Patterns of Injury 4valuation and decision ma@ing are far more difficult in blunt trauma than in #enetrating trauma. <ore energy is transferred over a wider area during blunt trauma than from a gunshot wound or a stab wound. "s a result, blunt trauma is associated with multi#le, widely distributed injuries, whereas in #enetrating injuries the damage is locali/ed to the #ath of the bullet or @nife in #enetrating wounds. :atients who have sustained blunt trauma are se#arated into categories according to their ris@ for multi#le injuries, high energy transfer and low energy transfer. 1njuries involving high energy transfer include auto+#edestrian accidents, motor vehicle accidents in which the car's change of s#eed exceeds -$ m#h or in which the #atient has been ejected, motorcycle accidents, and falls from heights greater than -$ feet. The greatest ris@ factors reflecting magnitude of injury from the field associated with life+threatening injures are death of another occu#ant in the vehicle and an extrication time greater than -$ min. :atients who have sustained high+energy+transfer trauma have certain #atterns of injury related to the mechanism, e.g., when unrestrained drivers suffer frontal im#acts, their heads stri@e the windshield, their chests and u##er abdomens hit the steering column, and their legs or @nees contact the dashboard. The resultant injuries fre>uently include facial fractures, cervical s#ine fractures, laceration of the thoracic aorta, myocardial contusion, injury to the s#leen and liver, and fractures of the #elvis

and lower extremities. The discovery of one of these injuries should #rom#t a search for others. 3ow+energy trauma, such as being struc@ with a club or falling from a bicycle, usually does not result in widely distributed injuries, but #otentially lethal lacerations of internal organs can still occur because the net energy transfer to that location may be substantial. Penetrating injuries are classified according to the wounding agent, i.e., stab wounds, gunshot wounds, or shotgun wounds. Hunshot wounds are subdivided further into high+ and low+velocity injuries because the s#eed of the bullet is much more im#ortant than its weight in determining @inetic energy. 4x#erience in urban trauma centers indicates that high+velocity gunshot wounds ;bullet s#eed greater than -$$$ ftBs= are rare in the civilian setting. Shotgun injuries are divided into close+range ;F , meters= and long+range wounds. 8lose+range shotgun wounds are com#arable to high+ velocity wounds because the entire energy of the load is delivered to a small area, often with devastating results. 3ong+range shotgun wounds result in a diffuse #ellet #attern in which many #ellets miss the victim, and those that do stri@e are dis#ersed and of com#aratively low energy. 7egional "ssessment and S#ecial 'iagnostic Tests "dditional diagnostic studies are often indicated on the basis of mechanism of injury, location of injuries, screening x+rays, and the #atient's overall condition. The #atient is in constant jeo#ardy when undergoing s#ecial diagnostic testing. The surgeon should be in attendance and be #re#ared to alter #lans as circumstances demand. &emodynamic, res#iratory, and mental statuses determine the most a##ro#riate course of action. &ead " score based on the Hlasgow 8oma Scale ;H8S= should be determined for all injured #atients ;Table A+-=. 1t is calculated by adding the scores of the best motor res#onse, best verbal res#onse, and eye o#ening. Scores range from . ;the lowest= to 1% ;normal=. Scores of 1. to 1% indicate mild head injury, ) to 1-, moderate injury, and less than ), a severe injury. The HS8 is useful for triage and #rognosis. 4xamination of the head should focus on #otentially treatable neurologic injuries. The #resence of laterali/ing findings are im#ortant, e.g., a unilateral dilated #u#il unreactive to light, asymmetric movement of the extremities either s#ontaneously or in res#onse to noxious stimuli, or a unilateral ?abins@i's reflex suggest a treatable intracranial mass lesion or major structural damage. Stro@e syndromes should #rom#t a search for carotid dissection or thrombosis using du#lex scanning or angiogra#hy. 6torrhea, rhinorrhea, Iraccoon eyes,J and ?attle's sign ;ecchymosis behind the ear= can be seen with basilar s@ull fractures. Chile not necessarily re>uiring treatment, these fractures carry an increased ris@ of meningitis in the #ostinjury #eriod. The head and face should be systematically #al#ated for fractures. :atients with a significant closed head injury ;H8S less than 14= should have a 8T scan #erformed. (or #enetrating injuries #lain s@ull films should be obtained as well, as they can #rovide information that 8T does not.

8erebral #athologic lesions from blunt trauma include hematomas, contusions, hemorrhage into ventricular and subarachnoid s#aces, and diffuse axonal injury ;'"1=. &ematomas are further classified according to location. 4#idural hematomas occur when blood accumulates between the s@ull and the dura and are caused by disru#tion of the middle meningeal artery or other small arteries in that #otential s#ace from a s@ull fracture ;(ig. A+1$=. Subdural hematomas occur between the dura and the cerebral cortex and are caused by venous disru#tion or laceration of the #arenchyma of the brain ;(ig. A+11=. ?ecause of the underlying brain injury, #rognosis is much worse with subdural hematomas. 1ntra#arenchymal hematomas and contusions can occur anywhere within the brain. &emorrhage may occur into the ventricles, and though usually not massive, this blood may cause #ostinjury hydroce#halus. 'iffuse hemorrhage into the subarachnoid s#ace may cause vasos#asm and reduce cerebral blood flow. '"1 results from high+ s#eed deceleration injury and re#resents direct axonal damage. 6n 8T a blurring of the grayBwhite matter interface may be seen, with multi#le, small, #unctate hemorrhages. Chile #rognosis is difficult to #redict, early evidence of '"1 on 8T scan is associated with a #oor outcome. <agnetic resonance imaging ;<71= can often identify '"1 with greater #recision than 8T. Significant #enetrating injuries usually are #roduced by bullets from handguns, but an array of other wea#ons or instruments can injure the cerebrum via the orbit or through the thinner tem#oral region of the s@ull. Chile the diagnosis usually is obvious, in some instances wounds in the auditory canal, mouth, and nose can be elusive. :rognosis is variable, but most su#ratentorial wounds that injure both hemis#heres are fatal. 2ec@ 1n evaluating the nec@ of a blunt trauma victim, attention should be focused on signs and sym#toms of an occult cervical s#ine injury. ?ecause of the devastating conse>uences of >uadri#legia, all #atients should be assumed to have cervical s#ine injuries until #roven otherwise. The #resence of #osterior midline #ain or tenderness should #rovo@e a thorough radiologic evaluation. There is no #erfect test to detect all injuries. " cervical s#ine series including lateral view with visuali/ation of 8,KT1, antero#osterior view, and transoral odontoid view is sufficient to detect most significant fractures and subluxations. 1f #ain or tenderness #ersists in s#ite of normal a##earance on #lain x+ray films, a 8T scan should be done. 8T identifies most fractures but can miss some subluxations. " combination of #lain film and 8T imaging can identify virtually all injuries. "n exce#tion to this is a #urely ligamentous injury. These rare and dangerous injuries may not be visible with standard imaging techni>ues. (lexion and extension views can be #erformed and may reveal o#ening of the intervertebral s#ace. This should only be done in the #resence of an ex#erienced surgeon #atients with injuries have become #ermanently >uadri#legic when flexed and extended by inex#erienced individuals ;(ig. A+1-=. " safer method may be to instruct the #atient to carefully move his or her head without assistance from the surgeon! #atients will not #ith themselves. S#inal cord injuries can be com#lete or #artial. 8om#lete injuries cause #ermanent >uadri#legia or #ara#legia, de#ending on the level of the injury. These #atients have a com#lete loss of motor function and sensation two or more levels below the bony injury. :atients with high s#inal cord disru#tion are at ris@ for s#inal shoc@ from

#hysiologic disru#tion of sym#athetic fibers. Significant neurologic recovery is rare. There are several #artial or incom#lete s#inal cord injury syndromes. 8entral cord syndrome usually occurs in older #ersons who suffer hy#erextension injuries. <otor function, #ain, and tem#erature sensation are #reserved in the lower extremities but diminished in the u##er extremities. Some functional recovery usually occurs, but it is seldom a return to normal. "nterior cord syndrome is characteri/ed by diminished motor function and #ain and tem#erature sensation below the level of the injury. :osition, vibratory, and crude touch sensation are maintained. :rognosis for recovery is #oor. ?rown+SL>uard's syndrome usually is the result of a #enetrating injury in which the right or left half of the s#inal cord is transected. This rare lesion is characteri/ed by the i#silateral loss of motor function, #ro#rioce#tion, and vibratory sensation! #ain and tem#erature sensation are lost on the contralateral side. :enetrating injuries of the anterior nec@ that violate the #latysma are considered significant because of the density of critical structures in this region. <andatory ex#loration may be a##ro#riate in some circumstances, but #atients are now managed selectively in most centers ;(ig. A+1.=. Selective management is based on the nec@'s division into three /ones ;(ig. A+14=. Mone 1 is between the clavicles and the cricoid cartilage, and is also referred to as the thoracic outlet. Mone 11 is between the cricoid cartilage and the angle of the mandible, and Mone 111 is above the angle of mandible. The evaluation and management of visceral and vascular injuries in Mone 1 ;the thoracic outlet= are com#licated by the overlying ribs, sternum, and clavicles. ?ecause the o#erative incision to be made may de#end on the injured structures, a #recise #reo#erative diagnosis is desirable. :atients with Mone 1 injuries should undergo angiogra#hy of the great vessels, soluble+contrast eso#hagram followed by barium eso#hagram, eso#hagosco#y, and bronchosco#y. &emodynamically unstable #atients should not undergo this extensive evaluation but should be ta@en directly to the o#erating room. :atients with Mone 11 injuries are the easiest to evaluate. Unstable #atients or those with evidence of airway com#romise, an ex#anding hematoma, or significant external hemorrhage ;including hemorrhage into the mouth= should be ex#lored #rom#tly. Stable #atients without these findings can be evaluated selectively. :enetrating nec@ wounds in stable #atients should be locally ex#lored to determine the de#th of #enetration. Counds that do not #enetrate the #latysma are insignificant and should be closed! these #atients can be discharged. The vast majority of the remaining Mone 11 #enetrating wounds are observed for 1- h. :atients with right+to+left transcervical gunshot wounds may re>uire diagnostic studies. 8arotid and vertebral angiogra#hy, direct laryngosco#y, tracheosco#y, eso#hagosco#y, and eso#hagram might be necessary, de#ending on the bullet's trajectory. :atients with Mone 111 #enetrating injuries re>uire carotid and vertebral angiogra#hy if there is evidence of arterial bleeding. This is im#ortant for three reasons ;1= ex#osure of the distal internal carotid and vertebral arteries is difficult! ;-= the internal carotid artery may have to be ligated, a maneuver associated with a high ris@ of stro@e! and ;.= active hemorrhage from the external carotid and vertebral arteries can be controlled by selective emboli/ation. "ssociated injuries of the #harynx are inconse>uential and re>uire no s#ecial evaluation. 8hest

?lunt trauma to the chest may involve the chest wall, thoracic s#ine, heart, lungs, thoracic aorta and great vessels, and the eso#hagus. <ost of these injuries are assessable by #hysical examination and chest x+ray. :atients with large air lea@s after tube thoracostomy and those who are difficult to ventilate should undergo fibero#tic bronchosco#y to search for bronchial tears or foreign bodies. The most threatening occult injury in trauma surgery is a tear of the descending thoracic aorta. Cidening of the mediastinum on antero#osterior chest x+ray strongly suggests this injury. The widening is caused by the formation of a hematoma around the injured aorta that is tem#orarily contained by the mediastinal #leura. :osterior rib fractures and laceration of small vessels also can #roduce similar hematomas. Should the hematoma ru#ture into the chest with an aortic injury, the #atient exsanguinates in seconds. 6ther findings suggestive of an aortic tear are noted in Table A+.. This injury may be #resent with an entirely normal chest x+ray, although the incidence is a##roximately - #ercent. ?ecause of the dire conse>uences of missing the diagnosis, 8T and angiogra#hy are fre>uently #erformed after certain ty#es of injury. "ortic tears occur when shearing forces are created in the chest. This is most often seen in high+ energy+transfer deceleration motor vehicle accidents with frontal or lateral im#act. 1t may occur after an ejection injury or fall. The tear usually occurs just distal to the left subclavian artery, where the aorta is tethered by the ligamentum arteriosum ;(ig. A+1%=. 1n - to % #ercent of cases the tear occurs in the ascending aorta, in the transverse arch, or at the dia#hragm. 'ynamic, s#iral 8T is an excellent screening test. :ositive findings are a hematoma around the aorta or injury of the aorta. This test is highly sensitive, but its s#ecificity is un@nown. " clearly widened mediastinum on chest x+ray or abnormalities on 8T are an absolute indication for emergent aortogra#hy. :enetrating thoracic trauma is considerably easier to evaluate. :hysical examination, #lain #osteroanterior and lateral chest x+rays with metallic mar@ings of entrance and exit wounds, and 85: measurement disclose the vast majority of injuries. 1njuries of the eso#hagus and trachea are exce#tions. 'e#ending on the estimated trajectory of the missile or blade, bronchosco#y should be #erformed to evaluate the trachea. 4so#hagosco#y can be #erformed to evaluate the eso#hagus, but injuries have been missed with the use of this techni>ue alone. :atients at ris@ also should undergo a soluble contrast eso#hagram. 1f no extravasation of contrast medium is seen, a barium eso#hagram should be #erformed for greater detail. (ailure to identify extant eso#hageal injuries leads to fulminant mediastinitis that is often fatal. "s in the nec@, right+to+left transmediastinal gunshot wounds fre>uently cause visceral or vascular injuries. Stable #atients should be carefully evaluated for tracheal and eso#hageal injuries. "ngiogra#hy occasionally is indicated. "bdomen Cith few exce#tions, it is not necessary to determine which intraabdominal organs are injured, only whether an ex#loratory la#arotomy is necessary. :hysical examination of the abdomen is unreliable in ma@ing this determination, but most authorities agree that the #resence of abdominal rigidity or gross abdominal distention in a #atient with truncal trauma is an indication for #rom#t surgical ex#loration. (or the majority of #atients suffering blunt abdominal trauma, however, it is not clear whether ex#loration is needed. Serial examinations by the same surgeon can detect early #eritoneal inflammation and the need for la#arotomy before serious infections and

hemorrhagic com#lications occur. 'rugs, alcohol, or injuries of the head or s#inal cord com#licate #hysical examination. 3a#arotomy also may be im#ractical in #atients who re>uire general anesthesia for the treatment of other injuries. These #atients re>uire additional diagnostic testing. The diagnostic a##roaches to #enetrating and to blunt abdominal trauma differ substantially. 3ittle #reo#erative evaluation is re>uired for firearm injuries in which the #eritoneal cavity is #enetrated because the chance of internal injury is over )$ #ercent and la#arotomy is mandatory. "nterior truncal gunshot wounds between the fourth intercostal s#ace and the #ubic sym#hysis whose trajectory as determined by x+ ray or entranceBexit wound suggests #eritoneal #enetration should be o#erated on. Hunshot wounds to the bac@ or flan@ are more difficult to evaluate because of the greater thic@ness of tissue between the s@in and the abdominal organs. 1f in doubt, it is always safer to ex#lore the abdomen than to e>uivocate when the de#th of #enetration is uncertain. 1n contrast to gunshot wounds, stab wounds that #enetrate the #eritoneal cavity are less li@ely to injure intraabdominal organs. "nterior and lateral stab wounds to the trun@ should be ex#lored under local anesthesia in the emergency room to determine whether the #eritoneum has been violated. 1njuries that do not #enetrate the #eritoneal cavity do not re>uire further evaluation. Stab wounds to the flan@ and bac@ are more difficult to evaluate. Some authorities have recommended a tri#le contrast 8T scan to detect occult retro#eritoneal injuries of the colon, duodenum, and urinary tract. ?ecause 8T does not always identify enteric injuries, the authors have used soluble contrast radiogra#hs of the colon and duodenum followed by barium if necessary. The larger final images may im#rove sensitivity. 'iagnostic #eritoneal lavage ;':3= remains the most sensitive test available for determining the #resence of intraabdominal injury ;(ig. A+ 1A=. (or stab wounds to the abdomen, its sensitivity for detecting intraabdominal injury exceeds )% #ercent. The results of ':3 are considered to be grossly #ositive if more than 1$ m3 of free blood can be as#irated after insertion of the catheter. 1f less than 1$ m3 is withdrawn, 1 3 of normal saline solution is instilled and the #atient is gently roc@ed from side to side and u# and down. The effluent is withdrawn and sent to the laboratory for red blood cell count and determination of amylase and al@aline #hos#hatase levels. " red blood cell count greater than 1$$,$$$Bmm. is considered #ositive. The detection of bile, vegetable or fecal material, or the observation of effluent draining through a chest tube, a nasogastric tube, or a (oley catheter also constitutes a #ositive result. 1n e>uivocal cases, measurement of amylase and al@aline #hos#hatase levels can be hel#ful in identifying #erforation of hollow viscera. The white blood cell count of the lavage effluent is not considered a valid indicator of intra#eritoneal injury. Stab wounds to the lower chest #resent a diagnostic o##ortunity. "fter the administration of ade>uate local anesthesia and extension of the wound as necessary, a finger is #laced into the thoracic cavity to #al#ate the dia#hragm. 8onfirmation of dia#hragm #enetration is an indication for la#arotomy. Chen a hole is not #al#able but ris@ of a dia#hragmatic injury exists, a ':3 should be #erformed. " red cell count in the effluent of more than 1$,$$$Bmm. is considered #ositive when evaluating for a dia#hragmatic injury. (or red cell counts between 1,$$$ and 1$,$$$Bmm., thoracosco#y should be considered.

?lunt abdominal trauma is evaluated by ultrasound imaging in most major trauma centers and, in selected cases, with 8T scanning to refine the diagnosis. Ultrasonogra#hy #erformed by a surgeon or an emergency #hysician in the emergency room has largely re#laced ':3. 4valuation of the entire abdomen is not the goal, but ultrasound is used in s#ecific anatomic regions ;e.g., <orison's #ouch, the left u##er >uadrant, the #elvis= to identify free intra#eritoneal fluid ;(ig. A+1,=. This method is ex>uisitely sensitive for detecting intra#eritoneal fluid collections larger than -%$ m3, but it is relatively #oor for staging solid organ injuries. ':3 is a##ro#riate for #atients whose condition cannot be ex#lained with ultrasound imaging. The use of 8T scanning for the diagnosis of blunt abdominal trauma gained considerable #o#ularity in the early 1)*$s. 1t was re#orted that injuries of the liver, s#leen, and @idneys could be diagnosed with great #recision using this method. <uch of the initial enthusiasm has been tem#ered by the recognition of several limitations ;1= the need for high+>uality radiogra#hs, ;-= the need for radiologists s@illed in the inter#retation of #ostinjury 8T images, ;.= the need for #ro#er #atient #re#aration, ;4= #oor sensitivity for intestinal injuries and acute #ancreatic injuries, and ;%= relatively #oor correlation between s#lenic and he#atic 8T images and the subse>uent ris@ of bleeding re>uiring an o#eration. 'es#ite these limitations, 8T is an im#ortant diagnostic tool because of its s#ecificity for he#atic, s#lenic, and renal injuries ;(ig. A+ 1*=. 8T is indicated #rimarily for hemodynamically stable #atients who are candidates for nono#erative thera#y. 8T also is indicated for hemodynamically stable #atients who have unreliable #hysical examinations or other conditions ;i.e., intracranial injury= re>uiring 8T evaluation. The algorithm the authors use to evaluate blunt abdominal trauma is outlined in (ig. A+1). ?ecause of the excellent view #rovided of the liver and anterior dia#hragm, la#arosco#y seems to be an ideal diagnostic tool for stable #atients who have #ossible anterior u##er abdominal injuries. 6ne theoretic concern is carbon dioxide gas embolism through injuries of the he#atic veins, but this #otential com#lication can be eliminated with gasless la#arosco#y. The role of la#arosco#y remains to be clarified, but it may ex#and with the availability of a smaller la#arosco#e that can be inserted under local anesthesia. :elvis ?lunt injury to the #elvis fre>uently #roduces com#lex fractures ;(ig. A+ -$=. :lain x+ rays reveal gross abnormalities, but 8T scanning may be necessary to assess the #elvis for stability. Shar# s#icules of bone can lacerate the rectum or vagina. The finding of gross blood on digital examination strongly suggests injury to these organs. :roctosco#y or s#eculum examination may reveal the injury. 1n >uestionable cases, soluble+contrast x+rays are diagnostic. The bladder can be lacerated by shar# fracture fragments, or, if the bladder is full, a direct blow to the hy#ogastrium can generate sufficient intravesicular #ressure to cause ru#ture. Hross blood on urinalysis may not always occur, and a cystogram should be #erformed if more than a few red cells #er high+#ower field are seen on urinalysis. Urethral injuries are sus#ected by the findings of blood at the meatus, scrotal or #erineal hematomas, and a high+riding #rostate on rectal examination. Urethrograms should be done in stable #atients before #lacing the (oley catheter to avoid false #assage and subse>uent stricture.

<ajor vascular injuries are uncommon in blunt #elvic trauma! however, thrombosis or disru#tion of the arteries or veins in the iliofemoral system may occur. "ngiogra#hy is indicated if thrombosis of the arterial system is sus#ected. 4valuation of #enetrating injuries of the #elvis is similar to that for blunt injuries in stable #atients. 5isceral and vascular injuries are much more common, and la#arotomy is often re>uired. 3ife+ threatening hemorrhage can be associated with #elvic fractures. The source may be the lower lumbar arteries and veins or branches of the internal iliac arteries and veins. These injuries are fre>uently not amenable to surgical re#air and usually occur with disru#tion of the #osterior elements of the #elvis. 4xtremities 1njury of the extremities from any cause re>uires #lain x+ray films to evaluate fractures. 3igamentous injuries, #articularly those of the @nee and shoulder when related to s#orts activities, can be imaged with <71. The assessment of vascular injuries is somewhat controversial. 5ascular diagnosis usually is limited to the arterial system unless there is uncontrolled external venous hemorrhage or venous injuries are uncovered during o#erative ex#loration. 1t is uncommon to see a #atient with a venous com#lication related to trauma that was not identified and treated while an arterial injury was being evaluated. :hysical examination serves to identify and locali/e arterial injuries in many instances. :hysical findings are classified as hard signs or soft signs ;Table A+4=. &ard signs constitute indications for o#erative ex#loration, whereas soft signs are indications for observation or additional testing. "rteriogra#hy may be hel#ful in locali/ing the injury in some #atients with #enetrating injuries and hard signs. (or exam#le, a bullet that enters the lateral hi# and exits below the @nee medially, when there is also a femoral shaft fracture and no #o#liteal #ulse, could have injured the femoral or #o#liteal artery anywhere. "rteriogra#hy would be useful to locali/e the injury and limit the dissection. The controversy in vascular trauma is in the management of #atients with soft signs of injury, #articularly injuries that are in #roximity to major vessels. 1t is @nown that some of these #atients will be found to have arterial injuries that re>uire re#air. 6ne a##roach has been to measure systolic blood #ressures using 'o##ler ultrasonogra#hy and com#are the injured side to the uninjured side. 1f the #ressures are within 1$ #ercent of each other, a significant injury is excluded and no further evaluation is #erformed. 1f the difference is greater than 1$ #ercent, an arteriogram is indicated. Some argue that there are occult injuries, such as #seudoaneurysms or injuries of the #rofunda femoris or #eroneal arteries, which may not be sam#led with this techni>ue. 1f hemorrhage occurs from these injuries, com#artment syndrome and limb loss may occur. Chile trauma centers debate this issue, the surgeon who is treating the injured #atient can #erform angiogra#hy in selected #atients who have soft signs. T74"T<42T Heneral 8onsiderations Seriously injured #atients are more fragile than their age and #hysical condition im#ly. :rocedures that are well tolerated in older #atients, such as he#atic lobectomy for he#atoma, usually are lethal in the multi#ly injured #atient. There has been a remar@able change in o#erative a##roach over the #ast -$ years. (aster techni>ues are used, and shorter serial o#erations have become common. (or exam#le, at the authors'

institution virtually all suture lines are created with a running single layer. There is no evidence that this method is less secure than interru#ted multilayer techni>ues, and it is clearly faster. 'rains, once considered mandatory for many #arenchymal injuries and some anastomoses, have virtually disa##eared. (luid collections that accumulate in a delayed fashion are now effectively managed by interventional radiologists. 1njuries once thought to mandate resection, such as s#lenic injuries, are now managed with suture re#air or even nono#eratively. The treatment of colonic injuries by #rimary re#air is another exam#le. These conce#tual changes have significantly im#roved survival in trauma #atients, and all have been develo#ed through the extensive ex#erience of major urban trauma centers and the forums for the free exchange of ideas #rovided by the "merican 8ollege of Surgeons 8ommittee on Trauma, the "merican "ssociation for the Surgery of Trauma, the 1nternational "ssociation of Trauma and Surgical 1ntensive 8are, the :an+"merican Trauma 8ongress, and other surgical organi/ations. The management of #atients with multi#le injuries re>uires the early establishment of thera#eutic #riorities. Chile the conce#t of life over limb and limb over cosmesis seems obvious, decision ma@ing can be subtle. <any combinations of injuries and #hysiologic states can be antici#ated that have an im#act on decision ma@ing. 1t is the trauma surgeon's res#onsibility to assess the #robable outcomes of different thera#eutic strategies and choose which is in the #atient's best interest. Transfusion ?ecause fresh whole blood, the o#timal re#lacement material for shed blood, is no longer available, whole blood must be recreated from its com#onent #arts #ac@ed red blood cells ;#7?8=, fresh+fro/en #lasma ;((:=, and #latelet #ac@s. 2ot all trauma #atients re>uiring transfusions receive all three com#onents. <ost trauma #atients receive between 1 and % units of #7?8 and no other com#onents, but major trauma centers have the ca#ability of transfusing tremendous >uantities of blood com#onents. 1t is not unusual for 1$$ com#onent units to be transfused during one #rocedure. 7ed cell transfusion rates of -$ to 4$ units of #7?8 #er hour are common in severely injured #atients. Transfusion #ractices in trauma re>uire the surgeon to identify the insidious signs of coagulo#athy, such as excessive bleeding from the cut edges of s@in, fascia, and #eritoneum that were #reviously controlled. Chile the local volume of coagulo#athic hemorrhage in one visual field seems low com#ared to that of a hole in the aorta or venae cavae, blood loss from the entire area of dissection can lead to exsanguination. The usual measurements of coagulation ca#ability, i.e., #rothrombin time ;:T=, #artial thrombo#lastin time ;:TT=, and #latelet count have a turnaround time of more than .$ min in most institutions. These tests are of limited value in #atients who have lost two or three blood volumes while waiting for test results. Under such conditions, transfusion must be em#iric and based on the surgeon's observations. "t the first sign of coagulo#athic hemorrhage, the #reviously lost #lasma #roteins and #latelets must be restored with ((: and #latelet #ac@s. "dditional transfusions should be administered with e>ual ratios of #7?8, ((:, and #latelets. The causal relationshi# of core hy#othermia metabolic, acidosis, and #ostinjury coagulo#athy has been observed in a number of studies. The #atho#hysiology is multifactorial and includes inhibition of tem#erature+ de#endent en/yme+activated

coagulation cascades, #latelet dysfunction, endothelial abnormalities, and a #oorly understood fibrinolytic activity. The role of metabolic acidosis in the #athogenesis of a coagulo#athy is unclear. 4x#eriments have demonstrated im#aired hemostasis at a #& of ,.-$! others have suggested that #& directly affects #latelet function. 6ther series im#licated acidosis in the #ro#agation of disseminated intravascular coagulation with the secondary consum#tion of clotting factors. &y#othermia and metabolic acidosis have adverse effects on myocardial #erformance and tissue #erfusion. :rimary hemostasis relies on #latelet adherence and aggregation to injured endothelium, resulting in the formation of the #latelet #lug. " #latelet count of %$,$$$Bmm. is considered ade>uate for tissue hemostasis if the #latelets are normal. &owever, #latelet dysfunction is a well+documented com#lication of massive transfusion that is aggravated by associated hy#othermia. 8onse>uently, the recommended target of more than 1$$,$$$Bmm. for #latelet transfusion in other high+ ris@ #atients should be extended to the severely injured. ?lood ty#ing and, to a lesser extent, crossmatching is essential to avoid life+ threatening intravascular hemolytic transfusion reactions. " com#lete ty#e and crossmatch re>uires -$ to 4% min to com#lete and reduces the ris@ of an intravascular hemolysis to a##roximately $.$$4 #ercent. 1f -$ units of #7?8 are needed within an hour, an army of technicians would be re>uired to #erform this service. Twenty to 4% min is too long for a #atient with an exsanguinating hemorrhage to wait. Therefore, trauma #atients re>uiring emergency transfusions are given ty#e 6, ty#e+s#ecific, or biologically com#atible red blood cells. "s a cross+chec@ for "?6 com#atibility, a saline crossmatch is often #erformed. The administrative and laboratory time re>uired is a##roximately % min, and the ris@ of intravascular hemolysis is about $.$% #ercent. The ris@ increases to 1.$ #ercent with a history of #revious transfusions or #regnancy, and u# to ..$ #ercent with both. This increased ris@ of transfusion reaction is a result of the #resence of irregular antibodies ;e.g., Gell, 'uffy, Gidd, etc.= in the #atient's #lasma that occur in about 1B1$$$ #atients. 1ntravascular hemolysis can occur with "?6+com#atible #7?8 if the #atient has an irregular antibody. 1t usually is not as severe as "?6 incom#atible hemolytic reactions, and the time re>uired to detect the antibodies biochemically or by crossmatch ma@es the increased ris@ of hemolytic reaction a reasonable trade for ra#id availability. :reformed antibodies are ra#idly de#leted by hemorrhage and are #roduced slowly, diminishing the severity of intravascular hemolysis if it occurs. "n alternative strategy for those #atients who are consistently stable and do not have serious injuries is to #erform a ty#e and screen as a cost+saving measure. 1f blood is subse>uently needed urgently, low+titer, ty#e+s#ecific red cells can be administered with the same ris@ of intravascular hemolysis as with fully ty#ed and crossmatched blood, #rovided the screen for irregular antibodies is negative. Unstable #atients should receive 6+ negative, 6+#ositive, or ty#e+s#ecific red cells, de#ending on the #atient's age and sex and the availability of blood cell ty#es. 6ther com#onents should be ty#e s#ecific or biologically com#atible. :ro#hylaxis "ll injured #atients undergoing an o#eration should receive #reem#tive antibiotic thera#y. The authors use second+generation ce#halos#orins for la#arotomies and first+

generation ce#halos#orins for all other o#erations. "dditional doses should be administered during the #rocedure on the basis of blood loss and the half+life of the antibiotic. The role of #osto#erative antibiotic thera#y in trauma #atients remains to be defined, but the trend has been to reduce the duration. Tetanus #ro#hylaxis is administered to all #atients according to the "merican 8ollege of Surgeons guidelines ;see 8ha#. %=. 'ee# venous thrombosis and other venous com#lications occur more often in injured #atients than is generally believed. This is #articularly true for #atients with major fractures of the #elvis and lower extremities, those with s#inal cord injury or in a coma, and those with injury of the large veins in the abdomen and lower extremities. The authors use #ulsatile com#ression stoc@ings in all injured #atients and selectively #lace inferior vena caval filters for those at very high ris@. The role of inferior vena caval filters may ex#and in the future when removable devices become commercially available. 3ow+molecular+weight he#arins have been demonstrated to be safe and effective in #atients with ortho#aedic injuries. Their use in #atients with other injuries remains to be elucidated. "nother #ro#hylactic measure is thermal #rotection. &emorrhagic shoc@ im#airs #erfusion and metabolic activity throughout the body. Cith declining metabolism, heat #roduction and body tem#erature decrease. The injured #atient receives a second thermal insult with the removal of insulating clothing. "s a result, trauma #atients can become seriously hy#othermic, with tem#eratures as low as .4N8 by the time they reach the o#erating room. &y#othermia im#airs coagulation and myocardial contractility and increases myocardial irritability. 1ntentional hy#othermia has #rotective features for #atients with massive head injuries, but most authorities agree that the deleterious effects outweigh the #otential benefits. 1njured #atients whose intrao#erative core tem#erature dro#s below .-N8 are at ris@ for fatal arrhythmias and defective coagulation. Thermal #ro#hylaxis should begin in the emergency room by maintaining the ambient tem#erature comfortable for an ex#osed #atient. (luids should be stored at body tem#erature and blood #roducts should be administered through ra#id+warming devices. Chen examination is com#leted, the #atient should be @e#t scru#ulously covered with warm blan@ets or other devices until body tem#erature returns to normal. 5ascular 7e#air The initial control of vascular injuries should be accom#lished digitally by a##lying enough #ressure directly on the bleeding site to sto# the hemorrhage. Some bleeding vessels may need to be gently #inched between the thumb and index finger. These maneuvers, along with suction, usually create a dry enough field to safely #ermit the dissection necessary to define the injury. Shar# dissection with fine scissors is #referable to blunt dissection because the latter can aggravate the injury. Chen a sufficient length of vessel is available, a vascular thumb force#s is used to gras# the vessel. 1f the vessel is not transected, force#s can be #laced directly across the injury. This minimi/es or eliminates bleeding while the dissection necessary for clam#ing is com#leted. 1f the vessel is transected ;or nearly so= digital control is maintained on one side while the other is occluded with a thumb force#s. The vessel is then shar#ly mobili/ed to allow an a##ro#riate vascular clam# to be a##lied. Chen definitive control of all injuries is achieved, he#arini/ed saline is injected into the #roximal and distal ends of the injured vessel to #revent thrombosis. The ex#osed intima and media

at the site of the injury are highly thrombogenic, and small clots often form. These clots should be carefully removed to #revent thrombosis or embolism when the clam#s are removed. ?ecause of the fre>uency that embolism occurs, routine balloon catheter ex#loration of the distal vessel has been recommended. 7agged edges of the injury site should be judiciously debrided using shar# dissection. 1njuries of the large veins such as the venae cavae, or the innominate and iliac veins #ose a s#ecial #roblem for hemostasis. 2umerous large tributaries ma@e ade>uate hemostasis difficult to achieve, and their thin walls render them susce#tible to additional iatrogenic injury. Chen a large+ vessel injury is encountered, tam#onade with a folded la#arotomy #ad held directly over the bleeding site usually establishes hemostasis sufficient to #revent exsanguination. 1f hemostasis is not ade>uate to ex#ose the vessel #roximal and distal to the injury, s#onge stic@s can be #laced strategically on either side of the injury and carefully adjusted to im#rove hemostasis. This maneuver re>uires s@ill and disci#line to maintain a dry field. The o#erative field is sometimes sufficient to delineate and re#air the injury. 1t is often difficult for the assistant to maintain com#lete control of hemorrhage with s#onge stic@s. 1n this situation, the vessel can be ex#osed on either side of the s#onge stic@ and a vascular clam# a##lied. The clam# can then be se>uentially advanced toward the injury until hemostasis is com#lete. 6#tions for the treatment of vascular injuries are listed in Table A+%. Some arteries and most veins can be ligated without significant se>uelae. "rteries for which re#air should always be attem#ted include the aorta and the carotid, innominate, brachial, su#erior mesenteric, #ro#er he#atic, renal, iliac, femoral, and #o#liteal arteries. 1n the forearm and lower leg at least one of the two #al#able vessels should be salvaged. The list of veins for which re#air should be attem#ted is short the su#erior vena cava, the inferior vena cava #roximal to the renal veins, and the #ortal vein. There are notable vessels for which re#air is not necessary, e.g., the subclavian artery and the su#erior mesenteric vein. The #ortal vein can be ligated successfully #rovided ade>uate fluid is administered to com#ensate for the dramatic but transient edema that occurs in the bowel. 3igation of some vessels, such as the #o#liteal vein and the left or right branch of the #ortal vein, can result in morbidity for the #atient that is not life threatening. The authors attem#t to re#air all arteries larger than . mm and all veins larger than 1$ mm in diameter, de#ending on the #atient's #hysiologic condition. Some arterial injuries have been treated by observation without subse>uent com#lications. These include small #seudoaneurysms, intimal dissections, small intimal fla#s and arteriovenous fistulas in the extremities, and occlusions of small ;Fmm= arteries. (ollow+u# angiogra#hy is obtained within - to 4 wee@s to ensure that healing has occurred. 3ateral suture is a##ro#riate for small arterial injuries with little or no loss of tissue. 4nd+to+end anastomosis is used if the vessel is transected or nearly so. The severed ends of the vessel are mobili/ed, and small branches are ligated and divided as necessary to obtain the desired length. "rterial defects of 1 to - cm usually can be bridged. The surgeon should not be reluctant to divide small branches to obtain additional length because most injured #atients have normal vasculature and the #reservation of #otential collateral flow is not as im#ortant as in atherosclerotic surgery. To avoid #osto#erative stenosis, #articularly in smaller arteries, some

techni>ue such as beveling or s#atulation should be used so that the com#leted anastomosis is slightly larger in diameter than the native artery ;(ig. A+-1=. 1nter#osition grafts are used when end+to+end anastomosis cannot be accom#lished without tension des#ite mobili/ation. (or vessels less than A mm in diameter, autogenous sa#henous vein from the groin should be used because #olytetrafluoroethylene ;:T(4= grafts less than A mm in diameter have a #rohibitive rate of thrombosis. 1njuries of the brachial, #o#liteal, and internal carotid arteries re>uire the sa#henous vein for inter#osition grafting. Chen the sa#henous vein is harvested for treating an arterial injury in the lower extremity, it should be ta@en from the contralateral extremity. ?ecause the status of the i#silateral venous system is un@nown, the sa#henous vein on that side may become an im#ortant tributary. 3arger arteries must be bridged by artificial grafts. Some authorities advocate the use of free internal iliac artery grafts because of the greater thic@ness and strength of its wall com#ared to the sa#henous vein. The authors believe that this vessel is overly tedious to remove and has no advantage over the sa#henous vein. Trans#osition #rocedures can be used when an artery has a bifurcation of which one vessel can safely be ligated. 1njuries of the #roximal internal carotid can be treated by mobili/ing the adjacent external carotid, dividing it distal to the internal injury and #erforming an end+to+end anastomosis between it and the distal internal carotid ;(ig. A+--=. The #roximal stum# of the internal carotid is oversewn in such a way as to avoid a blind #oc@et where clot may form. 1njuries of the i#silateral external and contralateral common iliac arteries can be handled in a similar fashion #rovided flow is maintained in at least one internal iliac artery ;(ig. A+-.=. "rterial injuries are often grossly contaminated from enteric or external sources, in which case many surgeons are reluctant to #lace artificial grafts in situ. This situation arises most often in injuries to the aortic or iliac artery when the colon also is injured. (or the aorta there are few o#tions. 3igation of the aorta with unilateral or bilateral axillofemoral by#ass can be #erformed. These are lengthy #rocedures that are #rone to thrombosis and infection. <ost #atients who re>uire an aortic graft cannot tolerate surgery for the amount of time re>uired to #erform an axillofemoral by#ass. Therefore, even in the #resence of fecal contamination, it is common #ractice to use :T(4 or 'acron in situ for aortic injuries. 4very effort is made to remove and control contamination after the control of hemorrhage but before the graft is brought into the o#erative field. This includes co#ious irrigation of the abdominal cavity and changing of dra#es, gowns, gloves, and instruments. "fter #lacement of the graft, it is covered with #eritoneum or omentum before definitive treatment of the enteric injuries. Hraft infection is rare in these instances. " similar a##roach can be used for injuries to the iliac artery, but in most cases this can be avoided by the innovative use of trans#osition #rocedures. Suture selection for arterial injuries is based on the diameter of the vessel being re#aired ;Table A+A=. The use of #rogressively finer suture for smaller+ diameter vessels encourages the inclusion of less tissue with more closely #laced sutures, which is necessary for successful re#air. Chen #erforming anastomoses in which the vessels are tethered, e.g., the thoracic artery and the abdominal aorta, the authors use the #arachute techni>ue to ensure #recise #lacement of the #osterior suture line ;(ig. A+-4=. 1f this techni>ue is used, traction on both ends of the sutures must be

maintained or lea@age from the #osterior as#ect of the suture line is #robable. " single tem#orary suture 1*$ degrees from the #osterior row is used to maintain alignment. 5enous injuries are more difficult to re#air successfully because of their #ro#ensity to thrombose. Small injuries without loss of tissue can be treated with lateral suture. <ore com#lex re#airs often fail. Thrombosis does not occur acutely but rather gradually over 1 to - wee@s. "de>uate collateral circulation, sufficient to avoid acute venous hy#ertensive com#lications, usually develo#s within several days. Therefore it is reasonable to use :T(4 for venous inter#osition grafting and acce#t a gradual but eventual thrombosis while waiting for collateral circulation to develo#. 8onversely, chronic venous hy#ertensive com#lications in the lower extremities often can be avoided with any level of ligation by ;1= elastic bandages carefully a##lied in the o#erating room at the end of the #rocedure, and ;-= continuous elevation of the lower extremities to .$ degrees. These measures should be maintained for 1 wee@, after which the #atient is ambulated. 1f no edema occurs with the bandages removed, elevation is no longer necessary. 1t is a reasonable #recaution to have the #atient wear com#ressive stoc@ings u# to the @nee for a few months afterward. There are several circumstances in which a more aggressive a##roach should be considered. 3igation of the su#erior vena cava has been associated with sudden blindness resulting from com#ression of the o#tic nerve from venous hy#ertension. 3igation of the su#rarenal inferior vena cava is believed to be associated with acute renal failure from venous hy#ertension. 8hronic venous insufficiency of the lower extremities may be caused by ligation of the infrarenal vena cava or any in+line vein below that level, #articularly the #o#liteal vein. 1nter#osition grafting can be considered in these situations, but the choice of material is #roblematic. 6ne o#tion is to use artificial material because it is ra#idly available in hemodynamically correct si/es. The drawbac@ is that thrombosis is inevitable when such grafts are #laced below the renal veins. "rtificial grafts have #erformed satisfactorily in cases of su#rarenal inferior vena caval and su#erior vena caval re#lacement. The jugular vein can be used to re#lace vessels of similar si/e, e.g., the #ortal or femoral vein. The sa#henous vein is too small to re#lace any im#ortant vein. :anel grafts and s#iral grafts constructed around a mandrel ;chest tube= using sa#henous vein have occasionally been #erformed, but these #rocedures are extremely tedious and have no a##arent advantage over ligation in most instances. The technology used by interventional radiologists is advancing ra#idly. They have the ability to cannulate virtually any artery in the body and dilate it, #lace an intraluminal filter, stent, or graft in it, or occlude it. Their services are most valuable for treating arterial or venous injuries that are surgically inaccessible, such as stent #lacement in the internal carotid artery near or in the base of the s@ull, or controlling hemorrhage in he#atic injuries or #elvic fractures ;(igs. A+-%, A+-A, and A+-,=. Staged 6#erations The most common causes of death for trauma #atients are head injury, exsanguination from cardiovascular injuries, and se#sis with multi#le organ failure. "nother cause of death has become a##arent as the ca#ability of delivering massive >uantities of red blood cells and other com#onents has develo#ed. Surgeons are able to o#erate on the most severely injured #atients until a constellation of metabolic derangements develo#s. These are characteri/ed by the triad of an obvious coagulo#athy, #rofound

hy#othermia, and metabolic acidosis. &y#othermia from eva#orative and conductive heat loss and diminished heat #roduction occurs in s#ite of warming blan@ets and blood warmers. The metabolic acidosis of shoc@ is exacerbated by aortic clam#ing, vaso#ressors, massive transfusions, and im#aired myocardial #erformance. 8oagulo#athy is caused by dilution, hy#othermia, and acidosis. 4ach of these factors reinforces the others, resulting in a critically ill #atient who is at high ris@ for a fatal arrhythmia. This downward s#iral has been referred to as Ithe bloody vicious cycleJ ;(ig. A+-*=. &eat loss a##ears to be the central event because neither of the other com#onents can be corrected until core tem#erature returns toward normal. 3aboratory and mathematical heat exchange models have demonstrated that eva#orative heat loss from an o#en abdomen is by far the greatest source. " concomitant o#en thoracic cavity greatly accelerates the rate of the #atient's deterioration and can cause the syndrome by itself. This is the rationale for the immediate abdominal closure and the reason it has been successful. Staged o#erations are indicated when a coagulo#athy develo#s and core tem#erature dro#s below .4N8. " refractory acidosis is almost always #resent. Several unorthodox techni>ues can be used to ex#edite wound closure. ?leeding raw surfaces, often of the liver, are #ac@ed with la#arotomy #ads. Small enteric injuries are closed with sta#les, and large ones are sta#led on both sides with the H1" sta#ler and the damaged segment removed. 8lam#s may be left on unre#aired vascular injuries, or the vessels may be ligated. 1njuries of the #ancreas and @idneys are not treated if they are not bleeding. 2o drains are #laced, and the abdomen is closed with shar# towel cli#s #laced - cm a#art, which include only the s@in ;(ig. A+-)=. Towel cli#s are used because they do not cause bleeding as needles do, and they can be a##lied very ra#idly, usually in A$ to )$ seconds. The closure of just the s@in allows for the abdominal or thoracic cavity to accommodate a greater volume without increased #ressure. The cli#s are covered with a towel, and a #lastic adhesive sheet is #laced over the towel to #revent excessive fluid from draining onto the #atient's bedding. 8old wet dra#es are removed, and the #atient is covered from head to toe with layers of warm blan@ets. Some of the unorthodox treatments used, including the creation of closed+loo# bowel obstructions and unre#aired renal injuries, are not com#atible with survival! however, reo#eration is #lanned within - to -4 h, and the treatments are tolerated well within that time frame. The goal is to com#lete the #rocedure as soon as #ossible, or the #atient will die. 1f the surgeon believes that the #atient's metabolic #roblems can be corrected in a short time ;- h or less=, the #atient can remain in the o#erating room while additional blood #roducts are administered and rewarming measures are instituted. :atients who are in very #oor condition and re>uire several hours for metabolic corrections should be transferred to the surgical intensive care unit. 1f the #atient's condition im#roves as evidenced by normali/ation of coagulation studies, the correction of acidBbase imbalance, and a core tem#erature of at least .AN8, the #atient should be returned to the o#erating room for removal of #ac@s and definitive treatment of injuries. There are several com#lications associated with this treatment. (ailure to identify noncoagulo#athic hemorrhage can lead to exsanguination. <ost #atients with coagulo#athic hemorrhage have a gradual decrease in the need for #7?8, ((:, and #latelets and an im#rovement in coagulation studies as tem#erature rises. 1n the case

of vascular hemorrhage coagulo#athy does not correct itself, and these #atients must be returned to the o#erating room for reex#loration. " second com#lication is referred to as the abdominal or thoracic com#artment syndrome, which are caused by an acute increase in intracavitary #ressure. 1n the abdomen the com#liance of the abdominal wall and the dia#hragm #ermit the accumulation of many liters of fluid before intraabdominal #ressure ;1":= increases. There are #rimarily two sources for this fluid, blood, and edema. ?lood accumulates as a result of the coagulo#athy or missed vascular injury described above. The cause of edema is multifactorial. 1schemia and re#erfusion cause ca#illary lea@age, loss of oncotic #ressure occurs, and in the case of the small bowel, which is often eviscerated, #rolongation and narrowing of veins and lym#hatics caused by traction im#airs venous and lym#hatic drainage. The resulting edema may be dramatic ;(ig. A+.$=. Similar #henomena occur in the chest. "s fluid continues to accumulate, the com#liant limit of the abdominal cavity is eventually exceeded, and 1": increases. Chen 1": exceeds 1% mm&g, serious #hysiologic changes begin to occur. The lungs are com#ressed by the u#ward dis#lacement of the dia#hragm. This causes a decrease in functional residual ca#acity, increased airway #ressure, and, ultimately, hy#oxia. 8ardiac out#ut decreases as a conse>uence of diminished venous return to the heart and increased afterload. ?lood flow to every intraabdominal organ is reduced because of increased venous resistance. "s 1": exceeds -% to .$ mm&g, life+threatening hy#oxia and anuric renal failure occur. 8ardiac out#ut is further reduced but can be returned toward normal with volume ex#ansion and inotro#ic su##ort. The only method for treating hy#oxia and renal failure is to decom#ress the abdominal cavity by o#ening the incision. This results in an immediate diuresis and a resolution of hy#oxia. (ailure to decom#ress the abdominal cavity eventually causes lethal hy#oxia or organ failure. There have been a few re#orts of sudden hy#otension when the abdomen is o#ened, but volume loading to enhance cardiac out#ut has largely eliminated this #roblem. 1": is measured using the (oley catheter. ?ecause the bladder is a #assive reservoir at low volumes ;%$ to 1$$ m3=, it im#arts no intrinsic #ressure but can transmit 1":. (ifty m3 saline solution is injected into the as#iration #ort of the urinary drainage tube with an occlusive clam# #laced across the tube just distal to the #ort. The saline is used to create a standing column of fluid between the bladder and #ort that can transmit 1": to a recording device. The needle in the #ort is connected to a 85: manometer using a three+way sto#coc@. The manometer is filled with saline and o#ened to the drainage tube. 1": is read at the meniscus with manometer /eroed at the #ubic sym#hysis. ?ladder #ressures measured in this fashion are reliable and consistent. :ressures less than 1% mm&g do not re>uire decom#ression. Table A+, lists recommendations according to 1":. 1n the chest similar #henomena occur. 4dema of the heart and lungs develo#s, and the heart also may dilate. ?lood accumulation is rarely a #roblem because of the use of chest tubes. The diagnosis usually is a##arent in the o#erating room because the heart tolerates com#ression #oorly. "ttem#ts to close the chest in this setting are associated with #rofound hy#otension, and an alternative method of closure is necessary. The most #o#ular material used to accommodate the addition of volume in the chest or abdomen is a .+liter #lastic urologic irrigation bag that has been cut o#en and

sterili/ed. The bag is sewn to the s@in or fascia using 2o. - nylon suture with a sim#le running techni>ue ;(ig. A+.1=. "s many as four bags may need to be sewn together to cover a large defect. 8losed+ suction drains are #laced beneath the #lastic to remove blood and serous fluid that inevitably accumulate. The entire closure is covered with an iodinated #lastic adhesive sheet to sim#lify nursing care. :atients whose renal function has not been im#aired will have a remar@able diuresis. 4xogenous fluids are held to a minimum to facilitate the resolution of edema. 'efinitive wound closure can usually be #erformed in 4* to ,- h. 1n the case of #atients who develo# se#sis and multi#le organ failure ;<6(=, edema does not resolve until se#sis and <6( have resolved. This may re>uire several wee@s. The bags have been left in #lace u# to . wee@s with the #atient surviving. The authors ma@e every effort to close the s@in over the viscera to decrease #rotein and heat loss and to inhibit infection. 1f these attem#ts are unsuccessful and the abdomen remains o#en with granulating tissue ex#osed, lateral traction forces of the abdominal wall eventually cause an enteric fistula. The ris@ of develo#ing a fistula increases ra#idly after - wee@s with an o#en abdomen. These #roblems are extremely difficult to treat. Several a##roaches have been used to avoid this catastro#hic com#lication, including #olyglycolic acid or #oly#ro#ylene mesh sewn to the fascia, s#lit+thic@ness s@in grafts #laced directly on the bowel, musculocutaneous fla#s, and traction devices. 6f these o#tions, s@in grafts have the greatest success rates, although the abdominal wall hernia eventually re>uires reconstruction. 2ono#erative <anagement 2ono#erative treatment for blunt injuries of the liver, s#leen, and @idneys is now the rule rather than the exce#tion. U# to )$ #ercent of children and %$ #ercent of adults are treated in this manner. "s interventional radiology continues to advance, these numbers will increase. The #rimary re>uirement for this thera#y is hemodynamic stability. The extent of the #atient's injuries should be delineated by 8T scanning. 7ecurrent hemorrhage from the liver and @idneys has been infre>uent, but delayed hemorrhage or ru#ture of the s#leen is an im#ortant consideration in the decision to #ursue nono#erative management. The #atient should be monitored in the intensive care unit for the first -4 h. ?ecause 8T misses some enteric injuries, fre>uent abdominal examination should be #erformed. Usually the fall in hematocrit level stabili/es within -4 h. 1f the hematocrit level continues to fall, angiogra#hy with emboli/ation of bleeding sites should be considered, #articularly for he#atic and renal injuries. 8T scanning usually is re#eated at least once during the hos#itali/ation to assess major he#atic or s#lenic lesions re>uiring transfusion. Hradually increasing activity is #ermitted after discharge. :atients involved in contact s#orts should have com#lete healing of the injury documented radiogra#hically before resuming #artici#ation. This can ta@e several months. 8om#lications of nono#erative treatment include continuing hemorrhage, delayed hemorrhage, necrosis of liver, s#leen, or @idney from emboli/ation, abscess, biloma, and urinoma. &emorrhage may be treated by interventional radiology, though o#en o#erative control often is necessary. <ost infectious com#lications can be treated by #ercutaneous drainage. ?ilomas usually are resorbed. &ead

Heneral #rinci#les for the management of cerebral injuries have changed in recent years. "ttention is now focused on maintaining or enhancing cerebral #erfusion rather than merely lowering intracranial #ressure ;18:=. &y#erventilation to a #86- below .$ mm&g to induce cerebral vasoconstriction exacerbates cerebral ischemia in s#ite of decreasing 18:. These secondary iatrogenic cerebral injuries cause more harm than #reviously a##reciated. 6ther treatments or conditions that must be avoided include decreased cardiac out#ut because of the excessive use of osmotic diuretics, sedatives, or barbiturates, and hy#oxia. 2evertheless, the measurement of 18: is im#ortant and is efficiently accom#lished with a ventriculostomy tube. The tube also #ermits the withdrawal of cerebros#inal fluid, which is the safest method for lowering 18:. "lthough an 18: of 1$ mm&g is believed to be the u##er limit of normal, thera#y is not usually initiated until the 18: reaches -$ mm&g. 8erebral #erfusion #ressure ;8::=, which is e>ual to the mean arterial #ressure ;<":= minus the 18:, is an im#ortant measurement that is used to monitor thera#y. The lowest acce#table 8:: is A$ mm&g. This figure can be adjusted by lowering 18: or raising <":. 1nduced #aralysis, sedation, osmotic diuresis, and barbiturate+ induced coma are used. The goal of fluid thera#y is to achieve a euvolemic state, and arbitrary fluid restriction is avoided. 1t is unclear whether outcome is im#roved by boosting <": with #ressors or inotro#es in #atients with an elevated 18: resistant to treatment. 1ndications for o#erative intervention for s#ace+occu#ying hematomas are based on the amount of midline shift, the location of the clot, and the #atient's 18:. " shift of more than % mm usually is considered an indication for evacuation. This is not an absolute rule, however. Smaller hematomas causing less shift in treacherous locations, such as the #osterior fossa, can re>uire drainage because of the threat of brainstem com#ression or herniation. 7emoval of small hematomas also may im#rove 18: and 8:: in #atients with an elevated 18: that is refractory to medical thera#y. The treatment of diffuse axonal injury includes the control of cerebral edema and general su##ortive care. The authors fre>uently use #ercutaneous tracheostomy for airway control and #ercutaneous endosco#ic gastrostomy for enteral access in head+ injured #atients whose recovery is unli@ely or #rolonged. :rognosis is related to Hlasgow 8oma Scale score. Serious head injuries, H8S .K*, have a #oor #rognosis, and an institutional existence is almost a certainty. <ild brain injuries, H8S 1.K1%, have a good #rognosis! inde#endent living is #robable, but neuro#sychiatric testing often reveals significant abnormalities. Heneral surgeons in small or rural communities without emergency neurosurgical coverage may be re>uired to drill a burr hole in one life+ saving circumstance in a #atient with an e#idural hematoma. "s blood from a torn vessel, usually the middle meningeal artery, accumulates, the tem#oral lobe is forced medially, which com#resses the third cranial nerve and eventually the brainstem. The ty#ical course is ;1= initial loss of consciousness! ;-= awa@ening and a lucid interval! ;.= recurrent loss of consciousness with a unilaterally fixed, dilated #u#il! and ;4= cardiac arrest. These #atients usually do not have a serious underlying cortical injury, and com#lete recovery often is #ossible. The burr hole should be made on the same side as the dilated #u#il, as shown in (ig. A+.-. The goal of the #rocedure is not to control the hemorrhage but to decom#ress the intracranial s#ace. " craniotomy is re>uired for the control of hemorrhage. The #atient's head should be loosely wra##ed with a thic@

layer of gau/e to absorb the bleeding, and the #atient should be transferred to a facility with emergency neurosurgical ca#ability for a craniotomy. 2ec@ ?lunt 1njury 8ervical S#ine Treatment of injuries to the cervical s#ine is based on the level of injury, the stability of the s#ine, the #resence of subluxation, the extent of angulation, and the extent of neurologic deficit. 8autious axial traction in line with the mastoid #rocess is used to reduce subluxations. " halo+vest combination can accom#lish this and also #rovide rigid external fixation for definitive treatment when left in #lace for . to A months. This device is the treatment of choice for many cervical s#ine injuries. Surgical fusion usually is reserved for those with neurologic deficit, those who demonstrate angulation greater than 11 degrees on flexion and extension x+rays, or those who are unstable after external fixation. S#inal 8ord 1njuries of the s#inal cord, #articularly com#lete injuries, are essentially untreatable. "##roximately . #ercent of #atients who #resent with flaccid >uadri#legia have concussive injuries, and these #atients re#resent the very few who seem to have miraculous recoveries. " #ros#ective randomi/ed study com#aring methyl#rednisolone with #lacebo demonstrated a significant im#rovement in outcome ;usually one or two s#inal levels= for those who received the corticosteroid within * h of injury. The standard dosage is .$ mgB@g given as an intravenous bolus followed by a %.4 mgB@g infusion administered over the next -. h. 3arynx The larynx may be fractured by a direct blow, which can result in airway com#romise. " hoarse voice in a trauma #atient is highly suggestive of laryngeal fracture. 1n cases of severe fracture a cricothyroidotomy or tracheostomy should be #erformed to #rotect the airway. The larynx is re#aired with fine wires and sutures. 1f direct re#air of internal laryngeal structures is necessary, the thyroid cartilage is s#lit longitudinally in the midline and o#ened li@e a boo@. This is referred to as a laryngeal fissure. 8arotid and 5ertebral "rteries ?lunt injury to the carotid or vertebral arteries may cause dissection, thrombosis, or #seudoaneurysm. <ore than half the #atients with such injuries have a delayed diagnosis. (acial contact resulting in hy#erextension and rotation a##ears to be the mechanism of injury. To reduce delayed recognition, the authors use 8T angiogra#hy in #atients at ris@ to identify these injuries before neurologic sym#toms develo#. The injuries fre>uently occur at or extend into the base of the s@ull and usually are not surgically accessible. "cce#ted treatment for thrombosis and dissection is anticoagulation thera#y with he#arin followed by warfarin sodium ;8oumadin= for . months. :seudoaneurysms also occur near the base of the s@ull. 1f they are small, they can be followed with re#eat angiogra#hy. 1f enlargement occurs, consideration should be given to the #lacement of a stent across the aneurysm by an interventional radiologist. "nother #ossibility is to a##roach the intracranial #ortion of the carotid artery by removing the overlying bone and #erforming a direct re#air. This method has only recently been described and has been #erformed in a limited number of #atients.

5enous 1njuries Thrombosis of the internal jugular veins caused by blunt trauma can occur unilaterally or bilaterally. These injuries usually are discovered incidentally and are generally asym#tomatic. ?ilateral thrombosis can aggravate cerebral edema in #atients with serious head injuries. Stent #lacement should be considered in such #atients if their 18: remains elevated. 3aryngeal edema resulting in airway com#romise also can occur. :enetrating 1njuries :enetrating injuries in Mone 11 or 111 that re>uire o#erative intervention are ex#lored using an incision along the anterior border of the sternocleidomastoid muscle. 1f bilateral ex#loration is necessary, the inferior end of the incision can be extended to the o##osite side. <idline wounds or significant bilateral injuries can be ex#osed via a large collar incision at the a##ro#riate level. "lternatively, bilateral anterior sternocleidomastoid incisions can be used. 8arotid and 5ertebral "rteries 4x#osure of the distal internal carotid artery in Mone 111 is difficult ;(ig. A+ ..=. The first ste# is to divide the ansa cervicalis and mobili/e the hy#oglossal nerve. 2ext, the #ortion of the #osterior belly of the digastric muscle that overlies the internal carotid artery is resected. The glosso#haryngeal and vagus nerves are mobili/ed and retracted. 1f accessible, the styloid #rocess and attached muscles are removed. "t this #oint anterior dis#lacement of the mandible may be hel#ful, and various methods for accom#lishing this have been devised. Some authorities have advocated division and elevation of the vertical ramus, but two remaining structures still #revent ex#osure of the internal carotid to the base of the s@ull the #arotid gland and the facial nerve. 4xcessive anterior traction on the mandible or #arotid may damage the facial nerve, #articularly the mandibular branch. Unless the surgeon is willing to resect the #arotid and divide the facial nerve, division of the ramus is seldom hel#ful. :enetrating carotid artery injuries, regardless of the #atient's neurologic status, usually re>uire re#air, exce#t in comatose #atients. 1naccessible carotid artery injuries near the base of the s@ull can be treated by interventional radiologists with a stent if the anatomy of the injury is favorable. 6therwise the artery will need to be thrombosed or ligated. 1f ligation is necessary, the #atient should be given anticoagulation thera#y with he#arin followed by warfarin sodium ;8oumadin= for . months. This treatment may #revent a stro@e by inhibiting the generation of thrombi from the surface of the clot at the circle of Cillis while the endothelium heals. Cithout anticoagulation thera#y the ris@ of stro@e with ligation has been a##roximately -$ to .$ #ercent, and most stro@es occur a few days after ligation. Tangential wounds of the internal jugular vein should be re#aired by lateral venorrha#hy, but extensive wounds are efficiently attended to by ligation. 5ertebral artery injuries usually result from #enetrating trauma, although thrombosis and #seudoaneurysms can occur from blunt injury. The diagnosis is made by angiogra#hy or when significant hemorrhage is noted #osterior to the carotid sheath during nec@ ex#loration. 4x#osure of the vertebral artery above the 8A vertebra where it enters its bony canal is com#licated by the overlying anterior elements of the canal and the tough fascia covering the artery between the elements. The artery is a##roached through an anterior nec@ incision by retracting the contents of the carotid

sheath laterally ;(ig. A+.4=. The muscular attachments to the anterior elements are removed. 8are must be ta@en to avoid injury to the cervical s#inal nerves that are located directly behind and lateral to the bony canal. Some authorities have recommended using a high+s#eed burr to remove the anterior as#ect of the canal, thereby avoiding the venous #lexus between the elements. The authors have not found this to be a #roblem and have often excised the fascia between the elements and lifted the artery out of its canal with a tissue force#s. The treatment for vertebral artery injuries is ligation #roximal and distal to the injury. There is rarely, if ever, an indication for re#air. 2eurologic com#lications are uncommon. 4x#osure of the vertebral artery above 8- is extremely difficult. 7ather than using a direct o#erative a##roach, the authors ex#ose the vessel below 8%, outside the bony canal, clam# the artery #roximally, and insert a 2o. . balloon+ti##ed catheter. The catheter is advanced to the level of the injury or distal to it, and the balloon is inflated with saline solution until bac@ bleeding sto#s. The tube to the catheter is crim#ed over on itself and secured in this #osition with several heavy sil@ sutures. The catheter is trimmed so that it can be left in the wound under the s@in. The #roximal end of the artery is ligated. 6ne wee@ later the catheter is removed under local anesthesia. 7ebleeding has not occurred in our ex#erience. The same a##roach can be used for the distal internal carotid artery. "n alternative a##roach is to have the interventional radiologist #lace coils to induce thrombosis #roximal and distal to the injury if the lesion is diagnosed by angiogra#hy. 2ot all vertebral artery injuries can be treated by this method. 1njuries of the #roximal vertebral artery can be ex#osed by a median sternotomy with a nec@ extension. Trachea and 4so#hagus 1njuries of the trachea are re#aired with a running .+$ absorbable monofilament suture. Tracheostomy is not re>uired in most #atients. 4so#hageal injuries are re#aired in a similar fashion. 1f an eso#hageal wound is large, or if tissue is missing, a sternocleidomastoid muscle #edicle fla# is warranted, and a closed+suction drain is a reasonable #recaution. The drain should be near but not in contact with the eso#hageal or any other suture line. 1t can be removed in , to 1$ days if the suture line remains secure. 8are must be ta@en when ex#loring the trachea and eso#hagus to avoid iatrogenic injury to the recurrent laryngeal nerves. :enetrating injuries of the nec@ often create wounds in adjacent hollow structures, e.g., the trachea and eso#hagus or the carotid artery and eso#hagus. 1f, after re#air, these adjacent suture lines are in contact, the stage is set for devastating #osto#erative fistulous com#lications. To avoid these com#lications, viable tissue should routinely be inter#osed between adjacent suture lines. 5iable stri#s of the sternocleidomastoid muscle or stra# muscles are useful for this #ur#ose. Thoracic 6utlet Hreat 5essels <ost injuries of the great vessels of the thoracic outlet ;Mone 1= are caused by #enetrating trauma, although the innominate and subclavian arteries are occasionally injured from blunt trauma. "ngiogra#hy is desirable for #lanning the incision. 1f this is not #ossible because of hemodynamic instability, a reasonable a##roach can be inferred from the chest x+ray and the location of the wounds. 1f the #atient has a left

hemothorax, a left third or fourth inters#ace anterolateral thoracotomy should be #erformed because the #roximal left subclavian artery may be injured. &emorrhage can be controlled digitally until the vascular injury is delineated. "dditional incisions or extensions are often re>uired. " third or fourth inters#ace right anterolateral thoracotomy may be used for thoracic outlet injury #resenting with hemodynamic instability and a right hemothorax. " median sternotomy with a right clavicular extension also can be used. Unstable #atients with injuries near the sternal notch may have a large mediastinal hematoma or have lost blood directly to the outside. These #atients should be ex#lored via a median sternotomy. 1f angiogra#hy has identified an arterial injury, a more direct a##roach can be used. (ig. A+.% shows the various incisions that are used de#ending on the location of the arterial injury. " median sternotomy is used for ex#osure of the innominate, #roximal right carotid and subclavian, and #roximal left carotid arteries. The #roximal left subclavian artery #resents a uni>ue challenge. ?ecause it arises from the aortic arch far #osteriorly, it is not readily a##roached via a median sternotomy. " #osterolateral thoracotomy #rovides excellent ex#osure but severely limits access to other structures and is not recommended. The best o#tion is to create a full+thic@ness fla# of the u##er chest wall. This is accom#lished with a third or fourth inters#ace anterolateral thoracotomy for #roximal control, a su#raclavicular incision with a resection of the medial third of the clavicle, and a median sternotomy, which lin@s the two hori/ontal incisions. The ribs can be cut laterally for additional ex#osure, which allows the fla# to be folded laterally with little effort. This incision has been referred to as a boo@ or tra#door thoracotomy ;(ig. A+.A=. The mid#ortion of the subclavian artery is accessible by removing the #roximal third of either clavicle, with the s@in incision made directly over the clavicle. <uscular attachments are stri##ed away, and the clavicle is divided with a Higli's wire saw. The medial remnant of the clavicle is forcibly elevated. The #eriosteum is dissected from the #osterior as#ect of the bone until the sternoclavicular joint is reached. The ca#sular attachments are cut with a heavy scissors or @nife, and the bone is discarded. The #eriosteum and underlying fascia are very tough and must be shar#ly incised along the direction of the vessel. The subclavian vein is mobili/ed, and the artery is directly underneath. The anterior scalene muscle is divided for injuries just #roximal to the thyrocervical trun@! the relatively small #hrenic nerve should be identified on its anterior as#ect and s#ared. 1atrogenic injury to cords of the brachial #lexus can occur. The great vessels are fragile and easily torn during dissection or crushed with a clam#. Some advocate oversewing #roximal injuries of the artery on the side of the aortic arch and sewing a graft onto a new location on the arch. The graft is then sewn to the artery without tension. The authors have not found this necessary, #rovided the vessels are handled with care. Trachea and 4so#hagus The trachea and eso#hagus are difficult to a##roach at the thoracic outlet. The combination of a nec@ incision and a high anterolateral thoracotomy may be used. "lternatively, these structures can be a##roached via a median sternotomy, #rovided the left innominate vein and artery are divided. Tem#orary division of the innominate artery is tolerated well in otherwise healthy #eo#le, but the vessel should be re#aired after treatment of the tracheal or eso#hageal injury. The vein does not need to be

re#aired. "s in the nec@, adjacent suture lines should be se#arated by viable tissue. " #ortion of the sternocleidomastoid can be rotated down for this #ur#ose. 8hest The most common life+threatening com#lications from blunt and #enetrating thoracic injury are hemothorax, #neumothorax, or a combination of the two. "##roximately *% #ercent of these #atients can be treated definitively with a chest tube. ?ecause of the viscosity of blood at various stages of coagulation, a .A( or larger chest tube should be used. 1f one tube fails to com#letely evacuate the hemothorax ;a Ica@ed hemothoraxJ=, a second tube should be #laced ;(ig. A+.,=. 1f the second chest tube does not remove the blood, a thoracotomy should be #erformed because of the ris@ of life+threatening hemorrhage. 8ommon sources of blood loss include intercostal vessels, internal thoracic artery, #ulmonary #arenchyma, and the heart. 3ess common sources are the great vessels, aortic arch, a/ygos vein, su#erior vena cava, and inferior vena cava. ?lood may also enter the chest from an abdominal injury through a #erforation or tear in the dia#hragm. 1ndications for o#erative treatment of #enetrating thoracic injuries are listed in Table A+*. The indications for thoracotomy in blunt trauma are based on s#ecific #reo#erative diagnoses. These include #ericardial tam#onade, tear of the descending thoracic aorta, ru#ture of a main bronchus, and ru#ture of the eso#hagus. Thoracotomy for hemothorax in the absence of the above diagnoses is rarely indicated. " shattered chest wall that #roduces a hemothorax is better treated by the interventional radiologist with emboli/ation. Thoracic 1ncisions The selection of incision is im#ortant and de#ends on the organs being treated. (or ex#loratory thoracotomy for hemorrhage, the #atient is su#ine and an anterolateral thoracotomy is #erformed. 'e#ending on findings, the incision can be extended across the sternum or even farther for a bilateral anterolateral thoracotomy. The fifth inters#ace usually is #referred unless the surgeon has a #recise @nowledge of which organs are injured and @nows that ex#osure would be enhanced by selecting a different inters#ace. The heart, lungs, aortic arch, great vessels, and eso#hagus are accessible with these incisions. 8are should be ta@en to ligate the internal thoracic artery and veins if they are transected. This ste# often is overloo@ed, resulting in continuous blood loss that obscures the field and endangers the #atient. The heart also can be a##roached via a median sternotomy. ?ecause little else can be done in the chest through this incision, it usually is reserved for stab wounds of the anterior chest in #atients who #resent with #ericardial tam#onade. :osterolateral thoracotomies rarely are used since ventilation is im#aired in the de#endent lung, and the incision cannot be extended. There are two s#ecific exce#tions. 1njuries of the #osterior as#ect of the trachea or main bronchi near the carina tracheae are inaccessible from the left or from the front. The only #ossible a##roach is through the right chest using a #osterolateral thoracotomy. " tear of the descending thoracic aorta can be re#aired only through a left #osterolateral thoracotomy. ?ecause the authors use left heart by#ass for these #rocedures, the #atient's hi#s and legs are rotated toward the su#ine #osition to gain access to the left groin for femoral artery cannulation. 1t is also hel#ful for o#timal ex#osure to resect the fourth rib and enter the chest through its bed.

&eart <ost cardiac injuries are the result of #enetrating trauma, and any #art of the heart is susce#tible. 8ontrol of hemorrhage while the heart is being re#aired is crucial, and several techni>ues can be used. The atria can be clam#ed with a Satins@y vascular clam#. 'igital control and suturing beneath the finger is #ossible anywhere in the heart, though the techni>ue re>uires s@ill and a long, curved cardiovascular needle. &owever, the reality of blood+borne viral infections raises the >uestion of whether this method should be used. 1f the hole is small, a I#eanutJ s#onge clam#ed in the ti# of a hemostat can be #laced into the wound, or the blood loss may be acce#ted while sutures are being #laced. (or larger holes a 1A( (oley catheter with a .$ m3 balloon can be inflated with 1$ m3 of saline solution. Hentle traction on the catheter controls hemorrhage from any cardiac wound because wounds too large for balloon tam#onade are incom#atible with survival. Suture #lacement with the balloon inflated is #roblematic. Usually the ends of the wound are closed #rogressively toward the middle until the amount of blood loss is acce#table with the balloon removed. The use of s@in sta#les for the tem#orary control of hemorrhage has become #o#ular, #articularly when emergency room thoracotomy has been #erformed. The use of sta#les has the advantages of reducing the ris@ of needle+stic@ injury to the surgeon and of not demanding the attention re>uired by a balloon catheter. 1n most instances, hemostasis is neither #erfect nor definitive. 1nflow occlusion of the heart by clam#ing the su#erior and inferior venae cavae can be #erformed for short #eriods, and this may be essential for the treatment of extensive or multi#le wounds as well as for those that are difficult to ex#ose. 1mmediate re#air of valvular damage or acute se#tal defects rarely is necessary and re>uires total cardio#ulmonary by#ass, which has a high mortality in this situation. <ost #atients who survive to ma@e it to the hos#ital do well with only external re#air. "fter recovery, the heart can be thoroughly evaluated, and, if necessary, secondary re#air can be #erformed under more controlled conditions. 8oronary artery injuries also #ose difficult #roblems. 3igation leads to acute infarction distal to the tie, but reconstruction re>uires by#ass. The right coronary artery can be ligated anywhere, but the resultant arrhythmias may be extremely resistant to treatment. The left anterior descending and circumflex arteries cannot be ligated #roximally without causing a large infarct. These injuries are rare and usually #roduce death in the field. 3ungs :ulmonary injuries re>uiring o#erative intervention usually result from #enetrating injury. (ormerly the entrance and exit wounds were oversewn to control hemorrhage. This set the stage for air embolism, which occasionally caused sudden death in the o#erating room or in the immediate #osto#erative #eriod. :ulmonary tractotomy has been used to reduce this #roblem as well as the need for #ulmonary resection. 3inear sta#ling devices are inserted directly into the injury tract and #ositioned to cause the least degree of devasculari/ation ;(ig. A+.*=. Two sta#le lines are created and the lung is divided between. This allows direct access to the bleeding vessels and lea@ing bronchi. 2o effort is made to close the defect. 3obectomy or #neumonectomy rarely is necessary. 3obectomy is indicated only for a com#letely devasculari/ed or destroyed lobe. :arenchymal injuries severe enough to re>uire #neumonectomy rarely are survivable, and major #ulmonary hilar injuries necessitating #neumonectomy usually are lethal in the field.

Trachea and 4so#hagus 1njuries of the trachea and eso#hagus are managed in the same fashion as described above for lung injuries. ?ecause ex#osure can be difficult, #rovisions should be made to deflate the lung on the o#erative side by using a double+lumen endotracheal tube ;a double+lumen tube is seldom needed for cardiac or #ulmonary injury=. 7e#air of injuries of the main bronchi and the trachea near the carina tracheae can result in a com#lete loss of ventilation when the overlying #leura is o#ened, even if a double+ lumen tube is used. Hases from the ventilator #referentially esca#e from the injury and neither lung will be ventilated. 'igital occlusion of the injury can control air loss if the injury is small. 3arger injuries are an imminent threat to life. To avoid this catastro#he, a A or , mm cuffed endotracheal tube should be on the o#erative field and a second ventilator available. 1f ventilation is inade>uate, the surgeon can insert and inflate the endotracheal tube into the main bronchus on the o##osite side through the injury to #ermit ventilation of one lung while the injury is re#aired. 4ventually, the tube will have to be removed to close the defect, but the remaining hole can be controlled digitally. "lternatively, it may be #ossible for the anesthesiologist to cannulate the o##osite bronchus. 'escending Thoracic "orta The occurrence of #ara#legia from ischemic injury of the s#inal cord has been a concern in injuries to the descending thoracic aorta. 8once#tually, two techni>ues have been advocated. The sim#ler techni>ue, often referred to as Iclam# and sew,J is accom#lished with the a##lication of vascular clam#s #roximal and distal to the injury and re#air or re#lacement of the damaged #ortion of the aorta. This method results in transient hy#o#erfusion of the s#inal cord distal to the clam#s as well as all abdominal organs. 3arge doses of vasodilators also are re>uired to reduce afterload and avoid acute left heart failure. 1f the clam#ing time is short, less than .$ min, #ara#legia is uncommon. 3onger clam#ing times have been associated with #ara#legia in a##roximately 1$ #ercent of #atients. 8lam#ing times of less than .$ min are difficult to achieve where there are many tears re>uiring com#lex re#air. "n alternative a##roach is to #rovide some method for maintaining a reasonable degree of #erfusion for organs distal to the clam#s. Two techni>ues have been used to accom#lish this goal. The first is with the use of a shunt, a tem#orary extraanatomic route around the clam#s. " he#arin+im#regnated tube, the Hott shunt, has been designed s#ecifically for this #ur#ose, but the volume of blood flow to the distal aorta is marginal. The second method is to use left heart by#ass. Cith this method a volume of oxygenated blood is si#honed from the left heart and #um#ed into the distal aorta. (low rates of to . 3Bmin a##ear to #rovide ade>uate #rotection by maintaining a distal #erfusion #ressure higher than A% mm&g. This is the #referred method. The left su#erior #ulmonary vein, rather than the left atrium, is cannulated to remove blood from the heart because the vein is tougher and less #rone to tearing ;(ig. A+.)=. The left femoral artery is cannulated to return the blood to the distal aorta. " centrifugal #um# is used because it is not as thrombogenic as a roller #um# and, strictly s#ea@ing, he#arini/ation is not re>uired. This can be a significant benefit in #atients with multi#le injuries, #articularly in those with intracranial hemorrhage. 6ccasional small cerebral infarcts have occurred, and %,$$$ to 1$,$$$ units of he#arin usually is administered unless contraindicated by associated injuries.

6nce by#ass is initiated, the #roximal vascular clam# is a##lied between the left common carotid and left subclavian arteries, and the distal clam# is #laced distal to the injury. The left subclavian artery is clam#ed se#arately. The hematoma is entered and the injury evaluated. 1n most #atients a short gelatin+sealed 'acron graft is #laced, usually 1* to -- mm in diameter. :rimary re#air without a graft is #ossible in some #atients. (or the anastomoses or suture lines, .+$ #oly#ro#ylene suture is used. "ir and clot are flushed from the aorta between two clam#s and the subclavian artery before tying the final suture. "fter com#letion of the re#air the clam#s are removed and the #atient is weaned from the #um#. The cannulae are removed, and the vessels are re#aired. <eta+analysis com#aring the clam#+and+sew and left heart by#ass methods revealed a significantly lower incidence of #ara#legia when the #um# is used. 1njuries of the transverse aortic arch do occur from blunt trauma. The #roximal clam# usually can be #laced between the innominate and left carotid arteries without cerebral infarction. The #roximal clam#, however, cannot be #laced #roximal to the innominate artery. " #ossible a##roach to injuries in which the clam#s com#letely exclude the cerebral circulation is to use #rofound hy#othermia and circulatory arrest. Small intimal fla#s of the thoracic aorta without hematomas can be treated nono#eratively. 1ntraluminal mediastinal stents also may #rovide a solution, but their role remains to be defined. :enetrating injuries of the thoracic aorta are rare and do not afford enough time to set u# the #um#. There is no choice but to use the clam#+ and+sew techni>ue with #artially occluding clam#s, if #ossible. "bdomen "ll abdominal ex#lorations in adults are #erformed using a long midline incision because of its versatility. (or children under the age of A years, a transverse incision may be advantageous. 1f the #atient has been in shoc@ or is currently unstable, no attem#t should be made to control bleeding from the abdominal wall until major sources of hemorrhage have been identified and controlled. The incision should be made with a scal#el rather than with an electrosurgical unit, because it is faster. 3i>uid and clotted blood are ra#idly evacuated with multi#le la#arotomy #ads and suction. "dditional #ads are #laced in each >uadrant to locali/e hemorrhage, and the aorta is #al#ated to estimate blood #ressure. 1f exsanguinating hemorrhage is encountered on o#ening the abdomen, it usually is caused by injury to the liver, aorta, inferior vena cava, or iliac vessels. 1f the liver is the source, the he#atic #edicle should be immediately clam#ed ;a :ringle maneuver= and the liver com#ressed #osteriorly by tightly #ac@ing several la#arotomy #ads between the he#atic injury and the underside of the right anterior chest wall ;(igs. A+ 4$, A+41=. This combination of maneuvers tem#orarily controls the hemorrhage from most survivable he#atic injuries. 1f exsanguinating hemorrhage originates near the midline in the retro#eritoneum, direct manual #ressure is a##lied with a la#arotomy #ad, and the aorta is ex#osed at the dia#hragmatic hiatus and clam#ed. The same a##roach is used in the #elvis exce#t that the infrarenal aorta can be clam#ed, which is easier and safer because s#lanchnic and renal ischemia are avoided. 1njuries of the iliac vessels #ose a #articular #roblem for emergency vascular control. ?ecause there are so many large vessels in #roximity,

multi#le vascular injuries are common. 5enous injuries are not controlled with aortic clam#ing. " hel#ful maneuver in these instances is #elvic vascular isolation ;(ig. A+ 4-=. (or stable #atients with large midline hematomas, clam#ing the aorta #roximal to the hematoma also is a wise #recaution. <any surgeons ta@e a few moments, once overt hemorrhage has been controlled, to identify obvious sources of enteric contamination and minimi/e further s#illage. This can be accom#lished with a running suture or with ?abcoc@ clam#s. "ny organ can be injured by blunt or #enetrating trauma, but certain organs are injured more often, de#ending on the mechanism. 1n blunt trauma, organs that cannot yield to im#act by elastic deformation are most li@ely to be injured. The solid organs Eliver, s#leen, and @idneysEare re#resentative of this grou#. (or #enetrating trauma, organs with the largest anterior surface area are most #rone to injury, i.e., the small bowel, liver, and colon. ?ullets and @nives usually follow straight lines, and adjacent structures are commonly injured, e.g., the #ancreas and duodenum. :enetrating trauma is not limited by the elastic #ro#erties of the tissue, and vascular injuries are far more common. Chile these general #rinci#les sim#lify the locali/ation of injuries, unless the #atient has exsanguinating hemorrhage, a methodical ex#loration always should be #erformed. "bdominal organs are systematically examined by visuali/ation or #al#ation. <issed injuries are a serious #roblem with often fatal results. 1n #enetrating trauma missed injuries can occur if wound trac@s are not followed their entire course. 1njuries also can be missed if the surgeon fails to ex#lore retro#eritoneal structures such as the ascending and descending colon, the second and third #ortion of the duodenum, and the ureters. 1njuries of the aorta or venae cavae may be tem#orarily tam#onaded by overlying structures. 1f the retro#eritoneum is o#ened and the injury overloo@ed, delayed massive hemorrhage can occur after abdominal closure. ?lunt abdominal injuries usually are obvious, but injuries of the #ancreas, duodenum, bladder, and even the aorta can be overloo@ed. 5ascular 1njuries 1njury to the major arteries and veins in the abdomen are a technical challenge to the surgeon and often are fatal. "ll vessels are susce#tible to injury in #enetrating trauma. 5ascular injuries in blunt trauma are far less common and usually involve the renal arteries and veins, though all other vessels, including the aorta, can be injured. Several vessels are difficult to ex#ose the retrohe#atic vena cava, the su#rarenal aorta, the celiac axis, the #roximal su#erior mesenteric artery, the junction of the su#erior mesenteric, s#lenic, and #ortal veins, and the bifurcation of the vena cava. Techni>ues to aid in the ex#osure of these vessels have been described. The su#rarenal aorta, the celiac axis, and the #roximal su#erior mesenteric and left renal arteries can be ex#osed by left medial visceral rotation ;(ig. A+ 4.=. This is accom#lished by incising the left lateral #eritoneal reflection beginning at the distal descending colon and extending the incision #ast the s#lenic flexure, around the #osterior as#ect of the s#leen, behind the gastric fundus, and ending at the eso#hagus. This incision #ermits the left colon, s#leen, #ancreas, and stomach to be rotated toward the midline. 'ivision of the left crus of the dia#hragm #ermits access to the aorta well above the celiac axis. 1n contrast, mobili/ation of the right colon and a Gocher maneuver ex#oses the entire inferior vena cava exce#t the retrohe#atic #ortion, and it is technically sim#le. This is referred to as a right medial visceral rotation ;(ig. A+44=.

The @idney can be left in situ or mobili/ed with the remaining viscera with right and left medial rotations. The junction of the su#erior mesenteric, s#lenic, and #ortal veins can be ex#osed in elective surgery by dissecting the vessels from the #ancreas, as re>uired when #erforming a distal s#lenorenal shunt. 1n the #resence of massive bleeding from a venous injury, this may be im#ossible. Therefore, the nec@ of the #ancreas is divided without hesitation. This #rovides excellent ex#osure of this difficult area. The bifurcation of the vena cava is obscured by the right common iliac artery. This vessel should be divided to ex#ose extensive vena caval injuries of this area ;(ig. A+ 4%=. The artery must be re#aired after the venous injury is treated. "m#utation occurs in a##roximately %$ #ercent of #atients in whom the vessels are not re#aired. 3iver The lower costal margins im#air visuali/ation and a direct a##roach to the liver. 4x#osure of the right lobe can be im#roved by elevating the right costal margin with a large 7ichardson retractor. The right lobe can be mobili/ed by dividing the right triangular and coronary ligaments. "fter division of the right triangular ligament, the dissection is continued medially, dividing the su#erior and inferior coronary ligaments. The right lobe then can be rotated medially into the surgical field. <obili/ation of the left lobe is accom#lished in the same fashion. 8are must be ta@en when dividing any of the coronary ligaments because of their #roximity to the he#atic veins and the retrohe#atic vena cava. 6n occasion it may be necessary to extend the midline abdominal incision into the chest. This is best accom#lished with a median sternotomy. The #ericardium and dia#hragm can be divided toward the center of the inferior vena cava. The combination of incisions #rovides outstanding ex#osure of the he#atic veins and retrohe#atic vena cava while avoiding injury to the #hrenic nerves. The :ringle maneuver is one of the most useful techni>ues for evaluating the extent of he#atic injuries ;see (ig. A+4$=. 1n #atients with extensive he#atic injuries, the :ringle maneuver differentiates between hemorrhage from the he#atic artery and #ortal vein, which ceases when the clam# is a##lied, and hemorrhage from the he#atic veins and retrohe#atic vena cava, which does not. The authors #refer to manually tear the lesser omentum and #lace the clam# from the left side while guiding the #osterior blade of the clam# through the foramen of Cinslow with the aid of the left index finger. This a##roach has the advantage of avoiding injury to the structures within the he#atic #edicle, assuring that the clam# will be #laced #ro#erly the first time, and including any anomalous or accessory left he#atic arteries between the blades of the clam#. Techni>ues for the tem#orary control of hemorrhage from the liver are necessary when dealing with an extensive injury to #rovide the anesthesiologist with sufficient time to restore circulating blood volume before #roceeding, and because it is not #ossible to control hemorrhage from more than one location in the abdomen simultaneously. The tem#orary hemostatic techni>ues that have #roved most useful are he#atic com#ression, the :ringle maneuver, and #erihe#atic #ac@ing. <anual com#ression of a bleeding he#atic injury may be a lifesaving maneuver ;(ig. A+4A=. The addition of la#arotomy #ads on the surface of the liver distributes digital forces and lessens the chance of aggravating the injury. 1f the lacerated edges of the liver are carefully o##osed and the #ro#er forces a##lied, hemorrhage from almost any he#atic

injury can be controlled. The obvious drawbac@ is that considerable s@ill is re>uired and that little else can be done while the liver is being com#ressed. <anual com#ression is best suited for immediate attem#ts to #revent exsanguination and for #eriodic control during a com#lex #rocedure. :erihe#atic #ac@ing also is ca#able of controlling hemorrhage from most he#atic injuries, and it has the advantage of freeing the surgeon's hands. The la#arotomy #ads, two or three stac@ed together, should remain folded. The right costal margin is elevated, and the #ads are strategically #laced over and around the bleeding site ;see (ig. A+41=. "dditional #ads should be #laced between the liver, dia#hragm, and anterior chest wall until the bleeding has been controlled. Ten to 1% #ads may be re>uired to control the hemorrhage from an extensive right lobar injury. The effectiveness of #ac@ing may be enhanced by downward #ressure on the right costal margin by an assistant. :ac@ing of injuries of the left lobe is not as effective because there is insufficient abdominal and thoracic wall anterior to the left lobe to #rovide ade>uate com#ression with the abdomen o#en. &emorrhage from the left lobe usually can be controlled by mobili/ing the lobe and com#ressing it between the surgeon's hands. Two com#lications might be caused by #ac@ing he#atic injuries. Tight #ac@ing can com#ress the inferior vena cava and reduce cardiac filling, and the right dia#hragm will be forced ce#halad, increasing airway #ressure and decreasing tidal volume and functional residual ca#acity. The surgeon must decide whether these com#lications outweigh the ris@ of additional blood loss. :erihe#atic #ac@ing will not reliably control hemorrhage from larger branches of the he#atic artery. The :ringle maneuver often is used as an adjunct to #ac@ing for the tem#orary control of the arterial hemorrhage. :ro#erly a##lied, a :ringle maneuver eliminates all he#ato#etal flow. The length of time that a :ringle maneuver can remain in #lace without causing irreversible ischemic damage to the liver is un@nown. Several authors have documented a :ringle maneuver a##lied for over 1 h without a##reciable he#atic damage! this is a reasonable figure. "nother o#tion for tem#orary control of he#atic hemorrhage is to use a tourni>uet. "fter mobili/ation of the bleeding lobe, a 1+inch :enrose drain is wra##ed around the liver near the anatomic division between the left and right lobes. The drain is cinched until hemorrhage ceases! tension is maintained by #lacing a clam# on the drain. Tourni>uets are difficult to use, however, because they often sli# off or even tear through the #arenchyma. "n alternative is to use the 3in liver clam#, though it has the same shortcomings as the tourni>uet. 1f successful, the occluding device is removed in -4 h and nonviable tissue is resected. S#ecial techni>ues have been develo#ed for controlling hemorrhage from juxtahe#atic venous injuries. These formidable #rocedures include he#atic vascular isolation with clam#s, the atriocaval shunt, and the <oore+:ilcher balloon. &e#atic vascular isolation with clam#s is accom#lished by the a##lication of a :ringle maneuver, clam#ing the aorta at the dia#hragm, and clam#ing of the su#rarenal and su#rahe#atic vena cava. "lthough this techni>ue has success in elective #rocedures, its use in trauma #atients has had mixed results because #atients in #rofound hemorrhagic shoc@ do not tolerate the #reci#itous loss of venous return to the heart.

The atriocaval shunt was designed to achieve he#atic vascular isolation while #ermitting venous blood to enter the heart from below the dia#hragm. 4nthusiasm for the shunt has declined as mortality rates with its use range from %$ to *$ #ercent. The shunt must be #recisely constructed and #ro#erly #ositioned on the first attem#t because #atients with juxtahe#atic venous injuries do not tolerate the continuing blood loss associated with re#eated unsuccessful attem#ts to #osition the shunt correctly. " variation of the original atriocaval shunt has been the substitution of a )+mm endotracheal tube for the usual large chest tube ;(ig. A+4,=. Chile this change may seem trivial, surrounding the su#rarenal vena cava for a snare tourni>uet is extremely difficult because exsanguinating hemorrhage must be controlled by #osterior com#ression of the liver, which severely restricts access to that segment of the vena cava. "n alternative to the atriocaval shunt is the <oore+:ilcher balloon. This device is inserted through the femoral vein and advanced into the retrohe#atic vena cava. Chen the balloon is inflated, the he#atic veins and vena cava are occluded, thereby achieving vascular isolation. The catheter itself is hollow, and holes #laced below the balloon #ermit blood to flow into the right atrium from the inferior vena cava. Surgeons attem#ting he#atic vascular isolation should be aware that none of the techni>ues #rovides com#lete hemostasis. The residual bleeding after successful vascular isolation can be removed readily with suction. 7egardless of the techni>ue used, a :ringle maneuver should always be used. ?ecause of the technical challenge and high mortality of he#atic vascular isolation, there has been a trend toward avoiding a direct o#erative a##roach to the injured vessels. 1f massive venous hemorrhage is seen from behind the liver, and, if hemostasis can be achieved with #erihe#atic #ac@ing, the #atient can be transferred to the interventional radiology suite, where hemorrhage from arterial sources are emboli/ed and stents are #laced to bridge venous injuries ;see (ig. A+-A=. 2umerous methods for the definitive control of he#atic hemorrhage have been develo#ed. <inor lacerations may be controlled with manual com#ression a##lied directly to the injury site. (or similar injuries that do not res#ond to com#ression, to#ical hemostatic techni>ues have been successful. Small bleeding vessels may be controlled with electrocautery, although the #ower out#ut of the machine may have to be increased. ?leeding surfaces immune to electrocautery may res#ond to the argon beam coagulator. <icrocrystalline collagen can be used. The #owder is #laced on a clean 4 O 4 s#onge and a##lied directly to the oo/ing surface. :ressure is maintained for % to 1$ min. To#ical thrombin also can be a##lied to minor bleeding injuries by saturating a gelatin foam s#onge or a microcrystalline collagen #ad and a##lying it to the bleeding site. (ibrin glue has been used for su#erficial and dee# lacerations and is an effective to#ical agent. (ibrin glue is made by mixing concentrated human fibrinogen ;cryo#reci#itate= with bovine thrombin and calcium. ?ecause the coagulum forms >uic@ly, the fibrinogen and thrombin+calcium solution are #laced in se#arate syringes joined with a D connector. S#ray+on a##licators also have been used. 4nthusiasm has been tem#ered by re#orts of fatal ana#hylactic reactions and idio#athic hy#otension related to an antigenic res#onse to the bovine com#onent.

Suturing of the he#atic #arenchyma is an effective hemostatic techni>ue. This treatment has been maligned as a cause of he#atic necrosis, but he#atic sutures often are used for #ersistently bleeding lacerations less than . cm in de#th. 1t also is an a##ro#riate alternative for dee#er lacerations if the #atient will not tolerate further hemorrhage. The #referred suture is -+$ or $ chromic attached to a large, curved, blunt needle. The large diameter of the suture hel#s to #revent it from #ulling through Hlisson's ca#sule. " sim#le running techni>ue is used to a##roximate the edges of shallow lacerations. 'ee#er lacerations can be managed with interru#ted hori/ontal mattress sutures #laced #arallel to the edge of the laceration. Chen tying the suture, ade>uate tension exists when visible hemorrhage ceases or the liver blanches around the suture. <ost sources of venous hemorrhage within the liver can be managed with #arenchymal sutures, and even injuries of the retrohe#atic vena cava and he#atic veins have been successfully tam#onaded by closing the he#atic #arenchyma over the bleeding vessel. 5enous hemorrhage resulting from #enetrating wounds that traverse the central #ortion of the liver can be managed by suturing the entrance and exit wounds with hori/ontal mattress sutures. 1ntrahe#atic hematomas might form, which can become infected, though this may be #referable to intracaval shunt or dee# he#atotomy. Suturing of the he#atic #arenchyma is not always successful in controlling the hemorrhage, #articularly when the hemorrhage is of arterial origin. &e#atotomy with selective ligation of bleeding vessels is an im#ortant techni>ue usually reserved for transhe#atic #enetrating wounds. &e#atotomy is #erformed using the finger fracture techni>ue. The dissection continues until the bleeding vessels are identified and controlled. 8onsiderable blood loss may be incurred because the division of additional viable he#atic tissue is often re>uired to reach the bleeding vessels. "n alternative to suturing the entrance and exit wounds of a transhe#atic injury or extensive he#atotomy is the use of an intrahe#atic balloon. 6ur method is to tie a large :enrose drain to a hollow catheter and ligate the o##osite end of the drain ;(ig. A+4*=. The balloon is then inserted into the bleeding wound and inflated with soluble contrast medium. 1f control of the hemorrhage is successful, a sto#coc@ or clam# is used to occlude the catheter and maintain inflation. The catheter is left in the abdomen and removed at an o#eration -4 to 4* h later. 7ecurrent hemorrhage may occur when the balloon is deflated but usually is amenable to selective emboli/ation. &e#atic arterial ligation may be a##ro#riate for #atients with recalcitrant arterial hemorrhage from dee# within the liver. 1ts utility is limited because hemorrhage from the #ortal and he#atic venous systems continues. 1ts #rimary role is in transhe#atic injuries when a##lication of the :ringle maneuver results in the cessation of arterial hemorrhage. "rterial ligation is a reasonable alternative to a dee# he#atotomy, #articularly in unstable #atients. Chile ligation of the right or left he#atic artery is well tolerated, the fate of dearteriali/ed lobe is un#redictable. 3obar necrosis re>uiring anatomic lobectomy after arterial ligation has been described. 3igation of the #ro#er he#atic artery may not be tolerated. "n uncommon, #er#lexing he#atic injury is the subca#sular hematoma. This lesion occurs when the #arenchyma of the liver is disru#ted by blunt trauma, but Hlisson's ca#sule remains intact. The hematoma may be recogni/ed at the time of the surgery or #reo#eratively if 8T is #erformed, and subse>uent decision ma@ing is often difficult.

Subca#sular hematomas discovered during an ex#loratory la#arotomy that involve less than %$ #ercent of the surface of the liver and are not ex#anding or ru#tured should be left alone or #ac@ed. &ematomas that are ex#anding during an o#eration may re>uire ex#loration. These lesions often are caused by uncontrolled arterial hemorrhage, and #ac@ing alone may not be successful. "n alternative strategy is to #ac@ the liver to control venous hemorrhage, close the abdomen, and trans#ort the #atient to the angiogra#hic suite for he#atic arteriogra#hy and emboli/ation of the bleeding vessel. 7u#tured hematomas re>uire ex#loration and selective ligation, with or without #ac@ing. 7esectional debridement is indicated for the removal of #eri#heral #ortions of nonviable he#atic #arenchyma. The mass of tissue removed should rarely exceed -% #ercent of the liver. ?ecause additional blood loss may occur, it should be reserved for #atients who are in good metabolic condition and who will tolerate additional blood loss. 7esectional debridement is #erformed by finger fracture. "n alternative for #atients with extensive unilobar injuries is anatomic he#atic resection, but the mortality rate for trauma #atients exceeds %$ #ercent in most series. 1t has largely been re#laced by #erihe#atic #ac@ing, resectional debridement, and he#atotomy with selective ligation and usually is not indicated in the acute setting. There are two circumstances, however, in which anatomic resections are a##ro#riate. The first is when there are extensive injuries of the lateral segment of the left lobe. ?ecause hemorrhage can be easily controlled with bimanual com#ression, uncontrolled blood loss is not as #roblematic as with the left or right anatomic lobectomies. "nother indication for anatomic lobectomy occurs in #atients whose hemorrhage has been controlled by #erihe#atic #ac@ing or arterial ligation but whose left or right lobe is nonviable. The mass of the remaining necrotic liver is large and the ris@ of subse>uent infection high, and it should be removed as soon as the #atient's condition #ermits. Several centers have re#orted #atients with devastating he#atic injuries or necrosis of the entire liver who have undergone successful he#atic trans#lantation. The #atient must have all other injuries delineated, #articularly of the central nervous system, and have an excellent chance of survival excluding the he#atic injury. 8ost and donor availability limit such #rocedures, but it is #robable that he#atic trans#lantation for trauma will continue to be #erformed in rare circumstances. 6mentum has been used to fill large defects in the liver, with the rationale that it #rovides an excellent source for macro#hages and that it fills a #otential dead s#ace with viable tissue. The omentum also can #rovide some additional su##ort for #arenchymal sutures and often is strong enough to #revent them from cutting through Hlisson's ca#sule. Several #ros#ective and retros#ective studies have demonstrated that the use of :enrose or sum# drains is associated with a greater ris@ of intraabdominal se#sis than the use closed+suction drains or no drains. 'rains are not necessary for minor lacerations. They should be used if bile is seen oo/ing from the liver and in most #atients with dee# central injuries. The com#lications after significant he#atic trauma include hemorrhage, infection, and various fistulas. :osto#erative hemorrhage can be ex#ected in a considerable #ercentage of #atients treated with #erihe#atic #ac@ing. The source may be #ersistent

coagulo#athy or missed vascular injury. 1n most instances in which #osto#erative hemorrhage is sus#ected, the #atient is best served by returning to the o#erating room. "rteriogra#hy with emboli/ation can be considered in selected #atients. 1nfections within and around the liver occur in about . #ercent of injured #atients. :erihe#atic infections develo# more often in victims of #enetrating trauma than blunt trauma, #resumably because of the greater fre>uency of enteric contamination of the former. :ersistent elevation of tem#erature and white blood cell count after the third or fourth #osto#erative day should #rom#t a search for intraabdominal infection. 1n the absence of #neumonia, line se#sis, or urinary tract infection, an abdominal 8T scan with intravenous and u##er gastrointestinal contrast should be obtained. <any #erihe#atic infections can be treated with 8T+guided drainage. 1nfected hematomas and infected necrotic liver cannot be ex#ected to res#ond to #ercutaneous drainage. 7ight twelfth rib resection remains an excellent a##roach for #osterior infections and allows su#erior drainage. ?ilomas are loculated collections of bile that may or may not be infected. 1f infected, the biloma is essentially an abscess and should be treated as such. 1f sterile, it will eventually be reabsorbed. ?iliary ascites is caused by disru#tion of a major bile duct. 7eo#eration with the establishment of a##ro#riate drainage is the #rudent course. 4ven if the source of bile lea@age can be identified, #rimary re#air of the injured duct is unli@ely to be successful. 1t is best to wait until a firm fistulous communication is established with ade>uate drainage. ?iliary fistulas occur in a##roximately . #ercent of #atients with he#atic injuries. They usually are of little conse>uence and most will close without s#ecific treatment. 7arely, a fistulous communication with intrathoracic structures forms in #atients with associated dia#hragm injuries and results in a bronchobiliary or #leurobiliary fistula. "s a result of the #ressure differential between the biliary tract and thoracic cavity, most of these fistulas re>uire o#erative closure, but the authors have treated a #leurobiliary fistula by endosco#ic s#hincterotomy with stent #lacement, which then closed s#ontaneously. &emorrhage from he#atic injuries often is treated without identifying and controlling each individual bleeding vessel! arterial #seudoaneurysms may develo#. 1f the #seudoaneurysm enlarges, it eventually ru#tures into the #arenchyma of the liver, a bile duct, or an adjacent #ortal venous branch. 7u#ture into a bile duct results in hemobilia, which is characteri/ed by intermittent e#isodes of right u##er >uadrant #ain, u##er gastrointestinal hemorrhage, and jaundice. 1f the aneurysm ru#tures into a #ortal vein, #ortal venous hy#ertension with bleeding eso#hageal varices can occur. These com#lications are exceedingly rare and are best managed with he#atic arteriogra#hy and emboli/ation. ?iliovenous fistulas also have been re#orted. Serum bilirubin rises very ra#idly, and extremely high values are common. S#hincterotomy of the #a#illa of 5ater may hasten closure. Hallbladder and 4xtrahe#atic ?ile 'ucts 1njuries of the gallbladder are treated by lateral suture or cholecystectomy, whichever is easier. 1f lateral suture is #erformed, absorbable suture should be used to #revent the formation of calculi. 1njuries of the extrahe#atic bile ducts are a challenge. ?ecause of the #roximity of the #ortal vein, he#atic artery, and vena cava, associated

vascular injuries are common and the #atient's #hysiologic status is often #oor. The ducts are of normal si/e and texture, i.e., small in diameter and thin+walled. These factors usually #reclude #rimary re#airs exce#t for the smallest lacerations with no loss of tissue. These injuries can be treated by the insertion of a T tube through the wound or by lateral suture using 4+$ to A+$ monofilament absorbable suture. <ost transections and any injury associated with significant tissue loss re>uire a 7oux+en+D choledochojejunostomy. The anastomosis is #erformed using a single+layer interru#ted techni>ue, as it is almost im#ossible to do a running stitch, using 4+$ or %+ $ monofilament absorbable suture. " round #atch of seromuscular tissue the si/e of the common duct is removed from the jejunum at the site of the anastomosis to inhibit wound contraction. The mucosa and submucosa are #unctured but not resected. (ull+ thic@ness bites of the duct and jejunum are ta@en. ?ecause of the small si/e of the duct, only six to eight stitches can be used. T tubes are not #laced. The jejunum is then sutured to the areolar tissue of the he#atic #edicle or #orta he#atis to relieve tension from the anastomosis. 1njuries of the he#atic ducts are almost im#ossible to re#air satisfactorily under emergency circumstances. 6ne a##roach is to intubate the duct for external drainage and attem#t a re#air when the #atient recovers. "lternatively, the duct can be ligated if the o##osite lobe is normal and uninjured. (or #atients who are critically ill, the common duct also can be treated by intubation with external drainage. S#leen S#lenic injuries are treated by s#lenic re#air ;s#lenorrha#hy=, #artial s#lenectomy, resection, or nono#eratively, de#ending on the extent of the injury and the condition of the #atient. 4nthusiasm for s#lenic salvage has been driven by the evolving trend toward nono#erative management of solid organ injuries and the rare, but often fatal, com#lication of overwhelming #osts#lenectomy infection ;6:S1=. These infections are caused by enca#sulated bacteria, e.g., Stre#tococcus #neumoniae, &aemo#hilus influen/ae, and 2eisseria meningitidis, and are very resistant to treatment. 6:S1 occurs most often in young children and immunocom#romised adults. 1t is uncommon in otherwise healthy adults. To re#air or remove the s#leen safely, it should be mobili/ed to the extent that it can be brought to the surface of the abdominal wall without tension. This re>uires division of the attachments between the s#leen and s#lenic flexure of the colon. "n incision is made in the #eritoneum and endoabdominal fascia beginning at the inferior #ole, 1 or - cm from the s#leen, and continuing #osteriorly and su#eriorly until the eso#hagus is encountered! this is similar to a left medial visceral rotation ;(ig. A+4)=. 8are must be ta@en not to #ull on the #osterior as#ect of the s#leen or it will tear at the #eritoneal reflection, causing significant hemorrhage. The s#leen should be rotated countercloc@wise with #osterior #ressure a##lied to ex#ose the #eritoneal reflection. 1t is often hel#ful to rotate the o#erating table -$ degrees to the #atient's right so that the weight of abdominal viscera aids in their own retraction. " #lane can then be established between the s#leen and #ancreas and the renal fascia ;Herota's fascia= that can be extended to the aorta. This com#letes mobili/ation and #ermits re#air or removal of the s#leen without struggle for ex#osure. &ilar injuries or a #ulveri/ed s#lenic #arenchyma usually are treated by s#lenectomy. The authors have selectively reim#lanted six #ieces of the s#leen ;4$ O 4$ O . mm=

within the leafs of the omentum. Technetium scans have confirmed their viability. 1g< levels have normali/ed. The #atient's res#onse to an antigenic challenge has not been evaluated. S#lenectomy also is indicated for lesser s#lenic injuries in #atients with multi#le abdominal injuries who have develo#ed a coagulo#athy! it usually is necessary in #atients with failed s#lenic salvage attem#ts. :artial s#lenectomy can be used in #atients in whom only a #ortion of the s#leen has been destroyed, usually the su#erior or inferior half. "fter removal of the damaged #ortion, the same methods used to control hemorrhage from he#atic #arenchyma can be used for the s#leen. Chen #lacing hori/ontal mattress sutures across a raw edge, gentle com#ression of the #arenchyma by an assistant facilitates hemostasis ;(ig. A+%$=. "fter ligation of the sutures and releasing com#ression, the s#leen ex#ands slightly and further tightens the sutures. 'rains are never used after com#letion of the re#air or resection. 1f s#lenectomy is #erformed, vaccines against the enca#sulated bacteria are administered. The #neumococcal vaccine is routinely given, and those effective against &aemo#hilus influen/ae and 2eisseria meningitidis should be used. 'ia#hragm 1n blunt trauma the dia#hragm is injured on the left in ,% #ercent of cases, #resumably because the liver diffuses some of the energy on the right side. (or blunt and #enetrating trauma the diagnosis is suggested by an abnormality of the dia#hragmatic shadow on chest x+ray. <any of these are subtle, #articularly with #enetrating injuries, and additional diagnostic evaluation may be warranted. The ty#ical dia#hragmatic injury from blunt trauma is a tear in the central tendon that may be large. "cute injuries are re#aired through an abdominal incision. The laceration is closed with 2o. 1 monofilament #ermanent suture using a sim#le running techni>ue. 6ccasionally, large avulsions or shotgun wounds with extensive tissue loss re>uire #oly#ro#ylene mesh to bridge the defect. 'uodenum 'uodenal hematomas are caused by a direct blow to the abdomen, and they occur more often in children than adults. ?lood accumulates between the seromuscular and submucosal layers, eventually causing obstruction. The diagnosis is sus#ected by the onset of vomiting after blunt abdominal trauma! barium x+ray examination of the duodenum reveals the coiled+ s#ring sign of obstruction. <ost duodenal hematomas in children can be managed nono#eratively with nasogastric suction and #arenteral nutrition. 7esolution of the obstruction occurs in the majority of #atients if this thera#y is continued for , to 14 days. 1f surgical intervention is necessary, evacuation of the hematoma is associated with e>ual success and fewer com#lications than by#ass #rocedures. 'es#ite a lac@ of existing data on adults, there is no reason to believe that their hematomas should be treated differently from those of children. " new a##roach is la#arosco#ic evacuation if the obstruction #ersists more than , days. 'uodenal #erforations can be caused by blunt and #enetrating trauma ;(ig. A+%1=. ?lunt injuries are difficult to diagnose because the contents of the duodenum have a neutral #& and few bacteria and are often contained by the retro#eritoneum. <ortality can exceed .$ #ercent if the lesion is not identified and treated within -4 h. The #erforations are not reliably identified by initial oral contrast 8T examinations! therefore, the authors often obtain contrast x+rays with soluble contrast medium followed with barium if necessary. <ost #erforations of the duodenum can be treated by #rimary re#air. The authors #refer to use a running, single+layer suture of .+$

monofilament. The wound should be closed in a direction that results in the largest residual lumen. 6ccasionally, #enetrating injuries damage only the #ancreatic as#ect of the second or third #ortion. ?ecause the duodenum cannot be ade>uately mobili/ed to re#air the injury directly, the wound should be extended laterally or the duodenum divided so that the #ancreatic as#ect can be sutured from the inside. 'uodenal re#airs or anastomoses do not benefit from adjunctive external drainage. 8hallenges arise when there is a substantial loss of duodenal tissue. 4xtensive injuries of the first #ortion of the duodenum can be re#aired by debridement and anastomosis because of the mobility and rich blood su##ly of the distal gastric antrum and #ylorus. 1n contrast, the second #ortion is tethered to the head of the #ancreas by its blood su##ly and the #ancreatic and accessory #ancreatic ducts ;ducts of Cirsung and Santorini= so that the length of duodenum that can be mobili/ed from the #ancreas is limited to a##roximately 1 cm. Unli@e the jejunum, ileum, or colon, this mobili/ation yields little additional tissue to alleviate tension on suture line. "s a result, suture re#air of the second #ortion when tissue is lost often results in an unacce#tably narrow lumen, and an end+to+end anastomosis is almost im#ossible, re>uiring more so#histicated re#airs. (or extensive injuries #roximal to the accessory #a#illa, debridement and end+to+end anastomosis are a##ro#riate. (or lesions between the accessory #a#illa and the #a#illa of 5ater, a vasculari/ed jejunal graft, either a #atch or a tubular inter#osition graft, may be re>uired. 4x#erience with these #rocedures is limited. 'uodenal injuries with tissue loss distal to the #a#illa of 5ater and #roximal to the su#erior mesenteric vessels are best treated by 7oux+en+D duodenojejunostomy ;(ig. A+%-=. The distal #ortion of the duodenum is oversewn! the jejunum is sutured end+to+end to the #roximal duodenum, and the defunctionali/ed distal duodenum and #roximal jejunum are drained into the jejunum. "lternatively, the short defunctionali/ed duodenum can be resected. This is a rather tedious dissection behind the su#erior mesenteric vessels that may not be tolerated by a #atient who has been in #rotracted shoc@. 1njuries to the third and fourth #ortions of the duodenum with tissue loss #ose other #roblems. ?ecause of the short mesentery of the third and fourth #ortions of the duodenum, the ris@ of ischemia limits mobili/ation. Chile end+to+end duodenojejunal anastomoses are #ossible in these regions, the techni>ue used must resemble that of a hand+sewn, low anterior rectal anastomosis with a #osterior row of interru#ted sutures #laced while the ends of the bowel are far a#art. The jejunum is then #arachuted down to the duodenum, and the anterior row is com#leted. 'uodenal fistulas are common when this method is used. 7esection of the third and fourth #ortions and a duodenojejunostomy on the right side of the su#erior mesenteric vessels is recommended. "n im#ortant adjunct for high+ris@ or com#lex duodenal re#airs is the #yloric exclusion techni>ue ;(ig. A+%.=. ?y occluding the #ylorus and #erforming a gastrojejunostomy, the gastrointestinal stream can be diverted away from the duodenal re#air. 1f a fistula does develo#, it is functionally an end fistula, which is easier to manage and more li@ely to close than a lateral fistula, and the #atient can ta@e food by mouth to maintain nutritional status. To #erform a #yloric exclusion, a gastrostomy is made on the greater curvature as close to the #ylorus as #ossible. The #ylorus is then gras#ed with a ?abcoc@ clam# via the gastrostomy and oversewn with a $ #oly#ro#ylene suture. " gastrojejunostomy restores gastrointestinal continuity.

5agotomy is not necessary because marginal ulceration occurs at the same fre>uency ;a##roximately . #ercent= as duodenal ulceration occurs in the same #atient #o#ulation. "bsorbable sutures do not last long enough to be effective, and even heavy #oly#ro#ylene will give way in . to 4 wee@s in most #atients. " linear sta#le line across the outside of the #ylorus #rovides the most enduring #yloric closure. :ancreas ?lunt #ancreatic transection at the nec@ of the #ancreas can occur with a direct blow to the abdomen. "s an isolated injury, it is more difficult to detect than blunt duodenal ru#ture, but a missed #ancreatic injury is more benign. ?ecause the main #ancreatic duct is transected, the #atient develo#s a #seudocyst or #ancreatic ascites! there is minimal inflammation because the #ancreatic en/ymes remain inactivated. The diagnosis occasionally can be made with 8T using fine slices through the #ancreas. 8T will not identify a significant number of transections if #erformed within A h of injury. 6#timal management of #ancreatic trauma is determined by the location of the injury and whether or not the main #ancreatic duct is injured. :ancreatic injuries in which the #ancreatic duct is not injured may be treated by drainage or left alone. 1n contrast, #ancreatic injuries associated with a ductal injury always re>uire treatment to #revent #ancreatic ascites or a major external fistula. 'irect ex#loration of #erforations or lacerations confirms the diagnosis of a ductal injury in most instances. This leaves a small but significant #ercentage of #atients whom the diagnosis is in doubt and in whom more invasive investigations may be re>uired. 6ne recommendation has been to #erform o#erative #ancreatogra#hy. This #rocedure re>uires direct access to the duct by way of a duodenotomy or after resection of the tail of the #ancreas. The duct is cannulated with a %( #ediatric feeding tube, and - to 4 m3 of full+strength contrast medium is slowly injected! injuries are identified by obstruction or extravasation. 8are must be ta@en to avoid overdistention of the duct with contrast medium, which can #roduce #ancreatitis. The obvious shortcoming of this a##roach is the creation of a duodenal wound that must heal in a less than o#timal environment. Chile those who advocate transduodenal #ancreatogra#hy have had few duodenal fistulas, some have occurred. The #roblems associated with lateral duodenal fistulas are sufficient to dam#en enthusiasm for this a##roach. 1f the #atient already has a duodenal wound in the second #ortion, the above objections to #ancreatogra#hy are mitigated. "n ex#editious alternative to #ancreatogra#hy is to #ass a 1.% to -.$ mm coronary artery dilator into the main duct via the #a#illa and observe the #ancreatic wound. 1f the dilator is seen in the wound, a ductal injury is confirmed. Chen inserted through the #a#illa of 5ater, care must be ta@en to ensure that the dilator enters the #ancreatic duct and not the bile duct. This can be determined by #al#ation of the he#atic #edicle. The limitations of this a##roach are the same as those for #ancreatogra#hy. " third method for identifying #ancreatic ductal injuries is the use of endosco#ic retrograde #ancreatogra#hy ;47:=. This techni>ue may be difficult to #erform in an anestheti/ed #atient in the o#erating room, but the surgeon can assist by mani#ulating the duodenum or occluding the distal #ortion to facilitate air insufflation. 47: is very hel#ful in the delayed diagnosis of a ductal injury or in those #atients who are too sic@ to ex#lore ade>uately during the initial o#eration.

2o ideal method exists for identifying #ancreatic ductal injuries that cannot be ruled out by direct ex#loration. This dilemma tends to encourage aggressive local ex#loration, which may create a ductal injury where none existed. (or injuries involving the nec@, body, or tail of the #ancreas, this is of minor conse>uence because a sim#le resection distal to the injury cures the lesion. This is not the case for injuries to the head of the #ancreas, which cannot be treated with a sim#le resection. 7ather than acce#ting the ris@s of #ancreatogra#hy or aggressive local ex#loration, a final o#tion for identifying ductal injuries in the head of the #ancreas is to do nothing other than drain the #ancreas ;(ig. A+%4=. 1f a #ancreatic fistula or #seudocyst develo#s, the diagnosis is confirmed. The majority of #ancreatic fistulas close s#ontaneously with only su##ortive care. The authors #refer this a##roach to o#erative #ancreatogra#hy when the diagnosis of ductal injury in the head of the #ancreas is not a##arent and 47: is not #rom#tly available. Several o#tions are available for treating injuries of the nec@, body, and tail of the #ancreas when the main duct is transected. 'istal #ancreatectomy with s#lenectomy has been the #referred a##roach, but increasing interest in s#lenic #reservation has stimulated the use of the s#lenic+#reserving distal #ancreatectomy. This #rocedure is #erformed by dissecting the #ancreas from the s#lenic vein. "nother method for s#lenic #reservation is to bury the distal transected end of the #ancreas in a 7oux+en+ D limb. This techni>ue also conserves the distal #ancreas but is seldom #erformed because of the added com#lexity of the 7oux+en+D and the ris@s of #ancreatojejunostomy. (or injuries to the head of the #ancreas that involve the main #ancreatic duct but not the intra#ancreatic bile duct, there are few o#tions. 'istal #ancreatectomy is rarely indicated because the ris@ of #ancreatic insufficiency is significant if more than *% to )$ #ercent of the gland is resected. " more limited resection from the site of the injury to the nec@ of the #ancreas, with #reservation of the #ancreaticoduodenal vessels and common duct, allows closure of the injured #roximal #ancreatic duct. :ancreatic function can then be #reserved by a 7oux+en+D #ancreatojejunostomy with the distal #ancreas ;(ig. A+%%=. 1n contrast to injuries of the #ancreatic duct, diagnosis of injuries to the intra#ancreatic common bile duct is sim#le. The first method is to s>uee/e the gallbladder and observe the #ancreatic wound. 1f bile is seen lea@ing from the #ancreatic wound, the #resence of an injury is established. 6#erative cholangiogra#hy is diagnostic in >uestionable cases. 1f a #atient with an intra#ancreatic bile duct injury is critically ill from hemorrhage, external drainage can be used until the #atient is fit for definitive treatment. Small tangential #erforations of the intra#ancreatic bile duct may heal with this treatment, but it is seldom recommended. <ost authorities advocate division of the common bile duct su#erior to the first #ortion of the duodenum, ligation of the distal common duct, and reconstruction with a 7oux+en+D choledochojejunostomy. The use of drains has #layed an im#ortant role in the management of #ancreatic injuries. <any authorities advocate routine drainage of all #ancreatic injuries, but the authors do not drain contusions, lacerations in which the #robability of a major ductal injury is small, or #ancreatic anastomoses. :ancreatic injuries should be drained when there is a #ossible unidentified major ductal injury. 1f a drain is desirable, #ros#ective

studies have demonstrated that closed+suction devices are associated with fewer infectious com#lications than sum# or :enrose drains. "lmost all #ancreatic fistulas close s#ontaneously. 2utritional su##ort is im#ortant, and electrolyte re#lacement may be necessary. :ancreaticoduodenal 1njuries ?ecause the #ancreas and duodenum are in #hysical contact, combined #ancreaticoduodenal injuries are not uncommon, #articularly in #enetrating trauma. These lesions are dangerous because of the ris@ of duodenal suture line dehiscence and the develo#ment of a lateral duodenal fistula. The sim#lest treatment is to re#air the duodenal injury and drain the #ancreatic injury. This method is a##ro#riate for combined injuries without major duodenal tissue loss and without #ancreatic or biliary ductal injuries. Cith more extensive injuries, consideration should be given to #roviding additional #rotection for the duodenal suture line. The authors #refer #yloric exclusion to other alternatives. Chile most #ancreatic and duodenal injuries can be treated with relatively sim#le #rocedures, a few re>uire extensive o#erations, such as #ancreatoduodenectomy ;(ig. A+%A=. 4xam#les of such injuries include transection of the intra#ancreatic bile duct and the main #ancreatic duct in the head of the #ancreas, avulsion of the #a#illa of 5ater from the duodenum, and destruction of the entire second #ortion of the duodenum. <ost injuries of that nature are caused by higher+energy gunshot wounds. 1n #atients with a #ancreaticoduodenal injury who also have an intra#ancreatic bile duct injury, it is #ossible to use the combination of a #yloric exclusion and 7oux+en+D choledochojejunostomy to avoid a #ancreatoduodenectomy. The com#lexity and un#redictable #hysiology of the combined #rocedures ma@es the #ancreatoduodenectomy more attractive. 8olon There are three conce#tually different methods for treating colonic injuries #rimary re#air, colostomy, and exteriori/ed re#air. :rimary re#airs include lateral suture of #erforations and resection of the damaged colon with reconstruction by ileocolostomy or colocolostomy. The advantage of #rimary re#airs is that definitive treatment is carried out at the initial o#eration. The disadvantage is that suture lines are created in subo#timal conditions, and lea@age may occur. Several different styles of colostomies are used to manage colonic injuries. 1n some instances, the injured colon can be exteriori/ed li@e a loo# colostomy. The injured area can be resected and an end colostomy or ileostomy #erformed! the distal colon can be brought to the abdominal wall as a mucous fistula or oversewn and left in the abdominal cavity. " loo# colostomy can be created #roximal to a suture line that is left in the abdominal cavity. The advantage of colostomy is that it avoids an un#rotected suture line in the abdomen. The disadvantage is that a second o#eration is re>uired to close the colostomy. 6ften overloo@ed disadvantages are the com#lications associated with the creation of a colostomy, some of which may be fatal. 4xteriori/ed re#airs are created by the sus#ending of a re#aired #erforation or anastomosis on the abdominal wall with an a##liance after the fashion of a loo# colostomy. 1f after 1$ days the suture line does not lea@, it can be returned to the abdominal cavity under local anesthesia without subse>uent ris@ of lea@age. 1f the re#air brea@s down before 1$ days, it is treated as a loo# colostomy. &ealing is successful in %$ to A$ #ercent of cases. The

advantage is avoidance of an intra#eritoneal suture line when it is at ris@ of lea@age, and the disadvantage is that 4$ to %$ #ercent of #atients re>uire colostomy closure. Stomal com#lications similar to those of colostomies also can occur with the exteriori/ation. 2umerous large retros#ective and several #ros#ective studies have demonstrated that #rimary re#air is safe and effective in the majority of #atients with #enetrating injuries. 8olostomy is a##ro#riate in a few #atients but the current dilemma is how to select them. 4xteriori/ed re#air is no longer indicated because most #atients who were once candidates for this treatment are successfully managed by #rimary re#air. Two methods have been advocated that result in ,% to )$ #ercent of #enetrating colonic injuries being safely treated by #rimary re#air. The first is to re#air all #erforations that do not re>uire resection. 1f resection is re>uired because of the local extent of the injury and it is #roximal to the middle colic artery, the #roximal #ortion of the right colon u# to and including the injury is resected and an ileocolostomy #erformed. 1f resection is re>uired distal to the middle colic artery, an end colostomy is created and the distal colon oversewn and left within the abdomen. 1leocolostomy heals more reliably than colocolostomy because, in the trauma #atient who has suffered shoc@ and may be hy#ovolemic, assessing the ade>uacy of the blood su##ly of the colon is much less reliable than in elective #rocedures. The blood su##ly of the terminal ileum is never a #roblem. "nother a##roach is to re#air all injuries regardless of the extent and location ;including colocolostomy= and reserve colostomy for #atients with #rotracted shoc@ and extensive contamination. Systemic factors are more im#ortant than local factors in determining whether a suture line heals. ?oth of these a##roaches are reasonable and result in the majority of #atients being treated by #rimary re#airs. Chen a colostomy is re>uired, #erforming a loo# colostomy #roximal to a distal re#air should be avoided because a #roximal colostomy does not #rotect a distal suture line. "ll suture lines and anastomoses are #erformed with the running single+ layer techni>ue described in (ig. A+%,. 8om#lications related to the colonic injury and its treatment may include intraabdominal abscess, fecal fistula, wound infection, and stomal com#lications. 1ntraabdominal abscess occurs in a##roximately 1$ #ercent of #atients, and most are managed with #ercutaneous drainage. (istulas occur in 1 to . #ercent of #atients and usually #resent as an abscess or wound infection, which, after drainage, is followed by continuous fecal out#ut. <ost colonic fistulas heal s#ontaneously. Cound infection can be effectively avoided by leaving the s@in and subcutaneous tissue o#en and relying on healing by secondary intention. The s@in can be closed #rimarily in a##roximately A$ #ercent of #atients without develo#ing an infection. This treatment should be reserved for injuries with little contamination and in #atients with minimal blood loss and little subcutaneous fat. Stomal com#lications include necrosis, stenosis, obstruction, and #rola#se. Ta@en together they occur in a##roximately % #ercent of #atients, and most re>uire reo#eration. 2ecrosis is a serious com#lication that must be recogni/ed and treated #rom#tly. (ailure to do so can result in life+ threatening se#tic com#lications, including necroti/ing fasciitis. 7ectum

7ectal injuries are similar to colonic injuries with res#ect to the ecology of the luminal contents, the structures and blood su##ly of the wall, and the nature and fre>uency of com#lications. They differ in two im#ortant ways mechanisms of injury and accessibility. The rectum is often injured by gunshot wound, rarely by stab wound, and fre>uently by acts of autoeroticism and sexual misadventure. The rectum also is subject to high+ #ressure injuries that can be caused by air guns or water under high #ressure, as used in golf course irrigation systems. The second difference is limited access to the rectum because of the surrounding bony #elvis. The diagnosis is suggested by the course of #rojectiles, the #resence of blood on digital examination of the rectum, and history. :atients in whom a rectal injury is sus#ected should undergo #roctosco#y. &ematomas, contusions, lacerations, and gross blood may be seen. 1f the diagnosis is in >uestion, x+ray examinations with soluble contrast medium enemas are indicated. 1t may be difficult to determine whether an injury is #resent. These #atients should be treated as though an injury were #resent. The #ortion of the rectum #roximal to the #eritoneal reflection is referred to as the intra#eritoneal segment, and that #ortion distal to the reflection as the extra#eritoneal segment. This distinction is blurred somewhat because the broad #osterior as#ect of the intra#eritoneal #ortion could be considered as either. 1njuries of the intra#eritoneal #ortion ;including its #osterior as#ect= are treated as #reviously outlined in the section on colonic injuries. "ccess to extra#eritoneal injuries is so restricted, es#ecially in the narrow male #elvis, that indirect treatment usually is re>uired. Chile colostomies #roximal to a suture line are avoided in #atients with colonic injuries, there is often no o#tion in #atients with extra#eritoneal injuries! sigmoid colostomies are a##ro#riate for most #atients. :ro#erly constructed loo# colostomies are #referred because they are >uic@ and easy to fashion, and they #rovide total fecal diversion. 4ssential elements include ;1= ade>uate mobili/ation of the sigmoid colon so that the loo# rests on the abdominal wall without tension! ;-= maintenance of the s#ur of the colostomy ;the common wall of the #roximal and distal limbs after maturation= above the level of the s@in with a 1 cm nylon rod or similar device! ;.= longitudinal incision in the taeniae coli! and ;4= immediate maturation in the o#erating room using .+$ braided absorbable suture ;(ig. A+%*=. " sta#le line can be a##lied across the distal limit to ensure com#lete diversion, but it is not necessary, and it com#licates closure of the colostomy. " mucous fistula is never re>uired and should be avoided because of the ris@ of necrosis if the inferior mesenteric or su#erior rectal arteries were injured or otherwise ligated. 1f a #erforation is inadvertently uncovered during dissection, it should be re#aired as described #reviously. 6therwise, it is not necessary to ex#lore the extra#eritoneal rectum to re#air #erforation. 1t may be extremely difficult or im#ossible to accom#lish ex#loration. 1f the injury is so extensive that it must be re#aired, the rectum is divided at the level of injury, the distal rectum is oversewn or sta#led, and an end colostomy is created ;&artmann's #rocedure=. 1n rare instances in which the anal s#hincters have been destroyed, an abdomino#erineal resection may be necessary. 4xtra#eritoneal injuries of the rectum should be drained via a retroanal incision ;see (ig. A+%*=. Caldeyer's fascia is #articularly tough at this level and may need to be shar#ly incised. The drains, :enrose or closed+suction, should be #laced close to the

#erforation or suture line and left until they fall out s#ontaneously or drainage diminishes, which usually occurs within , to 1$ days. 1rrigation of the distal rectum with various solutions is advocated by some authorities! this has not been determined to be hel#ful or harmful in retros#ective studies, but it may be of benefit in a #atient whose rectum is full of feces. 1f it is done, the irrigation solution should be isotonic and the anus should be mechanically dilated to avoid building u# #ressure that might force feces out of an unre#aired #erforation. 1f the #atient has a concomitant bladder injury and adjacent suture lines are created, a fla# of viable omentum should be #laced between them to reduce the ris@ of a rectovesical fistula. There have been re#orts of treating small extra#eritoneal rectal injuries by suture or drainage alone. The outcomes have been acce#table, and colostomies have been avoided. There is insufficient ex#erience to recommend this a##roach because #elvic se#sis associated with rectal injury is highly lethal. 8om#lications of rectal injuries are similar in nature and fre>uency to those of colonic injuries. :elvic osteomyelitis also may occur. ?one bio#sy and bacteriology should be #erformed to secure the diagnosis. 8ulture+s#ecific intravenous antibiotics should be administered for - to . months. 'ebridement might be necessary. Stomach and Small 1ntestine 1njuries of the stomach and small bowel #ose no s#ecial #roblems or controversies. Hastric injuries can be missed occasionally if a wound is located within the mesentery of the lesser curvature or high in the #osterior fundus. The stomach should be clam#ed at the #ylorus and inflated with air or methylene+blue+colored saline solution if there is any >uestion. :atients with injuries that damage the nerves of 3atarget or both vagus nerves should have a drainage #rocedure. 1f the distal antrum or #ylorus is severely damaged it can be reconstructed with a ?illroth 1 or 11 #rocedure. " running two+layer suture line is #referred for the stomach because of its rich blood su##ly and because #osto#erative hemorrhage has occurred when the single+layer techni>ue has been used in the stomach. There are no s#ecial issues in treating injuries of the small bowel. Counds of the mesenteric border can be missed if the ex#loration is not com#rehensive. <ost injuries are treated with a lateral single+layer running suture. <ulti#le #enetrating injuries often occur close together. 7ather than #erforming many lateral re#airs, judicious resections with end+to+end anastomosis can save considerable time. Gidneys Three imaging techni>uesE8T, intravenous #yelogra#hy ;15:=, and arteriogra#hyE can be used to evaluate accurately the extent of renal injury. The contrast medium re>uired for each is ne#hrotoxic and limits the number of studies that can be #erformed. The fact that there are two identical organs ma@es the sacrifice of one a viable thera#eutic o#tion. 2early )% #ercent of all blunt renal injuries are treated nono#eratively. The diagnosis is sus#ected by the finding of microsco#ic or gross hematuria and confirmed by 8T or 15:. <ost cases of urinary extravasation and hematuria resolve in a few days with bed rest. :ersistent gross hematuria can be treated by emboli/ation. :ersistent urinomas can be drained #ercutaneously. 6#erative treatment is necessary occasionally for similar lesions that do not res#ond to these less invasive measures.

1f a #erine#hric hematoma is encountered during la#arotomy from blunt trauma, ex#loration is indicated if it is ex#anding or #ulsatile. 5ery large hematomas should be ex#lored because of the ris@ of a major vascular injury. 5ascular control at the junction of the renal vessels with the aorta and vena cava is not always necessary before entering the hematoma. 1f emergent vascular control is needed, a large curved vascular clam# can be #laced easily across the hilum from below with the clam# #arallel to the vena cava and aorta. &emostatic and reconstructive techni>ues used to treat blunt renal injuries are similar to those used to treat the liver and s#leen. The collecting system should be closed se#arately and the renal ca#sule #reserved to close over the re#air of the collecting system ;(ig. A+%)=. :ermanent sutures should be avoided because of the ris@ of calculus formation. The authors #refer absorbable monofilament sutures because of their lac@ of abrasiveness. 1f ne#hrectomy is being considered and the status of the o##osite @idney is un@nown, the latter should be #al#ated. The #resence of a #al#ably normal o##osite @idney is assurance that the #atient will not be rendered ane#hric by a unilateral ne#hrectomy. Unilateral renal agenesis occurs in 1B1$$$ #atients. The renal arteries and veins are uni>uely susce#tible to traction injury caused by blunt trauma. "s the artery is stretched, the inelastic intima and media may ru#ture. This causes thrombus formation, resulting in high+grade stenosis or thrombosis. The injury can be detected by 8T, 15:, or du#lex scanning. 1f the #atient does not have more urgent injuries and treatment and re#air can be accom#lished within . h of admission, it should be attem#ted. Successful renal artery re#air in a #atient who #resents with com#lete thrombosis is rare. 1f re#air is not #ossible within this time frame, leaving the @idney in situ to resorb does not necessarily lead to hy#ertension or abscess formation. 1solated renal vein injuries can occur from blunt trauma. The vein may be torn or avulsed from the vena cava, and a large hematoma develo#s that often leads to an o#eration and ne#hrectomy. "ll #enetrating wounds to @idneys are ex#lored. ?leeding #erforations and lacerations are treated using the same hemostatic techni>ues described above. 7enal vascular injuries are common after #enetrating trauma, and they may be dece#tively tam#onaded and result in delayed hemorrhage. 1njuries involving the collecting system should be closed se#arately if they are large. Small #erforations that #enetrate the collecting system can be controlled by suture of the ca#sule and #arenchyma. :erforations of the renal #elvis should be meticulously re#aired with fine sutures. Ureters 1njuries of the ureters from external trauma are rare. They occur in a few #atients with #elvic fractures and are uncommon in #enetrating trauma because the silhouette they #resent is so small. The diagnosis in blunt trauma may be made by 8T, 15:, or retrograde ureterogra#hy. The injury often is not identified until a com#lication, e.g., a urinoma, is a##arent. 1n #enetrating trauma, ureteral injuries are discovered during the ex#loration of the retro#eritoneum, although missed injuries also are not unusual. 1f an injury is sus#ected but not identified, methylene blue or indigo carmine is administered intravenously. Staining of the tissue adjacent to the injury can facilitate identification of the injury site. <ost injuries can be re#aired #rimarily using the same techni>ue as that described earlier for small arteries, using %+$ absorbable

monofilament suture. Chen the ureter is mobili/ed, the dissection should be at least 1 cm lateral and medial to the ureter to avoid injury to its delicate vascular #lexus. The @idney also can be mobili/ed to increase ureteral mobility. 1njuries of the distal ureter can be treated by reim#lantation. The #soas hitch and ?oari fla# may be hel#ful in selected distal ureteral injuries ;(ig. A+A$=. 1f the #atient is critically ill and being considered for a staged la#arotomy or if the surgeon is uncomfortable with ureteral re#air, the ureter can be ligated on both sides of the injury and a ne#hrostomy #erformed ;(ig. A+A1=. ?ladder ?ladder injuries are diagnosed by cystogra#hy, 8T, or during la#arotomy. " #ostvoid view enhances the accuracy of cystogra#hy. ?lunt ru#tures of the intra#eritoneal #ortion are closed with a running single+layer closure using .+$ absorbable monofilament suture. ?lunt extra#eritoneal ru#ture is treated with a (oley catheter! direct o#erative re#air is not necessary. 8ystograms can be used to determine when the catheter can be removed, which is usually in 1$ to 14 days. :enetrating bladder injuries are treated in the same fashion, although injuries near the trigone should be re#aired through an incision in the dome so that iatrogenic injury to the intravesicular ureter is avoided by direct visuali/ation. Urethra ?lunt disru#tion of the #osterior urethra is managed by bridging the defect with a (oley catheter. This usually re>uires #assing catheters through the urethral meatus and through an incision in the bladder. 6nce the catheter bridges the defect, healing occurs as the intervening hematoma resorbs. Strictures are not uncommon but can be managed electively. :enetrating injuries are treated by direct re#air. Hynecologic 1njuries Hynecologic injuries are rare. 6ccasionally, the vagina is lacerated by a shar# bone fragment from a #elvic fracture. :enetrating injuries to the vagina, uterus, fallo#ian tubes, and ovaries also are uncommon. The usual hemostatic techni>ues are used to control bleeding, and suture re#air is used to close defects that communicate with a lumen. 7e#air of a transected fallo#ian tube can be attem#ted but #robably is unjustified! a subo#timal re#air increases the ris@ of tubal #regnancy. Transection at the injury site with #roximal ligation and distal sal#ingectomy is a more #rudent a##roach. Trauma in #regnancy also is rare. ?lunt trauma can cause uterine ru#ture, which almost always results in fetal demise. The outcome of #enetrating uterine injuries is more variable and is de#endent on #enetration of the uterine cavity, damage to the #lacenta, and fetal injury. S#ontaneous abortion is a fre>uent outcome. 6n occasion, a mother #resents with life+ threatening injuries, including severe head injury or cardiac arrest from hemorrhagic shoc@. 1f the fetus is viable by dates or examination, an emergency cesarean section should be considered whether or not the mother's life can be saved. This occurs more often with severe head injury than cardiac arrest from hemorrhagic shoc@. 8om#letion of the 3a#arotomy and :osto#erative 8onsiderations

"fter re#air of all injuries, the abdomen is irrigated with saline warmed to body tem#erature. This will not eliminate all bacteria, but an effort should be made to remove blood clots, food #articles, and gross enteric and fecal contamination. :atients with moderate to severe injuries are at ris@ for multi#le organ failure and nosocomial infection. The integrity of the gut has a #ivotal role in the severity and outcome of these com#lications. 2eedle+catheter jejunostomies are #laced in all such #atients before abdominal closure ;(ig. A+A-=. 4nteric feedings are initiated as soon as the #atient arrives in the intensive care unit and are advanced to full strength within ,- h. Total #arenteral nutrition might be necessary in some #atients, but it causes mucosal atro#hy, which may im#air the barrier function of the mucosa. The abdominal incision is closed with a running 2o. - nylon suture that includes at least 1.% cm of fascia. Tension of the suture should be just enough to a##roximate the fascia but no more. Subcutaneous sutures are never used. The s@in is closed selectively, de#ending on the amount of contamination and subcutaneous tissue. The greater the degree of contamination and subcutaneous fat, the more fre>uently the s@in and subcutaneous tissue should be left o#en. :atients initially treated with staged la#arotomy should have the s@in and subcutaneous tissue left o#en. :elvis :elvic fractures can cause exsanguinating retro#eritoneal hemorrhage without associated major vascular injury! branches of the internal iliac vessels and the lower lumbar arteries are often res#onsible. &emorrhage also comes from small veins and from the cancellous #ortion of the fractured bones. " direct surgical a##roach is rarely effective because many of the sources of hemorrhage are outside of the surgical field. <ost #elvic fractures that cause life+threatening hemorrhage involve disru#tion of the #osterior elements, i.e., the sacroiliac joints and associated ligaments, and are often biomechanically unstable. " hemodynamically unstable #atient with an unstable #elvic fracture may be bleeding from sources other than the #elvis, such as the s#leen. 3arge retro#eritoneal hematomas also can cause a hemo#eritoneum, #articularly if overlying #eritoneum ru#tures. 'etermining the source of hemorrhage #oses a thera#eutic #roblem because it is desirable not to o#erate for a retro#eritoneal hematoma, whereas a la#arotomy may be essential to deal with hemorrhage from the s#leen or liver. Ultrasonogra#hy and ':3 have been used to aid in this decision. 1f 1$ m3 or more of free blood can be as#irated from the #eritoneal cavity, or if the ultrasound scan is une>uivocally #ositive, then the blood is assumed to be coming from an injury unrelated to the #elvic fracture, and a la#arotomy is #erformed. 1f the ':3 is #ositive by laboratory analysis or if it is negative, attention is directed toward treating the #elvic fracture. The decision to o#erate or not may #rove to have been the wrong course, and the #lan may need to be altered accordingly. Several methods have been used to control hemorrhage associated with #elvic fractures. These include immediate external fixation, medical antishoc@ trousers ;<"ST=, angiogra#hy with emboli/ation, and #elvic #ac@ing. 2o single techni>ue is effective for treating all fractures, and there is little agreement among s#ecialists as to which should be used. "nterior external fixation is not intended to #rovide definitive fracture stabili/ation in most instances. 1ts advocates intend for the device to decrease

#elvic volume, to tam#onade bleeding, and to #revent secondary hemorrhage that may occur if the fractured bones shift. <any ortho#aedic surgeons are unconvinced of the efficacy of external fixation for grossly unstable #osterior fractures. "ntishoc@ trousers can #rovide some stability for the fracture and #robably tam#onade venous hemorrhage. The disadvantages are the loss of access to the abdomen and the ris@ of lower+extremity com#artment syndrome. "ngiogra#hy with emboli/ation is very effective for controlling arterial hemorrhage, but arterial hemorrhage occurs in only 1$ to -$ #ercent of #atients with active hemorrhage from #elvic fractures. :elvic #ac@ing may control venous hemorrhage. The only reason to consider its use is when a #elvic hematoma is inadvertently entered or if it has ru#tured. "n algorithm for managing #atients is shown in (ig. A+A.. "nother challenge is the o#en #elvic fracture. 1n many instances the wounds are located in the #erineum, and the ris@ of #elvic se#sis and osteomyelitis is high. To reduce the ris@ of infection, a sigmoid colostomy is recommended. The #elvic wound is manually debrided and irrigated daily with a high+#ressure #ulsatile irrigation system until granulation tissue covers the wound. The wound is then left to heal by secondary intention. This a##roach has been highly successful. 4xtremities 5ascular 1njuries with (ractures 5ascular injuries associated with fractures are rare, occurring in only $.% to . #ercent of all #atients with extremity fractures. They also are more severe than isolated vascular injuries or fractures, and am#utation rates of more than %$ #ercent have been noted. These injuries can be caused by blunt and #enetrating trauma. :articular fractures and dislocations are more li@ely to be associated with vascular injury than others. 1n the u##er extremity, a fracture of the clavicle or the first rib may lacerate the distal subclavian artery. The axillary artery may be injured in #atients with dislocations of the shoulder or #roximal humeral fractures. Su#racondylar fractures of the distal humerus and dislocations of the elbow are @nown for their association with brachial artery injuries. 1n all these fractures and dislocations, vascular injuries are uncommon and occur in only a small fraction of #atients. 1n the lower extremity, the ortho#aedic injury most commonly associated with vascular injury is dislocation of the @nee, in which the #o#liteal artery or vein may be injured in as many as .$ #ercent of #atients. The #o#liteal vessels also may be injured in #atients with su#racondylar fractures of the femur or tibial #lateau fractures. 5ascular injury can occur in #atients with combined fractures of the tibia and fibula. The im#ortance of a careful neurologic examination in these #atients is critical. Three distinctly different mechanisms can #roduce #aralysis and numbness in an injured extremity ischemia, nerve injury, and com#artment syndrome. "s a result, failure to accurately #erform and document the neuromuscular function of the injured extremity can lead to missed injuries, im#ro#er treatment, and unrealistic ex#ectations on the #art of the #atient. :erha#s the greatest controversy in the treatment of #atients with combined ortho#aedic and vascular injuries is the order in which the #rocedures are to be #erformed. "dvocates of initial fracture treatment argue that it is difficult to judge the length of a vascular graft ;or whether one is re>uired= when the ends of the fractured

bone are overriding or if angulation is #resent. "lso, extensive ortho#aedic mani#ulation can easily disru#t delicate vascular re#airs. 6##onents of this a##roach argue that the length of time re>uired to stabili/e the fracture may cause further ischemic damage of the limb. The use of tem#orary intravascular shunts has been recommended as a com#romise to avoid ischemia during fracture treatment. " rational a##roach is to consider all the above o#tions in light of the condition of the #atient's injured extremity. 1f the extremity is clearly viable and there is no hemorrhage from the vascular injury, the fracture should be treated first. 1f the limb is at ris@ from ischemia, #rom#t revasculari/ation is re>uired. Chen little or no fracture mani#ulation is antici#ated, definitive vascular re#air is #erformed first. 1f extensive mani#ulation is re>uired in an ischemic extremity, tem#orary shunts can be #laced and vascular re#air #erformed after the fracture has been treated ;(ig. A+A4=. The extent of injury causing combined ortho#aedic and vascular injuries fre>uently results in o#en fractures, and the use of external fixation devices for these injuries has become common. These devices may significantly hinder vascular re#air because of their location and bul@. :reo#erative #lanning between the vascular and ortho#aedic surgeon should serve to avoid this technical #roblem. ?ecause of the severity of combined ortho#aedic and vascular injuries, the need for immediate am#utation might arise. :rimary am#utation should be strongly considered when the #rimary nerve is transected in addition to a fracture and arterial injuryE such as when the #o#liteal nerve is transected along with injuries to the #o#liteal artery and the distal femur. This difficult decision is best reached through a collaborative effort involving the trauma surgeon, the ortho#aedic surgeon, and, in certain cases, the neurosurgeon. :rolonged rehabilitation resulting in a #araly/ed, anesthetic extremity #rone to ulceration is hardly better than the #rom#t fitting of a good #rosthesis. 8om#artment Syndrome " com#artment syndrome can occur anywhere in the extremities, including the thighs, buttoc@s, arms, and hands. The #atho#hysiology is an acute increase in #ressure in a closed s#ace that im#airs blood flow to the structures within. The causes of extremity com#artment syndrome include arterial hemorrhage into a com#artment, venous ligation or thrombosis, crush injuries, infections, crotalid envenomation, and ischemiaBre#erfusion. 1n conscious #atients, #ain is the #rominent sym#tom. "ctive or #assive motion of involved muscles increases the #ain. :rogression to #aralysis can occur. The most fre>uent site is in the anterior com#artment of the leg! a well+ described early sign is #aresthesia or numbness between the first and second toes caused by #ressure on the dee# #eroneal nerve. 1n comatose or obtunded #atients, the diagnosis is more difficult to secure. " com#atible history, firmness of the com#artment to #al#ation, and diminished mobility of the joint are suggestive. The #resence or absence of a #ulse distal to the affected com#artment is notoriously unreliable in the diagnosis of a com#artment syndrome. " fro/en joint and myoglobinuria are late signs and suggest a #oor #rognosis. 8om#artment #ressure can be measured. The small, hand+held Stry@er manometer is a convenient tool for this #ur#ose. :ressures greater than 4% mm&g

usually re>uire o#erative intervention. :ressures between .$ and 4% mm&g should be carefully evaluated and watched closely. Treatment consists of measures to reduce com#artment #ressure, including elevation of the extremity, evacuation of hematomas, and fasciotomy. "s long as neurologic and muscular function are intact, elevation and observation are sufficient. The evacuation of hematomas as a conse>uence of arterial injury almost always results in a fasciotomy, because the com#artment must be o#ened to treat the vascular injury. ?ecause the lower extremity is most fre>uently involved, the two+incision, four+ com#artment fasciotomy is shown in (ig. A+A%. 2ote that the soleus muscle must be detached from the tibia to decom#ress the dee# flexor com#artment. :rognosis is related to the severity, duration, and cause of the com#artment syndrome. The best results are obtained in #atients with arterial hemorrhage and venous ligation or thrombosis who undergo early fasciotomy. Those who develo# com#artment syndrome from crush injuries, crotalid envenomation, and #articularly ischemiaBre#erfusion have a #oor #rognosis because of the #reexisting muscle and nerve damage caused by the original insult. (asciotomy should be attem#ted, although infection and am#utation are a fre>uent outcome. :rognosis and 6utcome 4valuation :rognosis and outcome evaluation for various injuries began during Corld Car 1. "t that time, mortality was calculated according to the organ injured. (or exam#le, all #atients who suffered an injury to the colon were determined to have lived or died. "ccordingly, fre>uency of death was assigned to that #articular organ, and it was assumed that any #atient with a colonic injury had the same #robability of dying. ?ecause no other factors such as associated injuries or #hysiologic condition were considered, it is not sur#rising that any abdominal visceral injury was associated with a mortality rate of %$ to A$ #ercent. This #ractice continued during Corld Car 11 and resulted in some remar@able conclusions that were subse>uently shown to be incorrect. :erha#s the best exam#le of this was the conclusion that #erforming colostomies for all colonic injuries during Corld Car 11 resulted in a reduction of mortality for #atients so treated from A$ #ercent during the first Corld Car 1 to .$ #ercent in Corld Car 11. 8ivilian literature in the second half of this century recogni/ed that the number of injured organs, major fractures, blood loss, and the #resence of shoc@ were all #redictive of outcome but only in the crudest fashion. The >uality of the local 4<S system is another confounding factor. 7egions with ra#id res#onse and trans#ort are more li@ely to bring severely injured #atients to the emergency room with signs of life than less efficient systems. "s a result, mortality is #aradoxically greater in regions with better 4<S systems. Today there are anatomic and #hysiologic grading systems. The anatomic systems are derived from the "bbreviated 1njury Scale ;"1S=, which was develo#ed during the 1)%$s. The "1S is a list that assigns a number from 1 ;minor injury= to A ;always fatal= for the various s#ectra of organ injuries. The "1S evaluates only solitary injuries! it cannot reflect the additional im#act of multi#le injuries. The 1njury Severity Score ;1SS= was devised to su##lement this shortcoming. The 1SS is calculated by s>uaring the "1S from the worst injured of three body com#artments ;head and nec@, face, chest, abdomen and #elvis, #elvic girdle, and extremities= and adding them together. Cith the always+fatal score of A excluded, scores can range

from 1 to ,%. 1SS is further characteri/ed according to the mechanism of injury ;blunt versus #enetrating= and age ;less than %% years versus %% years or greater=. The 1SS, however, suffers from the inability to consider multi#le injuries in one com#artment, the assum#tion that all com#artments are of e>ual significance, and the lac@ of recognition of the #atient's #hysiologic status. Several #hysiologic scoring systems have been develo#ed. The 7evised Trauma Score ;7TS= is most commonly used. 1t is calculated from the Hlasgow 8oma Scale, blood #ressure, and res#iratory rate, with the H8S being most heavily weighted. The 7TS is a #urely #hysiologic score that is com#romised by the relative insensitivity of these common clinical measurements. The T71SS method ;Trauma and 1njury Severity Score= was develo#ed to incor#orate the 7TS and 1SS, thereby combining #hysiologic and anatomic score and enhancing the im#ortance of head injury. T71SS remains fundamentally flawed because of the limitations of 7TS and 1SS. 2ewer versions of the T71SS conce#t, such as "S86T ;" Severity 8haracteri/ation of Trauma=, also have failed to im#rove the #rediction of #ostinjury mortality. :erha#s more im#ortant than mortality, outcome assessment must include the critical issues of total medical resource consum#tion ;com#lications, hos#ital length of stay, cost for medical care, etc.= and ca#acity to return to #reinjury functional status. Several functional outcome scales have been develo#ed, but a standard has yet to be established. ?1T4S "2' ST12HS 6( "21<"3S "2' 12S48TS 7abies 1n 1)%$ a##roximately %$$$ cases of rabies were re#orted among dogs and 1* were re#orted in humans. 6nly 1A$ cases of rabies in dogs were re#orted in 1)*). 1n 1))1 there were three #atients in the United States who died from rabies. Cild animals, therefore, constitute the most im#ortant #otential source of infection for humans and domestic animals in the United States! however, the ex#osure that results from fre>uent contact between domestic dogs and humans continues to be the basis of most antirabies treatment. "##roximately 1$,$$$ #atients receive #ostex#osure #ro#hylaxis for rabies annually. 7abies among wild animals, es#ecially s@un@s, foxes, raccoons, and bats, account for more than *% #ercent of @nown cases of animal rabies. "lthough any mammal may carry rabies, rodents are seldom found to be infected with rabies and have not been @nown to cause rabies in human beings in the United States. Coodchuc@s accounted for ,$ #ercent of rabies among rodents re#orted to the 8enters for 'isease 8ontrol and :revention ;8'8=. 1n all cases involving rodents, the state or local health de#artment should be consulted before a decision is made to initiate #ostex#osure antirabies #ro#hylaxis. <any of the cases of human rabies re#orted in the #ast 1$ years have resulted from ex#osure outside of the United States! in much of the rest of the world the dog is the major s#ecies with rabies and the major source of rabies among human beings. 8ircumstances surrounding the attac@ fre>uently furnish vital information as to whether or not vaccination is indicated. <ost domestic animal bites are #rovo@ed attac@s! if this history is obtained, rabies vaccine usually can be withheld if the animal a##ears healthy. 8hildren are fre>uently bitten while attem#ting to se#arate fighting animals or while teasing or accidentally hurting the animal. ?ites during attem#ts to feed or handle an a##arently healthy animal are generally regarded as #rovo@ed. :ostex#osure #ro#hylaxis combining local wound treatment, #assive immuni/ation,

and vaccination is over )$ #ercent effective when a##ro#riately a##lied. "n un#rovo@ed attac@ by a domestic animal is more li@ely than a #rovo@ed attac@ to indicate that the animal is rabid. " fully vaccinated dog or cat is unli@ely to become infected with rabies, although rare cases have been re#orted. "ny #enetration of the s@in by teeth constitutes a bite ex#osure. ?ites to the face and hands carry the highest ris@, but the site of the bite should not influence the decision to begin treatment. 2onbites include scratches, abrasions, o#en wounds, or mucous membranes contaminated with saliva. 1f the material containing the virus is dry, the virus can be considered noninfectious. 6ther contact by itself, such as #etting a rabid animal and contact with the blood, urine, or feces of a rabid animal, does not constitute an ex#osure and is not an indication for #ro#hylaxis. <ost animal bites sustained by human beings are caused by dogs and cats, and in most instances it is #ossible to observe the biting animal for the develo#ment of rabies. 'omestic animals that bite a #erson should be ca#tured and observed for sym#toms of rabies for 1$ days. 1f none develo#, the animal may be assumed to be nonrabid. 1f the animal dies or is @illed, the head is sent #rom#tly to a #ublic health laboratory for examination. The tissue re>uires refrigeration, but not free/ing, and trans#ortation to the laboratory after the animal's death must be ra#id. 8linical signs of rabies in wild animals cannot be inter#reted reliably! therefore, any wild animal that bites or scratches a #erson should be @illed at once ;without unnecessary damage to the head= and the brain examined for evidence of rabies. Travelers to "sia, "frica, and 8entral and South "merica should be aware that more than %$ #ercent of the rabies cases among human beings in the United States result from ex#osure to dogs outside the United States ;Table A+)=. 1t is acce#ted that the incubation #eriod for rabies in human beings ranges from 1$ days to 1 year, with most cases occurring within -$ to )$ days of ex#osure. 1n cases of ex#osure of the head, nec@, or u##er extremities, the incubation #eriod is #otentially less than .$ days. 3ocal care of the animal bite should consist of thorough irrigation, cleansing with soa# solution, and debridement. "dministration of tetanus toxoid and an antibiotic may be indicated. :ostex#osure #ro#hylaxis in addition to local wound treatment consists of human rabies immune globulin ;&71H= ;1mogam 7abies= and vaccine. There are two rabies vaccines available in the United States human di#loid cell rabies vaccine ;&'85= or rabies vaccine adsorbed ;75"= ;1movax=. 4ither is administered in conjunction with &71H at the beginning of #ostex#osure thera#y. " regimen of five 1+m3 doses of &'85 or 75" is given intramuscularly. The first dose of the five+dose course is given as soon as #ossible after ex#osure. "dditional doses are given on days ., ,, 14, and -* after the first vaccination. (or adults, the vaccine is always administered intramuscularly in the deltoid area. (or children, the anterolateral as#ect of the thigh also is acce#table. The gluteal area should never be used for &'85 or 75" injections because administration in this area results in lower neutrali/ing antibody titers. :ostex#osure antirabies vaccinations should always include administration of #assive antibody and vaccine, exce#t for those who have #reviously received com#lete vaccine regimens with a cell culture vaccine or who have been vaccinated with other

ty#es of vaccines and have had documented rabies antibody titers! these #ersons should receive only vaccine. ?ecause the antibody res#onse after the recommended #ostex#osure vaccination regimen has been satisfactory, routine #ostvaccination serologic testing is not recommended unless the #atient is @nown to be immunosu##ressed. The state health de#artment can be contacted for recommendations. &71H is administered only once to #rovide immediate antibodies until the #atient res#onds to the vaccine by actively #roducing antibodies. 1f &71H was not given when vaccination was begun, it can be given through the seventh day after administration of the first dose of vaccine. ?eyond the seventh day, &71H is not indicated because the antibody res#onse to cell culture vaccine is #resumed to have occurred. The recommended dosage of &71H is -$ 1UB@g body weight. This formula is a##licable for all age grou#s, including children. 1f anatomically feasible, u# to one+ half the dose of &71H should be thoroughly infiltrated in the area around the wound, and the rest should be administered intramuscularly in the gluteal area. &71H should never be administered in the same syringe or into the same anatomic site as vaccine. ?ecause &71H may #artially su##ress active #roduction of antibody, no more than the recommended dose should be given ;Table A+ 1$=. 3ocal reaction such as #ain, erythema, and swelling or itching at the injection site has been re#orted in .$ to ,% #ercent of reci#ients. &eadache, nausea, abdominal #ain, muscle aches, and di//iness have been re#orted from % to 4$ #ercent of reci#ients. 8ases of neurologic illness resembling Huillain+?arrL syndrome that resolved have been re#orted. 3ocal #ain and low+grade fever may follow injections of &71H. There is no evidence that he#atitis ? virus, human immunodeficiency virus, or other viruses have ever been transmitted by commercially available &71H in the United States. 8orticosteroids can interfere with the develo#ment of active immunity after vaccination and may #redis#ose the #atient to rabies. Chen rabies #ostex#osure #ro#hylaxis is administered to #ersons receiving steroids or other immunosu##ressive thera#y, it is es#ecially im#ortant that a serum sam#le be tested for rabies antibody to ensure that an acce#table antibody res#onse has develo#ed. ?ecause of the #otential conse>uences of inade>uately treated rabies ex#osure, and because there is no indication that fetal abnormalities have been associated with rabies vaccination, #regnancy is not considered a contraindication to #ostex#osure #ro#hylaxis. <anifestations and Treatment of 7abies Sym#toms of rabies include a -+ to 4+day #rodromal #eriod in which the #atient reaches the excited stage. :aresthesia in the region of the bite is an im#ortant early sym#tom. 6ther sym#toms include headaches, vertigo, stiff nec@, malaise, lethargy, and severe #ulmonary, sym#toms including whee/ing, hy#erventilation, and dys#nea. The #atient may have s#asm of the throat muscles with dys#hagia. The outstanding sym#tom of rabies is related to swallowing. 'rooling, maniacal behavior, and convulsions ensue and are followed by coma, #aralysis, and death. 1ntensive res#iratory su##ortive care is essentially the only treatment to offer. :henytoin ;'ilantin= can be used for sei/ures. Sna@es 1n 2orth "merica all the #oisonous sna@es of medical im#ortance are #it vi#ers, of the family 8rotalidae, and the coral sna@e, of the 4la#idae family. The #it vi#ers include

rattlesna@es, cottonmouth moccasin, and the co##erhead. "##roximately *$$$ #ersons are bitten each year by #oisonous sna@es, with over )* #ercent of bites occurring on the extremities. 7attlesna@es are res#onsible for a##roximately ,$ #ercent of deaths from sna@ebites, while death from the bite of a co##erhead is extremely rare. :it 5i#ers :it vi#ers are named for the characteristic #it, a highly sensitive heat+ sensing organ that is located between the eye and the nostril on each side of the head. These sna@es may be identified by their elli#tical #u#il, as o##osed to the round #u#il of harmless sna@es. 2on#oisonous sna@es do not have #its. &owever, the coral sna@e does have a round #u#il and lac@s the facial #it. :it vi#ers have two well+develo#ed fangs that #rotrude from the maxillae, whereas most non#oisonous sna@es have rows of teeth without fangs. :it vi#ers also may be identified by turning the sna@e's belly u#ward and noting the single row of subcaudal #lates ;(ig. A+AA=. The coral sna@e is a small, brightly colored sna@e with red, yellow, and blac@ rings. This color combination also occurs in non#oisonous sna@es, but the alternation of colors is different. 6nly the coral sna@e has a red ring next to a yellow ring. The nose of the coral sna@e is blac@. The venoms of #oisonous sna@es consist of en/ymatic com#lex #roteins that affect all soft tissues. 5enoms have been shown to have neurotoxic, hemorrhagic, thrombogenic, hemolytic, cytotoxic, antifibrinolytic, and anticoagulant effects. <ost venoms contain hyaluronidase, which enhances the ra#id s#read of venom by way of the su#erficial lym#hatics. There may be considerable variation in the venom effect. 2eurotoxic features such as muscle cram#ing, fasciculation, wea@ness, and res#iratory #aralysis or hemolytic characteristics may #redominate, de#ending on the sna@e. :ain from the bite of a #it vi#er is excruciating and #robably the sym#tom that most easily differentiates #oisonous from non#oisonous sna@ebites. :it vi#ers characteristically #roduce one or two fang mar@s. &y#otension, wea@ness, sweating and chills, di//iness, nausea, and vomiting are other systemic sym#toms. 3ocal signs and sym#toms can include swelling, tenderness, #ain, and ecchymosis and may a##ear within minutes at the site of venom injection. 1f no edema or #ain is #resent within .$ min after injury, the sna@e #robably did not inject any venom. Swelling may continue to increase for -4 h. &emorrhage vesiculations, bullae, and #etechiae may a##ear between * and .A h, with thrombosis of su#erficial vessels and eventual sloughing of tissues. Systemic sym#toms include #aresthesias and muscle fasciculations. <uscle fasciculations are most common after a rattlesna@e bite and often in the #erioral region. (asciculations rarely follow a co##erhead bite or a cottonmouth bite. They are often seen in the face muscles and over the nec@, bac@, and the involved extremity and can occur within 1$ min. The venom from rattlesna@es #roduces deleterious changes in the blood cells, defects in blood coagulation, injuries to the intimal linings of vessels, damage to the heart muscles, alterations in res#iration, and to a lesser extent, changes in neuromuscular conduction. :ulmonary edema is common in severe #oisoning, and hemorrhage into the lungs, @idneys, heart, and #eritoneum can occur. &ematemesis, melena, changes in salivation, and muscle fasciculations may be seen. Urinalysis may reveal hematuria, glycosuria, and #roteinuria. 7ed blood cells and #latelets can decrease, and

bleeding and clotting times usually are #rolonged. Total afibrinogenemia is a hallmar@ of severe envenomation. ?lood should be immediately drawn for ty#ing and crossmatching because hemolysis may later ma@e this difficult. ?ecause hemolysis and injury to @idneys and liver may occur, it is im#ortant to follow alterations in clotting mechanism, renal and liver function, and electrolyte status. 8oral Sna@es The coral sna@e contributes to only . #ercent of all bites and 1.% #ercent of all deaths from #oisonous sna@es. ?ites by the coral sna@e occasionally #rovo@e blurred vision, #tosis, drowsiness, increased salivation, and sweating. The #atient may notice #aresthesia about the mouth and throat, sometimes slurring of s#eech, nausea, and vomiting. :ain is not a constant com#laint, nor is edema a constant finding. 8oral sna@e venom causes more extensive changes in the nervous system, and death may occur from inade>uate ventilation. <anagement of Sna@e ?ites "##lication of a tourni>uet, incision, and suction are a##ro#riate if used within 1 h of the time of the bite. The sna@e injects venom into the subcutaneous tissue, which is absorbed by ca#illaries and lym#hatics. The tourni>uet should be a##lied loosely to obstruct only venous and lym#hatic flow. The tourni>uet is not released once a##lied and may be left in #lace during the .$ min that suction is a##lied. The tourni>uet may be removed after definitive treatment has been instituted and the #atient is not in shoc@. 1ncision and suction for .$ min may be beneficial if accom#lished within .$ minutes after sna@ebite. The incision should be longitudinal and not cruciate. Chen two fang mar@s are seen, the de#th of the venom injection is generally considered to be one+ third of the distance between the fang mar@s. Severe bites may result in envenomations dee# to the fascia, and surgical ex#loration may be indicated. 1ncisions made #roximal to the bite are contraindicated. The average sna@ebite does not re>uire surgical excision. This #rocedure is reserved for the most severe envenomations. 1t has been shown that wide excision of the entire area around the sna@ebite within 1 h of the time of injection can remove most of the venom. 4xcision of the fang mar@s including s@in and subcutaneous tissue should be considered in severe bites and in #atients @nown to be allergic to horse serum and who are seen within 1 h of the bite. <ost fatalities from sna@ebites do not occur for A to 4* h after the bite, giving time to institute other measures. The most im#ortant treatment for a sna@ebite is antivenin, although many #atients do not re>uire it. 8o##erhead envenomation rarely necessitates antivenin. <ost sna@ebite fatalities in the United States during the #ast -$ years have involved either delay in obtaining treatment, no antivenin treatment, or inade>uate dosage. ?ecause antivenin contains horse serum, before its administration s@in testing is re>uired. 4#ine#hrine 1B1$$$ in a syringe should be available before antivenin is given. ?ecause the rattlesna@e, cottonmouth moccasin, and co##erhead belong to the same biologic family, their bites can be treated by the same antivenin ;antivenin 8rotalidae

#olyvalent=. The coral sna@ebite is rare, and the antivenin is different from that for the #it vi#er. " 2orth "merican coral sna@e ;<icrurus fulvius= antivenin has been develo#ed. 1t effectively treats <icrurus sna@ebites but is not effective in treating bites of <icruroides, the genus native to "ri/ona and 2ew <exico. 8oral sna@e antivenin can be obtained from state health de#artments. 1nformation concerning identification of a sna@e or the #ro#er antivenin fre>uently can be obtained from the nearest /oo her#etarium. " major #roblem with bites by exotic #oisonous sna@es is the choice and availability of suitable antiserum. :hysicians confronted with this situation may obtain advice from the local #oison center or the "ntivenin 1ndex 8enter of 6@lahoma :oison 1nformation 8enter, 6@lahoma 8ity, 6@lahoma ;4$%+-,1+ %4%4=. "ntivenin should be withheld until a #hysician can determine whether it is indicated. "##roximately .$ #ercent of all #oisonous sna@ebites in the United States result in no envenomation. The indication for antivenin is governed by the degree of envenomation. Cith fre>uent observations using the classification #resented in Table A+11, the severity of the bite is often found to increase with time, and thus change in grade is observed. <ost bites will have reached a final staging within 1- h. "ntivenin usually is not re>uired for grade $ or 1 envenomation. Hrade 11 may re>uire . or 4 am#ules, and grade 111 usually re>uires % to 1% am#ules. 1f sym#toms increase, several am#ules may be re>uired during the first - h. :ro#er dosage can be estimated by observing the clinical signs and sym#toms. 1f systemic manifestations are severe, antivenin should be given ra#idly, by intravenous dri#, in large doses. The injection of antivenin locally around the bite is not advised. 1f antivenin is indicated, . to % am#ules are given by intravenous dri# in %$$ m3 normal saline solution or %P glucose solution. 1f severe systemic sym#toms are already #resent, A to * am#ules are given in addition. The dose of intravenously administered antivenin can be more easily titrated with res#onse to treatment, and the amount administered is based on im#rovement in signs and sym#toms, not on the weight of the #atient. "ntivenin is administered until severe local or systemic sym#toms im#rove. Chen it is obvious that antivenin thera#y will be instituted, the tourni>uet should be left in #lace until antivenin is started. 1f too much time has ela#sed for excision to be effective and the #atient is allergic to horse serum, a slow infusion of 1 am#ule of antivenin in -%$ m3 of %P glucose solution may be given in a )$+min #eriod with constant monitoring of the blood #ressure and electrocardiogram, de#ending on the seriousness of the bite. This is accom#lished in an active emergency de#artment or an intensive care unit. 1f an immediate reaction occurs, the antivenin is sto##ed, and a vaso#ressor and e#ine#hrine may be re>uired. The incidence of serum sic@ness is directly related to the volume of horse serum injected. 6f #atients receiving 1$$ to -$$ m3 of horse serum, *% #ercent have some degree of sensitivity within * to 1- days after injection. 1ntravenous fluids are fre>uently re>uired to re#lace the decreased extracellular fluid volume resulting from edema. (ascial #lanes may become very tense with obstruction

of venous and later arterial flow, re>uiring fasciotomy. "de>uate antivenin treatment usually ma@es surgical intervention unnecessary. These #atients may need blood, since anemia can develo# from the hematologic effects of envenomation. "s afibrinogenemia has been re#orted, fibrinogen may be re>uired. 5itamin G also may also be re>uired. ?leeding and clotting abnormalities are treated with antivenin in addition to blood com#onents. "ntibiotics are recommended to #revent secondary infection, although their benefit is un#roved. Tetanus toxoid is administered. The most common s#ecies of bacteria isolated from rattlesna@e venom are :seudomonas aeruginosa, :roteus s#ecies, 8lostridium s#ecies, and ?acteroides fragilis. Stinging 1nsects and "nimals &ymeno#tera The most im#ortant insects that #roduce serious and #ossibly fatal ana#hylactic reactions are arthro#ods of the order &ymeno#tera. This grou# includes the honeybee, bumblebee, was#, yellow and blac@ hornet, and the fire ant. The venom of these stinging insects is just as #otent as that of sna@es and causes more deaths in the United States yearly than are caused by sna@ebites. &ymeno#terans, exce#t the bee, retain their stinger and are able to sting re#eatedly, each time injecting some #ortion of the venom sac contents. The wor@er honeybee sin@s its barbed sting into the s@in and it cannot be withdrawn. "s the bee attem#ts to esca#e, it is disemboweled. The stinger with the bowel, muscles, and venom sac attached is left behind. The muscles controlling the venom sac, although se#arated from the bee, rhythmically contract for as long as -$ min, driving the stinger dee#er and dee#er into the s@in and continuing to inject the venom. Sym#toms consist of one or more of the following locali/ed #ain, swelling, generali/ed erythema, a feeling of intense heat throughout the body, headache, blurred vision, injected conjunctivae, swollen and tender joints, itching, a##rehension, urticaria, #etechial hemorrhages of the s@in and mucous membranes, di//iness, wea@ness, sweating, severe nausea, abdominal cram#s, dys#nea, constriction of the chest, asthma, angioneurotic edema, vascular colla#se, and #ossible death from ana#hylaxis. (atal cases may manifest glottal and laryngeal edema, #ulmonary and cerebral edema, visceral congestion, meningeal hy#eremia, and intraventricular hemorrhage. 'eath results from a combination of shoc@, res#iratory failure, and central nervous system changes. <ost deaths from insect stings occur within 1% to .$ min. 4arly a##lication of a tourni>uet may #revent ra#id s#read of the venom. ?itten #ersons should be taught to remove the venom sac if #resent, being careful not to s>uee/e the sac. 1t may be necessary for some #atients to carry an emergency @it, which is commercially available. :atients should be taught to give themselves an e#ine#hrine injection. :atients having severe reactions should first receive $.. to $.% m3 of a 1 1$$$ solution of e#ine#hrine intravenously. Stingrays "##roximately ,%$ #ersons each year are stung by stingrays. "s the s#ine, which is curved and has serrated edges, enters the flesh, the sheath surrounding the s#ine ru#tures, and venom is released. "s the s#ine is withdrawn, fragments of the sheath may remain in the wound. The wound edges are often jagged and bleed freely. :ain

usually is immediate and severe, increasing to maximum intensity in 1 to - h and lasting for 1- to 4* h. Treatment consists of co#ious irrigation with water to wash out any toxin and fragments of the s#ine's integumentary sheath. 5enom is inactivated when ex#osed to heat. The area of the bite should be #laced in water as hot as the #atient can stand without injury for .$ min to 1 h. "fter soa@ing, the wound may be further debrided and treated a##ro#riately. :atients treated in this manner have ra#id and uncom#licated healing of the wound. :atients not treated with heat have tissue necrosis with #rolonged drainage and chronically infected wounds. :ortuguese <an+of+Car "fter a severe sting by a :ortuguese man+of+war there may be almost immediate severe nausea, gastric cram#ing, and constriction and tightness of throat and chest with severe muscle s#asm. There is intense, burning #ain with wea@ness and #erha#s res#iratory distress. The most im#ortant emergency treatment is to inactivate the nematocysts immediately to #revent their continuous firing of toxins. This is accom#lished by a##lications of a substance of high alcohol content, such as rubbing alcohol, followed by a##lication of a drying agent, such as flour, ba@ing soda, talc, or shaving cream. The tentacles may then be removed by shaving. "n al@aline agent such as ba@ing soda is then a##lied in order to neutrali/e the toxins, which are acidic. 'emerol and ?enadryl may dramatically relieve the #ain and sym#toms. "erosol corticosteroid+ analgesic balm is hel#ful. S#iders ?lac@ Cidow S#ider The most common biting s#ider in the United States is the blac@ widow ;3atrodectus mactans= ;(ig. A+A,=. The female s#ider has a reddish orange hourglass+sha#ed mar@ing on its ventral surface. 3atrodectus mactans venom is #rimarily neurotoxic in action and centers on the s#inal cord. "fter a bite by the blac@ widow s#ider, the majority of #atients ex#erience #ain within .$ min, and a small wheal with an area of erythema a##ears. 2ausea and vomiting occur in a##roximately one+third of #atients, headache in one+fourth, and dys#nea may develo#. The time of onset of sym#toms after the bite is .$ min to A h. The severe sym#toms last from -4 to 4* h. Henerali/ed muscle s#asm is the most #rominent #hysical finding. 8ram#ing muscle s#asms occur in the thighs, lumbar region, abdomen, or thorax. :ria#ism and ejaculation have been re#orted. <ost #atients recover within -4 h. Treatment consists of narcotics for the relief of #ain and a muscle relaxant for relief of s#asm. <ethocarbamol ;7obaxin= or 1$ m3 of a 1$P solution of calcium gluconate relieves the sym#toms. 1t is believed that calcium acts by de#ressing the threshold for de#olari/ation at the neuromuscular junctions. 8alcium gluconate may give instant relief of muscular #ain, and methocarbamol can be administered intravenously 1$ m3 over a %+min #eriod, with a second am#ule started in a saline solution dri#. "lthough 3atrodectus mactans antivenin is available, it is rarely re>uired. The manufacturer recommends its use for #atients with underlying cardiovascular disease. The antivenin is #re#ared from horse serum and is administered intramuscularly after a##ro#riate s@in tests. &os#itali/ation may be re>uired for the young, the elderly, #atients with significant chronic diseases, or those with severe signs and sym#toms of envenomation. ?rown 7ecluse S#ider

The distinguishing mar@ of the 3oxosceles reclusa is the dar@er violin+ sha#ed band over the dorsal ce#halothorax ;(ig. A+A*=. The s#ider is native to the south central United States. The body ranges from , mm to 1- mm! including the legs, the s#ider's si/e ranges from - to . cm. The initial bite may go unnoticed or be accom#anied by a mild stinging sensation. :ain may recur A to * h afterward. " mild envenomation is associated with local urticaria and erythema that usually resolve s#ontaneously. <ore severe bites result in #rogression to necrosis and sloughing of s@in with residual ulcer formation. " generali/ed macular and erythematous rash may a##ear in 1- to -4 h. 4rythema develo#s, with bleb or blister formation surrounded by an irregular area of ischemia. " /one of hemorrhage and induration and a surrounding halo of erythema may develo# #eri#herally. The central ischemia turns dar@, and eschar forms by day ,! by day 14 the area sloughs, leaving an o#en ulcer. "##roximately . wee@s is re>uired for the lesion to heal. The #ain may be out of #ro#ortion with the si/e of the area involved. The #rogression from blue to blac@ gives the bite a necrotic a##earance, and the more severe bites develo# within a few hours to - days. Systemically, the #atient may have fever, nausea, vomiting, wea@ness, arthralgia, malaise, and even #etechiae. The two #rinci#al systemic effects, hemolysis and thrombocyto#enia, have been res#onsible for deaths. &emoglobinemia, hemoglobinuria, leu@ocytosis, and #roteinuria also may occur, and there may be eventual renal failure. 3oxosceles reclusa venom is chiefly cytotoxic in action. 3aboratory studies are obtained in #atients with severe envenomation, including #rothrombin time, #artial thrombo#lastin time, #latelet count, and urinalysis. 1n the #atho#hysiology of this s#ider bite, intravascular coagulations and the formation of microthrombi occur within the ca#illary, leading to ca#illary occlusion, hemorrhage, and necrosis. Treatment is conservative because of the difficulty in #redicting the severity of the bite. 5arious treatments have been advocated in addition to early excision, including treatment with corticosteroids, he#arin, #hentolamine, dextran, and infusion, but clinical studies have failed to identify the benefit of these agents. The dose for steroids has varied from .$ to *$ mg methyl#rednisolone daily ta#ered over a #eriod of several days. " leu@ocyte inhibitor, da#sone ;used in le#rosy= is effective in reducing inflammation at the site of the brown recluse venom injection. Treatment with da#sone is 1$$ mg daily for 14 days before surgical excision, if re>uired. The incidence of scarring and deformity was found to be much less in a da#sone+treated grou# than in a grou# treated with observation and subse>uent surgical excision. There are significant side effects associated with da#sone treatment, including dose+ de#endent hemolytic anemia, methemoglobinemia, and rash. 8onservative thera#y usually is the #referred treatment. 4xcision of the necrotic area with s@in grafting may be re>uired at a later date. Scor#ions 6f the numerous s#ecies of scor#ions in the United States, only one, 8entruroides exilicauda or the bar@ scor#ion, is medically significant. 1t is found #rimarily in the desert Southwest. 7anging in length from 1 to , cm, it is usually yellowish brown in color and may have vertical bands on its dorsum. " tubercle at the base of the stinger distinguishes the bar@ scor#ion from other s#ecies. The venom is neurotoxic and causes the release of neurotransmitters from the autonomic nervous system and the adrenal glands. 1t also causes the de#olari/ation of neuromuscular junctions.

The sting causes intense #ain with few other local sym#toms. &y#eresthesia #ersists at the site so that a light ta# will re#roduce the intense #ain. The ta# test reinforces the diagnosis. 1n addition to #ain, other sym#toms reflect the neurotoxic nature of the venom, including anxiety, blurred vision or tem#orary blindness, wandering eye movements, dys#nea, whee/ing, dys#hagia, involuntary urination and defecation, and o#isthotonos. Somatic muscular contractions resembling sei/ures, hy#ertension, su#raventricular tachyarrhythmias, and fever also are seen. These stings have been of little significance in adults and are satisfactorily treated with cold com#resses. 1n contrast, infants and small children have died from scor#ion envenomation, though not since 1)A*. Small children with signs of envenomation should be admitted to the hos#ital and monitored. 2o s#ecial diagnostic tests are indicated. Treatment consists of airway management for excessive secretions, sedation, and treatment of arrhythmias and hy#ertension if indicated. 8alcium gluconate has been used to treat muscle s#asms. 2arcotics should not be used because they aggravate the neurotoxic effects of the venom. " goat+derived antivenin is available but only in the state of "ri/ona.