trauma abdominal schwartz

 E, Pieracci  et al.. If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Immediate stabilization of fractures or unstable joints is done in the ED using Hare traction, knee immobilizers, or plaster splints. [The importance of laparoscopy in blunt abdominal trauma]. Laparoskopische Versorgung einer traumatischen Milzläsion mittels Fibrinklebung und Kollagenvlies. Patients with acute massive blood loss may have paradoxical bradycardia.13 Blood pressure and pulse should be measured at least every 5 minutes in patients with significant blood loss until normal vital sign values are restored.  CC, Johnson The current options are loop ileostomy and sigmoid loop colostomy. 7-51).69 The typical clinical course of an epidural hematoma is an initial loss of consciousness, a lucid interval, and recurrent loss of consciousness with an ipsilateral fixed and dilated pupil. The Glasgow coma scale (GCS) score should be determined for all injured patients (Table 7-3). INITIAL EVALUATION AND RESUSCITATION OF THE INJURED PATIENT, Immediately life-threatening injuries to be identified during the primary survey, Current indications and contraindications for emergency department thoracotomy, Signs and symptoms of advancing stages of hemorrhagic shock, Findings on chest radiograph suggestive of a descending thoracic aortic tear, Criteria for “positive” finding on diagnostic peritoneal lavage, American Association for the Surgery of Trauma grading scales for solid organ injuries, Signs and symptoms of peripheral arterial injury, Options for the treatment of vascular injuries, Indications for operative treatment of thoracic injuries, Abdominal compartment syndrome grading system, Principles of Rehabilitation Medicine Case-Based Board Review, Regional Assessment and Special Diagnostic Tests, http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf, http://www.cdc.gov/ncipc/fact_book/InjuryBook2006.pdf, [JAMA and JAMA Network Journals Full Text]. In patients sustaining gunshot wounds, velocity, caliber, distance, and presumed path of the bullet are important, if known. Patients with diffuse cerebral edema resulting in excessive ICP may require a decompressive craniectomy, although a recent AAST multicenter trial questions the benefits.67,68 Patients with open or depressed skull fractures, with or without sinus involvement, may require operative intervention. Ann Surg 204: 438–445, Lange DA, Zaret P, Merlotti GJ et al. Specific injuries, their associated signs and symptoms, diagnostic options, and treatments are discussed in detail later in this chapter. The authors currently use a sequential closure technique with the wound VAC device that is based on constant fascial tension and return to the OR every 48 hours until closure is complete (Fig. In addition to operative intervention, postinjury care directed at limiting secondary injury to the brain is critical. Examples of such injuries include transection of both the intrapancreatic bile duct and the main pancreatic duct in the head of the pancreas, avulsion of the papilla of Vater from the duodenum, and destruction of the entire second portion of the duodenum.  FD, Dietz The ATLS format and basic tenets are followed throughout this chapter, with some modifications. The tympanic membrane is examined to identify hemotympanum, otorrhea, or rupture, which may signal an underlying head injury. Alternatively, the distal femur can be used if the tibia is fractured. As is true in adults, the vast majority of thoracic trauma is also blunt. Patients undergoing monitoring for nonoperative management of grade II or higher solid organ injuries should receive nothing by mouth for at least 48 hours in case they require an operation.  C, McClure  PF, Vanderheiden  I, Cheng  K, Ives Grundlage der militärchirurgischen Damage Control Surgery*Military surgical aspects of abdominal traumaFounding the damage control surgery doctrine of resourcesAus der Abteilung für Allgemein- und Viszeralchirurgie (Abteilungsleiter: Flottenarzt Dr. S. Lenz) am Bundeswehrkrankenhaus Berlin¹ (Chefarzt: Admiralarzt Dr. W. Titius), der Klinik und Poliklinik für Chirurgie (Chefarzt: Prof. Dr .  et al.. Finally, angioembolization is an effective adjunct in any of these scenarios and should be considered early in the course of treatment. B. Conceptually, the bloody vicious cycle, first described in 1981, is the lethal combination of coagulopathy, hypothermia, and metabolic acidosis (Fig. The goal of fluid resuscitation is to re-establish tissue perfusion. Meyer L, Kluge J, Marusch F, Zippel R, Gastinger I. Zentralbl Chir. With the advent of CT scanning, nonoperative management of solid organ injuries has replaced routine operative exploration. (2005) Das Abdominaltrauma. Venovenous bypass and hepatic vascular isolation as adjuncts in the repair of destructive wounds to the retrohepatic inferior vena cava. Acute traumatic brain injury is the most common cause of death and disability in any pediatric age group. Mattox KL, Moore EE, Feliciano DV, eds. aktive Blutung innerhalb der, Segmentaler oder kompletter Niereninfarkt aufgrund einer Gefäßthrombosierung ohne aktive Blutung, Vollständige Organzerstörung (Shattered Kidney), Zusätzlich Erfragen von Verletzungsmuster, Symptomen und bisheriger Behandlung, Relevante Vorerkrankungen bzw. 192 (5): 1179-89. Bulger Injuries are repaired using 5-0 absorbable monofilament, and mobilization of the kidney may reduce tension on the anastomosis. Burch In addition to pre-existing conditions and severity of injury, the occurrence of complications compounds the risk for mortality. General surgeons in communities without emergency neurosurgical coverage should have a working knowledge of burr hole placement in the event that emergent evacuation is required for a life-threatening epidural hematoma (Fig.  et al.. Pericardiocentesis is successful in decompressing tamponade in approximately 80% of cases; the majority of failures are due to the presence of clotted blood within the pericardium. A curved hemostat is a useful adjunct to create the curve. Trauma, Fachgebiete: : Preperitoneal pelvic packing for hemodynamically unstable pelvic fractures : Aa paradigm shift.  MJ, Holford In fact, pulmonary embolus can occur much earlier in the patient’s hospital course than previously believed.61 Patients at higher risk for venous thromboembolism are those with multiple fractures of the pelvis and lower extremities, coma or spinal cord injury, and requiring ligation of large veins in the abdomen and lower extremities. The patient must sustain a SBP of 70 mm Hg after RT and associated interventions to be considered resuscitatable, and hence transported to the OR.17,18, Patients sustaining witnessed penetrating trauma to the torso with <15 min of prehospital CPR, Patients sustaining witnessed blunt trauma with <10 min of prehospital CPR, Patients sustaining witnessed penetrating trauma to the neck or extremities with <5 min of prehospital CPR. Venovenous bypass permits hepatic vascular isolation with continued venous return to the heart. A. An error has occurred sending your email(s). The normally negative intrapleural pressure becomes positive, which depresses the ipsilateral hemidiaphragm and shifts the mediastinal structures into the contralateral chest. Gunshot wounds to the abdomen are associated with a 70% injury rate to the uterus and 35% mortality rate of the fetus. The goal is to normalize lactate within 24 hours. Maxillofacial injuries are common with multisystem trauma and require coordinated management by the trauma surgeon and the specialists in otolaryngology, plastic surgery, ophthalmology, and oral and maxillofacial surgery. Ein stumpfes Bauchtrauma erkennt man an der markanten Schonhaltung in Zusammenhang mit der Abwehrspannung des Geschädigten.  DV, Spjut-Patrinely The second key component of DCS is limiting enteric content spillage. For automobile collisions, the speed of the vehicles involved, angle of impact, use of restraints, airbag deployment, condition of the steering wheel and windshield, amount of intrusion, ejection of the patient from the vehicle, and fate of other passengers should be ascertained. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. If closed suction drains have been inserted for major pancreatic trauma, these should remain in place until the patient is tolerating an oral diet or enteral nutrition. PTFE is preferred over Dacron because of the reported decreased risk of infection.62 Aortic or iliac arterial injuries may be complicated by enteric contamination from colon or small bowel injuries. The first method is to squeeze the gallbladder and look for bile leaking from the pancreatic wound.  V Autologous splenic transplantation is performed by placing sections of splenic parenchyma, 40 × 40 × 3 mm in size, into pouches in the greater omentum. In the authors’ experience, this results in hemodynamic stability and abrupt cessation of the need for ongoing blood transfusion in the majority of cases.125 Patients also can undergo additional procedures such as laparotomy, thoracotomy, external fixation of extremity fractures, open fracture débridement, or craniotomy. Arterial defects of 1 to 2 cm often can be bridged by mobilizing the severed ends of the vessel after ligating small branches. An anterolateral thoracotomy, with the patient placed supine, is the most versatile incision for emergent thoracic exploration. For patients with stab wounds, the length and type of object is helpful.  MG, Knudson Abdomen agudo en pacientes ancianos apítulo 55 abdomen agudo introducción se define abdomen agudo aquella situación que cursa con síntomas abdominales graves  PJ  PC, Schöchl Generally, it is accepted that “safe” doses of radiation from radiography are <5 rad.130 A chest radiograph results in a dose of 0.07 mrad; CT scan of the chest, <1 rad; and CT scan of the abdomen, 3.5 rad. The recipient(s) will receive an email message that includes a link to the selected article. Diaz Blood transfusion: an independent risk factor for postinjury multiple organ failure. Although immediate needle thoracostomy decompression with a 14-gauge angiocatheter in the second intercostal space in the midclavicular line may be indicated in the field, tube thoracostomy should be performed immediately in the ED before a chest radiograph is obtained (Fig. This compromises ventilation due to equilibration of atmospheric and pleural pressures, which prevents lung inflation and alveolar ventilation, and results in hypoxia and hypercarbia. The concept of hypotensive resuscitation in the ED remains controversial, and it is primarily relevant for patients with penetrating vascular injuries. Because gastric distension can inhibit adequate ventilation, placement of a nasogastric tube may facilitate effective gas exchange. Operative exposure for midline structures of the neck (e.g.,trachea, thyroid, bilateral carotid sheaths) is obtained through a collar incision; this is typically performed two finger breadths above the sternal notch, but can be varied based on the level of anticipated injury. If access is needed to both pleural cavities, the original incision can be extended across the sternum with a Lebsche knife, into a “clamshell” thoracotomy (Fig. Zollinger's Video Atlas of Surgical Operations, General Surgery Examination and Board Review, Metabolic and Bariatric Surgery Exam and Board Review, INITIAL EVALUATION AND RESUSCITATION OF THE INJURED PATIENT. In general, systolic blood pressure (SBP) must be 60 mm Hg for the carotid pulse to be palpable, 70 mm Hg for the femoral pulse, and 80 mm Hg for the radial pulse.  CL.  MJ, MacKenzie Classic signs and symptoms of shock are tachycardia, hypotension, tachypnea, altered mental status, diaphoresis, and pallor(Table 7-4). Injuries of the hepatic ducts are almost impossible to satisfactorily repair under emergent circumstances. If intra-abdominal bleeding is difficult to control in hemodynamically unstable patients, damage control surgery with packing of the liver, total splenectomy, and provisional closure of hollow viscus injuries is of importance. The first decision is whether the patient has a supracolic or an infracolic vascular injury.  EJ, Kellam  C, Freeman Unilateral neck exploration is done through an incision extending from the mastoid down to the clavicle, along the anterior border of the sternocleidomastoid muscle (Fig. Urethral injuries are managed by bridging the defect with a Foley catheter, with or without direct suture repair. Die posttraumatische Belastungsstörung wird auch posttraumatisches Belastungssyndrom genannt, da sie manchmal viele verschiedene Symptome umfasst. Rinker Nelson An alternative, which preserves both the spleen and distal transected end of the pancreas, is either a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy.  MJ, Mattox Balloon tamponade for bilobar transfixing hepatic gunshot wounds. As discussed later in “Damage Control Surgery,” options include intraparenchymal tamponade with a Foley catheter or balloon occlusion (see Fig. The disadvantage of orotracheal intubation is that conscious patients usually require neuromuscular blockade, which may result in inability to intubate, aspiration, or medication complications.  MA, Abraham  JL, Moore Arterial access for on-table lower extremity angiography can be obtained percutaneously at the femoral vessels with a standard arterial catheter, via femoral vessel exposure and direct cannulation, or with superficial femoral artery (SFA) exposure just above the medial knee. Mattox KL, Moore EE, Feliciano DV, eds. Similarly, perfusion of the iliac system and infrainguinal vessels can be restored with a vascular shunt, with interposition graft placement delayed until hours later. A.  EJ, Rivara Multiple studies have confirmed the importance of early total enteral nutrition (TEN) in the trauma population, particularly its impact in reducing septic complications.112 The route of enteral feedings (stomach vs. small bowel) tends to be less important, because gut tolerance appears equivalent unless there is upper GI tract pathology. 1. The recognition of the bloody vicious cycle and the introduction of damage control surgery (DCS) have improved the survival of critically injured patients. Bei ausgedehnten Rupturen (Grad IV, V und VI) oder persistierende Blutungen bei instabilen Kreislaufverhältnissen stehen zunächst die Blutstillung und somit Wiederherstellung stabiler Kreislaufverhältnisse im Vordergrund. 7-63). In children older than 11 years, standard cricothyroidotomy is performed.  DW, Shapiro The gravid uterus is a large target, and any penetrating injury to the abdomen may result in fetal injury depending on trajectory and uterine size. Abdominal compartment syndrome, as noted earlier, is defined as intra-abdominal hypertension sufficient to produce physiologic deterioration and frequently manifests via such end-organ sequelae as decreased urine output, increased pulmonary inspiratory pressures, decreased cardiac preload, and increased cardiac afterload. Vascular injuries, either isolated or in combination with fractures, require emergent repair. Screening for blunt cardiac injury: An an Eastern Association for the Surgery of Trauma practice management guideline. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. The use of pyloric exclusion in the management of severe duodenal injuries. Soft collars do not effectively immobilize the cervical spine.  PJ, Moore Ragged edges of the injury site should be débrided using sharp dissection.  et al.. Postoperative bile duct strictures: management and outcome in the 1990s. -, Unfallchirurg. Injury to contiguous body cavities (i.e., the abdomen and neck) must be excluded; plain radiographs are a rapid, effective screening modality. Destructive injuries or multiple penetrating injuries occurring close together are treated with segmental resection followed by end-to-end anastomosis using a continuous, single-layer 3-0 polypropylene suture.111 Mesenteric injuries may result in an ischemic segment of intestine, which mandates resection. Schema zum Behandlungskonzept der traumatischen Milzruptur. Subsequently, the contralateral lung is compressed and the heart rotates about the superior and inferior vena cava; this decreases venous return and ultimately cardiac output, which culminates in cardiovascular collapse.  BB, McAninch Subkapsuläre Hämatome kleiner als 10% der Organoberfläche und nicht blutende Kapseleinrisse nicht tiefer als 1 cm in das Parenchym reichend (Grad I) können in der Regel konservativ behandelt werden. 7-69). Demetriades Thus, patients undergoing cardiopulmonary resuscitation upon arrival to the ED should undergo RT selectively based on injury and transport time (Fig. Additionally, pulsatile compression stockings (also termed sequential compression devices) are used routinely unless there is a fracture.  DB As a result, blunt trauma is associated with multiple widely distributed injuries, whereas in penetrating wounds the damage is localized to the path of the bullet or knife. A ligamentous injury may not be visible with standard imaging techniques.33 Flexion and extension views or MRI are obtained to further evaluate patients at risk or those with persistent symptoms, but generally are not done in the acute setting. Der Traumamechanismus ist von essenzieller Bedeutung für die weiteren Diagnostik- und Therapieentscheidungen! Patients with an open abdomen lose between 500 and 2500 mL per day of abdominal effluent. Imaging to diagnose descending torn aorta includes computed tomographic angiography (A), with three-dimensional reconstructions (B, anterior; C, posterior) demonstrating the proximal and distal extent of the injury (arrows). Conditions in which the bladder pressure is unreliable include bladder rupture, external compression from pelvic packing, neurogenic bladder, and adhesive disease. Guidelines for transfusion in the trauma patient. Type II injuries are more distal injuries within the tracheobronchial tree and manifest with pneumothorax. Minino However, primary arterial repair should be done when possible. Moreover, 25% of patients with a normal GCS score of 15 had intracranial bleeding, with an associated mortality of 50%.123 Just as there is no absolute age that predicts outcome, admission GCS score is a poor predictor of individual outcome. Die Letalität beim Lebertrauma ist aufgrund von Blutungskomplikationen sowie simultanen intraabdominalen Verletzungen, welche in bis zu 50% der Fälle auftreten, hoch und beträgt zwischen 10 und 25% [2, 19]. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. If such findings are noted or if vasoactive agents are required, cardiac function can be continuously monitored using a pulmonary artery catheter and serial SICU transthoracic or transesophageal ECHO.  SW, Soto 7-14). Small GI injuries (stomach, duodenum, small intestine, and colon) may be controlled using a rapid whipstitch of 2-0 polypropylene. Trauma centers and their associated blood banks must have the capability of transfusing tremendous quantities of blood components, because it is not unusual to have 100 component units transfused during one procedure and have the patient survive. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. For example, a patient with an absent popliteal pulse and femoral shaft fracture due to a bullet that entered the lateral hip and exited below the medial knee could have injured either the femoral or popliteal artery anywhere along its course (Fig. Zone II is located between the clavicles and the angle of the mandible. However, the sensitivity in detecting hollow viscus injuries is low and the role of laparoscopy in blunt abdominal injury has not been defined. and transmitted securely. Overzealous jejunal feeding can lead to small bowel necrosis in the patient recovering from profound shock. Injuries are often categorized by type of structure that is damaged: Abdominal wall.  JV, Murray 9 Edición. einer Gallenfistel, Zweizeitige Ruptur nach symptomfreiem Intervall möglich, Bei hämodynamischer Stabilität: Konservative Therapie, Bei hämodynamischer Stabilität: Intensivmedizinische Überwachung, ggf.  J, et Ziel des Traumamanagement ist es, das Ausmaß und die Prognose des Abdominaltraumas rasch zu definieren, um die Prioritäten sowie die Reihenfolgen in Diagnostik und Therapie festzulegen. Perhaps surprisingly, the sutures maintain diversion for only 3 to 4 weeks. 7-72). Significant sternal displacement (A; arrows) can be reduced and stabilized with sternal plating (B). Beim Nachweis von freier abdominaler Flüssigkeit sowie Kreislaufinstabilität besteht prinzipiell die Indikation zur Notfalllaparotomie. Exposure of the distal carotid artery in zone III is difficult (see Fig. (1995) Organ injury scaling: spleen and liver. Nur in Ausnahmefällen muss, z. PubMed Google Scholar. Etwa 30% Milzmasse reichen aus, um die Komplikationen einer Asplenie zu vermeiden [21]. Pancreatic fistula develops in over 20% of patients with combined injuries and should be managed similar to fistulas after elective surgery (see Chap. This prevents ischemic injury of the spinal cord as well as the splanchnic bed, and reduces left ventricular afterload.36 Heparinization is not required, a significant benefit in patients with multiple injuries, particularly in those with intracranial hemorrhage. Fortunately, hemorrhage from the left lobe usually can be controlled by mobilizing the lobe and compressing it between the surgeon’s hands.  al; the WTA Study Group.  JF Bei perforierendem Abdominaltrauma wird regelmäßig eine Laparotomie durchgeführt, da kleinere Verletzungen des Darmes im Rahmen der Diagnostik häufig nicht erkannt werden. First, outcomes are worse in this age group than in their younger counterparts. Gabe eines Protonenpumpeninhibitors, bspw.  A, Laufer  EE, Franciose Computed tomographic images reveal critical information about solid organ injuries, such as associated contrast extravasation from a grade IV laceration of the spleen (A; arrows) and the amount of subcapsular hematoma in a grade III liver laceration (B; arrows). In conscious patients, pain is the prominent symptom, and active or passive motion of muscles in the involved compartment increases the pain. For the purpose of evaluating penetrating injuries, the neck is divided into three zones. In children, the standard physiologic response to hypovolemia is peripheral vasoconstriction and reflex tachycardia; this may mask significant hemorrhagic injury, because children can compensate for up to a 25% loss of circulating blood volume with minimal external signs. Operative approach for a brachial artery injury is via a medial upper extremity longitudinal incision; proximal control may be obtained at the axillary artery, and an S-shaped extension through the antecubital fossa provides access to the distal brachial artery. Delis 17 (2): 29-39.  JD thermische Energie möglich, Alle Verletzungen mit aktiver Blutung innerhalb der, Organruptur mit Beteiligung von 25–75% eines, Alle Verletzungen mit aktiver Blutung aus der, Organruptur mit Beteiligung von >75% eines. For patients in whom peripheral angiocatheter access is difficult, intraosseous (IO) needles can be rapidly placed in the proximal tibia of the lower extremity (Fig. Weiterhin sollten Röntgenaufnahmen des Abdomens und des Thorax angefertigt werden. Blood pressure diminishes during the first two trimesters due to a decrease in systemic vascular resistance and rises again slightly during the third trimester (mean values: first = 105/60, second = 102/55, third = 108/67). Please enable it to take advantage of the complete set of features! Bladder pressure is then measured on the manometer in centimeters of water (Table 7-12) and correlated with the physiologic impact of abdominal compartment syndrome. Siegel Midline laparotomy wounds are inspected 48 hours postoperatively by removing the sterile surgical dressing. The Malaysian journal of medical sciences : MJMS. Partrick 7-52).  JM, Franciose On-table angiography may be useful to localize the arterial injury and thus, limit tissue dissection in patients with hard signs of vascular injury.  et al.. Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries.  et al.. Davis Repeated operative débridement may be necessary, and early involvement of the reconstructive surgery service for possible flap coverage is advised. Conversely, patient outcome is poor when RT is done for blunt trauma, with 2% survival among patients in shock and <1% survival among those with no vital signs. Expectant management is employed for bronchial injuries that are less than one-third the circumference of the airway and have no evidence of a persistent major air leak.11,12 In patients with peripheral bronchial injuries, indicated by persistent air leaks from the chest tube and documented by endoscopy, bronchoscopically directed fibrin glue sealing may be useful. Do not assume that someone who was stabbed was not also assaulted; the patient may have a multitude of injuries and cannot be presumed to have only injuries associated with the more obvious penetrating mechanism. In damage control circumstances, the ureter can be ligated on both sides of the injury and a nephrostomy tube placed. The high levels of progesterone impair gallbladder contractions, which results in bile stasis and an increased incidence of gallstone formation; this may not affect the trauma bay evaluation but becomes important in a prolonged ICU stay. Fistulas occur in 1% to 3% of patients and usually present as an abscess or wound infection with subsequent continuous drainage of fecal output; the majority will heal spontaneously with routine care (see Chap. The patient should immediately be placed in Trendelenburg’s position to trap the air in the apex of the left ventricle. In a patient with multisystem trauma, enteral access via gastrostomy tube or needle-catheter jejunostomy should be considered. unmittelbare chirurgische Therapie möglich, Konversion auf offenes Verfahren bei Nachweis ausgeprägter intraabdomineller Verletzungen, Frühzeitig Anlage großlumiger Infusionszugänge erwägen, Ausschluss freier abdomineller Flüssigkeit, Möglichkeit zur kontinuierlichen Überwachung. Cardiac tamponade (life-threatening injury number two) occurs most commonly after penetrating thoracic wounds, although occasionally blunt rupture of the heart, particularly the atrial appendage, is seen. Transthoracic and transesophageal ECHO are now becoming routine in many surgical intensive care units (SICUs).25,26 Patients with refractory cardiogenic shock may occasionally require placement of an intra-aortic balloon pump to decrease myocardial work and enhance coronary perfusion. Repair of a transected fallopian tube can be attempted but probably is unjustified, because a suboptimal repair will increase the risk of tubal pregnancy. After débridement of devitalized tissue, tracheal injuries are repaired end-to-end using a single layer of interrupted absorbable sutures. If a wound infection is identified—as evidenced by erythema, pain along the wound, or purulent drainage—the wound should be widely opened by removing skin staples. Flexible endoscopy for the diagnosis of esophageal trauma. En conjunto, constituyen el 10% de todas las muertes por traumatismos.  A Diese kann entscheidende diagnostische Hinweise geben und beinhaltet zudem die Möglichkeit einer gleichzeitigen Therapie. ACT = activated clotting time; Cryo = cryoprecipitate; FFP = fresh-frozen plasma; INR = International Normalized Ratio; MA = maximum amplitude; PRBCs = packed red blood cells; PTT = partial thromboplastin time; SBP = systolic blood pressure; TEG = thromboelastography; EPL = estimated percent lysis. Life-threatening injuries must be identified (Table 7-1) and treated before being distracted by the secondary survey. Emergency thoracotomy is followed by cross-clamping of the pulmonary hilum on the side of the injury to prevent further introduction of air (Fig. Stumpfe Verletzungen werden z.B. The venous cannula is inserted into the left superior pulmonary vein because it is less prone to tearing than the left atrium (LA). National Center for Injury Prevention and Control: Esposito A 6.0 endotracheal tube (maximum diameter in adults) is then advanced through the cricothyroid opening and sutured into place. Because of the proximity of other portal structures and the vena cava, associated vascular injuries are common.  MO, McKenney  RJ, Moore Although the coagulopathic “ooze” may seem minimal compared with the torrential hemorrhage from a hole in the aorta, blood loss from the entire area of dissection can lead to exsanguination. Moreover, suture repair using an end-to-end anastomosis in the second portion often results in an unacceptably narrow lumen.  E, Lavoie Rupturierte intraparenchymale Hämatome oder Abrisse von Segment- bzw. 7-13).  et al.. In patients under the age of 11, cricothyroidotomy is relatively contraindicated due to the risk of subglottic stenosis, and tracheostomy should be performed. 7,8. Shotgun injuries are divided into close-range (<20 feet) and long-range wounds. The authors’ sequential closure technique for the open abdomen. A “clamshell” thoracotomy provides exposure to bilateral thoracic cavities. Cothren Sign up for an account today! Duodenopankreatektomie) vorgenommen werden. (1D) 2. If massive venous hemorrhage is seen from behind the liver despite use of the Pringle maneuver, the patient likely has a hepatic vein or retrohepatic vena cava injury.  WL, Moore Because esophagoscopy can miss injuries following an apparent normal endoscopy, patients at risk should undergo soluble contrast esophagraphy followed by barium examination to look for extravasation of contrast to identify an injury.39 As with neck injuries, hemodynamically stable patients with transmediastinal gunshot wounds should undergo CT scanning to determine the path of the bullet; this identifies the vascular or visceral structures at risk for injury and directs angiography or endoscopy as appropriate. Bladder injuries are subdivided into those with intraperitoneal extravasation and those with extraperitoneal extravasation.  N, Einav Mullins In addition, patients at high risk for fetal loss (those experiencing vehicle ejection or involved in motorcycle or pedestrian collisions and those with maternal tachycardia, Injury Severity Score of >9, gestational period of >35 weeks, or history of prior assault) also warrant careful monitoring.132 Patients without these risk factors who are asymptomatic can be monitored for 6 hours in the ED and sent home if no problems develop. Flail chest occurs when three or more contiguous ribs are fractured in at least two locations. During laparotomy for blunt trauma, expanding or pulsatile perinephric hematomas should be explored. 7-68). In the comatose patient, the tongue may fall backward and obstruct the hypopharynx; this can be relieved by either a chin lift or jaw thrust. Values representing positive findings are summarized in Table 7-6.  et al.. Reappraising the concept of massive transfusion in trauma. A method advocated for access to the proximal left subclavian artery is through a fourth interspace anterolateral thoracotomy, superior sternal extension, and left supraclavicular incision (“trap door” thoracotomy). Heparinized saline (50 units/mL) is then injected into the proximal and distal ends of the injured vessel to prevent small clot formation on the exposed intima and media. Vaginal examination with a speculum should be performed in women with pelvic fractures to exclude an open fracture.  RS, Moore (1998) Changing patterns in the management of splenic trauma: the impact of nonoperative management. Vaughn Penetrating injuries are classified according to the wounding agent (i.e., stab wound, gunshot wound, or shotgun wound). Hypothermia aggravates coagulopathy and provokes myocardial irritability. 7-43). Standard 14-gauge catheters can be quickly placed, even in an exsanguinating patient with collapsed veins. Truitt auch mittels Laparoskopie). Complications should be expected after major pancreaticoduodenal injuries. Trauma surgeons often separate patients who have sustained blunt trauma into categories according to their risk for multiple injuries: those sustaining high energy transfer injuries and those sustaining low energy transfer injuries. Blunt injury to the pelvis may produce complex fractures with major hemorrhage (Fig. Furthermore, individuals in good physical condition with a resting pulse rate in the fifties may manifest a relative tachycardia in the nineties; although clinically significant, this does not meet the standard definition of tachycardia. In children, the airway is smaller and more cephalad in position compared with that of adults, and in children younger than 10 years, the larynx is funnel shaped rather than cylindrical as in adults. The site is secure.  et al.. Portal triad injuries. Radiographics : a review publication of the Radiological Society of North America, Inc. 13 (4): 735-52. 1 polypropylene suture. Injuries involving high energy transfer include auto-pedestrian accidents, motor vehicle collisions in which the car’s change of velocity (ΔV) exceeds 20 mph or in which the patient has been ejected, motorcycle collisions, and falls from heights >20 ft.30 In fact, for motor vehicle accidents the variables strongly associated with life-threatening injuries, and hence reflective of the magnitude of the mechanism, are death of another occupant in the vehicle, extrication time of >20 minutes, ΔV >20 mph, lack of restraint use, and lateral impact.30 Low-energy trauma, such as being struck with a club or falling from a bicycle, usually does not result in widely distributed injuries. The partial pressure of carbon dioxide (Pco2) should be maintained in a normal range (35–40 mm Hg), but for temporary management of acute intracranial hypertension, inducing cerebral vasoconstriction by hyperventilation to a Pco2 of <30 mm Hg is occasionally warranted.  et al.. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. This entails palpating for bony step-off of the facial bones and instability of the midface (by grasping the upper palate and seeing if this moves separately from the patient’s head). Anterior truncal gunshot wounds between the fourth intercostal space and the pubic symphysis whose trajectory as determined by radiograph or wound location indicates peritoneal penetration should undergo laparotomy (Fig. Rupture into a bile duct results in hemobilia, which is characterized by intermittent episodes of right upper quadrant pain, upper GI hemorrhage, and jaundice. [2], Dieser Artikel behandelt ein Gesundheitsthema. gerinnungshemmende Wirkstoffe), Begrenzte Aussagekraft, Durchführung dennoch empfohlen. Preferred access to the popliteal space for an acute injury is the medial one-incision approach with detachment of the semitendinosus, semimembranosus, and gracilis muscles (Fig. Because treatment must be instituted during the latent period between injury and onset of neurologic sequelae, diagnostic imaging is performed based on identified risk factors (Fig. All of these diagnoses should be made during the initial physical examination. Optimal early resuscitation is mandatory and determines when the patient can undergo definitive diagnosis as well as when the patient can be returned to the OR after initial damage control surgery. Loop colostomy will completely divert the fecal flow, allowing the low rectal injury to heal. 33). Auch in diesen Fällen ist bei Milzmonotraumen eine laparoskopische Versorgung alternativ zur Laparotomie zu erwägen (Abb. This acts as a flutter valve, permitting effective ventilation on inspiration while allowing accumulated air to escape from the pleural space on the untaped side, so that a tension pneumothorax is prevented. A multicenter experience. In high-risk patients, removable inferior vena caval filters should be considered if there are prolonged contraindications to administration of LMWH. 7-58). Clancy The most commonly missed gastric injury is the posterior wound of a totally penetrating injury. Translobar gunshot wounds of the liver are best controlled with balloon catheter tamponade, whereas deep lacerations can be controlled with Foley catheter inflation deep within the injury track (Fig.  F, Groeneweg Die häufigsten Komplikationen sind Abszesse, Fisteln und Pankreatitiden [6]. Bowel injury is suggested by findings of thickened bowel wall, “streaking” in the mesentery, free fluid without associated solid organ injury, or free intraperitoneal air.45,46 Patients with free intra-abdominal fluid without solid organ injury are closely monitored for evolving signs of peritonitis; if patients have a significant closed head injury or cannot be serially examined, DPL should be performed to exclude bowel injury. Unter dem Abdominaltrauma versteht man Verletzungen der Organe im Abdomen, die durch eine Gewalteinwirkung auf die Leibeswand hervorgerufen wurden. Bei ausgedehnten Verletzungen bzw.  JL, Graham B. Type-specific RBCs should be administered as soon as available. An internal carotid artery pseudoaneurysm documented by angiography. Removing the patient’s clothes causes a second thermal insult, and infusion of cold PRBCs or room temperature crystalloid exacerbates the problem. Persistent hypotension due to uncontrolled hemorrhage is associated with high mortality. Bei freier Flüssigkeit und Kreislaufinstabilität muss unverzüglich laparotomiert werden. If the bullet traverses the uterus and the fetus is viable, cesarean section should be performed. On the other hand, clavicle fractures often are isolated injuries and should be managed with pain control and immobilization. Cogbill Bei ausgedehnten Verletzungen bzw. Am häufigsten kommt es zur Verletzung parenchymatöser Organe, wobei die Milz und die Leber öfter betroffen sind, Verletzungen der Hohlorgane oder des Pankreas dagegen seltener vorkommen [3, 17] (Tab. Tetanus prophylaxis is administered to all patients according to published guidelines.  Z. Posttraumatic pulmonary pseudocyst: Computed computed tomography findings and management in 33 patients. This is important because among patients not attaining fascial closure, 20% suffer GI tract complications that prolong their hospital course. Kozar The evaluation for abdominal trauma in the pediatric patient is similar to that in the adult. Although policies vary at individual institutions, most agree patients in extremis with need for Foley catheter placement should undergo one attempt at catheterization; if the catheter does not pass easily, a percutaneous suprapubic cystostomy should be considered.  et al.. Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2. Although operative exploration is appropriate in some circumstances, selective nonoperative management has been proven safe (Fig. Central pancreatectomy preserves the common bile duct, and mobilization of the pancreatic body permits drainage into a Roux-en-Y pancreaticojejunostomy (Fig. If the patient has an SBP of <70 mmHg when the abdomen is opened, digital pressure or a clamp should be placed on the aorta at the diaphragmatic hiatus. With complete tracheal transection, the endotracheal tube is placed directly into the distal aperture, with care taken not to push the trachea into the mediastinum. B.  D  et al.. Such a delay is particularly troublesome for patients who have lost two blood volumes while waiting for the test results to return. Fibrinolysis is another important component of the ACOT; present in only 5% of injured patients requiring hospitalization, but 20% in those requiring massive transfusion.52 Fresh whole blood, arguably the optimal replacement, is not available in the United States. Klassifikation nach ICD-10. Tension pneumothorax, the most frequent cause of cardiac failure, and pericardial tamponade have been discussed earlier. Continuous intercostal nerve blockade for rib fractures: ready for primetime?  C, Moore Occasionally, endoscopic sphincterotomy with stent placement will be required to address the pressure differential, and the pleurobiliary fistula will close spontaneously. Alternatively, if the patient has an associated pancreatic injury, the graft should be tunneled from the distal aorta beneath the duodenum to the distal SMA. Injured patients with life-threatening hemorrhage develop an acute coagulopathy of trauma (ACOT). (Image used with permission from Vincent D. Eusterman, MD, DDS.). The authors elect to repack the patient’s pelvis if there is persistent oozing and perform serial washouts of the preperitoneal space if it appears infected. While decompression of subdural hematomas may be delayed, epidural hematomas require evacuation within 70 minutes.68 The final stages of this sequence are caused by blood accumulation that forces the temporal lobe medially, with resultant compression of the third cranial nerve and eventually the brain stem. The vast majority of injuries are treated similarly whether the patient is pregnant or not.  CR, Demarest The heart, lungs, descending aorta, pulmonary hilum, and esophagus are accessible with this approach. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. Alternatively, air can be introduced via the NG tube with the abdomen filled with saline. Western Trauma Association multi-institutional study of enteral nutrition in the open abdomen after injury. Hassan R, Abd Aziz A. Computed Tomography (CT) Imaging of Injuries from Blunt Abdominal Trauma: A Pictorial Essay. Stassen All blunt trauma patients should be assumed to have cervical spine injuries until proven otherwise. The patient’s initial chest radiograph often underestimates the extent of the pulmonary parenchymal damage (Fig. C. The collecting system is closed separately with absorbable suture. Zone I is inferior to the clavicles encompassing the thoracic outlet structures, zone II is between the thoracic outlet and the angle of the mandible, and zone III is above the angle of the mandible. Physical examination often identifies arterial injuries, and findings are classified as either hard signs or soft signs of vascular injury (Table 7-8). Once resuscitation is complete, initiation of TEN, even at trophic levels (20 mL/h), should be considered in all injured patients with an open abdomen.  L, Liu bei Personen mit nur einer, Nephrektomie bei arterieller Gefäßverletzung oder hochgradiger Parenchymschädigung häufig nicht zu vermeiden, Am Torso (im Gegensatz zu den Extremitäten) keine direkte Blutungskontrolle mittels Kompression möglich, Neurologische Defizite durch Minderperfusion des, Physiologische Anpassung der Organe und des Kreislaufs an die, Leichtes Trauma: Stationäre Überwachung für, Geringeres Risiko für subkapsuläre und intraparenchymatöse Blutungen, Radiologische Diagnostik generell nach dem, Häufig konservative Therapie unter stationärer Überwachung ausreichend, Keine zwingende OP-Indikation bei Nachweis freier intraabdomineller Flüssigkeit, Bei gegebener Indikation zur operativen Therapie, Die folgenden fünften Stellen sind bei der Kategorie, 0: Art der Verletzung nicht näher bezeichnet, 4: Oberflächlicher Fremdkörper (Splitter). Because hemorrhage from hepatic injuries often is treated without isolating individual bleeding vessels, arterial pseudoaneurysms may develop, with the potential for rupture. Patients with a SBP <60 mm Hg warrant resuscitative thoracotomy (RT) with opening of the pericardium for rapid decompression and to address the injury. Heart rate increases by 10 to 15 beats per minute during the first trimester and remains elevated until delivery. Topical hemostatic techniques include the use of an electrocautery (with the device set at 100 watts), argon beam coagulator, microcrystalline collagen, thrombin-soaked gelatin foam sponge, fibrin glue, and BioGlue.   •  Accessibility Blunt cerebrovascular injuries have been recognized as a significant, preventable source of neurologic morbidity and mortality. Specific transfusion triggers for individual blood components exist. Therefore, these patients should ideally undergo diagnostic imaging before operation if they remain hemodynamically stable.  J, Stein The resurgent interest in viscoelastic hemostatic assays (thrombelastography [TEG] and thrombelastometry [ROTEM]) has facilitated the appropriate and timely use of clotting adjuncts, including the prompt recognition of fibrinolysis.  C, Halvorsen The aspirate is considered to show positive findings if >10 mL of blood is aspirated. After penetrating trauma, a great vessel or pulmonary hilar vessel injury should be presumed. Simultaneously, all patients with blunt trauma require cervical spine immobilization until injury is excluded.  JJ  et al.. A national evaluation of the effect of trauma-center care on mortality. The anterior and lateral compartments are approached from a lateral incision, with identification of the fascial raphe between the two compartments.  CE, Ledgerwood Emergency medical service personnel and police are trained to evaluate an injury scene and should be questioned while they are present in the ED.  EM, Arneson  et al.. Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? Persistent gross hematuria may require embolization, whereas urinomas can be drained percutaneously. Based on mechanism, location of injuries identified on physical examination, screening radiographs, and the patient’s overall condition, additional diagnostic studies often are indicated. Regelmäßige sonographische Untersuchungen sind deshalb obligat. Perforado trauma abdominal - debido a heridas por .  S, Keim  DJ, Rosenfeld Packing of injuries of the left lobe is not as effective, because there is insufficient abdominal and thoracic wall anterior to the left lobe to provide adequate compression with the abdomen open. While the spleen is gently rotated medially, a plane is developed between the pancreas and left kidney (B). Approximately one third of preventable deaths in children are related to airway management; therefore, if airway control cannot be obtained using a standard endotracheal method, surgical establishment of an airway should be considered. Advanced operative techniques in the management of complex liver injury. The surgeon performing this maneuver must then walk with the patient to the OR for definitive treatment. The Denver grading scale for blunt cerebrovascular injuries. Patients with suspected associated perforation, suggested by clinical deterioration or imaging with retroperitoneal free air or contrast extravasation, should undergo operative exploration. 7-61) to achieve partial immunocompetence in younger patients who do not have an associated enteric injury. Regardless of the choice of definitive procedure, the pancreatic duct in the proximal edge of transected pancreas should be individually ligated or occluded with a TA stapler. 7-47).49 Hypothermia from evaporative and conductive heat loss and diminished heat production occurs despite the use of warming blankets and blood warmers. ED preparation for the pediatric trauma patient includes assembling age-appropriate equipment (e.g., intubation equipment; IV catheters, including intraosseous needles and 4F single-lumen lines), laying out the Broselow Pediatric Emergency Tape (which allows effective approximation of the patient’s weight, medication doses, size of endotracheal tube, and chest tube size), and turning on heat lamps. Some specific injuries due to abdominal trauma are discussed elsewhere, including those to the liver , spleen , and genitourinary tract .

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