Martin / Beekley / MD Front Line Surgery

A Practical Approach
1. Auflage 2010
ISBN: 978-1-4419-6079-5
Verlag: Springer
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 350 Seiten

Both editors are active duty officers and surgeons in the U.S. Army. Dr. Martin is a fellowship trained trauma surgeon who is currently the Trauma Medical Director at Madigan Army Medical Center. He has served as the Chief of Surgery with the 47th Combat Support Hospital (CSH) in Tikrit, Iraq in 2005 to 2006, and most recently as the Chief of Trauma and General Surgery with the 28th CSH in Baghdad, Iraq in 2007 to 2008. He has published multiple peer-reviewed journal articles and surgical chapters. He presented his latest work analyzing trauma-related deaths in the current war and strategies to reduce them at the 2008 annual meeting of the American College of Surgeons. Dr. Beekley is the former Trauma Medical Director at Madigan Army Medical Center. He has multiple combat deployments to both Iraq and Afghanistan, and has served in a variety of leadership roles with both Forward Surgical Teams (FST) and Combat Support Hospitals (CSH).

Matthew J. Martin, MD, FACS Trauma Director Madigan Army Medical Center Deployment Experience: Chief of Surgery 47th Combat Support Hospital Tikrit, Iraq 2005-2006 Chief, General Surgery and Trauma Theater Consultant for General Surgery 28th Combat Support Hospital Baghdad, Iraq 2007-2008 Alec C. Beekley, MD, FACS Staff Surgeon Madigan Army Medical Center Deployment Experience: Staff Surgeon 102nd Forward Surgical Team Kandahar Airfield, Afghanistan 2002-2003 Chief of Surgery 912th Forward Surgical Team Al Mussayib, Iraq 2004 Staff Surgeon 31st Combat Support Hospital Baghdad, Iraq 2004 Director Deployed Combat Casualty Research Team 28th Combat Support Hospital Baghdad, Iraq 2007

Autoren/Hrsg.

Beekley, Alec

MD,

FACS,

Martin, Matthew

Martin, Md

Beekley, Md

Inhaltsverzeichnis

1;Chapter 1: Prehospital and Enroute Care;23
1.1;BLUF Box (Bottom Line Up Front);23
1.2;Critical Tasks and Priorities;24
1.3;Psychology of Prehospital Care;25
1.4;Some Important Considerations for Treatment;27
1.4.1;Tourniquets (Fig. 1.2);27
1.4.2;Thoracic Needle Decompression;28
1.4.3;Airway Treatment;28
1.4.4;IV Fluids for Resuscitation;29
1.4.5;Resuscitation Fluid Choice;30
1.5;En Route Considerations;31
1.5.1;Secure the Patient;31
1.5.2;Airway;31
1.5.3;Be Wary of the IV Drip;31
1.5.4;Wound Dressing;32
1.5.5;Chest Decompression;32
1.5.6;Hypothermia Prevention;32
1.6;General Considerations;33
1.6.1;Chest Seals;33
1.6.2;Hemostatic Dressings (Fig. 1.4);33
1.6.3;Chest Tubes;35
1.6.4;Pre-hospital Antibiotics;35
1.6.5;Pain Control;36
1.6.6;Ketamine;36
1.6.7;Recombinant Factor VIIa;36
1.6.8;Prehospital Blood and Plasma;37
1.7;Summary;37
2;Chapter 2: Combat Triage and Mass Casualty Management;39
2.1;BLUF Box (Bottom Line Up Front);39
2.2;Introduction;40
2.3;Resources;40
2.3.1;Security;40
2.3.2;Context;41
2.3.3;Trained and Ready Personnel;41
2.3.4;Culture;41
2.3.5;Supply and Transport;43
2.4;Rehearsal;43
2.4.1;Plan;43
2.5;Response;45
2.5.1;During the Event;45
2.5.2;Hospital Level Triage and the “Triage Officer”;47
2.5.3;Special Considerations: Mental, Behavioral Health and Spiritual Needs;51
2.6;Route;51
2.7;Reset;52
2.7.1;Ethics and Resiliency;52
2.8;Conclusion;53
3;Chapter 3: Initial Management Priorities: Beyond ABCDE;54
3.1;BLUF Box (Bottom Line Up Front);54
3.2;Initial Management Priorities;56
3.2.1;Sick or Not Sick?;56
3.3;Hemorrhage Control Über Alles;57
3.4;Tension Pneumothorax;59
3.5;Open Pneumothorax;59
3.6;Airway;60
3.7;Massive Extremity Injuries;61
3.8;Unexploded Ordinance;62
3.9;Operating Room Priorities;63
3.10;The “Blood Vicious Cycle” Revisited;64
3.11;The Multi-System Combat Casualty: Putting It All Together;65
4;Chapter 4: Damage Control Resuscitation;67
4.1;BLUF Box (Bottom Line Up Front);67
4.2;Introduction;68
4.3;Damage Control;69
4.4;Acute Coagulopathy of Trauma Shock (ACoTS);69
4.5;Identification of Patients Requiring DCR;70
4.6;When Does DCR Start;71
4.7;Creation of DCR Protocol;71
4.8;Delivery of DCR;72
4.9;Termination of DCR;74
4.10;Fresh Whole Blood;74
4.11;Organization of Walking Blood Bank;75
4.12;Collection of Fresh Whole Blood;76
4.13;Recombinant Factor VIIa;76
4.14;The Aftermath of DCR;77
4.15;Forward Surgical Team Specifics;77
5;Chapter 5: To Operate or Image? (Pulling the Trigger);79
5.1;BLUF Box (Bottom Line Up Front);79
5.2;The Stable Patient;80
5.3;The “Rule Out” Head or Spine Injury;82
5.4;The Unstable Patient;83
5.5;The Sirens of Combat Trauma Imaging (Specific Pitfallsand How to Avoid them);84
5.6;Final Points;86
6;Chapter 6: Ultrasound in Combat Trauma;87
6.1;BLUF Box (Bottom Line Up Front);87
6.2;Why Ultrasound?;88
6.2.1;Advantages of US;89
6.2.2;Disadvantages of US (for the Average Ultrasonographer);89
6.3;How to Perform an EFAST;90
6.4;Basic Terms and Knobology;90
6.5;Abdomen;92
6.5.1;RUQ (Perihepatic or Hepatorenal) View;92
6.5.2;LUQ (Perisplenic or Splenorenal) View;93
6.5.3;Pelvic View;94
6.5.4;Pericardial View;96
6.5.5;Pneumothorax Scan;97
6.6;Making Clinical Decisions with EFAST Findings;98
6.6.1;Other Useful Applications;99
6.6.2;Evaluation of Hemodynamic Status/CVP Measurement;99
6.6.3;Triage;100
6.6.4;Procedural;100
6.6.5;Foreign Body/Soft Tissue/Musculoskeletal Application;100
6.6.6;Other;100
7;Chapter 7: The Bowel: Contamination, Colostomies, and Combat Surgery;102
7.1;BLUF Box (Bottom Line Up Front);102
7.2;Does the Patient Have a GI Tract Injury?;103
7.3;What to Do Once in the Operating Room?;104
7.4;Injuries to the Stomach;105
7.5;Injuries to the Small Intestine;106
7.6;Injuries to the Colon;110
7.7;Injuries to the Rectum;113
7.8;Timing of Reconstruction After Damage Control;115
7.9;“Used” Trauma;116
7.10;Tractotomies/Treatment of Entrance and Exit Wounds;116
7.11;Final Points;117
8;Chapter 8: Liver and Spleen Injury Management in Combat (Old School);118
8.1;BLUF Box (Bottom Line Up Front);118
8.2;Introduction;119
8.3;Basic Concepts;119
8.4;Diagnosis;120
8.5;Exposure;121
8.6;Are You a “Packer” or a “Sucker”?;122
8.7;Spleen;124
8.8;Liver;126
8.9;Postop Pearls;131
9;Chapter 9: Pancreatic and Duodenal Injuries (Sleep When You Can…);133
9.1;BLUF Box (Bottom Line Up Front);133
9.2;Making the Diagnosis;134
9.3;Anatomy: The Key to the Battle Plan;135
9.4;The Body and Tail of the Pancreas;138
9.5;Injury to the Head of the Pancreas;140
9.6;The Pancreatic Duct;140
9.7;Duodenal Injuries;141
9.8;The Trauma Whipple;145
10;Chapter 10: Operative Management of Renal Injuries;147
10.1;BLUF Box (Bottom Line Up Front);147
10.2;Introduction;148
10.3;Indications for Operation and Renal Exploration;148
10.4;Exposure and Injury Evaluation;150
10.5;Repair and Resection;154
10.5.1;Parenchymal Injuries;154
10.5.2;Vascular Injuries;156
10.5.3;Nephrectomy;157
10.6;Complications;157
11;Chapter 11: Major Abdominal Vascular Trauma;159
11.1;BLUF Box (Bottom Line Up Front);159
11.2;Introduction;159
11.3;The Basics in the ER;160
11.4;In the OR: Getting Started;161
11.5;In the OR: Injuries Encountered;161
11.6;In the OR: Operative Technique;163
11.7;Zone 1 Supramesocolic Injuries;163
11.7.1;Specific Zone I Supramesocolic Vascular Injuries;164
11.8;Zone 1 Inframesocolic Injuries;165
11.8.1;Specific Zone I Inframesocolic Vascular Injuries;165
11.9;Zone 2 Vascular Injuries;167
11.10;Zone 3 Vascular Injuries;168
11.10.1;Damage Control in Abdominal Vascular Trauma;171
11.11;The Massive Pelvic Disruption;171
11.12;Tips and Tricks;172
11.13;Final Thoughts;172
12;Chapter 12: To Close or Not to Close: Managing the Open Abdomen;173
12.1;BLUF Box (Bottom Line Up Front);173
12.2;Why Leave the Abdomen Open?;174
12.3;How to Temporarily Close the Open Abdomen;177
12.4;Serial Abdominal Closure;179
12.5;Complex Abdominal Wall Reconstruction: Component Separation;182
12.6;Specific Pitfalls and How to Avoid them;184
12.7;Final Points;185
13;Chapter 13: Choice of Thoracic Incision;188
13.1;BLUF Box (Bottom Line Up Front);188
13.2;Why This Chapter Matters to You;189
13.3;Rules of Engagement;189
13.4;One Way In and Only One Way Out;195
13.5;Variation on BLUF #6: The Costal Margin is Just Cartilage;196
13.6;Bottom Line;198
14;Chapter 14: Lung Injuries in Combat;199
14.1;BLUF Box (Bottom Line Up Front);199
14.2;Surgical Approach (“You Can’t Get There from Here”);200
14.3;Damage Control Principles in the Chest (This Ain’t The Abdomen);201
14.4;Pneumothorax and Hemothorax;202
14.5;Lung Parenchymal Injuries;203
14.6;The Pulmonary Hilum: Tread Lightly;206
14.7;Pulmonary Hilar Control;209
14.8;Pneumonectomy (It Is Not a Dirty Word);210
14.9;Air Embolism;212
14.10;Evacuation;213
14.11;Final Points;214
15;Chapter 15: Diagnosis and Management of Penetrating Cardiac Injury;215
15.1;BLUF Box (Bottom Line Up Front);215
15.2;Introduction;216
15.3;Diagnosis of Penetrating Cardiac Injury;216
15.4;Important Techniques in the Diagnosis and Management of PCI;219
15.5;Pericardial Window;219
15.6;Median Sternotomy;220
15.7;Pericardial Well;221
15.8;Identifying Penetrating Cardiac Injury;222
15.9;Repairing Penetrating Cardiac Injury;223
15.10;Intra-cardiac Injury;227
15.11;Summary;228
16;Chapter 16: Thoracic Vascular Injuries: Operative Management in “Enemy” Territory;229
16.1;BLUF Box (Bottom Line Up Front);229
16.2;Introduction;230
16.3;Wounding Patterns and Physiology on the Modern Battlefield;230
16.4;Pre-operative Management;231
16.5;Patient Preparation;232
16.6;What Incision Do I Make?;233
16.7;Principles of Repair for Specific Injuries;233
16.8;Use of Heparin;237
16.9;Shunts;238
16.10;Surgical Technique;239
16.11;Conduits;239
16.12;Closure of Incisions;240
16.13;Endovascular Procedures;240
16.14;Required Equipment;244
16.15;Summary;244
17;Chapter 17: Chest Wall and Diaphragm Injury;245
17.1;BLUF Box (Bottom Line Up Front);245
17.2;Chest Wall Injuries;246
17.3;Flail Chest;249
17.4;Diaphragmatic Injuries;250
17.4.1;Diagnosis;250
17.4.2;Treatment;250
17.5;Final Points;253
18;Chapter 18: Soft Tissue Wounds and Fasciotomies;254
18.1;BLUF Box (Bottom Line Up Front);254
18.2;Large Soft Tissue Wounds;255
18.3;Small Multiple Wounds;261
18.4;Fasciotomies;262
18.5;Upper Extremity Fasciotomy;263
18.6;Lower Extremity Fasciotomy;265
18.7;How to Manage the Fasciotomy Wound;266
18.8;Pulley Suture: Trick of the Trade;267
18.9;Final Thoughts;270
19;Chapter 19: Extremity Injuries and Open Fractures;271
19.1;BLUF Box (Bottom Line Up Front);271
19.2;Anatomy;272
19.3;Open Fractures;273
19.4;Stabilization;274
19.5;External Fixation;275
19.6;Compartment Syndrome: A Contrarian Opinion;279
19.7;Nerve and Tendon;280
19.8;Final Thoughts;281
20;Chapter 20: Mangled Extremities and Amputations;282
20.1;BLUF Box (Bottom Line Up Front);282
20.2;Initial Assessment and Resuscitation;283
20.3;Amputation Vs. Limb Salvage;284
20.3.1;Amputation: Forward Techniques;286
20.4;Debridement;287
20.5;Skeletal Stabilization;288
20.6;Definitive Amputation Closure;289
20.6.1;Transtibial Amputation Technique: Long Posterior Myofascial Flap;289
20.6.2;Transfemoral Amputation Technique;292
20.7;Care for Local Nationals;293
20.8;Final Thoughts;294
21;Chapter 21: Peripheral Vascular Injuries;295
21.1;BLUF Box (Bottom Line Up Front);295
21.2;Initial Assessment & Operative Planning: Peripheral Vascular Injury;296
21.3;Surgical Management: General Tips & Techniques;297
21.4;Specific Injuries and Approaches;302
21.4.1;Femoral and Popliteal Vessels;302
21.4.2;Upper Extremity Vessels;304
21.4.3;Pseudoaneurysms;306
21.5;Postoperative Care & Evacuation;306
21.6;Final Points;307
22;Chapter 22: The Neck;308
22.1;BLUF Box (Bottom Line Up Front);308
22.2;Why Is the Neck an Important Area to Understand the Anatomy and Injury Patterns?;308
22.3;Mechanisms and Types of Injuries to the Neck;309
22.4;What Are the Life Threatening Neck Injuries?;309
22.5;What Are the Injuries that Are Easy to Miss but Can Lead to Late Morbidity or Death?;309
22.6;How Should I Evaluate a Patient with a Neck Wound?;310
22.7;Techniques of Exposure, Exploration and Repair of the Common Injuries;312
22.7.1;Vascular Injuries: Common, Internal, and External Carotid Arteries, Jugular Vein;312
22.7.2;Esophagus;318
22.7.3;Trachea;322
22.7.4;Vertebral Arteries;322
22.8;Final Thoughts;323
23;Chapter 23: Genitourinary Injuries (Excluding Kidney);325
23.1;BLUF Box (Bottom Line Up Front);325
23.2;What Genitourinary Injuries will I have to Deal with in Combat?;326
23.3;What Do I Need to Assess in a Patient with Scrotal or Penile Wound?;326
23.4;How Can I Best Diagnose a Bladder or Urethral Injury?;327
23.5;Management for the General Surgeon;328
23.5.1;Penis;328
23.5.2;Urethra;330
23.5.3;Scrotum and Testicles;332
23.5.4;Bladder;334
23.5.5;Ureter;335
23.6;Tips and Techniques;336
23.6.1;Difficult Foley Placement;336
23.6.2;The “Hyperlube” Technique of Foley Catheter Placement;338
23.6.3;Suprapubic Tube Placement;339
23.6.4;Open Suprapubic Tube;339
23.6.5;Percutaneous Placement of the Suprapubic Tube;340
23.7;Performance of the Retrograde Urethrogram;340
23.8;Performance of the Cystogram;342
23.9;Summary;342
24;Chapter 24: Neurosurgery for Dummies;343
24.1;BLUF Box (Bottom Line Up Front);343
24.2;Introduction;344
24.3;The Basics;345
24.4;When Do I Need a CT Scan/What If I Don’t Have a CT Scan?;345
24.5;How Do I Know If There Is an “ICP Problem”?;346
24.6;The Isolated Severe Head Injury;346
24.7;Severe Head Injury in the Multiple Trauma Patient;347
24.8;Placement of ICP Monitor “Bolt” or EVD (Required Kits Must Be Available);348
24.9;Preparation;348
24.10;Marking the Patient;348
24.11;Placing the Device (ICP Monitor);349
24.12;Placing an EVD;351
24.13;Decompressive Craniectomy Tips;352
24.14;Preparation;352
24.15;Final Thoughts;359
25;Chapter 25: Spine Injuries;361
25.1;BLUF Box (Bottom Line Up Front);361
25.2;Assessing Spinal Cord Injuries;362
25.3;Shocking: Spinal Shock vs. Neurogenic Shock;365
25.4;Steroids;368
25.5;Managing Closed Spine Trauma;368
25.6;Managing Open Spine Trauma;370
25.7;A Is for Airway;370
25.8;Spinal Immobilization and Spinal Stability;371
25.9;Spinal Cord Syndromes;373
25.10;No Spine Consult Needed;373
25.11;Final Comments;373
26;Chapter 26: Face, Eye, and Ear Injuries;376
26.1;BLUF Box (Bottom Line Up Front);376
26.2;Getting Started;377
26.3;The Basics: Airway;378
26.4;The Basics: Hemostasis;379
26.5;The Eyes;380
26.6;Imaging;381
26.7;The Soft Tissue;382
26.8;The Bones;385
26.9;The Ears;389
26.10;Finally;390
27;Chapter 27: Burn Care in the Field Hospital;391
27.1;BLUF Box (Bottom Line Up Front);391
27.2;Immediate Care in the Field (Tactical Combat Casualty Care);392
27.3;Acute Burn Care (In the Trauma Bay);393
27.4;Burn Critical Care (The ICU Phase);397
27.5;Areas of Special Interest (Face and Hands);398
27.6;Transport of the Burn Casualty;399
27.7;Keys To Success for the Burn Casualty Who Has Nowhere Else To Go;399
27.8;Final Points;403
28;Chapter 28: The Pediatric Patient in Wartime;405
28.1;BLUF Box (Bottom Line Up Front);405
28.2;Intravenous Access;407
28.3;Special Considerations in the ER;410
28.4;Special Considerations in the OR;411
28.5;Special Considerations in the ICU;413
28.6;Humanitarian and Non-trauma Care;415
29;Chapter 29: The Combat ICU Team;417
29.1;BLUF Box (Bottom Line Up Front);417
29.2;Introduction;418
29.3;When Do You Need an ICU?;418
29.4;Who Should Staff the ICU?;419
29.5;How Should the ICU Work?;420
29.6;How Do You Set Up a Forward ICU and What Pieces of Equipment/Supplies Do I Need?;420
29.7;What If I Have Scarce Resources and Too Many Critical Patients?;424
29.8;Random but Practical and Important Points for the ICU;426
29.9;Final Thoughts;426
30;Chapter 30: Postoperative Resuscitation;428
30.1;BLUF Box (Bottom Line Up Front);428
30.2;Introduction;429
30.3;Principles of Combat Resuscitation;429
30.4;What Fluids Should I Use? When Do I Give Blood Products?;430
30.5;How Do I Tell If I Am Winning or Losing the Battle? What Is the Best Endpoint?;431
30.6;Who Does Not Need Resuscitation?;434
30.7;When Do I Need to Go Back to the OR?;435
30.8;Final Thoughts;435
31;Chapter 31: Monitoring;437
31.1;BLUF Box (Bottom Line Up Front);437
31.2;Introduction;438
31.3;Pulse Oximetry;439
31.4;Electrocardiography/Telemetry;440
31.5;Central Venous Pressure;440
31.6;Venous Oxygen Saturation;441
31.7;Pulmonary Artery Catheters;443
31.8;Arterial Lines;443
31.9;Assessing Volume Status: The Holy Grail;444
31.10;Intracranial Pressure Monitors (ICP);445
31.11;Monitoring for Shock and Adequacy of Resuscitation;447
31.12;Correction of Coagulopathy;447
31.13;Advanced Continuous Monitors;448
31.14;Closed-Loop Systems;450
31.15;Summary;450
32;Chapter 32: Ventilator Management;452
32.1;BLUF Box (Bottom Line Up Front);452
32.2;Which Combat Casualties Need Mechanical Ventilation?;453
32.3;Respiratory Failure in Combat Casualties: The Role of Blast Lung Injury;454
32.4;Initiation of Mechanical Ventilation;455
32.5;Lessons Learned from a Senior Respiratory Therapist;457
32.5.1;Equipment and Planning;457
32.5.2;Maintenance;457
32.5.3;Patient Care;458
32.5.4;Helpful References;458
32.6;Troubleshooting Common Ventilator Problems;460
32.6.1;Hypercapnea and Respiratory Acidosis;460
32.6.2;Hypoxemia and ARDS;461
32.7;Final Points;463
33;Chapter 33: Practical Approach to Combat-Related Infections and Antibiotics;464
33.1;BLUF Box (Bottom Line Up Front);464
33.2;Introduction;465
33.3;Prevention of Infection;466
33.3.1;Care at Point of Injury (Level I);466
33.3.2;Professional Medical Care Without Surgical Support (Levels I and IIa);467
33.3.3;Care with Surgical Support (Levels IIb and III);467
33.3.4;Care of Personnel Not Evacuated Rapidly Out of the Combat Zone;471
33.4;Final Points;472
34;Chapter 34: Stabilization and Transfer from the Far Forward Environment;473
34.1;BLUF Box (Bottom Line Up Front);473
34.2;Advanced Trauma Life Support;474
34.3;Secondary Survey;475
34.4;Resuscitation;475
34.5;Forward Surgical Intervention;478
34.6;Evacuation;480
34.7;Command;484
34.8;Conclusion;488
35;Chapter 35: Humanitarian and Local National Care;489
35.1;BLUF Box (Bottom Line Up Front);489
35.2;Medical Rules of Engagement Qualified;491
35.3;Medical Civic Assistance Programs;492
35.4;Local National Clinics;494
35.5;Educational Opportunities;499
35.6;Final Points;500
36;Chapter 36: Expectant and End of Life Care in a Combat Zone;501
36.1;BLUF Box (Bottom Line Up Front);501
36.2;Combat Care and the “God Complex”;503
36.3;Determining Expectant Status;504
36.4;Location of Expectant Care;505
36.5;Delivery of Expectant Care;506
36.6;Aftermath of Expectant Care;508
37;Appendix A: Improvise, Adjust, Overcome: Field Expedient Methods in a Forward Environment;510
38;Appendix B: Combat Burn Flowsheet andOrder Set;517
39;Appendix C: Resources, References, and Readiness;521