1. What is the leading cause of death in children in the United States?

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Injuries cause more death and disability in children from ages 1 to 18 years than all other causes combined. Unintentional injury deaths account for 65% of all injury deaths in children under 19 years of age. Each year, approximately 20,000 children and teenagers die as a result of injury and 50,000 children suffer permanent disabilities. Each year, nearly one child in four receives medical treatment for an injury. The estimated annual cost is $15 billion.

2. What age groups are at particular risk for traumatic death?

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Infants younger than age 2 years have a consistently higher mortality rate for the same level of injury. During adolescence, however, injury takes the greatest toll, accounting for nearly 80% of deaths.

3. What primary mechanisms account for pediatric traumatic injuries?

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Blunt (90%), penetrating (9%), and crush injuries (< 1%). Motor vehicle accidents are the most common cause of injury (50%) and death in childhood.

4. What is the incidence of injuries by body region?

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Multiple (50%), extremities (20%), head and neck (15%), abdomen (3%), face (2%), and thorax (1%).

5. What is the overall mortality from injury in children?

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2% of all injured children and 3% of hospitalized injured children.

6. What is the mortality rate of injuries by mechanism?

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See Table 36-1.
Table 36-1. MORTALITY RATE BY MECHANISM OF INJURY

7. Are boys and girls equally susceptible to injury?

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No. Boys are injured twice as often as girls. Boys and men are at a 4 times greater risk for “successful” suicide (although boys try it less often), 3 times greater risk for drowning, 2.5 times greater risk for homicide, and 2 times greater risk for motor vehicle-related trauma. The second X chromosome is clearly protective.

8. How is a child’s airway different from an adult’s?

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Children are at increased risk of airway obstruction because of their large tongue; floppy epiglottis; increased lymphoid tissue; and short, small-diameter trachea. Uncuffed endotracheal tubes are appropriate in children younger than age 8 years to minimize vocal cord trauma, subglottic edema, and ulceration. The narrowest part of a child’s airway is the cricoid ring, which functions as a seal for the uncuffed endotracheal tube.

9. What is the appropriate size of endotracheal tube to place in a child?

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The endotracheal tube should be the same size as the child’s small finger. For newborns, use a 3-mm tube; children in first year of life, 4-mm tube; children older than 1 year, internal diameter of the endotracheal tube = 18 + patients’s age in years ÷ 4 (but, in an urgent situation do not resort to extensive calculations; simply look at the child’s pinky).

10. What if oral endotracheal intubation cannot be accomplished?

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A needle cricothyrotomy is preferable to surgical cricothyrotomy and can be performed with a 14-gauge catheter. Conceptually, this is the same as jet insufflation in adults. Surgical cricothyrotomy is much more difficult in small children and has a high association with secondary subglottic stenosis.

11. What is a child’s total blood volume?

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80 mL/kg (8% of body weight).

12. What is the first sign of significant blood loss in children?

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Tachycardia. Young children are incredibly tough and have a remarkable tolerance to blood loss. Hemorrhage of 30% of blood volume may result in no blood pressure change, but such blood loss does cause a rapid increase in heart rate. A child’s cardiac output depends largely on heart rate; unlike adults, children have a limited capacity to increase stroke volume.

13. What are signs of hypovolemic shock in children?

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Tachycardia (progressing to bradycardia), altered mental status, respiratory compromise, delayed capillary refill (> 2 sec), and decreased or absent peripheral pulses.

14. Is hypotension a reliable indicator of blood loss in children?

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No. Fewer than half of injured children with documented hypotension have an identifiable insult resulting in significant volume loss. Hypotension is often associated with an isolated closedhead injury, especially in children younger than age 6 years.

15. Why are children at increased risk for hypothermia during resuscitation?

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The child’s surface area is large relative to internal body mass-an unclothed child can lose heat fast. Cold intravenous fluids and inhaled gases can exacerbate hypothermia, leading to hypoxemia, which causes pulmonary hypertension and progressive metabolic acidosis. Particularly vulnerable are infants < 6 months of age, who lack significant subcutaneous fat and an effective shivering mechanism.

16. What sites are preferred for venous access in children?

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Two large-bore intravenous (IV) catheters should be inserted percutaneously in the upper extremities. The second choice is percutaneous access to the distal saphenous vein (or a cutdown).

KEY POINTS: PEDIATRIC HEMODYNAMICS

1. Blood volume: 80 mL/kg.
2. The first sign of hypovolemia is tachycardia, which progresses to bradycardia.
3. Hypotension is not a reliable indicator of blood loss; children can lose 30% of blood volume without detectable change in blood pressure.
4. Preferred IV access routes in order: (1) two large-bore upper extremity IVs; (2) distal saphenous vein or cutdown; (3) intraosseous access.
5. Resuscitation fluid is lactate Ringer’s, 20 mL/kg × 2; then packed red blood cells (10 mL/kg) if instability continues.

17. What if you cannot establish an IV line?

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The intraosseous route is safe and actually requires less time than a venous cutdown. The anteromedial surface of the proximal tibia is used most commonly, with the needle placed 3 cm distal to the tibial tuberosity. The proximal femur, distal femur, and distal tibia are other potential sites. Saline, glucose, blood, bicarbonate, atropine, dopamine, epinephrine, diazepam, antibiotics, phenytoin, and succinylcholine have been administered successfully via the intraosseous route. Complications are rare and result primarily from infection or extravasation. Intraosseous volume resuscitation facilitates subsequent cannulation of the venous circulation.

18. What are the appropriate crystalloid and blood resuscitation volumes in children?

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Administer 20 mL/kg of Ringer’s lactate solution or normal saline by bolus. A response is a decrease in heart rate and an increase in urinary output. The 20-mL/kg bolus should be repeated if assessment reveals inadequate tissue perfusion. If evidence of shock persists after two bolus infusions of crystalloid solution, 10 mL/kg of packed red blood cells (type specific if available or O-negative) should be administered. Unfortunately, a favorable response to resuscitation does not exclude a big abdominal or thoracic injury.

19. Why are head injuries more common in children than adults?

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Similar to Olympic ski jumpers, children lead with their heads. Until age 10 years, children’s heads are larger in relation to the body than heads of adults. Central nervous system injury is the leading cause of death among injured children and, thus, is the principal determinant of outcome.

20. What types of head injuries are more common in children?

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Epidural hemorrhage is the most common; subdural hemorrhage is relatively rare. However, mortality from subdural hemorrhage is 40% versus 4% for an epidural bleed. Pediatric patients also tend to sustain injuries that produce diffuse edema rather than focal, space-occupying lesions.

21. Can children have significant chest trauma without rib fractures?

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Absolutely. The chest wall is much more compliant in children than in adults; thus, kinetic energy is transmitted more readily to structures within the thorax. A child with significant blunt chest trauma is at increased risk of life-threatening contusion to the lungs or heart even with no or relatively few rib fractures. Furthermore, pneumothorax may prove rapidly fatal in children because of a more mobile mediastinum. When present, rib fractures in children reflect non-accidental trauma. Thoracic injury is the second leading cause of death (after head trauma) in children.

22. What types of thoracic injuries are common or uncommon in children?

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Pulmonary contusion, traumatic asphyxia, and tracheobronchial injuries are common. Traumatic aortic rupture, flail chest, diaphragmatic rupture, and open pneumothorax are unusual.

23. What is the frequency of abdominal organ injury in blunt trauma?

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In decreasing order of frequency, they are spleen, liver, kidneys, intestine, pancreas, urinary bladder, and major blood vessels. Approximately one third of children with major trauma have significant intraperitoneal injuries that must be recognized and treated expeditiously.

24. How accurate is physical examination in the evaluation of pediatric blunt abdominal trauma?

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Poor. Physical examination is misleading in ≤ 50% of injured children.

25. What are the advantages and disadvantages of diagnostic peritoneal lavage (DPL) in children?

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DPL is 96% accurate in detecting intraabdominal injury. However, it may lead to nontherapeutic laparotomy rates of 15%.

26. What are the advantages and disadvantages of computed tomography (CT) in children?

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Abdominal CT scan is safe, noninvasive, and can assess retroperitoneal structures as well as identify specific organ injuries. CT is critical in the decision to manage children nonoperatively. Disadvantages include insensitivity for hollow visceral injury and the need for IV and enteral contrast agents. In addition, CT is time consuming (spiral CT may prove better) and requires patient transport and sedation. A trip to the scanner leaves patients vulnerable and unmonitored. Thus, CT is risky in unstable patients.

27. Is ultrasonography effective in the evaluation of children with abdominal traumaShow answer
Yes. It is simple, fast, readily available, and can be performed at the bedside. In addition, it is noninvasive and easily repeatable. The sensitivity and specificity of a focused abdominal ultrasonographic examination for traumatic injury exceeds 95%. Abdominal ultrasound is best used as a triage tool to detect significant intraperitoneal fluid, thus identifying hemodynamically unstable patients who might benefit from a laparotomy.
28. Is there a reliable method to diagnose hollow visceral injury in children?

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No. Serial physical examinations remain the gold standard. Repeat physical examination by the trauma surgical team is mandatory.

29. What are the “soft signs” of pediatric intraabdominal injury?

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* Lap-belt ecchymosis corresponds to a high incidence of solid organ injury, hollow viscus injury, and lumbar spine injury.
* Gross hematuria has a 30% risk for significant intraabdominal injury not even involving the genitourinary system.
* Elevation of the liver enzymes aspartate aminotransferase (> 250 U/L) or alanine aminotransferase (> 450 U/L) corresponds to a 50% risk for liver injury.
* Children with documented pelvic fracture have at least a 20% risk for associated intraabdominal injury.
* Children with severe neurologic impairment (Glasgow Coma Scale score < frequently suffer concurrent intraabdominal injury.

30. What should be suspected in children with seat-belt or handlebar injuries?

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The seat-belt complex consists of ecchymosis of the abdominal wall, a flexion-distraction injury to the lumbar spine (Chance fracture), and intestinal injury. Approximately 30% of children with the seat-belt sign have an associated intestinal injury.
A handlebar injury classically causes disruption of the pancreas at the junction of the body and tail, where the pancreas crosses the vertebral column and is vulnerable to anterior blunt compression.

31. Does the presence of hemoperitoneum in children require laparotomy?

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No. Unlike in adults, < 15% of children with hemoperitoneum require laparotomy for control of bleeding or repair of an injury.

32. Do all children with solid organ injuries require operative repair?

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No. Selective nonoperative management of solid organ injuries has revolutionized the management of pediatric trauma and is even gaining acceptance as safe and effective in the management of solid organ injuries in adults.

33. When is nonoperative management of solid organ injury in children appropriate?

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When the vital signs remain stable, 50% of the blood volume is replaced, and no other significant intraabdominal injuries are present. The decision for nonoperative management versus laparotomy should be based on the child’s physiologic condition and not on the extent of injury as documented radiographically.

34. What are the indications for operative intervention for solid organ injuries?

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Massive bleeding on presentation and transfusion of > 50% of blood volume (40 mL/kg) within 24 hours of injury.

35. What is SCIWORA?

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Spinal cord injury without radiologic abnormalities (SCIWORA) is a problem unique to children. A child’s spine has increased elasticity, shallow and horizontally oriented facet joints, anterior wedging of the vertebral bodies, and poorly developed uncinate processes. The spinal cord can be completely disrupted in young children without apparent disruption of the vertebral elements. However, most patients have evidence of spinal cord injury on magnetic resonance imaging. Two thirds of SCIWORA cases are seen in children ≤ 8 years of age.

36. What is the hallmark of SCIWORA?

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A documented neurologic deficit that may have changed or resolved by the time the child arrives in the emergency department. The danger is that immediate reinjury of the same area may produce permanent disability. Many children with SCIWORA tend to develop neurologic deficits hours to days after the reported injury. Therefore, spinal immobilization should continue, and thorough neurosurgical evaluation is essential in any child with reliable evidence of even a transient neurologic deficit.

37. What percentage of pediatric deaths attributed to injury are caused intentionally?

Twenty-five percent. More than 80% of deaths from head trauma in children younger than 2 years are caused by intentional abuse.

38. What signs are suspicious for nonaccidental trauma (NAT)?

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* History of failure to thrive
* Delay in obtaining medical care
* Multiple previous injuries
* Absent or uninterested caregiver
* Fluctuating or conflicting histories
* History inconsistent with the injury or developmental level of the victim

Suspicious physical findings include bite, pinch, slap, or cord marks or bruises in various stages of healing; multiple or bilateral skull fractures; a skull fracture in a fall < 4 feet; and retinal hemorrhages (from shaking).

39. List the characteristics of shaken-baby syndrome.

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* Retinal hemorrhage
* Subdural or subarachnoid hemorrhage
* Little evidence of external trauma
* Age < 2 years

40. What fracture patterns are suspicious for NAT?

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* Multiple rib fractures of different ages
* Extremity fractures such as metaphyseal “chip” or “bucket-handle” fractures
* Diaphyseal spiral fracture in children < 9 months of age
* Transverse midshaft long-bone fracture
* Femur fracture in infants < 2 years of age
* Fracture of the acromion process of the scapula
* Proximal humerus fracture

41. What percentage of NAT cases involve burn injuries? What are their characteristics?

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20% of abuse cases involve burns. Scalding by hot water is the most common. Specific patterns of injury may raise suspicion of abuse, including burns involving the buttocks and perineum (bathing trunk distribution), back, dorsum of the hand, and stocking-glove distribution. Cigarette burns look like circular punched-out ulcers of similar size.

42. What are the necessary steps in evaluation of children with suspected NAT?

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Any child with suspected NAT should have a detailed physical examination, head CT scan, skeletal survey (babygram), and retinal funduscopic examination. The appropriate child protective services should be contacted immediately.

43. How common is postinjury multiple organ failure in children?

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It is rare. With equivalent injury severity, multiple organ failure in children is much lower than in adults and carries a much lower mortality.

References
WEB SITE
http://www.emedicine.com/med/topic3223.htm

BIBLIOGRAPHY
1. American College of Surgeons Committee on Trauma: Recognition of Physical Child Abuse. Chicago, American College of Surgeons, 1997.
2. Calkins CM, Bensard DD, Moore EE, et al: The injured child is resistant to multiple organ failure: a different inflammatory response? J Trauma 53:1058-1063, 2002.

3. Dare AO, Dias MS, Li V: Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality. J Neurosurg 97(1 suppl):33-39, 2002.
4. Mazzola CA, Adelson PD: Critical care management of head trauma in children. Crit Care Med 30(11 suppl): S393-S401, 2002.
5. Mehall JR, Ennis JS, Saltzman DA, et al: Prospective results of a standardized algorithm based on hemodynamic status for managing pediatric solid organ injury. J Am Coll Surg 193:347-353, 2001. Medline Similar articles Full article
6. Partrick DA, Bensard, DD, Janik JS, et al: Is hypotension a reliable indicator of blood loss from traumatic injury in children? Am J Surg 184:555-560, 2002. Full article
7. Partrick DA, Bensard DD, Moore EE, et al: Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population. J Trauma 45:57-63, 1998. Medline Similar articles Full article
8. Stafford PW, Blinman TA, Nance ML: Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am 82:273-301, 2002.

1. Why is it essential to have sound clinical knowledge of urgent and emergent burn care?

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The events of September 11, 2001, have vividly underlined the fact that wars, plane crashes, nuclear and industrial accidents, and many other potential disasters can produce large numbers of burn-injured victims in an instant

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2. How prevalent are burn injuries and deaths from burns?

Roughly, 1.5 million burn injuries occur annually in the United States. Approximately 75,000 of these patients are hospitalized annually. About one half of those hospitalized need the skills of specialized burn centers.
In 1998, 146,941 trauma-related deaths occurred in the United States (population of 270,248,524). This equates to 54.4 deaths per 100,000 people. Of the quoted trauma deaths recorded in 1998, 3813 were burn deaths, representing 1.4 burn deaths per 100,000 people per year. Thus, based on 1998 data, more than 10 people die per day in the United States because of a burn injury.

3. Where do burn injuries occur?

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Eighty percent of burn-related injuries occur in the home, mostly in low-income, multifamily dwellings.

4. Who is at risk of suffering burns?

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The male-to-female ratio for burn injuries is roughly 2:1. The combined annualized death rate for children younger than 5 years and adults age 65 or older is five to six times higher than for the rest of the population.
Work-related burn injuries account for most of the male/female disparity, with accidents in the petrochemical and transportation industries responsible for a significant proportion. Alcohol abuse and illicit drug activity also increase the risk of burn injury and death.
The incidence of burn injuries and deaths in the United States is substantially higher than that of the rest of the industrialized world. Data published in 1995 reveal that New York City (population, 7 million) had more deaths than all of Japan (population, 120 million). The U.S. city of Baltimore, roughly the same size as Amsterdam in the Netherlands, recorded a 13 times higher fire death rate than Amsterdam’s in 1990.

5. Who should provide care for patients with burn injuries?

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This is determined by the severity of the injury and the ability of the provider. All level I, II, and III trauma centers should have well-defined protocols and well-established affiliations with specialized burn centers. A list of these burn centers can be found on the Internet at the American Burn Association’s Web site (www.ameriburn.org) and the American College of Surgeon’s Web site (www.facs.org/dept/trauma).

6. What are the outcomes of the victims of burn injuries?

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Of the roughly 75,000 burn victims hospitalized annually in the United States, approximately 3800 died in 1998, equating to a mortality risk of 7.6%. Pediatric burn centers record mortalities between 2% and 3%. Mortality for those older than 50 years is more than three times higher than the national mean. Above 70 years of age, mortality exceeds one in three victims.

7. Which factors influence burn outcomes most profoundly?

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Using logistic regression analysis on 1665 burn injuries treated in single specialty burn centers, three risk factors were identified with essentially equal weight in predicting mortality. The three factors were burn size of > 40% total body surface area (TBSA), patient age older than 60 years, and presence of inhalation injury to the lungs. The cumulative probability of death when one or more of these factors is presented in Table 35-1.
Table 35-1. MORTALITY RATES ASSOCIATED WITH BURN INJURY

8. Do any other variables influence survival?

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Ethanol abuse and illicit drug abuse can be added to the three factors listed above, increasing the risk of death by a factor of two to four times.

9. As a single mode of injury, why do burns pose such a devastating challenge and threat to victims?

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* Extensive damage to the skin (considered the largest single organ in the body and consuming almost 20% of the cardiac output) sets the stage for bacterial invasion.
* Because humans are almost 70% water, enclosed by a complex integumentary system, serious derangements in fluid homeostasis occur when the skin envelope is destroyed.
* Heat-induced denaturation of integumentary proteins enter the circulation. Systemic infection or sepsis remains the dominant precipitant of organ failure and death; this points to a burn injury-related immune dysfunction or failure.

10. What happens to the body of a burn victim?

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The pathophysiologic damage is both local and systemic.

11. What happens locally?

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The injury site may be divided into three zones by standard light microscopy: an inner zone of necrosis, a middle zone of stasis, and an outer zone of hyperemia. In the zone of necrosis, all proteins are denatured; all microvascular and macrovascular structure and function are destroyed. Surrounding this central zone is a zone of stasis. Here, cellular morphology is intact but cells are swollen with microstructural changes with extravasation of leukocytes and red blood cells into the interstitial space, increased interstitial fluid, and capillary stasis. A third zone of hyperemia then gently transitions into the adjacent normal tissues where no abnormalities are seen.

12. What changes occur systemically?

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Systemic events become clinically significant beyond an injury size of 10% TBSA. Two important abnormalities occur: (1) a trend to fluid retention with generalized edema, caused by an increased systemic microvascular permeability of very rapid onset (minutes to hours) and (2) a definite and reproducible decrease in cardiac output that gradually resolves over 12-36 hours to evolve into an ensuing cardiovascular hyperdynamism at 36 hours postinjury. To summarize, the pump is failing, and the microvasculature is leaking.
KEY POINTS: FACTORS STRONGLY ASSOCIATED WITH MORTALITY AFTER BURN INJURY

1. Burn size > 40% TBSA
2. Patient age > 60 years
3. Presence of inhalation injury
4. One risk factor: 3% mortality rate; all three risk factors: 90% mortality rate

13. How can burn victims be managed in a rational way from the time of injury?

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Five phases of care can be identified:

1. Burn first aid
2. Prehospital care
3. Emergency department
4. Transport to burn unit
5. Stabilization in burn unit or patient room

14. What can first responders do when witnessing a burn injury?

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First, do no harm. No ice, butter, dry ice, or any other substance should be applied to the wound after extinguishing the fire. Instead, focus on caring for the patient’s needs. If the burn is minor (< 10% TBSA), running tepid tap water over the burn with a hand-held shower for 20 minutes is beneficial. The time and effort required to apply wet soaks with towels appears to provide no benefit and may provoke hypothermia. If stranded in a remote area, encourage oral fluid intake and cover the wound with clean towels. Aspirin or ibuprofen may benefit the patient and the wound. Elevate any burned extremities and encourage full range of motion of all joints.

15. What actions are needed from prehospital providers (i.e., after the prehospital crew arrives, what are their priorities)?

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The American College of Surgeons’ Committee on Trauma (ACS-COT) advises that all ambulance crews follow “scoop and run” procedure guidelines for all burn victims within 60 minutes of an appropriate hospital (level I or II trauma center or burn facility). Attempt to place an intravenous (IV) line en route, but this is not essential if the travel time is < 60 minutes. Lines may be placed through burned skin, preferably in antecubital veins.
16. How does the hospital-based emergency department contribute to the care of the patients with major burns? Show answer
Urgency in caring for the victim, not the wound, is pivotal for the ultimate survival of the victim:

A Airway-Look for soot in the pharynx and for extensive facial burns.
B Breathing-Identify hoarseness, or stridor. Listen for breath sounds on both sides.
C Circulation-Place two peripheral IV lines, start fluids as lactated Ringer's solution; calculate the Parkland formula = 4 mL × kg body weight × % body burn [half of volume in first 8 hours; other half over 16 hours].
D Neurologic deficit-Examine central nervous system (CNS) and cranial nerves; assess the neurologic status of burned extremities.
E Expose and examine the skin, log roll and meticulously determine burn size on the posterior body, and then cover and preserve body heat. The patient's environment should be heated to 90°F.
F Fluid therapy should be assessed for effect as demonstrated by 1 mL of urine output per kilogram of body weight every hour.

Pain management and psychoemotional support are also vitally important. Avoid overdosing with narcotics.

17. What initial yardstick determines the severity of a burn injury?

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Burn wound size, which is expressed as a percentage of the total body surface, determines the severity. Remember that the Parkland formula for fluid resuscitation uses the burn wound size to calculate the volume of resuscitation. Therefore, overestimation of burn size leads to overestimation of fluid requirements, which may lead to excessive edema (including such unwanted outcomes as abdominal compartment syndrome). Underestimation of burn size may lead to persistent shock.
Contrary to popular belief, the depth of a burn injury has much less impact on the severity of the injury. The depth of injury also remains an area in which accurate clinical diagnosis, even by experts, is lacking. Burn depth, however, does determine whether a wound will heal on its own or whether skin grafting has to be done.
18. How are burns sized? Show answer
This determination is done clinically, with the aid of three important clinical tools:

1. The volar surface of the victim’s opened hand (including fingers) = 0.8-1.0% of TBSA; most useful for the sizing of small, scattered wound areas
2. Rule of nines: most commonly used; easy to memorize; not very accurate; usually overestimates
* Adult head = 9%
* Total upper extremity = 9%
* Total lower extremity = 2 × 9%
* Anterior torso = 2 × 9%
* Posterior torso including buttocks = 2 × 9%
* Genitals = 1%
Note that adults and children differ significantly by the difference in the relative size of the head (9% in adults, 15% in infants). By contrast, a thigh in an infant is much smaller than in adults (6% versus 10%).
3. Lund and Browder chart: more accurate; time consuming; requires practice; not easy to memorize

19. Besides the actual skin injury, what other associated injuries may occur?

Show answer
Inhalation injury is diagnosed in ± 10% of all hospitalized burn victims. Other physical trauma is frequently associated with explosions or merely the attempts to escape the fire. Awareness of associated trauma justifies the importance of a careful Advanced Trauma Life Support (ATLS)-guided trauma evaluation.

20. How is inhalation injury defined?

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In contrast to the visible and somewhat quantifiable external burn injury to the skin, the inhalation of heat, carbon monoxide (CO), cyanide, and other toxic or noxious vapors is less visible and less quantifiable, yet very dangerous. Four separate mechanisms of injury to the airways are sometimes incorrectly grouped as inhalation injury:

1. CO intoxication: CO is a product of incomplete combustion of organic or synthetic materials. CO has a 250 times greater affinity for hemoglobin than does oxygen, causing a decrease in blood oxygen content with possible hypoxic neurologic, cardiac, and kidney damage. Levels around 5% are routinely found in cigarette smokers, burn victims become symptomatic around 15-20%, and life is threatened around 30%. Management is by administration of 100% oxygen, which reduces the half-life of carboxyhemoglobin from 200 to 40 minutes.
2. Heat damage to upper airways: Although building fires can reach temperatures of 1000°F, the countercurrent mechanism of blood flow in upper air passages that normally helps us warm very cold air in the winter is equally capable of cooling down the air to temperatures > 100°F. However, prolonged breathing of superheated air or steam provokes damage to the naso-, oro-, and laryngopharynx and, most critically, the vocal folds. Even minimal vocal-fold edema presents as altered phonation or hoarseness and may rapidly progress to stridor, acute laryngeal edema, asphyxia, and death. Therefore, patients with altered phonation (see question 21) need immediate endotracheal intubation. Intubation is then usually necessary for 2-3 days or until airway edema has subsided.
3. Inhalation of toxic smoke components that are produced by the combustion of modern synthetic materials used in the interior decoration of houses, buildings, and cars. Examples include plastics, vinyl, paints, carpets, synthetic fabrics, and floor tiling. The overall mortality from this kind of injury (for which the term parenchymal inhalation lung injury could be more descriptive and appropriate) approaches 50%. The ultimate effect of the inhaled toxins is direct damage to airway mucosa, necrosis of mucociliary brush border, and death of surfactant-producing type 2 alveolar pneumocytes, leading to pulmonary failure.
4. Cyanide poisoning: The combustion of many synthetic materials also produces cyanide gas, which binds to the cytochrome enzyme system and inhibits mitochondrial function and cellular respiration. Blood cyanide levels should be assessed in all patients with CO levels > 10%. A toxicology center should be contacted. Sodium nitrite is usually administered intravenously, followed by IV sodium thiosulfate.

21. How is inhalation injury diagnosed and managed?

Show answer
It is diagnosed and managed with the following five entities:

1. Obvious hoarseness or stridor
2. Substantial head and neck or facial burns
3. Entrapment in enclosed space or direct proximity to an explosion
4. Extensive total body burns (> 50% in young adults; less in elderly individuals)
5. Event history of superheated steam

In the absence of these findings, immediate airway intervention (intubation) is not warranted, because endotracheal intubation immediately sets the stage for other respiratory complications, including pneumonia. Laryngoscopy or dynamic pulmonary function testing (flow-loop) may be helpful but are not essential or of definitive value. Repeated clinical assessment (e.g., respiratory rate, progressive hoarseness, use of accessory muscles) is more helpful than special tests. Sit the patient up as soon as possible, when stabilized, to help limit edema in head and neck and airway.
The diagnosis and management of CO poisoning rests on the blood level of CO, but all victims of dwelling fires should receive 100% oxygen through a non-rebreathing mask until the CO level is documented < 10%. Levels > 15% justify endotracheal intubation with 100% oxygen. The diagnosis of smoke inhalation is determined by the event history (e.g., when the victim has been trapped in an enclosed space for a significant period of time). The presence of soot in the mouth or in expectorated sputum is not diagnostic in itself. Significant smoke inhalation mandates endotracheal intubation. CO levels are critical, as well as a cyanide level, if the CO level is > 10%.

22. What treatment has most influenced the outcome of burn victims over the past 100 years?

Show answer
Adequate and timely fluid resuscitation.

23. Why should fluid be resuscitated, and by what route?

Show answer
All patients with burns > 10% TBSA should receive fluid. Fluid resuscitation through the gastrointestinal tract with an orogastric tube is used quite often in pediatric burn centers. In adults, the IV route is mandatory.

24. How is fluid therapy managed?

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The fluid management plan has two components. First, determine the burn wound size and the patient’s weight in kilograms, calculate the hourly fluid rate by the Parkland formula, and administer lactated Ringer’s solution at the hourly rate calculated.
The second component of the plan is just as important. Monitor the effectiveness of your fluid therapy plan and adjust it promptly when indicated. Our goals are a hemodynamically normalized individual, with a urine output of 0.5-1.0 mL of urine per kilogram body weight per hour. Avoid bolus therapy. Simply adjust your hourly rate. Be aggressive when you have to increase the hourly rate and very cautious when you decrease it in response to excessive urine flow.

25. What should be done if this treatment algorithm fails to achieve clinical improvement and patient stabilization?

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Failure to respond to the Parkland formula is indicative of a poor prognosis. However, some additional measures may be beneficial but are not currently considered as part of the standard of care. These include the use of hypertonic saline solutions in massive burns, early use of colloids in massive burns, and the early use of inotropes (dopamine is preferred in most burn texts). Finally, at least two prospective studies have failed to show benefit of invasive cardiac monitoring in the absence of preinjury cardiac disease.

26. How are fluid requirements calculated when there has been a delay in the initiation of therapy?

Show answer
Sometimes delay is unavoidable. In an attempt to address a perceived backlog of fluid resuscitation, current teaching is to proportionally increase the fluid volume in an attempt to get the desired total volume for 8 hours into the patient before the 8-hour period elapses. This remedy does require some common sense-one should not apply this guideline if the patient arrives at the resuscitation site later than 3 hours after the injury. Instead, administer fluids based on blood pressure, pulse, and urine output.

27. What is the best way to care for burn wounds initially?

Show answer
Early on, these wounds need simple coverage with a surgically clean or, if available, sterile sheet or surgical drape. The ACS-COT burn and trauma guidelines state that definitive wound care need not occur up to 24 hours postinjury. No ointment or specific antibacterial treatment is initially required. The patient should be kept warm because exposure precipitates systemic hypothermia.
For definitive wound care, the entire patient is washed or showered, and residual debris and damaged epidermis are removed. Then the extent of the injury is mapped, usually on a Lund and Browder chart, along with very preliminary attempts to determine the depth of the injury. A burn wound is usually a mosaic of different areas injured to varying degrees (depths). All burn wounds deepen to some extent over the first 48-96 hours, so a better prediction of which areas require grafting will come with time.
If appropriate wound care is applied, healing should occur within 14-18 days in areas where germinal cells are present in sufficient numbers. Wherever an area of burn injury is identified as a full-thickness injury, healing will never occur; these areas require skin grafting.

28. Why and how is the depth of a burn injury graded?

Show answer
This depends on the presence of skin appendages (hair follicle and sweat gland) that carry the germinal layer deep into the dermis, from which re-epithelialization can occur. On the day of injury, the visual ability to differentiate burn wound that will heal from that which will not is poor (50% accurate). Over time (next 3-7 days), the accuracy of clinical prediction will improve somewhat (≤ 90%). The following table helps to elucidate these aspects. (See Table 35-2.)
Fourth-degree burns involve damage to structures deeper than the dermis (e.g., fat, muscle, bone, tendon, nerve, joint capsule). Burns are designated as fifth degree when tissue is lost, blown off, or vaporized by the burn or blast.

Table 35-2. DEPTH OF INJURY WITH CLINICAL SIGNS AND PROBABLE OUTCOME

29. When should surgical excision of the burn wound begin?

Show answer
It should start as soon as possible, but it should be blended with common sense and pragmatism, which implies a hemodynamically “normalized” patient with no signs of sepsis or other contraindication to major surgery. This can be as soon as 24 hours after injury in small to moderate size burns (≤ 30% depending on age) but may take up to 4-10 days in unstable, septic, or frail patients. The overall goal remains to remove the infected or necrotic burned tissue as soon as possible without unduly stressing the patient. It is better for the patient to have a large surgically created wound than a wound containing large amounts of burn-damaged tissue exuding proinflammatory cytokines. Excisional strategies include staged excisions in several sessions, not exceeding 2 hours of operating time. Some authorities stop excising tissue as soon as 75% of the patient’s blood volume has been transfused. Burn wound excision can be a huge physiological stress, but is vastly safer than any alternative.

30. How is the excised area managed?

Show answer
A significant advance in burn management occurred in the early 1970s when Janzekovic demonstrated that excised wounds should be immediately grafted with skin. This remains the goal. If donor sites are insufficient, cadaver skin, pigskin, or biosynthetic products (e.g., Integra, Biobrane, or Transcyte) can be used for wound coverage. These areas require autografting subsequently. Cultured autologous keratinocytes are an attractive theoretical alternative, but they still lack consistent high-percentage engraftment when used on large areas.

31. What is the impact of a severe burn injury on the body?

Show answer
A big burn is on the top of the list of diseases or injuries that are best avoided. The metabolic response peaks at 2.5 times the basal metabolic rate (BMR) in all burns > 50% TBSA. This maximal acceleration of the body’s metabolism by burn injury leads to rapid and severe catabolism, further aggravated by periods of septicemia as well as heat loss through increased evaporation. Recent evidence suggests that growth hormone (HGH) therapy may have benefits in massively burned patients, but problems with glucose control are substantial during HGH-therapy. Several recent studies have also demonstrated the benefit of using beta-adrenergic receptor blockade (metoprolol) early in burns, with substantial benefits toward ameliorating the hypermetabolism.

32. How can we best supply fuel to the metabolic furnace of the body?

Show answer
Nutritional support of the burn victim is paramount. However, the total reliance on the gut as the primary route of nutritional support (as opposed to IV nutrition) has been slow to achieve acceptance. Total enteral nutrition may have the added benefit of maintaining the intestinal barrier function, which is purported to reduce septic events by preventing bacterial translocation. Currently, the concept of immuno-nutrition is in vogue, but it is fraught with intense controversy surrounding the role of glutamine and, more especially, arginine.

33. What major life-threatening complications may occur during the healing period?

Show answer
Septicemia, sepsis or septic shock, pneumonia, multiple organ dysfunction, and multiple organ failure.

34. What is the role of antibiotics in burn care?

Show answer
Antibiotics are never administered prophylactically for burn injuries. Fewer than 10% of all burn injuries require systemic antibiotics during the entire course of treatment. However, early and appropriate antibiotic therapy is a critically important and life-saving tool in the management of established infections in burn patients. The key to appropriate antibiotic therapy is the early diagnosis of an infective or septic event and wise selection of the appropriate drug or drugs based on the unique infectious profile of the burn victim. The antibiotic selected must be adjusted after culture and sensitivity information becomes available.
One real dilemma of burn care, however, is that a raised core body temperature does not always indicate infection or sepsis. It is important to view abnormal temperature readings in conjunction with other aberrations in clinical, biochemical (C-reactive protein; procalcitonin), and microbiologic data. Such warning signs include sudden changes in hemodynamic parameters, mental status, general appearance of the patient (he or she suddenly looks ill or is unwilling to cooperate), arterial blood gas changes, sudden intolerance of enteric feeding, thrombocytopenia, glucose intolerance, and oliguria.
35. How are chemical burn injuries approached? Show answer
Brush off all chemicals that remain in powdered form on the victim. Thereafter, immediate and prolonged irrigation (30 minutes) of the contaminated skin should be done with running tap water; in the case of alkali burns, irrigate for 60 minutes. Some chemicals may be absorbed; therefore, immediate contact with a toxicology center is indicated.

36. How are patients with electrical burns managed?

Show answer

An injury caused by electricity may either be an electrical flash burn or contact or conduction injury. In electrical flash injury, the air or atmosphere is ionized by the electrical discharge, without conduction of current through the body. Thus, the injury is only cutaneous. A true electrical flash burn most frequently heals without much grafting. Airway compromise is rare. In electrical conduction injury, however, tissue is damaged through the actual transfer of electrical energy through the patient from entry point to exit. Thermal energy is generated within the tissues because of the relative resistance to the conduction of current, with resultant protein denaturation and cell death. Different structures (e.g., bone, skin, muscle, nerve, tendon, lung) exhibit different electrical conductivity, resulting in unpredictable conduction pathways. Thus, the skin is often only minimally involved at the entry and exit sites, with extensive muscle, nerve, tendon, and even bone necrosis in erratic patterns. Neurologic injury, compartment syndrome, and myoglobinuria are frequent complications. Rapid tissue decompression (i.e., fasciotomy) is essential with early and repeated reexploration to remove necrotic tissue. The goal of fluid therapy should be to achieve high urine volumes (> 1.0-1.5 mL/kg/h). Alkalinization of the urine is also beneficial.

37. After burn injuries have healed, what important issues remain to be addressed in the rehabilitation period?

Show answer
The rehabilitation of a burn victim must begin on the day of admission and is a total team effort that involves physiatrists, plastic surgeons, occupational therapists, physical therapists, nutritionists, psychologists, social workers, pulmonologists, microbiologists, pharmacists, speech therapists, and nurses. Rehabilitation of the mind and body must occur in concert.

38. Are burnt children just small adults with burn injuries?

Show answer
No. Children really are different, so a pediatrician should be consulted.

39. Does this chapter provide a complete review of contemporary burn care?

Show answer
No, this is just an overview. Please review the bibliography below. Injury by lightning, ionizing radiation, and cold also warrant special attention.

References
WEB SITE
http://www.ameriburn.org/

BIBLIOGRAPHY
1. Demling RL: Burn care in the immediate resuscitation period. In American College of Surgeons: Surgery: Principles and Practice. Chicago, American College of Surgeons, 2002.
2. Gibbons J: Prevention. In Gibbons J (ed): Fire! 38 Lifesaving Tips for You and Your Family. Seattle, Ballard Publishing, 1995, pp 15-64.
3. Heyland DK, Novak F, Drover JW, et al: Should immuno nutrition become routine in critically ill patients? JAMA 29:944-953, 2001.
4. McDonald-Smith GP, Saffle JR, Edelman L, et al: National Burn Repository 2002 Report. Chicago, American Burn Association, 2002.
5. McGill V, Kahn S, Gamelli RL, et al: The impact of substance use on mortality and morbidity from thermal injury. J Trauma 38:931-934, 1995. Medline Similar articles Full article
6. Pruitt BA, Goodwin CW, Mason AD Jr: Epidemiological, demographic and outcome characteristics of burn injury. In Herndon DN (ed): Total Burn Care, 2nd ed. London, W.B. Saunders, 2002, pp 16-33. Full article
7. Ryan CM, Sheridan RL, Tompkins RG, et al: Objective estimates of the probability of death from burn injuries. N Engl J Med 338:362-368, 1998. Medline Similar articles Full article

1. What are the goals of hand repair?

Show answer
Functional considerations override cosmesis in the treatment of hand trauma. There are no minor hand injuries. Initial diagnosis and management determine the final result; expert secondary repair cannot overcome primary errors in diagnosis or decision making.

2. What determines the final outcome of a hand injury?

Show answer
It is determined by minimal sacrifice of tissue and primary healing accomplished by early wound closure. Minimization of scar tissue by control of edema, prevention of infection, early wound closure, and vigorous physical therapy produce the optimal functional outcome.

3. What factors influence treatment of hand trauma?

Show answer
Mechanism, location, and timing of injury; hand dominance; occupation; age; and general health of the patient.

4. How common are occupational hand injuries?

Show answer
Hand injuries result in more days lost from work than any other type of occupational injury.

5. What are the essentials of examination of the hand?

Show answer
Inspection of position, color, and temperature often reveals the injury. Location suggests possible injury to underlying structures. Motor, sensory, and Doppler ultrasonic examination are confirmatory. All injuries must be radiographed, and surgical exploration provides the definitive diagnosis.

6. How and where should hand injuries be explored?

Show answer
Hand wounds should be explored under tourniquet control with adequate analgesia using delicate instruments in a well-lighted surgery suite. Visual magnification is usually mandatory.

7. How is emergency hemostasis of injured hands achieved?

Show answer
In the acute setting (outside the operating suite), no tourniquet should be applied, and there should be no blind clamping of any structures. Hemostasis may be achieved by elevation of the extremity and with direct compression of the wound. This approach prevents injury to delicate underlying structures that are tough to see.

8. How are fingertip injuries treated?

Show answer
If < 1 cm of pulp is disrupted, the wound will heal spontaneously with daily cleansing and dressing with nonadherent, moist gauze. Larger defects may require a skin graft, which can often be provided by defatting the amputated piece. Bone exposure necessitates flap coverage if digital length is to be maintained. Digital nerves cannot be repaired distal to the distal interphalangeal (DIP) joint.

9. What is the classification system for fingertip amputations?

Show answer

Classification for fingertip amputations is based on the amount of remaining sensate volar skin. Although the favorably angulated amputation commonly removes some nail and bone, the volar skin is available for easy coverage. This amputation type is “favorable” for treatment by dressings only, allowing wound repair by contraction and epithelialization. The volarly angulated amputation angle is “unfavorable” for conservative management and usually requires a reconstructive procedure. (Image from Ditmars DM Jr: Fingertip and nail bed injuries. In Kasdan ML (ed): Occupational Hand and Upper Extremity Injuries and Disease. Philadelphia, Hanley & Belfus, 1991, with permission.) (See Figure 34-1.)

Figure 34-1 Fingertip amputations.

10. How are nail bed injuries repaired?

Show answer
Repair of the disruption of the germinal matrix must be meticulously approximated under magnification and the nail bed splinted, preferably with the avulsed part. Subungual hematomas should be evacuated by a hot-tipped paperclip or battery-powered electric cautery. Repair of the disruption of the sterile eponychial fold must be maintained for 3 weeks with Xeroform gauze or with the original nail. Often, nail bed disruption cannot be diagnosed without removal of the nail.

11. What is the initial management of flexor tendon?

Show answer
Flexor tendon laceration is not an emergency, and repair should not be undertaken in the emergency department. If a hand surgeon is unavailable, the wound should be copiously irrigated and sutured and prophylactic antibiotics instituted. This injury can wait for definitive repair.

12. What is the proper management of an open fracture?

Show answer
Open fractures should be cultured and then undergo copious lavage with normal saline or Ringer’s lactate. Broad-spectrum antibiotic coverage should be instituted, and the hand should be splinted in the position of function with a bulky dressing.

13. What is the proper treatment for hand infection?

Show answer
The extremity should be immobilized and elevated, and parenteral antibiotics should be given. The patient should be immediately referred for possible surgical drainage.

14. What is the proper management of human bites?

Show answer
After cleansing of the wound, a radiograph should be taken. The wound should be left open-never closed. Antibiotics should be started, and the wound should be rechecked at 24 and 48 hours. If evidence of infection is present, parenteral antibiotics should be instituted and referred for possible surgical drainage. The so-called fight bite occurs over the metacarpophalangeal (MCP) joint or proximal interphalangeal joint when a clenched fist is impaled on the front teeth of an adversary. This often inoculates the MCP joint with anaerobic streptococci. When infection is diagnosed, immediate arthrotomy and lavage should be performed.

15. How are injection injuries treated?

Show answer
Despite their innocuous appearance, injection injuries may cause profound destruction of hand structures. Any such injury requires immediate hospitalization with prompt and extensive decompression, drainage, and debridement.

KEY POINTS: CARPAL TUNNEL SYNDROME

1. Symptoms: numbness, tingling, pruritus of the palm, thumb, middle, and index fingers.
2. Mechanical cause is compression of median nerve and carpal tendons.
3. Women are affected twice as often as men; the syndrome is more common after 40 years of age.
4. Predilection for people who perform repetitive manual labor.

16. What is carpal tunnel syndrome (CTS)?

Show answer
CTS is the most common peripheral compression neuropathy; it is signaled by numbness and tingling of the hand.

17. Is CTS more common in older or younger people? Men or women?

Show answer
CTS is more common in people older than age 40 years, but an increasing number of young people with CTS have been reported in recent years, usually those whose jobs involve repetitive manual labor. Women are affected approximately twice as often as men.

18. What are the most preventable causes of deformity in hand injuries?

Show answer
Edema and infection lead to increased scarring and restricted function. Prolonged immobilization in a poor position also impairs function, as does delayed skin closure. Failure to obtain a radiograph leads to a missed diagnosis with delay in recognition of an injury.

19. What is the proper emergency department treatment of all hand injuries?

Show answer
The patient should be sedated and the wound cultured and irrigated. A thorough examination must be performed and a sterile compression dressing placed. The upper extremity should be splinted, tetanus prophylaxis should be administered, and broad-spectrum antibiotic coverage should be instituted for crush avulsion or heavily contaminated wounds. Radiographs of the hand should always be obtained.

20. What are the guidelines for replantation of an amputated finger?

Show answer
There are no absolute guidelines. A microsurgeon who is a member of a replantation team should be consulted. If replantation is planned, parts should not be immersed directly in water or put directly on ice or dry ice. The part should be copiously irrigated, wrapped in a moist sponge, and placed in a sterile plastic container; the plastic container should be placed in an ice-water slurry for transport.

References
WEB SITE

* http://www.ninds.nih.gov
o Search: carpal tunnel

BIBLIOGRAPHY
1. Dunn R, Watson S: Suturing versus conservative management of hand lacerations. Hand lacerations should be explored before conservative treatment. Comment on Br Med J 325(7359):299, 2002. Br Med J 325(7372):1113, 2002.

2. Hansen TB, Carstensen O: Hand injuries in agricultural accidents. J Hand Surg 24B:190-192, 1999.
3. Irvine AJ: Suturing versus conservative management of hand lacerations. Incisions are not lacerations. Comment on Br Med J 325(7359):299, 2002. Br Med J 325(7372):1113, 2002; author reply 325(7372):1113, 2002.
4. Lee SJ, Montgomery K: Athletic hand injuries. Orthop Clin North Am 33:547-554, 2002. Medline Similar articles Full article
5. McAuliffe JA: Hand care in the new millennium: Surgeons’ perspective. J Hand Ther 12:178-181, 1999. Medline Similar articles
6. Riaz M, Hill C, Khan K, Small JO: Long-term outcome of early active mobilization following flexor tendon repair in zone 2. J Hand Surg 24B:157-160, 1999.
7. Taras JS, Lamb MJ: Treatment of flexor tendon injuries: Surgeons’ perspective. J Hand Ther 12:141-148, 1999. Medline Similar articles
8. Van der Molen AB, Matloub HS, Dzwierzynski W, Sanger JR: The hand injury severity scoring system and workers’ compensation cases in Wisconsin, USA. J Hand Surg 24B:184-186, 1999.

14. What controversies exist regarding the care and repair of facial lacerations?

Show answer
There is little controversy about the care and repair of facial lacerations. Attention to basic principles of wound care usually produces a satisfactory scar. Because of the cosmetic considerations in facial trauma, primary repair in some instances is undertaken for the sake of appearance despite the risk of infection that would be deemed unacceptable in other areas of the body.

References
BIBLIOGRAPHY
1. Adame N Jr, Bayless P: Carotid arteriovenous fistula in the neck as a result of a facial laceration. J Emerg Med 16:575-578, 1998. Medline Similar articles Full article
2. Amiel GE, Sukhotnik I, Kawar B, Siplovich l: Use of N-butyl-2-cyanoacrylate in elective surgical incisions: Long-term outcomes. J Am Coll Surg 189:21-25, 1999. Medline Similar articles Full article
3. Farion KJ, Osmond MH, Hartling L, et al: Tissue adhesives for traumatic lacerations: A systematic review of randomized controlled trials. Acad Emerg Med 10:110-118, 2003.
4. Hollander JE, Richman PB, WerBlud M, et al: Irrigation in facial and scalp lacerations: Does it alter outcome? Ann Emerg Med 31:73-77, 1998. Full article
5. Keyes PD, Tallon JM, Rizos J: Topical anesthesia. Can Fam Physicians 44:2152-2156, 1998.
6. Mitchell RB, Nanez G, Wagner JD, Kelly J: Dog bites of the scalp, face, and neck in children. Laryngoscope 113:492-495, 2003.
7. Quinn J, Wells G, Sutcliffe T, et al: A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 277:1527-1530, 1997. Medline Similar articles Full article
8. Simon HK, Zempsky WT, Burns TB, Sullivan KM: Lacerations against Langer’s lines: To glue or suture? J Emerg Med 16:185-189, 1998. Full article

1. What distinguishes facial from other lacerations?

Show answer
Appearance is clearly of primary importance. Quality of the final result depends on strict adherence to basic principles of wound management and painstaking technique. Copious irrigation, judicious debridement, gentle tissue handling, meticulous hemostasis, and minimization of sutures combined with early stitch removal are critical to an optimal result. Fine suture and sharp instruments should be used; eversion of the wound margin with layered closure, obliteration of dead space, and lack of tension are mandatory.

2. What factors influence treatment for the wound?

Show answer
The mechanism of injury, the clinical assessment of contamination, and the time elapsed since wounding dictate treatment. Clean lacerations, heavily contaminated wounds, crush injuries, and bites are treated very differently.

3. How are clean lacerations repaired?

Show answer
They should be irrigated with normal saline or Ringer’s lactate. Only the surrounding skin should be prepared, and no antiseptic should be introduced into the wound. Regional anesthesia is preferred because of the potential for spread of contamination with direct injection of the wound margin. Epinephrine should be avoided because it devitalizes tissue and potentiates infection. Wounds should be repaired in layers with absorbable suture in deep tissue. The smallest number of sutures necessary to overcome the natural resting wound tension should be used. Sutures should be removed within 3-5 days, and the wound margin should be subsequently supported with Steri-strips.

4. How are dirty lacerations repaired?

Show answer
Heavily contaminated wounds should remain open after irrigation and debridement to undergo delayed closure. Because of cosmetic considerations, however, this approach is unacceptable in the face. For this reason, meticulous debridement of devitalized tissue and removal of all foreign material is essential. The wound should be cultured before copious irrigation, and a broad-spectrum antibiotic should be instituted prophylactically. The patient must be informed of the potential of a postrepair infection.
KEY POINTS: FACIAL LACERATIONS

1. Appearance is of paramount importance.
2. Clean lacerations are treated with minimal, tension-free, fine monofilament suture placement and early suture removal (3-5 days).
3. Heavily contaminated wounds are irrigated, debrided, and repaired with administration of antibiotics.
4. Human and animal bites are highly prone to infection; therefore, antibiotics and delayed closure are necessary.
5. N-butyl-2-cyanoacrylate (Dermabond) is used to repair pediatric facial lacerations.

5. What factors influence suture selection?

Show answer
Any method of suturing provokes tissue damage, impairs host defense, increases scar proliferation, and invites infection. Presence of a single silk suture in a wound lowers the infective threshold by a factor of 10,000. Therefore, fine, monofilament suture, just strong enough to overcome the resting wound tension, should be used. Use as few sutures as possible. Wounds with little or no retraction may be closed with tape alone.

6. Which wounds are suitable for closure with tissue adhesives?

Show answer
N-butyl-2-cyanoacrylate may suffice for cutaneous closure of low-tension lacerations in children (preferred method) and adults. This adhesive effectively closes low-tension lacerations. This method is fast and relatively painless. It has a low complication rate and produces excellent cosmetic outcomes. In many instances, if initial wound orientation is against Langer’s lines, it may, in fact, offer an advantage over conventional manual suturing.

7. Should eyebrows be shaved when facial lacerations are repaired?

Show answer
No. They provide a landmark for realignment of disrupted tissue edges and do not always grow back.
8. How should crush avulsion injuries with associated skin loss be repaired? Show answer
Nonviable elements must be surgically excised because they predispose to infection and lead to excessive scarring. If viability is in doubt, the wound should be irrigated thoroughly and left open with moist dressings. A delayed closure can be accomplished when the questionable areas have declared themselves. It is often prudent to close facial tissue as it lies; this technique often produces a less obtrusive scar than straight-line debridement and closure.

9. How should bites be treated?

Show answer
Both animal and human bite wounds are big-time contaminated and prone to infection. The wound should be left open and closed in a delayed fashion. Antibiotic prophylaxis is indicated. If the wound becomes infected, the sutures must be removed and the wound allowed to drain and heal. The patient should be informed that a scar revision will be necessary.

10. Should skin grafts or flaps be used for primary closure of a wound?

Show answer
Complicated tissue transfer techniques have no place in the acute treatment of facial wounds. Closure should be achieved in the simplest way possible and complex reconstructive efforts should be deferred until the scar has matured (months). When tissue loss prevents closure, it may be necessary to use a thin split-thickness skin graft for coverage.

11. When are antibiotics indicated in the treatment of facial lacerations?

Show answer
Copious irrigation, debridement, and gentle tissue handling are more pertinent to the prevention of infection than the use of antibiotics in clean and clean-contaminated wounds. Antibiotic coverage is indicated, however, in crush avulsion injuries, bites, and heavily contaminated injuries.

12. What determines the quality of the scar?

Show answer
Location of the wound, age of the patient, and type and quality of skin determine it. Lesser determinants are the type and quantity of suture material and wound care. Final appearance depends little on the method of suture. Contusion, infection, retained foreign body, improper orientation of laceration, tension, and beveling of edges predict a poor outcome. Differences among suture materials are negligible; however, the technical factors of suture placement to produce wound eversion and time to removal affect the final result.

13. When should scars be revised?

A scar usually has its worst appearance at 2 weeks to 2 months after suturing. Scar revision should await complete maturation, which may take 4-24 months. A good rule of thumb is to undertake no revisions for at least 6-12 months after initial repair. The maturation of the wound may be assessed by its degree of discomfort, erythema, and induration.

1. What are the “hard signs” of arterial injury?

Show answer

* Distal circulatory deficit: ischemia or diminished or absent pulses
* Bruit
* Expanding or pulsatile hematoma
* Arterial (pulsatile) bleeding

2. What are the four ways in which an arterial injury may present?

Show answer

1. Hemorrhage
2. Thrombosis
3. Arteriovenous fistula
4. Pseudoaneurysm

3. What are the “soft” signs of arterial injury?

Show answer

* Small- or moderate-sized stable hematoma
* Adjacent nerve injury
* Shock not explained by other injuries
* Proximity of penetrating wound to a major vascular structure

4. What are the symptoms of acute arterial occlusion?

Show answer
The six P’s: pain, pallor, pulse deficit, paresthesia, paralysis, and poikilothermia (cold).

5. What initial screening test is used to evaluate an extremity for occult vascular injury?

Show answer
Calculation of arterial pressure indices (APIs).

6. What are the APIs for the upper extremity and lower extremity called?

Show answer
An API for the upper extremity is the wrist brachial index (WBI).
An API for the lower extremity is the ankle brachial index (ABI).

7. How are WBI and ABI measured, and what is considered a normal value?

Show answer
A hand-held Doppler and blood pressure cuff are used to measure systolic blood pressure in the brachial, radial, ulnar, dorsalis pedis (DP), and posterior tibial (PT) arteries bilaterally. The ABI for each leg is the highest DP or PT divided by the highest brachial pressure. The WBI for each arm is the highest radial or ulnar artery pressure divided by the highest brachial pressure. A value of 1.0 is normal.
8. What API value raises concern for arterial injury, and what is the sensitivity and specificity? Show answer

* An API value < 0.9 has a sensitivity of 95% and specificity of 97% for major arterial injury.
* An API > 0.9 has a negative predictive value of 99%.

9. When the API value is < 0.9 in an injured extremity, what should be the next diagnostic test?

Show answer
Arteriography to establish the diagnosis and plan for operative intervention.

10. What abnormalities on arteriography determine a positive test result?

Show answer

* Obstruction of flow
* Extravasation of contrast
* Early venous filling or arteriovenous fistula
* Wall irregularity or filling defect
* False aneurysm (pseudoaneurysm)

11. What study should be performed for patients with proximity injury or soft signs (API > 0.9)?

Show answer
Duplex ultrasonography to rule out occult vascular injury.

12. What occult vascular injuries can be detected by duplex ultrasonography?

Show answer

* Intimal flap
* Pseudoaneurysm
* Arteriovenous fistula
* Focal vessel narrowing
* Nonoperative observation of these injuries is safe and effective: 89% of them do not require surgery

13. What is a pseudoaneurysm?

Show answer
It is a disruption of the arterial wall leading to a pulsatile hematoma contained by fibrous connective tissue (but not all three arterial wall layers). (See Figures 32-1 and 32-2.)

Figure 32-1 Subtraction angiography demonstrating intimal flap with stenosis of superficial femoral artery.

Figure 32-2 Duplex ultrasound of common femoral artery demonstrating pseudoaneurysm sac and associated neck between pseudoaneurysm sac and femoral artery after percutaneous access for angiography.

14. What is a true aneurysm?

Show answer
Dilatation of all three layers of the vessel wall (i.e., intima, media, and adventitia).

15. What is the most effective way to control arterial bleeding in an injured extremity?

Show answer
Direct digital pressure.

16. What means of controlling vascular injury should be avoided? Why?

Show answer
A tourniquet should be avoided because collateral circulation is occluded and leads to increased tissue ischemia.
Blind clamping should also be avoided because it causes further vessel damage, making reconstruction more difficult.

17. How should a patient with an extremity vascular injury be prepared and draped in the operating room?

Show answer
The entire involved extremity should be in the sterile field. The major arterial trunk proximal to the site of injury (for proximal control) and a portion of lower extremity permitting access to saphenous vein should be included in the sterile field.

18. What else should be prepared and draped for proximal extremity injuries?

Show answer
The chest should be prepped for proximal injuries of the upper extremity. The abdomen should be prepped for proximal injuries of the lower extremity. (Access to the chest or abdomen may be necessary to obtain proximal vascular control.)

19. What are the operative principles relative to repair of vascular injuries?

Show answer

* Perform longitudinal incisions over vessels to be explored.
* Initial dissection should be away from the site of suspected injury and adjacent hematoma.
* Obtain proximal and distal control of the injured vessel.
* Debride the injured vessel.
* Perform primary repair if tension free (fully extend extremity to ensure tension-free repair).
* Repair with autogenous interposition vein graft if there is inadequate length (tension).

20. What is the best conduit to use if primary repair is not possible? Why?

Show answer
Saphenous or cephalic vein from the uninjured extremity to preserve venous flow.

21. Should injuries to major veins of the extremities be repaired?

Show answer
Yes. Repair of a major vein enhances the success of a concomitant arterial repair by improving outflow. Late thrombosis often occurs after venous repair, but initial patency helps by allowing collateral circulation to develop. This may also reduce the incidence of postoperative venous insufficiency.

22. When should injured major veins be ligated?

Show answer
Major veins should be ligated rather than repaired when the patient is hemodynamically unstable or the repair is too complex.

23. What complications can develop after ligation of major extremity veins?

Show answer
Possible complications include rapid increase in muscle compartment pressure, leading to compromised venous or arterial flow and compartment syndrome. Also, postoperative venous stasis may occur, which can be alleviated with intermittent pneumatic calf compression and leg elevation.

24. What is a compartment syndrome?

Show answer
Development of pathologically elevated tissue pressures (preventing perfusion) within nonexpansile envelopes (inside fascial compartments) of the arm or leg.
KEY POINTS: COMPARTMENT SYNDROME

1. Pathologically elevated tissue pressures in nonexpansile fascial compartments prevent tissue perfusion.
2. The most common cause is ischemia-reperfusion injury following traumatic extremity injuries.
3. The earliest clinical sign is numbness in the first dorsal webspace associated with compromise of the deep peroneal nerve. Other signs: pain with passive joint motion, pain out of proportion to injury, tense and tender muscle compartments.
4. Distal pulses are evident until late in the diagnosis and should not be used to rule out compartment syndrome.
5. Hand-held manometer is used to measure muscular compartments. Normal pressure = < 10 mmHg; pathologic pressure = > 30 mmHg.
6. Treatment is emergent fasciotomy.

25. What is the most common cause of a compartment syndrome?

Show answer
Ischemia-reperfusion injury when ischemia depletes intracellular energy stores and then reperfusion leads to toxic oxygen radicals, causing cellular swelling and interstitial fluid accumulation.

26. What is the earliest sign of compartment syndrome after vascular repair of an extremity?

Show answer
Neurologic deficit in the distribution of the peroneal nerve with weak dorsiflexion and numbness in the first dorsal webspace.

27. Are there any other signs of a developing compartment syndrome of an extremity?

Show answer

* Increased pain with passive motion of the ankle
* Pain out of proportion to clinical findings (ischemia hurts)
* Tense muscle compartments that are tender to palpation

Distal pulses can remain intact.
28. How is the objective diagnosis of a compartment syndrome made?

Show answer
By measuring compartment pressures with a percutaneous needle and pressure transducer. Criteria for compartment syndrome are as follows:

* When diastolic pressure-compartment pressure is ≤ 20 mmHg or
* When mean arterial pressure-compartment pressure is ≤ 30 mmHg

29. What is the treatment for compartment syndrome of an extremity?

Show answer
Emergent fasciotomy, with decompression of the four compartments of the lower leg (anterior, lateral, superficial posterior, and deep posterior) or decompression of the forearm compartments.

30. What is the result of untreated compartment syndrome?

Show answer
Loss of perfusion promotes eventual myoneuronecrosis.
31. Which are the most commonly injured arteries in the upper extremity?

32. Which are the most commonly injured arteries in the lower extremity?

33. Can a patient with an extremity arterial injury have palpable distal pulses?

Show answer
Yes. In ≤ 20% of proven arterial injuries, a distal pulse is palpable (often because of collateral circulation).

34. What orthopedic injuries commonly have associated vascular injuries?

Show answer

* Supracondylar humerus fractures are associated with brachial artery injuries.
* Knee dislocations are associated with popliteal artery injuries.
* Femur fractures can be associated with injury to the superficial femoral artery.

35. For an injured extremity with concomitant fracture and vascular injury, which repair should be performed first?

Show answer
The vascular repair should be performed first to restore flow and reverse tissue ischemia.

36. After reducing or fixing an extremity fracture, what must you always do?

Show answer
Evaluate the distal pulses to ensure adequate vascular inflow (especially if fixation or any manipulation follows a vascular repair).

37. What is the likely diagnosis in a patient with repetitive palmar trauma and finger ischemia or necrosis?

Show answer
Hypothenar hammer syndrome (HHS). The mechanism is thought to be repetitive palmar trauma in patients with preexisting palmar artery fibrodysplasia. (The arteriogram shows digital artery occlusions with segmental ulnar artery occlusion or “corkscrew” elongation.) (See Figure 32-3.)

Figure 32-3 Angiography demonstrating intimal flap in superficial femoral artery associated with femur fracture.

38. What complications can occur after angiography when a percutaneous closure device is used on the femoral artery?

Show answer

* Thrombosis, ischemia, or both when the closure suture involves the posterior wall (back wall) of the artery
* Infected pseudoaneurysm
* Distal embolization when a hemostatic plug closure device is used

References
WEB SITES

1. http://www.east.org/tpg/lepene.pdf
2. http://www.surgery.ucsf.edu/eastbaytrauma/Protocols/ER%20protocol%20pages/extremity.htm

BIBLIOGRAPHY
1. Ferris BL, Taylor LM Jr, Oyama K, et al: Hypothenar hammer syndrome: Proposed etiology. J Vasc Surg 31:104-113, 2000. Medline Similar articles
2. Rutherford RB (ed): Vascular Surgery, 5th ed. Philadelphia, W.B. Saunders, 2000, pp 862-870.
3. Schwartz SI (ed): Principles of Surgery, 7th ed. New York, McGraw-Hill, 1999, pp 158-177.

1. What are the causes of bladder injury?

Show answer
Iatrogenic manipulation and penetrating or blunt trauma. Because of the rich detrusor blood supply, bladder injury is usually accompanied by hematuria. Other signs may include suprapubic pain, inability to void, or incomplete recovery of catheter irrigation.

2. What types of bladder injury may occur with blunt trauma?

Show answer
Laceration or perforation may be either intra- or extraperitoneal. Hematuria with a normal cystogram defines bladder contusion in the absence of upper tract injury. Extraperitoneal injuries constitute the majority of bladder trauma and tend to concentrate at the bladder base or parasymphyseal area. These can be managed conservatively with urinary catheter drainage for at least 10 days. Intraperitoneal (IP) ruptures typically occur when the bladder is distended at the time of trauma, causing a blowout of the dome of a bladder. IP vesical rupture should be surgically repaired using a two-layer closure with absorbable sutures and placement of suprapubic and urethral catheters.
KEY POINTS: MANAGEMENT OF BLADDER INJURY DUE TO BLUNT TRAUMA

1. Diagnose with CT cystography and retrograde cystourethrography.
2. Extraperitoneal injuries are more common and may be managed conservatively with a Foley catheter for 10 days.
3. Intraperitoneal injuries are more likely if the bladder is distended at the time of injury; they require surgical repair with suprapubic and Foley drainage postoperatively.

3. What is the likelihood of a bladder injury in patients with a fractured pelvis?

Show answer
Extraperitoneal bladder injury occurs in 10% of all pelvic fractures. Conversely, approximately 85% of blunt bladder injury is associated with pelvic fracture. Bladder injuries occur more often with parasymphyseal pubic arch fractures and more often with bilateral than unilateral fractures. Isolated ramus fractures produce bladder laceration in 10% of cases.

4. How is bladder injury evaluated?

Show answer
Both computed tomography (CT) cystography and retrograde cystourethrography provide great diagnostic accuracy for bladder rupture. The bladder should be filled under gravity with a total of 300-400 mL of a 50% dilution of standard radiocontrast agent using the Foley catheter. Films should include anteroposterior, lateral, and oblique views. Finally, a postvoid film should be obtained. When renal or distal ureteral injury is suspected, upper tract imaging (intravenous pyelogram [IVP] or CT scan) should precede the cystogram.

5. What are the retrograde cystourethrographic patterns of bladder injury?

Show answer
Extraperitoneal injury allows contrast agent to escape adjacent to the symphysis, but it is confined to the bladder base by the intact peritoneum. Intraperitoneal extravasation produces a “sunburst” appearance from the bladder dome, which may collect in the paracolic gutters, outline loops of bowel, or pool under the liver or spleen. It is pivotal to obtain postvoid films.

6. How is bladder rupture managed?

Show answer
Extraperitoneal lacerations can be managed with an indwelling catheter for 7-10 days, at which time cystogram usually confirms resolution of extravasation. Intraperitoneal lacerations require operative repair. Bladder contusion requires catheter drainage until gross bleeding has subsided.

7. When should urethral injury be investigated?

Show answer
The mechanism of injury (e.g., crushing or deceleration/impact, straddle injuries) and associated trauma (e.g., pelvic fracture), blood at the meatus, penile or scrotal swelling and ecchymosis, upward prostatic displacement on digital rectal examination, and inability to void or to pass a urethral catheter (do not try this) should be investigated.

8. When a patient presents with a pelvic fracture, is concomitant urethral injury a major concern?

Show answer
Yes. Urethral trauma occurs in 10% of pelvic fractures; it is more common with anterior disruption of the pelvic ring, including 20% of unilateral and 50% of bilateral parasymphyseal fractures. Posterior (prostatomembranous) avulsion is associated with potentially disabling sequelae and requirements for complex and challenging operative corrections. In contrast, more distal urethral injuries avoid impotence and incontinence issues and are more surgically accessible.

9. How is urethral injury best assessed?

Show answer
Retrograde urethrography must always be performed before inserting a Foley catheter. Incomplete urethral transection produces local contrast dye extravasation and bladder opacification. Total avulsion produces extensive local extravasation, and no contrast dye gets into the bladder. Incomplete transection is more common with anterior (50%) than posterior (10%) urethral injuries.

10. How is urethral injury managed?

Show answer
For incomplete transection regardless of site, either catheter stenting across the defect or diversion by suprapubic cystostomy permits resolution. With complete urethral transection, the bladder should be decompressed initially via suprapubic cystostomy. Early restoration of continuity by placement of a bridging urethral catheter should be performed endoscopically. A bridging catheter reduces complex scarring and avoids subsequent surgery in many patients.

11. What are the complications of urethral injury?

Show answer
Strictures, incontinence, and impotence (associated with traumatic prostatic displacement). Iatrogenic complications are associated with retropubic dissection.

12. What is the differential diagnosis in blunt scrotal trauma?

Show answer
Testicular rupture, hematocele, scrotal hematoma, intratesticular hematoma, and testicular torsion. Ultrasonography helps sort this out.

13. What is the sonographic sign of testicular rupture?

Show answer
The sign is loss of the normal homogenous echo texture of the testicle, with areas of irregular hyper- or hypoechogenicity.

14. How are patients with acute testicular rupture managed?

Show answer
Management includes surgical exploration and debridement of extruded, nonviable tubules and evacuation of the hematoma. After proper hemostasis is achieved, the tunica albuginea should be closed with running absorbable suture.

15. What is the most common cause of penile fractures?

Show answer
Penile fracture is a rupture of the corpus cavernosum, most commonly associated with sexual intercourse, masturbation, or an abnormally forced bending of the erect penis. Characteristically the patient hears a popping sound, followed by pain and detumescence.

16. What are the physical examinations findings with a penile fracture?

Show answer
Injury to the tunica albuginea causes formation of hematoma and deviation of the shaft to the opposite side of injury. If Buck’s fascia is intact, the hematoma will be confined to the penis; disruption of Buck’s fascia allows spread of the hematoma under Colles’ and Scarpa’s fascia onto the perineum and abdominal wall.

17. How are penile fractures managed?

Show answer
Surgically. A retrograde urethrogram should be performed when urethral injury is suspected. Closure of the defect (or defects) along the tunica albuginea and evacuation of hematoma are performed after degloving the penis.

18. In penile amputation injuries, how should the amputated portion of the penis be preserved for transport?

Show answer
The amputated portion of the penis should be wrapped in saline-soaked gauze, placed in a plastic bag with ice slush surrounding the bag.

19. How is major scrotal skin loss managed?

Show answer
If primary repair is not possible, meshed split-thickness skin grafts may be used to cover the testis. When delayed repair is necessary, thigh pouches should be created until permanent reconstruction is feasible.

20. A 50-year-old woman complains of urine leakage from her vagina after a hysterectomy. What is the most likely diagnosis?

Show answer
Unrecognized bladder injury during hysterectomy with subsequent urine extravasation into the surgical field and drainage via the vaginal cuff suture line leads to formation of vesicovaginal fistula.

21. What is the best time to repair a vesicovaginal fistula secondary to an uncomplicated hysterectomy?

Show answer
Although 3-6 months after injury has been recommeded in the past, early repair can be successful if there is minimal inflammation and there are no complicating factors.

References
WEB SITES

1. http://www.east.org/tpg/GUmgmt.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0510.htm

BIBLIOGRAPHY
1. Armstrong PA, Litscher LJ, Key DW, McCarthy MC: Management strategies for genitourinary trauma. Hosp Phys 34:19-25, 1998.
2. Jacob TD, Gruen GS, Udekwu AO, Peitzman AB: Pelvic fracture. Surg Rounds (Aug):583, 1993.
3. Jordan GH: Lower Genitourinary Tract Trauma and Male External Genital Trauma (Nonpenetrating Injuries, Penetrating Injuries, and Avulsion Injuries). In American Urological Association Update Series, Vol. XIX, Lesson 11, part 2. Baltimore, American Urological Association, 2000.
4. Kim FJ: Urologic trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma Companion Handbook, 4th ed. New York, McGraw-Hill, 2002.
5. McAninch JW: Traumatic and Reconstructive Urology. Philadelphia, W.B. Saunders, 1996.
6. Peterson NE: Current management of urethral injuries. In Rous S (ed): 1998 Urology Annual. New York, Appleton-Century-Crofts, 1988, pp 143-179.
7. Peterson NE: Traumatic posterior urethral avulsion. Mongr Urol 7:61, 1986.
8. Spirnak JP: Pelvic fracture and injury to the lower urinary tract. Surg Clin North Am 68:1057, 1988. Medline Similar articles

1. What is the most common type of renal trauma in the United States, blunt or penetrating?

Show answer
Blunt, by far.

2. Do most kidney injuries require surgery?

Show answer
No. Fewer than 2% of blunt injuries require surgery, and many penetrating injuries can also be treated nonoperatively.

3. Are pediatric kidneys more susceptible to major injury?

Show answer
Yes. Because of children’s weaker abdominal muscles, less-ossified thoracic cage, decreased perirenal fat, and increased renal size in relation to the rest of the body, the risk for renal injury is greater in the pediatric population.

4. When should potential renal trauma be investigated?

Show answer
All blunt trauma patients with gross hematuria or with microscopic hematuria and shock (systolic blood pressure < 90 mmHg) should be closely examined. Penetrating injuries with any degree of hematuria should be imaged. For pediatric patients, liberal use of studies is advisable. When children spill < 50 red blood cells (RBCs) per high-powered field (hpf) on microscopic urinalysis, significant renal injury is rare. Furthermore, shock is not a useful guide in children.

5. When does one suspect renal trauma?

Show answer
The mechanism of injury, physical examination (e.g., flank ecchymosis, location of penetrating wounds), and associated injuries (e.g., rib fractures) should raise suspicion of renal trauma. Although the degree of hematuria does not correlate with the degree of renal injury, when hematuria is out of proportion to the history of trauma, it suggests preexisting renal abnormality (e.g., hydronephrosis, ectopic kidney, tumor, cystic disease, vascular malformation). Conversely, renal pedicle injuries (grade 4) may bleed little because of arterial interruption.

6. What imaging study is best to evaluate renal trauma?

Show answer
Computed tomography (CT) scan of the abdomen and pelvis with and without intravenous (IV) contrast should be performed, but it is pivotal that the perfusion and excretion phases (10 minutes after IV contrast is administered) are obtained during the study.

7. What is a single-shot IVP, and when do you perform it?

Show answer
It is an extremely abbreviated form of intravenous pyelogram (IVP) performed in emergent cases when a full evaluation is not permitted. A bolus (2 mL/kg contrast agent) is injected intravenously, and the first film should be obtained at approximately 10 minutes, with additional films at 10-minute intervals as necessary for diagnosis. Intraoperative IVP is recommended when renal damage is first suggested (e.g., retroperitoneal hematoma) during emergency surgery for other injuries.

8. How is renal trauma classified?

Show answer

* Grade 1: contusion
* Grade 2: superficial laceration
* Grade 3: deep laceration without collecting system damage
* Grade 4: contained renal pedicle injury or deep laceration and collecting system damage
* Grade 5: shattered kidney or avulsion of renal hilum

Grade 1, 2, and 3 injuries are safe to watch with nonoperative management, whereas grades 4 and 5 typically require operative intervention for repair or removal. Grade 4 injury (pedicle injury) is picked up by ipsilateral urographic nonfunction and nominal bleeding. Grade 5 injury is manifested by urographic nonfunction, parenchymal shattering, and significant gross hematuria.

9. What are the different kinds of renal pedicle trauma?

Show answer
The renal pedicle may be interrupted by thrombosis or complete avulsion; both events are characterized by urographic nonvisualization and minimal hematuria. The most common site of arterial interruption is the junction of the proximal and middle thirds of the main renal artery. Although hematuria is often absent, one may see transitory gross hematuria or microhematuria, emphasizing the requirement for urinalysis in all circumstances.

10. How long can a nonperfused kidney tolerate warm ischemia?

Show answer
Irreversible renal damage may be seen in kidneys after 30 minutes of warm ischemia, and after 8 hours of ischemia, renal salvage is minimal. Recently, single reports of renovascular trauma with intimal tear treated with endovascular stents have been encouraging.

11. What is the significance of delayed gross hematuria?

Show answer
This occurs 3-4 weeks after trauma and may indicate an arteriovenous fistula. Selective embolization is the next step if conservative therapy (bed rest) fails. Rarely, operative intervention, usually for partial nephrectomy, is necessary.

12. How do you deal with unexpected retroperitoneal bleeding noted at operation?

Show answer
A pulsatile hematoma suggests a major vascular injury, and exploration should be preceded by vascular control (both proximal and distal) and preparation for rapid blood replacement. Stable hematomas (above the pelvic brim) may be left undisturbed unless studies (preoperative or intraoperative) disclose severe renal damage. When doubt exists, exploration is justified, with the likelihood of losing a kidney.

13. How are patients with posttraumatic urine extravasation managed?

Show answer
When urine extravasation is caused by a major laceration into the collecting system and coexists with significant persistent bleeding, surgical correction is advised. Otherwise, urine extravasation commonly resolves promptly. Reimaging at 48-72 hours defines cases requiring drainage, stenting, or operative repair.

14. What is included in conservative management of renal trauma?

Show answer
Conservative management includes bed rest until gross hematuria has subsided. Strenuous activity is avoided until microhematuria has subsided (usually within 3 weeks). Patients followed for grade 5 renal trauma should undergo ultrasonography, CT scan of the abdomen and pelvis, or urography at 6 weeks. Hospitalization is not required during these periods.

15. What is the likelihood of subsequent hypertension?

Show answer
Documented posttraumatic hypertension occurs in < 2% of patients and is renin mediated. Onset generally occurs within the first several months of injury. The mechanisms of posttraumatic hypertension are renal artery stenosis or occlusion, renal parenchymal compression (extravasation of blood or urine), and posttrauma arteriovenous fistula.

16. How are most ureters damaged?

Show answer
In the civilian world, excluding iatrogenic injuries, penetrating trauma is responsible for 4% of ureteral injuries, and 1% are caused by blunt trauma.

KEY POINTS: PRINCIPLES OF URETERAL REPAIR

1. Primary tension-free anastomosis is preferred over stent with absorbable suture.
2. For a distal injury in the lower third of the ureter, perform ureteroneocystostomy; suspend the bladder if tension exists.
3. For middle third injuries, perform end-to-side transretroperitoneal ureteroureterostomy.
4. For proximal injury with significant length loss, use nephrostomy tube for drainage.

17. How do you evaluate and identify ureteral injury?

Show answer
The site and mechanism of trauma should prompt the surgeon to suspect ureteral injury. The clinical manifestations are characteristically subtle and often obscured by coexisting injury and complaints. The majority of gunshot wounds and stabbings that injure the ureter also injure bowel, colon, liver, spleen, blood vessels, or pancreas. Hematuria is often microscopic, but it may be absent. Extravasation of contrast may be detected with noninvasive (IVP and CT scan) and invasive (anterograde and retrograde ureteropyelogram) imaging studies. If ureteral injury is suspected during laparotomy, indigo carmine (1 vial IV bolus) should be given to identify the site of leakage (blue coloration).

18. What are the potential consequences of missed ureteral injury?

Show answer
Fever, leukocytosis, azotemia, flank pain, ileus, urinoma, or urinary fistula. Presentation is often delayed by several weeks after the injury.

19. What are the principles of ureteral repair?

Show answer
Devitalized tissue must be debrided, and the two ends of the ureters should be mobilized, spatulated, and anastomosed (tension free) over a ureteral stent using absorbable suture. Placement of a drain should be performed without rubbing on the fresh anastomosis. Distal injuries permit direct implantation of the ureter into the bladder. Midureteral injuries may be repaired by primary anastomosis. Pediatric patients are more susceptible to proximal complete ureteral disruption. Urgent surgical repair is mandatory. Rarely, when nephrectomy is not an option and ureteral damage prevents standard methods of reconstruction, other elective and more complex surgical reconstructive techniques may be applied. These include kidney autotransplantation, ileal interposition, transureteroureterostomy, Boari flap with nephropexis, and ureterocalicostomy.

20. The distal ureter is injured and ureteral reimplantation with a psoas hitch (tack up the bladder to the psoas muscle) is performed. Postoperatively, the patient complains of anterior thigh numbness. What did you do wrong?

Show answer
The genitofemoral nerve lies on the anterior aspect of the ileopsoas muscle. You caught this nerve when you synched this to the tendon of the psoas muscle.

References
WEB SITES

1. http://www.east.org/tpg/GUmgmt.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0510.htm

BIBLIOGRAPHY
1. Armstrong PA, Litscher LJ, Key DW, McCarthy MC: Management strategies for genitourinary trauma. Hosp Phys 34:19-25, 1998.
2. Campbell EW Jr, Filderman PS, Jacobs SC: Ureteral injury due to blunt and penetrating trauma. Urology 40:216-220, 1992. Medline Similar articles Full article
3. Carroll PR, McAninch JW, Klosterman PW, et al: Renovascular trauma: Risk assessment, surgical management, and outcome. J Trauma 30:547-552, 1990. Medline Similar articles Full article
4. Kim FJ: Urologic trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma Companion Handbook, 4th ed. New York, McGraw-Hill, 2002.
5. McAninch JW: Traumatic and Reconstructive Urology. Philadelphia, W.B. Saunders, 1996.
6. McAninch JW, Santucci R: Genitourinary trauma. In Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 3707-3744.
7. Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: Spleen, liver, and kidney. J Trauma 29:1664-1666, 1998.
8. Peterson NE: Genitourinary trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma, 4th edition. Norwalk, CT, Appleton & Lange, 1996, pp 661-694.
9. Skinner EC, Parisky YR, Skinner DG: Management of complex urologic injuries. Surg Clin North Am 76:861-878, 1996. Medline Similar articles

1. What are the first steps in the evaluation and treatment of a patient with pelvic trauma?

Show answer
The ABCs (airway, breathing, and circulatory assessment). The answer to this first trauma question is always the same. Trauma patients with displaced pelvic fractures have a high incidence of associated injuries to the head, chest, and abdomen.

2. What are the sources and potential volume of bleeding in the displaced pelvic fracture?

Show answer
Pelvic fractures bleed from exposed cancellous bone surfaces, pelvic veins, and pelvic arteries. Cadaveric injection studies have demonstrated that 90% of patients with trauma fatalities with pelvic fractures bleed to death from exposed bone and injured veins. Only 10% bleed from arteries. The total volume the pelvis can hold is 4-6 L before a tamponade effect slows venous and bone bleeding.

3. Should a Foley catheter be placed in trauma patients with displaced pelvic fractures?

Show answer
Yes. Contraindications include urethral injuries, which should be suspected when blood is observed at the penile meatus or vaginal introitus. A manual rectal examination in men and a bimanual examination in women are mandatory to exclude an open fracture into the vagina or rectum or a high-riding prostate. If a urethral injury is present, a suprapubic catheter can be easily inserted percutaneously, and both a urethrogram and cystogram are performed.

4. What is the incidence of urologic injury associated with pelvic fractures?

Show answer
The overall incidence is 16%.

5. What are the commonly used radiographic classification schemes for pelvic fractures?

Show answer
The mechanistic classification describes pelvic fractures as anteroposterior compression (APC), lateral compression (LC), vertical shear (VS), or combined mechanism (CM). The Tile classification categorizes fractures into three groups, A, B, or C, with numbered subgroups based on increasing severity of ligamentous and bony disruption.

6. What is an open pelvic fracture?

Show answer
An open fracture has been contaminated via a laceration in the skin, vagina, or rectum. When an open pelvic fracture is suspected, patients should receive a rectal examination with an ano-scope, as well as a vaginal examination performed bimanually and with a speculum. With open fractures, the morbidity and mortality rates are increased both in the acute period (because of hemorrhage) and in the delayed period (because of infection). Open injuries in the rectal or perirectal region often require a diverting colostomy to prevent deep pelvic infection.

7. When is acute mechanical stabilization of a pelvic fracture indicated?

Show answer

Open-book and vertical shear fractures with displacement may benefit from acute mechanical stabilization. When hemodynamic instability persists in the face of ongoing aggressive resuscitation, pelvic stabilization with a beanbag, external wrap, or external fixation device may help to decrease pelvic bleeding by decreasing pelvic volume (tamponade effect), stabilizing fracture surfaces, and promoting clot formation.

8. What is the role of angiography in an acute pelvic fracture?

Show answer
It is both diagnostic and therapeutic. Angiography can identify and embolize arterial bleeding caused by pelvic fractures. But only a low percentage of pelvic bleeding is from arterial injury. Suspicion should be increased when patients with hypotension fail to respond to pelvic ring stabilization and aggressive fluid resuscitation.

9. Why do patients die from pelvic fractures?

Show answer
Mortality is usually caused by associated injuries rather than the pelvic fracture. Only 2% of patients with a pelvic fracture experience isolated trauma to the pelvis. For example, patients with LC pelvic fractures are more likely to die secondary to associated head injuries rather than from pelvic hemorrhage. Death related to pelvic hemorrhage is generally seen in patients with massive pelvic displacement associated with APC or VS injury patterns. Early stabilization and mobilization, however, decrease the mortality from 26% to 6%.
KEY POINTS: BLOOD LOSS FROM PELVIC FRACTURES

1. 90% of deaths related to pelvic bleeding result from venous and bony bleeding.
2. The remaining 10% are due to arterial bleeding-most commonly from the superior gluteal artery.
3. Normally the pelvis can hold 4-6 L of blood before a tamponade effect occurs.
4. Pelvic wraps or fixation can limit bleeding, reduce bony shear, and promote clot formation.
5. Angiography is therapeutic and diagnostic, but only 10% of injuries are predominantly arterial.

10. What is external fixation?

Show answer
External fixation by the use of pins placed into the iliac wings and connected to a frame or by pins placed into the bone just superior to the acetabulum and connected to a C clamp can be used as a temporary method of fracture reduction and stabilization. External fixation does not prevent vertical and posterior displacement of the pelvis in the case of complete posterior disruption. The fixation device must be placed in a manner that permits abdominal access for laparotomy, diagnostic imaging, and the definitive operative approach for open reduction and internal fixation.

11. Is there a role for pneumatic antishock garments (PASGs) in the treatment of pelvic fractures?

Show answer
PASGs are falling out of favor in the treatment of pelvic fractures. Their potential role is limited to emergency transportation and initial stabilization of patients with a complex pelvic fracture. PASGs can reduce displacement of anteroposterior compression fractures but may increase the displacement of a lateral compression fracture. The garment also restricts access to the patient, compromises pulmonary reserve, and is associated with increased risk of compartment syndrome.

12. When can patients with a pelvic fracture ambulate?

Show answer
Patients with fractures involving only the anterior pelvic ring, such as unilateral or bilateral pubic rami fractures, may bear weight immediately. If the fracture pattern involves the posterior structures, such as the sacroiliac joint or iliac wing, patients must not bear weight for 10 weeks.

13. What is the most common source of arterial bleeding associated with a pelvic fracture?

Show answer
The superior gluteal artery.

14. Which gender and what portion of the urethra is most commonly injured in patients with a displaced pelvic fracture?

Show answer
The male urethra is more commonly injured. The urethra passes through the urogenital diaphragm or pelvic floor, transitioning in an abrupt fashion from the membranous to the bulbous urethra. The urethra at this point is attenuated and relatively fixed above, accounting for the large number of injuries at the membranous bulbous junction. The female urethra is much shorter and the pelvic floor is less well developed, allowing for greater mobility of the female urethra (or perhaps it is because girls are smarter, more cautious, and do not get injured as often). The most common site of urethral injury in girls and women is at the bladder neck.

15. Describe the mechanism that results in a bladder rupture.

Show answer
The bladder is both an intraperitoneal and extraperitoneal structure. Compression of a distended bladder results in an intraperitoneal rupture along the bladder dome. Extraperitoneal rupture, a more common injury, results from the laceration of the bladder by displaced pubic rami fracture fragments.
16. What are the three radiographic views required to evaluate patients with pelvic fractures? Show answer

1. Anteroposterior pelvis view
2. Inlet view
3. Outlet view

17. What is the appropriate insertion location for a diagnostic peritoneal lavage catheter in the presence of a pelvic fracture?

Show answer
A supraumbilical location avoids inadvertent decompression of the pelvic hematoma and a false-positive result.

18. What percent of patients with an unstable pelvic fracture will suffer an associated neurologic injury?

Show answer
Associated injuries of the lumbosacral plexus, sacral foramina, and sacral canal are reportedly as high as 50%.

19. What is a potential pitfall of aggressive blood transfusion of hemodynamically unstable pelvic fracture patients?

Show answer
Coagulopathy. Forty percent of patients with unstable pelvic fractures may require ≥ 10 units of blood. Fresh frozen plasma and platelets should be transfused early in the resuscitation.

20. What is the significance of an L5 transverse process (TP) fracture in a patient with a pelvis fracture?

Show answer
A TP fracture at the level of L5 may indicate vertical instability of the pelvic fracture. The iliolumbar ligaments attach to the TP and the iliac wing, often resulting in the avulsion of the TP when the pelvis vertically displaces.

References
WEB SITE
http://www.east.org/tpg/pelvis.pdf

BIBLIOGRAPHY
1. Biffl WL, Smith WR, Moore EE, et al: Evolution of a multidisciplinary key clinical pathway for the management of unstable pelvis fractures. Ann Surg 233:843-850, 2001. Medline Similar articles Full article
2. Buehle R, Browner B, Morandi M: Emergency reduction for pelvic ring disruptions and control of associated hemorrhage using the pelvic stabilizer. Tech Orthop 9:258-266, 1995.
3. Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 30:848-856, 1990. Medline Similar articles
4. Cook RE, Keating JF, Gillespie I: The role of angiography in the management of haemorrhage from major fractures of the pelvis. J Bone Joint Surg 84B:178-182, 2002.
5. Gruen GS, Leit ME, Gruen RJ, Peitzman AB: The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures. J Trauma 36:706-713, 1994. Medline Similar articles
6. Kellam JF, Browner BD: Fractures of the pelvic ring. In Browner BD, et al (eds): Skeletal Trauma, 2nd ed. Philadelphia, W.B. Saunders, 1997.
7. Perez JV, Hughes TM, Bowers K: Angiographic embolisation in pelvic fracture. Injury 29:187-191, 1998.
8. Poole GV, Ward EF: Causes of mortality in patients with pelvic fractures. Orthopaedics 17:691-696, 1994.
9. Routt ML, Simonian PT, Ballmer E: A rational approach to pelvic trauma: Resuscitation and early definitive stabilization. Clin Orthop 318:61-74, 1995. Medline Similar articles
10. Starr AJ, Griffin DR, Reinert CM, et al: Pelvic ring disruptions: Prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 16:553-561, 2002. Medline
11. Tile M: Pelvic ring fractures: Should they be fixed? J Bone Joint Surg 70B:1-12, 1988. Full article
12. Velmahos GC, Toutouzas KG, Vassiliu P, et al: A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 53:303-308, 2002. Full article

9. How do rectal injuries occur?

Show answer
Similar to colon injuries, most rectal injuries result from penetrating trauma. Blunt pelvic fractures should be assessed with a strong suspicion for rectal (and urethral) injury.

10. How are rectal injuries diagnosed?

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A thorough examination is crucial, and the diagnosis is suggested by the course of the projectiles and the presence of blood on digital rectal examination. If rectal trauma is suspected, the patient should undergo proctoscopy to look for hematomas, contusions, lacerations, or gross blood. If the diagnosis is in question, radiographs with soluble-contrast enemas should be performed.
11. How are patients with intraperitoneal rectal injuries treated differently from those with

extraperitoneal injuries?

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The portion of the rectum proximal to the peritoneal reflection is called the intraperitoneal segment. Injuries of this portion are treated similar to colonic injuries.

12. What are the four basic principles for managing simple extraperitoneal rectal injuries?

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1. Diversion: either a loop or an end-sigmoid colostomy is appropriate.
2. Drainage: a retroanal incision should be used to place Penrose or closed-suction drains near the perforation site.
3. Repair: appropriate, when possible
4. Washout: irrigation of the distal rectum with isotonic solution until the effluent is clear. The role of washout remains controversial, but it may benefit patients whose rectum is full of feces.

13. How are complex extraperitoneal rectal injuries managed?

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In patients with massive pelvic trauma and an associated rectal injury, an abdominoperineal resection may be required for adequate debridement and hemostasis. An abdominoperineal resection is also required in rare instances in which anal sphincters have been destroyed.

14. What complications are associated with rectal trauma and its treatment?

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They are similar to those in colonic injuries. In addition, pelvic osteomyelitis may occur. In this case, debridement may be necessary, and culture-specific intravenous antibiotics should be administered for 2-3 months.

15. What is the role of antibiotics in colorectal trauma?

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Antibiotics are important. They should be initiated preoperatively (you need a good blood level at the time you make your incision) and ended quickly (12-24 hours postoperatively). Broad-spectrum, combination therapy is superior to single-agent therapy.

References
BIBLIOGRAPHY
1. Berne J, Velmahos G, Chan LS, et al: The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries. Surgery 123:157-164, 1998. Medline Similar articles
2. Burch J, Franciose R, Moore E: Trauma. In Schwartz S (ed): Principles of Surgery, 8th ed. New York, McGraw-Hill, 1999, pp 155-221.
3. Demetriades D, Murray J, Chan LS, et al: Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: A multicenter study. J Trauma 52:117-121, 2002.
4. Demetriades D, Murray J, Chan L, et al: Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma 50:765-775, 2001. Similar articles Full article
5. Velmahos G, Vassiliu P, Demetriades D, et al: Wound management after colon injury: Open or closed? A prospective randomized trial. Am Surg 68:795-801, 2002. Medline Similar articles