Hepatic & Biliary Trauma. Surgical Anatomy Of The Liver
SURGICAL ANATOMY OF THE LIVER
7. How many anatomic lobes are present in the liver? What is their topographic boundary?
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The liver is divided into two anatomic lobes, the right and the left. Their boundary lies in an oblique plane extending from the gallbladder fossa anteriorly to the inferior vena cava posteriorly. The three hepatic veins define the division between the lobar segments and the planes of surgical resection. Lobar segments are numbered I-VIII, according to Couinaud’s nomenclature. (See Figure 25-1.)
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Hepatic & Biliary Trauma
25 HEPATIC AND BILIARY TRAUMA
Reginald J. Franciose M.D., Ernest E. Moore M.D.
1. How often is the liver injured in trauma?
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The liver is both big and central, so it is an easy target.
2. Do the liver and spleen respond similarly to injury?
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No. The liver has a unique ability to establish spontaneous hemostasis even with extensive injuries. For this reason, the majority of liver injuries in hemodynamically stable patients can be managed nonoperatively. In contrast, many splenic fractures continue to bleed; therefore, a greater percentage require operative intervention.
Penetrating Abdominal Trauma. Controversy
CONTROVERSY
14. What is the role of laparoscopy and thoracoscopy after penetrating abdominal trauma?
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Although an intriguing diagnostic modality with additional therapeutic capabilities, laparoscopy thus far appears to have limited application after trauma. With the exception of suspected diaphragmatic injury, an isolated solid organ injury, or evaluation for peritoneal penetration, laparoscopy has yet to demonstrate advantages over the algorithm delineated above. The potential for missed injuries, poor evaluation of the retroperitoneum, and expense are major drawbacks. In patients with wounds to the lower chest with pneumothorax (and, thus, an indication for chest tube placement), thoracoscopy is reasonable to exclude diaphragmatic injury.
Penetrating Abdominal Trauma
24 PENETRATING ABDOMINAL TRAUMA
Clay Cothren M.D., Ernest E. Moore M.D.
1. Why is there a different approach to stab and gunshot wounds?
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Whereas one third of stab wounds to the anterior abdomen do not penetrate the peritoneum, 80% of gunshot wounds violate the peritoneum. Furthermore, penetration of the peritoneum by a bullet is associated with visceral or vascular injuries in > 95% of cases, whereas only one third of stab wounds violating the peritoneal cavity produce significant injury. (See Figure 24-1.)
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Blunt Abdominal Trauma
23 BLUNT ABDOMINAL TRAUMA
David J. Ciesla M.D., Ernest E. Moore M.D.
1. What elements of the history are important in evaluating a patient with suspected blunt abdominal trauma (BAT)?
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First, the mechanism of injury (e.g., motor vehicle collision, automobile-pedestrian accident, fall) is important. In motor vehicle accidents, note the position of the victim in the car, velocity of impact (high, moderate, low), type of accident (front, lateral, or rear impact; side swipe; rollover), and type of restraint used (shoulder restraint, air-bag, lap belt). Information about damage to the vehicle, such as a broken windshield or bent steering wheel, may raise suspicion of cervical and chest injuries. In a fall, it is important to note the distance fallen and the site of anatomic impact. Vertical landing on the feet or in a sitting position causes a different pattern of injury than lateral landing on the side. Serial vital signs and mental status are always important.
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Penetrating Thoracic Trauma
22 PENETRATING THORACIC TRAUMA
Jeffrey L. Johnson M.D., Ernest E. Moore M.D.
1. How often do patients with penetrating chest wounds need an operation?
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Surprisingly rarely. Most civilian penetrating injuries are from knives and low-energy handguns. Consequently, although injuries to the chest wall and lung are common, the majority of patients can be treated with tube thoracostomy alone. Formal thoracotomy or median sternotomy is required in < 15% of isolated penetrating chest injuries.
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Blunt Thoracic Trauma
21 BLUNT THORACIC TRAUMA
Jeffrey L. Johnson M.D., Ernest E. Moore M.D.
1. How often do patients with isolated blunt chest trauma need an emergent operation?
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Rarely. In patients who arrive in the hospital alive, operative injuries to the pulmonary, vascular, and mediastinal structures are surprisingly rare; only 5% of patients with isolated blunt injury to the chest require thoracotomy.
2. In a patient with a hemothorax after blunt chest injury, what is the most important guide for the decision to operate?
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The hemodynamic status of the patient. Hemothorax after blunt injury is most often caused by nonoperative lesions of the lung and chest wall. In stable patients, therefore, evacuation of the hemothorax (with a chest tube); reexpansion of the lung, and correction of coagulopathy, hypothermia, and acidosis should be the initial focus. Chest tube output is helpful but is not the principal consideration.
3. What is a tension pneumothorax?
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Air in the pleural space under pressure caused by a one-way valve mechanism. This can be a life-threatening condition because the increase in intrathoracic pressure decreases venous return, which impaires right ventricular filling, resulting in a decrease in cardiac output.
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Penetrating Neck Trauma
20 PENETRATING NECK TRAUMA
Clay Cothren M.D., Ernest E. Moore M.D.
1. Why are penetrating neck wounds unique?
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Although comprising only a small percentage of body surface area, the neck contains a heavy concentration of vital structures.
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Spinal Cord Injuries
19 SPINAL CORD INJURIES
J. Paul Elliott M.D., Sanjay Misra M.D.
1. What is the difference between a spinal injury and a spinal cord injury?
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Spinal injuries include damage to the bone, disc, or ligaments. These injuries sometimes result in spinal instability. They also may be associated with spinal cord injury, which is damage to the neural tissue, often with clinical deficit. It is crucial to determine whether there is (1) a spinal injury, (2) a spinal cord injury, and (3) spinal instability.
2. Describe the evaluation of a patient with a suspected spine injury.
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First, be sure that the patient is adequately immobilized and everyone knows to maintain spinal precautions. Second, inspect and palpate the spine for external trauma and step-off. Finally, do a complete neurologic examination including all four extremities. Assess strength, sensation (light touch/proprioception and pain/temperature), muscle tone, reflexes, and rectal tone. Carefully document your results.
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Traumatic Brain Injury
18 TRAUMATIC BRAIN INJURY
J. Paul Elliott M.D., Sanjay Misra M.D.
1. Is traumatic brain injury (TBI) a common problem?
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Yes. In the United States, 1 in 12 deaths is due to injury. One third of traumatic deaths are associated with TBI. Of deaths resulting from motor vehicle accidents, 60% are due to brain injury. Even more common is minor TBI, which accounts for 75% of admissions for head trauma.
Posttraumatic Hemorrhagic Shock
17 POSTTRAUMATIC HEMORRHAGIC SHOCK
John B. Moore M.D., Ernest E. Moore M.D.
1. Are hemorrhagic shock and hypovolemic shock the same?
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Yes.
2. What is hemorrhagic shock?
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Shock exists when the cardiovascular system is no longer able to meet the body’s metabolic and oxygen needs-inadequate tissue perfusion.
Hemorrhage is the most common cause of shock after injury. Depletion of the vascular volume results in decrease of the driving pressure returning blood to the heart, decrease of the end-diastolic ventricular volume, and decrease in stroke volume; all result in decrease in cardiac output.
InitialAssessment. Controversies
CONTROVERSIES
28. What is the role of the pneumatic antishock garment?
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The military antishock trouser (MAST) has fallen out of favor in most instances. The MAST suit is valuable for patients requiring long-distance transfer who have major bleeding from pelvic fractures. The MAST suit should be avoided in the presence of major thoracoabdominal trauma, especially if a diaphragmatic injury is suspected. The traction splints still are preferred for femur fracture transfer; they decrease bleeding and assist with pain control.
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Initial Assessment
16 INITIAL ASSESSMENT
Eric L. Sarin M.D., John B. Moore M.D.
1. What is the “golden hour”?
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The first hour after injury provides a unique opportunity to provide life-saving interventions. Because more than half of trauma deaths occur early due to bleeding or brain injury, rapid transport, appropriate triage, evaluation, resuscitation, and intervention can affect outcomes. The “golden hour” concept needs to be extended to several hours in the rural setting, but with the same structured approach. Trauma surgeons harbor the unique idea that an injured patient is their responsibility before they reach the hospital.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
