Acute Care Surgery (eBook)

Preface 5
A Tribute 6
Table of Contents 8
Contributors 12
Part I General Principles 21
1 Initial Assessment and Early Resuscitation 22
Triage 22
Unique Aspects of the Trauma and Acute Care Surgical Patient 23
Systematic Evaluation and Treatment 23
Airway and Breathing 23
Circulation 26
Fluid Resuscitation 27
Transfusion 28
Other Resuscitation Efforts 29
Assessment of Resuscitation 29
Classic Physical Examination Findings and Vital Signs 29
Urine Output 29
Bladder Pressure (Abdominal Compartment Syndrome) 29
Ventricular Preload 30
Lactate Level 30
Base Deficit 30
The Triad of Death: Hypothermia, Acidosis, and Coagulopathy 31
Shock 31
Hypovolemic and Hemorrhagic Shock 31
Cardiogenic Shock 32
Obstructive Shock 32
Traumatic Shock 32
Vasodilatory Shock 33
Acute Abdominal Pain 34
Reevaluation and Definitive Care 36
References 36
2 The Operating Theater for Acute Care Surgery 43
Location Within the Hospital 43
Relationship to Ambulance Unloading Dock 44
Relationship to the Emergency Center 44
Relationship to the Intensive Care Unit 44
Life Science and Building Safety Considerations 44
Air Exchanges 44
Temperature and Humidity Control 44
Lighting 45
Electrical Safe Current Leakage Standards 45
Competing Microwave Signals 45
Medical Informatics Capabilities 45
Internet Access 45
Interfacing with Real-Time Clinical Information 45
Imaging Capability 46
Equipment Considerations 46
Required “Zones” in the Operation Environment 46
Administrative Zone 46
Operating Zone 47
Anesthesia Zone 47
Surgeon’s Zone 47
Scrub Nurse’s Zone 47
Circulator’s Zone 47
Imaging Zone 47
Observer’s Zone 47
Interactive/Internet/Robotic Zone 47
Storage Zone 47
Engineering Zone 48
Policy Issues 48
References 48
3 Anesthesia and Acute Care Surgery 49
Prioritizing 49
Preoperative Management 50
Intraoperative Management 52
Postoperative Management 53
Acute Care Situations 53
Intracranial Emergencies 53
Neck Injury and Unstable Spine 55
Vascular Emergencies 56
Acute Abdomen 56
Necrotizing Fasciitis, Soft Tissue Wounds, and Burns 57
Orthopedic Emergencies 58
Pediatric Emergencies 59
References 60
4 Fundamental Operative Approaches in Acute Care Surgery 62
Neck 64
Emergent Airway 64
Damage Control 66
Chest 67
Resuscitative Thoracotomy 67
Anterolateral Thoracotomy 68
Transsternal Anterior Thoracotomy 68
Left Book Thoracotomy 68
Median Sternotomy 69
Median Sternotomy with Right or Left Cervical Extension 69
Left Posterolateral Thoracotomy 69
Exposure 69
Great Vessels 69
Descending Thoracic Aorta 70
Esophagus 70
Pulmonary Hilum 70
Damage Control 71
Abdomen 71
Incision 72
Exploration 73
Exposure 73
Supramesocolic Viscera 73
Suprarenal Aorta 73
Esophagus 73
Suprahepatic Inferior Vena Cava 74
Pancreas and Duodenum 74
Portal Structures 76
Liver 76
Inframesocolic Exposure 77
Root of the Mesentery 77
Infrarenal Aorta 77
Inferior Vena Cava 77
Pelvis 77
Damage Control 78
Liver 78
Spleen 79
Kidney 79
Gastrointestinal Tract 79
Arteries 80
Veins 80
Wound Closure 80
Extremities 80
Exposure 80
Upper Extremity 81
Lower Extremity 81
Fasciotomy 82
Damage Control 83
References 85
5 The Perioperative Management of the Acute Care Surgical Patient 86
A Perspective on Stress and Response 86
Preoperative Care of the Acute Care Surgical Patient Following Initial Resuscitation 87
Physiologic Reassessment and the Second Phase of the Stress Response 87
Preoperative Actions 87
Relevant History 87
Pre-Illness Physiology 88
Specific Signs and Symptoms 88
Discussion of Perioperative Care Environments 89
Actions in the Operating Room 89
Preparation of the Intensive Care Unit and its Team for Receipt of a Preoperative Patient 90
The Hand-Off 90
Ongoing Care in Anticipation of Operation 91
Postoperative Intensive Care 91
The Third Phase of the Stress Response 91
Actions and Considerations at the Bedside 93
Cardiac Monitoring and Care 93
Pulmonary Monitoring and Care 95
Neurologic Monitoring and Care 96
Renal Monitoring and Care 96
Gastrointestinal Monitoring and Care 97
Hematologic Monitoring and Care 98
Endocrine Monitoring and Care 98
Infectious Disease Monitoring and Care 99
Sustained and Chronic Critical Illness 99
The Hypothalamic-Pituitary-Adrenal Axis in Chronic Critical Illness 100
Growth Hormone and Thyroid Hormone in Chronic Critical Illness 100
Testosterone and Luteinizing Hormone in Chronic Critical Illness 100
Prolactin in Chronic Critical Illness 100
Conclusion 100
References 100
6 The Hemodynamically Labile Patient: Cardiovascular Adjuncts and Assist Devices 103
Pharmacological Circulatory Support:Vasopressin 103
Mechanical Circulatory Systems 104
Extracorporeal Membrane Oxygenation 104
Intraaortic Balloon Pump 106
Ventricular Assist Devices 106
Bridge to Recovery 107
Bridge to Transplantation 107
Destination Therapy–Still in its Infancy 108
References 108
7 Principles and Practice of Nutritional Support for Surgical Patients* 110
Metabolism, Nutrition, and Infection 110
Goals of Nutritional Support 112
Nutritional Support:Who, How Much, and What 113
Nutritional Support: Route and Timing 116
Nutrient Pharmacology 119
Anabolic Agents 120
References 122
8 The Intensive Care Unit: The Next-Generation Operating Room 125
Rationale 125
What Resources Are Needed? 126
Preparation of the Unit and Staff 126
Preparation of the Patient 127
A Culture of Safety and Accountability 127
Infection Control 129
Anesthesia, Analgesia, and Sedation 130
Ultrasound 130
Bedside Neurologic Surgery 130
Bedside Surgery of the Head and Neck 131
The Cervicothoracic Interface: Tracheostomy 131
Bedside Thoracic Surgery 133
Bedside Abdominal Surgery 134
Paracentesis 134
Peritoneal Dialysis Catheter Placement 135
Percutaneous Cholecystostomy 135
Enteral Feeding Access 135
Other Uses of Bedside Endoscopy 136
Bedside Laparotomy 137
Bedside Laparoscopy 137
Bedside Extremity Surgery 137
Surgical Debridement for Necrotizing Fasciitis 138
Bedside Arthrocentesis 138
Lower Extremity Compartment Pressure Measurement, Bedside Fasciotomy, and Escharotomy 138
Bedside Inferior Vena Cava Filter Placement 139
References 140
9 Burns 144
Epidemiology 144
Pathophysiology 146
Local Effects 146
Systemic Response 147
Resuscitation Priorities 149
Fluid Administration 150
Ventilatory Support and Treatment of Inhalation Injury 153
Pathophysiology 153
Asphyxiants 154
Airway Management 155
Mechanical Ventilation 156
Other Organ System Support 156
Pain Control 156
Neurologic Deficits 157
Gastrointestinal Responses and Complications 157
Wound Care 158
Initial Wound Care 158
Topical Antimicrobial Therapy 158
Burn Wound Excision and Grafting 161
Skin Substitutes 164
The Treatment of Special Thermal Injuries 165
Electric Injury 165
Chemical Injuries 165
Bitumen Burns 166
Cold Injuries 166
Radiation Injury 167
Toxic Epidermal Necrolysis 168
Mechanical Injury 169
Metabolic and Nutritional Support 170
Estimation and Measurement of Metabolic Rate 170
Nutritional Support 170
Monitoring 171
Complications 171
Transportation and Transfer 172
Survival Data 174
References 174
10 Electrical and Lightning Injuries 180
Pathophysiology and Manifestations 180
Approach to Management 181
Acute Care 181
Diagnostic Evaluation 182
Early Management 183
Rehabilitation 184
References 184
11 Soft Tissue Infections 185
Pathophysiology 186
Microbiology 186
Presentation and Diagnosis 188
Clinical Management 189
Critical Care Management 190
Surgical Debridement 191
Wound Care 191
References 192
12 The Open Abdomen: Management from Initial Laparotomy to Definitive Closure 195
Indications for Leaving the Abdomen Open 195
Temporary Wound Management Techniques for the Open Abdomen 196
Timing of Reconstruction and Subsequent Laparotomies 200
Techniques for Delayed Primary Closure 201
Small Intestinal Submucosa 201
Human Acellular Dermis 201
Additional Techniques 201
Component Separation 202
References 203
13 Acute Care Surgery and the Elderly 206
Normal Physiologic Changes Associated with Aging 206
Clinical Presentation of Elderly Patients 207
Preoperative Assessment 208
Perioperative Management of the Elderly 208
Acute Care Surgery: Specific Considerations 209
Ethical and End-of-Life Issues 210
References 210
14 Acute Care Surgery in the Rural Setting 213
Defining Rurality and the Rural Surgeon 213
Prehospital Care, Stabilization, and Transportation 214
Early Management of the Surgical Emergency 215
Trauma Systems,ATLS, and Referral 216
Crucial Colleagues 216
General and Vascular Emergencies 217
Surgical Subspecialty Emergencies 217
Endoscopy 217
Telemedicine 218
Surgical Education 218
Conclusion 218
References 219
15 Prehospital Care in the Acute Setting 221
Emergency Medical Services Systems 221
Personnel 221
Emergency Medical Technician-Basic 222
Emergency Medical Technician-Intermediate 222
Emergency Medical Technician-Paramedic 222
Emergency Medical Technician-Paramedic 222
Communications 222
Protocols Versus Standing Orders 223
Medical Control 223
Direct Medical Control (On Line) 223
Indirect Medical Control (Off Line) 223
Quality Assurance 224
Kinematics (Mechanism of Injury) 224
Cavitation 224
Blunt Trauma 225
Vehicular Collisions 225
Frontal 225
Rear 230
Rotational 230
Rollover 230
Falls 230
Motorcycle Collisions 230
Blast Force 231
Penetrating Trauma 231
Energy 231
Anatomy 232
Assessment and Management in the Field 233
Safety 233
Situation 233
Initial Patient Assessment 233
Primary Survey 234
A: Airway 235
B: Breathing and Ventilation 236
C: Cardiac Evaluation 237
D: Disability 237
Resuscitation 237
Secondary Survey 239
Definitive Field Care 239
Shock and Fluid Resuscitation 239
Energy Production 239
Oxygen Delivery 240
Physiology of Fluid Replacement 240
Bernoulli Principle 240
Assessment 241
Blood Pressure 241
Field Special Skills 241
Airway 241
Manual 241
Mechanical 241
Transtracheal 242
Double Lumen Airway 242
Laryngeal Mask Airways 243
Spinal Immobilization 243
Field Clearance of the Cervical Spine 243
Cervical Collars 244
Backboard 244
Field Helmet Removal 245
Musculoskeletal Trauma 245
References 246
16 Disaster and Mass Casualty Management 248
Classification of Disasters 249
Level of Response 249
Mechanism 249
Nature of Injuries 249
Extent and Timing 250
Phases of Disaster Response 250
Chaotic Phase 250
Initial Response and Reorganization 250
Site Clearing 251
Search And Rescue 251
Medical Care of Casualties 252
Initial Phase 252
Definitive Phase 253
Record Keeping 253
The Role and Importance of Triage 254
Triage Categories 254
Triage Accuracy 255
Triage Decisions 256
Incident Command 257
Command 257
Operations 258
Planning 258
Logistics 258
Finance/Administration 258
Terrorism 258
Biological Agents 258
Chemical Agents 259
Nuclear/Radiologic Agents 260
Explosive Disasters 261
Blast Physics and Pathophysiology 261
Patterns of Injury, Mortality, and Severity 262
Disaster Planning and Reporting 263
References 265
17 Principles of Injury Prevention and Control 268
Basic Principles of Injury Prevention and Control 268
Motor Vehicle Crashes 269
Pedestrian Injuries 270
Nontraffic Injuries in Children 271
Motorcycle and Bicycle Helmets 272
Falls by the Elderly 272
Burns 273
Water-Related Injuries 274
Suicide 274
Child Maltreatment 275
Intimate Partner Violence 275
Youth Violence 276
Firearm Injuries 277
Alcohol and Injury 277
Education 278
Program Evaluation 278
References 279
18 Education: Surgical Simulation in Acute Care Surgery 282
Classifications of Simulators/Simulations 283
Goals of Simulations 284
Educational Principles 284
Education Objectives 284
Teaching Strategies 285
Principles of Simulation Education 285
Evaluation 286
Validity of Simulation 286
Simulations in Surgery and Traumatology 287
ATOM: An Example of Simulation Education 290
References 292
Part II Organ-Based Approach 294
19 Pharynx and Larynx 295
History and Physical Examination 295
History 295
Database 295
Chief Complaint 295
History of the Present Illness 296
Past Medical History 296
Review of Systems 296
Physical Examination 296
External Examination 296
Symmetry 296
Speech 297
Airway 297
Skin 297
Ears 297
Eyes 297
Nose and Sinuses 297
Lower Face, Mandible, and Salivary Glands 297
Neck 297
Internal Examination 298
Nose 298
Oral Cavity/Oropharynx 298
Nasopharynx 298
Hypopharynx and Larynx 299
Diagnosis 299
Pharynx 301
Anatomy 301
Physiology 302
Tympanomastoid Ventilation 302
Swallowing 302
Taste 303
Complaints 303
Symptoms 304
Signs 304
Larynx 304
Anatomy 304
Laryngeal Skeleton 304
Muscles 304
Vasculature 304
Lymphatics 305
Nerves 305
Physiology 305
Complaints 305
Symptoms 306
Emergencies 306
Hemorrhage 306
Infection/Inflammation 306
Caustic Ingestion 307
Foreign Body 307
Case Studies 308
Case 1 (Pharynx): “The Flickering Candle” 308
Indications 308
Operative Findings 308
Discussion 309
Conclusions 309
Case 2 (Pharynx): “Routine Surgery” 309
Indications 309
Description of Procedure 309
Discussion 309
Conclusions 309
Case 3 (Pharynx): “Chokehold” 310
Indications 310
Description of Procedure 310
Discussion 310
Conclusions 311
Case 4 (Pharynx): “Cry Baby” 311
Indications 311
Description of Procedure 311
Discussion 311
Conclusions 312
Case 5 (Larynx): “Wheezing” 312
Description of Procedure 312
Discussion 312
Conclusions 312
Case 6 (Larynx and Bronchus): “The Cough” 312
Indications 312
Description of Procedure 313
Discussion 313
Conclusions 313
Case Study 7 (Pharynx and Larynx): “The Cobra” 314
The Arrival 314
Physical Examination 314
Assessment 314
Treatment 314
Discussion 314
Conclusions 314
Discussion 315
Airway 315
Intubation 316
Assessment 316
Preparation 317
Technique 317
Airway Strategy 318
Decannulation 318
Endotracheal Tube 318
Tracheotomy Tube 319
Options 319
Ventilation 319
Hemostasis 319
Vascular Injury 319
Air Embolism 319
Carotid (Blow) Catastrophe 319
Carotid Artery Injury 320
Subclavian Artery 320
Transverse Cervical Artery 320
Epistaxis 320
Pressure 320
Vasoconstriction 320
Packing 320
Embolization 321
Ligation 321
Incision and Drainage 321
Superficial Layer 321
Middle Layer 321
Deep Layer 321
Carotid Sheath 321
Final Comments 322
References 322
20 Head and Neck: Pediatrics 323
Inflammatory Disease of the Airway 323
Acute Supraglottitis 323
Croup 324
Bacterial Tracheitis 326
Inflammatory Diseases of the Neck 326
Peritonsillar Abscess 326
Retropharyngeal Abscess 326
Lateral Pharyngeal Abscess 327
Trauma 328
Facial Fracture 328
Neck Trauma 329
Laryngeal Trauma 330
References 331
21 Esophagus 332
General Considerations 332
Anatomic Considerations 332
Bacteriology 333
Traumatic Injuries 333
Frequency and Mechanism of Injury 333
Diagnosis 333
Clinical Symptomatology 333
Plain Films 333
Esophagography 334
Esophagoscopy 335
Computed Tomography Scan 335
Management 335
Selective Management or Routine Exploration of Penetrating Neck Injuries 335
Selective Operative Management of Documented Pharyngoesophageal Trauma 336
Operative Therapy 337
Complications of Operative Therapy 338
Nontraumatic Emergencies 338
Esophageal Perforation 338
Assessment 339
Treatment 340
Options for the Neglected Perforation or the Unstable Patient 341
Dealing with Associated Esophageal Disease 341
Caustic Ingestion 341
Foreign Body Impaction 342
Food 342
Presentation 342
Assessment 343
Conservative Treatment 343
Endoscopic Treatment 343
Indigestible Foreign Body 344
Assessment 344
Definitive Treatment 344
Esophageal Hemorrhage 345
Acute Tracheoesophageal Fistula 346
References 346
22 Central Nervous System 350
An Approach to Neurologic Emergencies 350
Identification of Pathology: The History 351
Context of Presentation 351
Past Illness 351
Age of Patient 351
Pattern of Presentation 352
Primary Survey: Immediate Actions 352
Secondary Survey 353
The Focused Neurologic Examination 353
Imaging 353
Operative Decision Making 354
Specific Disease Entities 354
Traumatic Emergencies 354
Glasgow Coma Score 354
Blunt Head Injuries 354
Epidural Hematoma 354
Subdural Hematoma 354
Contusions 355
Cerebral Edema 355
Vascular Injury 355
Management of Blunt Head Injuries 355
Penetrating Head Injuries 356
Traumatic Spine Injury 357
Management of Spinal Fractures 357
Penetrating Spine Trauma 358
Peripheral Nerve Injury 358
Nontraumatic Emergencies 359
Cerebrovascular Accidents 359
Hemorrhagic Cerebrovascular Accidents 359
Ischemic Cerebrovascular Accidents 360
Brain Tumors 361
Pituitary Apoplexy 361
Infection 361
Shunt Malfunction 362
Nontraumatic Spinal Emergencies 363
Cauda Equina Syndrome 363
References 363
23 Chest Wall 366
Injuries Associated with Chest Wall Trauma 367
Mortality Rate 367
Biomechanics 367
Injury Prevention 368
Acute Care Management: Initial Evaluation 369
Categories of Chest Wall Injuries 369
Hematoma 369
Rib Fractures 369
Flail Chest 370
Rib Fracture and Flail Chest Repair 371
Sternal Fractures 372
Fractures of the Clavicle and Shoulder 373
Chest Wall Defects 374
Pain Management 374
References 376
24 Lungs and Pleura 380
Airway 380
Thoracotomy 381
Thoracoscopy 381
Trauma 381
Tracheobronchial Injury 381
Parenchymal Injury 383
Retained Parenchymal Missiles 385
Retained Hemothorax 385
Massive Pulmonary Embolism 386
Presentation 386
Diagnosis 386
Persistent Air Leak 388
Surgical Management of Infections 389
Empyema 389
Complex Parenchymal Infections 391
Necrotizing Pneumonia 391
Lung Abscess 392
Lung Gangrene 392
Descending Necrotizing Mediastinitis 393
Diagnosis 394
Management 394
Second-Look Operations 395
Lobar Torsion 396
Massive Hemoptysis 396
Etiology 396
Diagnosis 396
“Occult” Massive Hemoptysis 397
Initial Management 397
Strategies to Prevent Further Airway Contamination 398
Diffuse Parenchymal Bleeding 398
Subsequent Treatment 398
Angioembolization 399
Surgical Versus Medical Therapy for Massive Hemoptysis 399
Tracheoinnominate Artery Fistula 400
Recognition and Initial Management 400
Operative Repair 400
Pulmonary Artery Catheter-Induced Hemoptysis 401
Etiology 401
Management 401
Superior Vena Cava Syndrome 402
Presentation 402
Initial Management 402
Treatment 402
References 403
25 Heart 407
Penetrating Cardiac Injury 407
Diagnosis 408
Cardiac Tamponade 409
Venue 410
Exposure 410
Repair Technique 410
Coronary Injuries 410
Destructive Injuries 411
Follow-Up 411
Factors Affecting Prognosis 411
Blunt Cardiac Injury 412
Diagnosis 413
Imaging 413
Myocardial Contusion 413
Cardiac Enzymes 414
Blunt Coronary Artery Injury 414
Blunt Valvular Injury 414
Follow-Up for Blunt Cardiac Injury 414
Special Circumstances 415
Iatrogenic Endovascular Cardiac Injury 415
Transmediastinal Gunshot Wounds 415
Cardiopulmonary Bypass 416
References 416
26 Thoracic Aorta 418
Blunt Aortic Trauma 418
History and Incidence 418
Etiology and Pathogenesis 418
Clinical Presentation and Initial Management 419
Diagnostic Studies 419
Management 421
Operative Technique 422
Complications and Outcomes 424
Aortic Dissection 424
History and Incidence 424
Etiology and Pathogenesis 425
Clinical Presentation 426
Diagnostic Studies 426
Classification and Management Decisions 427
Operative Technique for Type A Dissection 429
Technique for Type B Dissection 431
Outcomes and Complications 432
References 433
27 Diaphragm 438
Anatomic and Physiologic Considerations 438
Blunt Diaphragmatic Injuries 439
History 439
Incidence 439
Mechanism 439
Associated injuries 440
Diagnosis 440
Treatment 441
Penetrating Injuries to the Diaphragm 443
Incidence 443
Diagnosis 443
Radiographs 443
Thoracoscopy 444
Laparoscopy 444
Treatment 445
Observation 445
Minimally Invasive Approach 445
Open Approach 446
Outcomes 446
Morbidity 446
Mortality 446
Conclusions 447
Surgical Emergencies Related to Hiatal Hernia 447
Upper Gastrointestinal Hemorrhage 448
Hiatal Hernia Ulcer Perforation 448
Acute Gastric Volvulus 449
References 450
28 Abdominal Wall 453
Anatomy 453
Evaluation of Abdominal Wall 454
Hernias 455
Groin Hernias 455
Other Abdominal Wall Hernias 457
Ventral Hernias 457
Parastomal Hernias 458
Abdominal Wall Trauma 459
Abdominal Compartment Syndrome 460
Definition 460
Etiology 461
Treatmen 461
Closure of the Abdominal Wall and/or Skin 461
Skin Closure 461
The Decision to Close Fascia and Subsequent Management of the Open Abdomen 463
The Planned Ventral Hernia 465
References 466
29 Foregut 468
Foregut Symptoms 468
Esophagus, Esophagogastric Junction, Stomach, Duodenum 469
Evaluation 469
Obstruction 470
Differential Diagnosis 471
Physical Examination 471
Endoscopic Examinations 471
Radiographic Studies 472
Diverticula 472
Hypopharyngeal Diverticulum (Zenker’s Diverticulum) 472
Epiphrenic Diverticulum 473
Intraluminal Duodenal Diverticulum (Recanalization Failure in the Duodenum) 473
Achalasia of the Esophagus 473
Hiatus Hernia 473
Minimally Invasive Surgery 474
Transdiaphragmatic Approach to the Distal Esophagus 474
Transthoracic Versus Transabdominal Approach 475
The Role of Fundoplication 475
Peptic Stricture of the Esophagus 475
Nissen Fundoplication 476
Closure of Esophageal Hiatus 476
Obstructing Mass Lesions: Esophagus, Stomach, and Duodenum 476
Obstructing Duodenal Ulcer (Peptic Stricture of Gastric Outlet) 476
Gastric Resection Versus Pyloroplasty? Open Surgery Versus Laparoscopic Exploration? 476
Duodenal Obstruction 479
Internal Hernia 479
Perforation 480
Diagnosis and Management 480
Esophagus 480
Gastric and Duodenal Perforation 481
Bleeding 482
Sentinel Bleeding 482
Varices of Esophagus or Stomach 483
Ulcers of the Stomach and Duodenum 483
Endoscopic Examination 483
Endoscopic Interpretation 484
Operative Treatment 484
Esophagus 484
Gastritis 484
Gastric Ulcers 484
Type I Gastric Ulcer 484
Types II and III Gastric Ulcer 485
Type IV Gastric Ulcer 485
Marginal Ulcers Following Previous Operations 485
Duodenal and Pyloric Channel Ulcers 485
References 487
30 Small Intestine 489
Obstruction 489
Diagnosis 489
Treatment 490
Perforation 491
Diagnosis 491
Treatment 492
Gastrointestinal Bleeding 492
Peptic Ulcer Disease 492
Diagnosis 492
Therapy 493
Meckel’s Diverticulum 493
Diagnosis 493
Treatment 493
Mesenteric Ischemia 494
Diagnosis 494
Treatment 494
References 495
31 Liver and Biliary Tract 497
Anatomy 497
Physiology 498
Technology 498
Infections 499
Hepatic Pyogenic Abscess 499
Cholangitis 500
Parasitic 502
Calculus Disease of the Gallbladder and Common Bile Duct 502
Cholecystitis 502
Biliary Obstruction 503
Pancreatitis 504
Gallstone Ileus 504
Neoplasms 505
Tumor Rupture 506
Abscess 507
Biliary Obstruction 508
Portal Hypertension 509
Hemobilia 510
References 510
32 Pancreas 515
Pertinent Anatomy for Trauma Surgeons 515
Anatomic Location of Injury 517
Associated Injuries 518
Surgical Techniques 520
Intraoperative Evaluation and Exposures 520
Intraoperative Adjunct Techniques 520
Injury Classification 521
Principles of Injury Management 521
Special Situations 522
Pancreaticoduodenal Injuries 522
Mortality 524
Morbidity 525
Pancreatic Emergencies (Nontrauma)* 526
References 527
33 Spleen 531
Clinical Anatomy 532
Function 533
Indication for Operative Intervention 533
Operative Management 534
General 534
Operative Approach 535
Management Options of Specific Injuries 536
Drainage 539
Postsplenectomy Complications 539
References 539
34 Intraabdominal Vasculature 542
Acute Mesenteric Ischemia 543
Anatomy and Pathophysiology 543
Surgical Management 544
Endovascular Management 545
Ischemia Associated with Aortic Dissection 546
Acute Renal Ischemia 548
Acute Aortic Occlusion 548
Other Acute Arterial Occlusions 549
Acute Venous Occlusions 550
Acute Mesenteric Venous Thrombosis Including Portal Vein Thrombosis 551
Acute Renal Vein Thrombosis 551
Acute Complications of Aneurysmal Disease 552
Symptomatic Abdominal Aortic Aneurysm Including Rupture 552
Etiology and Risk Factors of Aneurysm Rupture 552
Clinical Presentation and Diagnosis 552
Management 553
The Preoperative Phase 553
The Operation 554
Postoperative Management 555
Aortoenteric Fistula 555
Ruptured Visceral or Renal Artery Aneurysm 555
Abdominal and Pelvic Vascular Trauma 556
Diagnosis and Evaluation 556
Management 557
Operative Management 557
Endovascular Management 558
Specific Vascular Injuries and Their Management 558
Abdominal Aortic Injuries 558
Iliac Vessel Injuries 558
Inferior Vena Cava Injuries 559
Renovascular Injuries 559
Mesenteric Vascular Injuries 560
Portal Region Injuries 560
References 560
35 Colon and Rectum 567
Anorectal Disease and Trauma 567
Abscess 567
Hemorrhoids 568
Anal Fissure 569
Pilonidal Cyst-Abscess 569
Rectal Procedentia (Rectal Prolapse) 569
Colorectal Disease and Trauma 570
Neoplastic Disease 570
Diverticular Disease 571
Inflammatory Bowel Disease 573
Colonic Volvulus 575
Ogilvie’s Syndrome 576
Ischemic Colitis 576
Colorectal Trauma 577
References 577
36 Urogenital Tract 579
Infection 579
Emphysematous Pyelonephritis 579
Definition 579
Clinical Presentation 579
Diagnosis 579
Management 579
Prognosis 580
Renal and Perirenal Abscess 580
Definition 580
Clinical Presentation 581
Diagnosis 581
Management 581
Pyonephrosis 582
Definition 582
Clinical Presentation 582
Diagnosis 582
Management 582
Prostatic Abscess 583
Definition 583
Clinical Presentation 583
Diagnosis 583
Management 583
Acute Prostatitis 583
Definition 583
Clinical Presentation 583
Diagnosis 583
Treatment 584
Infected Urinary and Genital Prosthetics 584
Definition 584
Clinical Presentation 584
Diagnosis 584
Treatment 584
Necrotizing Gangrene of the Genitalia and Perineum 585
Background 585
Clinical Presentation 585
Diagnosis 586
Treatment 586
Prognosis 586
Hemorrhage 586
Angiomyolipoma of the Kidney 586
Definition 586
Clinical Presentation 587
Diagnosis 587
Management 587
Arteriovenous Malformation of Kidney 588
Definition 588
Clinical Presentation 588
Diagnosis 588
Management 588
Acute Urinary Tract Obstruction 588
Upper Tract Obstruction 588
Definition 588
Clinical Presentation 588
Diagnosis 588
Management 589
Prognosis 590
Lower Tract Obstruction 590
Definition 590
Presentation 590
Evaluation 590
Management 590
Penile Emergencies 591
Priapism 591
Background 591
Clinical Presentation 591
Diagnosis 592
Management 592
Prognosis 593
Penile Fracture 593
Diagnosis 593
Presentation and Evaluation 593
Management 594
Prognosis 594
Acute Scrotum 594
Torsion 594
Definition 594
Presentation 594
Evaluation 594
Management and Prognosis 594
Epididymitis 595
Presentation 595
Evaluation 595
Management 595
Prognosis 595
Iatrogenic Complications 595
Ureteral Injury 595
Definition and Background 595
Presentation 595
Evaluation 596
Management 596
Bladder Injury 598
Definition 598
Presentation 598
Evaluation 598
Management and Prognosis 598
Male Urethral Injuries 599
Pediatric Emergencies 599
Circumcision Complications 599
Ambiguous Genitalia 600
Definition 600
Clinical Presentation 600
Diagnosis 600
Posterior Urethral Valves 602
Definition 602
Clinical Presentation 602
Diagnosis 602
Management 602
References 603
37 Pelvis 607
Anatomy of the Pelvic Ring 607
Pelvic Stability and Mechanism of Injury 608
Lateral-Compression Force 608
External-Rotation Force 609
Anterior-Posterior Force 609
Shearing Force 609
Classification 609
Young and Burgess Classification 609
Lateral Compression 609
Anterior Posterior 610
Vertical Shear 610
Combined Mechanical 611
Tile Classification 611
Tile A 611
Tile B 611
Tile C 611
Evaluation 612
Clinical Evaluation 612
Associated Injuries 612
Radiographic Evaluation 612
Hemodynamic Status and Emergent Stabilization 614
References 618
38 Lower Extremities 620
Infections 620
Necrotizing Soft Tissue Infections 620
Septic Joints 621
The Nontraumatic Ischemic Extremity 621
Compartment Syndrome 622
Trauma 624
Irreducible Dislocations 624
Hip 624
Knee 625
Ankle and Foot 625
Femoral Neck Fractures in the Young 625
Vascular Injury 626
Femoral Artery Injuries 627
Popliteal Artery 628
Infrapopliteal Arteries 628
Open Fractures and Open Joints 628
The Mangled Extremity 629
References 629
39 Hand and Upper Extremities 633
Principles 633
Treatment Planning 633
Anesthesia 634
Tourniquet Application 635
Incisions 635
Dressings and Splints 635
Examination and Diagnosis 636
Observation 636
Neurovascular Examination 636
Musculoskeletal Examination 637
Special Investigations 639
Fingertip and Nailbed Injuries 640
Open Soft Tissue Injuries and Complex Wounds 644
Replantations and Amputations of the Upper Extremity 649
Operative Procedure for Replantation 650
Tendon Injuries 651
Flexor Tendons 651
Extensor Tendons 653
Nerve Injuries 655
Fractures and Dislocations 656
Clavicle Fractures 657
Proximal Humerus Fractures 657
Humeral Shaft Fractures 657
Fractures of the Distal Humerus 658
Olecranon Fractures 658
Radial Head Fractures 658
Forearm Fractures 658
Distal Radius Fractures 658
Scaphoid Fractures 659
Metacarpal Fractures 659
Phalangeal Fractures 660
Carpal Dislocations 660
Dislocations Involving the Hand 661
Vascular Emergencies 662
High-Pressure Injuries 663
Frostbite and Chemical and Extravasation Injuries 664
Frostbite 664
Chemical Burns 664
Extravasation Injuries 664
Compartment Syndrome 665
Acute Upper Extremity Infections 667
Routes of Infection and Infecting Organisms 667
Anatomy of Hand Infections 668
Types of Infections 669
Superficial Paronychial Infections 669
Infections at Intermediate Depths 669
Deep Infections 670
Deep Palmar Space Infections 670
Pyogenic Flexor Tenosynovitis 670
Acute Fulminant Infections 670
Necrotizing Fasciitis 670
Clostridial Myonecrosis (Gas Gangrene) 671
Diabetic Gangrene 671
Nondiabetic Gangrene 671
References 671
40 Peripheral Vasculature 674
Upper Extremity 674
Embolic Occlusion of the Brachial Artery 674
Diagnosis 674
Treatment 675
Arterial Thrombosis Secondary to a Monitoring Device 675
Diagnosis 675
Treatment 676
Occlusion or Infection of an Angioaccess Graft 676
Traumatic Injuries to Arteries 677
Diagnosis 677
Treatment 678
Traumatic Injuries to Veins 681
Diagnosis 681
Treatment 681
Compartment Syndromes and Fasciotomies 681
Diagnosis 681
Treatment 682
Lower Extremity 682
Catheterization Injuries of the Femoral Artery 683
Diagnosis 683
Treatment 683
Embolic or Thrombotic Occlusion of the Femoral Artery 684
Diagnosis 684
Treatment 684
Ruptured Femoral Artery Pseudoaneurysm Secondary to Inadvertent Injection of Illicit Drugs 686
Diagnosis 686
Treatment 686
Embolic Occlusion of the Popliteal “Trifurcation”Vessels 687
Diagnosis 687
Treatment 687
Traumatic Injuries to Arteries 687
Diagnosis 687
Treatment 688
Traumatic Injuries to Veins 689
Diagnosis 689
Treatment 689
Compartment Syndromes and Fasciotomies 690
Diagnosis 690
Treatment 690
References 691
Part III Administration, Ethics, and Law 693
41 Understanding the Latest Changes in EMTALA: Our Country’s Emergency Care Safety Net 694
Understanding the Basics for Hospitals: Obligation to Examine, Treat, and Stabilize 694
Physician Obligations Under EMTALA 695
EMTALA On-Call Requirements 696
Continuous Call 696
Simultaneous Call 696
Scheduling Elective Surgery While On-Call 696
Scope of Privileges 697
EMTALA Reforms Included in Medicare Prescription Drug Law 697
Managed Care Reimbursement for EMTALA-Related Services 697
EMTALA Technical Advisory Group 697
Issues Remaining 698
Managed Care Pressures 698
Impact on Trauma Centers and Community Hospitals 698
Suggestions from the Surgical Community for Solidifying the Safety Net over the Next Decade 698
References 699
42 Informed Surgical Consent 700
General Rule 700
Evidence of Consent 700
What Constitutes a Medical Emergency 700
Exceptions to Informed Consent 701
The Unconscious Patient 701
Capacity to Consent 702
Intoxicated Patients 702
Minors 702
Patient’s Refusal to Consent 703
Documentation 704
References 704
43 Advance Directives 706
History of the Development of Advance Directives 706
Ethical Foundation 706
Legal Foundation 706
The Patient Self-Determination Act 707
Types of Advance Directives 709
Living Wills 709
Durable Health Care Power of Attorney 710
Advance Directives: Unfulfilled Potential 712
Advance Directives: Relevance to the Acute Care Surgeon 713
Recommendations 714
References 715
44 The Nonviable Patient and Organ Procurement 718
Defining the Problem 718
The Problem with Futility 719
Communication Is the Key 720
End-of-Life Care 721
Withdrawal of Life-Sustaining Treatment 722
The Determination of Brain Death 723
Care of the Potential Organ Donor 725
Cardiovascular System Issues 725
Fluid and Electrolyte Issues 727
Acid–Base Balance Issues 727
Coagulation System Issues 728
Temperature Regulation Issues 728
Ventilator Management Issues 729
References 729
45 Ethical Dilemmas and the Law 732
Considerations for Surgeons 732
General Concepts 732
Defining the Problem 732
What Makes the Surgeon Special? 733
Special Problems of Acute Care Surgery 733
Principles of Bioethics 734
Philosophical Principles 734
Respect for Autonomy 735
Beneficence 735
Nonmaleficence 735
Justice 735
Religion and Medical Ethics 736
Legal Principles 736
Malpractice 737
Statutory Law 737
Regulatory Law 737
Physician-Based Ethics 738
General Principles 738
The “Clinical Ethics” System 738
Specific Dilemmas of Acute Care Surgery 739
Categories of Patient Encounters 739
Severe Emergency: Life in Immediate Jeopardy 739
Urgent: Serious Problem needing Surgery 739
Semi-Elective:Will Probably Need Surgery 739
Informed Consent 739
General Concepts 739
Using Newly Deceased Patients for Teaching Purposes 740
Participation in Research 741
Conflict of Interest: Industry and Drug Money 741
Autonomy, Decision-Making Capacity, and Competency 742
General Concepts 742
Refusal of Treatment 743
Telling the Truth/Disclosing Errors 743
Impaired Decision-Making Capacity 744
Suicidal Patients 744
Advance Directives 744
General Principles 744
Living Will 745
Durable Power of Attorney 745
Problems 745
Confidentiality 746
General Principles 746
Abuse of the Elderly 746
Futility and Withholding Treatment 746
Withdrawal of Treatment 748
General Principles 748
Applying the Principles 748
Palliative Care 748
Determination of Death 749
Organ Donation 749
Ethical and Legal Consultations 750
Good Samaritan 750
A Case 750
General Concepts 750
Pain Relief and the Doctrine of Double Effect 751
Confusing Principles 751
Double Effect 751
Hastening Death 751
Know Your Intent 752
A Final Thought 756
References 756
Part IV System and Curriculum Development 757
46 Development of a Regional System for Surgical Emergencies (RSSE) 758
The Problem—The Solution 758
Regionalization: A Concept for Optimal Care 758
Trauma System: A New Paradigm for Emergency Surgical Care 760
Administrative Components 760
Leadership and System Development 760
Legislation 761
Operational and Clinical Components 761
Public Information and Prevention 761
Human Resources 762
Prehospital Issues 762
Definitive Care 762
Evaluation 763
Rehabilitation 765
Research 765
Building on a Trauma System 765
Disaster Preparedness 765
References 765
47 Acute Care Surgery: A Proposed Curriculum 767
48 Emergency General Surgery: The Vanderbilt Model 769
Background 769
The Concept of Nontrauma Acute Care Surgery 769
The Regional Referral Center 769
The Acute Care Surgery/Trauma Paradigm 769
System Infrastructure 771
The Service Concept 771
The Surgical Director 771
Hospital Support 771
The Emergency Department 771
The Operating Room—Urgent/Emergent 771
Radiology 771
The Surgical Intensive Care Unit and the Intensive Care Unit Team/Bedside Surgery 771
The Hospital Floor 772
Emergency General Surgery Clinic 772
Referrals and the Catchment Area 772
Intrahospital Communications 772
Marketing 772
Transfer Center 772
Transportation 772
Aeromedical Transport 772
Staffing the Service 773
The Skill Set 773
Faculty Coverage 773
Surgical and Medical Subspecialty Consultants 773
The House Staff Team 773
Physician Extenders 774
Responsibility and Credentialing 774
The Nonphysician Clinician Skill Set 774
Promoting a Continuum of Care 774
Case Management 774
Social Worker 774
Rehabilitation/Extended Care 775
The Emergency General Surgery Registry 775
The Model 775
Practice Management Guidelines 775
The Financial Model 775
Historical Perspective 775
The Need for an Emergency General Surgery Service Designation 775
The Budget: Basics 776
Analysis 776
References 776
Part V The International Communities 779
49 Acute Care Surgery: United Kingdom 780
Emergency General Surgery 781
Introduction 781
On-Call Surgical Team 781
Early Investigation of Patients with Emergency Surgical Problems 782
Blood Tests 782
Ultrasonography 783
Contrast Radiology 783
Small Bowel Obstruction 783
Large Bowel Obstruction 783
Acute Diverticulitis 783
Computed Tomography 784
Emergency Theater Availability 784
Surgical Subspecialization 784
Future Provision of Emergency General Surgical Services in the United Kingdom 784
Emergency Surgery and Organ Transplantation 785
Introduction 785
Organ Retrieval from Cadaveric Donors 785
Non-Heart-Beating Donations 786
Uncontrolled Non-Heart-Beating Donation 786
Controlled Non-Heart-Beating Donation 786
Cadaveric Organ Transplantation 787
Super-Urgent Transplantation 787
Surgical Emergencies in Organ Transplant Recipients 787
Emergency Vascular Surgery 788
Introduction 788
Present Arrangements 788
Proposals 788
Trainees 789
Radiology 789
Summary 789
Emergency Surgery in Remote and Rural Areas 789
Introduction 789
General Principles 789
Medical and Nursing Staff 789
Surgeons 790
Hospitals 790
Patient Transport 790
Patient Transport with Paramedic Escort 790
Patient Transport with Local Medical Support 790
Patient Transport with a Distantly Based Transport Team 791
Procedures 791
Life-Threatening Emergencies Requiring Immediate Surgical Intervention 791
Life-Threatening Emergencies Requiring Resuscitation Followed by Expeditious Surgical Intervention 791
Life-Threatening Emergencies That Might Not Require Surgical Intervention 791
Emergencies That Might Become Life Threatening if Not Managed with Expeditious Surgical Intervention 791
Emergencies That Will Lead to Incapacity and Disability if Not Managed by Immediate Surgical Intervention 792
Emergencies That Will Lead to Incapacity and Disability if Not Managed by Surgical Intervention 792
Emergency Surgery Outcome 792
Trauma Services in the United Kingdom 792
Introduction 792
A Historical Perspective 792
Present Arrangements 793
Incidence and Costs of Severe Injury 793
The Future 793
The Emergency Department (Acute Care Facility) of the Future 794
References 795
50 Acute Care Surgery:Australia 799
Geography and Demography 799
The Australian Medical System 800
Distribution and Provision of Surgical Services 800
Acute Care Trauma Surgery in Australia 801
Prehospital Care 801
Designation of Hospitals to Receive Trauma Patients 802
Triage, Transfer, and Retrieval Services 803
Trauma Care in the Other States of Australia 804
Nontrauma Acute Care Surgery 804
Surgical Training in Australia 804
Rural Surgeon Training 805
Surgical Training for General Practitioners 805
Outreach Services 805
The Use of Information Technology in Providing Surgical Services 806
Challenges to Trauma and Acute Care Surgery in the Developing World 807
References 808
51 Acute Care Surgery: Japan 809
Acute Care Surgery in Developing Countries 809
Malnutrition 809
Infectious Diseases 810
Malaria 810
Schistosomiasis 810
Amebiasis 811
Ascariasis 811
Bacterial Enteritis 812
Thermoregulatory Disorders 812
Acute Care Surgery in Japan 812
Anisakiasis 813
Gastroduodenal Perforation 814
Fulminant Hepatic Failure 814
Acute Pancreatitis 816
Acute Care Surgery in the Future 816
Tele-Surgery 816
Regenerative Medicine 816
Global Health Care 818
References 818
Index 821

"Part IV System and Curriculum Development (p. 742-743)

Centralization 46 Development of a Regional System for Surgical Emergencies (RSSE)

A. Brent Eastman, David B. Hoyt, and J.Wayne Meredith

The Problem—The Solution

In the United States, in the ?rst decade of the twenty-?rst century, a 60-year-old man run over by a truck may have better access to life-saving care than a man with a perforated viscus or a ruptured abdominal aortic aneurysm. The reason is that many states and counties now have regional systems to coordinate the care of injured patients, but the concept of a geographic plan for nontraumatic, but devastating, surgical emergencies is new. The trauma system model is appropriate for these other surgical emergencies and possibly for certain medical emergencies as well, such as stroke and acute myocardial infarction.

The concept of trauma system development is based on the principle that the system adds value over and above the efforts of individual practitioners or hospitals.1–3 It is historical irony that today there are well-trained and quali?ed surgeons in most of the country’s community hospitals, but there are too few surgeons who are committed to providing emergency department coverage 24 hours a day. Training has improved over the past 30 years to the point that most surgeons who complete an accredited general surgery program are well quali?ed to perform most acute care operations.

Yet surgical coverage in emergency department call panels is a critical health care challenge in the United States. The problem has many compounding causes. The ?rst is a physician shortage nationwide: some experts estimate that the United States will be short some 200,000 physicians within the next decade, and a large portion of the missing physicians will be specialists in surgery.4 There is also inadequate reimbursement for providers along with soaring medical malpractice insurance costs. Furthermore, a powerful cultural change has occurred prompting many young surgeons to seek a more balanced life style.

The net effect is fewer professional hours devoted to patient care. Finally, the population is aging, with octogenarians representing the most rapidly growing segment, and the resources required for the elderly with acute severe illnesses are greater than for younger patients with the same emergencies (Table 46.1).5 All of these factors speak to the urgent need for a system designed to coordinate and ensure access to emergency surgical care. The trauma system model should be strongly considered in addressing the treatment of nontraumatic surgical emergencies (NTSEs).

Trauma systems are designed to identify injured patients in the prehospital setting, establish triage guidelines, and institute protocols of care. Furthermore, a trauma system provides for the immediate availability of a coordinated team with the resources necessary to care for critically injured patients. In regions without a trauma system, autopsy records have shown an unacceptable rate of preventable deaths (i.e., deaths of patients who would have survived with appropriate surgical intervention).

Lowered rates of preventable deaths re?ect the presence of a system that rapidly identi?es those at risk and transports them to the appropriate facility. 7,8 An analogous situation may exist for NTSEs. Figure 46.1 describes the preventable death data derived from the San Diego Trauma Registry. The San Diego Trauma Registry was inaugurated in 1984 with the resultant immediate decline in the number of preventable deaths. This dramatic change is directly attributable to the implementation of all components of a regionalized trauma system plan."