FFP = fresh-frozen plasma; RBC = red blood cell. Pieracci Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. Anterior truncal gunshot wounds between the fourth intercostal space and the pubic symphysis whose trajectory as determined by radiograph or wound location indicates peritoneal penetration should undergo laparotomy (Fig. Early institution of effective pain control is essential. 7-26). Primary repair of the injured intrahepatic duct is unlikely to be successful. If the patient shows no clinical or radiographic improvement within 3 weeks, operative evaluation is warranted. The popliteal space is commonly accessed using a single medial incision (the detached semitendinosus, semimembranosus, and gracilis muscles are identified by different suture types). A.  GJ Transection at the injury site with proximal ligation and distal salpingectomy is a more prudent approach. Kramer If DPL is pursued, an infraumbilical approach is used (Fig.  et al.. Operative strategies for management of abdominal aortic gunshot wounds. The recipient(s) will receive an email message that includes a link to the selected article. Biffl In general, physician-supervised axial traction, via cervical tongs or the more commonly used halo vest, is used to reduce subluxations and stabilize the injury. Chest wall defects, particularly those seen with open pneumothorax, are repaired using local approximation of tissues or tissue transfer for coverage. Bei komplexeren Verletzungen mit Gangbeteiligung werden die Patienten in der Akutsituation oft ebenfalls zunächst mit einer Dränage versorgt und sekundär einer definitiven chirurgischen Therapie zugeführt.  S, Keim Although current critical care guidelines indicate that PRBC transfusion should occur once the patient’s hemoglobin level is <7 g/dL,53 in the acute phase of resuscitation a hemoglobin of 10 g/dL is suggested to facilitate hemostasis.54 The traditional thresholds for blood component replacement in the patient manifesting a coagulopathy have been INR >1.5, PTT >1.5 normal, platelet count > 50,000/μL, and fibrinogen >100 mg/dl. Roux-en-Y duodenojejunostomy is used to treat duodenal injuries between the papilla of Vater and superior mesenteric vessels when tissue loss precludes primary repair. gerinnungshemmende Wirkstoffe), Begrenzte Aussagekraft, Durchführung dennoch empfohlen. More than 1500 mL of blood in the pleural space is considered a massive hemothorax. A prospective study of 1,561 patients.  MJ, Holford  MD, Badellino Es stellt oft bereits die definitive Versorgung dar, kann aber auch als Überbrückung bis zur endgültigen Versorgung genutzt werden. 7-32). (1990) Organ injury scaling. The pylorus is then grasped with a Babcock clamp, via the gastrostomy, and oversewn with an O polypropylene suture. Man unterscheidet das häufigere stumpfe vom meist selteneren perforierenden Bauchtrauma. Intermittent release of the Pringle is helpful to attenuate hepatic cellular loss.  DB, Moore Radiology. Each rib fracture can produce 100 to 200 mL of blood loss; for tibial fractures, 300 to 500 mL; for femur fractures, 800 to 1000 mL; and for pelvic fractures >2000 mL. Heparin, started without a loading dose at 15 units/kg per hour, is titrated to achieve a PTT between 40 and 50 seconds or antiplatelet agents are initiated (aspirin 325 mg/d or clopidogrel 75 mg/d). Thus, patients undergoing cardiopulmonary resuscitation upon arrival to the ED should undergo RT selectively based on injury and transport time (Fig. If the difference is >10%, CT angiography or arteriography is indicated. Nonoperative management of solid organ injuries is pursued in hemodynamically stable patients who do not have overt peritonitis or other indications for laparotomy. 5. The type of antibiotic is determined by the anticipated source of contamination in the abdomen or other operative region; additional doses should be administered during the procedure based on blood loss and the half-life of the antibiotic. In comatose or obtunded patients, the diagnosis is more difficult to secure. The right common iliac artery can be divided to expose the bifurcation of the inferior vena cava and the right common iliac vein. Extensive injuries may warrant presacral drainage with Penrose drains placed along Waldeyer’s fascia via a perianal incision (see Fig. Once a secure airway is obtained, adequate oxygenation and ventilation must be ensured. A. Pelvic packing is performed through a 6- to 8-cm midline incision made from the pubic symphysis cephalad, with division of the midline fascia. Subkapsuläre Hämatome kleiner als 10% der Organoberfläche und nicht blutende Kapseleinrisse nicht tiefer als 1 cm in das Parenchym reichend (Grad I) können in der Regel konservativ behandelt werden.  EE Johnston Unable to load your collection due to an error, Unable to load your delegates due to an error. Air embolism is a frequently overlooked lethal complication of pulmonary injury.  MM, Burlew The majority of duodenal hematomas are managed nonoperatively with nasogastric suction and parenteral nutrition. MacKenzie Paresthesias may also be described. Bracken However, the additional work of breathing and chest wall pain caused by the flail segment is rarely sufficient to compromise ventilation. (1998) Abdominaltrauma. Als Ultima ratio kommt bei schwerster Leberzertrümmerung (Grad V–VI), wenn eine Blutungskontrolle durch die genannten Maßnahmen nicht zu erreichen ist, eine ein- oder zweiseitige Lebertransplantation in Frage, welche in Einzelfällen beschrieben wurde [1]. 7-31). Die häufigste Todesursache bei Frauen im reproduktiven Alter ist ein traumatisches Ereignis.  D, Chan Although safe for emergent use, the needle should be removed once alternative access is established to prevent osteomyelitis. The management algorithm for hemodynamically stable patients is based on the presenting symptoms and anatomic location of injury, with the neck being divided into three distinct zones (Fig. Durch die anatomischen Veränderungen werden vor allem Gebärmutter und Harnblase häufiger verletzt, während Darmverletzungen seltener vorkommen. Suturing of the hepatic parenchyma with a blunt tipped 0 chromic suture (e.g., a “liver suture”) can be an effective hemostatic technique.  R, Curry Example: jdoe@example.com. Fluid resuscitation begins with a 2 L (adult) or 20 mL/kg (child) IV bolus of isotonic crystalloid, typically Ringer’s lactate. Esperamos que este video haya sido útil para ti. Such lesions include hematomas, contusions, hemorrhage into ventricular and subarachnoid spaces, and diffuse axonal injury (DAI).  et al.. 2,576 ultrasounds for blunt abdominal trauma. The American College of Surgeons Committee on Trauma addresses this issue by assisting in the development of trauma . After the sticky clear plastic vacuum-assisted closure (VAC) dressing is placed over the white sponges and adjacent 5 cm of skin, the central portion is removed by cutting along the wound edges. Patients with > grade II injuries should be admitted to the SICU with frequent hemodynamic monitoring, determination of hemoglobin, and abdominal examination. 66.94.110.250  EE, Knudson Primary repairs include lateral suture repair or resection of the damaged segment with reconstruction by ileocolostomy or colocolostomy. Admission chest film may not show the full extent of the patient’s pulmonary parenchymal injury. Patients with intracranial hemorrhage, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, intracerebral hematoma or contusion, and diffuse axonal injury, are admitted to the SICU. No attempt should be made to control intracranial hemorrhage through the burr hole.  et al.. Blunt carotid arterial injuries: implications of a new grading scale. It is important, therefore, to limit radiographs to those that are essential and to shield the pelvis with a lead apron when possible. For example, a patient with a gunshot wound to the upper abdomen should have a chest radiograph to ensure that the bullet did not traverse the diaphragm causing intrathoracic injury. Bei freier Flüssigkeit und Kreislaufinstabilität muss unverzüglich laparotomiert werden. Die Ursachen für die hohe Letalität liegen zum einen in den fatalen Blutungskomplikationen, zum anderen jedoch auch in den postoperativ auftretenden septischen Komplikationen und gesteigerten Raten an Organversagen [13]. Beim Nachweis von freier abdominaler Flüssigkeit sowie Kreislaufinstabilität besteht prinzipiell die Indikation zur Notfalllaparotomie. Thoracoabdominal trauma should be evaluated with a combination of chest radiograph, FAST, and pelvic radiograph. Yu Although early colloid administration is appealing, evidence to date does not support this concept. less common abdominal trauma injuries: gallbladder.  GJ, Hoyt 7-24). Advanced operative techniques in the management of complex liver injury. Covering the wound with excessive dressings may permit ongoing unrecognized blood loss that is hidden underneath the dressing. 7-41) may be required to control hemorrhage for adequate visualization of the injuries. Carretta  MA Diverting ileostomy with colocolostomy, however, is used for most other high-risk patients. 7. Nicht jede traumatische Milzverletzung muss notwendigerweise operativ versorgt werden. Angio = angiography; ASA = acetylsalicylic acid; BRB = bright red blood; CHI = closed head injury; C-spine = cervical spine; CT = computed tomography; DAI = diffuse axonal injury; GCS = Glasgow Coma Scale score; MRI = magnetic resonance imaging; MS = mental status; Neg = negative; pt = patient; PTT = partial thromboplastin time; TIA = transient ischemic attack. An anterolateral thoracotomy, with the patient placed supine, is the most versatile incision for emergent thoracic exploration. The location of the incision is in the fifth interspace, in the inframammary line (Fig. In the aging population, perhaps due to osteoporosis, less force is required to cause a fracture. Temporary management of this injury includes covering the wound with an occlusive dressing that is taped on three sides. Operative approach for a brachial artery injury is via a medial upper extremity longitudinal incision; proximal control may be obtained at the axillary artery, and an S-shaped extension through the antecubital fossa provides access to the distal brachial artery. A. Such a finding should prompt imaging to rule out an associated extracranial cerebrovascular injury. Some specific injuries due to abdominal trauma are discussed elsewhere, including those to the liver , spleen , and genitourinary tract . The disadvantage of orotracheal intubation is that conscious patients usually require neuromuscular blockade, which may result in inability to intubate, aspiration, or medication complications.  WL, Moore Chirurg 75: 447–467, Traub A, Giebink GS, Smith C et al. In patients with significant intra-abdominal fluid as the primary component of abdominal compartment syndrome, rather than bowel or retroperitoneal edema, decompression can be accomplished effectively via a percutaneous drain. 7-44). Operative exposure for midline structures of the neck (e.g.,trachea, thyroid, bilateral carotid sheaths) is obtained through a collar incision; this is typically performed two finger breadths above the sternal notch, but can be varied based on the level of anticipated injury. Spinal cord injuries can vary in severity. To mobilize the spleen, an incision is made into the endoabdominal fascia 1 cm lateral to the reflection of the peritoneum onto the spleen (A).  A, Offner Google Scholar, Buntain WL, Lynn HB (1979) Splenorrhaphy: changing concepts for the traumatized spleen. Performing surgery within 24 hours may decrease length of stay and complications.76 Complete injuries of the spinal cord remain essentially untreatable. Moore Due to technical difficulties of injury exposure and varying operative approaches, a precise preoperative diagnosis is desirable for symptomatic zone I and III injuries. Originally, penetrating towel clips were used to approximate the skin; however, the ensuing bowel edema often produces a delayed abdominal compartment syndrome. In the case of hepatobiliary and splenic trauma the main challenge lies in the need to control life-threatening bleeding, while in pancreatic injuries the primary goal is the avoidance of septic complications. CT in abdominal and pelvic trauma. A burr hole is made for decompression of an epidural hematoma as a life-saving maneuver. Typisch sind auch Flashbacks: das wiederholte Erleben der traumatischen . After blunt trauma, a major hemothorax usually is due to multiple rib fractures with severed intercostal arteries, but occasionally bleeding is from lacerated lung parenchyma which is usually associated with an air leak. 7-36). Sometimes 10 to 15 pads may be required to control the hemorrhage from an extensive right lobar injury. Letztere gehen mit einer hohen Letalität einher.  et al.. A cost-minimization analysis of. ), https://accesssurgery.mhmedical.com/content.aspx?bookid=2576§ionid=210406250. Due to lack of mobility of the abdominal aorta, few injuries are amenable to primary repair. Zone I is to the level of the clavicular heads and is also known as the thoracic outlet. Standard 14-gauge catheters can be quickly placed, even in an exsanguinating patient with collapsed veins.  GC, Scalea Hierdurch kann in den meisten Fällen eine sekundäre Resektion mit Pankreatikoenterostomien vermieden werden. In addition to operative intervention, postinjury care directed at limiting secondary injury to the brain is critical. After stabilization, the patient is transferred to a facility with neurosurgical capability for formal craniotomy. Epidemiology. CT = computed tomography; CTA = computed tomographic angiography; GSW = gunshot wound. The right or left hepatic artery, or in urgent situations the portal vein, may be selectively ligated; occasionally, lobar necrosis will necessitate delayed anatomic resection. Loop colostomy will completely divert the fecal flow, allowing the low rectal injury to heal. The presence of lateralizing findings (e.g., a unilateral dilated pupil unreactive to light, asymmetric movement of the extremities either spontaneously or in response to noxious stimuli, or unilateral Babinski’s reflex) suggests an intracranial mass lesion or major structural damage. 7-43). Die Peritoneallavage wird nur noch selten genutzt. When the suture is tied, tension is adequate when visible hemorrhage ceases or the liver blanches around the suture. Additional hematologic changes include a moderate leukocytosis (up to 20,000 mm3) and a relative hypercoagulable state due to increased levels of factors VII, VIII, IX, X, and XII and decreased fibrinolytic activity. Aside from hemorrhage and hepatic necrosis, additional complications after significant hepatic trauma include bilomas, arterial pseudoaneurysms, and biliary fistulas (Fig. Injuries of the proximal internal carotid can be treated by mobilizing the adjacent external carotid, dividing it distal to the internal injury, and performing an end-to-end anastomosis between it and the distal internal carotid (Fig.  RT CT-guided catheter drainage may be required in such cases, because 25% of patients do not respond to antibiotic therapy alone. For example, when an unrestrained driver sustains a frontal impact, the head strikes the windshield, the chest and upper abdomen hit the steering column, and the legs or knees contact the dashboard. J Trauma 29: 606–608, PubMed  The metabolic acidosis of shock is exacerbated by aortic clamping, administration of vasopressors, massive RBC transfusions, and impaired myocardial performance. Diese kann in Zentren und bei entsprechender Erfahrung des Chirurgien auch laparoskopisch durchgeführt werden. Regardless of the choice of definitive procedure, the pancreatic duct in the proximal edge of transected pancreas should be individually ligated or occluded with a TA stapler. Cervical vascular injuries due to either blunt or penetrating trauma can result in devastating neurologic sequelae or exsanguination.  FA Im Rahmen des Notfalllabors sollten ein Blutbild, eine Blutgerinnung, Leber-, Nieren-, Pancreasparameter sowie die Elektrolyte abgenommen werden.  LS, Bhasin NCI CPTC Antibody Characterization Program, J Trauma. Current management algorithms in the United States incorporate variable time frames for bony stabilization and fixation, as well as hemorrhage control by preperitoneal pelvic packing and/or angioembolization. (Suppl 2), S127–S131 (2007).  D, Dipiro Similarly, perfusion of the iliac system and infrainguinal vessels can be restored with a vascular shunt, with interposition graft placement delayed until hours later. Hemorrhage from the raw splenic edge is controlled with horizontal mattress sutures, with gentle compression of the parenchyma (Fig. If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.  et al.. Decompressive craniectomy for medical management for refractory intracranial hypertension: An AAST-MITC propensity score analysis. Algorithm directing the use of resuscitative thoracotomy (RT) in the injured patient undergoing cardiopulmonary resuscitation (CPR). Partrick 7-30). Als Spätfolge nach Pankreastrauma ist mit der Bildung von Pankreaspseudozysten zu rechnen, die sich in über der Hälfte der Fälle jedoch spontan zurückbilden. Otherwise it is hidden from view.  JP, Magnotti Pregnant patients have a progressive increase in circulating blood volume over gestation; therefore, they must lose a relatively larger volume of blood before manifesting signs and symptoms of hypovolemia (see Special Trauma Populations). In the US in 2016 there were 37,461 fatalities from 34,439 fatal MVAs, 5286 .  MJ, Call Patients with pelvic fractures who are hemodynamically unstable are a diagnostic and therapeutic challenge for the trauma team. Indications to limit the initial operation and institute DCS techniques include a combination of refractory hypothermia (temperature <35°C), profound acidosis, (arterial pH <7.2, base deficit <15 mmol/L), and refractory coagulopathy.49,65 The decision to abbreviate a trauma laparotomy is made intraoperatively as the patient’s clinical course becomes clearer and laboratory values become available.66.  P. Conservative and surgical treatment of acute posttraumatic tracheobronchial injuries. Administration of atropine before rapid-sequence intubation will prevent bradycardia. Morris 7-7). Das Abdominaltrauma stellt nach wie vor eine Herausforderung im klinischen Alltag dar. PMC Laparotomy for blunt abdominal trauma in a civilian trauma service. For patients with open fractures, fracture reduction with stabilization via splints will limit bleeding both externally and into the subcutaneous tissues. unmittelbare chirurgische Therapie möglich, Konversion auf offenes Verfahren bei Nachweis ausgeprägter intraabdomineller Verletzungen, Frühzeitig Anlage großlumiger Infusionszugänge erwägen, Ausschluss freier abdomineller Flüssigkeit, Möglichkeit zur kontinuierlichen Überwachung.  JW, Veldenz  et al.. Splenorrhaphy: the alternative. Bony fractures or knee dislocations should be realigned before definitive vascular examination.  CC. Vaginal bleeding can signal early cervical dilation and labor, abruptio placentae, or placenta previa. Plasma albumin level decreases from a normal of around 4.3 g/dL to an average of 3.0 g/dL. Some injuries of the pancreatic head do not involve either the pancreatic or common bile duct; if no clear ductal injury is present, drains are placed. C and D. Black VAC sponges are placed on top of the white sponges and plastic-protected skin with standard occlusive dressing and suction. The opened track permits direct access to injured vessels or bronchi for individual ligation. Dabei ist meist die explorative Laparotomie angezeigt, bei der dann im Sinne der Damage Control Surgery die Blutungs- und Kontaminationskontrolle im Vordergrund steht. Injuries to solid organs exert a particularly strong influence on the patient’s prognosis and clinical course. Fetal monitoring should be performed with a cardiotocographic device that measures both contractions and fetal heart tones (FHTs). Named arteries that usually tolerate ligation include the right or left hepatic artery and the celiac artery. Injury Severity Score is probably the best overall predictor of patient outcome in the elderly; however, for any given individual its sensitivity may not be precise, and there is a time delay in obtaining sufficient information to calculate the final score. 7-42). Small intestine injuries can be repaired using a transverse running 3-0 PDS suture if the injury is less than one- third the circumference of the bowel. 7-27) in Morrison’s pouch, the left upper quadrant, and the pelvis. Mission (goal) of curriculum in professional training: • The outcome of the study of surgical diseases is the development of each student's clinical thinking. Soft collars do not effectively immobilize the cervical spine. Burlew, Clay Cothren., and Ernest E. Moore. Fachgebiete: Chirurgie , Notfallmedizin. After injuries are identified, whether to use damage control techniques or perform primary repair of injuries is based on the patient’s intraoperative physiologic status (see sections, Damage Control Surgery and Treatment of Specific Injuries). A. Pyloric exclusion is used to treat combined injuries of the duodenum and the head of the pancreas as well as isolated duodenal injuries when the duodenal repair is less than optimal. The https:// ensures that you are connecting to the In patients with any hemodynamic disturbance, a pericardial drain is placed using ultrasound guidance (Fig. In general, outcome after pelvic vascular injuries is related to (a) the technical success of the vascular reconstruction and (b) associated soft tissue and nerve injuries. Once resuscitation is complete, initiation of TEN, even at trophic levels (20 mL/h), should be considered in all injured patients with an open abdomen.  MG, Perrin The Pringle maneuver, performed with a vascular clamp, occludes the hepatic pedicle containing the portal vein, hepatic artery, and common bile duct. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. Duodenal injuries with tissue loss distal to the papilla of Vater and proximal to the superior mesenteric vessels are best treated by Roux-en-Y duodenojejunostomy with the distal portion of the duodenum oversewn (Fig. For example, a patient with an absent popliteal pulse and femoral shaft fracture due to a bullet that entered the lateral hip and exited below the medial knee could have injured either the femoral or popliteal artery anywhere along its course (Fig. B. Patients in shock have a lower tolerance to warm ischemia, and an occluded extremity is prone to small vessel thrombosis. Tetanus prophylaxis is administered to all patients according to published guidelines. Delayed hemorrhage is rare but may occur with pancreatic necrosis or abdominal infection; this usually can be managed by angioembolization. As with hepatic injuries, splenorrhaphy hemostasis is achieved by topical methods (electrocautery; argon beam coagulation; application of thrombin-soaked gelatin foam sponges, fibrin glue, or BioGlue), envelopment of the injured spleen in absorbable mesh, and pledgeted suture repair.  et al.. The resurgent interest in viscoelastic hemostatic assays (thrombelastography [TEG] and thrombelastometry [ROTEM]) has facilitated the appropriate and timely use of clotting adjuncts, including the prompt recognition of fibrinolysis. An alternative, which preserves both the spleen and distal transected end of the pancreas, is either a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy. Eine Antibiotikagabe >24 h ist nur bei Hohlorganperforation mit Peritonitis bzw. Pancreatic fistula is diagnosed after postoperative day 5 in patients with drain output of >30 mL/d and a drain amylase level three times the serum value. Fractures of tooth-bearing bone are considered open fractures and require antibiotic therapy and semiurgent repair to preserve the airway as well as the functional integrity of the occlusion (bite) and the aesthetics of the face. Pulmonary contusion often progresses during the first 12 hours. When repairing a tear of the descending thoracic aorta, perfusion of the spinal cord while the aorta is clamped is achieved by using partial left heart bypass.   •  Privacy Policy B. ), https://accessmedicine.mhmedical.com/content.aspx?bookid=980§ionid=59610848.  WR  et al.. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. The flaccid aorta is identified as the first structure encountered on top of the spine when approached from the left chest. Moore En el examen físico Inspección Auscultacion Palpación Percusión. CTA of the neck and chest determines trajectory of the injury tract; further studies are performed based on proximity to major structures.35 Such additional imaging includes angiography, soluble contrast esophagram followed by barium esophagram, esophagoscopy, or bronchoscopy. Cátedra Cirugía Dr. González. 7-6).14,15 All medications administered IV may be administered in a similar dosage intraosseously. In the remainder of venous injuries the vein may be ligated.  MA, Abraham 7-65).115 If the duodenal repair breaks down, the resultant fistula is an end fistula, which is easier to manage and more likely to close than a lateral fistula.  JV, Murray Therefore, defects in the second portion of the duodenum should be patched with a vascularized jejunal graft. If the patient is physiologically compromised, distal pancreatectomy with splenectomy is the preferred approach. The role of selective angioembolization (SAE) in splenic salvage remains controversial with some groups advocated pre-emptive SAE.106 It is clear, however, that up to 20% of patients with splenic trauma warrant early splenectomy and that failure of nonoperative management often represents inappropriate patient selection.107,108 Unlike hepatic injuries, which usually rebleed within 48 hours, delayed hemorrhage or rupture of the spleen can occur up to weeks after injury. Examination of the oral cavity includes inspection for open fractures, loose or fractured teeth, and sublingual hematomas. The authors emphasize the parachute technique to ensure precision placement of the posterior suture line (Fig. The physical examination should be literally head to toe, with special attention to the patient’s back, axillae, and perineum, because injuries here are easily overlooked. : Preperitoneal pelvic packing for hemodynamically unstable pelvic fractures : Aa paradigm shift. 7-33).  et al.. Rib fractures in the elderly. For example, patients in class II shock are tachycardic but they do not exhibit a reduction in blood pressure until over 1500 mL of blood loss, or class III shock.  MK Chest film findings associated with descending torn aorta include apical capping (A; arrows) and tracheal shift (B; arrows). Bilomas are loculated collections of bile, which may or may not be infected. Dieses Kapitel befasst sich mit traumatischen Abdominalverletzungen. To delineate a questionable injury, the stomach can be digitally occluded at the pylorus while methylene blue-colored saline is instilled via a nasogastric tube. Für traumatische Thoraxverletzungen siehe: Thoraxtrauma. Penetrating injuries to the carotid artery and internal jugular vein usually are obvious on operative neck exploration.  JM, Chiu  et al. When a transverse incision is made in the cricothyroid membrane, the blade of the knife should be angled inferiorly to avoid injury to the vocal cords. These patients have a complete loss of motor function and sensation two or more levels below the bony injury. Oberflächliche Verletzung des Abdomens, der Lumbosakralgegend und des Beckens. Stürze oder Verkehrsunfälle. 1. Thrombosis of the internal jugular veins caused by blunt trauma can occur unilaterally or bilaterally and is often discovered incidentally, because most patients are asymptomatic. Hassan R, Abd Aziz A. Computed Tomography (CT) Imaging of Injuries from Blunt Abdominal Trauma: A Pictorial Essay. Scores of 13 to 15 indicate mild head injury, 9 to 12 moderate injury, and ≤8 severe injury. If bleeding can be controlled with perihepatic packing, the packing should be left undisturbed and the patient observed in the SICU. Auch das Überrollt-Werden von einem Fahrzeug (Überrolltrauma) führt häufig zum stumpfen Bauchtrauma. Resectional débridement is indicated for the removal of peripheral portions of nonviable hepatic parenchyma.  KG, Velmahos As a rule, minimal evaluation is required before laparotomy for gunshot or shotgun wounds that penetrate the peritoneal cavity, because over 90% of patients have significant internal injuries.  C Additionally, increased intrapericardial pressure impedes myocardial blood flow, which leads to subendocardial ischemia and a further reduction in cardiac output. Pericardiocentesis is successful in decompressing tamponade in approximately 80% of cases; the majority of failures are due to the presence of clotted blood within the pericardium. Stomal complications (necrosis, stenosis, obstruction, and prolapse) occur in 5% of patients and may require either immediate or delayed reoperation. Although optimal initial management includes treatment for the evolving infarction, such as lytic therapy and emergent angioplasty, these decisions must be individualized in accordance with the patient’s other injuries. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE. 7-45). 8600 Rockville Pike A left medial visceral rotation is used to expose the abdominal aorta.  EE, Biffl Although prognosis for these injuries is extremely variable, early evidence of DAI is associated with a poor outcome. Screening and treatment algorithm for blunt cerebrovascular injuries (BCVIs). 7-16). A. Angiography reveals a 1-cm pseudoaneurysm of the innominate artery origin. Toy 7-2). Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. Fetal loss may be related to both maternal shock and direct injury to the uterus or fetal head. After splenectomy or splenorrhaphy, postoperative hemorrhage may be due to loosening of a tie around the splenic vessels, an improperly ligated or unrecognized short gastric artery, or recurrent bleeding from the spleen if splenic repair was used. Es erfordert ein strukturiertes Management mit dem Ziel einer raschen Diagnostik und Therapie zur Senkung der Morbidität und Letalität. B.  M. Pericardiocentesis in traumatic and nontraumatic cardiac tamponade. Compartment syndrome is common, and presumptive four-compartment fasciotomies are warranted in patients with combined arterial and venous injury. Air emboli can occur after blunt or penetrating trauma, where air from an injured bronchus enters an adjacent injured pulmonary vein (bronchovenous fistula) and returns air to the left heart.  I, Cheng  D  et al..  P, Popovsky  TP, Gaarder In the upright position, blood is visible dependently in the right pleural space. This div only appears when the trigger link is hovered over. The patient should immediately be placed in Trendelenburg’s position to trap the air in the apex of the left ventricle. 7-39). ADVERTISEMENT: Supporters see fewer/no ads. Mishelle Chavez. B. Sequential sites of aspiration include the left ventricle, the aortic root, and the right coronary artery. The running, single-layer suture is started at the mesenteric border. Evaluation in the ED focuses on identification of injuries mandating operative intervention (e.g., massive hemothorax, ruptured spleen) and injuries related to pelvic fracture that alter management (e.g., injuries to the iliac artery). Learn and reinforce your understanding of Abdominal trauma: Clinical practice. The uterus may also compress the ureters and bladder, causing hydronephrosis and hydroureter. Kliegel BioGlue hemostasis of penetrating cardiac wounds in proximity to the left anterior descending coronary artery. aScore is calculated by adding the scores of the best motor response, best verbal response, and eye opening. © 2023 Springer Nature Switzerland AG. Patients with ongoing hemodynamic instability, whether “nonresponders” or “transient responders,” require systematic evaluation and prompt intervention.The spectrum of disease in patients with persistent hypotension ranges from overwhelming multisystem injury to easily reversible problems such as a tension pneumothorax. B. They should be counseled regarding warning signs that mandate prompt return to the ED. If the patient develops high-grade fever, the wound should be inspected sooner to exclude an early necrotizing infection. • Initial tube thoracostomy drainage of >1000 mL (penetrating injury) or >1500 mL (blunt injury), • Ongoing tube thoracostomy drainage of >200 mL/h for 3 consecutive hours in noncoagulopathic patients, • Caked hemothorax despite placement of two chest tubes, • Great vessel injury (endovascular techniques may be used in selected patients), • Massive air leak from the chest tube with inadequate ventilation, • Tracheal or main stem bronchial injury diagnosed by endoscopy or imaging.  B, Moore When undergoing laparotomy for trauma, the best policy is to explore all penetrating wounds to the kidneys.122 Parenchymal renal injuries are treated with hemostatic and reconstructive techniques similar to those used for injuries of the liver and spleen: topical methods (electrocautery; argon beam coagulation; application of thrombin-soaked gelatin foam sponge, fibrin glue, or BioGlue) and pledgeted suture repair. Hemorrhage is presumed when a fluid stripe is visible between the right kidney and liver (A), between the left kidney and spleen (B), or in the pelvis (C). thermische Energie möglich, Alle Verletzungen mit aktiver Blutung innerhalb der, Organruptur mit Beteiligung von 25–75% eines, Alle Verletzungen mit aktiver Blutung aus der, Organruptur mit Beteiligung von >75% eines. CAI = carotid artery injury; VAI = vertebral artery injury. Trauma is the most common cause of death for all individuals between the ages of 1 and 44 years, and is the third most common cause of death regardless of age.1 It is also the leading cause of years of productive life lost.  K, Branco The anterior and posterior aspects of the stomach should be inspected, which requires opening the lesser sac for complete visualization. A simplified management guideline. Abdominaltrauma. For thoracic injuries requiring DCS several options exist. At this point anterior displacement of the mandible (subluxation) may be helpful. Point-of-care TEG results, which provide a comprehensive assessment of clot capacity and fibrinolysis, can be available within 10 minutes. Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma. Für die detaillierte Untersuchung bei hämodynamischer Stabilität siehe: Durchführung typischerweise als Ganzkörper-, Bei isoliertem Abdominaltrauma ggf. Pelvic vascular isolation. Algorithm for the management of penetrating neck injuries. In the critically injured patient requiring large amounts of blood component therapy, a massive transfusion protocol should be followed (Fig. If the injury is accessible (e.g., in the posterior intraperitoneal portion of the rectum), repair of the injury should also be attempted. Access to the pericardium is obtained through a subxiphoid approach, with the needle angled 45 degrees up from the chest wall and toward the left shoulder. Guidelines for shock resuscitation. Google Scholar, Aufmolk M, Nast-Kolbe D (2001) Abdominaltrauma. The type of operative repair for a vascular injury is based on the extent and location of injury. Controversy exists regarding which should be done first, fracture fixation or arterial repair.  RJ. Fasciotomy is indicated in patients with a gradient of <35 mm Hg (gradient = diastolic pressure – compartment pressure), ischemic periods of >6 hours, or combined arterial and venous injuries. Interrupted No. Bladder pressure is then measured on the manometer in centimeters of water (Table 7-12) and correlated with the physiologic impact of abdominal compartment syndrome.  AM, Heron Focused abdominal sonography for trauma imaging detects intra-abdominal hemorrhage. Indications for immediate operative intervention for penetrating cervical injury include hemodynamic instability and significant external arterial hemorrhage; the management algorithm for hemodynamically stable patients is based on the presenting symptoms and anatomic location of injury, with the neck being divided into three distinct zones. In patients with gunshot wounds to the chest or abdomen, a chest and abdominal film, with radiopaque markers at the wound sites, should be obtained to determine the trajectory of the bullet or location of a retained fragment. E. On return to the operating room (OR) 48 hours later, fascial sutures are placed from both the superior and inferior directions until tension precludes further closure; skin is closed over the fascial closure with skin staples. For penetrating neck wounds, however, cervical collars are not believed useful because they provide no benefit, but may interfere with assessment and treatment. Adequate urine output is 0.5 mL/kg per hour in an adult, 1 mL/kg per hour in a child, and 2 mL/kg per hour in an infant <1 year of age. A final prophylactic measure that is usually not considered is thermal protection. Curet Truitt PubMed Google Scholar. Prompt revascularization of the internal carotid artery, using a temporary Pruitt-Inahara shunt, should be considered in patients arriving in profound shock.  RE, Lacroix In general, patients who are conscious, without tachypnea, and have a normal voice are unlikely to require early airway intervention. Möglich sind nur Prellmarken und ein Hämatom der Bauchdecke, aber auch das Vollbild eines akuten Abdomens.  FA, Moore  PM, Moore FAST is not 100% sensitive, however, so diagnostic peritoneal aspiration is warranted in hemodynamically unstable patients without a defined source of blood loss to rule out abdominal hemorrhage.27 FAST is used to identify free intraperitoneal fluid (Fig. Wenn nicht anders angegeben, beziehen sich die epidemiologischen Daten auf Deutschland.  WL The ATLS course refers to the primary survey as assessment of the “ABCs” (Airway with cervical spine protection, Breathing, and Circulation).  OH, Graham ein Pneumothorax, ein Pleuraerguss oder auch eine Ruptur des Zwerchfells nachweisen. Occasionally, tractotomy reveals a more proximal vascular injury that must be treated with formal lobectomy. https://doi.org/10.1007/s10039-006-1205-0, DOI: https://doi.org/10.1007/s10039-006-1205-0.  M, Polterauer Pneumothorax is treated similarly in the pediatric population; patients who are asymptomatic with a pneumothorax of <15% are admitted for observation, whereas those who have a pneumothorax of >15% or who require positive pressure ventilation undergo tube decompression.  RA. Twenty-seven cases were admitted over the past 5 years to our Level I trauma center. If a wound infection is identified—as evidenced by erythema, pain along the wound, or purulent drainage—the wound should be widely opened by removing skin staples. Repair of the torn descending thoracic aorta using the centrifugal pump with partial left heart bypass.  GB descending colon is only rarely involved.  et al.. Postinjury life- threatening coagulopathy: is 1:1 fresh frozen plasma: packed red blood cells the answer? PubMed  The effluent is withdrawn via siphoning and sent to the laboratory for RBC count, white blood cell (WBC) count, and determination of amylase, bilirubin, and alkaline phosphatase levels. Success rates of nonoperative management approach 95%, with an associated 10% to 23% transfusion rate. Callaway Numerous large retrospective and several prospective studies have now clearly demonstrated that primary repair is safe and effective in virtually all patients with penetrating wounds.116 Colostomy is still appropriate in a few patients, but the current dilemma is how to select which patients should undergo the procedure. During the circulation section of the primary survey, four life-threatening injuries must be identified promptly: (a) massive hemothorax, (b) cardiac tamponade, (c) massive hemoperitoneum, and (d) mechanically unstable pelvic fractures with bleeding.  et al.. Blunt injury of the abdominal aorta: a review. Topical hemostatic techniques include the use of an electrocautery (with the device set at 100 watts), argon beam coagulator, microcrystalline collagen, thrombin-soaked gelatin foam sponge, fibrin glue, and BioGlue. Gunshot wounds to the back or flank are more difficult to evaluate because of the retroperitoneal location of the injured abdominal organs. Common combined injuries include clavicle/first rib fractures and subclavian artery injuries, dislocated shoulder/proximal humeral fractures and axillary artery injuries, supracondylar fractures/elbow dislocations and brachial artery injuries, femur fracture and superficial femoral artery injuries, and knee dislocation and popliteal vessel injuries. Surgery, ranging from partial resection to anatomic lobectomy, is indicated for unresolving complex pneumatoceles or infected lesions refractory to antibiotic therapy and drainage. The types of antithrombotic treatment appear equivalent in published studies to date, and the duration of treatment is empirically recommended to be 6 months.79,80 The role of carotid stenting for grade III internal carotid artery injuries remain controversial. Serial lactate determinations for prediction of outcome after cardiac arrest. A running suture is used to approximate the edges of shallow lacerations, whereas deeper lacerations are approximated using interrupted horizontal mattress sutures placed parallel to the edge of the laceration.
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