Penetrating Trauma A Practical Guide on Operative

Technique and Peri Operative Management

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To my parents, who lit my past, and to my wife and children, who light my present and future.

George C. Velmahos

To my patients, who taught me a lot, and to my teachers, who taught me everything.

Elias Degiannis

To my parents and family, my wife and my children, and to my teachers. Time is love.

Dietrich Doll
Foreword I

This ambitious textbook on “Penetrating Trauma: A practical Guide on Operative

Technique and Peri-operative Management” is a significant addition to the body of
published work on trauma. The editors are amongst the most experienced academic
trauma surgeons in the world with unique experience in all types of penetrating inju-
ries. This project represents many decades of collective experience in some of the
busiest trauma centers in the world. The book is divided in 7 practical sections and 77
chapters, which cover all aspects of penetrating trauma, including prehospital care,
penetrating injuries to the various body areas, specific organ injuries, orthopedic inju-
ries, injuries to special group of patients, military injuries and many others.
The structure of the book makes it easy to read and provides clear and practical
guidance on the evaluation, indications for operation, surgical techniques and peri-
operative problems. It is supported by numerous top quality photographs, illustra-
tions and x-rays.
This book will be a great companion to residents and surgeons, in both civilian
trauma centers and the military.
It will provide comfort and confidence to the surgeon who faces a catastrophic
injury where a split second decision can make the difference between life and death,
and good functional outcome and permanent disability.

Demetrios Demetriades, M.D., Ph.D., F.A.C.S.

Division of Trauma Surgery and Surgical Critical Care
Los Angeles County General Hospital
University of Southern California
Los Angeles, CA, USA

vii
Foreword II

This book is directed toward the surgery and care of trauma, and is very timely. Over
the past two decades, penetrating trauma wounds have decreased in most cities and
experience in management of these injuries has declined as well. Thus, this book is a
welcome addition to the trauma surgeon’s library.
One of the major strengths of the book is how the authors articulate “how to do it.”
This makes it easy for the reader to find out what to do quickly. Despite this being an
area of little Level I evidence, the authors offer reasonable approaches of how to man-
age difficult problems, based on personal experience and unequivocal expertise.
Another strength of the book is the geographical diversity of the authors represent-
ing many countries. This adds interest to the contents and challenges entrenched
dogma. In the next edition I would welcome invited commentaries describing the
multiple different alternatives.

Donald Dean Trunkey, M.D., F.A.C.S.

Professor Emeritus
Oregon Health & Science University
Oregon, USA

ix
Preface

In the age of easy communication we are privileged to be bombarded by limitless bits

of medical information. Textbooks, journals, tapes, and webpages rest at our finger-
tips. We can literally access everything and anything in our areas of interest. And
exactly therein lurks the problem!
Penetrating trauma offers excitement, variety, and glory. It does not offer time.
Decisions must be fast, solutions drastic. The patients bleed and ache and twist and
turn and scream and do not cooperate. All happens when it is least expected – in the
middle of the night, on a weekend, over a holiday. The surgeon is often alone with
little help and even less resources. Questions need to be answered, actions to be
taken. Not everybody is a trained trauma surgeon. How to repair a Grade IV duodenal
injury? What is the best maneuver to stop the bleeding from the deep pelvis? How to
control a bullet trajectory in the liver? Should this missile, lodged in the spine, be
removed? Venous or synthetic graft for the arterial injury? Primary repair or a stoma
after colectomy?
Suddenly, the endless sea of information becomes a liability. Confronted with an
urgent scenario, the clinician does not have the time to study every possible alternative, to
weigh in advantages and disadvantages of the available options. Punching on the key-
board the words “severe duodenal injury” produced 1,210,000 results. We argue that one
does not have time to critically evaluate over a million of possibilities, when the duodenal
hole is leaking. One needs to know a reasonable, safe, proven, and efficient way of man-
aging the injury. This is what, we hope, this book offers. We assembled a group of experts
who speak from personal experience. They describe how “I do this.” Their approach is not
the only one but is a good one! It paves a secure pathway to the end of the tunnel. It is an
approach to remember, practice, and – with growing experience – even improve. It is a
solid foundation on which one can comfortably rest and fearlessly build.
A picture is worth a thousand words! With multiple illustrations the steps of each
operation are described in detail and with authority. We cannot appreciate enough the
numerous authors who, yet again, responded to one more call for one more book
chapter. They spent precious time to pass on their knowledge to the reader. We expect
this book to be a useful first-aid manual for our colleagues who give the fight against
the toll of penetrating trauma. Even if one life is saved because some surgeon, some-
where in the world scrolled through these pages and practiced a technique he read in
this book, we have done our duty and fulfilled our promise of being responsible phy-
sicians and teachers.

Boston, MA, USA George C. Velmahos

Johannesburg, South Africa Elias Degiannis
Marburg, Germany Dietrich Doll

xi
Contents

Part I Prehospital Care, Diagnostic Tools and Resuscitation Strategies

1 Prehospital Care in Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . 3

David Carlbom and Eileen M. Bulger
2 Airway Management in Penetrating Trauma . . . . . . . . . . . . . . . . . . . . 11
David A. Baker and Eileen M. Bulger
3 Hypotensive Resuscitation in Penetrating Trauma:
Rules of the Game . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Suresh Agarwal, Lejla Hadzikadic, and Peter Burke
4 BCLS Versus ACLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Alasdair K.T. Conn
5 Prehospital Care and Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Michael A. Frakes, Heather A. Waden, and Suzanne K. Wedel
6 Prehospital Monitoring During Transport . . . . . . . . . . . . . . . . . . . . . . . 41
Heidi Frankel and Clinton J. Pace
7 Trauma Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Heena P. Santry and Marc de Moya
8 ABC Heuristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Pantelis Vassiliu
9 Pediatric Trauma Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Elizabeth S. Soukup and Peter T. Masiakos
10 Fluids, Blood Substitutes, and New Tools . . . . . . . . . . . . . . . . . . . . . . . . 67
David C. Griffin and Raminder Nirula
11 Emergency Department Thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Carlos V.R. Brown and D.J. Green
12 Intensive Care: Principles and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 85
Terence O’Keeffe
13 Plain X-Rays for Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Marko Bukur and Donald J. Green
14 Computed Tomography in the Workup of Patients
with Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Mark E. Hamill

xiii
xiv Contents

15 Portable Ultrasound as an Adjunct in Penetrating Trauma . . . . . . . . . 111

Jim Connolly
16 Laparoscopy and Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Megan Wolthuis Grunander and Daniel R. Margulies
17 Angiography and Interventional Radiology . . . . . . . . . . . . . . . . . . . . . . 125
Marc Kalinowski
18 Imaging of Penetrating Urologic Trauma . . . . . . . . . . . . . . . . . . . . . . . . 131
Beat Schnüriger and Donald J. Green
19 Video-Assisted Thoracic Surgery in Penetrating Chest Trauma . . . . . 135
François Pons, Federico Gonzalez, and Jean Philippe Arigon
20 Diagnostic Peritoneal Lavage (DPL) Unplugged . . . . . . . . . . . . . . . . . . 143
Terence O’Keeffe
21 Mass Casualties and Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
James M. Ryan and Dietrich Doll

Part II Surgical Strategies in Penetrating Trauma to Head, Face, and Neck

22 Surgical Strategies in Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Hasan B. Alam
23 Surgical Strategies in Trauma to the Head, Face and Neck . . . . . . . . . 169
Heather L. Evans and Eileen Bulger
24 Gunshot Injuries to the Head. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Ekkehard M. Kasper, Markus M. Luedi, and Burkhard S. Kasper
25 Penetrating Injuries of the Face. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Rizan Nashef and Thomas B. Dodson
26 Operative Strategies in Penetrating Trauma to the Neck . . . . . . . . . . . 203
Marc de Moya
27 Access to the Neck in Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . 209
Jeffrey Ustin
28 Penetrating Trauma to the Larynx and the Cervical Trachea . . . . . . . 215
Alicia Kieninger and Elliott R. Haut
29 Penetrating Injury to the Pharynx and Cervical Esophagus . . . . . . . . 221
Angela L. Neville and Timothy L. VanNatta
30 Carotid, Jugular and Vertebral Blood Vessel Injuries . . . . . . . . . . . . . 229
Dirk Le Roux and Martin Veller

Part III Surgical Strategies in Penetrating Trauma to the Chest

31 Penetrating Trauma to the Subclavian Vessels. . . . . . . . . . . . . . . . . . . . 239

Daniel Francois Du Toit
32 Penetrating Trauma to the Thoracic Oesophagus . . . . . . . . . . . . . . . . . 253
Elias Degiannis, Tugba H. Yilmaz, and Lisa A. Burnell
Contents xv

33 Pulmonary and Bronchotracheal Trauma . . . . . . . . . . . . . . . . . . . . . . . 259

Elias Zigiriadis, Peter Loogna, and Tugba H. Yilmaz
34 Mediastinal Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Philip R. Calderbank, Nigel R.M. Tai, and Douglas M. Bowley
35 Penetrating Cardiac Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Elias Degiannis, Tugba H. Yilmaz, and Dietrich Doll
36 Penetrating Injuries to the Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Elmin Steyn
37 Thoracoabdominal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Elias Degiannis, Tugba H. Yilmaz, and Dietrich Doll
38 Loss of the Chest Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
John C. Mayberry

Part IV Surgical Strategies in Penetrating Trauma

to the Abdomen and Pelvis

39 Access to the Abdomen: Emergency Laparotomy . . . . . . . . . . . . . . . . . 301

George C. Velmahos
40 Damage Control Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Frank Plani and Riaan Pretorius
41 Abdominal Esophagus and Stomach. . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Clay Cothren Burlew and Ernest E. Moore
42 Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
George C. Velmahos
43 Penetrating Trauma to the Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Martin D. Smith and Elias Degiannis
44 Liver and Extrahepatic Bile Ducts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Frederick Millham
45 Large and Small Bowel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Herb A. Phelan
46 Injury of the Kidney, Ureter, and Bladder . . . . . . . . . . . . . . . . . . . . . . . 353
Dorothy W. Bird and Suresh Agarwal
47 Lower Genitourinary Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Donald Hannoun and Charles D. Best
48 Major Abdominal Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Peep Talving and Kenji Inaba
49 Major Abdominal Arteries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Lydia Lam and Kenji Inaba
50 Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Heena P. Santry
51 Penetrating Rectal Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Andrew John Nicol and Pradeep Navsaria
xvi Contents

52 Abdominal Compartment Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 401

Zsolt J. Balogh, Osamu Yoshino, and Michael Sugrue
53 SNOM: Conservative Management of Solid Viscera . . . . . . . . . . . . . . . 407
Pradeep H. Navsaria
54 Bleeding in the Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Edward Kelly

Part V Surgical Strategies in Penetrating Trauma

and Orthopedic Injuries

55 Introduction to Orthopedic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419

Thomas Scalea
56 Extremity Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Jeffrey Ustin
57 Compartment Syndrome of the Extremities . . . . . . . . . . . . . . . . . . . . . 427
Mark W. Bowyer
58 Anterior Exposure of the Thoracic and Lumbar Spine . . . . . . . . . . . . 437
Hani Seoudi
59 Penetrating Trauma: Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Cyrus E. Taghavi, Nelson F. Soohoo, and Areti Tillou

Part VI Peripheral Arterial Injuries

60 Peripheral Arterial Injuries from Penetrating Trauma . . . . . . . . . . . . 457

Matthew J. Martin and Ali Salim
61 Axillary and Brachial Vessels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Ali Salim and Matthew J. Martin
62 Femoral Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
David R. King
63 Popliteal Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Matthew J. Martin and Ali Salim

Part VII Other Topics

64 Burns and Inhalational Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483

Jennifer Lang and Herb A. Phelan
65 Crush Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Herb A. Phelan
66 Blast Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Joe DuBose, David S. Plurad, and Peter M. Rhee
67 The Elderly Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
Thomas Lustenberger and Kenji Inaba
68 The Pediatric Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Graeme Pitcher
Contents xvii

69 The Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Dimitrios Theodorou and Andreas Larentzakis
70 Anticoagulation in Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 537
David R. King
71 Care Under Austere Conditions: Unlimited Restraints. . . . . . . . . . . . . 541
Terence O’Keeffe
72 The Impact of Trauma on the Psyche . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
F.Y. Jeenah and M.Y.H. Moosa
73 Early Neurotrauma Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Ronald E. Hirschberg
74 Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
Amy H. Phelan
75 Penetrating Injury Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
David S. Plurad
76 The Economics of Trauma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
Frederick Millham
77 Organ Donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
Eric J. Ley and Ali Salim
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587