Complications of Trauma Surgery

Definition

Trauma-related injury (TRI) is the leading cause of death in the United States for persons between 1 and 45 years old and is the fifth-leading cause of death overall. Because TRI affects primarily the young, it is the leading cause of years of life lost before age 75 years. The World Health Organization (WHO) estimates that TRI is the leading cause of mortality globally for both men and women between 15 and 45 years of age. Also, WHO estimates that by 2020, TRI will be the third-leading cause of death in all age groups.

TRI victims present unique challenges to the health care delivery system. They often have multiple injuries to multiple organ systems that necessitate resource-intensive care. Further, TRI can adversely interact with many chronic underlying medical conditions. The top four TRI causes are motor vehicle accidents (cars, trucks, motorcycles), falls, assaults, and pedestrians hit by vehicles.

Many trauma injuries are preventable. Alcohol or drug use was documented in 40% of car and truck crash injuries involving adults and in 38% of motorcycle crash injuries. Trauma is classified as either intentional (e.g., homicide) or accidental, as well as according to the mechanism of injury (e.g., penetrating versus blunt). Owing to improvements in trauma care, there has been a decline in trauma-related deaths in recent years.

Recognition

Evaluation of acute trauma victims has three key components: rapid overview, primary survey, and secondary survey. Resuscitation can be initiated at any time during this triage. Rapid overview takes only a few seconds and is used to determine whether the patient is stable, unstable, or dead. The primary survey involves the rapid evaluation of functions that are critical to survival. The ABCs of airway patency, breathing, and circulation are assessed, followed by a brief neurologic examination. Priority is then given to cervical spine injury or impending cerebral herniation. The rapid overview and the primary survey are also referred to as the “golden hour” because rapid intervention to identify and treat life-threatening injuries in the first 60 minutes can affect survival and outcomes of trauma patients. The secondary survey entails a systematic, comprehensive evaluation of each anatomic region and usually detects injuries that were overlooked initially. Three quarters of such previously undetected injuries are orthopedic. Based on the results of the secondary survey, patients are rushed immediately to the operating room for surgery, transferred to the radiology suite for further diagnostic studies, or reexamined and observed in an intensive care unit.

Knowledge of the patterns of injury associated with different mechanisms of trauma (i.e., clusters of injury) can help anticipate and identify injuries early. The presence of the worst possible injuries should be assumed until the diagnoses are either confirmed or excluded. Many trauma-related complications are diagnosed intraoperatively ( Box 53.1 ).