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Determination of brain death and management of the brain-dead organ donor

Introduction The diagnosis of death using neurologic criteria is recognized as the complete and irreversible loss of capacity for consciousness and all brain function as a consequence of catastrophic brain injury. Historically and in many countries, this diagnosis is called “brain death.” Some countries and academic papers have moved away from this term, which can be a source of confusion, especially in the media. Although supportive…

Pelvic fractures and long bone fractures

Introduction Pelvic and long bone fractures are found frequently in trauma patients, especially in blunt polytrauma patients with significant injury burden. Initial intensive care management of severe pelvic fractures or long bone injury is similar: damage control resuscitation, hemorrhage control, antibiotic prophylaxis for open fractures, identification and treatment of concomitant injuries, early nutrition, and supportive care for known complications like pulmonary embolism and fat embolism syndrome.…

Abdominal trauma

Introduction Trauma is the leading cause of death in patients between 1 and 44 years of age. The trauma patient requires rapid and systematic evaluation by a multidisciplinary team using principles defined by Advanced Trauma Life Support (ATLS). These principles allow the effective transition of care from the prehospital to hospital environment. External signs of abdominal injury can be absent; effective diagnosis relies heavily on recognizing…

Thoracic trauma

Thoracic trauma is responsible for approximately 20% of all trauma-related deaths and is second only to central nervous system injury as the primary cause of death at the scene. For patients arriving at the emergency department (ED) alive, rapid diagnosis and treatment of potentially life-threatening injuries are required to prevent death during the “golden hour” of initial resuscitation. However, many thoracic injuries that are not immediately…

Burns, including inhalation injury

Introduction Patients with severe burns today are more likely to survive compared with those injured decades ago. Advances in early source control of deep burns, antimicrobial strategies, and critical care medicine are largely responsible, buoyed by translational research in burn-induced inflammation, hypermetabolism, and the wound environment. As survival rates improve, burn clinicians are challenged to address the sequelae of critical illness after recovery. Designated burn centers…

Pressure ulcers

Epidemiology A pressure ulcer is any wound that develops in the upper, outer layers of the skin as a result of sustained, external pressure. Pressure ulcers are serious complications among hospitalized patients. They increase healthcare costs, decrease patient quality of life, and often result in prolonged hospital stays. Hospital-acquired pressure ulcers are generally considered to be preventable, and if allowed to progress to full-thickness skin loss…

Atheroembolization

Atherosclerosis and its thromboembolic complications are leading causes of mortality and morbidity. This progressive disorder usually remains clinically silent until it causes end-organ damage resulting in stroke, ischemic heart disease, and/or peripheral vascular insufficiency. Atherosclerosis characteristically affects the aorta, with the abdominal aorta more widely involved than the thoracic aorta. Lower limb vessels are more frequently affected than upper limb vessels, whereas renal, pulmonary, and mesenteric…

Thromboembolization and thrombolytic therapy

Introduction Thrombolytic agents comprise a diverse group of compounds that indirectly initiate the lysis of a thrombus. After the initiation of the coagulation cascade, fibrinolytic mechanisms are concomitantly activated to prevent unconstrained thrombosis. Fibrinolysis begins with the cleavage of proenzyme plasminogen to plasmin, which hydrolyzes key bonds within a fibrin clot matrix, resulting in clot lysis ( Fig. 152.1 ). Thrombolytic agents function by converting plasminogen…

Extremity compartment syndromes

Epidemiology Extremity compartment syndrome occurs whenever the tissue pressure within a limited space of the body reaches the point where the circulation, nerve function, and muscle function of that space are compromised. For compartment syndrome to occur, the body compartment should be enveloped by fascia that prevents inner tissue expansion, and there should be at least one cause of increased tissue pressure present, either externally or…

Abdominal compartment syndrome

Historical perspective Pediatric surgeons closing omphaloceles have long recognized the lethal combination of pulmonary compromise and impaired renal function caused by increased intraabdominal pressure (IAP). Silo closure with gradual reduction of abdominal defect was recommended to prevent fulminant organ failure. Concurrent improved survival of patients with ruptured abdominal aortic aneurysms (AAAs) increased awareness of the adverse consequences of high IAP. Vascular surgeons popularized the use of…

Mesenteric ischemia

Introduction Mesenteric ischemia is a generic term that implies inadequate blood flow to the intestines. It is relevant from a clinical standpoint as two separate disease processes: acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Although the underlying process is similar (i.e., inadequate intestinal blood flow) between the two conditions, the clinical presentation, diagnostic concerns, and treatment algorithms are different. CMI is usually related to…

Aortic dissection

Introduction Aortic dissection, first described in the 18th century, continues to be one of the most lethal cardiovascular emergencies in the current era despite the evolution in diagnostic modalities, medical management, and surgical techniques and technologies. Herein, we discuss the current practice for diagnosing and managing aortic dissections for optimal outcomes. Pathophysiology and definition The aortic wall consists of three layers, the intima, media, and adventitia,…

Intestinal and multivisceral transplantation: The ultimate treatment for intestinal failure

Introduction Intestinal and multivisceral transplantation remains a dynamic process, moved forward by advances in the multidisciplinary care of intestinal failure, surgical techniques, innovative immunosuppressive strategies, and an improved understanding of intestinal transplantation immunology. More recently, great strides have been made in the medical and surgical management of patients with intestinal failure, which has resulted in a decrease in the number of patients added to the intestinal…

Perioperative management of the liver transplant patient

Introduction The introduction of liver transplantation over 50 years ago has revolutionized outcomes for patients with both acute and chronic liver failure. Since experimental beginnings, liver transplantation has grown worldwide, with the number of transplants per year ranging from approximately 400 in Australia to over 1000 in the UK and over 8000 in the United States. Concurrently, survival from transplantation continues to improve, with 5-year survival…

Intensive care unit management of lung transplant patients

Overview of lung transplant Lung transplantation offers hope for improved survival and quality of life for selected patients with end-stage lung disease. The availability of suitable donor organs and preservation injury remain the initial limiting factors to successful transplantation. Novel techniques aiming to extend the donor pool have resulted in the ability to offer transplantations to more patients, both by allowing for better evaluation of questionable…

Management of the postoperative cardiac surgical patient

Intensive care may account for more than one-third of the total hospital costs for cardiac surgery patients, and much of the short-term morbidity and mortality are based on perioperative events. The overall mortality after cardiac surgery is low. However, this ranges from less than 1% for elective coronary artery bypass grafting to more than 30% for more complex surgery in patients with significant myocardial dysfunction and…

Epistaxis

Epistaxis is an acute hemorrhage from within the nasal cavity, including the nasopharynx, and accounts for 0.5% of all U.S. emergency department visits. Approximately 60% of individuals experience epistaxis at least once in their lifetime, although only 6% of cases require medical treatment. , The peak incidence of epistaxis in adults is in the 45- to 65-year-old age group, and the incidence of severe posterior bleeding…

Mediastinitis

The mediastinum is the thoracic space confined by the sternum anteriorly, the spine posteriorly, the pleural laterally, the diaphragm inferiorly, and the thoracic outlet superiorly. It can be divided anatomically into superior and inferior compartments by the sternal angle. The inferior compartment is further divided into the anterior (between the posterior sternum and the anterior pericardium), middle (the intrapericardial contents), and posterior (bounded anteriorly by the…

Resuscitation of hypovolemic shock

Alfred Blalock demonstrated that injury precipitates local and regional fluid loss, the effects of which can be ameliorated by vigorous restoration of intravascular volume. This concept is foundational to understanding the pathophysiology of shock and provides the rationale underlying intravenous (IV) therapy for hemorrhage and hypovolemia. Severe hypovolemia consists of loss of intravascular or total body fluid volume necessary to cause insufficient tissue perfusion at the…

Poisoning: Overview of approaches for evaluation and treatment

Patients presenting to the hospital with overdoses and poisonings should undergo an initial evaluation to determine whether a specific poisoning can be detected that would lead to specific management options. History and physical examination are key to determine what poisoning, such as a toxidrome—a syndrome related to a toxic exposure (cholinergic, anticholinergic, sympathomimetic, opioid, sedative-hypnotic, or withdrawal syndromes)—could be causing a patient’s presentation. Once a poisoning…