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Neurosurgical Emergencies

Care of the neurotrauma patient involves evaluation of injuries to the cranium, spine, peripheral nerves, or often a combination thereof. Rapid evaluation and decisive intervention are essential to significantly reduce the risk of morbidity and mortality. After stabilizing the airway, breathing, and circulation in a patient with suspected neurotrauma, attention then must turn to the rapid assessment of level of consciousness and systematic evaluation for neurologic…

Burn Care

Each year, approximately 1 million people in the United States sustain burn injuries. Sadly, more than 90% of these injuries are preventable, many of which are related to smoking and substance abuse. Fortunately due to advances in burn care, as well as the establishment of large burn centers, the number of burn deaths has been steadily decreasing every year. Treatment with a multidisciplinary, multispecialty team approach…

Extremity Trauma

Investigation for extremity injuries is a critical portion of the trauma evaluation. During these examinations, the surgeon must look for fractures, dislocations, soft tissue damage, vascular injuries, and neurologic deficits. Upon completion of the tertiary survey, the patient should have undergone a complete and systematic evaluation of every body part. This chapter outlines the keys to diagnosing and managing common extremity injuries seen in the trauma…

Thoracic Trauma

No new method and no new discovery can overcome the natural difficulties that attend a wound of the heart. James Paget, 1896 I Epidemiology of Thoracic Trauma A Thoracic Trauma Thoracic trauma ranks third in incidence behind head and extremity trauma, with motor vehicle crashes being the most common mechanism in the United States. These injuries are directly responsible for 15%–25% of trauma deaths and contribute…

Abdominal Trauma

I Pathophysiology 1. Significant blunt force, deceleration, and penetrating wounds should be considered to have intraperitoneal injuries until ruled out by further diagnostic evaluation. 2. The abdominal cavity can hold a significant amount of blood without obvious signs, so a high level of suspicion is warranted based on type of trauma. 3. Trauma mortality has a trimodal distribution. a. First peak: This occurs seconds to minutes…

Primary and Secondary Survey

Push it. Examine all things intensely and relentlessly. Annie Dillard I Epidemiology A Mortality Trauma is the third leading cause of death in the United States for all ages and the leading cause of deaths in persons younger than 45 years. 1. A total of 50% of deaths occur within minutes after injury. 2. A total of 30% of deaths occur within 24 hours of injury.…

Mechanical Ventilation

Development in most fields of medicine appears to occur according to sound scientific principles. However, exceptions can be found, and the development of mechanical ventilatory support is one of them. J. Rasanen The goal of mechanical ventilation is to facilitate gas exchange for tissue oxygen delivery, provide ventilation for removal of carbon dioxide, unload the work of the respiratory muscles, and minimize the detrimental effects of…

Cardiopulmonary Monitoring

In the event of a cardiac arrest, the first procedure is to take your own pulse. Samuel Shem The goal of cardiopulmonary monitoring is to assess the adequacy of the cardiac and pulmonary systems in meeting the metabolic needs of the patient. Although these goals may appear simple, this monitoring can become amazingly complicated in practice. The most important idea to grasp is that no single…

Shock

The person, although severely injured, congratulates himself upon having made an excellent escape, and flatters himself that he is not only in no danger, but that he will soon be well; in fact, to look at him one would hardly suppose, at first sight, that there was anything serious the matter with him; the countenance appears well, the breathing is good, the pulse is but little…

Hemorrhage and Coagulation

For the life of the flesh is in the blood. Leviticus 17:11 I General Topics A Normal Blood Volume and Composition 1. Total blood volume (TBV) = 70 mL/kg total body weight (80 mL/kg for newborns) 2. Total volume red blood cells (RBCs) = TBV × hematocrit a. Approximately 26 mL/kg for male patients, 24 mL/kg for female patients b. Can be measured using chromium-tagged erythrocytes,…

Surgical Infection

Within one linear centimeter of your lower colon, there lives and works more bacteria than all humans who have ever been born. Yet many people continue to assert that it is we who are in charge of the world. Neil deGrasse Tyson Surgical infection has been around as long as surgical procedures have been performed. Advances in our understanding of infections began to expand exponentially in…

General Anesthesia

Although an anesthesiologist plays a critical role in the perioperative management of patients, it is important that the surgeon be familiar with the general principles of anesthesia and their potential impact on the surgical patient. Surgical care of the patient begins in the preoperative period and extends through the postoperative recovery; therefore understanding by the surgeon of anesthetic techniques and recognition and management of complications is…

Conscious Sedation

Some of you say that religion makes people happy. So does laughing gas. Clarence Darrow The ability to understand and administer conscious sedation to perform invasive procedures is a necessity for the practicing surgeon. It is no longer solely the role of the anesthesiologist to provide sedation and analgesia for patients undergoing less complex but still painful or stimulating procedures. A surgeon must be familiar with…

Local Anesthesia

The safest sedation is no sedation. Anonymous Local anesthesia is not only a common adjunct to higher levels of sedation but may also be an effective stand-alone method of anesthesia in many situations. When used appropriately, local anesthesia can simplify the treatment of many surgical ailments without the dangers and costs of general anesthesia. The surgeon should have an understanding of the risks, benefits, and appropriate…

Suture Types, Needle Types, and Instruments

Give us the tools, and we will finish the job. Winston Churchill Despite sufficient knowledge of anatomy, pathophysiology, and disease processes, a surgeon will be lost in the operating room without a comprehensive knowledge of the surgical tools at his or her disposal. Learning the nomenclature and specific utility of all the various tools in the operating room can be a daunting task for a surgeon…

Surgical Risk Assessment

Risk comes from not knowing what you’re doing. Warren Buffett I Risks and Benefits of Surgery 1. Whether it is a life-saving liver transplant or a cosmetic procedure, surgical intervention offers some benefit to the patient, at the risk of complications, morbidity, or even death. The surgeon must carefully weigh the relative risks and benefits of surgery before proceeding with any operation. Perioperative care requires the…

Wound Healing

Wound healing is a complex process, and every surgeon should have an understanding of the basic principles and ways to maximize healing. I Phases of Wound Healing A Hemostasis (5–10 Minutes Post Injury) 1. Begins with endothelial injury and subsequent vasoconstriction 2. Platelet activation resulting in cytokines and growth factors released a. Platelet-derived growth factor (PDGF): chemotaxis b. Fibroblast growth factor (FGF): epithelialization c. Epidermal growth…

Nutrition

Let thy food be thy medicine and let thy medicine be thy food. Hippocrates I Nutrition Basics 1. There are three sources of nutrition (normally, carbohydrates and fat provide 85% of daily energy expenditure, with protein supplying 15%). 2. Glucose yields 4 kcal/g, parenteral dextrose 3.4 kcal/g, protein 4 kcal/g, and fat 9 kcal/g (10 kcal/g for 20% intravenous [IV] fat emulsion). 3. Brain, red blood…

Fluids and Electrolytes

The living organism does not really exist in the milieu exterior, but in the liquid milieu interior formed by circulating organic liquid. Claude Bernard I Basic Physiology A Body Fluid Composition 1. Total body water (TBW) a. Composed of intracellular and extracellular fluid (ECF) compartments b. A total of 50%–70% of total body weight c. Male (60%) greater than female (50%) percentage d. Adjusted for body…

Surgical History and Physical Examination

I Introduction and Initial Contact 1. The history and physical examination are an integral aspect of patient care. Many diagnoses can be confirmed or refuted with a carefully obtained history. The physical examination can also direct further need for other diagnostic modalities such as imaging and serologic tests. During this initial encounter, the surgeon also establishes a patient-doctor relationship, which is essential to patient care. In…