Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Thromboelastography: Techniques and uses

Hemorrhage continues to be the leading cause of death for traumatically injured patients despite all the advances that have been made in the past 20 years. Time to hemorrhage control is one of the most, if not the most, critical factor in saving the life of a traumatically injured patient. Delays in identifying and treating the fatal triad of hypothermia, acidosis, and trauma-induced coagulopathy (TIC) portend…

Transfusion: Management of blood and blood products in trauma

Approximately 15% of all blood transfusions in the United States are used in the care of patients who have sustained traumatic injury. Blood transfusion in trauma is lifesaving for those patients in hemorrhagic shock, as the median time to hemorrhagic death in trauma is 2.0 to 2.6 hours, and approximately 85% of hemorrhagic deaths occur within 6 hours after hospital admission. Importantly, concomitant attempts at prompt…

Management of endocrine disorders in the surgical intensive care unit

The neuroendocrine axis The endocrine system is a complex system allowing communication between the nervous system and the end organs. It consists of the neuroendocrine axis (hypothalamus, pituitary, and glands), all of which influence the response to stress and critical illness. Critically ill patients have a physiologic response to their illness that results in alterations in the endocrine system. Alternatively, they may have underlying endocrine disorders…

Management of coagulation disorders in the surgical intensive care unit

Surgeons commonly encounter coagulation disorders in the course of caring for patients, especially those with serious injury and those undergoing or recovering from surgery. Whereas bleeding is a condition that has been well known throughout human history, understanding the pathophysiology of bleeding and coagulation and developing effective therapies for them have come relatively recently and continue to undergo change as more is learned about the complex…

Acute kidney injury and renal replacement therapy in the surgical intensive care unit

Acute kidney injury (AKI) refers to an acute decrease in the glomerular filtration rate (GFR). AKI develops in approximately 20% of patients admitted to the hospital and in 50% of patients admitted to the ICU. Short- and long-term mortality is impacted by multiple clinical factors including age, baseline renal function, malignancy, severe sepsis and septic shock, recurrent episodes of AKI, and the degree of renal recovery.…

Advanced techniques in mechanical ventilation

Key points ■ Mechanical ventilation (MV) must support gas exchange and promote patient comfort while minimizing lung injury due to elevated airway pressures. ■ Protective, low tidal volume ventilation reduces morbidity and mortality rates in patients following acute respiratory distress syndrome (ARDS). ■ Pressure-controlled ventilation (PCV) determines inhaled tidal volumes via a preset inspiratory pressure and intrinsic respiratory mechanics. ■ Airway pressure release ventilation (APRV) allows…

Fundamentals of mechanical ventilation

Key points ■ New technology as illustrated in the next chapter provides several modes by which a patient may be ventilated based on the fundamentals of mechanical ventilation (MV), with the goal of improved gas exchange, better patient comfort, and rapid liberation from the ventilator. ■ Noninvasive ventilation (NIV) may avoid intubation or reintubation for awake, cooperative patients with marginal oxygenation or ventilation. With COVID-19 therapy,…

Diagnosis and management of cardiac dysrhythmias

In the intensive care unit, it is not uncommon for today’s surgeon to take care of patients with multiple comorbidities unrelated to their surgical disease. A common knowledge of most major medical issues, and their potential consequences, is thus critical for any surgeon caring for inpatients after complex surgery. Given that the patients undergoing major surgery will often be placed in settings allowing for continuous monitoring…

Pharmacologic support of cardiac failure

According to statistics provided by the American Heart Association in 2019, congestive heart failure (CHF) affects approximately 6.5 million American adults. The Centers for Disease Control estimates that CHF contributes to 1 in 8 deaths. Although survival from heart failure has improved, the risk of death remains high with a 5-year survival rate of approximately 58% after diagnosis. The total health care cost for treating CHF…

Oxygen transport

The primary role of the cardiorespiratory system is to match the metabolic needs of the cells comprising the tissues of the body by delivering adequate amounts of oxygen (O 2 ) to meet metabolic requirements and to remove excess carbon dioxide (CO 2 ). Adequate tissue oxygenation is determined by the balance between oxygen delivery to the tissues and the oxygen required to sustain aerobic metabolism,…

Cardiac hemodynamics: Pulmonary artery catheter and the meaning of its readings

The pulmonary artery catheter (PAC) is a physical object creating a conundrum. Since its introduction in the 1970s, the PAC has been simultaneously hailed for its ability to provide physiologic data not easily obtainable by other means and condemned as a useless and potentially harmful invasive monitor. Very little hard data support continued use of the PAC, and some data support avoiding its use altogether. Despite…

Genomics of profound shock and trauma

Unlike many disease processes, trauma affects patients of every age group and from all demographics. It is a leading cause of death worldwide, particularly in those less than 45 years of age, and can result in devastating disability among survivors. The complexity of this patient population is due to both the initial traumatic injury as well as the secondary, posttraumatic physiologic response. Interestingly, despite improvements in…

Microbiome and trauma

Over the past decade, the human microbiome has been discovered to be a major factor in human health and disease. The human microbiome consists of complex communities of bacteria and microorganisms that inhabit the human body including viruses, fungi, protozoa, and archaea. These microbial communities have the ability to occupy specific niches within the body as a result of a lifetime of coevolutionary strategies that have…

Danger associated molecular patterns, complements, and other novel biomarkers in trauma patient management

Trauma is a leading cause of death for those aged 1 to 46 years and the third overall leading cause of death for all ages in the United States. Trauma accounts for nearly 10% of all deaths and 16% of disabilities worldwide and is the most common cause of life-years lost before 75 years of age. Hemorrhage used to be the most common cause of death…

Combat trauma care: Lessons learned from recent combat operations

Overview of modern forward trauma care The modern battlefield is a highly complex and deadly arena that continues to drive innovation and advancements in both civilian and military trauma care. Prior to World War I, the vast majority of battlefield morbidity and mortality was due to infectious and other medical diseases. Simultaneous advances in medicine and weaponry subsequently resulted in trauma becoming the predominant focus of…

Common errors in trauma care

Errors in management occur frequently in medicine. A notable Institute of Medicine report estimated that 44,000 to 98,000 deaths each year were caused by medical errors. Most of these medical and surgical errors occur in low-intensity, nonemergent scenarios. Obviously, trauma care is a much more difficult setting to perform in an error-free manner. Care of injured patients must occur at a rapid pace and in an…

Soft tissue infections

The skin is the largest organ of the body and acts as a structural barrier to invasion by microbes. Skin and soft tissue infections (SSTIs) vary from minor to life-threatening. These infections may involve the epidermis, dermis, subcutaneous tissue, deep fascia, and muscle. They are the result of diverse causes, and the host may be either healthy or compromised. Prompt diagnosis helps to ensure effective treatment.…

Burns

The frequency of burn injury and its subsequent multisystem effects make the treatment of burn patients a commonly encountered management challenge for the trauma/critical care surgeon. The emergency surgery components of initial burn care include fluid resuscitation and ventilatory support, as well as preservation and restoration of remote organ function. Following appropriate resuscitation, burn patient management is focused on wound care and provision of the necessary…

Trauma in our “elders”

The year 2030 marks a turning point for the US population. In 2030, all baby boomers (born 1946 to 1964) will be older than 65 years of age. One in every five Americans will be of retirement age ( Fig. 1 ). By 2034, older adults will outnumber children for the first time in US history. By 2060 there is projected to be almost 95 million…

Trauma in pregnancy

The pregnant trauma patient presents significant challenges to the trauma surgeon. The physiologic changes in the mother during pregnancy represent both diagnostic and treatment dilemmas, and the need to treat two patients simultaneously may represent both clinical and emotional challenges for the trauma team. Epidemiology Trauma complicates 7% to 8% of pregnancies and is the leading nonobstetric cause of maternal death. The incidence of significant maternal…