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Penetrating carotid artery injuries

Carotid arterial injuries are the most difficult and certainly the most immediate life-threatening injuries found in penetrating neck trauma. Their propensity to bleed actively and potentially occlude the airway makes surgical intervention very challenging. Their potential for causing fatal neurologic outcomes demands that trauma surgeons exercise excellent judgment in the approach to their definitive management ( Fig. 1 ). Frequently, the rapidity with which these injuries…

Diagnosis of vascular trauma

The diagnosis of vascular trauma is usually not a problem, as most injuries manifest overt blood loss, shock, or loss of critical pulses. However, in certain instances, the lesion may not be recognized initially, only to manifest itself later by sudden secondary hemorrhage or the development of critical organ or extremity ischemia. Most of the vascular injuries of immediate concern to the clinician are those related…

Vascular anatomy of the extremities

From Egyptian, Greek, and Roman battlefields centuries ago, extremity vascular injuries were identified and treated. Subsequently, knowledge regarding the management of vascular trauma has also been gained from more modern military conflicts. Napoleon’s surgeon Larrey was an expert with rapid amputations, having documented 200 amputations in 24 hours during the Battle of Borodino in 1812. During the American War Between the States, amputation was the known…

Torso trauma on the modern battlefield

Introduction to combat torso trauma In the modern era, combat trauma care frequently involves the management of major torso injuries that would have been rapidly fatal in previous conflicts. In addition to the severe wounds and altered physiology, surgical teams are increasingly required to resuscitate patients and operate in a variety of austere forward settings with significant limitations in personnel and equipment, particularly in the early…

Abdominal compartment syndrome, damage control, and the open abdomen

Current critical care supportive measures make it possible for patients with severe injuries and physiologic impairment to survive what otherwise might have been lethal conditions. One of the major surgical consequences of extensive resuscitation efforts regards the condition of the abdominal wall. Although the objective should be to always close the abdomen following laparotomy, primary closure may be technically impossible or deleterious owing to any number…

Surgical techniques for damage control operations for abdominal, thoracic, pelvic, and extremity trauma

Injury severity and the spectrum of injuries continue to evolve, resulting in greater and different challenges for the trauma surgeon. High-energy blunt trauma, as well as increased availability of military firearms with greater wounding capacity, have resulted in an increase in complex injuries involving multiple organs. Improvements in prehospital care and trauma resuscitation have allowed moribund patients to reach the hospital alive but in extremis. Damage…

Newer strategies from the use of blood and blood products: Lessons learned from recent wars

The broad indications for blood transfusion are based on the fact that transfused blood is the best substitute for blood lost in acute haemorrhages. —L. Bruce Robertson, MD, Captain, Canadian Army Medical Corp, 1916 Salt water is for cooking pasta, blood is for resuscitation. —Geir Strandenes, MD, Senior Medical Officer, Norwegian Naval Special Operations Command, 2018 As with so many other aspects of care of the…

Damage control resuscitation: An evidence-based report

Damage control resuscitation (DCR) has become a staple of modern surgical management of traumatic injuries. Hemorrhage secondary to trauma accounts for 40% of trauma fatalities and is the leading cause of preventable death in trauma. Research in military and civilian populations regarding DCR have focused on ways to improve survival in patients with severe hemorrhage. It should be mentioned that the majority of trauma patients do…

Exsanguination: Reliable models to indicate damage control

Exsanguination has been defined as an extreme form of hemorrhage with ongoing bleeding that, if not surgically controlled, will lead to death. Exsanguination is second only to neurologic injury among causes of fatality after trauma. Therefore, the speed by which the exsanguinating trauma patient moves through the prehospital phase, emergency department, operating room, and intensive care unit (ICU) is important to survival. The syndrome of exsanguination…

Current concepts in the diagnosis and management of hemorrhagic shock

Hemorrhagic shock is the leading cause of preventable death following injury. Historically, major advances in the management of hemorrhagic shock have come during periods of armed conflict, when hemorrhage occurs at higher rates and in situations where the military is able to rapidly institute new protocols and measure effectiveness in a defined population. Among the most recent of these advances is the concept of damage control…

Multidisciplinary management of pelvic fractures: Operative and nonoperative management

Few injuries are as complex as pelvic fractures in the multiply injured patient. The pelvis is a complex anatomic region—the bony pelvis provides great protection to the structures it contains and within the pelvis are vital gastrointestinal, genitourinary, vascular, and neurologic structures. The force necessary to fracture a pelvis is extreme, and therefore every pelvic fracture must be assumed to be a high-energy injury. Approximately 9%…

Gynecologic injuries: Trauma to uterus, ovaries, and female genitalia

The female reproductive organs are protected by their location in the pelvis, making injuries uncommon, except during pregnancy or situations in which they are pathologically enlarged. Gynecologic trauma includes a large variety of relatively rare and challenging injuries from blunt and penetrating mechanisms. Pelvic fractures, straddle injuries, accidental penetration, and sudden forced stretching of the perineum are the most common types of injury that often result…

Genitourinary tract injuries

Kidney trauma Incidence and mechanisms of injury At most urban trauma centers, mechanisms of kidney injuries are predominantly blunt (80%–90%) and uncommonly penetrating (10%–20%). The kidney is injured in up to 5% of all trauma cases. Children are more likely to sustain a blunt renal injury owing to the relatively large size of the kidney, scant perirenal fat, fetal lobulations, and incomplete rib ossification. The majority…

Colon and rectal injuries

Management of colon and rectal injuries has greatly evolved over recent decades. Historically, treatment consisted of resection and end colostomy based on experience with battlefield casualties. Although a difference between civilian and military injuries was recognized, the treatment by civilian trauma surgeons paralleled that of their military counterparts. Numerous prospective randomized trials in civilian centers have since established primary repair as the preferred treatment for most…

Abdominal vascular injury

After blunt or penetrating abdominal trauma, the major sites of hemorrhage are the viscera, mesentery, and major abdominal vessels ( Figs. 1–3 ). “Abdominal vascular injury” refers to injury to major intraperitoneal and retroperitoneal vessels and is classified into four zones ( Table 1 , Figs. 4–8 ). Open full size image FIGURE 1 Vascular anatomy. Supramesocolic aorta and branches. Open full size image FIGURE 2…

Splenic injuries

The proclivity for the spleen to bleed from blunt abdominal trauma was not lost on the Thuggee cult. A group of professional assassins who existed from the 13th to 19th centuries in India, they murdered others to worship Kali, a Hindu goddess of destruction. They often targeted blunt trauma to the left upper quadrant of their victims. This is where the spleen, often fragile and swollen…

Liver injury

The liver is the most commonly injured intraabdominal organ with an incidence of 30% to 40%. The overwhelming majority of liver injuries, however, are minor, with spontaneous cessation of hemorrhage almost always the rule, and operative intervention is rarely required. On the other hand, complex hepatic injuries continue to challenge even the most experienced trauma surgeons. Hepatic injuries have been a fascinating topic since the publication…

Pancreatic injuries and pancreaticoduodenectomy

Injuries to the pancreas remain uncommon, occurring in <1% of all adult traumas and 3.7% to 11% of abdominal trauma. Despite advances in modern trauma care, including damage control surgery and improved imaging techniques, injuries to the pancreas present a continuing challenge to the trauma surgeon for several reasons. First, the pancreas is relatively protected within the confines of the retroperitoneum, confounding the clinical detection of…

Duodenal injuries

Trauma surgeons must possess a comprehensive understanding of the diagnostic and treatment algorithms for duodenal injury as these injuries are unusual, but not rare, and can be difficult to diagnose. The surgical approaches are nuanced and can be complex, implying that a thoughtful consideration of how to approach duodenal injures requires prior study and learning. A penetrating mechanism accounts for 75% to 80% of injuries. Diagnosis…

Small bowel injury

History Injuries to the small intestine have been described in the medical literature throughout history. Hippocrates was the first to describe intestinal injury from penetrating trauma. Aristotle is recognized as the first to report a small bowel perforation from blunt trauma. Throughout the Middle Ages and into the early 20th century, physicians have reported on surgical techniques and the nature of these injuries. In 1275, Guillaume…