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Prehospital airway management: Intubation, devices, and controversies

Introduction Prehospital trauma airway management is probably the biggest challenge faced by emergency medical services (EMS) providers. These professionals must acquire and maintain essential skills to adequately manage airway problems at the scene and during transport of trauma victims to trauma centers. Options for airway management have different levels of invasiveness and complexity with different technologies and required levels of expertise. Emergency airway management in trauma…

En route care

Introduction The transport of combat casualties by air parallels the history of military aviation. Although many texts cite balloon transport during the Franco-Prussian War (1870) as the first instance of aeromedical evacuation (AE), the true initiation of AE awaited the successful development of the fixed wing aircraft. During World War I (1914–1918) British, French, German, and American forces all utilized fixed wing evacuation on a limited…

Field triage in the civilian arena

In 2018 over 28 million Americans sought treatment for nonfatal injuries and an additional 240,583 deaths occurred from all injury-related causes. Annually, 826,000 emergency medical services (EMS) field providers care for these injured patients, accounting for 18% of all EMS transports and approximately 5.4 million patients. The term “triage” is derived from the French word meaning “to sort” and can be defined as the process by…

Trauma systems on the battlefield

History of battlefield trauma systems Ever since man has gone to war, civilizations have made preparations for the care of battlefield casualties. The earliest written reports of such battlefield care date back to the Egyptians with the Edwin Smith Papyrus, an ancient Egyptian medical text named after its procurer. Throughout history the majority of contributions to combat casualty care have focused on the individual casualty and…

Field triage in the military arena

Mass casualties due to combat operations, or natural or manmade disasters, have the capacity to overwhelm multiple levels of care and evacuation capabilities of any system. Military and civilian institutions need a mass casualty response plan in order to facilitate the transition from the routine care of patients to an exponential increase in the required personnel, supplies, and equipment in order to meet the demand. Open…

Prehospital trauma care: Influence of emergency medical services on trauma center patient outcomes

Since the proven effectiveness of trauma systems in the 1970s, the evaluation, treatment, and transport of trauma victims in the prehospital arena have played an important role in the overall management of those victims. Although some aspects of that role have raised controversy, the rapid and effective transport of severely injured patients leaves little room for doubt. Though standardized by the National EMS Scope of Practice…

Simulation-based training for combat surgery

Introduction The experience of general surgery residents with major, open surgical procedures is low compared with historical norms and continues to decline. Many reasons for this have been adduced, including a decrease in resident training hours, nonoperative management of many trauma patients, decreased societal violence, and the dominance of minimally invasive and endovascular techniques to treat conditions formerly requiring open operations. It is probable that the…

Trauma scoring

Trauma was the first medical specialty to regionalize health care delivery to specialized centers and to systematically measure health care outcomes. The first trauma scores were designed for a specific purpose: to standardize injury descriptions and rank injury severity to effectively triage injured patients to the appropriate trauma center. Since then trauma scores have evolved to serve two new purposes: to allow risk adjustment for comparisons…

Lessons learned in military trauma in Colombia

Throughout history, wars have resulted in the development of medical care techniques that have been later adopted successfully in civilian trauma. Colombia as a whole has been involved since the early 1960s in nonconventional warfare fueled by the cocaine drug trade and leftist guerrilla groups. This internal conflict has yielded a large volume of war injuries inflicted upon both the civilian and military populations. The National…

Role of alcohol and other drugs in trauma

Injury is increasingly recognized as a disease, with predictable risk factors, treatment options, and outcomes. However, it is also often thought to be a comorbid condition of another disease, that being excessive alcohol use, illicit drug use, or misuse of prescription drugs. Between 30% and 50% of trauma patients are under the influence of alcohol at the time of injury. If other drug use is included,…

Injury severity scoring: Its definition and practical application

The urge to prognosticate following trauma is as old as the practice of medicine. This is not surprising, because injured patients and their families wish to know if death is likely, and physicians have long had a natural concern not only for their patients’ welfare but for their own reputations. Today there is a growing interest in tailoring patient referral and physician compensation based on outcomes,…

Trauma center organization and verification for current therapy of trauma and surgical critical care

Formed in 1922 with a legacy as one of the oldest standing committees of the American College of Surgeons, the American College of Surgeons Committee on Trauma has vigorously advocated for improvements in care for the injured patient. In 1966, the National Academy of Sciences published “Accidental Death and Disability: The Neglected Disease of Modern Society,” noting trauma to be one of the most significant public…

Development of trauma systems

Modern trauma care consists of three primary components: prehospital care, acute surgical care or hospital care, and rehabilitation. Ideally, a society, through state (department, province, regional, etc.) government, should provide a trauma system that ensures all three components. The purpose of this chapter is to show how trauma systems have evolved, to discuss whether or not they work, and to define current problems. From an historical…

Surgical Treatment of Lymphedema

Physical therapy, compression garments, manual lymphatic drainage, and intermittent pneumatic compression pumps are currently the first line of treatment in patients with chronic lymphedema. Current guidelines recommend that surgical management can be attempted in selected patients who have failed conservative treatment. Indications for Surgical Treatment Indications for surgical intervention are impaired mobility secondary to extremity size and weight, recurrent episodes of cellulitis and lymphangitis, intractable pain,…

Lymphedema : Medical and Physical Therapy

Managing the complex care related to lymphedema requires a thorough understanding of the associated anatomy, pathophysiology, risk factors, clinical presentation, and diagnostic tests. In addition, understanding individual risk factors and comorbidities allows one to develop an optimal management strategy for each patient. Structure and Function of the Lymphatic System The lymphatic system is a closed vascular system composed of endothelial-lined channels that parallel the arterial and…

Lymphedema

Lymphedema is defined as a pathologic condition in which there is an interstitial accumulation of protein-rich fluid. This condition affects more than 1 percent of the United States population and more than 150 million people worldwide. Lymphedema occurs secondary to an anatomic or functional obstruction in the lymphatics or the lymph nodes. Although it can result in edema in the truncal area, it usually occurs distally…

Venous Aneurysms

Venous aneurysms are uncommon. The term aneurysm is used to describe saccular or fusiform dilatations of veins. A varix is defined as the association of dilatation with tortuosity, and phlebectasia is the term used to describe diffuse fusiform venous dilatations. Aneurysmal dilatation of veins can be found in association with partial venous obstruction, high-flow states, or congenital venous malformations. When a venous dilatation, whether saccular or…

Permanent and Temporary Inferior Vena Cava Filters

Inferior vena cava (IVC) filters are placed for the sole purpose of preventing a potentially fatal pulmonary embolism (PE). Development and introduction of retrievable IVC filters has been associated with a general liberalization of the indications for IVC filters. In fact, the number of IVC filters placed for extended indications or prophylaxis in the absence of demonstrable venous thromboembolism (VTE) increased more than 80% from 1998…

Surgical Treatment of Acute and Chronic Pulmonary Embolism

Thrombosis is a physiologic hemostatic response to vascular injury. Pathologic thrombosis is based on the core triad of vascular trauma, blood flow stasis, and hypercoagulable hemostasis identified in the 19th century by German cytopathologist Rudolf Virchow. Pulmonary embolism (PE) occurs when venous thromboembolic material lodges in the pulmonary circulation. The exact incidence of PE remains unknown, but estimates have increased since the advent of computed tomographic…