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Pancreatic and Duodenal Injury

1 How common are pancreatic and duodenal injuries? Injury to the pancreas and duodenum remain uncommon, likely because of the intimate association with other vital structures within the retroperitoneum. The recently documented incidence of duodenal injury is 0.2%–0.3%, followed by 0.004%–0.6% for pancreas injury. In patients undergoing laparotomy for trauma the incidence is 3%–6%. Traditionally, the incidence of pancreatic injury is higher in penetrating trauma; however,…

Splenic Trauma

1 What is the physiologic role of the spleen? In fetal development, the spleen serves as a major site of hematopoiesis. Later in life the spleen produces immunoglobulin M (IgM), properdin, and tuftsin, important factors in immunologic function. The spleen also acts as a filter, allowing resident macrophages to remove abnormal red blood cells, cellular debris, and encapsulated and poorly opsonized bacteria. 2 What injury patterns…

Hepatic and Biliary Trauma

1 How often is the liver injured in trauma? The liver is both large and central, so it is vulnerable to blunt trauma and an easy target for penetrating wounds. It is the most frequently injured intraabdominal organ in trauma. 2 What are the determinants of mortality after acute liver injury? The mechanism of injury, grade of injury, and the associated abdominal organs injured determine mortality.…

Penetrating Abdominal Trauma

1 Why is the evaluation different for patients with stab wounds (SWs) versus gunshot wounds (GSWs)? Although one-third of SWs to the anterior abdomen do not penetrate the peritoneum, 80% of GSWs violate the peritoneum. Additionally, of those wounds that penetrate the peritoneum, 95% of GSWs have associated visceral or vascular injuries, while only one-third of SWs do ( Fig. 25.1 ). 2 What are the…

Blunt Abdominal Trauma

1 What are the key components of the history and physical exam when evaluating a patient with blunt abdominal trauma? The tenets of the initial assessment and resuscitation of patients with blunt abdominal trauma remain the same as with all trauma patients. Evaluation is divided into the primary and secondary surveys, with resuscitation, intervention, and reevaluation as needed. The primary survey aims to identify and treat…

Penetrating Thoracic Trauma

1 How often do patients with penetrating chest wounds need an operation? Most penetrating injuries seen in civilian practice are from knives and low-energy handguns. Consequently, although injuries to the chest wall and lung are common, the vast majority can be treated with tube thoracostomy alone. Formal thoracotomy or median sternotomy is required in <15% of isolated penetrating chest injuries. 2 What are the indications for…

Blunt Thoracic Trauma

1 How often do patients with isolated blunt chest trauma need an emergent operation? Rarely. The majority of injuries can be managed with aggressive pain control, mechanical ventilation, tube thoracotomy, and other simple supportive care. Only 5% of patients with isolated blunt injury to the chest require thoracotomy, as operative injuries to pulmonary, vascular, and mediastinal structures are surprisingly rare. 2 In a patient with a…

Penetrating Neck Trauma

1 Why are penetrating neck wounds unique? Although comprising only a small percentage of body surface area, the neck contains a heavy concentration of vital structures: Vascular (common, internal, and external carotid arteries, vertebral arteries, internal and external jugular veins) Respiratory (larynx, trachea) Gastrointestinal (oropharynx, esophagus) Lymphatic (thoracic duct) Endocrine (thyroid and parathyroid glands) Nervous (spinal cord, cranial nerves IX, X, XI, XII) Skeletal (cervical vertebra,…

Spinal Cord Injuries

1 What is the difference between a spinal column injury and a spinal cord injury? Injuries to the spinal column can include damage to bone, disks, and/or ligaments. These injuries may induce spinal instability. Instability results when the spine can no longer maintain its alignment, protect the neural elements, or prevent incapacitating pain under physiologic loads. Injuries to the spinal column may also be associated with…

Traumatic Brain Injury

1 Is traumatic brain injury (TBI) a common problem? Yes. In the United States, 1 in 12 deaths are due to injury. About 30% of traumatic deaths are associated with TBI. Of deaths resulting from motor vehicle accidents, 60% are a result of brain injury. Even more common is mild TBI, which accounts for 75% of admissions for head trauma. There are over 200,000 patients hospitalized…

Posttraumatic Hemorrhagic shock

1 What is hemorrhagic shock? Shock exists when the cardiovascular system is no longer able to meet the body’s metabolic and oxygen needs, resulting in cellular injury. In other words, the tissues are not adequately perfused to meet their oxygen and nutrient requirements. Hemorrhagic is a subtype of shock directly related to blood loss, which decreases oxygen delivery as a result of loss of circulating volume…

Initial Assessment

1 What are the major components of the initial assessment of the trauma patient? The major components of the initial assessment of the trauma patient are primary survey and resuscitation, primary survey adjuncts, secondary survey, reevaluation as needed, and transfer to definitive care center (if necessary). 2 What is the purpose of the primary survey? The purpose of the primary survey is to identify and treat…

Frailty

1 What defines a geriatric patient? “Geriatrics” is best described as promoting the health of seniors. There is no specific age at which a patient is prescribed geriatric treatments. The United Nations uses 60+ as the numerical criterion, and most developed countries use 65 years. Currently, 15% of the US population is age 65+; an age group that consumes approximately 40% of healthcare resources. 2 How…

Sepsis

1 What is sepsis? Sepsis is a profound host immune response to infection. This systemic process can be accompanied by hypotension and can cause acute organ dysfunction. 2 What is septic shock? Septic shock is when hypotension secondary to sepsis persists despite adequate fluid resuscitation. A patient in septic shock will have signs of hypoperfusion, such as altered mental status, hypoxemia, acidosis, elevated lactate, tachypnea, and…

Risks of Blood-Borne Disease

1 What infectious diseases are transmissible via blood transfusion? Over 100 million blood donations are collected annually worldwide. Approximately half of these are collected in developed countries. Viruses, parasites, and bacteria and the diseases they transmit have all been found in donated blood. HBV, HCV, HIV 1 and 2, HTLV1 and 2, CMV, Parvovirus B19, Dengue virus, West Nile virus, trypanosomiasis, malaria, and variant Creutzfeldt-Jakob disease…

Surgical Infectious Disease

1 Have modern antibiotic developments controlled many, if not most, of the problems of surgical infection? No. In seriously ill surgical patients in intensive care unit (ICU) settings, the problems of sepsis have increased and remain among the principal causes of death in ICU patients, especially those with multiple organ failure (MOF) and impairments of host defense. Antibiotic treatment may change the biographical sketch of the…

Priorities in Evaluation of the Acute Abdomen

1 What is the surgeon’s responsibility when confronted by a patient with an acute abdomen? a. To identify how sick the patient is (treat the patient first and then the disease). b. To determine whether the patient (1) needs to go directly to the operating room, (2) should be admitted for resuscitation or observation, or (3) can be sent safely home. 2 What is the most…

Surgical Wound Infection

1 What is a surgical site infection? Surgical wound infections are now more appropriately referred to as “surgical site infections” (SSIs). There are different types of SSIs, which are classified by depth, timing after surgery, clinical criteria, and symptoms. The three categories of SSIs as defined by the Centers for Disease Control and Prevention are: a. Superficial incisional b. Deep incisional c. Organ/deep space Superficial incisional…

What does Postoperative Fever Mean?

1 What is a fever? Normal core temperature varies between 36°C and 38°C. Because humans hibernate a little at night, we are cool (36°C) just before rising in the morning; after revving our engines all day, we are hot at night (38°C). A fever is a pathologic state reflecting a systemic inflammatory process. The core temperature is >38°C but rarely >40°C. 2 What is malignant hyperthermia?…

Nutritional Assessment, Parenteral, And Enteral Nutrition

Nutritional Assessment 1 What does a nutritional assessment include? The medical and surgical history determine preexisting conditions, metabolic stress, and alterations in organ function that influence nutritional support. Nutritional status is recently having a resurgence of importance as it can be predictive of morbidity and mortality. Assessment begins with the physical exam and evaluates muscle mass, adipose stores, skin integrity, temporal muscle wasting, and clinical signs…