et al.. Although such fractures may not require treatment, there is an association with blunt cerebrovascular injuries, cranial nerve injuries, and risk of meningitis. Simultaneously, all patients with blunt trauma require cervical spine immobilization until injury is excluded. Separate multiple email address with semi-colons (up to 5). However, possible complications vary and range from mild, self-resolving ecchymoses or edema to more persistent complications. Following repair of GI tract injuries, there is an obligatory postoperative ileus. Patients with a SBP <60 mm Hg warrant resuscitative thoracotomy (RT) with opening of the pericardium for rapid decompression and to address the injury.  H. The acute coagulopathy of trauma: mechanisms and tools for risk stratification. Terms of Use MeSH Evaluation of the CVP may further assist in distinguishing between these two categories.  GC, Karaiskakis  EJ, Kellam While the spleen is gently rotated medially, a plane is developed between the pancreas and left kidney (B). bei Personen mit nur einer, Nephrektomie bei arterieller Gefäßverletzung oder hochgradiger Parenchymschädigung häufig nicht zu vermeiden, Am Torso (im Gegensatz zu den Extremitäten) keine direkte Blutungskontrolle mittels Kompression möglich, Neurologische Defizite durch Minderperfusion des, Physiologische Anpassung der Organe und des Kreislaufs an die, Leichtes Trauma: Stationäre Überwachung für, Geringeres Risiko für subkapsuläre und intraparenchymatöse Blutungen, Radiologische Diagnostik generell nach dem, Häufig konservative Therapie unter stationärer Überwachung ausreichend, Keine zwingende OP-Indikation bei Nachweis freier intraabdomineller Flüssigkeit, Bei gegebener Indikation zur operativen Therapie, Die folgenden fünften Stellen sind bei der Kategorie, 0: Art der Verletzung nicht näher bezeichnet, 4: Oberflächlicher Fremdkörper (Splitter).  SJ. Several management points deserve attention. In blunt trauma, organs that cannot yield to impact by elastic deformation are most likely to be injured, namely, the solid organs (liver, spleen, and kidneys).  SG, Bakoyiannis However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply injured patients. [2], Dieser Artikel behandelt ein Gesundheitsthema.  GB, Cameron Grade IV: vessel occlusion. Once placed inside the injury tract, the balloon is inflated with saline until hemorrhage stops. Rarely, with open wounds a straight posterior approach with an S-shaped incision can be used. Patients with electrocardiographic (ECG) abnormalities or dysrhythmias require continuous ECG monitoring and antidysrrhythmic treatment as needed. stomach.  P, Constantinou Unable to load your collection due to an error, Unable to load your delegates due to an error. The patient’s initial chest radiograph often underestimates the extent of the pulmonary parenchymal damage (Fig. Letztere gehen mit einer hohen Letalität einher. Demetriades The most commonly missed gastric injury is the posterior wound of a totally penetrating injury. Selective nonoperative management of penetrating abdominal solid organ injuries. B. Sternal transection requires individual ligation of both the proximal and distal internal mammary arteries on the undersurface of the sternum.  DB, Moore For penetrating thoracic trauma, physical examination, plain posteroanterior and lateral chest radiographs with metallic markings of wounds, pericardial ultrasound, and CVP measurement will identify the majority of injuries.  et al.. Rib fractures in the elderly. Injuries to solid organs exert a particularly strong influence on the patient’s prognosis and clinical course. However, it is not advisable to ligate both jugular veins due to potential intracranial hypertension. Heart rate increases by 10 to 15 beats per minute during the first trimester and remains elevated until delivery. In conscious patients, pain is the prominent symptom, and active or passive motion of muscles in the involved compartment increases the pain. PubMed Google Scholar. Such guidelines are designed to limit the transfusion of immunologically active blood components and decrease the risk of transfusion-associated lung injury and secondary multiple organ failure.55,56.  N, Manson 15–20% der Fälle ist nach initialer konservativer Therapie doch noch eine operative Behandlung erforderlich! A.  RJ.  K Hildebrand, P., Hindel , C., Roblick, U. et al. For these reasons, trauma must be considered a major public health issue. The primary objectives of damage control laparotomy are to control bleeding and limit GI spillage. Alternatively, the duct can be ligated if the opposite lobe is normal and uninjured. A structured management routine is nescessary to ensure rapid diagnosis and treatment so as to reduce morbidity and mortality. All patients can be rapidly transported to the OR and packing can be accomplished in under 30 minutes. Establishing a definitive airway (i.e., endotracheal intubation) is indicated in patients with apnea; inability to protect the airway due to altered mental status; impending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling, or aspiration; and inability to maintain oxygenation. The site is secure.  EL, Burlew  CC. To mobilize the spleen, an incision is made into the endoabdominal fascia 1 cm lateral to the reflection of the peritoneum onto the spleen (A). If the difference is >10%, CT angiography or arteriography is indicated. With sufficient mobilization, a primary single-layer end-to-end anastomosis may be performed after appropriate débridement. B. vorsichtige Sondierung erwägen, Im Körper verbliebene Fremdkörper (insb. Because the pericardium is not acutely distensible, the pressure in the pericardial sac will rise to match that of the injured chamber. Cothren When a transverse incision is made in the cricothyroid membrane, the blade of the knife should be angled inferiorly to avoid injury to the vocal cords. and transmitted securely. Howes N, Walker T, Allorto NL, Oosthuizen GV, Clarke DL. Deaths: final data for 2004. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral. Abdominal compartment syndrome, as noted earlier, is defined as intra-abdominal hypertension sufficient to produce physiologic deterioration and frequently manifests via such end-organ sequelae as decreased urine output, increased pulmonary inspiratory pressures, decreased cardiac preload, and increased cardiac afterload. (1987) Splenic reticuloendothelial function after splenectomy, spleen repair and splenic autotransplantation. Regelmäßige sonographische Untersuchungen sind deshalb obligat.  F, Groeneweg  et al.. Blunt carotid arterial injuries: implications of a new grading scale. Patients may have distended neck veins due to impedance of venous return, but the neck veins may be flat due to concurrent systemic hypovolemia.  MA, Abraham Appropriate volume compensation for this albumin-rich fluid remains controversial, with regard to both the amount administered (replacement based on clinical indices vs. routine ½ mL replacement for every milliliter lost) as well as the type of replacement (crystalloid vs. colloid). The glossopharyngeal and vagus nerves are also mobilized and retracted as necessary. Knudson In fact, optimizing crystalloid administration is a challenging aspect of early care (i.e., balancing cardiac performance against generation of an abdominal compartment syndrome and generalized tissue edema). Persistence of a hemothorax despite two tube thoracostomies is termed a caked hemothorax and is an indication for prompt thoracotomy. The Denver grading scale for blunt cerebrovascular injuries. Kozar As a result, the vagus nerve has taken central stage in trauma treatment. More distal SMA injuries, Fullen zones III and IV, are approached directly within the mesentery. Classic signs and symptoms of shock are tachycardia, hypotension, tachypnea, altered mental status, diaphoresis, and pallor(Table 7-4). Air and thrombus are flushed from the aortic graft before the final suture is tied, and the occluding vascular clamps are removed. Bronchoscopy confirms diagnosis and directs management. Success rates of nonoperative management approach 95%, with an associated 10% to 23% transfusion rate.  DW, Shapiro The gold standard for determining if there is a blunt descending torn aorta injury is CT scanning; indications are primarily based on injury mechanisms. Because hemorrhage from hepatic injuries often is treated without isolating individual bleeding vessels, arterial pseudoaneurysms may develop, with the potential for rupture. Nasal fractures, which may be evident on direct inspection or palpation, typically bleed vigorously. Two caveats are recognized, however: The collecting system should be closed separately, and the renal capsule should be preserved to close over the repair of the collecting system (Fig. There are no pathognomonic ECG findings, and cardiac enzyme levels do not correlate with the risk of cardiac complications.23 Therefore, patients for whom there is high clinical suspicion of cardiac contusion and who are hemodynamically stable should be monitored for dysrhythmias for 24 hours by telemetry.  GC, Kaminski 7-70). 1996 Jan;40(1):31-8 In spezialisierten Zentren sowie bei bestimmten Patienten ist auch bei Grad-IV-Verletzungen eine laparoskopische Versorgung bis hin zur Teilresektion möglich. Gunshot wounds to the back or flank are more difficult to evaluate because of the retroperitoneal location of the injured abdominal organs. The use of pyloric exclusion in the management of severe duodenal injuries. This is particularly true if primary nerve transection is present in addition to fracture and arterial injury.126 Collaborative decision making by the trauma, orthopedic, and plastic/reconstructive team is essential.  JA Due to technical difficulties of injury exposure and varying operative approaches, a precise preoperative diagnosis is desirable for symptomatic zone I and III injuries.  S, Keim Resultant hypoventilation and hypoxemia may require intubation and mechanical ventilation. On-table angiography in the OR facilitates rapid intervention and is warranted in patients with evidence of limb threat at ED arrival. 2-Penetrating abdominal trauma. Similarly the left renal vein can usually be ligated adjacent to the IVC due to collateral decompression. -, J Trauma. Davis 7-40). Für die Versorgung der traumatischen Milzruptur kommen verschiedene Operationstechniken und Materialien zum Einsatz, wobei das Verfahren stets dem Verletzungsmuster sowie der Gesamtsituation des Patienten angepasst werden muss.  EE, Beauchamp In the seriously injured patient arriving in shock, an arterial blood gas, cross-matching for possible red blood cell (RBC) transfusion, and a coagulation panel should be obtained. Rarely, patients sustain destructive injuries to the head of the pancreas or combined pancreaticoduodenal injuries that require pancreaticoduodenectomy. Finally, angioembolization is an effective adjunct in any of these scenarios and should be considered early in the course of treatment. Adverse sequelae of excessive crystalloid resuscitation include increased intracranial pressure, worsening pulmonary edema, and intra-abdominal visceral and retroperitoneal edema resulting in secondary abdominal compartment syndrome.  H, Sterz  RJ, Martin  AM, Heron In a patient with multisystem trauma, enteral access via gastrostomy tube or needle-catheter jejunostomy should be considered.  EE, Smith Patients with gunshot or stab wounds to the left lower chest should be evaluated with diagnostic laparoscopy or DPL to exclude diaphragmatic injury. Before the patient is returned to the SICU, the abdomen must be temporarily closed. Trauma centers and their associated blood banks must have the capability of transfusing tremendous quantities of blood components, because it is not unusual to have 100 component units transfused during one procedure and have the patient survive.  JW. Patients with ongoing hemodynamic instability, whether “nonresponders” or “transient responders,” require prompt intervention; one must consider the dominant causes of acute shock, i.e., hemorrhagic, cardiogenic, and neurogenic shock. Do not assume that someone who was stabbed was not also assaulted; the patient may have a multitude of injuries and cannot be presumed to have only injuries associated with the more obvious penetrating mechanism. If the chest tube output is initially 20% of the patient’s blood volume (80 mL/kg) or is persistently >1 to 2 mL/kg per hour, thoracotomy should be considered. These patients mandate immediate identification of the source of hypotension with appropriate intervention to prevent a fatal outcome. Diverting ileostomy with colocolostomy, however, is used for most other high-risk patients.  WL, Cothren  JD An anterolateral thoracotomy, with the patient placed supine, is the most versatile incision for emergent thoracic exploration. For patients in whom peripheral angiocatheter access is difficult, intraosseous (IO) needles can be rapidly placed in the proximal tibia of the lower extremity (Fig. Blunt avulsions of the portal structures are particularly problematic if located at the hepatic plate, flush with the liver; hemorrhage control at the liver can be attempted with directed packing or Fogarty catheters. Injuries are often categorized by type of structure that is damaged: Abdominal wall. A predominant hematoma on the left suggests the far more common descending torn aorta (A; arrows), whereas a hematoma on the right indicates a relatively unusual but life-threatening innominate artery injury (B; arrows).  GV, Scalea Amniotic sac rupture can result in prolapse of the umbilical cord with fetal compromise. Sie ist das am häufigsten geschädigte Organ beim stumpfen Bauchtrauma.  A In addition to operative intervention, postinjury care directed at limiting secondary injury to the brain is critical. 7-1) is performed through a generous vertical incision, with sharp division of the subcutaneous tissues. Klassifikation nach ICD-10. Stumpfe Verletzungen werden z.B. 7-48).101 If tamponade is successful with either modality, the balloon is left inflated for 24 to 48 hours followed by sequential deflation and removal at a second laparotomy. Signs of rebleeding are usually conspicuous, and include a falling hemoglobin, accumulation of blood clots under the temporary abdominal closure device, and bloody output from drains; the magnitude of hemorrhage is reflected in ongoing hemodynamic instability and metabolic monitoring. Daher ist bei stabilen Kreislaufverhältnissen eine weiterführende abgestufte Diagnostik gerechtfertigt.  L, Yin  PJ, Janczyk Unilateral neck exploration is done through an incision extending from the mastoid down to the clavicle, along the anterior border of the sternocleidomastoid muscle (Fig.  et al.. Hypothermia Pediatric Head Injury Trial Investigators and the Canadian Critical Care Trials Group. Urethral injuries are managed by bridging the defect with a Foley catheter, with or without direct suture repair. Seine Verletzungen sind aufgrund seiner retroperitonealen Lage unter den parenchymatösen Organverletzungen beim Bauchtrauma selten. Bei schwerer hämodynamischer Instabilität aufgrund einer (vermuteten) intraabdominellen Verletzung muss ggf. ED preparation for the pediatric trauma patient includes assembling age-appropriate equipment (e.g., intubation equipment; IV catheters, including intraosseous needles and 4F single-lumen lines), laying out the Broselow Pediatric Emergency Tape (which allows effective approximation of the patient’s weight, medication doses, size of endotracheal tube, and chest tube size), and turning on heat lamps. Temporary abdominal closure and a second-look operation to evaluate bowel viability should be done. After débridement and repair, vascularized tissue is interposed between the repaired esophagus and trachea, and a closed suction drain is placed. En conjunto, constituyen el 10% de todas las muertes por traumatismos.  S, Gleason Evaluation in the ED focuses on identification of injuries mandating operative intervention (e.g., massive hemothorax, ruptured spleen) and injuries related to pelvic fracture that alter management (e.g., injuries to the iliac artery).  et al.. Nonoperative management of solid organ injuries in children results in decreased blood utilization.  K, Ives Common combined injuries include clavicle/first rib fractures and subclavian artery injuries, dislocated shoulder/proximal humeral fractures and axillary artery injuries, supracondylar fractures/elbow dislocations and brachial artery injuries, femur fracture and superficial femoral artery injuries, and knee dislocation and popliteal vessel injuries. Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. One caveat concerns the patient who presents after a delay.  AM.  S. The pregnant motor vehicle accident casualty: adherence to basic workup and admission guidelines. Plain radiographs are used to evaluate fractures, whereas ligamentous injuries, particularly those of the knee and shoulder, can be imaged with magnetic resonance imaging. In general, outcome after pelvic vascular injuries is related to (a) the technical success of the vascular reconstruction and (b) associated soft tissue and nerve injuries. On-table angiography in the operating room isolates the area of vascular injury to the superficial femoral artery in a patient with a femoral fracture after a gunshot wound to the lower extremity. Angio = angiography; ASA = acetylsalicylic acid; BRB = bright red blood; CHI = closed head injury; C-spine = cervical spine; CT = computed tomography; DAI = diffuse axonal injury; GCS = Glasgow Coma Scale score; MRI = magnetic resonance imaging; MS = mental status; Neg = negative; pt = patient; PTT = partial thromboplastin time; TIA = transient ischemic attack. 2014 Sep 15;8:14. doi: 10.1186/1752-2897-8-14. Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Die häufigste Todesursache bei Frauen im reproduktiven Alter ist ein traumatisches Ereignis. Fullen zone I SMA injuries, located posterior to the pancreas, are best exposed by a left medial visceral rotation. Repair of the chest wall defect and tube thoracostomy remote from the wound is definitive treatment.  et al.. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. Heavy scissors are used to cut through the intercostal muscle into the pleural space. 1). Scapular and sternal fractures rarely require operative intervention but are markers for significant thoracoabdominal force during injury; significant displacement may benefit from sternal plating (Fig. 7-28). Einfache Dekapsulierungen und oberflächliche Parenchymeinrisse (Grad I, II und ggf. In blunt trauma, particular constellations of injury or injury patterns are associated with specific injury mechanisms.  BB, McAninch Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: Results results of 145 cases. De los órganos que corren el riesgo de lesionarse en trauma abdominal Órganos sólidos Vísceras huecas. Howdieshell Although the diagnosis usually is obvious, in some instances wounds in the auditory canal, mouth, and nose can be elusive. The GlideScope¯, a video laryngoscope that uses fiber optics to visualize the vocal cords, is being employed more frequently.9 Advantages of orotracheal intubation include the direct visualization of the vocal cords, ability to use larger-diameter endotracheal tubes, and applicability to apneic patients. Selective radiography and laboratory tests are done early in the evaluation after the primary survey. In either scenario, a massive hemothorax is an indication for operative intervention, but tube thoracostomy is critical to facilitate lung re-expansion, which may improve oxygenation and cardiac performance as well as tamponade venous bleeding. ADVERTISEMENT: Supporters see fewer/no ads. Blood should be drawn simultaneously for a bedside hemoglobin level and routine trauma laboratory tests.  JL, Moore  MB, Shepard Unless myocardial infarction is suspected, there is no role for routine serial measurement of cardiac enzyme levels—they lack specificity and do not predict significant dysrhythmias.23 In patients who have no identified injuries who are being considered for discharge from the ED, the combination of a normal EKG and troponin level at admission and 8 hours later, rules out significant blunt cardiac injury.24 The patient with hemodynamic instability requires appropriate resuscitation and may benefit from hemodynamic monitoring to optimize preload and guide inotropic support. After blunt trauma, a major hemothorax usually is due to multiple rib fractures with severed intercostal arteries, but occasionally bleeding is from lacerated lung parenchyma which is usually associated with an air leak. Penetrating Abdominal Trauma is usually diagnosed based on clinical signs, blunt abdominal trauma is more likely to be missed because clinical signs are less obvious.  et al.. Validating the Western Trauma Association algorithm for managing patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. If <10 mL is withdrawn, a liter of normal saline is instilled. Patients with neurogenic shock as a component of hemodynamic instability often are recognized during the disability section of the primary survey to have paralysis, but those patients chemically paralyzed before physical examination may be misdiagnosed. Open repair of the descending aorta is accomplished using partial left heart bypass.86 With the patient in a right lateral decubitus position, the patient’s hips and legs are rotated 45 degrees toward the supine position to gain access to the left groin for common femoral artery cannulation.  LS, Bhasin Liegen trotz unauffälliger Sonographie instabile Kreislaufverhältnisse vor, müssen weitere Untersuchungen angeschlossen werden, um weitere traumatische Ursachen (z. Splenectomy is indicated for hilar injuries, pulverized splenic parenchyma, or any >grade II injury in a patient with coagulopathy or multiple injuries. Significant intracranial penetrating injuries usually are produced by bullets from handguns, but an array of other weapons or instruments can injure the cerebrum via the orbit or through the thinner temporal region of the skull.  MA Finally, some patients experience a combination of blunt and penetrating trauma. Intraparenchymal hematomas and contusions can occur anywhere within the brain. Definitive treatment requires closure of the chest wall defect and tube thoracostomy remote from the wound. The utility of RT has been debated for decades. Liver function test values increase, with the alkaline phosphatase level nearly doubling. Following aortic interposition grafting, the patient’s SBP should not exceed 120 mm Hg for at least the first 72 hours postoperatively. Blunt bowel and mesenteric injury: MDCT diagnosis.  R, Singer  LK, Schiff  SD  RJ, Lucas Meyer L, Kluge J, Marusch F, Zippel R, Gastinger I. Zentralbl Chir. Burlew Alternatively, tracheostomy may be performed. For bleeding peripheral pulmonary injuries, wedge resection using a stapler is performed. IV access for fluid resuscitation is obtained with two peripheral catheters, 16-gauge or larger in adults.  EE, Moore As with abdominal vascular injuries, a Pruitt-Inahara shunt can be used for temporary shunting of the vessel for damage control. Manifestation of the “bloody vicious cycle” (the lethal combination of coagulopathy, hypothermia, and metabolic acidosis) is the most common indication for damage control surgery. C. A 14-gauge IV catheter is introduced and secured with sutures and tape to prevent dislodgment. The exception is posterior dislocation of the clavicular head, which may injure the subclavian vessels. Blunt injuries to the carotid and vertebral arteries are usually managed with systemic antithrombotic therapy. Serial lactate determinations for prediction of outcome after cardiac arrest. As a result, injured patients can become hypothermic, with temperatures below 34°C (93.2°F) upon arrival in the OR. Debate remains over whether the optimal diagnostic approach is serial examination, diagnostic peritoneal lavage (DPL), or CT scanning; the most recent evidence supports serial examination and laboratory evaluation.42,43 Patients with stab wounds to the right upper quadrant can undergo CT scanning to determine trajectory and confinement to the liver for potential nonoperative care.41 Those with stab wounds to the flank and back should undergo triple-contrast CT to assess for the potential risk of retroperitoneal injuries of the colon, duodenum, and urinary tract. Once circulation is restored, the patient should be kept in Trendelenburg’s position with the pulmonary hilum clamped until the pulmonary venous injury is controlled operatively. A Satinsky clamp is used to clamp the pulmonary hilum to prevent further bronchovenous air embolism. Penetrating injuries to the carotid artery and internal jugular vein usually are obvious on operative neck exploration. Such lesions include hematomas, contusions, hemorrhage into ventricular and subarachnoid spaces, and diffuse axonal injury (DAI). In desperate situations, the vertical ramus of the mandible may be divided. 7-25). Complications after hepatic trauma include bilomas (A; arrow), hepatic duct injuries (B), and hepatic necrosis after hepatic artery ligation or embolization (C). The artery must be repaired after the venous injury is treated, however, because of limb-threatening ischemia. Because uterine and retroperitoneal veins may dilate to 60 times their original size, hemorrhage from these vessels may be torrential. The injured vessel segment is excised, and an end-to-end interposition RSVG graft is performed.  FA With complete mobilization, the spleen can reach the level of the abdominal incision. In general, wounds sustained from trauma should be examined daily for progression of healing and signs of infection. Beim Nachweis von freier abdominaler Flüssigkeit sowie Kreislaufinstabilität besteht prinzipiell die Indikation zur Notfalllaparotomie. IV. (1990) Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refinement of a useful technique. Todd Patients in shock have a lower tolerance to warm ischemia, and an occluded extremity is prone to small vessel thrombosis. Although immediate needle thoracostomy decompression with a 14-gauge angiocatheter in the second intercostal space in the midclavicular line may be indicated in the field, tube thoracostomy should be performed immediately in the ED before a chest radiograph is obtained (Fig. 7-13). The left colon, spleen, pancreas, and stomach are then rotated toward the midline. Please consult the latest official manual style if you have any questions regarding the format accuracy. Administration of low molecular weight heparin (LMWH) is initiated as soon as bleeding has been controlled and there is stable intracranial pathology. Ein Abdominaltrauma, auch Bauchtrauma genannt, ist eine Verletzung des Bauches (Abdomen). Trotzdem kann es vor allem durch eine vorzeitige Plazentalösung zum intrauterinen Fruchttod kommen. It is divided into two types blunt or penetrating and may involve damage to the abdominal organs. This lesion is characterized by the ipsilateral loss of motor function, proprioception, and vibratory sensation, whereas pain and temperature sensation are lost on the contralateral side. For other injury mechanisms, critical information includes such things as height of a fall, surface impact, helmet use, and weight of an object by which the patient was crushed.  CL.  EE A ligamentous injury may not be visible with standard imaging techniques.33 Flexion and extension views or MRI are obtained to further evaluate patients at risk or those with persistent symptoms, but generally are not done in the acute setting. This may result in the patient’s having airway compromise due to blood running down the posterior pharynx, or there may be vomiting provoked by swallowed blood. Continuous intercostal nerve blockade for rib fractures: ready for primetime? Although repair is not mandated, it should be performed if physiologically feasible. 7-53).77 Early recognition and management of these injuries is paramount, because patients treated with antithrombotics have a stroke rate of <1% compared with stroke rates of 20% in untreated patients. Patients with high spinal cord disruption are at greatest risk for neurogenic shock due to physiologic disruption of sympathetic fibers; treatment consists of volume loading and a dopamine infusion which is both inotropic and chronotropic. Messerstiche oder Schüsse Ursachen einer perforierenden Verletzung sind.   •  Privacy Policy Cothren Part of Springer Nature. Also, pregnant patients may desaturate more rapidly, particularly in the supine position and during intubation. Lap = laparotomy. Scalp lacerations through the galea aponeurotica tend to bleed profusely; these can be temporarily controlled with skin staples, Raney clips, or a large full-thickness continuous running nylon stitch.  M, Burch Because donor availability will limit such procedures, hepatic transplantation for trauma will continue to be performed only in extraordinary circumstances. Late pseudocysts may be a complication of operative management and are treated much like those in patients with pancreatitis (see Chap. Acute traumatic brain injury is the most common cause of death and disability in any pediatric age group. Decompressive craniectomy in diffuse traumatic brain injury. Pulmonary contusion often progresses during the first 12 hours. Die Inzidenz des Bauchtraumas bei polytraumatisierten Patienten beträgt in Deutschland etwa 20%, in 95% der Fälle handelt es sich um stumpfe Verletzungen [3]. Primary repairs include lateral suture repair or resection of the damaged segment with reconstruction by ileocolostomy or colocolostomy. 7-54).78 After identification of an injury, antithrombotics are administered if the patient does not have contraindications (intracranial hemorrhage, falling hemoglobin level with solid organ injury or pelvic fracture). Epidural hematomas (A) have a distinctive convex shape on computed tomographic scan, whereas subdural hematomas (B) are concave along the surface of the brain. Small duodenal perforations or lacerations should be treated by primary repair using a running single-layer suture of 3-0 monofilament. Who should we feed? Central venous catheter placement or saphenous vein cutdown may be considered as the third choice of access based upon provider experience. Begleitende Verletzungen im Bereich der Organe im Thorax sind möglich. In high risk patients, (e.g. For injuries of the pancreatic head that involve the pancreatic duct but spare the common bile duct, central pancreatic resection with Roux-en-Y pancreaticojejunostomy prevents pancreatic insufficiency.  et al.. Western trauma association critical decisions in Trauma: resuscitative thoracotomy.  EE, Biffl  JC, Mosier If hemorrhage occurs from these injuries, compartment syndrome and limb loss may occur. Most of these injuries can be evaluated by physical examination and chest radiography, with supplemental CT scanning based on initial findings. Brunicardi F, & Andersen D.K., & Billiar T.R., & Dunn D.L., & Kao L.S., & Hunter J.G., & Matthews J.B., & Pollock R.E.(Eds. In patients with a compatible history and a tense extremity, compartment pressures should be measured with a hand-held Stryker device. Admission chest film may not show the full extent of the patient’s pulmonary parenchymal injury. Injury.  EE, Biffl The recognition of the bloody vicious cycle and the introduction of damage control surgery (DCS) have improved the survival of critically injured patients. Das Leberpacking sollte nach 24–48 h wiederholt oder entfernt werden. Examination should seek active bleeding from a scalp laceration that may be readily controlled with clips or staples. The renal vein may be torn or completely avulsed from the vena cava due to blunt trauma. Bilateral thrombosis can aggravate cerebral edema in patients with serious head injuries; stent placement should be considered in such patients if ICP remains elevated. Signs and symptoms include hoarseness, subcutaneous emphysema (Fig. Abstract. Der Transfusionsbedarf darf hierbei 30 ml/kg Körpergewicht nicht überschreiten. A “clothesline” injury can partially or completely transect the anterior neck structures, including the trachea. Das Abdominaltrauma stellt nach wie vor eine Herausforderung im klinischen Alltag dar. Historically, a lateral cervical spine radiograph was also obtained, hence the reference to the big three films, but currently patients preferentially undergo CT scanning of the spine rather than plain film radiography. Additionally, intubated patients, patients with distracting injuries, or another identified spine fracture should undergo CT imaging. For subclavian or axillary artery repairs, 6-mm PTFE graft and RSVG are used. Bei größeren subkapsulären Hämatomen und blutenden Kapseleinrissen (Grad II) ist meist eine operative Blutstillung notwendig. N Engl J Med 317: 1559–1564, Treutner KH, Bertram P, Schumpelick V (1993) Prinzipien der Milzerhaltung beim stumpfen Bauchtrauma.  FA Similarly, perfusion of the iliac system and infrainguinal vessels can be restored with a vascular shunt, with interposition graft placement delayed until hours later. Cerebral perfusion pressure (CPP) is equal to the mean arterial pressure minus the ICP, with a target range of >50 mm Hg.29 CPP can be increased by either lowering ICP or raising mean arterial pressure. 7-75). The endovascular approach to acute aortic trauma. Bilomas are loculated collections of bile, which may or may not be infected. No chronologic age is associated with a higher morbidity or mortality, but a patient’s comorbidities do impact the individual’s postinjury course and outcome. The resultant injuries can include facial fractures, cervical spine fractures, laceration of the thoracic aorta, myocardial contusion, injury to the spleen and liver, and fractures of the pelvis and lower extremities. 7-51).69 The typical clinical course of an epidural hematoma is an initial loss of consciousness, a lucid interval, and recurrent loss of consciousness with an ipsilateral fixed and dilated pupil. at the patient's bedside, formulation of diagnosis, establishment of surgical tactics, amassing. The defect is temporarily managed with an occlusive dressing that is taped on three sides, which allows accumulated air to escape from the pleural space and thus prevents a tension pneumothorax. Common injuries are divided into two categories: solid organ (e.g., liver, spleen, pancreas, kidneys) and hollow organ (e.g., stomach, large and small bowel, gall bladder, urinary bladder) injuries. Additionally, because bullets and knives usually follow straight lines, adjacent structures are commonly injured (e.g., the pancreas and duodenum). Homicides, suicides, and other causes are responsible for another 50,000 deaths each year. MVAs are the most common cause of blunt abdominal trauma, causing about 75% of such injuries. Benutze zusätzlich T89.0-, um das Vorliegen von Komplikationen wie Fremdkörper, Arteria mesenterica (inferior) (superior), Rissverletzung, die nur die Kapsel betrifft oder ohne bedeutendere Beteiligung des, Rissverletzung mit bedeutender Zerreißung des, Multiple mittelschwere Rissverletzungen, mit oder ohne, Verletzungen, die in mehr als einer der Kategorien. If bleeding can be controlled with perihepatic packing, the packing should be left undisturbed and the patient observed in the SICU. Patienten mit Abdominaltrauma werden in der Regel nach der Stabilisierung der Vitalparameter stationär aufgenommen.  J However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply . However, the seriously injured patient is in constant jeopardy when undergoing special diagnostic testing; therefore, the surgeon must be in attendance and must be prepared to alter plans as circumstances demand. During diagnostic evaluation, type O RBCs (O-negative for women of childbearing age) and thawed AB plasma should be administered at a ratio of 2:1. Diese Eingriffe sind allerdings mit einer hohen Letalität von bis zu 85% behaftet [15]. 192 (5): 1179-89. Although the coagulopathic “ooze” may seem minimal compared with the torrential hemorrhage from a hole in the aorta, blood loss from the entire area of dissection can lead to exsanguination. In most patients a short PTFE graft (usually 18 mm in diameter) is placed using a running 3-0 polypropylene suture. Ouellet A. A method advocated for access to the proximal left subclavian artery is through a fourth interspace anterolateral thoracotomy, superior sternal extension, and left supraclavicular incision (“trap door” thoracotomy).  RR, Bokhari Laparoscopic repair is becoming common in patients not requiring laparotomy for other injuries. Collisions with side impact also carry the risk of cervical spine and thoracic trauma, diaphragm rupture, and crush injuries of the pelvic ring, but solid organ injury usually is limited to either the liver or spleen based on the direction of impact.  C Epidemiology. During exploration of the lesser sac, visualization and palpation of the pancreas is done to exclude injury. Unilateral neck exploration is performed through an incision along the anterior border of the sternocleidomastoid muscle; exposure of the carotid artery requires early division of the facial vein. Deutsche Gesellschaft für Unfallchirurgie. The right or left hepatic artery, or in urgent situations the portal vein, may be selectively ligated; occasionally, lobar necrosis will necessitate delayed anatomic resection. The spectrum of injuries to the duodenum includes hematomas, perforation (blunt blow-outs, lacerations from stab wounds, or blast injury from gunshot wounds), and combined pancreaticoduodenal injuries. Blood, vomit, the tongue, foreign objects, and soft tissue swelling can cause airway obstruction; suctioning affords immediate relief in many patients. Chirurg. A venous injury behind the pancreas, from the junction of the superior mesenteric, splenic, and portal veins, is accessed by dividing the neck of the pancreas. Ann Surg 227: 708–719, Patton JH, Lyden SP, Croce MA et al. Fachgebiete: Chirurgie , Notfallmedizin.  TG. 3). B. The pelvic hematoma often dissects the preperitoneal and paravesical space down to the presacral region, which facilitates packing; alternatively, blunt digital dissection opens the preperitoneal space for packing. AASW = anterior abdominal stab wound; CT = computed tomography; DPL = diagnostic peritoneal lavage; GSW = gunshot wound; LWE = local wound exploration; RUQ = right upper quadrant; SW = stab wound. Fistulas occur in 1% to 3% of patients and usually present as an abscess or wound infection with subsequent continuous drainage of fecal output; the majority will heal spontaneously with routine care (see Chap.  Jr., Hirshberg A. Sus causas principales son debidas al tráfico como causa más frecuente, pero también a accidentes laborales y a precipitados. More superior and lateral structures are accessed by extending the collar incision upward along the sternocleidomastoid muscle; this may be done bilaterally if necessary. B.  JB. Please try again later or contact an administrator at OnlineCustomer_Service@email.mheducation.com. Removal of small hematomas may also improve ICP and cerebral perfusion in patients with elevated ICP that is refractory to medical therapy. A. Complications related to colorectal injuries include intra-abdominal abscess, fecal fistula, wound infection, and stomal complications. Mishelle Chavez. Radiation damage has three distinct phases of damage and effect: preimplantation, during the period of organogenesis from 3 to 16 weeks, and after 16 weeks. Callaway Splenic injuries are managed operatively by splenectomy, partial splenectomy, or splenic repair (splenorrhaphy), based on the extent of the injury and the physiologic condition of the patient. 7-62). Therefore, defects in the second portion of the duodenum should be patched with a vascularized jejunal graft.  PC, Kufera  KL. Due to the devastating consequences of quadriplegia, a diligent evaluation for occult cervical spine injuries is mandatory. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE.  JT. The most common technique is to measure the patient’s bladder pressure. Feliciano A simplified management guideline. Sign up for an account today! Please consult the latest official manual style if you have any questions regarding the format accuracy. C. The continuous suture is tied near the antimesenteric border. - 173.236.137.254. Algorithm for the management of penetrating neck injuries. If the patient’s primary source of bleeding is the fracture-related hematoma, several options exist for hemorrhage control. Shotgun injuries are divided into close-range (<20 feet) and long-range wounds. Fluid resuscitation begins with a 2 L (adult) or 20 mL/kg (child) IV bolus of isotonic crystalloid, typically Ringer’s lactate. ECG = electrocardiogram; OR = operating room; SBP = systolic blood pressure. Pelvic packing, in which six laparotomy pads (four in children) are placed directly into the paravesical space through a small suprapubic incision, provides tamponade for the bleeding (Fig. C. Right internal iliac artery transposed to the right external iliac artery. Performing surgery within 24 hours may decrease length of stay and complications.76 Complete injuries of the spinal cord remain essentially untreatable. Intravascular shunts are used when there are multiple life-threatening injuries or the arterial injury is anticipated to require saphenous vein interposition reconstruction. Distal pancreatectomy alone is rarely indicated due to the extended resection of normal gland and the resultant risk of pancreatic insufficiency. Lustenberger Gastric wounds can be oversewn with a running single-layer suture line or closed with a stapler. Guidelines for diagnostic imaging during pregnancy. These measures should be maintained for 1 week; if the patient has no peripheral edema with ambulation, these maneuvers are no longer required. sharing sensitive information, make sure you’re on a federal Die explorative Laparatomie ist der Goldstandard in der operativen Therapie nach schwerem Abdominaltrauma!  CC, Biffl Options for thoracic exposure include the most versatile incision, the anterolateral thoracotomy (1), as well as a median sternotomy (2) and a “trap door” thoracotomy (3). Gómez-Caro Gestational age may be estimated by noting fundal height, with the fundus approximating the umbilicus at 20 weeks and the costal margin at 40 weeks.  C 2). Major vascular injuries causing exsanguination are uncommon in blunt pelvic trauma; however, thrombosis of either the arteries or veins in the iliofemoral system may occur, and CT angiography should be performed for evaluation. An open pneumothorax or “sucking chest wound” occurs with full-thickness loss of the chest wall, permitting free communication between the pleural space and the atmosphere (Fig. Although these patients may initially have an adequate airway, it may become obstructed if soft tissue swelling, hematoma formation, or edema progresses. Chirurg 64: 860–886. Otherwise, carotid shunting should be done selectively as in elective carotid endarterectomy but the patient should be systemically anticoagulated. Therapie von Verletzungen parenchymatöser Organe, Trauma und Berufskrankheit  RT, Millington Bei tieferen Gewebeverletzungen kann zusätzlich eine Ausräumung von Nekrosen und des Hämatoms notwendig werden (Grad II). The pylorus is then grasped with a Babcock clamp, via the gastrostomy, and oversewn with an O polypropylene suture. 7-47).49 Hypothermia from evaporative and conductive heat loss and diminished heat production occurs despite the use of warming blankets and blood warmers. 3.  C, Freeman Verletzte Trabekelgefäße müssen selektiv dargestellt und ligiert werden. Stomal complications (necrosis, stenosis, obstruction, and prolapse) occur in 5% of patients and may require either immediate or delayed reoperation. Optimal management of pancreatic trauma is determined by where the parenchymal damage is located and whether the intrapancreatic common bile duct and main pancreatic duct remain intact. In the comatose patient, the tongue may fall backward and obstruct the hypopharynx; this can be relieved by either a chin lift or jaw thrust. Partrick A sagittal view of packs placed to control hepatic hemorrhage.  V, Burch Tube thoracostomy is performed in the midaxillary line at the fourth or fifth intercostal space (inframammary crease) to avoid iatrogenic injury to the liver or spleen. Rupture into a bile duct results in hemobilia, which is characterized by intermittent episodes of right upper quadrant pain, upper GI hemorrhage, and jaundice. Removing the patient’s clothes causes a second thermal insult, and infusion of cold PRBCs or room temperature crystalloid exacerbates the problem. A Satinsky clamp can be used to control anterior caval wounds. The authors prefer placement of temporary intravascular shunts first with arterial occlusions to minimize ischemia during fracture treatment, with definitive vascular repair following. The authors use autotransplantation of splenic implants (Fig. 5 Laparotomy for Abdominal Trauma (∼5%) A transfusion requirement of ≥40 mL/kg within a 24-h period probably mandates laparotomy and intervention. All patients with blunt injury should be assumed to have unstable cervical spine injuries until proven otherwise; one must maintain cervical spine precautions and in-line stabilization. With complete tracheal transection, the endotracheal tube is placed directly into the distal aperture, with care taken not to push the trachea into the mediastinum. The renal capsule is carefully preserved. S35.-. The distal internal carotid artery is exposed by dividing the ansa cervicalis, which permits mobilization of the hypoglossal nerve.  EE, Biffl Messer) zunächst nicht manipulieren, Prellmarken durch den Anschnallgurt (Seat Belt Sign). In contrast, after a penetrating wound the search for bleeding should pursue the trajectory of the penetrating device. 1-Blunt abdominal trauma. At the other end of the spectrum are patients classified as “nonresponders” who have persistent hypotension despite aggressive resuscitation. inferior vena cava, renal vessels, celiac axis, superior mesenteric vessels, lumbar vessels, and iliac . Ecografía de Urgencia en Adultos con Traumatismo Abdominal y Torácico Ecografía de Urgencia en Adultos con Traumatismo Abdominal y Torácico. Otherwise it is hidden from view. A laryngeal fracture results in air tracking around the trachea along the prevertebral space (arrows). Drs. Although busy trauma centers continue to debate this issue, the surgeon who is obliged to treat the occasional injured patient may be better served by performing CT angiography in selected patients with soft signs. (1991) Distal pancreatectomy for trauma. 5. Emergency craniotomy in a rural level III trauma center. Ein hypovolämischer Schock entsteht bei ausgeprägten Blutverlusten. Options for endotracheal intubation include nasotracheal, orotracheal, or operative routes. This site uses cookies to provide, maintain and improve your experience. Pelvic vascular isolation. 1 polydioxanone sutures are placed approximately 5 cm apart (dashed arrow), which puts the fascia under moderate tension over the white sponge. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. For penetrating trauma, organs with the largest surface area when viewed from the front are most prone to injury (small bowel, liver, and colon).  GJ Penetrierende Verletzungsmuster wie nach Schuss- oder Stichverletzungen sind in Europa eher selten. During evaluation in the ED, the primary and secondary surveys commence, with mindfulness that the mother always receives priority while conditions are still optimized for the fetus.129 This management includes provision of supplemental oxygen (to prevent maternal and fetal hypoxia), aggressive fluid resuscitation (the hypervolemia of pregnancy may mask signs of shock), and placement of the patient in the left lateral decubitus position (or tilting of the backboard to the left) to avoid caval compression. Chest film findings associated with descending torn aorta include apical capping (A; arrows) and tracheal shift (B; arrows). Dyer Additional pads should be placed between the liver, diaphragm, and anterior chest wall until the bleeding has been controlled. A nasogastric tube should be inserted in all intubated patients to decrease the risk of gastric aspiration but may not be necessary in the awake patient. Instead, it is the decreased compliance and increased shunt fraction caused by the associated pulmonary contusion that is the source of acute respiratory failure. Rinker High-velocity gunshot wounds (bullet speed >2000 ft/s) are infrequent in the civilian setting.  et al.. During pregnancy, 7% of women are injured. Careful monitoring for distal embolic events and reperfusion injury necessitating fasciotomy is imperative. If hemostasis is not adequate to expose the vessel proximal and distal to the injury, sponge sticks can be strategically placed on either side of the injury and carefully adjusted to improve hemostasis. Os sinais clínicos costumam ser discretos, obscurecidos pela dor causada por lesões extra-abdominais associadas ou mascaradas por TCE e/ou uso de entorpecentes ou álcool.  T. Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients.
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