One or more of your email addresses are invalid. 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. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. Life-threatening injuries must be identified (Table 7-1) and treated before being distracted by the secondary survey. The wound is then left to heal by secondary intention with a wound vacuum-assisted wound closure (VAC) device. Zusätzlich kann der Defekt mit Fibrinkleber oder Kollagenvlies versiegelt werden. Inaba Transport of a hypotensive patient out of the ED for computed tomographic (CT) scanning is hazardous; monitoring is compromised, and the environment is suboptimal for dealing with acute problems. The authors use autotransplantation of splenic implants (Fig. Zone I is to the level of the clavicular heads and is also known as the thoracic outlet. Primary repair of the injured intrahepatic duct is unlikely to be successful. Das Ausmaß einer traumainduzierten Koagulopathie kann durch die standardisierten Bedingungen der Labordiagnostik (konstante Temperatur mit Puffersubstanzen und Calziumüberschuss) verschleiert werden! Der Traumamechanismus ist von essenzieller Bedeutung für die weiteren Diagnostik- und Therapieentscheidungen! Stichverletzungen im Bauchraum sind eine häufige Ursache für perforierende Abdominaltraumata. 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. If an injury is suspected during operative exploration but is not clearly identified, methylene blue or indigo carmine is administered IV with observation for extravasation. Cothren Burlew, Clay, and Ernest E. Moore. There are a multitude of management algorithms aimed at accomplishing these goals, the majority of which involve goal-directed resuscitation with initial volume loading to attain adequate preload, followed by judicious use of inotropic agents or vasopressors.127 Although the optimal hemoglobin level remains debated, during shock resuscitation a hemoglobin level of >10 g/dL is generally accepted to optimize hemostasis and ensure adequate oxygen delivery. For vessels <6 mm in diameter (e.g., internal carotid, brachial, superficial femoral, and popliteal arteries), autogenous saphenous vein from the contralateral groin should be used, because polytetrafluoroethylene (PTFE) grafts of <6 mm have a prohibitive rate of thrombosis. Pelvic packing also eliminates the often difficult decision by the trauma surgeon: OR vs. interventional radiology? Schema zum Behandlungskonzept der traumatischen Milzruptur. A Pringle maneuver can help delineate the source of hemorrhage. Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. 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. The proximal stump of the internal carotid is oversewn, with care taken to avoid a blind pocket where a clot may form. Roblick & H.P. Grade I: irregularity of the vessel wall, dissection/intramural hematoma with <25% luminal stenosis. CF, Hersch Seriously injured patients must have all of their clothing removed to avoid overlooking limb- or life-threatening injuries. The position is satisfactory if bone marrow can be aspirated and saline can be easily infused without evidence of extravasation. A. Finally, angioembolization is an effective adjunct in any of these scenarios and should be considered early in the course of treatment. 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). JT. B. Occasionally the vaginal wall will be lacerated by a bone fragment from a pelvic fracture. C. The incision is digitally explored to confirm intrathoracic location and identify pleural adhesions. K, Ives Additionally, the child’s tongue is much larger in relation to the oropharynx. Patients with distal ductal disruption undergo distal pancreatectomy, preferably with splenic preservation. Generally, no specific bladder pressure prompts therapeutic intervention, except when the pressure is >35 mm Hg. Acute traumatic brain injury is the most common cause of death and disability in any pediatric age group. Hemorrhage from these vessels obscures vision and prolongs the procedure. et al.. A cost-minimization analysis of. If necessary, emergent vascular control can be obtained by placing a curved vascular clamp across the hilum from an inferior approach. Alternatively, air can be introduced via the NG tube with the abdomen filled with saline. The wound should be closed in a direction that results in the largest residual lumen. The acute coagulopathy of trauma is now well recognized, and underscores the importance of pre-emptive blood component administration. JL, Barnett C, Halvorsen Chirurg 75: 447–467, Traub A, Giebink GS, Smith C et al. This compromises ventilation due to equilibration of atmospheric and pleural pressures, which prevents lung inflation and alveolar ventilation, and results in hypoxia and hypercarbia. Minor lacerations may be controlled with manual compression applied directly to the injury site. BC, Menaker BT, Efron 7-31). Prognosis is variable, but virtually all supratentorial wounds that injure both hemispheres are fatal. et al.. A national evaluation of the effect of trauma-center care on mortality. PC, Wells While decompression of subdural hematomas may be delayed, epidural hematomas require evacuation within 70 minutes.68 The final stages of this sequence are caused by blood accumulation that forces the temporal lobe medially, with resultant compression of the third cranial nerve and eventually the brain stem. In patients with abnormal findings on CT scans and GCS scores of ≤8, intracranial pressure (ICP) should be monitored using fiber-optic intraparenchymal devices or intraventricular catheters.29 Although an ICP of 10 mm Hg is believed to be the upper limit of normal, therapy generally is not initiated until ICP is >20 mm Hg.29 Indications for operative intervention to remove space-occupying hematomas are based on the clot volume, amount of midline shift, location of the clot, GCS score, and ICP.29 A shift of >5 mm typically is considered an indication for evacuation, but this is not an absolute rule. If the trachea is completely transected, a nonpenetrating clamp should be placed on the distal aspect to prevent tracheal retraction into the mediastinum; this is particularly important before placement of the endotracheal tube. Moore CT = computed tomography; ED = emergency department; FAST = focused abdominal sonography for trauma; HD = hemodynamic; PLT = platelets; PRBCs = packed red blood cells; SICU = surgical intensive care unit. 9 Edición. Perforierende Verletzungen führen in absteigender Reihenfolge zu Verletzungen im Bereich des Dünndarms, des Mesenteriums, der Leber und des Kolons. A-A index = systolic blood pressure on the injured side compared with that on the uninjured side. Injuries of the duodenum and pancreas after blunt abdominal trauma are often associated with other intra-abdominal injuries and the treatment depends on their location and severity. The aspirate is considered to show positive findings if >10 mL of blood is aspirated. When operative decompression is required with egress of the abdominal contents, temporary coverage is obtained using a subfascial 45 × 60 cm sterile drape and Ioban application (see Fig. LeBedis 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. et al.. Penetrating iliac vascular injuries: experience with 233 consecutive patients. Verletzung von Blutgefäßen in Höhe des Abdomens, der Lumbosakralgegend und des Beckens. 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. Weiterhin sollten Röntgenaufnahmen des Abdomens und des Thorax angefertigt werden. R, Shavit AWMF-Leitlinie Nr. In blunt trauma, particular constellations of injury or injury patterns are associated with specific injury mechanisms. The ATLS format and basic tenets are followed throughout this chapter, with some modifications. Serial base deficit measurements are helpful; a persistent base arterial deficit of >8 mmol/L implies ongoing cellular shock.19,20 Serum lactate is also used to monitor the patient’s physiologic response to resuscitation.21 Evolving technology, such as near infrared spectroscopy, may provide noninvasive monitoring of oxygen delivery to tissue.22 Except for patients transferred from outside facilities >12 hours after injury, few patients present in septic shock in the trauma bay. Trauma, or injury, is defined as cellular disruption caused by environmental energy that is beyond the body's resilience, which is compounded by cell death due to ischemia/reperfusion. Persistent hypotension due to uncontrolled hemorrhage is associated with high mortality. III. If repair is not possible within this time frame, leaving the kidney in situ does not necessarily lead to hypertension or abscess formation. The GCS is a quantifiable determination of neurologic function that is useful for triage, treatment, and prognosis. 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. Fracture-related blood loss, when additive, may be a potential source of the patient’s hemodynamic instability. V, Burch For the remainder of patients, a variety of diagnostic adjuncts are used to identify abdominal injury. Orotracheal intubation is the preferred technique used to establish a definitive airway. et al.. An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. In addition, the upward pressure on the diaphragm calls for caution when placing a thoracostomy tube; standard positioning may result in an intra-abdominal location or perforation of the diaphragm. Blood should be drawn simultaneously for a bedside hemoglobin level and routine trauma laboratory tests. Although as many as one-third of patients sustaining significant blunt chest trauma experience some degree of blunt cardiac injury, few such injuries result in hemodynamic embarrassment. Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Otherwise, carotid shunting should be done selectively as in elective carotid endarterectomy but the patient should be systemically anticoagulated. Air emboli can occur after blunt or penetrating trauma, where air from an injured bronchus enters an adjacent injured pulmonary vein (bronchovenous fistula) and returns air to the left heart. Fetal monitoring should be performed with a cardiotocographic device that measures both contractions and fetal heart tones (FHTs). Compartment syndromes, which can occur anywhere in the extremities, involve an acute increase in pressure inside a closed space, which impairs blood flow to the structures within. CT-guided catheter drainage may be required in such cases, because 25% of patients do not respond to antibiotic therapy alone. Surgical fusion typically is performed in patients with neurologic deficit, those with angulation of >11 degrees or translation of >3.5 mm, and those who remain unstable after halo placement. If hemorrhage occurs from these injuries, compartment syndrome and limb loss may occur. 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. Abdominal Trauma • Penetrating Abdominal Trauma • Stabbing 3x more common than firearm wounds • GSW cause 90% of the deaths • Most commonly injured organs: small intestine > colon > liver • Blunt Abdominal Trauma • Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to . The sources of increased intra-abdominal pressure include gut edema, ascites, bleeding, and packs. Over 90% of thoracic great vessel injuries are due to penetrating trauma, although blunt injury to the innominate, subclavian, or descending aorta may cause a pseudoaneurysm or frank rupture.40,81,82 Simple lacerations of the ascending or transverse aortic arch can be repaired with lateral aortorrhaphy. Bilateral thrombosis can aggravate cerebral edema in patients with serious head injuries; stent placement should be considered in such patients if ICP remains elevated. et al.. Operative strategies for management of abdominal aortic gunshot wounds. 7-12). As the artery is stretched, the inelastic intima and media may rupture, which causes thrombus formation and resultant stenosis or occlusion. CTA of the neck and chest determines trajectory of the injury tract; further studies are performed based on proximity to major structures.35 Such additional imaging includes angiography, soluble contrast esophagram followed by barium esophagram, esophagoscopy, or bronchoscopy. Small GI injuries (stomach, duodenum, small intestine, and colon) may be controlled using a rapid whipstitch of 2-0 polypropylene. 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. 7-74). The PTFE graft is anastomosed end to side from the proximal undamaged aorta and anastomosed end-to-end to the innominate artery (Fig. RA, Moore Because 85% of bleeding due to pelvic fractures is venous or bony in origin the authors advocate immediate external fixation and preperitoneal pelvic packing.124,125 Anterior external fixation decreases pelvic volume, which promotes tamponade of venous bleeding and prevents secondary hemorrhage from the shifting of bony elements. Loop colostomy will completely divert the fecal flow, allowing the low rectal injury to heal. En el examen físico Inspección Auscultacion Palpación Percusión. Injuries of the extrahepatic bile ducts are a challenge due to their small size and thin walls. Translobar gunshot wounds of the liver are best controlled with balloon catheter tamponade, whereas deep lacerations can be controlled with Foley catheter inflation deep within the injury track (Fig. Acutely, <100 mL of pericardial blood may cause pericardial tamponade.16 The classic Beck’s triad—dilated neck veins, muffled heart tones, and a decline in arterial pressure—is usually not appreciated in the trauma bay because of the noisy environment and associated hypovolemia. Disclaimer, National Library of Medicine During laparotomy for blunt trauma, expanding or pulsatile perinephric hematomas should be explored. Not only do such devices allow minute-to-minute monitoring of the patient, but the added information on the patient’s volume status, cardiac function, peripheral vascular tone, and metabolic response to injury permits appropriate therapeutic intervention. Central pancreatectomy preserves the common bile duct, and mobilization of the pancreatic body permits drainage into a Roux-en-Y pancreaticojejunostomy (Fig. 7-21). Because uterine and retroperitoneal veins may dilate to 60 times their original size, hemorrhage from these vessels may be torrential. 1. Bei tieferen Gewebeverletzungen kann zusätzlich eine Ausräumung von Nekrosen und des Hämatoms notwendig werden (Grad II). Higher doses of LMWH are required in injured patients to attain adequate anti-Xa levels, and antiplatelet therapy should probably be added. 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. Domestic violence is also common, affecting between 10% and 30% of pregnant women and resulting in fetal mortality of 5%. EE, Biffl For destructive parenchymal or irreparable renovascular injuries, nephrectomy may be the only option; a normal contralateral kidney must be palpated, because unilateral renal agenesis occurs in 0.1% of patients. 7-47).49 Hypothermia from evaporative and conductive heat loss and diminished heat production occurs despite the use of warming blankets and blood warmers. In the 15% of patients for whom emergent laparotomy is mandated, the primary goal is to arrest hemorrhage. Urethrograms should be obtained for stable patients before placing a Foley catheter to avoid false passage and subsequent stricture. RA, Moore et al.. Predictors of outcome in trauma during pregnancy: Identification identification of patients who can be monitored for less than 6 hours. Lillemoe JA. Injuries to the ureters are uncommon but may occur in patients with pelvic fractures and penetrating trauma. et al.. Decompressive craniectomy for medical management for refractory intracranial hypertension: An AAST-MITC propensity score analysis. Determining fetal age is key for considerations of viability. Moreover, 25% of patients with a normal GCS score of 15 had intracranial bleeding, with an associated mortality of 50%.123 Just as there is no absolute age that predicts outcome, admission GCS score is a poor predictor of individual outcome. SJ, Morris Regelmäßige sonographische Untersuchungen sind deshalb obligat. Because esophagoscopy can miss injuries following an apparent normal endoscopy, patients at risk should undergo soluble contrast esophagraphy followed by barium examination to look for extravasation of contrast to identify an injury.39 As with neck injuries, hemodynamically stable patients with transmediastinal gunshot wounds should undergo CT scanning to determine the path of the bullet; this identifies the vascular or visceral structures at risk for injury and directs angiography or endoscopy as appropriate. With these issues in mind, additional diagnostic tests are discussed on an anatomic basis.
Additionally, because bullets and knives usually follow straight lines, adjacent structures are commonly injured (e.g., the pancreas and duodenum). Indications to limit the initial operation and institute DCS techniques include a combination of refractory hypothermia (temperature <35°C), profound acidosis, (arterial pH <7.2, base deficit <15 mmol/L), and refractory coagulopathy.49,65 The decision to abbreviate a trauma laparotomy is made intraoperatively as the patient’s clinical course becomes clearer and laboratory values become available.66. Injuries of the hepatic ducts are almost impossible to satisfactorily repair under emergent circumstances. Patients with ongoing hemodynamic instability, whether “nonresponders” or “transient responders,” require prompt intervention; one must consider the four categories of shock that may represent the underlying pathophysiology: hemorrhagic, cardiogenic, neurogenic, and septic. C. Three standard surgical laparotomy pads are placed on each side of the bladder, deep within the preperitoneal space; the fascia is closed with an O polydioxanone monofilament suture and the skin with staples. Gross hematuria demands evaluation of the genitourinary system for injury. Due to lack of mobility of the abdominal aorta, few injuries are amenable to primary repair. kritischem, Flächiges intra- und/oder extramuskuläres, Organfragmentierung, Hilusabriss oder Milzberstung, Oberflächliche Blutung bzw. 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. Liegen trotz unauffälliger Sonographie instabile Kreislaufverhältnisse vor, müssen weitere Untersuchungen angeschlossen werden, um weitere traumatische Ursachen (z. HHS Vulnerability Disclosure, Help CC, Biffl Heart and Thoracic Vascular Injury. MJ, Tsai Delay in addressing these systems that control vision, hearing, smelling, breathing, eating, and phonation may produce dysfunction and disfigurement with serious psychological impact. Cátedra Cirugía Dr. González. Specific injuries, their associated signs and symptoms, diagnostic options, and treatments are discussed in detail later in this chapter. et al.. DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. WL, Majercik Please consult the latest official manual style if you have any questions regarding the format accuracy. A. Patients with persistent pneumothorax, large air leaks after tube thoracostomy, or difficulty ventilating should undergo fiber-optic bronchoscopy to exclude a tracheobronchial injury or presence of a foreign body. Patients with high spinal cord disruption are at risk for shock due to physiologic disruption of sympathetic fibers. Pulmonary contusion often progresses during the first 12 hours. FS, Bair Patients with hemothorax must have a chest radiograph documenting complete evacuation of the chest; a persistent hemothorax that is not drained by two chest tubes is termed a caked hemothorax and mandates immediate thoracotomy (Fig. Liquid and clotted blood are evacuated with multiple laparotomy pads to identify the major source(s) of active bleeding. Penetrierende Verletzungsmuster wie nach Schuss- oder Stichverletzungen sind in Europa eher selten. A marked drop in nasogastric tube output heralds resolution of the hematoma, which typically occurs within 2 weeks; repeat imaging to confirm these clinical findings is optional. Patients in shock have a lower tolerance to warm ischemia, and an occluded extremity is prone to small vessel thrombosis. Alternatively, if the patient has an associated pancreatic injury, the graft should be tunneled from the distal aorta beneath the duodenum to the distal SMA. Upper extremity fasciotomy is rarely required unless the patient manifests preoperative neurologic changes or diminished pulse upon revascularization, or the time to operative intervention is extended. Ist der Patient kreislaufstabil, ist eine konservative Therapie unter intensivmedizinischer Überwachung möglich. Moore Several options exist for treating injuries of the pancreatic body and tail. 2007 Oct;78(10):894-901. doi: 10.1007/s00104-007-1397-2. The most common technique is to measure the patient’s bladder pressure. Hemorrhage from most major hepatic injuries can be controlled with effective perihepatic packing. For patients with open fractures, fracture reduction with stabilization via splints will limit bleeding both externally and into the subcutaneous tissues. C, Zannini G Over 90% of blunt renal injuries are treated nonoperatively. et al.. Single-layer continuous versus two-layer interrupted intestinal anastomosis: a prospective randomized trial. Pancreatic pseudocysts in patients managed nonoperatively suggest a missed injury, and ERCP should be done to evaluate the integrity of the pancreatic duct. Therefore, it should be the overall trend of the resuscitation rather than a rapid reduction of the base deficit that is the goal. Splenectomy is indicated for hilar injuries, pulverized splenic parenchyma, or any >grade II injury in a patient with coagulopathy or multiple injuries. Based on the initial response to fluid resuscitation, hypovolemic injured patients can be separated into three broad categories: responders, transient responders, and nonresponders. Following standard protocols for nonoperative management of blunt trauma avoids the risks associated with general anesthesia. Rarely, a biliary fistulous communication will form with intrathoracic structures in patients with associated diaphragm injuries, resulting in a bronchobiliary or pleurobiliary fistula. Aesthetic and cosmetic medical practices have attracted considerable consumer attention globally. Die posttraumatische Belastungsstörung wird auch posttraumatisches Belastungssyndrom genannt, da sie manchmal viele verschiedene Symptome umfasst. Patienten mit Abdominaltrauma werden in der Regel nach der Stabilisierung der Vitalparameter stationär aufgenommen. 7-61) to achieve partial immunocompetence in younger patients who do not have an associated enteric injury. To prevent aortic rupture, pharmacologic therapy with a selective β1 antagonist, esmolol, should be instituted in the trauma bay, with a target SBP of <100 mm Hg and heart rate of <100/min.36,83 Endovascular stenting is now the mainstay of treatment, but open operative reconstruction is warranted, or necessary, in select patients.84,85 Endovascular techniques are particularly appropriate in patients who cannot tolerate single lung ventilation, patients >60- years-old who are at risk for cardiac decompensation with aortic clamping, or patients with uncontrolled intracranial hypertension. 7-9). The uterus may also compress the ureters and bladder, causing hydronephrosis and hydroureter. • Privacy Policy
B. Maegele Close monitoring for calf compartment syndrome is mandatory. 7-72). JB. [17]. Chest film findings reflect the positioning of the patient. Subdural hematomas occur between the dura and cortex and are caused by venous disruption or laceration of the parenchyma of the brain. Patients with gunshot or stab wounds to the left lower chest should be evaluated with diagnostic laparoscopy or DPL to exclude diaphragmatic injury. 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). In contrast to diagnosis of pancreatic duct injuries, identification of intrapancreatic common bile duct disruption is relatively simple. Das Abdominaltrauma stellt nach wie vor eine Herausforderung im klinischen Alltag dar. In contrast, long-range shotgun blasts result in a diffuse pellet pattern in which many pellets miss the victim, and those that do strike are dispersed and of comparatively low energy. Eventuell können auch ein Urogramm und eine Urothro-Zystographie notwendig werden, wenn der Verdacht auf Verletzungen im Bereich der Harnblase besteht. With complete mobilization, the spleen can reach the level of the abdominal incision. B. Stitches are spaced 3 to 4 mm from the edge of the bowel and advanced 3 to 4 mm, including all layers except the mucosa. RS, Moore Ziel des Traumamanagement ist es, das Ausmaß und die Prognose des Abdominaltraumas rasch zu definieren, um die Prioritäten sowie die Reihenfolgen in Diagnostik und Therapie festzulegen. K Inadvertent femoral artery cannulation, however, may result in limb-threatening distal arterial spasm. ADVERTISEMENT: Supporters see fewer/no ads. 7-36). Air and thrombus are flushed from the aortic graft before the final suture is tied, and the occluding vascular clamps are removed. Massive air leak occurs from major tracheobronchial injuries. Sind bei der Wundexploration eine Verletzung des vorderen Faszienblatts ersichtlich und sonographisch freie abdominale Flüssigkeit nachweisbar, sollte eine explorative Laparoskopie durchgeführt werden. E, Lavoie 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. JF, Roberts Epidural hematomas occur when blood accumulates between the skull and dura, and are caused by disruption of the middle meningeal artery or other small arteries in that potential space, typically after a skull fracture (Fig. Unter dem Abdominaltrauma versteht man Verletzungen der Organe im Abdomen, die durch eine Gewalteinwirkung auf die Leibeswand hervorgerufen wurden. GB, Cameron 7-65).115 If the duodenal repair breaks down, the resultant fistula is an end fistula, which is easier to manage and more likely to close than a lateral fistula. The primary objectives of damage control laparotomy are to control bleeding and limit GI spillage. Resuscitation efforts aim for a euvolemic state and an SBP of >100 mm Hg. Blood transfusion rates, however, are significantly lower in patients managed nonoperatively than in patients undergoing operation (13% vs. 44%).139. Ann Surg 26: 524, Schiefers K, Gerometta P (1981) Blunt and penetrating abdominal injury. If access is needed to both pleural cavities, the original incision can be extended across the sternum with a Lebsche knife, into a “clamshell” thoracotomy (Fig. B. Alternatively, a medial approach with two incisions may be used. FA If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. 2014 Jan;45(1):122-7. doi: 10.1016/j.injury.2013.08.022. The evaluation for abdominal trauma in the pediatric patient is similar to that in the adult. Pancreatic fistula is diagnosed after postoperative day 5 in patients with drain output of >30 mL/d and a drain amylase level three times the serum value. Proximal control of the aorta is obtained at the diaphragmatic hiatus; if an aortic injury is supraceliac, transecting the left crus of diaphragm or extending the laparotomy via a left thoracotomy may be necessary. Life-threatening hemorrhage can be associated with pelvic fractures and may initially preclude definitive imaging. Ann Surg 204: 438–445, Lange DA, Zaret P, Merlotti GJ et al. Return of bowel function is indicated by a decrease in gastrostomy or nasogastric tube output. Federal government websites often end in .gov or .mil. Western Trauma Association multi-institutional study of enteral nutrition in the open abdomen after injury. Im Rahmen des Notfalllabors sollten ein Blutbild, eine Blutgerinnung, Leber-, Nieren-, Pancreasparameter sowie die Elektrolyte abgenommen werden. The principles of vascular repair techniques (discussed previously) apply to carotid injuries, and options for repair include end-to-end primary repair (often possible with mobilization of the common carotid), graft interposition, and transposition procedures. RT is best accomplished using a generous left anterolateral thoracotomy, with the skin incision started to the right of the sternum (Fig. et al.. Postinjury life- threatening coagulopathy: is 1:1 fresh frozen plasma: packed red blood cells the answer? Access to the pericardium is obtained through a subxiphoid approach, with the needle angled 45 degrees up from the chest wall and toward the left shoulder. The authors’ sequential closure technique for the open abdomen. 7-60). MA Patients who are symptomatic, defined by the presence of uterine irritability or contractions, abdominal tenderness, vaginal bleeding, or blood pressure instability, should be monitored in the hospital for at least 24 hours. Virtually all transections and any injury associated with significant tissue loss will require a Roux-en-Y choledochojejunostomy.103 The anastomosis is performed using a single-layer interrupted technique with 5-0 monofilament absorbable suture. Bei schwerer hämodynamischer Instabilität aufgrund einer (vermuteten) intraabdominellen Verletzung muss ggf. T, Talving The tongue of omentum not only obliterates potential dead space with viable tissue but also provides an excellent source of macrophages. Injury is the leading cause of death among children over the age of 1 year, with 15,000 to 25,000 pediatric deaths per year. Homicides, suicides, and other causes are responsible for another 50,000 deaths each year. Trotzdem kann es vor allem durch eine vorzeitige Plazentalösung zum intrauterinen Fruchttod kommen. Grade III: pseudoaneurysm. R, Nicholls Lustenberger In a patient with multisystem trauma, enteral access via gastrostomy tube or needle-catheter jejunostomy should be considered. Fox As a result, blunt trauma is associated with multiple widely distributed injuries, whereas in penetrating wounds the damage is localized to the path of the bullet or knife. 7,8. Mattox KL, Moore EE, Feliciano DV, eds. Daher ist bei stabilen Kreislaufverhältnissen eine weiterführende abgestufte Diagnostik gerechtfertigt. Removing as little as 15 to 20 mL of blood will often temporarily stabilize the patient’s hemodynamic status, and alleviate subendocardial ischemia with associated lethal arrhythmias, and allow safe transport to the OR for sternotomy. Although it may be estimated on chest radiograph, tube thoracostomy is the only reliable means to quantify the amount of hemothorax. PubMed Google Scholar. The distal internal carotid artery is exposed by dividing the ansa cervicalis, which permits mobilization of the hypoglossal nerve. Because hemorrhage from hepatic injuries often is treated without isolating individual bleeding vessels, arterial pseudoaneurysms may develop, with the potential for rupture. https://doi.org/10.1007/s10039-006-1205-0. More superior and lateral structures are accessed by extending the collar incision upward along the sternocleidomastoid muscle; this may be done bilaterally if necessary. This site uses cookies to provide, maintain and improve your experience. Vaughn WD, Hoffman-Snyder An RBC count of >10,000/μL is considered a positive finding and an indication for abdominal evaluation; patients with a DPL RBC count between 1000/μL and 10,000/μL should undergo laparoscopy or thoracoscopy. 7-36). B. Rapid exposure of the intra-abdominal vasculature can prove challenging in the face of exsanguinating hemorrhage. Urologic injuries may require catheter diversion. MM, Pachter To reduce anastomotic tension, the jejunum should be sutured to the areolar tissue of the hepatic pedicle or porta hepatis. Verletzte Trabekelgefäße müssen selektiv dargestellt und ligiert werden. et al.. Nonoperative management of solid organ injuries in children results in decreased blood utilization. Deterioration in mental status may be subtle and may not progress in a predictable fashion. WL, Kaups The aorta, subclavian artery, and brachial artery, however, are difficult to mobilize for additional length. Cox Such an approach is reasonable for venous injuries of the superior vena cava, suprarenal vena cava, SMV, and popliteal vein because ligation of these is associated with significant morbidity. et al.. Polytrauma / Schwerverletzten-Behandlung. J, et et al.. The most common approach has been to measure SBP using Doppler ultrasonography and compare the value for the injured side with that for the uninjured side, termed the A-A index.47 If the pressures are within 10% of each other, a significant injury is unlikely and no further evaluation is performed. The current role of operative rib fixation remains controversial. In situations where knives are embedded in the head or neck, preoperative imaging may be useful to anticipate arterial injuries. aScore is calculated by adding the scores of the best motor response, best verbal response, and eye opening. This is typically accomplished by applying a hard collar or placing sandbags on both sides of the head with the patient’s forehead taped across the bags to the backboard. Evaluation of the CVP may further assist in distinguishing between these two categories. High-velocity gunshot wounds (bullet speed >2000 ft/s) are infrequent in the civilian setting. Resectional débridement is indicated for the removal of peripheral portions of nonviable hepatic parenchyma. Rupture into a bile duct results in hemobilia, which is characterized by intermittent episodes of right upper quadrant pain, upper GI hemorrhage, and jaundice. A curved hemostat is a useful adjunct to create the curve. et al.. Imaging children with abdominal trauma. TG. Preferred access to the popliteal space for an acute injury is the medial one-incision approach with detachment of the semitendinosus, semimembranosus, and gracilis muscles (Fig. Early in the course of tamponade, blood pressure and cardiac output will transiently improve with fluid administration due to increased central venous pressure. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. Ein hypovolämischer Schock entsteht bei ausgeprägten Blutverlusten. The diagnosis of tension pneumothorax is presumed in any patient manifesting respiratory distress and hypotension in combination with any of the following physical signs: tracheal deviation away from the affected side, lack of or decreased breath sounds on the affected side, and subcutaneous emphysema on the affected side. 7-7). These patients mandate immediate identification of the source of hypotension with appropriate intervention to prevent a fatal outcome. Diese kann entscheidende diagnostische Hinweise geben und beinhaltet zudem die Möglichkeit einer gleichzeitigen Therapie. AS, Turner The most common injuries from both blunt and penetrating thoracic trauma are hemothorax and pneumothorax. The typical case is a patient with a penetrating thoracic injury who is hemodynamically stable but experiences cardiac arrest after being intubated and placed on positive pressure ventilation. An initial approximation of the patient’s cardiovascular status can be obtained by palpating peripheral pulses. Because of the proximity of other portal structures and the vena cava, associated vascular injuries are common. Alternatively, open ends of the bowel may be ligated using umbilical tapes to limit spillage. Accidentes de tráfico (alrededor del 70%) Lesiones por impacto (alrededor del 15%) Caídas (aprox. Duodenal injuries with tissue loss distal to the papilla of Vater and proximal to the superior mesenteric vessels are best treated by Roux-en-Y duodenojejunostomy with the distal portion of the duodenum oversewn (Fig. Operative intervention after blunt trauma is limited to renovascular injuries and destructive parenchymal injuries that result in hypotension. Feliciano Massive hemoperitoneum and mechanically unstable pelvic fractures are discussed in “Emergent Abdominal Exploration” and “Pelvic Fractures and Emergent Hemorrhage Control,” respectively. III) können mittels temporärer Kompression, Parenchymnaht, Infrarot- oder Argonkoagulation sowie Kollagenvlies oder Fibrinkleber versorgt werden. The authors prefer to leave the kidney in situ when mobilizing the viscera because this exaggerates the separation of the renal vessels from the SMA. Significant neurologic recovery is rare. In these patients, secondary large bore cannulae should be obtained via the femoral or subclavian veins, or saphenous vein cutdown; Cordis introducer catheters are preferred over triple-lumen catheters. Insbesondere die Verletzung der parenchymatösen Organe bestimmt die Prognose und den Verlauf des Patienten. Insertion of a Pruitt-Inahara shunt (arrow) provides temporary restoration of blood flow, which prevents ischemia during fracture treatment. JM, Collier Palpating the anterior surface is not sufficient, because the investing fascia may mask a pancreatic injury; mobilization, including evaluation of the posterior aspect, is critical. They should be counseled regarding warning signs that mandate prompt return to the ED. Small injuries without loss of tissue can be treated with lateral suture repair. EE, Sauaia A particular challenge in the pregnant trauma patient is a major pelvic fracture. If DPL is pursued, an infraumbilical approach is used (Fig. Three-dimensional computed tomographic scan illustrating Le Fort II maxillary (L) and alveolar (A) fractures, and fracture of the mandible (M) at the midline and at the weaker condyle (C). All injured patients should receive supplemental oxygen and be monitored by pulse oximetry. JP, Magnotti sharing sensitive information, make sure you’re on a federal N, Rajani 2), wobei 75% dem Grad I–III zugeordnet werden können [11]. In these cases, often after a “clothesline” injury, direct visualization and instrumentation of the trachea usually is done through the traumatic anterior neck defect or after a generous collar skin incision (Fig. However, potentially lethal lacerations of internal organs can occur, because the net energy transfer to any given location may be substantial. 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.
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