Textbook of Polytrauma Management: A Multidisciplinary Approach

✍ Scribed by Hans-Christoph Pape (editor), Joseph Borrelli Jr. (editor), Ernest E. Moore (editor), Roman Pfeifer (editor), Philip F. Stahel (editor)

• Publisher: Springer
• Year: 2022
• Tongue: English
• Leaves: 661
• Category: Library

✦ Synopsis

This textbook is a fully updated and revised third edition of a highly successful practical guide to the care of the polytrauma patient. Broadening its readership to students, this new edition comprehensively describes the clinical course of multiple and severe injuries, from the accident scene to rehabilitation.

It provides essential practical information on the care of patients both with blunt and penetrating trauma to multiple body regions, and discusses the management of truncal injuries (head, chest, abdomen) as well as fractures of the extremities, pelvis and spine. Further, the book highlights associated injuries that may alter decisions concerning patients with polytrauma.

This new, revised edition takes full account of recent developments, including the increasing economic pressure on health care systems, prehospital treatment, changes in trauma systems and related education, and the improved survival of polytrauma patients. Also covering improved monitoring options along with issues in late patient outcomes and rehabilitation this work will greatly assist students, emergency personnel, trauma surgeons, orthopaedic traumatologists, and anesthesiologists.

✦ Table of Contents

Foreword
Preface
Contents
Part I: General Aspects of Trauma Care
1: Impact of Trauma on Society
1.1 Introduction
1.1.1 Definitions
1.1.2 Case Load of Trauma
1.1.3 What Type of Trauma/Injury? Polytrauma—Potentially Life-Threatening Combination of Injuries
1.1.4 Sport and Fun
1.1.5 Impact
1.1.6 Conclusion
References
2: Economic Aspects of Trauma Care
2.1 Introduction
2.2 Cost of Injury
2.3 Implications of Economic Prosperity
2.4 Prevention
2.4.1 Road Traffic Injuries
2.4.2 Osteoporosis
2.5 Economical Impact of Osteosynthesis in Trauma Care
2.6 Conclusion
References
3: Evidence-Based Trauma Care
3.1 Principles of Evidence-Based Management
3.2 Quality of Evidence and the Hierarchy of Evidence
3.3 Presentation of Research Findings
3.4 Making Recommendations
3.5 Conclusion
References
Part II: Acute Period (1–3 h)/Prehospital Phase and Trauma Bay
4: Trauma System and Rescue Strategies
4.1 Trauma Systems
4.1.1 Definition of Trauma System
4.1.2 Trauma System Components
4.1.3 Implementing, Monitoring, and Improving Trauma Systems
4.1.3.1 Education and Training
4.1.3.2 System Evaluation and Quality Management
4.1.3.3 Hospital Resources
4.1.3.4 Interhospital Transfer
4.2 Rescue Strategies
4.2.1 First Tier: First Responders
4.2.2 Second Tier: Basic Prehospital Trauma Care
4.2.3 Third Tier: Advanced Prehospital Trauma Care
4.2.4 “Scoop and Run” Versus “Stay and play”
4.2.5 Prehospital Endotracheal Intubation
4.2.6 Prehospital Fluids
4.2.7 Field Triage Scores
4.3 Conclusion
References
5: Preclinical Management/Rescue
5.1 Introduction
5.2 The Basic Concept
5.3 Special Features of Individual Body Regions
5.3.1 Skull and Brain Trauma
5.3.2 Thoracic Injuries
5.3.3 Abdominal Injuries
5.3.4 Spinal and Pelvic Injuries
5.3.5 Extremity Injuries
5.3.6 Soft Tissue Injuries and Burns
5.4 Other Special Features
5.4.1 Strategic Aspects
5.4.2 Mass Casualty Incident
5.4.3 Principles for Drug Therapy in the Out-of-Hospital Phase
5.5 Case Report
5.6 Take-Home-Message and Conclusion
References
6: Initial Assessment and Diagnostics
6.1 Introduction
6.2 The Primary Survey
6.2.1 A—Airway
6.2.2 B—Breathing
6.2.3 C—Circulation
6.2.3.1 “Is the Patient in Shock?”—Clinical Assessment
Stable
Borderline (“At Risk”)
Unstable
In Extremis
6.2.3.2 “Is the Patient in Shock?”—Laboratory Tests
6.2.3.3 Postinjury Coagulopathy
6.2.3.4 Imaging Studies
6.2.3.5 Monitoring Resuscitation
6.2.4 D—Disability
6.2.5 E—Exposure
6.3 Secondary and Tertiary Survey
6.4 Conclusion
References
7: Volume and Blood Management
7.1 Introduction
7.2 Volume Therapy
7.3 Transfusion Management
7.4 Coagulation Management
7.5 Management of Anticoagulated Trauma Patients
7.5.1 Screening for Oral Anticoagulants
7.5.2 Reversal and Treatment of Oral Anticoagulants
7.5.2.1 Reversal of Vitamin K-Dependent Oral Anticoagulants
7.5.2.2 Reversal of Factor Xa Inhibitors
7.5.2.3 Reversal of Direct Thrombin Inhibitors
7.5.2.4 Reversal of Platelet Inhibitors
7.6 Conclusion
References
8: Resuscitative Endovascular Balloon Occlusion of the Aorta
8.1 Introduction
8.2 REBOA for Pelvic Fractures and Refractory Shock
8.3 An FDA Approved Device for Trauma
8.4 Procedural Steps
8.5 Treatment Algorithm
8.6 Techniques to Reduce Ischemia
8.7 Potential Complications
8.8 Future Directions
8.9 Conclusion
References
9: Preperitoneal Pelvic Packing
9.1 Background
9.2 Initial Evaluation and Management of the Pelvic Fracture Patient
9.3 Indications for Preperitoneal Pelvic Packing
9.4 Operative Approach
9.5 Role of Angiography
9.6 PPP Outcomes
9.7 Conclusion
References
Part III: Primary Period (First 72 h)/Clinical Phase
10: Pathophysiology: Trauma-Induced Coagulopathy
10.1 Introduction
10.2 Cell Mediated Hemostasis
10.3 Diminished Thrombin Generation
10.4 Platelet Dysfunction
10.5 Endotheliopathy
10.6 Hypofibrinogenemia
10.7 Fibrinolysis Dysregulation
10.8 Conclusion
References
11: The Inflammatory and Barrier Response After Polytrauma
11.1 Sensing of Danger After Polytrauma by the Immune System
11.1.1 Sensing of DAMPs
11.1.2 Sensing of MAMPs
11.2 Innate Immune Response After Polytrauma Drives Inflammation
11.2.1 Fluid Phase
11.2.2 Cellular Phase
11.3 Monitoring of the Posttraumatic Immune Response
11.3.1 Static Immune Monitoring
11.3.2 Functional Immune Monitoring
11.4 Posttraumatic Immune and Organ Dysfunction is Driven by Haemorrhagic Shock
11.5 Polytrauma-Induced Barrier Dysfunction
11.5.1 Macrobarriers
11.5.2 Microbarriers
11.6 Barrier Breakdown Drives Organ Failure After Polytrauma
11.7 Conclusion/Outlook
References
12: Pathophysiology: Remote Organ Injury
12.1 Introduction
12.2 Danger Associated Molecular Patterns
12.2.1 Protein DAMPs
12.2.2 Non-protein DAMPs
12.3 Immune Cells and Organ Dysfunction After Trauma
12.3.1 Polymorphonuclear Granulocytes
12.3.2 Monocytes/Macrophages
12.3.3 Lymphocytes
12.4 Humoral Factors and Organ Dysfunction After Trauma
12.4.1 Complement System
12.4.2 TNF-Alpha
12.4.3 Interleukin-1β
12.4.4 Interleukin-6
12.4.5 Interleukin-10
12.5 Conclusion
References
13: Polytrauma Scoring
13.1 Introduction
13.2 Anatomically Based Scoring Systems
13.2.1 Abbreviated Injury Scale (AIS)
13.2.2 Injury Severity Score (ISS)
13.2.3 New Injury Severity Score (NISS)
13.3 Pre-Hospital Scoring Systems
13.3.1 Revised Trauma Score (RTS)
13.3.2 Trauma and Injury Severity Score (TRISS)
13.3.3 Revised Injury Severity Classification RISC
13.3.4 The AdHOC Score
13.4 In-Hospital Scoring Systems
13.4.1 Early Appropriate Care (EAC) Protocol
13.4.2 Clinical Grading Scale (CGS)
13.4.3 Polytrauma Grading Score (PTGS)
13.5 Summary of Scoring Systems
13.5.1 Pre-Hospital Scoring Systems
13.5.2 In-Hospital Scoring Systems
13.6 Conclusion
References
14: Head Injuries
14.1 Introduction
14.2 The Quest for a Serum Biomarker
14.3 Hypoxia and Hypotension: The “Lethal Duo”
14.4 Classification of Head Injuries
14.4.1 Severity of Injury (GCS)
14.4.2 Morphology of Injury (CT)
14.4.2.1 Skull Fractures
14.4.2.2 Intracranial Lesions
14.5 Initial Assessment and Management
14.6 Pharmacological Therapy
14.7 Surgical Management
14.7.1 Scalp Wounds
14.7.2 Depressed Skull Fractures
14.7.3 Intracranial Mass Lesions
14.8 The “Polytrauma Conundrum”: TBI with Associated Femur Fracture
14.9 Conclusion
References
15: Chest Trauma: Classification and Influence on the General Management
15.1 Introduction
15.2 Injuries After Chest Trauma
15.2.1 Chest Wall Injuries
15.2.2 Injuries of the Intrathoracic Organs
15.2.2.1 Pleural Injuries
15.2.2.2 Diaphragm Injuries
15.2.2.3 Lung Injuries
15.2.2.4 Injuries to the Mediastinum
15.2.3 The Deadly Dozen
15.2.4 Pediatric Chest Trauma
15.3 Diagnostics
15.3.1 Plain Chest X-Ray
15.3.2 Computed Tomography
15.3.3 Thoracic Ultrasonography
15.3.4 Bronchoscopy
15.3.5 3D Printing for Surgical Stabilization of Rib Fractures
15.4 Classification
15.4.1 Abbreviated Injury Scale
15.4.2 Pulmonary Contusion Score
15.4.3 Computed Tomography-Dependent Wagner Score
15.4.4 Thoracic Trauma Severity Score
15.5 Treatment
15.5.1 Airway Management
15.5.2 Mechanical Ventilation
15.5.3 Positioning Therapy
15.5.4 Fracture treatment in multiple-trauma patients with thoracic trauma
15.5.5 Surgical Chest Wall Stabilization
15.5.6 Video-Assisted Thoracoscopic Surgery
15.6 Conclusion
References
16: Blunt Abdominal Trauma
16.1 Introduction
16.2 Clinical Evaluation
16.3 Diagnostic Testing
16.3.1 Focused Assessment by Sonography for Trauma
16.3.2 Diagnostic Peritoneal Aspiration (DPA)
16.3.3 Computed Tomography (CT)
16.4 Conduct of the Exploratory Laparotomy for Trauma
16.4.1 General Considerations and Setup
16.4.2 Initial Priorities
16.4.3 Systematic Exploration
16.5 Specific Organ Injury
16.5.1 Diaphragm
16.5.2 Hollow Viscus
16.5.3 Duodenum and Pancreas
16.5.3.1 Duodenum
16.5.3.2 Pancreas
16.5.4 Spleen
16.5.5 Liver
16.6 Conclusion
References
17: Penetrating Injuries of the Thorax
17.1 Introduction
17.2 Resuscitative Thoracotomy
17.2.1 Indications and Contraindications
17.2.2 Technique and Staff Safety
17.3 Tension Pneumothorax
17.3.1 Needle Decompression
17.3.1.1 Hemopneumothorax
17.3.2 Tube Thoracostomy
17.4 Cardiac Injury
17.4.1 Identification and Imaging
17.4.2 Indications to Intervene
17.4.3 Operative Exposure
17.4.4 Repair Options
17.4.5 Complications
17.5 Lung Injury
17.5.1 Identification and Imaging
17.5.2 Indications to Operate
17.5.3 Techniques for Exposure
17.5.4 Repair Options
17.6 Esophageal Injury
17.6.1 Identification and Imaging/Endoscopy
17.6.2 Indications for Operative Management
17.6.3 Exposure
17.6.4 Repair Options
17.6.5 Complications
17.7 Conclusion
References
18: Penetrating Abdominal Trauma
18.1 Introduction
18.2 Mandatory Laparotomy
18.3 Selective Nonoperative Management
18.3.1 Thoracoabdomen
18.3.2 Back/Flank
18.3.3 Anterior Abdomen
18.3.4 Gunshot Wounds
18.4 Conclusion
References
19: Pelvic Ring Injuries
19.1 Introduction
19.2 Classification of Pelvic Ring Injuries
19.3 The 2017 WSES Classification
19.4 The Role of Pelvic Binders
19.5 “Damage Control” External Pelvic Fixation
19.6 Pelvic Packing
19.7 Novel Innovative Concepts
19.7.1 Examination Under Anesthesia
19.7.2 Percutaneous Pelvic Ring Fixation
19.8 Conclusion
References
20: Spine Fractures
20.1 Introduction
20.2 Spine Fracture Classification
20.3 Spine Fracture-Dislocations
20.4 Diagnostic Workup
20.5 Spinal Precautions
20.6 Spinal Clearance
20.7 Initial Management
20.7.1 General Principles
20.7.2 Subaxial Cervical Spine
20.7.3 Thoracic and Lumbar Spine
20.7.4 Specific Injury Patterns
20.7.4.1 Occipital Condyle and Atlas Fractures
20.7.4.2 Odontoid Fractures
20.7.4.3 “Hangman’s Fracture”
20.7.4.4 “Chance” Fracture
20.7.4.5 Sacral Fractures
20.8 Surgical Timing
20.9 Postoperative Rehabilitation
20.10 Conclusion
References
21: Spinal Cord Injury
21.1 Introduction
21.2 Pathophysiology
21.3 Diagnostic Workup
21.4 Neurologic Evaluation
21.5 Terminology and Specific Injury Patterns
21.6 Neurogenic Versus Spinal Shock
21.7 Decision-Making and Treatment Options
21.8 Surgical Considerations
21.9 Surgical Timing
21.10 Principles of Postoperative Care
21.11 Special Considerations
21.11.1 The Role of Steroids Revisited
21.11.2 Riluzole
21.11.3 Blood Pressure Augmentation
21.11.4 Thromboembolic Prophylaxis
21.11.5 Timing of Tracheostomy
21.11.6 Gunshot Injuries
21.12 Conclusion
References
22: Urological Injuries in Polytraumatized Patients
22.1 Introduction
22.2 Renal Trauma
22.2.1 Clinical Symptoms
22.2.2 Imaging Studies
22.2.3 Treatment
22.2.4 Selective Angioembolizsation
22.3 Ureteral Trauma
22.3.1 Clinical Symptoms
22.3.2 Imaging
22.3.3 Management
22.4 Bladder Trauma
22.4.1 Clinical Symptoms
22.4.2 Imaging
22.4.3 Treatment
22.5 Urethral Trauma
22.5.1 Clinical Symptoms
22.5.2 Radiographic Examination
22.5.3 Treatment
22.5.3.1 Treatment for Urethral Injuries in Males
22.5.3.2 Treatment of Urethral Injuries in Females
References
23: Gyn. Injuries/Pregnant Patient in Polytrauma
23.1 The Pregnant Polytrauma Patient
23.2 Anatomic and Physiologic Changes During Pregnancy
23.3 The Right Patient to the Right Hospital
23.4 General Assessment of the Injured Pregnant Patient
23.4.1 Primary Survey
23.4.2 Guideline Recommendation During Primary Survey [28]
23.4.3 Secondary Survey
23.5 Radiological Assessment
23.5.1 Radiation Effects During Intrauterine LIFE
23.5.2 Cancer Risk After Intrauterine Irradiation
23.5.3 Genetic Effects After Irradiation
23.5.4 Imaging of the Pregnant Patient
23.6 General Recommendations for Surgical Interventions
23.6.1 Intraoperative Radiology
23.7 General Orthopedic Surgical Management
23.8 General Outcomes
23.9 Pelvic Fractures in Pregnant Polytrauma Patient
23.9.1 Pelvic Ring Injuries in Pregnant Patients
23.9.1.1 Pelvic Joint Changes During Pregnancy
23.9.1.2 Data on Pelvic Ring Fractures
23.9.2 Acetabular Fractures in Pregnant Patients
23.10 Special Features in treating Pregnant Women with Pelvic Ring Fractures
23.11 Vaginal Delivery After Pelvic Fractures
23.11.1 The Value of Implant Removal
23.12 Special Gynecological Injuries
23.12.1 Vulva Trauma
23.12.2 Vaginal Injury
23.12.2.1 Treatment
23.12.3 Rectal Injuries
23.12.4 Uterus Trauma
23.13 Summary
References
24: Vascular Injuries
24.1 Damage Control in Vascular Injury
24.2 REBOA
24.2.1 Indications
24.2.2 Technique
24.2.3 Complications
24.2.4 Courses
24.3 Hybrid Rooms
24.3.1 General Operative Techniques
24.3.2 Temporary Occlusion
24.3.3 Flow Restoration
24.3.3.1 Shunts
24.3.3.2 Lateral Repair
24.3.3.3 Stents
24.3.3.4 Complex Repairs and Grafts
24.3.4 Definitive Occlusion
24.3.4.1 Ligation
24.3.4.2 Coiling
24.3.4.3 Hemostatic Agents and Glues
24.3.4.4 Amputation
References
25: Compartment Syndrome: Pathophysiology, Diagnosis, and Treatment
25.1 Introduction
25.2 Diagnosis
25.3 History and Physical Examination
25.4 Interpretation of Intra-compartmental Pressures
25.5 Laboratory Measures
25.5.1 Treatment: Upper Extremity—Arm
25.5.2 Fasciotomies: Authors Preferred Technique
25.5.3 Treatment: Upper Extremity—Forearm
25.5.4 Fasciotomies: Authors Preferred Technique
25.6 ACS of the Hand
25.6.1 Fasciotomies: Authors Preferred Technique
25.7 Treatment: Lower Extremity
25.7.1 ACS of the Gluteal Compartment
25.7.2 Fasciotomies: Authors Preferred Technique
25.8 ACS of the Thigh
25.8.1 Fasciotomies: Authors Preferred Technique
25.9 ACS of the Leg
25.9.1 Fasciotomies: Authors Preferred Technique
25.10 ACS of the Foot
25.10.1 Fasciotomies: Authors Preferred Technique
25.10.2 Prognosis
25.10.3 Well Leg Compartment Syndrome (WLCS)
25.11 Wound Management After Fasciotomies
25.11.1 Authors Preferred Technique
25.12 Systemic Morbidity of ACS
25.12.1 Missed Compartment Syndrome
25.12.2 Author’s Preferred Technique
25.12.3 Morbidity of Properly Timed Fasciotomy
25.13 Outcomes
25.14 Summary
References
26: Damage Control in Abdomen and Thorax
26.1 Statement of Problem and Historical Context
26.2 Damage Control Resuscitation in the Pre-operative Phase: Initiation of Goal-Directed Resuscitation Without Delaying Surgery
26.3 Abdominal Damage Control Surgery and Organ-Specific Damage Control Maneuvers
26.3.1 Hollow Viscus
26.3.2 Liver
26.3.3 Spleen
26.3.4 Pancreas
26.3.5 Kidney/Ureter/Bladder
26.3.6 Intra-Abdominal Vascular
26.3.7 Management of the Open Abdomen
26.4 Thoracic Damage Control
26.4.1 Cardiac
26.4.2 Intra-Thoracic Vascular
26.4.3 Pulmonary
26.4.4 Chest Wall
26.4.5 Aerodigestive
26.4.6 Temporary Chest Closure
26.5 Damage Control Resuscitation in the Operating Room and Post-operatively
26.6 Conclusions
References
27: Fracture Management
27.1 Introduction
27.2 Assessment of the Fracture
27.2.1 Soft Tissue Injury in Closed Fractures
27.2.2 Open Fractures
27.3 Fracture Treatment
27.3.1 Upper Versus Lower Extremity Injuries
27.3.2 Fracture Care in Serial Extremity Fractures
27.4 Stages in Polytrauma
27.4.1 Acute Phase (1–3 h After Admission): Resuscitation/Hemorrhage Control
27.4.2 Primary Phase (1–48 h): Stabilization of Fractures
27.4.3 Secondary Period (2–10 Days): Regeneration
27.4.4 Tertiary Period (Weeks to Months after Trauma): Reconstruction and Rehabilitation
27.5 Assessment of the Patient
27.6 Physiology of Staged Treatment
27.6.1 Stable Condition
27.6.2 Borderline Conditions
27.6.3 Unstable
27.6.4 In Extremis Condition
27.7 Patient Assessment for Initial Definitive Surgery Versus Temporizing Orthopedic Surgery
27.8 Special Situations
27.8.1 Surgical Priorities in the Presence of Additional Head Injuries
27.8.2 Surgical Priorities in the Presence of Additional Chest Injuries
27.8.3 Surgical Priorities in the Presence of Additional Pelvic Ring Injuries
27.9 Conclusion
References
28: Mangled Extremity: Management in Isolated Extremity Injuries and in Polytrauma
28.1 Introduction
28.2 Mechanism of Injury
28.3 Common Injury Patterns
28.4 Scoring Systems
28.5 Management
28.6 Complications
28.7 Predictive Ability of Scoring Systems to Predict Final Outcome
28.8 Outcomes Following Limb Salvage Versus Amputation
28.9 Cost of Care
28.10 The Mangled Upper Extremity
28.11 The Mangled Extremity and Polytrauma
28.12 Conclusions
References
29: Surgical Management: Elderly Patient with Polytrauma
29.1 Introduction
29.2 Physiologic Differences between Younger Adults and Older Adults in the Trauma Situation
29.2.1 Physiologic Differences
29.2.2 Medical Comorbidities
29.3 Common Mechanisms of Injury
29.4 Frequent Patterns of Injury
29.4.1 Pelvic Ring Injuries
29.4.1.1 Representative Case: Non-op Pelvic Fracture Can Have Significant Bleeding Risk
29.4.2 Acetabular Fractures
29.4.2.1 Representative Case: Medium Energy Injury, High-Energy Fracture
29.4.3 Spine Fractures
29.4.4 Hip Fractures
29.4.5 Traumatic Brain Injury
29.4.6 Rib Fractures
29.5 Relevance of Scoring Systems
29.6 Appropriate Triage of the Older Adult Involved in Trauma
29.7 Initial Evaluation and Resuscitation
29.8 Pain Control/Anesthesia
29.9 Co-Management with Geriatrics and Palliative Care Specialists
29.10 Timing of Surgery
29.10.1 Representative Case: Timing of Surgery and Appropriate Team-Based Clearance
29.11 Initial Operative Management
29.12 Secondary Operative Management
29.12.1 Open Fractures
29.12.2 Osteoporotic Fractures
29.12.3 Peri- and Intra-Articular Fractures
29.12.4 Periprosthetic Fractures
29.12.4.1 Representative Case: Open Fractures and Osteoporotic Bone (High Energy Leads to Devastating Injury Complex)
29.13 Post-op Complications
29.14 Secondary Fracture Prevention and Fracture Liaison Services
29.15 Outcomes of Care and Expectations for the Patient and Family
29.16 Conclusions
References
30: Pediatric Polytrauma Management
30.1 Initial Assessment and Resuscitation
30.2 Head Injuries
30.3 Chest Injuries
30.4 Abdominal Injuries
30.4.1 Liver and Splenic Injuries
30.4.2 Hollow Viscus Injuries
30.4.3 Pancreatic Injuries
30.5 Pelvic Injuries
30.5.1 Pelvic Ring Fractures
30.5.2 Acetabulum Fractures
30.5.3 Associated Injuries
30.6 Spine Injuries
30.6.1 Cervical Spine Fractures
30.6.2 Thoracolumbar Spine Fractures
30.7 Extremity Trauma
30.7.1 Principles of Care
30.8 Pediatric Critical Care
30.9 Conclusion
References
31: Surgical Management: Management of Traumatic Bone Defects
31.1 Introduction
31.1.1 Epidemiology
31.1.2 Initial Patient Management
31.1.3 Reconstruction Versus Amputation
31.2 Skeletal Fixation and Soft Tissue Coverage
31.3 Management of Bone Defects
31.3.1 Definition of “Critical”-Sized Bone Defect
31.3.2 Autologous Bone Grafts
31.3.3 Distraction Osteogenesis (Ilizarov Technique)
31.3.4 Vascularized Bone Grafts (VBG)
31.3.5 Induced Membrane Technique (IMT)
31.3.6 Titanium Mesh Cages
31.3.7 Arthroplasty—Megaprosthesis
31.4 Conclusion
References
32: Surgical Management: Acute Soft Tissue and Bone Infections
32.1 Introduction
32.2 Classification of SSTIs
32.3 Specific Types of SSTIs
32.3.1 Traumatic Wound Infections
32.3.2 Surgical Site Infections (SSIs)
32.3.2.1 SSI Prevention
32.3.2.2 Microbiology of SSIs
32.3.2.3 Closed Long Bone Fractures
32.3.2.4 Open Fractures
32.3.3 Necrotizing Soft Tissue Infections (NSTIs)
32.3.3.1 Aids to Diagnosis of NSTIs
32.3.3.2 Diagnostic Imaging in NSTIs
32.3.3.3 Microbiology of NSTIs
32.3.4 Pyomyositis
32.3.4.1 Fracture-Related Infection (FRI)
32.3.5 Osteomyelitis
32.3.5.1 Microbiology of Osteomyelitis
32.3.5.2 Surgical Treatment of Osteomyelitis
32.3.6 Four Important Steps in SSTI Treatment
32.3.6.1 Early Diagnosis and Differentiation of Necrotizing Vs. Non-necrotizing SSTI
32.3.6.2 Early Initiation of Appropriate Empiric Broad-Spectrum Antimicrobial Therapy with Anti-MRSA Coverage and Consideration of Risk Factors for Specific Pathogens
Epidemiology and Microbiology of SSTIs
32.3.6.3 “Source Control,” I.E., Early Aggressive Surgical Intervention for Drainage of Abscesses and Debridement of Necrotizing Soft Tissue Infections
32.3.6.4 Pathogen Identification and Appropriate Escalation or de-Escalation of Antimicrobial Therapy
32.4 Conclusion
References
Part IV: Secondary Period (3–8 Days)
33: ICU Management: Disseminated Intravascular Coagulation (DIC)
33.1 Introduction
33.2 Trauma-Induced Coagulopathy and DIC
33.3 The Definition and Diagnosis
33.3.1 The Definition
33.3.2 The Diagnosis
33.4 Phenotypes and Time Courses
33.4.1 Phenotypes
33.4.2 Time Courses
33.5 Pathophysiology
33.5.1 Cytokines
33.5.2 Protease-Activated Receptors (PARs)
33.5.3 DAMPs and NETs
33.5.3.1 Cytokines and SIRS
33.5.3.2 Platelets and Coagulation
33.5.3.3 Anticoagulant Systems and Endothelial Cells
33.5.3.4 Activation and Impairment of Fibrinolysis
33.5.3.5 Brief Summary
33.5.4 Multiple Actions of Thrombin
33.6 MODS and the Prognosis
33.6.1 Microvascular Thrombosis
33.6.2 Histones and NETs
33.7 Management
33.7.1 Rationale
33.7.1.1 Why
33.7.1.2 To Whom
33.7.1.3 When
33.8 Underlying Disorders
33.9 Substitution Therapy
33.9.1 Anticoagulants
33.9.1.1 Heparin
33.9.1.2 Anticoagulant Factor Concentrates
33.9.2 Antifibrinolytics
33.9.3 Histones and NETs
33.10 Conclusions
References
34: Early ICU Management of Polytrauma Patients Who Develop Sepsis
34.1 Introduction
34.2 The Evolving Definition of Sepsis
34.3 Historic Perspective of Early Evidence-Based Sepsis Care
34.4 Current SSC EBG Care of Sepsis as It Pertains to Polytrauma Patients
34.5 Conclusion
References
35: Polytrauma and Multiple Organ Dysfunction
35.1 Introduction to Multiple Organ Dysfunction
35.1.1 Overview
35.1.2 Definitions of Multiple Organ Dysfunction
35.1.3 Scoring Systems
35.1.4 Epidemiology
35.1.5 Phenotypes
35.1.6 Intensive Care Utilization and Cost
35.2 Pathophysiology
35.2.1 Historical Context
35.2.2 Pathophysiologic Mechanisms and Host Responses to Injury
35.3 Actors Implicated in MOD Pathophysiology
35.3.1 Complement
35.3.2 Leukocytes
35.3.3 Platelets
35.3.4 Cytokines
35.3.5 The Gut
35.3.6 Secondary Insults
35.3.6.1 Transfusion
35.3.6.2 Infection and Sepsis
35.3.6.3 Surgery and Damage Control
35.4 Interventions to Prevent MOD
35.4.1 Damage Control Resuscitation
35.4.2 Judicious Use of Blood and Blood Product Transfusion
35.4.3 Timing of Secondary Interventions
35.4.4 Prevention of Ventilator-Induced Lung Injury
35.4.5 Immunonutrition
35.5 Long-Term Outcomes
35.6 Conclusion
References
36: ICU Management: General Management in the Elderly in ICU
36.1 Background
36.1.1 Frailty
36.1.2 Preexisting Conditions
36.1.3 Trauma Mechanism
36.1.4 Injury Severity
36.2 ICU Treatment for Geriatric Polytrauma
36.2.1 General Considerations
36.2.2 Development of Consensus Group
36.2.3 Therapeutic Options
36.2.3.1 Option A
36.2.3.2 Option B
36.2.3.3 Option C
36.3 Summary
References
37: ICU Management: Clearing Patients for Surgery
37.1 Introduction
37.2 Clinical Status After 24–48 h After ICU Admission
37.3 Clinical Status Following Day 2 After ICU Admission
References
38: ICU Management: Venous Thromboembolism
38.1 Definition and Epidemiology of Venous Thromboembolism
38.2 Risk Factors of VTE
38.3 VTE in Polytrauma Patients
38.4 Goal of VTE Care for Polytrauma Patients
38.5 Screening of VTE for Polytrauma Patients
38.6 VTE Prophylaxis for Polytrauma Patients
38.7 Mechanical Thromboprophylaxis
38.8 Chemical Thromboprophylaxis
38.8.1 Heparins
38.8.2 Fondaparinux
38.9 Inferior Vena Cava Filter
38.10 The American College of Chest Physicians Guidelines, 9th Edition
38.11 Treatment of VTE
38.12 Case Studies
38.12.1 Case 1: A 57-Year-Old Man
38.12.2 Case 2: A 71-Year-Old Man
38.13 Conclusion
References
Part V: Tertiary Period (After 8 Days)/Rehabilitation
39: Rehabilitation Strategies in Polytrauma
39.1 Introduction
39.2 Aims of Rehabilitation in Polytrauma
39.3 Phases of Rehabilitation
39.4 Outcome
References
40: Treatment of Fracture-Related Infections
40.1 Introduction
40.2 Pathogenesis
40.3 Definition and Diagnosis
40.3.1 Clinical Features
40.3.2 Laboratory Examination
40.3.3 Imaging Procedures
40.3.4 Microbiology and Histopathology
40.4 Treatment
40.4.1 General Considerations
40.4.2 Surgical Concepts
40.4.3 Antimicrobial Concepts
40.4.3.1 Empiric Antibiotic Therapy
40.4.3.2 Targeted Antibiotic Therapy
40.5 Follow-Up
40.6 Conclusion
References
41: Management of Aseptic Malunions and Nonunions
41.1 Introduction
41.2 Patient Evaluation and Diagnosis
41.3 Classification of Nonunion
41.4 Diagnosis of Nonunion
41.5 Treatment of Nonunion
41.6 Non-operative Treatment of Nonunion
41.7 Surgical Treatment of Aseptic Nonunion
41.8 Surgical Treatment of Malunion
41.9 Bone Grafting
41.10 Implantable Bone Stimulator
41.11 Conclusion
References
42: Strategies for Visceral Complications
42.1 General Considerations and Definitions
42.2 Deviation from an Ideal Postoperative Course
42.2.1 Postoperative Bleeding
42.2.2 Wound Healing Disorders
42.2.3 Small Bowel Obstruction
42.2.4 Anastomotic Leakage
42.2.5 Fistula Following Small Bowel Injuries
42.2.6 Abdominal Compartment Syndrome (ACS)
42.2.7 Incisional Hernia (Fig. 42.5)
42.2.8 How to Go on with Visceral Complications in Polytraumatized Patients?
42.2.9 Role of Laparoscopy
42.3 Examples
42.3.1 Example 1
42.3.1.1 What Happened, What Was Going Wrong?
42.3.2 Example 2
42.4 Conclusions
References
43: Rehabilitation: Soft Tissue Coverage
43.1 Timing of Soft Tissue Reconstruction and Patient Selection
43.2 The Trauma Zone
43.3 The Role of Negative Pressure Therapy
43.4 Definite Soft Tissue Reconstruction of the Lower Extremity
43.4.1 Skin Grafts
43.4.2 Local or Distant (Regional) Flaps
43.4.3 Free Tissue Transfer
43.4.4 Free Flap Choices
43.5 Postoperative Regime
43.5.1 Anticoagulation
43.5.2 Temperature
43.5.3 Nutritional Factors
43.5.4 Monitoring
43.5.5 Immobilization and Elevation
43.6 Outcome
References
44: Principles of Surgical Patient Safety
44.1 Introduction
44.2 From “Blame and Shame” to High Reliability
44.3 Effective Communication
44.3.1 Readbacks
44.3.2 SBAR
44.3.3 AIDET
44.4 Surgical Safety Checklists
44.4.1 Pre-procedure Verification
44.4.2 Surgical Site Marking
44.4.3 The Surgical “Time-Out”
44.5 The Next Frontier of Patient Safety: Individual Accountability
44.6 Conclusion
References
45: Psychiatric Issues in the Treatment of Severe Trauma
45.1 Introduction
45.2 Research Approaches to Psychiatric Disorders in Patients Receiving Treatment for Traumatic Injuries
45.3 Psychiatric Illness in Patients with Traumatic Injuries
45.3.1 Psychiatric Illness in Adult Patients with Traumatic Injuries
45.3.2 Psychiatric Illness in Pediatric Patients with Traumatic Injuries
45.3.3 Clinical Implications of Psychiatric Illness in Patients Receiving Treatment for Traumatic Injuries
45.4 Identification of Psychiatric Illness in Patients with Traumatic Injuries
45.5 Mental Health Care for Patients with Traumatic Injuries
45.6 Conclusions
References
46: Rehabilitation: Long-Term Outcome and Quality of Life
46.1 Introduction
46.2 Validity of Outcome Data
46.3 Level of Evidence
46.4 Outcome Measures
46.5 Patient Follow-Up
46.6 Numerical Results
46.7 Size of Treatment Effect
46.8 Precision of the Estimated Treatment Effect
46.9 Statistical Significance
46.10 Implications for the Clinical Practice
46.11 Outcome After Lower Extremity Injuries
46.12 Outcome After Upper Extremity Injuries
46.13 Conclusions
References
Correction to: Preclinical Management/Rescue
Correction to: Chapter 5 in: H.-C. Pape et al. (eds.), Textbook of Polytrauma Management, https://doi.org/10.1007/978-3-030-95906-7_5