Acute Care Surgery - Principles and Practice

Preface

A Tribute

Table of Contents

Contributors

Part I General Principles

1 Initial Assessment and Early Resuscitation

Triage

Unique Aspects of the Trauma and Acute Care Surgical Patient

Systematic Evaluation and Treatment

Airway and Breathing

Circulation

Fluid Resuscitation

Transfusion

Other Resuscitation Efforts

Assessment of Resuscitation

Classic Physical Examination Findings and Vital Signs

Urine Output

Bladder Pressure (Abdominal Compartment Syndrome)

Ventricular Preload

Lactate Level

Base Deficit

The Triad of Death: Hypothermia, Acidosis, and Coagulopathy

Shock

Hypovolemic and Hemorrhagic Shock

Cardiogenic Shock

Obstructive Shock

Traumatic Shock

Vasodilatory Shock

Acute Abdominal Pain

Reevaluation and Definitive Care

References

2 The Operating Theater for Acute Care Surgery

Location Within the Hospital

Relationship to Ambulance Unloading Dock

Relationship to the Emergency Center

Relationship to the Intensive Care Unit

Life Science and Building Safety Considerations

Air Exchanges

Temperature and Humidity Control

Lighting

Electrical Safe Current Leakage Standards

Competing Microwave Signals

Medical Informatics Capabilities

Internet Access

Interfacing with Real-Time Clinical Information

Imaging Capability

Equipment Considerations

Required “Zones” in the Operation Environment

Administrative Zone

Operating Zone

Anesthesia Zone

Surgeon’s Zone

Scrub Nurse’s Zone

Circulator’s Zone

Imaging Zone

Observer’s Zone

Interactive/Internet/Robotic Zone

Storage Zone

Engineering Zone

Policy Issues

References

3 Anesthesia and Acute Care Surgery

Prioritizing

Preoperative Management

Intraoperative Management

Postoperative Management

Acute Care Situations

Intracranial Emergencies

Neck Injury and Unstable Spine

Vascular Emergencies

Acute Abdomen

Necrotizing Fasciitis, Soft Tissue Wounds, and Burns

Orthopedic Emergencies

Pediatric Emergencies

References

4 Fundamental Operative Approaches in Acute Care Surgery

Neck

Emergent Airway

Damage Control

Chest

Resuscitative Thoracotomy

Anterolateral Thoracotomy

Transsternal Anterior Thoracotomy

Left Book Thoracotomy

Median Sternotomy

Median Sternotomy with Right or Left Cervical Extension

Left Posterolateral Thoracotomy

Exposure

Great Vessels

Descending Thoracic Aorta

Esophagus

Pulmonary Hilum

Damage Control

Abdomen

Incision

Exploration

Exposure

Supramesocolic Viscera

Suprarenal Aorta

Esophagus

Suprahepatic Inferior Vena Cava

Pancreas and Duodenum

Portal Structures

Liver

Inframesocolic Exposure

Root of the Mesentery

Infrarenal Aorta

Inferior Vena Cava

Pelvis

Damage Control

Liver

Spleen

Kidney

Gastrointestinal Tract

Arteries

Veins

Wound Closure

Extremities

Exposure

Upper Extremity

Lower Extremity

Fasciotomy

Damage Control

References

5 The Perioperative Management of the Acute Care Surgical Patient

A Perspective on Stress and Response

Preoperative Care of the Acute Care Surgical Patient Following Initial Resuscitation

Physiologic Reassessment and the Second Phase of the Stress Response

Preoperative Actions

Relevant History

Pre-Illness Physiology

Specific Signs and Symptoms

Discussion of Perioperative Care Environments

Actions in the Operating Room

Preparation of the Intensive Care Unit and its Team for Receipt of a Preoperative Patient

The Hand-Off

Ongoing Care in Anticipation of Operation

Postoperative Intensive Care

The Third Phase of the Stress Response

Actions and Considerations at the Bedside

Cardiac Monitoring and Care

Pulmonary Monitoring and Care

Neurologic Monitoring and Care

Renal Monitoring and Care

Gastrointestinal Monitoring and Care

Hematologic Monitoring and Care

Endocrine Monitoring and Care

Infectious Disease Monitoring and Care

Sustained and Chronic Critical Illness

The Hypothalamic-Pituitary-Adrenal Axis in Chronic Critical Illness

Growth Hormone and Thyroid Hormone in Chronic Critical Illness

Testosterone and Luteinizing Hormone in Chronic Critical Illness

Prolactin in Chronic Critical Illness

Conclusion

References

6 The Hemodynamically Labile Patient: Cardiovascular Adjuncts and Assist Devices

Pharmacological Circulatory Support:Vasopressin

Mechanical Circulatory Systems

Extracorporeal Membrane Oxygenation

Intraaortic Balloon Pump

Ventricular Assist Devices

Bridge to Recovery

Bridge to Transplantation

Destination Therapy–Still in its Infancy

References

7 Principles and Practice of Nutritional Support for Surgical Patients*

Metabolism, Nutrition, and Infection

Goals of Nutritional Support

Nutritional Support:Who, How Much, and What

Nutritional Support: Route and Timing

Nutrient Pharmacology

Anabolic Agents

References

8 The Intensive Care Unit: The Next-Generation Operating Room

Rationale

What Resources Are Needed?

Preparation of the Unit and Staff

Preparation of the Patient

A Culture of Safety and Accountability

Infection Control

Anesthesia, Analgesia, and Sedation

Ultrasound

Bedside Neurologic Surgery

Bedside Surgery of the Head and Neck

The Cervicothoracic Interface: Tracheostomy

Bedside Thoracic Surgery

Bedside Abdominal Surgery

Paracentesis

Peritoneal Dialysis Catheter Placement

Percutaneous Cholecystostomy

Enteral Feeding Access

Other Uses of Bedside Endoscopy

Bedside Laparotomy

Bedside Laparoscopy

Bedside Extremity Surgery

Surgical Debridement for Necrotizing Fasciitis

Bedside Arthrocentesis

Lower Extremity Compartment Pressure Measurement, Bedside Fasciotomy, and Escharotomy

Bedside Inferior Vena Cava Filter Placement

References

9 Burns

Epidemiology

Pathophysiology

Local Effects

Systemic Response

Resuscitation Priorities

Fluid Administration

Ventilatory Support and Treatment of Inhalation Injury

Pathophysiology

Asphyxiants

Airway Management

Mechanical Ventilation

Other Organ System Support

Pain Control

Neurologic Deficits

Gastrointestinal Responses and Complications

Wound Care

Initial Wound Care

Topical Antimicrobial Therapy

Burn Wound Excision and Grafting

Skin Substitutes

The Treatment of Special Thermal Injuries

Electric Injury

Chemical Injuries

Bitumen Burns

Cold Injuries

Radiation Injury

Toxic Epidermal Necrolysis

Mechanical Injury

Metabolic and Nutritional Support

Estimation and Measurement of Metabolic Rate

Nutritional Support

Monitoring

Complications

Transportation and Transfer

Survival Data

References

10 Electrical and Lightning Injuries

Pathophysiology and Manifestations

Approach to Management

Acute Care

Diagnostic Evaluation

Early Management

Rehabilitation

References

11 Soft Tissue Infections

Pathophysiology

Microbiology

Presentation and Diagnosis

Clinical Management

Critical Care Management

Surgical Debridement

Wound Care

References

12 The Open Abdomen: Management from Initial Laparotomy to Definitive Closure

Indications for Leaving the Abdomen Open

Temporary Wound Management Techniques for the Open Abdomen

Timing of Reconstruction and Subsequent Laparotomies

Techniques for Delayed Primary Closure

Small Intestinal Submucosa

Human Acellular Dermis

Additional Techniques

Component Separation

References

13 Acute Care Surgery and the Elderly

Normal Physiologic Changes Associated with Aging

Clinical Presentation of Elderly Patients

Preoperative Assessment

Perioperative Management of the Elderly

Acute Care Surgery: Specific Considerations

Ethical and End-of-Life Issues

References

14 Acute Care Surgery in the Rural Setting

Defining Rurality and the Rural Surgeon

Prehospital Care, Stabilization, and Transportation

Early Management of the Surgical Emergency

Trauma Systems,ATLS, and Referral

Crucial Colleagues

General and Vascular Emergencies

Surgical Subspecialty Emergencies

Endoscopy

Telemedicine

Surgical Education

Conclusion

References

15 Prehospital Care in the Acute Setting

Emergency Medical Services Systems

Personnel

Emergency Medical Technician-Basic

Emergency Medical Technician-Intermediate

Emergency Medical Technician-Paramedic

Emergency Medical Technician-Paramedic

Communications

Protocols Versus Standing Orders

Medical Control

Direct Medical Control (On Line)

Indirect Medical Control (Off Line)

Quality Assurance

Kinematics (Mechanism of Injury)

Cavitation

Blunt Trauma

Vehicular Collisions

Frontal

Rear

Rotational

Rollover

Falls

Motorcycle Collisions

Blast Force

Penetrating Trauma

Energy

Anatomy

Assessment and Management in the Field

Safety

Situation

Initial Patient Assessment

Primary Survey

A: Airway

B: Breathing and Ventilation

C: Cardiac Evaluation

D: Disability

Resuscitation

Secondary Survey

Definitive Field Care

Shock and Fluid Resuscitation

Energy Production

Oxygen Delivery

Physiology of Fluid Replacement

Bernoulli Principle

Assessment

Blood Pressure

Field Special Skills

Airway

Manual

Mechanical

Transtracheal

Double Lumen Airway

Laryngeal Mask Airways

Spinal Immobilization

Field Clearance of the Cervical Spine

Cervical Collars

Backboard

Field Helmet Removal

Musculoskeletal Trauma

References

16 Disaster and Mass Casualty Management

Classification of Disasters

Level of Response

Mechanism

Nature of Injuries

Extent and Timing

Phases of Disaster Response

Chaotic Phase

Initial Response and Reorganization

Site Clearing

Search And Rescue

Medical Care of Casualties

Initial Phase

Definitive Phase

Record Keeping

The Role and Importance of Triage

Triage Categories

Triage Accuracy

Triage Decisions

Incident Command

Command

Operations

Planning

Logistics

Finance/Administration

Terrorism

Biological Agents

Chemical Agents

Nuclear/Radiologic Agents

Explosive Disasters

Blast Physics and Pathophysiology

Patterns of Injury, Mortality, and Severity

Disaster Planning and Reporting

References

17 Principles of Injury Prevention and Control

Basic Principles of Injury Prevention and Control

Motor Vehicle Crashes

Pedestrian Injuries

Nontraffic Injuries in Children

Motorcycle and Bicycle Helmets

Falls by the Elderly

Burns

Water-Related Injuries

Suicide

Child Maltreatment

Intimate Partner Violence

Youth Violence

Firearm Injuries

Alcohol and Injury

Education

Program Evaluation

References

18 Education: Surgical Simulation in Acute Care Surgery

Classifications of Simulators/Simulations

Goals of Simulations

Educational Principles

Education Objectives

Teaching Strategies

Principles of Simulation Education

Evaluation

Validity of Simulation

Simulations in Surgery and Traumatology

ATOM: An Example of Simulation Education

References

Part II Organ-Based Approach

19 Pharynx and Larynx

History and Physical Examination

History

Database

Chief Complaint

History of the Present Illness

Past Medical History

Review of Systems

Physical Examination

External Examination

Symmetry

Speech

Airway

Skin

Ears

Eyes

Nose and Sinuses

Lower Face, Mandible, and Salivary Glands

Neck

Internal Examination

Nose

Oral Cavity/Oropharynx

Nasopharynx

Hypopharynx and Larynx

Diagnosis

Pharynx

Anatomy

Physiology

Tympanomastoid Ventilation

Swallowing

Taste

Complaints

Symptoms

Signs

Larynx

Anatomy

Laryngeal Skeleton

Muscles

Vasculature

Lymphatics

Nerves

Physiology

Complaints

Symptoms

Emergencies

Hemorrhage

Infection/Inflammation

Caustic Ingestion

Foreign Body

Case Studies

Case 1 (Pharynx): “The Flickering Candle”

Indications

Operative Findings

Discussion

Conclusions

Case 2 (Pharynx): “Routine Surgery”

Indications

Description of Procedure

Discussion

Conclusions

Case 3 (Pharynx): “Chokehold”

Indications

Description of Procedure

Discussion

Conclusions

Case 4 (Pharynx): “Cry Baby”

Indications

Description of Procedure

Discussion

Conclusions

Case 5 (Larynx): “Wheezing”

Description of Procedure

Discussion

Conclusions

Case 6 (Larynx and Bronchus): “The Cough”

Indications

Description of Procedure

Discussion

Conclusions

Case Study 7 (Pharynx and Larynx): “The Cobra”

The Arrival

Physical Examination

Assessment

Treatment

Discussion

Conclusions

Discussion

Airway

Intubation

Assessment

Preparation

Technique

Airway Strategy

Decannulation

Endotracheal Tube

Tracheotomy Tube

Options

Ventilation

Hemostasis

Vascular Injury

Air Embolism

Carotid (Blow) Catastrophe

Carotid Artery Injury

Subclavian Artery

Transverse Cervical Artery

Epistaxis

Pressure

Vasoconstriction

Packing

Embolization

Ligation

Incision and Drainage

Superficial Layer

Middle Layer

Deep Layer

Carotid Sheath

Final Comments

References

20 Head and Neck: Pediatrics

Inflammatory Disease of the Airway

Acute Supraglottitis

Croup

Bacterial Tracheitis

Inflammatory Diseases of the Neck

Peritonsillar Abscess

Retropharyngeal Abscess

Lateral Pharyngeal Abscess

Trauma

Facial Fracture

Neck Trauma

Laryngeal Trauma

References

21 Esophagus

General Considerations

Anatomic Considerations

Bacteriology

Traumatic Injuries

Frequency and Mechanism of Injury

Diagnosis

Clinical Symptomatology

Plain Films

Esophagography

Esophagoscopy

Computed Tomography Scan

Management

Selective Management or Routine Exploration of Penetrating Neck Injuries

Selective Operative Management of Documented Pharyngoesophageal Trauma

Operative Therapy

Complications of Operative Therapy

Nontraumatic Emergencies

Esophageal Perforation

Assessment

Treatment

Options for the Neglected Perforation or the Unstable Patient

Dealing with Associated Esophageal Disease

Caustic Ingestion

Foreign Body Impaction

Food

Presentation

Assessment

Conservative Treatment

Endoscopic Treatment

Indigestible Foreign Body

Assessment

Definitive Treatment

Esophageal Hemorrhage

Acute Tracheoesophageal Fistula

References

22 Central Nervous System

An Approach to Neurologic Emergencies

Identification of Pathology: The History

Context of Presentation

Past Illness

Age of Patient

Pattern of Presentation

Primary Survey: Immediate Actions

Secondary Survey

The Focused Neurologic Examination

Imaging

Operative Decision Making

Specific Disease Entities

Traumatic Emergencies

Glasgow Coma Score

Blunt Head Injuries

Epidural Hematoma

Subdural Hematoma

Contusions

Cerebral Edema

Vascular Injury

Management of Blunt Head Injuries

Penetrating Head Injuries

Traumatic Spine Injury

Management of Spinal Fractures

Penetrating Spine Trauma

Peripheral Nerve Injury

Nontraumatic Emergencies

Cerebrovascular Accidents

Hemorrhagic Cerebrovascular Accidents

Ischemic Cerebrovascular Accidents

Brain Tumors

Pituitary Apoplexy

Infection

Shunt Malfunction

Nontraumatic Spinal Emergencies

Cauda Equina Syndrome

References

23 Chest Wall

Injuries Associated with Chest Wall Trauma

Mortality Rate

Biomechanics

Injury Prevention

Acute Care Management: Initial Evaluation

Categories of Chest Wall Injuries

Hematoma

Rib Fractures

Flail Chest

Rib Fracture and Flail Chest Repair

Sternal Fractures

Fractures of the Clavicle and Shoulder

Chest Wall Defects

Pain Management

References

24 Lungs and Pleura

Airway

Thoracotomy

Thoracoscopy

Trauma

Tracheobronchial Injury

Parenchymal Injury

Retained Parenchymal Missiles

Retained Hemothorax

Massive Pulmonary Embolism

Presentation

Diagnosis

Persistent Air Leak

Surgical Management of Infections

Empyema

Complex Parenchymal Infections

Necrotizing Pneumonia

Lung Abscess

Lung Gangrene

Descending Necrotizing Mediastinitis

Diagnosis

Management

Second-Look Operations

Lobar Torsion

Massive Hemoptysis

Etiology

Diagnosis

“Occult” Massive Hemoptysis

Initial Management

Strategies to Prevent Further Airway Contamination

Diffuse Parenchymal Bleeding

Subsequent Treatment

Angioembolization

Surgical Versus Medical Therapy for Massive Hemoptysis

Tracheoinnominate Artery Fistula

Recognition and Initial Management

Operative Repair

Pulmonary Artery Catheter-Induced Hemoptysis

Etiology

Management

Superior Vena Cava Syndrome

Presentation

Initial Management

Treatment

References

25 Heart

Penetrating Cardiac Injury

Diagnosis

Cardiac Tamponade

Venue

Exposure

Repair Technique

Coronary Injuries

Destructive Injuries

Follow-Up

Factors Affecting Prognosis

Blunt Cardiac Injury

Diagnosis

Imaging

Myocardial Contusion

Cardiac Enzymes

Blunt Coronary Artery Injury

Blunt Valvular Injury

Follow-Up for Blunt Cardiac Injury

Special Circumstances

Iatrogenic Endovascular Cardiac Injury

Transmediastinal Gunshot Wounds

Cardiopulmonary Bypass

References

26 Thoracic Aorta

Blunt Aortic Trauma

History and Incidence

Etiology and Pathogenesis

Clinical Presentation and Initial Management

Diagnostic Studies

Management

Operative Technique

Complications and Outcomes

Aortic Dissection

History and Incidence

Etiology and Pathogenesis

Clinical Presentation

Diagnostic Studies

Classification and Management Decisions

Operative Technique for Type A Dissection

Technique for Type B Dissection

Outcomes and Complications

References

27 Diaphragm

Anatomic and Physiologic Considerations

Blunt Diaphragmatic Injuries

History

Incidence

Mechanism

Associated injuries

Diagnosis

Treatment

Penetrating Injuries to the Diaphragm

Incidence

Diagnosis

Radiographs

Thoracoscopy

Laparoscopy

Treatment

Observation

Minimally Invasive Approach

Open Approach

Outcomes

Morbidity

Mortality

Conclusions

Surgical Emergencies Related to Hiatal Hernia

Upper Gastrointestinal Hemorrhage

Hiatal Hernia Ulcer Perforation

Acute Gastric Volvulus

References

28 Abdominal Wall

Anatomy

Evaluation of Abdominal Wall

Hernias

Groin Hernias

Other Abdominal Wall Hernias

Ventral Hernias

Parastomal Hernias

Abdominal Wall Trauma

Abdominal Compartment Syndrome

Definition

Etiology

Treatmen

Closure of the Abdominal Wall and/or Skin

Skin Closure

The Decision to Close Fascia and Subsequent Management of the Open Abdomen

The Planned Ventral Hernia

References

29 Foregut

Foregut Symptoms

Esophagus, Esophagogastric Junction, Stomach, Duodenum

Evaluation

Obstruction

Differential Diagnosis

Physical Examination

Endoscopic Examinations

Radiographic Studies

Diverticula

Hypopharyngeal Diverticulum (Zenker’s Diverticulum)

Epiphrenic Diverticulum

Intraluminal Duodenal Diverticulum (Recanalization Failure in the Duodenum)

Achalasia of the Esophagus

Hiatus Hernia

Minimally Invasive Surgery

Transdiaphragmatic Approach to the Distal Esophagus

Transthoracic Versus Transabdominal Approach

The Role of Fundoplication

Peptic Stricture of the Esophagus

Nissen Fundoplication

Closure of Esophageal Hiatus

Obstructing Mass Lesions: Esophagus, Stomach, and Duodenum

Obstructing Duodenal Ulcer (Peptic Stricture of Gastric Outlet)

Gastric Resection Versus Pyloroplasty? Open Surgery Versus Laparoscopic Exploration?

Duodenal Obstruction

Internal Hernia

Perforation

Diagnosis and Management

Esophagus

Gastric and Duodenal Perforation

Bleeding

Sentinel Bleeding

Varices of Esophagus or Stomach

Ulcers of the Stomach and Duodenum

Endoscopic Examination

Endoscopic Interpretation

Operative Treatment

Esophagus

Gastritis

Gastric Ulcers

Type I Gastric Ulcer

Types II and III Gastric Ulcer

Type IV Gastric Ulcer

Marginal Ulcers Following Previous Operations

Duodenal and Pyloric Channel Ulcers

References

30 Small Intestine

Obstruction

Diagnosis

Treatment

Perforation

Diagnosis

Treatment

Gastrointestinal Bleeding

Peptic Ulcer Disease

Diagnosis

Therapy

Meckel’s Diverticulum

Diagnosis

Treatment

Mesenteric Ischemia

Diagnosis

Treatment

References

31 Liver and Biliary Tract

Anatomy

Physiology

Technology

Infections

Hepatic Pyogenic Abscess

Cholangitis

Parasitic

Calculus Disease of the Gallbladder and Common Bile Duct

Cholecystitis

Biliary Obstruction

Pancreatitis

Gallstone Ileus

Neoplasms

Tumor Rupture

Abscess

Biliary Obstruction

Portal Hypertension

Hemobilia

References

32 Pancreas

Pertinent Anatomy for Trauma Surgeons

Anatomic Location of Injury

Associated Injuries

Surgical Techniques

Intraoperative Evaluation and Exposures

Intraoperative Adjunct Techniques

Injury Classification

Principles of Injury Management

Special Situations

Pancreaticoduodenal Injuries

Mortality

Morbidity

Pancreatic Emergencies (Nontrauma)*

References

33 Spleen

Clinical Anatomy

Function

Indication for Operative Intervention

Operative Management

General

Operative Approach

Management Options of Specific Injuries

Drainage

Postsplenectomy Complications

References

34 Intraabdominal Vasculature

Acute Mesenteric Ischemia

Anatomy and Pathophysiology

Surgical Management

Endovascular Management

Ischemia Associated with Aortic Dissection

Acute Renal Ischemia

Acute Aortic Occlusion

Other Acute Arterial Occlusions

Acute Venous Occlusions

Acute Mesenteric Venous Thrombosis Including Portal Vein Thrombosis

Acute Renal Vein Thrombosis

Acute Complications of Aneurysmal Disease

Symptomatic Abdominal Aortic Aneurysm Including Rupture

Etiology and Risk Factors of Aneurysm Rupture

Clinical Presentation and Diagnosis

Management

The Preoperative Phase

The Operation

Postoperative Management

Aortoenteric Fistula

Ruptured Visceral or Renal Artery Aneurysm

Abdominal and Pelvic Vascular Trauma

Diagnosis and Evaluation

Management

Operative Management

Endovascular Management

Specific Vascular Injuries and Their Management

Abdominal Aortic Injuries

Iliac Vessel Injuries

Inferior Vena Cava Injuries

Renovascular Injuries

Mesenteric Vascular Injuries

Portal Region Injuries

References

35 Colon and Rectum

Anorectal Disease and Trauma

Abscess

Hemorrhoids

Anal Fissure

Pilonidal Cyst-Abscess

Rectal Procedentia (Rectal Prolapse)

Colorectal Disease and Trauma

Neoplastic Disease

Diverticular Disease

Inflammatory Bowel Disease

Colonic Volvulus

Ogilvie’s Syndrome

Ischemic Colitis

Colorectal Trauma

References

36 Urogenital Tract

Infection

Emphysematous Pyelonephritis

Definition

Clinical Presentation

Diagnosis

Management

Prognosis

Renal and Perirenal Abscess

Definition

Clinical Presentation

Diagnosis

Management

Pyonephrosis

Definition

Clinical Presentation

Diagnosis

Management

Prostatic Abscess

Definition

Clinical Presentation

Diagnosis

Management

Acute Prostatitis

Definition

Clinical Presentation

Diagnosis

Treatment

Infected Urinary and Genital Prosthetics

Definition

Clinical Presentation

Diagnosis

Treatment

Necrotizing Gangrene of the Genitalia and Perineum

Background

Clinical Presentation

Diagnosis

Treatment

Prognosis

Hemorrhage

Angiomyolipoma of the Kidney

Definition

Clinical Presentation

Diagnosis

Management

Arteriovenous Malformation of Kidney

Definition

Clinical Presentation

Diagnosis

Management

Acute Urinary Tract Obstruction

Upper Tract Obstruction

Definition

Clinical Presentation

Diagnosis

Management

Prognosis

Lower Tract Obstruction

Definition

Presentation

Evaluation

Management

Penile Emergencies

Priapism

Background

Clinical Presentation

Diagnosis

Management

Prognosis

Penile Fracture

Diagnosis

Presentation and Evaluation

Management

Prognosis

Acute Scrotum

Torsion

Definition

Presentation

Evaluation

Management and Prognosis

Epididymitis

Presentation

Evaluation

Management

Prognosis

Iatrogenic Complications

Ureteral Injury

Definition and Background

Presentation

Evaluation

Management

Bladder Injury

Definition

Presentation

Evaluation

Management and Prognosis

Male Urethral Injuries

Pediatric Emergencies

Circumcision Complications

Ambiguous Genitalia

Definition

Clinical Presentation

Diagnosis

Posterior Urethral Valves

Definition

Clinical Presentation

Diagnosis

Management

References

37 Pelvis

Anatomy of the Pelvic Ring

Pelvic Stability and Mechanism of Injury

Lateral-Compression Force

External-Rotation Force

Anterior-Posterior Force

Shearing Force

Classification

Young and Burgess Classification

Lateral Compression

Anterior Posterior

Vertical Shear

Combined Mechanical

Tile Classification

Tile A

Tile B

Tile C

Evaluation

Clinical Evaluation

Associated Injuries

Radiographic Evaluation

Hemodynamic Status and Emergent Stabilization

References

38 Lower Extremities

Infections

Necrotizing Soft Tissue Infections

Septic Joints

The Nontraumatic Ischemic Extremity

Compartment Syndrome

Trauma

Irreducible Dislocations

Hip

Knee

Ankle and Foot

Femoral Neck Fractures in the Young

Vascular Injury

Femoral Artery Injuries

Popliteal Artery

Infrapopliteal Arteries

Open Fractures and Open Joints

The Mangled Extremity

References

39 Hand and Upper Extremities

Principles

Treatment Planning

Anesthesia

Tourniquet Application

Incisions

Dressings and Splints

Examination and Diagnosis

Observation

Neurovascular Examination

Musculoskeletal Examination

Special Investigations

Fingertip and Nailbed Injuries

Open Soft Tissue Injuries and Complex Wounds

Replantations and Amputations of the Upper Extremity

Operative Procedure for Replantation

Tendon Injuries

Flexor Tendons

Extensor Tendons

Nerve Injuries

Fractures and Dislocations

Clavicle Fractures

Proximal Humerus Fractures

Humeral Shaft Fractures

Fractures of the Distal Humerus

Olecranon Fractures

Radial Head Fractures

Forearm Fractures

Distal Radius Fractures

Scaphoid Fractures

Metacarpal Fractures

Phalangeal Fractures

Carpal Dislocations

Dislocations Involving the Hand

Vascular Emergencies

High-Pressure Injuries

Frostbite and Chemical and Extravasation Injuries

Frostbite

Chemical Burns

Extravasation Injuries

Compartment Syndrome

Acute Upper Extremity Infections

Routes of Infection and Infecting Organisms

Anatomy of Hand Infections

Types of Infections

Superficial Paronychial Infections

Infections at Intermediate Depths

Deep Infections

Deep Palmar Space Infections

Pyogenic Flexor Tenosynovitis

Acute Fulminant Infections

Necrotizing Fasciitis

Clostridial Myonecrosis (Gas Gangrene)

Diabetic Gangrene

Nondiabetic Gangrene

References

40 Peripheral Vasculature

Upper Extremity

Embolic Occlusion of the Brachial Artery

Diagnosis

Treatment

Arterial Thrombosis Secondary to a Monitoring Device

Diagnosis

Treatment

Occlusion or Infection of an Angioaccess Graft

Traumatic Injuries to Arteries

Diagnosis

Treatment

Traumatic Injuries to Veins

Diagnosis

Treatment

Compartment Syndromes and Fasciotomies

Diagnosis

Treatment

Lower Extremity

Catheterization Injuries of the Femoral Artery

Diagnosis

Treatment

Embolic or Thrombotic Occlusion of the Femoral Artery

Diagnosis

Treatment

Ruptured Femoral Artery Pseudoaneurysm Secondary to Inadvertent Injection of Illicit Drugs

Diagnosis

Treatment

Embolic Occlusion of the Popliteal “Trifurcation”Vessels

Diagnosis

Treatment

Traumatic Injuries to Arteries

Diagnosis

Treatment

Traumatic Injuries to Veins

Diagnosis

Treatment

Compartment Syndromes and Fasciotomies

Diagnosis

Treatment

References

Part III Administration, Ethics, and Law

41 Understanding the Latest Changes in EMTALA: Our Country’s Emergency Care Safety Net

Understanding the Basics for Hospitals: Obligation to Examine, Treat, and Stabilize

Physician Obligations Under EMTALA

EMTALA On-Call Requirements

Continuous Call

Simultaneous Call

Scheduling Elective Surgery While On-Call

Scope of Privileges

EMTALA Reforms Included in Medicare Prescription Drug Law

Managed Care Reimbursement for EMTALA-Related Services

EMTALA Technical Advisory Group

Issues Remaining

Managed Care Pressures

Impact on Trauma Centers and Community Hospitals

Suggestions from the Surgical Community for Solidifying the Safety Net over the Next Decade

References

42 Informed Surgical Consent

General Rule

Evidence of Consent

What Constitutes a Medical Emergency

Exceptions to Informed Consent

The Unconscious Patient

Capacity to Consent

Intoxicated Patients

Minors

Patient’s Refusal to Consent

Documentation

References

43 Advance Directives

History of the Development of Advance Directives

Ethical Foundation

Legal Foundation

The Patient Self-Determination Act

Types of Advance Directives

Living Wills

Durable Health Care Power of Attorney

Advance Directives: Unfulfilled Potential

Advance Directives: Relevance to the Acute Care Surgeon

Recommendations

References

44 The Nonviable Patient and Organ Procurement

Defining the Problem

The Problem with Futility

Communication Is the Key

End-of-Life Care

Withdrawal of Life-Sustaining Treatment

The Determination of Brain Death

Care of the Potential Organ Donor

Cardiovascular System Issues

Fluid and Electrolyte Issues

Acid–Base Balance Issues

Coagulation System Issues

Temperature Regulation Issues

Ventilator Management Issues

References

45 Ethical Dilemmas and the Law

Considerations for Surgeons

General Concepts

Defining the Problem

What Makes the Surgeon Special?

Special Problems of Acute Care Surgery

Principles of Bioethics

Philosophical Principles

Respect for Autonomy

Beneficence

Nonmaleficence

Justice

Religion and Medical Ethics

Legal Principles

Malpractice

Statutory Law

Regulatory Law

Physician-Based Ethics

General Principles

The “Clinical Ethics” System

Specific Dilemmas of Acute Care Surgery

Categories of Patient Encounters

Severe Emergency: Life in Immediate Jeopardy

Urgent: Serious Problem needing Surgery

Semi-Elective:Will Probably Need Surgery

Informed Consent

General Concepts

Using Newly Deceased Patients for Teaching Purposes

Participation in Research

Conflict of Interest: Industry and Drug Money

Autonomy, Decision-Making Capacity, and Competency

General Concepts

Refusal of Treatment

Telling the Truth/Disclosing Errors

Impaired Decision-Making Capacity

Suicidal Patients

Advance Directives

General Principles

Living Will

Durable Power of Attorney

Problems

Confidentiality

General Principles

Abuse of the Elderly

Futility and Withholding Treatment

Withdrawal of Treatment

General Principles

Applying the Principles

Palliative Care

Determination of Death

Organ Donation

Ethical and Legal Consultations

Good Samaritan

A Case

General Concepts

Pain Relief and the Doctrine of Double Effect

Confusing Principles

Double Effect

Hastening Death

Know Your Intent

A Final Thought

References

Part IV System and Curriculum Development

46 Development of a Regional System for Surgical Emergencies (RSSE)

The Problem—The Solution

Regionalization: A Concept for Optimal Care

Trauma System: A New Paradigm for Emergency Surgical Care

Administrative Components

Leadership and System Development

Legislation

Operational and Clinical Components

Public Information and Prevention

Human Resources

Prehospital Issues

Definitive Care

Evaluation

Rehabilitation

Research

Building on a Trauma System

Disaster Preparedness

References

47 Acute Care Surgery: A Proposed Curriculum

48 Emergency General Surgery: The Vanderbilt Model

Background

The Concept of Nontrauma Acute Care Surgery

The Regional Referral Center

The Acute Care Surgery/Trauma Paradigm

System Infrastructure

The Service Concept

The Surgical Director

Hospital Support

The Emergency Department

The Operating Room—Urgent/Emergent

Radiology

The Surgical Intensive Care Unit and the Intensive Care Unit Team/Bedside Surgery

The Hospital Floor

Emergency General Surgery Clinic

Referrals and the Catchment Area

Intrahospital Communications

Marketing

Transfer Center

Transportation

Aeromedical Transport

Staffing the Service

The Skill Set

Faculty Coverage

Surgical and Medical Subspecialty Consultants

The House Staff Team

Physician Extenders

Responsibility and Credentialing

The Nonphysician Clinician Skill Set

Promoting a Continuum of Care

Case Management

Social Worker

Rehabilitation/Extended Care

The Emergency General Surgery Registry

The Model

Practice Management Guidelines

The Financial Model

Historical Perspective

The Need for an Emergency General Surgery Service Designation

The Budget: Basics

Analysis

References

Part V The International Communities

49 Acute Care Surgery: United Kingdom

Emergency General Surgery

Introduction

On-Call Surgical Team

Early Investigation of Patients with Emergency Surgical Problems

Blood Tests

Ultrasonography

Contrast Radiology

Small Bowel Obstruction

Large Bowel Obstruction

Acute Diverticulitis

Computed Tomography

Emergency Theater Availability

Surgical Subspecialization

Future Provision of Emergency General Surgical Services in the United Kingdom

Emergency Surgery and Organ Transplantation

Introduction

Organ Retrieval from Cadaveric Donors

Non-Heart-Beating Donations

Uncontrolled Non-Heart-Beating Donation

Controlled Non-Heart-Beating Donation

Cadaveric Organ Transplantation

Super-Urgent Transplantation

Surgical Emergencies in Organ Transplant Recipients

Emergency Vascular Surgery

Introduction

Present Arrangements

Proposals

Trainees

Radiology

Summary

Emergency Surgery in Remote and Rural Areas

Introduction

General Principles

Medical and Nursing Staff

Surgeons

Hospitals

Patient Transport

Patient Transport with Paramedic Escort

Patient Transport with Local Medical Support

Patient Transport with a Distantly Based Transport Team

Procedures

Life-Threatening Emergencies Requiring Immediate Surgical Intervention

Life-Threatening Emergencies Requiring Resuscitation Followed by Expeditious Surgical Intervention

Life-Threatening Emergencies That Might Not Require Surgical Intervention

Emergencies That Might Become Life Threatening if Not Managed with Expeditious Surgical Intervention

Emergencies That Will Lead to Incapacity and Disability if Not Managed by Immediate Surgical Intervention

Emergencies That Will Lead to Incapacity and Disability if Not Managed by Surgical Intervention

Emergency Surgery Outcome

Trauma Services in the United Kingdom

Introduction

A Historical Perspective

Present Arrangements

Incidence and Costs of Severe Injury

The Future

The Emergency Department (Acute Care Facility) of the Future

References

50 Acute Care Surgery:Australia

Geography and Demography

The Australian Medical System

Distribution and Provision of Surgical Services

Acute Care Trauma Surgery in Australia

Prehospital Care

Designation of Hospitals to Receive Trauma Patients

Triage, Transfer, and Retrieval Services

Trauma Care in the Other States of Australia

Nontrauma Acute Care Surgery

Surgical Training in Australia

Rural Surgeon Training

Surgical Training for General Practitioners

Outreach Services

The Use of Information Technology in Providing Surgical Services

Challenges to Trauma and Acute Care Surgery in the Developing World

References

51 Acute Care Surgery: Japan

Acute Care Surgery in Developing Countries

Malnutrition

Infectious Diseases

Malaria

Schistosomiasis

Amebiasis

Ascariasis

Bacterial Enteritis

Thermoregulatory Disorders

Acute Care Surgery in Japan

Anisakiasis

Gastroduodenal Perforation

Fulminant Hepatic Failure

Acute Pancreatitis

Acute Care Surgery in the Future

Tele-Surgery

Regenerative Medicine

Global Health Care

References

Index