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Trauma care aims to save the lives of injured patients and prevent further organ damage from the metabolic and phythemologic derangements caused by their injuries. To achieve this goal, a critical judgment affecting a trauma patient's survival is required every 72 seconds during the first hours of the patient's care. In-hospital errors in the management of trauma patients that ultimately lead to adverse outcomes can occur at any time during their management and begin on admission. The surgical procedure itself has been the subject of numerous safety analyses, and avoiding technical mishaps in the surgical management of individual injuries and organ systems is detailed elsewhere in this text. The risk of error during the intensive care unit (ICU) management of trauma patients is in the range of 1.7 adverse events per patient per day, of which 13% are life-threatening or fatal.

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In 2020, 278,345 people in the United States died of injuries, with injuries continuing to be the leading cause of death for people ages 1–44 years. Injuries are the leading cause of potential years of life lost before age 65. The prevention of injury morbidity and mortality requires multiple strategies and collaboration to develop, research, and implement evidence-based interventions at the primary, secondary, and tertiary prevention levels. The foundation of the prevention strategies encompasses ongoing surveillance data, engagement of the community, research, and evaluation, as well as consideration of the factors that affect the occurrence of injury events. In this chapter, the focus is on primary and secondary prevention, as tertiary prevention focuses on the interventions that occur after an injury event. Engagement of members of the community that is affected can also inform and prioritize prevention efforts.

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Modern trauma systems are dynamic networks that span cities and remote environments, collecting data to prevent injury, and, when injuries do occur, facilitating quick and seamless transfers of patients to optimal, state-of-the-art trauma care. Trauma systems have evolved both as a strategy to deliver coordinated, acute care when it is most urgently needed and as a comprehensive response to one of the greatest public health challenges of our time. In recent years, surgeons have taken critical roles in the development of a comprehensive approach to injury control. The ACS-COT considers injury control to be most effectively accomplished in a public health framework that includes approaches to prevention, optimization of access to acute care, acute care itself, rehabilitation, and research. The biggest gains in injury control will likely result from the identification of populations that remain vulnerable to injury, followed by thoughtful and comprehensive approaches to the modification of risk factors within each phase of injury in these groups.

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The development of trauma care has been a synergistic relationship between the military and civilian medical environments and has paralleled the history of war for the past several centuries. The impact of military outcome improvement has important civilian trauma implications. The impact of DeBakey's seminal paper is a prime example. Telecommunication and technology advances since the Vietnam War have enabled access to robust and improved battlefield combat casualty care data. Based on the military conflicts of antiquity, the epidemiology of combat injury has largely been documented by individuals, collated from medical administrative data, or by post hoc evaluation of data sources such as the Wound and Munitions Effectiveness Team data from Vietnam. The concept of damage control resuscitation provides for hemostatic and hypotensive resuscitation strategies in order to manage hemorrhage and coagulopathy after combat injury.

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Airway management is of paramount importance in caring for the trauma patient. The primary goals of airway intervention are to relieve or prevent airway obstruction, secure the unprotected airway from aspiration, provide adequate gas exchange, and maintain cervical spine stabilization. Gaining control of the traumatized airway is the ultimate test of the provider's adeptness and clinical acumen. When the airway is secured, it is important to complete a diagnostic workup to determine the severity of the injury, as structures that can potentially be damaged after trauma to the face and neck include the upper airway, cervical spine, and aerodigestive tract. Once the extent of the injury is determined, the choice remains whether to treat the injury conservatively or surgically. Presented first are some of the key questions a provider must understand to properly manage the airway of these patients. Addressed next is a discussion directed at successfully navigating the challenge of airway management in the presence of acute airway trauma.

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Traumatic injuries are the third leading cause of death among all age groups and the leading cause of death among Americans aged 44 years and younger. To improve outcomes, life-threatening injuries must be diagnosed and treated expeditiously. The trauma surgeon must decide what type of monitoring will ensure an accurate diagnosis of shock, adequate and timely resuscitation, and early identification of potential complications. HR and BP are not adequate indicators of shock. Trauma patients with significant blood loss may present in compensated shock with normal vital signs. Other data in addition to HR and BP must be determined to detect occult hypoperfusion. Current local perfusion measures such as NIRS, gastric intramucosal pH, and sublingual capnography may help identify occult hypoperfusion; however, their lack of sensitivity limits their ability to guide resuscitation. Evidence suggesting they improve outcomes is lacking.

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This chapter addresses several fundamental questions related to the resuscitation of the trauma patient within an evidence-based construct. The particular questions are important; however, they do not represent all possible resuscitation-related dilemmas that may confront the surgeon or clinician. The goal, therefore, is to demonstrate and differentiate those maneuvers that are based on scientific evidence and discriminate them from those based solely on historical opinion. This is not to say that our surgical forefathers were wrong in their approaches (because in many cases, they were right on target), but to simply articulate those therapies that have a scientific basis from those whose basis should be questioned and improved upon if shown to be false. Acute-phase trauma resuscitation may be conducted safely with any isotonic crystalloid, as well as hypertonic saline, but not colloids. In general, crystalloid solutions remain preferred because of their low cost and similar outcomes compared to colloids.

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Diagnostic imaging remains critical to the management of acutely injured trauma patients, especially in the era of selective nonoperative management of many traumatic injuries. As diagnostic technology evolves, constant reassessment is required to ensure that the sensitivity and specificity parameters of any diagnostic test are well-understood and that the target population is well-defined to minimize cost, radiation burden, patient movement, and time. For unstable trauma patients, operative exploration maintains a central role in diagnosis and management. Ultrasonography and computed tomography are widely available imaging modalities that have been fully incorporated into the armamentarium of the trauma surgeon and are essential components of trauma management algorithms. This chapter reviews the evidence base to support the use of these modalities for the initial assessment of the injured patient. Physical examination alone is unreliable for the diagnosis of intraabdominal injuries in patients who have sustained blunt abdominal trauma.

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Over the course of the past 20 years, the term “damage control” has become a part of the common vernacular among trauma surgeons, general surgeons, and orthopedists. Initially conceptualized as a temporizing measure to stabilize the victims of penetrating trauma, it is now a widely applied algorithm that has become a standard of care within the trauma community. The combination of damage control resuscitation concepts with damage control laparotomy (DCL) has seemingly continued to decrease mortality rates even further. Cotton et al. compared outcomes in 282 patients who underwent DCL before damage control resuscitation techniques with outcomes in 108 DCLs coupled with damage control resuscitation: The 24-hour and 30-day survival were significantly higher with the addition of damage control resuscitation (88% vs. 97% and 76% vs. 86%). Morris et al. found an overall complication rate of 1.09 complications per patient, with eight positive blood cultures, six intraabdominal abscesses, and abdominal compartment syndrome in 16 patients.

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Hemorrhagic shock can be compounded by trauma-induced coagulopathy (TIC), which is a hypocoagulable state that can develop immediately after injury and deteriorates with increasing tissue hypoperfusion. TIC is a disease state that includes impairments in clot formation, hemostasis, and ultimate breakdown of the clot due to disorders in both inflammatory and coagulopathic pathways. The rate of trauma patients receiving massive transfusions remains low; however, patients requiring this intervention are at highest risk for TIC. The identification of TIC can be achieved by conventional lab tests, including a platelet count; fibrinogen level; and coagulation assays such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR). The major limiting factor with these assays is the time to obtain the results. Accumulating data demonstrate whole blood transfusion can be a potentially lifesaving method of resuscitation in severely injured trauma patients.

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Traumatic brain injury (TBI) continues to be a major cause of death and disability. Head computed tomography (CT) is an invaluable tool in the evaluation of patients with suspected TBI. Most institutions obtain a head CT for any patient with blunt trauma and a Glasgow Coma Scale (GCS) score of less than 15. Repeat head CT scans are routinely performed to evaluate the progression of intracranial bleeding or to assess the need for neurosurgical intervention. Given the increased cost and risk of moving critically ill patients, several studies have called this practice into question. Chemical deep venous thrombosis (DVT) prophylaxis has been an intense area of research in the trauma literature. Grade B recommendations support low-molecular-weight heparin (LMWH) as the most effective method of prophylaxis to prevent DVT in trauma patients without TBI. Posttraumatic seizure activity occurs both early and late after injury.

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Spine injuries are common in the modern urban trauma setting. Although rare, spinal cord injury (SCI) carries an extremely high rate of morbidity and mortality. The annual incidence of SCI is approximately 54 cases per 1 million people in the United States, or 17,730 new traumatic SCIs each year. As with every other severe trauma patient, initial management includes securing a patent airway, controlling adequate oxygenation, and managing hemodynamics and perfusion. Numerous studies have tried to define spinal movement during airway management in patients with intact and injured cervical spines. Nevertheless, the evidence is limited due to the heterogeneity of the measurement techniques and the controversy about the clinical importance of the biomechanical findings. The accumulated experimental data suggest that airway management in the trauma patient with suspected CSI may inflict spinal movement. Manual inline axial stabilization of the neck during the airway intervention can safely be applied and significantly limit the allegedly dangerous spine motion.

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Facial injuries are among the most common emergencies seen in an acute care setting. They range from simple soft tissue lacerations to complex facial fractures associated with significant craniomaxillofacial injuries with soft tissue loss. Traditional management of facial lacerations includes closure of the skin with a nonabsorbable suture, citing the low tissue reactivity that minimizes scar formation and the high tensile strength preventing dehiscence. Facial injuries, in particular facial fractures, have long been noted to be associated with concomitant head and cerebral injuries. A retrospective review of trauma in motorcycle riders found the odds of traumatic brain injury (TBI) were 3.5 times greater with a facial injury than without a facial injury and 6.5 times greater with a facial fracture than without a facial fracture. Antibiotics are used widely in surgery and the management of facial injuries.

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Ocular trauma represents the leading cause of monocular blindness globally and accounts for an estimated one-third of all eye-related emergency department (ED) visits in the United States each year. Therefore, the goal of this chapter is to serve as a guide for acute care physicians, written by ophthalmic surgeons, for the rapid diagnosis and initial management of the most common ocular traumatic conditions seen in the acute care setting. The recommendations arising from this review are based on the strongest available level of evidence and are intended to familiarize nonophthalmic physicians with recent advances in diagnosis and primary interventions for these ocular conditions. The presence of an ocular foreign body (OFB) is considered an ocular emergency, requiring urgent diagnosis and treatment to maximize the chances of visual improvement and prevent globe loss. OFB patients are typically male, with injury most often occurring in the workplace (i.e., hammering).

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The neck has been an area that has spawned much debate and research in trauma over the past several decades. This chapter focuses on a few of the most commonly asked questions regarding the evaluation and treatment of aerodigestive and vascular injuries in the neck. To decrease the number of negative neck explorations, more emphasis has been placed on the physical exam, new imaging technology, and close observation. As our technology has improved, so has the incidence of occult injuries, raising questions about treatment. Physical exam is adequate to rule out significant airway and vascular injuries in the case of penetrating trauma. There is no appreciable difference in outcomes when comparing endovascular stents to medical therapy, including those with grade II and III injuries. Stenting should be reserved for large pseudoaneurysms and vessel narrowing secondary to dissection.

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Resuscitative thoracotomy (RT) is the performance of left anterolateral thoracotomy, potentially but not necessarily with extension to the right chest (i.e., “clamshell’ thoracotomy), in a patient with cardiovascular collapse after traumatic injury. In the absence of conclusive evidence to guide management, the decision to perform RT continues to rely on the clinical judgment of trauma physicians. Although institutional protocols have been advocated, the heterogeneity of patient and injury factors in such cases continues to demand a risk-benefit analysis on a case-by-case basis. Based on the retrospective data available, RT after blunt trauma is associated with a low overall rate of survival (1–10%). However, these results should be interpreted in the context of nearly universal lethality of cardiac arrest after blunt trauma with standard resuscitation efforts. Small retrospective reports have suggested that the use of RT may facilitate salvage in a select group of agonal patients with exsanguinating vascular injuries in the abdomen and pelvis.

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Trauma to the chest wall is common and may account for up to one-quarter of all traumatic deaths. Because thoracic trauma accounts for a significant portion of traumatic morbidity and mortality, proper management of these injuries has the potential to significantly and positively impact trauma outcomes. This chapter answers and makes recommendations in areas where sufficient evidence exists, specifically in the areas of surgical stabilization of the chest wall, autotransfusion, selection of chest tube size, and timing of VATS for evacuation of retained hemothorax. Small-bore chest tubes are as effective as large-bore drains in patients with traumatic hemothoraces. Smaller tubes reduce patient discomfort during insertion and should be used in the nonemergent setting for stable trauma patients with either a hemothorax or pneumothorax. In patients suffering blunt chest wall trauma, hemothorax is a frequent occurrence that is initially treated with tube thoracostomy.

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Chest injury from blunt trauma is a significant cause of morbidity and mortality. Most of the literature published on injury to the thoracic great vessels has focused on the aorta and on blunt thoracic aortic injury (BTAI), which is a devastating injury that requires early recognition to minimize morbidity and mortality. The chest X-ray is a good screening tool and is usually one of the first studies obtained on the trauma patient. Angiography remains the standard by which most other diagnostic tests are compared. CT of the chest with intravenous contrast is strongly recommended for making the diagnosis of blunt thoracic aortic injury. The nonoperative management of blunt aortic injuries stemmed from studies reporting the use of medical management of these injuries in patients who were poor operative candidates due to advanced age or comorbidities that prohibit emergency thoracic surgery.

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Cardiac injury remains a small percentage of trauma patients being received at trauma centers, despite a continual improvement in prehospital care and an unfortunate increase in penetrating trauma over the last few years. There are major differences between penetrating and blunt cardiac injury (BCI) in the presentation of the patient to the trauma bay, associated injuries, diagnostic methods, and therapeutic interventions. Depending on the mechanism of injury and management of these patients, low mortality is obtainable. There is clear evidence for those needing continuous monitoring when arrhythmia is present in the emergency room and/or cardiac enzymes are abnormal. For patients without these findings, there is no evidence for the need for continuous ECG monitoring. There are multiple approaches and techniques to treat a foreign body in the heart, depending on the characteristics of the impaled or retained object and the resources available at the hospital.

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David Hume, a Scottish philosopher, remarked that a wise man proportions his belief to the evidence. In the case of traumatic injuries to the esophagus and tracheobronchial tree, the evidence consists mostly of case reports, retrospective analyses, and opinions. The rarity of these injuries has prevented the accumulation of significant prospective data. This chapter covers incidence, mechanism of injury, and current practices in diagnosing and managing these rare injuries. It may not strengthen the wise physician's beliefs, but it accurately reflects the current evidence. Autopsy studies of blunt trauma patients reveal an incidence of tracheobronchial injury in 2.8% of fatalities. Series that include data on symptomatology and physical findings report the most common symptom as respiratory distress and the most common physical finding as subcutaneous emphysema. Certain patients with airway injury will have obvious findings on the physical exam such as air bubbling from a penetrating neck wound.

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Injury to the spleen is common, resulting in a significant number of hospital admissions, morbidity, and occasionally death. The spleen is the second most commonly injured organ in blunt abdominal trauma and the most common reason for laparotomy after blunt injury. Selective NOM of blunt splenic injuries has become standard for hemodynamically stable patients and those who respond rapidly to initial resuscitation (responders). The minimal criteria for NOM of blunt spleen injuries have been identified as hemodynamic stability and the absence of generalized peritonitis in the setting of a reliable and reproducible exam. As the role of NOM in penetrating abdominal injuries has increased in general, the rate of successful NOM in penetrating splenic injuries has increased as well. Splenic artery embolization (SAE) has become an important adjunct in patients at the highest risk for NOM failure. The focused abdominal sonography for trauma (FAST) exam is generally the initial imaging study performed for blunt trauma patients.

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The liver is the most commonly injured organ in patients with blunt abdominal trauma and the second most common in penetrating abdominal trauma. Less than 20% of patients with blunt liver injury will require emergent laparotomy because of either the liver or associated intraabdominal injuries. Associated intraabdominal injuries necessitating laparotomy, peritonitis, hemodynamic instability, and lack of appropriate clinical environment and/or availability of facilities or personnel to support adjuncts to NOM should the need arise constitute the four absolute contraindications to NOM. Based on the aforementioned criteria, more than 80% of blunt trauma patients are candidates for NOM, with a success rate of around 90%. In March 2010, the EAST published practice management guidelines for sNOM of penetrating abdominal trauma, which specifically addressed the indications for laparotomy for GSWs, postinjury imaging, and specific recommendations for sNOM.

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Injuries to the small intestine and colon are found in less than 5% of victims of blunt abdominal trauma but are the most common injuries sustained after penetrating abdominal trauma. There is no consensus on the issue of stapled versus hand-sewn anastomosis after small bowel or colon resection for trauma. The hand-sewn anastomosis may be preferable in situations where the portion of the intestine under consideration for anastomosis is edematous or is at risk of becoming edematous, such as in a patient requiring a large-volume resuscitation. Injury to the small intestine has not been shown to result in a high rate of infectious complications, and skin closure after small bowel trauma is generally recommended. The debate of antibiotic duration following trauma laparotomy in general and colon injury in particular continues. Despite the lack of truly definitive trials, it is advisable to limit antibiotic prophylaxis to no more than 24 hours after laparotomy for intestinal injury.

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Traumatic diaphragmatic injuries (TDIs) are uncommon injuries but most often are a result of penetrating trauma. The gold standard for establishing the diagnosis of TDI is direct visualization of the diaphragm by using either laparotomy or the minimally invasive techniques of laparoscopy or thoracoscopy. A “segmental diaphragmatic defect” may be observed with the abrupt loss of diaphragmatic continuity. While this is highly specific, it is not very sensitive for TDI. Diaphragmatic injuries due to penetrating trauma result most often from stab wounds and gunshot wounds to the thoracoabdominal region, defined as the region extending from the nipples to the costal margin. The chest X-ray is once again the initial imaging modality of choice. Radio-opaque markers must be used to mark the site of the external injury. Determination of the resultant trajectory allows estimation of the likelihood of diaphragmatic involvement. Findings may, however, be subtle or masked by associated injuries, making diagnosis difficult.

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Although pancreaticoduodenal injuries are uncommon, occurring in less than 0.5% of trauma patients, they can be associated with significant morbidity and mortality. Determinants of morbidity and mortality include the severity of the pancreaticoduodenal injuries, Injury Severity Score (ISS), concomitant injuries to other organs, major vascular injury, and shock on presentation. The organ injury scaling systems of the American Association for the Surgery of Trauma (AAST) are widely used in the published literature describing these injuries. Duodenal leaks occur in a substantial minority (8–32%) of patients after repair and are a significant source of morbidity and mortality. Available data demonstrate that primary repair of duodenal injury is safe and effective in most injuries, regardless of AAST grade or mechanism. Pyloric exclusion with or without gastrojejunostomy is still performed as an adjunctive procedure for the repair of severe duodenal injuries, but there are insufficient data to suggest that it improves outcomes or prevents complications.

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Abdominal vascular trauma is highly lethal. Many patients with major abdominal vascular injuries die at the scene. The clinical presentation will depend on the injured vessel, the size and type of injury, intraperitoneal or retroperitoneal location, polytrauma, and time since injury. This chapter aims to delineate the latest evidence-based management, treatment, and interventions to use in handling abdominal vascular trauma. Abdominal vascular trauma usually presents as hypotension or expanding hematoma. When blunt traumatic abdominal injury (BTAI) is present, the focused assessment with sonography in trauma (FAST), vitals, mechanism of injury, and physical exam help categorize the severity of the patient's status. For patients arriving at the emergency department in cardiac arrest, a left anterolateral thoracotomy should be performed with aortic cross-clamping and cardiac massage. If a return of spontaneous circulation (ROSC) is obtained, the patient is taken to the operating room (OR) for completion of exploration.

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Trauma is a leading cause of nonobstetric morbidity and mortality in pregnancy and complicates 6–7% of all pregnancies. The specific anatomic and physiologic changes that occur during pregnancy may alter the response to injury and hence necessitate a modified approach to management. Functional residual capacity decreases because of a decline in expiratory reserve and residual volumes. Relative to these changes, the injured pregnant patient poorly tolerates hypoxia; hence, supplemental oxygen should always be placed regardless of saturation. Increased levels of progesterone and estrogen inhibit gastrointestinal motility, intestinal secretion, and nutrient absorption. The most common cause of fetal death is maternal death. A key management principle is to treat the mother first because most medical measures that aid in the resuscitation of the mother will be helpful to the fetus. After the primary survey and stabilization of the patient, diagnostic modalities are used to determine the extent of injuries to the mother and fetus.

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Pelvic fractures are reported to account for 1–3% of all skeletal injuries and are present in approximately 5% of trauma patients requiring hospitalization. These fractures typically occur through a variety of blunt mechanisms, including motor vehicle collisions, pedestrian accidents, falls, and crush injuries, with penetrating mechanisms being much less common. As pelvic fracture hemorrhage appears to be largely venous in origin and frequently contained within the extraperitoneal spaces of the pelvis, theoretically reduction of pelvic volume may reduce the extent of bleeding via enhancing tamponade and reducing bony fracture bleeding. Early pelvic stabilization may be attempted by wrapping the pelvis in a sheet secured with clamps or application of commercially available devices such as the Trauma Pelvic Orthotic Device (T-POD). During the last decade, resuscitative endovascular balloon occlusion of the aorta (REBOA) has gained increased attention as an adjunctive measure for circulatory support and temporary vascular control in patients with noncompressible torso hemorrhage, including pelvic fracture bleeding.

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Extremity vascular injury caused by trauma remains a significant cause of mortality and morbidity in the injured patient. With technological advances, vascular surgery has changed dramatically over the past decade. Trauma surgeons are faced with these injuries daily and need to have the expertise to take care of these patients acutely. There is a growing body of evidence on which to base both diagnostic and therapeutic decisions in the acutely injured trauma patient with extremity vascular injury. This chapter reviews the recent literature related to the diagnosis and management of acute vascular extremity trauma, divided into relevant clinical questions, with recommendations based on the most recent evidence. Physical exam can adequately identify findings concerning extremity vascular injury. The use of tourniquets for the management of prehospital control of peripheral vascular trauma has the potential to save lives with minimal morbidity.

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Surgical decision-making in the setting of limb-threatening trauma is complex and time-sensitive. Although the multifaceted and emergent nature of this injury pattern has precluded the highest levels of a clinical study, evidence-based guidelines can be discerned from available clinical reviews, case series, and general clinical consensus. This chapter aims to identify and expand on evidence-based strategies that influence treatment decisions aimed at maximizing functional recovery following traumatic upper or lower extremity injury, including when to consider limb salvage versus amputation. The recent advances in the literature have translated military combat experience to knowledge gaps in the civilian literature. Upper and lower extremity trauma have various treatment paradigms, which reflect their unique subspecialty preferences, though this chapter focuses on the treatment of various injury patterns and complications to the extremities, such as bites, skin, and soft tissue infections. While these injuries are less severe than the subsequent mangled extremity, they are frequently seen in practice, and mismanagement can have devastating consequences.

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Significant advances in burn care over the past several decades have led to improved survival, particularly in young healthy patients. Through both observational and prospective basic science and clinical research, burn management no longer involves conservative wound management and deliberate observation. Instead, the science has resulted in goal-directed fluid management, early excision and grafting of burn wounds for wound closure, aggressive organ support, and directed rehabilitation strategies as the foundation for the successful management of burn patients. Primarily, these advancements involve resuscitation, wound care, prevention of infection, and critical care while work is ongoing in rehabilitation outcomes and scar management. The primary goal of burn shock management is the restoration or maintenance of vital organ perfusion and function at the least physiologic cost. Targeted early restoration of volume and sodium losses with appropriately estimated physiologic crystalloid solutions in a simplified fashion, taking care to closely monitor and adjust the response to therapy, is key.

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Traumatic injury to tissues is a common occurrence, and sequelae may range from relatively benign to major functional alterations or even death. The most common mechanisms include interpersonal violence and motor vehicular crashes. The less common causes of injury may often be more difficult to treat due to the lack of familiarity with the disease process, potential complications, and long-term derangements. Injuries resulting from electrical, cold, and chemical exposures fall into this latter category. In cases such as these, evidence-based medicine is a sound foundation upon which to base practice decisions. Electrical injuries may be misleading, as the external evidence of injury may be a poor reflection of actual tissue damage. Identification of necrotic tissue is important to allow proper debridement. Patients with significant electrical injury should be admitted to a monitored setting with telemetry and serial evaluation of laboratory values, including urine myoglobin.

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The estimated prevalence of chronic nonhealing wounds in developed countries ranges from 1% to 2% within the general population. The morbidity and the associated cost of treating chronic wounds can have significant implications on the cost of healthcare. Recent studies have shown that nearly 15% of Medicare beneficiaries had at least one type of wound infection, with surgical infections forming the largest category, followed by diabetic infections. The management of chronic wounds continues to be a significant yet understudied component of perioperative patient care. Wound healing is a dynamic process that can be influenced by both the wound microenvironment and the health and nutritional status of the individual. The wound healing process has been traditionally broken down into three integrated and often overlapping phases: Inflammation, proliferation, and maturation. In acute wounds, these processes occur in an orderly fashion and achieve the desired structural and functional restoration.

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Injuries in children are frequently managed similarly to adults. However, the unique anatomy, physiology, and psychology of children mandate care in the application of evidence obtained from studies of adults to the pediatric population. This chapter focuses on questions in pediatric trauma that are relevant to the daily practice of those who care for injured children. Neurologically intact (GCS = 15) children over 2 years of age with no loss of consciousness, vomiting, severe injury mechanism, signs of basilar skull fracture, or severe headache may be safely observed in the emergency department and discharged without a head CT. In younger children with GCS = 15 and a loss of consciousness over 5 seconds, a palpable skull fracture, a temporal/parietal cephalohematoma, or progressive headache or vomiting, a head CT should be obtained. Although a grade C recommendation can be made for the use of hypertonic saline to reduce ICP in children, there is no evidence for associated improvements in long-term outcomes.

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The advanced-age trauma patient can pose particular clinical challenges that, while not unique to older age groups, tend to concentrate on older patients and negatively impact their posttrauma outcomes. Older patients are more likely to be taking a beta-blocker or oral anticoagulation or antiplatelet agent. These vulnerabilities, combined with greater diversity in the patient's or family's goals of care in the setting of acute illness, make the study of the advanced-age trauma patient worthwhile for the traumatologist. Integrating palliative care processes into ICU care may increase the rate of establishment of advance directives. Clinical measures such as the elevated base deficit, elevated TS, and extensive polytrauma in advanced-age patients predict very high mortality and can be used to aid in goals-of-care discussions. The use of anticoagulation in the elderly is increasing and is an important consideration in the trauma population, especially in the setting of traumatic brain injury.

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Management of genitourinary (GU) trauma has changed over the past few decades. Because of utilization of advanced radiographic imaging, minimally invasive interventional techniques, and improvements in resuscitation, management has become less surgically aggressive. This chapter provides an evidence-based approach to the management of patient populations with traumatic injuries to the GU tract. The studies cited are mostly retrospective due to the logistics and ethics of executing prospective, randomized studies in the trauma setting. In the absence of hemodynamic instability, computed tomography (CT) with intravenous (IV) contrast in patients with blunt trauma with evidence of gross hematuria or microscopic hematuria is recommended. A CT with IV contrast should be considered in patients presenting with clinical findings consistent with urotrauma. Hemodynamically stable patients with blunt renal injury may initially be treated nonoperatively, while hemodynamically unstable patients who do not respond to resuscitation must undergo immediate intervention, with either surgery or angioembolization.

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Dysregulation of normal bowel movements in absence of obstruction is called ileus. The physiologic postoperative ileus is secondary to colonic dysmotility, as the colon is the last organ to recover (takes 48–72 hours), while the small bowel is the first to recover (takes 0–24 hours), and the paralytic ileus is secondary to small bowel dysmotility. Symptoms of ileus include nausea, vomiting, inability to tolerate any oral intake, abdominal distension, abdominal pain, and obstipation. Physical exam findings include diffuse tympanic percussion, mild tenderness, and reduction of bowel sounds. Management of ileus is conservative and supportive and includes correcting electrolytes, definitive source control of infection, starting the patient on a multimodal pain regimen, nutritional support, bowel rest, bowel decompression when excess vomiting is present, and serial abdominal exams. Resolution of ileus is assessed with a tolerance of diet; the passage of flatus/stool; return of bowel sounds; and decrease in nausea, vomiting, distension, and NGT output.

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Upper gastrointestinal (UGI) bleeding is a common cause of admission to the intensive care unit (ICU) and accounts for over 300,000 ICU admissions in the United States alone. Optimal outcomes depend on both the rapid identification of the etiology of the hemorrhage and the subsequent implementation of appropriate pharmacologic and procedural therapies. This chapter reviews the current evidence, including practice guidelines, for the prevention and management of UGI bleeding. The type and use of medical prophylaxis are highly dependent on the etiology of a UGI bleed. In some cases, medical prophylaxis is the primary means of prevention, while in others, secondary prevention is the goal. As ulcer disease is the most common cause of UGI bleeds, providers must identify the etiology of the ulceration. There are three principal causes: Stress-related mucosal damage (SRMD), nonsteroidal antiinflammatory drug (NSAID) use, and Helicobacter pylori infection.

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Enterocutaneous fistulas (ECFs) represent a catastrophic problem for patients and continue to be complex and labor-intensive issues for healthcare providers. In addition to the many physiologic and mental stressors that patients must endure, the development of ECFs also strains healthcare systems, resulting in prolonged hospital stays, multiple readmissions, and increased resource consumption. The management of ECFs has improved significantly, resulting in decreased mortality rates, from 50% in the 1950s to approximately 5–15% at present. Despite overall improvements in the care of these patients with ECFs, sepsis and malnutrition remain the leading causes of death. Postoperative ECFs are more common than spontaneous fistulas. They are often caused by unrecognized bowel injuries or anastomotic breakdown. Multiple preoperative patient factors can increase the likelihood of ECF development. These factors include previous and active infection, inflammatory bowel disease especially active disease, uncontrolled diabetes, electrolyte abnormalities, smoking, malnutrition, anemia, hypothermia, poor oxygen delivery, and emergent procedures.

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Hiatal hernias are characterized by the intrathoracic protrusion of elements of the abdominal cavity through a widened esophageal hiatus. They are anatomically classified into four types (I–IV). Types II–IV hernias are collectively referred to as paraesophageal hernias (PEHs). Surgical repair is analogous to all types of hiatal hernias; however, paraesophageal hernias have a characteristic presentation and workup and carry the potential for an acute presentation that sets them apart from sliding hiatal hernias. The natural history of PEHs is progressive enlargement such that eventually, the entire stomach herniates alongside the esophagus, with the pylorus juxtaposed to the gastric cardia, forming an intrathoracic upside-down stomach. The driving force for this progression is positive intraabdominal pressure combined with negative intrathoracic pressure. The decision to surgically repair a PEH is based on the patient's overall medical status, symptomatic complaints, and the chance of incarceration/strangulation.

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Lower gastrointestinal bleeding (LGIB) is defined as bleeding originating distal to the ligament of Treitz. This chapter focuses on LGIB from a colonic source, as that is the predominant reason for surgical consultation in the hospital setting. Gastrointestinal (GI) bleeding is the most common cause of hospitalization related to GI disease in the USA. The true incidence of LGIB is underestimated as minor episodes may never present to a hospital. LGIB has varied presentations due to its heterogeneous causes, and the large anatomical range of the “lower GI” distribution can pose a challenge for clinicians, as it is difficult at times to pinpoint the source of the bleeding, and this is critical for optimal management. Nuclear scintigraphy was classically the standard in noninvasive testing of LGIB. It remains effective compared to CTA, especially in scenarios with intermittent or slow bleeding. But due to less predictable availability and length of time to obtain nuclear imaging results, CTA is preferably used today.

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Acute appendicitis (inflammation of the vermiform appendix) remains the most common intraabdominal surgical emergency requiring operative intervention. The lifetime risk of developing appendicitis is around 7–9%. Men are more likely to develop acute appendicitis than women (1.4:1), and men are more likely to have a perforated appendix than women. Appendicitis can occur at any age but is most frequently seen in patients in their second and fourth decade of life, with a mean age of 31.3 and a median age of 22 years. In this chapter, the authors try to answer a few common issues clinicians face when diagnosing and managing acute appendicitis. Important questions to consider in caring for a patient with appendicitis include how to make an accurate diagnosis, whether to treat the patient medically or surgically, and whether to proceed surgically with an open or laparoscopic approach. The answers to these questions are based on an evidence-based review of the literature.

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Diverticular disease of the colon is a common condition, predominant in Western societies, that generates a significant socioeconomic burden. The prevalence of diverticulosis is age-related in Western societies, affecting only 5% of individuals less than 40 years of age, but involving two-thirds of adults over the age of 65. Complicated diverticulitis refers to cases in which patients present with an abscess, perforation, stricture, fistula formation, or sepsis. Approximately 22% of patients admitted for diverticulitis will undergo surgery for the management of their complicated disease. In this chapter, the authors review the existing evidence in the literature regarding the management of colonic diverticular disease, including indications for elective operative management, the role of the patient's age in operative decision-making, optimal operative management in the acute setting, the role of laparoscopy in the acute setting, and the prevention of recurrent attacks.

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Large bowel obstruction is a potentially life-threatening condition that can present as a result of a variety of mechanisms. The breadth of causes can complicate management and treatment decisions. Knowledge of anatomy, physiology, surgical treatment options, and critical care are all vital in managing this disease entity. Since patients can present with significant physiologic derangements, early identification followed by prompt intervention is necessary. Ogilvie's syndrome, or acute colonic pseudo-obstruction, presents with similar symptoms and is initially managed the same; however, in contrast to large bowel obstruction, nonoperative management remains the mainstay of treatment. This chapter presents the most up-to-date and applicable research. Recent review articles were also used to support some of the points presented in other retrospective and prospective evaluations. The presentation of colonic obstruction depends on the degree of intestinal luminal narrowing, duration of the obstruction, and etiology of the obstruction.

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Acute mesenteric ischemia (AMI) is a challenging and potentially fatal condition that requires a high index of suspicion, early diagnosis, and prompt restoration of blood flow to avoid fulminant bowel necrosis and death. Delays in diagnosis have been associated with a mortality of up to 80%. Intestinal ischemia is broadly categorized according to the segment of the bowel to which blood flow is compromised and the acuity of onset. The presentation, management strategies, and outcomes of these entities vary widely; an accurate diagnosis is thus paramount. AMI requires immediate intervention. Thrombotic or embolic occlusion of the superior mesenteric artery is the most common cause of AMI. Less frequent etiologies include mesenteric venous thrombosis and nonocclusive mesenteric ischemia (NOMI). The goal of the intervention is focused on expeditious restoration of visceral perfusion. In patients with embolic disease, this is achieved via midline laparotomy and open Fogarty catheter embolectomy.

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Hemorrhoids are classified as internal, external, or mixed. Internal Hemorrhoids (IHs) are vascular cushions found above the dentate line, and External Hemorrhoids (EHs) are found below the dentate line. This chapter focuses on recent evidence-based data on the treatment of hemorrhoids after the failure of conservative management. In 2014, Vidal et al. published a novel treatment modality for symptomatic hemorrhoids using endovascular embolization coined “emborrhoid”. This approach allows the interventionalist to identify the arterial branches of the hemorrhoidal cushions for embolization while reducing trauma seen in excisional approaches. Surgical intervention is usually reserved for patients who fail nonoperative management. Excisional hemorrhoidectomy has long been considered the mainstay operation; however, the approach to excision has dramatically evolved to include the use of stapling and energy devices. The exact etiology of thrombosis remains undefined but has been linked with increased intravenous pressure within the hemorrhoidal plexus that leads to rupture of the endothelial lining and subsequent thrombosis.

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Anorectal complaints are common, but often poorly understood. More often than not, a referral for “hemorrhoids” is often vague and can refer to any number of perianal abnormalities. Proper treatment depends on the correct diagnosis. Once an accurate assessment is made, therapy can be based on evidence-based guidelines for the treatment of anorectal abscesses, fistula, and fissures. This chapter covers anal abscess, anal fissure, and fistula-in-ano. Multiple randomized prospective trials have examined the role of various nonoperative therapies in the treatment of anal fissures. All effective modalities are aimed at decreasing the hypertonicity found in the internal anal sphincter of fissure patients. Therapies that do not lower sphincter pressures have been uniformly found to be no better than placebo. Most studies focus on chronic fissures. Nonsurgical therapies are superior to placebo but inferior to lateral internal sphincterotomy for healing anal fissures.

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Surgeons are often involved in the management of benign biliary diseases, including cholecystitis and cholangitis. Surgical treatment of cholecystitis was first described in 1882 by Langenbuch, while the first laparoscopic cholecystectomy was performed in 1985, leading to the widespread adoption of the laparoscopic technique thereafter. In this chapter, the authors explore the presentation, diagnosis, and management of both entities, focusing on the diseases caused by gallstones. The biliary anatomy is quite variable and contributes to the diagnostic and therapeutic difficulty of both acute cholecystitis and cholangitis. The textbook-like structure of the biliary tree with “classic” cystic duct drainage anatomy is only noted in about 17% of patients undergoing cholecystectomy. Ultrasound remains the initial study of choice for most patients. Laparoscopic cholecystectomy should be the initial approach of choice in the vast majority of cases.

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Acute pancreatitis (AP) is responsible for over one-quarter of a million hospital admissions in the United States annually, and its incidence is increasing in the United States and Europe. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive technique that is more sensitive than ultrasound and computed tomography (CT) as a modality to diagnose choledocholithiasis. This advantage, however, is encumbered by higher financial costs and a potential delay in more invasive therapeutic intervention. In conclusion, a selective approach that combines abnormal liver function tests and screening ultrasound criteria seems prudent to identify a population presenting with ABP appropriate for early up-front CCY or ERCP, eliminating the need for MRCP and reducing LOS. When utilized more conservatively, MRCP can avoid the need for invasive preoperative ERCP or the need for intraoperative IOC. Adherence to these evidence-base protocols represents an avenue to reduce costs and LOS while eliminating unnecessary expensive MRCP in certain circumstances and enhancing its efficacy in others.

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Pancreatic pseudocysts (PPs) are common sequelae of acute and chronic pancreatitis. Gouyon et al. retrospectively analyzed 90 patients with chronic pancreatitis and PP formation, and similar to the studies of patients with acute pancreatitis, the authors noted that PP size was associated with successful nonoperative management. Due to the limited size of existing studies and the overall paucity of literature on the subject, several meta-analyses have been published comparing surgical and endoscopic drainage in an attempt to pool the available data. LOS was shorter for the endoscopic treatment arm, and the authors also found endoscopic drainage was associated with a significantly reduced mean hospital cost. Despite the successful outcomes for endoscopic drainage, there likely remains a continued need for surgical drainage in patients requiring more dependent drainage due to the anatomic position of the PP or in cases of PP away from the lesser sac.

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Portal hypertension is typically the first and main manifestation of cirrhosis, and it is responsible for many of its complications. Since portal hypertension may occur before establishment of a formal anatomical diagnosis of cirrhosis. Endoscopy remains needed to identify other signs of portal hypertension such as hypertensive gastropathy that is often the cause of minor bleeding in patients with cirrhosis. Magnetic resonance elastography (MRE) has been used to grade the severity of cirrhosis and help calculate LS. Treatment of portal hypertension differs based on the stage of cirrhosis since the prognosis and mechanism of disease are different. Patients with cirrhosis presenting with gastrointestinal hemorrhage are at a high risk of bacterial infections. In a retrospective study of 210 patients with cirrhosis of the liver with GV, 34% underwent GVO, 20% underwent balloon-occluded retrograde transvenous obliteration (BRTO), and 46% were observed.

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A retrospective review examined patients treated with surgical embolectomy for acute limb ischemia. It is believed that thrombolytic therapy allows for enhanced clearance of thrombus from vessels too small for traditional embolectomy catheters and can diagnose underlying pathology. There was no demonstrable difference between limbs treated for thrombotic etiology versus embolic etiology. The major conclusion is a decreased need for open surgical revascularization and a reduced magnitude of the surgery. Intraarterial endovascular techniques as initial therapy for acute limb ischemia appear to be in equipoise relative to open surgical treatment for achieving limb salvage and may reduce mortality. Unfortunately, there is little high-quality data to guide our treatment of acute arterial embolus. While it is often possible to distinguish between embolic versus thrombotic etiologies based on history and examination, the error rate remains as high as 25%.

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A retrospective study of 248 patients with Ruptured Aortic Aneurysm (rAAA) over 10 years suggested that aggressive volume resuscitation before proximal aortic control predicted an increased perioperative risk of death, which was independent of systolic blood pressure. Although there are no definitive studies on patients with rAAA, it seems intuitive to recommend avoiding overt hypertension. The nature of fluids for resuscitation purposes in the perioperative period in patients with rAAA has been the subject of at least one prospective cohort study. It showed a decreased 30-day and 5-year mortality rate in patients treated with EVAR instead of open repair. The British IMPROVE trial had a different design in that it randomized patients with suspected rAAA to either an endovascular strategy or an immediate open surgery. The use of local anesthesia may be beneficial in patients undergoing EVAR for rAAA. Heparin anticoagulation before aortic clamping is routinely done in elective AAA surgery.

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The main short-term complication of DVT is pulmonary embolism (PE), while the long-term complication is postthrombotic syndrome. Multiple evidence-based reviews of the diagnosis and treatment of DVT and practice guidelines have been published. This chapter reviews venous thromboembolism (VTE) and addresses the topics of DVT and PE treatment. The review concluded that once-daily treatment with LMWH is as effective and safe as twice-daily treatment with LMWH. In 1994, the authors compared patients receiving UFH, SCD, or no treatment and found similar DVT rates in the three groups, except for a mild advantage of SCD over no treatment in neurosurgical patients. The effectiveness of inferior vena cava (IVC) filters relies on their ability to capture clots originating from the lower extremity or pelvic veins. There are multiple randomized studies in the literature, and all of them include either exclusively or predominantly medical patients.

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Necrotizing fasciitis has been described as a rapidly progressive process, but at least some patients may describe a relatively indolent period before seeking medical attention, with subsequent decompensation giving the outward appearance of rapid progression. The rationale for the former had its genesis in the treatment of anaerobic NSTIs such as clostridial necrotizing myositis, and the latter as an attempt to improve the treatment of aggressive group. A streptococcal infections and their complications such as streptococcal toxic shock syndrome. The most common synonyms for necrotizing muscle infections are gas gangrene, clostridial/streptococcal myonecrosis, and necrotizing myositis. There has been little in the literature to suggest a standardized approach to NSTI. HBO therapy is a theoretically attractive potential therapy for NSTIs, utilizing oxygen as a direct toxin to combat anaerobic bacteria. NSTIs are uncommon, highly lethal diseases requiring rapid diagnosis and treatment to achieve optimal outcomes.

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The introduction of the first polypropylene mesh and then expanded polytetrafluoroethylene (PTFE) changed the face of elective hernia repairs almost completely by the mid-1990s. Laparoscopic repairs were added to the elective hernia repair options in the early 1990s, and all utilize some form of prosthesis. A few small prospective trials have been performed to determine the optimal repair of incarcerated hernias with cohort sizes ranging from 40 to 54 patients, as well as a few retrospective studies. Primary tissue repair avoids foreign body–based infections; however, subsequent recurrences are common. Retrospective reviews suggest imperfect but acceptable results in contaminated fields with modest complication rates (infection and reoperation) equivalent between synthetic mesh and no mesh repairs regardless of the need for bowel resection. The management of incarcerated hernias has changed dramatically over the last half-century. The astronomical cost of the biologic mesh made this too expensive for researchers to finance outside of a large federal grant.

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Central diabetes insipidus (CDI) results from inadequate secretion of the hypothalamic polypeptide antidiuretic hormone (ADH). ADH originates in the supraoptic and paraventricular nuclei of the hypothalamus and is excreted by the posterior pituitary gland. Hypercalcemic crisis may also occur in the setting of malignancy, from either direct osteolysis by bony metastases or osteolysis from osteoclastic activity stimulated by parathyroid hormone-related protein (PTHrP) or proinflammatory mediators released by the tumor. In the setting of primary hyperparathyroidism, calcium and PTH will be elevated, while PTHrP is normal. Once the patient is medically optimized and calcium has decreased with medical management to less than 12 mg/dL, primary hyperparathyroidism may be definitively treated with parathyroidectomy. An adrenal crisis occurs with disruption of the hypothalamic-pituitary-adrenal (HPA) axis, primarily resulting in acute mineralocorticoid deficiency. Adrenal crisis in the critically ill is likely caused by an exaggerated inflammatory response, tissue resistance to corticosteroids, and intrinsic adrenal gland deficiency.