Table Of ContentEuropean Manual of Medicine
Hans-Jörg Oestern • Otmar Trentz
Selman Uranues
(Editors)
Wolfgang Arnold
Uwe Ganzer
(Series Editors)
Head, Thoracic,
Abdominal,
and Vascular Injuries
Trauma Surgery I
Editors
Prof. Hans-Jörg Oestern, MD Univ. - Prof. Selman Uranues, MD
Allgemeines Krankenhaus Celle Medizinische Universität Graz
Klinik für Unfall- und Auenbruggerplatz 15
Wiederherstellungschirurgie 8036 Graz
Siemensplatz 4 Austria
29223 Celle [email protected]
Germany
[email protected]
Prof. Otmar Trentz, MD
UniversitätsSpital Zürich
Forschungsabteilung Chirurgie
Klusweg 18
8032 Zürich
Switzerland
[email protected]
Series Editors
Prof. Wolfgang Arnold, MD Prof. Uwe Ganzer, MD
Director emeritus Director emeritus
Department of Otorhinolaryngology Department of Otorhinolaryngology
Head & Neck Surgery Head & Neck Surgery
Klinikum rechts der Isar University of Düsseldorf
Technical University of Munich Düsseldorf
Munich Germany
Germany [email protected]
[email protected]
ISBN 978-3-540-88121-6 e-ISBN 978-3-540-88122-3
DOI 10.1007/978-3-540-88122-3
Springer Heidelberg Dordrecht London New York
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Foreword of the Series Editors
The European Manual of Medicine was founded on the idea of offering resident as
well as specialized clinicians the latest and most up-to-date information on diagnosis
and treatment in Europe. In contrast to existing textbooks, the European Manual of
Medicine aims to find a consensus on the demands of modern European medicine
based on the “logbooks” recommended by the Union of European Medical Societies
(UEMS). Therefore, for each discipline those diagnostic and therapeutic principles
that are generally considered best practice are presented as “recommended European
standards.”
To fulfill these demands we – together with Springer – recruited editors who are
well established and recognized in their specialties. For each volume at least three
editors from different European countries were invited to contribute the high clinical
and scientific standards of their discipline to their book.
Wherever possible the volume editors were asked to follow a standardized structure
for each chapter so as to provide readers quick and easy access to the material. High-
quality illustrations and figures serve to provide additional useful information. Detailed
references allow interested readers to further investigate areas of individual interest.
The series editors wish to express their sincere gratitude to Springer-Verlag, espe-
cially to Gabriele Schroeder and Stephanie Benko for their support and assistance in
the realization of this project from the early stages.
The fifth volume of our European Manual of Medicine series is dedicated to
trauma surgery and will be published in three parts. The first part presented here
focuses on cranial, thoracic, abdominal and vascular trauma. The following two parts
will deal with trauma of the skeletal system and joints, of peripheral nerves and soft
tissues, as well as with the special care needed by trauma patients, handling compli-
cations, pain management, and principles of rehabilitation.
One of the main aims of this volume is to provide, especially, trainees with a compre-
hensive yet condensed guide to the core knowledge required in this broad surgical field
and also give them the ability to work in their specialty throughout the European Union.
The volume editors Prof. Hans-Jörg Oestern (Celle, Germany), Prof. Otmar Trentz
(Zürich Switzerland) and Prof. Selman Uranues (Graz, Austria), – who are leading
European experts in trauma surgery, – recruited contributors from different European
countries to compile a textbook that fulfills our original concept of the European
Manual of Medicine series.
Munich Wolfgang Arnold
Düsseldorf Uwe Ganzer
Fall 2010
v
Preface
Internationally, trauma is at the top, if not the very top of the list of causes of death
under the age of 50 years. At the same time, enormous developments continue to be
made in diagnostics and treatment, while the field of trauma/acute/emergency surgery
undergoes exciting and dramatic expansion and restructuring, with the establishment
of new surgical specialties. At this crucial juncture, it is desirable to work in the
direction of bringing evidence-based order and uniformity into the trauma care
system.
This first volume in the “Trauma Surgery” series deals with cranial, thoracic,
abdominal, and vascular trauma. These injuries frequently fulfill the criteria for “lethal
trauma” and are often camouflaged by more obvious associated lesions. Even though
the emergency and trauma surgeon may need the support of organ-focused specialists
for the definitive surgical care of many of the addressed injuries, he or she must be
able to detect the full trauma pattern, set priorities, and perform at least the most
urgent damage-control procedures. The organ-focused specialist, moreover, may
have had only sporadic exposure to critical organ lesions and the respective hand-
books may provide only marginal coverage of trauma issues.
Target groups of this volume are general and trauma surgeons looking for an up-
to-date outline of surgical trauma care or preparing for the EBSQ-Trauma exam. The
contributing authors are all highly experienced trauma surgeons or specialists in their
fields with strong trauma commitment. They are drawn in part from the professional
environment of the editors, and in part from the distinguished faculty of AAST and
ESTES congresses.
Progress is made when established techniques are challenged and know-how is
transmitted to critical colleagues. In this sense, the editors hope that surgeons, whether
young or established, will scrutinize the given recommendations, apply them, and
pass on their suggestions for improving them.
We express our sincere gratitude to all the authors who contributed to this volume
for sharing their extraordinary experience in the field of trauma.
Special appreciation also is due to Springer Publishing and in particular to Gabriele
Schroeder for initiating and publishing this volume of “Trauma Surgery.” Finally, we
are very much indebted to Stephanie Benko for her support of both the editors and the
authors.
Celle, Graz, and Zurich Hans-Jörg Oestern
Fall 2010 Otmar Trentz
Selman Uranues
vii
Contents
1 Traumatic Brain Injury....................................... 1
H.-G. Imhof and P. Lenzlinger
2 Intensive Care Treatment Options of Elevated
Intracranial Pressure Following Severe Traumatic Brain Injury..... 93
John F. Stover and Reto Stocker
3 Craniofacial Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Marius G. Bredell and Klaus W. Grätz
4 Chest Trauma............................................... 223
Demetrios Demetriades, Peep Talving, and Kenji Inaba
5 Diaphragm ................................................. 257
Luke P.H. Leenen
6 Esophageal and Gastric Injuries ............................... 263
Paul M. Schneider, Georg Lurje, Peter Bauerfeind,
and Marc Schiesser
7 Liver ...................................................... 275
Luke P.H. Leenen
8 Splenic Injuries.............................................. 285
Selman Uranues and Abe Fingerhut
9 Pancreas, Duodenum, Small Bowel ............................. 297
Ari K. Leppäniemi
10 Colorectal Injuries........................................... 305
Alexander Woltmann and Christian Hierholzer
11 Abdominal Compartment Syndrome, Abdominal
Decompression, and Temporary Abdominal Closure............... 317
Christoph Meier
ix
x Contents
12 Trauma Laparotomy: Indications, Priorities,
and Damage Control ......................................... 333
Selman Uranues and Abe Fingerhut
13 Laparoscopic Procedures in Trauma Care ....................... 343
Selman Uranues, Abe Fingerhut, and Roberto Bergamaschi
14 Traumatic Injury of the Urogenital System ...................... 351
Corinne Wanner Schmid and Daniel Max Schmid
15 Abdominal Vascular Injuries .................................. 369
Juan A. Asensio, Tamer Karsidag, Aytekin Ünlü,
Juan M. Verde, and Patrizio Petrone
16 Vascular Injuries of the Neck .................................. 381
Juan A. Asensio, Juan M. Verde, Aytekin Ünlü,
Daniel Pust, Mamoun Nabri, Tamer Karsidag, and Patrizio Petrone
17 Vascular Injuries of the Lower Extremities....................... 393
Juan A. Asensio, Tamer Karsidag, Aytekin Ünlü,
Juan M. Verde, and Patrizio Petrone
18 Vascular Injuries of the Upper Extremities....................... 403
Juan A. Asensio, Tamer Karsidag, Aytekin Ünlü,
Juan M. Verde, and Patrizio Petrone
Index ......................................................... 413
Traumatic Brain Injury 1
H.-G. Imhof and P. Lenzlinger
1.1 Introduction vast majority of cases. Falls are the leading cause of
trauma in Northern Europe [167, 383, 387]. Thirty five
to 50% of TBI patients are under the influence of alco-
Trauma of the head is a common cause of morbidity
hol [372]. Trauma of the head is common in children
and mortality and continues to be an enormous public
too: Annually, 280 children/100,000 population require
health problem. Tagliaferri and colleagues [391] com-
hospitalization for 24 h or more. Mild TBI accounts
piling data from 23 European reports including find-
for 82.7% of admissions. Each year, approximately
ings from national studies from Denmark, Sweden,
15% of children admitted with TBI will have a moder-
Finland, Portugal, Germany, and from regions within
ate or severe brain injury. Falls account for 60% of TBI
Norway, Sweden, Italy, Switzerland, Spain, Denmark,
admissions among under 5 years of age, and nonacci-
Ireland, the U.K., and France derived an aggregate
dental injuries account for 8.7% of TBI admissions for
hospitalized plus fatal traumatic brain injury (TBI)
children under 2 years of age [154].
incidence rate of about 235 per 100,000, an average
Ninety to 95% of all TBIs are considered mild [256,
mortality rate of about 15 per 100,000, and a case fatal-
391, 419]. European study of the TBI severity ratio of
ity rate of about 11 per 100. Prevalence is estimated to
hospitalized patients was about 22:1.5:1 for mild vs.
reach a 317 per 100,000 persons living in Denmark
moderate vs. severe cases, respectively.
with a work-precluding TBI sequelae in 1989 [97].
About 60% of the brain-injured patients have an
The highest incidence of TBI occurs in men aged
additional other injury that may add to the severity of
15–24 years, and is the leading cause of death among
cases and may worsen outcome [258, 360, 377].
people younger than 45 years [3, 177, 200].
The incidence of cervical spine trauma in moderately
While various mechanisms may cause TBI, the
or severely head-injured patients ranges from 4% to 8%.
most common causes include motor vehicle accidents
Head-injured patients sustaining MVA (motor vehicle
(e.g., collisions between vehicles, pedestrians struck
accident)-related trauma and those with an initial GCS
by motor vehicles, bicycle accidents), falls, assaults,
(Glasgow coma scale) score less than or equal to 8 are at
sports-related injuries, and penetrating trauma. The
the highest risk for concomitant cervical spine injury. A
percentages of TBI from external causes varied con-
disproportionate number of these patients sustain high
siderably from one European country to any other. In
cervical injuries, the majority of which are mechani-
Southern Europe, road traffic crashes constitute the
cally unstable and involve a spinal cord injury [161].
Gennarelli [126] and colleagues analyzed the
causes, incidence, and mortality in 16,524 patients
H.G. Imhof (*) (one third of the trauma center patients) with injury to
Department of Neurosurgery, University Hospital Zürich the brain or skull and compared them to patients with-
Rämistrasse 100, 8091 Zürich, Switzerland
out head injury. Relative to its incidence, patients with
e-mail: [email protected]
head injury composed a disproportionately high per-
P. Lenzlinger
centage (60%) of all the deaths. Overall mortality of
Department of Traumasurgery, University Hospital Zürich
patients with head injury (18.2%) was three times
Rämistrasse 100, 8091 Zürich, Switzerland
e-mail: [email protected] higher than if no head injury was present (6.1%). This
H.-J. Oestern et al. (eds.), Head, Thoracic, Abdominal, and Vascular Injuries, 1
DOI: 10.1007/978-3-540-88122-3_1, © Springer-Verlag Berlin Heidelberg 2011
2 H.-G. Imhof and P. Lenzlinger
mortality was only mildly influenced by extracranial 1.2.1.1 Primary Brain Damage
injuries except when minor and moderate head injuries
were accompanied by very severe – Abbreviated Injury Primary damage is a mechanical damage, occurring at
Scale (AIS) levels 4 to 6 [25] – injuries elsewhere. The the moment of the primary insult and is thought to be
cause of death in head-injured patients was approxi- irreversible. In treatment terms, this type of injury can
mated and it was found that 67.8% were due to head best be treated through avoidance, or blunting of the
injury, 6.6% due to extracranial injury, and 25.6% due impact through safety devices.
to both. Head injury is thus associated with more deaths The principal mechanisms of head injury are due to
(3,010 vs. 1,972) than all other injuries and causes the two phenomena of acceleration [125, 291, 298]
almost as many deaths (2,040 vs. 2,170) as extracranial and contact.
injuries. Because of its high mortality, head injury is
the single largest contributor to trauma center deaths.
Outcome in head injuries is influenced by accompa-
Impulsive Loading
nying extracranial injuries only if producing hypoten-
sion or hypoxia affecting cerebral metabolism
Acceleration results from a sudden motion without
– mortality rise from 12.8% to 62% – and if the head
significant physical contact, resulting in intracranial
injury is minor in relation to the extracranial injuries
and intracerebral pressure gradients and shear, tensile,
[68, 72, 127, 337, 359].
and compressive strains [86].
The nonimpact phenomena cause both subdural
hematoma resulting from tearing of bridging veins and
1.2 Traumatic Insults diffuse damage to axons (diffuse axonal injury, DAI)
attributed mainly to shear and tensile strain, with regard
to death, the two worst types of head injury [121, 124].
Head injury is a nonspecific term, which includes clini-
Indirect transmission of energy to the head results
cally evident external injuries to the face, scalp (as lacera-
in either translation, rotation, or a combined movement
tions, contusions, abrasions), and calvarium (fractures)
of the brain relatively to the skull and the dura mater
and may or may not be associated with traumatic brain
(with falx cerebri and tentorium cerebelli).
injury. Traumatic brain injury (TBI) is more properly
Translation: Translation causes focal lesions
defined as an alteration in brain function manifest as con-
fusion, altered level of consciousness, seizure, coma, or • Cortical contusions (gliding contusions; contrecoup
focal sensory or motor neurologic deficit resulting from contusions), cortical laceration
blunt or penetrating force to the head. Neurologic damage • Subdural hematoma
from TBI does not occur entirely at the moment of impact, Rotation: Sudden angular acceleration/deceleration
but evolves over the ensuing hours and days [291, 298]. generates shear forces in the brain that may cause dif-
fuse damage to axons (diffuse axonal injury, DIA) and
blood vessels. [4, 123]. These injuries decrease gradu-
ally from the surface to the center of the brain [214].
1.2.1 Mechanisms of Traumatic
Brain Injury: Primary Insult
Impact Loading Contact phenomena result from an
Traumatic brain injury is the consequence of a sudden
object striking the head resulting in focal lesions
impulsive or impact loading to the head – “the primary
insult” – during which energy (impulse) is transmitted
to the head, which undergoes sudden acceleration, • Bruise, abrasio, lacerations, and hematoma of the
deceleration, or rotation, or a combination of all. The scalp
result will be deformation of tissue by tissue compres- • Skull fracture
sion, tissue stretching, or tissue shear: produced when • Extradural hematoma
tissue slides over other tissue. Brain damage after head • Some types of cerebral contusion
injury can be classified by its time course. • Intracerebral hemorrhage
