Atlas of surgical techniques in trauma

Contents
List of contributors ix
Preface xi
Acknowledgments xii
Introduction – Kenneth L. Mattox

xiii

Section 1 – Operating Room General Conduct
1.

Trauma operating room 1
Kenji Inaba and Lisa L. Schlitzkus

12. Trachea and larynx 94
Elizabeth R. Benjamin and Kenji Inaba

Section 2 – Resuscitative Procedures in the
Emergency Room
2.

Cricothyrotomy 5
Peep Talving and Rondi Gelbard

3.

Thoracostomy tube insertion 12
Demetrios Demetriades and Lisa L. Schlitzkus

4.

Emergency room resuscitative thoracotomy
Demetrios Demetriades and Scott Zakaluzny

Insertion of intracranial pressure monitoring
catheter 29
Howard Belzberg and Matthew D. Tadlock

6.

Evacuation of acute epidural and subdural
hematomas 35
Gabriel Zada and Kazuhide Matsushima

13. Cervical esophagus 101
Elizabeth R. Benjamin and Kenji Inaba

Section 5 – Chest
14. General principles of chest trauma
operations 107
Demetrios Demetriades and Rondi Gelbard
18

15. Cardiac injuries 115
Demetrios Demetriades and Scott Zakaluzny
16. Thoracic vessels 126
Demetrios Demetriades and Stephen Varga

Section 3 – Head
5.

11. Vertebral artery injuries 88
Demetrios Demetriades and Nicholas Nash

17. Lung injuries 140
Demetrios Demetriades and
Jennifer Smith
18. Thoracic esophagus 150
Daniel Oh and Jennifer Smith
19. Diaphragm injury 162
Lydia Lam and Matthew D. Tadlock

Section 4 – Neck
Neck operations for trauma: general principles
Emilie Joos and Kenji Inaba

8.

Carotid artery and internal jugular vein injuries 53
Edward Kwon, Daniel J. Grabo, and George Velmahos

20. General principles of abdominal operations
for trauma 165
Heidi L. Frankel and Lisa L. Schlitzkus

9.

Subclavian vessels 69
Demetrios Demetriades and Jennifer Smith

21. Damage control surgery 172
Mark Kaplan and Demetrios Demetriades

10. Axillary vessels 83
Demetrios Demetriades and Emilie Joos

47

Section 6 – Abdomen

7.

22. Gastrointestinal tract 180
Kenji Inaba and Lisa L. Schlitzkus

vii


Contents

23. Duodenum 189
Edward Kwon and Demetrios Demetriades

33. Upper extremity fasciotomies 288
Jennifer Smith and Mark W. Bowyer

24. Liver injuries 198
Kenji Inaba and Kelly Vogt

34. Upper extremity amputations 294

Peep Talving and Scott Zakaluzny

25. Splenic injuries 209
Demetrios Demetriades and Matthew D. Tadlock
26. Pancreas 219
Demetrios Demetriades, Emilie Joos, and George Velmahos
27. Urological trauma 228
Charles Best and Stephen Varga
28. Abdominal aorta and visceral branches
Pedro G. Teixeira and Vincent L. Rowe

35. Femoral artery injuries 303
George Velmahos and Rondi Gelbard
36. Popliteal artery 307
Peep Talving and Nicholas Nash

240

37. Lower extremity amputations 314
Peep Talving, Stephen Varga, and Jackson Lee

29. Iliac injuries 257
Demetrios Demetriades and Kelly Vogt

38. Lower extremity fasciotomies 323
Peep Talving, Elizabeth R. Benjamin, and
Daniel J. Grabo

30. Inferior vena cava 262
Lydia Lam and Matthew D. Tadlock

Section 7 – Pelvis
31. Surgical control of pelvic fracture hemorrhage
Peep Talving and Matthew D. Tadlock

Section 9 – Lower Extremities

273

Section 10 – Orthopedic Damage
Control
39. Orthopedic damage control 337
Eric Pagenkopf, Daniel J. Grabo, and Peter Hammer

Section 8 – Upper Extremities
32. Brachial artery injury 281
Peep Talving and Elizabeth R. Benjamin

viii

Index

345


Section 4
Chapter

7

Neck

Neck operations for trauma: general principles
Emilie Joos and Kenji Inaba

Surface anatomy

 For trauma purposes, the neck is divided into three distinct
anatomical zones. Although these zones do not directly
impact clinical decision making, they are important for
documentation and communication purposes.

 Zone I: from the sternal notch to the cricoid
cartilage.
 Zone II: from the cricoid to the angle of the
mandible.
 Zone III: from the mandible to the base of the skull.

Zone III

Zone III

Zone II

Zone II

Zone I

Zone I

Fig. 7.1. For trauma purposes, the neck is divided into three distinct anatomical zones: Zone I, from the sternal notch to the cricoid cartilage; Zone II, from the
cricoid to the angle of the mandible; Zone III, from the mandible to the base of the skull.

Atlas of Surgical Techniques in Trauma, ed. Demetrios Demetriades, Kenji Inaba, and George Velmahos. Published by Cambridge University
Press. © Cambridge University Press 2015.

47


Chapter 7. Neck operations for trauma

(c)

(d)

Fig. 7.2(c),(d).
Fig. 7.2(a-d). Bleeding from a deep penetrating injury to the neck may be controlled by placement of a Foley catheter into the wound and inflation of the balloon
with sterile water.

 Always place intravenous lines in the arm opposite the
injury, especially in periclavicular injuries with suspected
subclavian vein injury.
 In suspected major venous injury, place patient in the
Trendelenburg position and occlude the wound with gauze,
in order to reduce risk of air embolism.

(a)

Suprasternal
notch

Positioning

 The patient should be in the supine position.
 If the cervical spine has been cleared, a roll should be
placed under the shoulders to provide extension of
the neck.
 If a sternocleidomastoid incision is planned, the head is
slightly extended with the placement of a shoulder roll and
turned to the opposite side of the injury. For a collar
incision the head is kept in the midline position.

Mastoid

Fig. 7.3(a). Position of patient for a sternocleidomastoid incision: the head is
slightly extended with the placement of a shoulder roll and turned to the
opposite side of the injury.

49


Section 4: Neck

Vagus nerve

Common carotid artery

Fig. 8.2. Carotid sheath contents. The carotid
sheath contains the common carotid and internal
carotid arteries medially, the internal jugular vein

laterally, and the vagus nerve posteriorly between
the vessels.

LEFT FACE

Internal jugular vein

Internal jugular vein

Fig. 8.3. The facial vein is the anatomical
landmark approximating the location of the carotid
bifurcation deep to it. The facial vein is ligated and
divided in order to mobilize the internal jugular
vein laterally and provide exposure to the
underlying carotid bifurcation.

Facial vein

LEFT FACE

54


Chapter 15. Cardiac injuries

(a)

(b)

Fig. 15.10(a),(b). (cont.)

Fig. 15.10(a),(b). A Foley balloon can be used to temporarily control the
bleeding from a cardiac wound. Exert gentle traction on the catheter to achieve
tamponade of the wound. Avoid excessive traction to prevent pulling the
balloon through the defect and creating a larger wound.

 Skin staples may be used temporarily for cardiac wound
closure in the emergency room, and are primarily effective
for stab wounds. This does not work well in patients who
have sustained gunshot wounds associated with cardiac
tissue loss. The staples should be replaced by sutures in the
operating room.
 Partial transection of a major coronary artery can be
repaired with interrupted sutures under magnification,
while the heart is beating. If this is not technically
possible, ligation is performed and the cardiac activity
is observed. Distal injuries are usually tolerated well.
If no arrhythmia develops, then nothing further is

required. If arrhythmia occurs, the suture is removed and
gentle finger pressure is applied, while a cardiac team with
cardiopulmonary bypass capabilities is mobilized.
 Cardiopulmonary bypass is largely unnecessary during
the acute operation. The surgical goal is to save the
patient’s life. Any non-life-threatening intracardiac defects
should be repaired electively under optimal conditions at
a later stage.
 Inspection and repair of injuries to the posterior cardiac
wall can be difficult, as lifting of the heart often causes
arrhythmia or cardiac arrest. These injuries can be

exposed and repaired by grasping the apex of the heart
with a Duval clamp and applying mild traction and
elevation. Another option is to place a figure-of-eight
2–0 suture on a tapered needle through the apex of the
heart for traction and elevation. This option should be
performed cautiously because the myocardium may
tear during traction. An alternative approach is to

121