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The third edition of the Color Atlas of Emergency Trauma brings the reader to the bedside of patients with traumatic injuries, at one of the largest and busiest trauma centers in North America. It includes over 1200 images, designed as a comprehensive visual and reference guide to emergency trauma care. Organized by major body regions, this atlas explores the full spectrum of common and uncommon traumatic injuries, including those caused by firearms, stab wounds, blunt trauma, crush injury, and burns. It also covers special patient groups, such as pregnant, pediatric and geriatric populations. Each chapter is augmented with patient images at presentation, radiographic, intraoperative and autopsy images, and color illustrations and photographs showing key anatomy from the cadaver laboratory. With common pitfalls discussed and invaluable tips from a multidisciplinary group of experienced trauma care providers, this book is a useful and practical resource for all those involved in trauma care.
Prehospital vital signs are used to triage trauma patients to mobilize appropriate resources and personnel prior to patient arrival in the emergency department (ED). Due to inherent challenges in obtaining prehospital vital signs, concerns exist regarding their accuracy and ability to predict first ED vitals.
The objective of this study was to determine the correlation between prehospital and initial ED vitals among patients meeting criteria for highest levels of trauma team activation (TTA). The hypothesis was that in a medical system with short transport times, prehospital and first ED vital signs would correlate well.
Patients meeting criteria for highest levels of TTA at a Level I trauma center (2008-2018) were included. Those with absent or missing prehospital vital signs were excluded. Demographics, injury data, and prehospital and first ED vital signs were abstracted. Prehospital and initial ED vital signs were compared using Bland-Altman intraclass correlation coefficients (ICC) with good agreement as >0.60; fair as 0.40-0.60; and poor as <0.40).
After exclusions, 15,320 patients were included. Mean age was 39 years (range 0-105) and 11,622 patients (76%) were male. Mechanism of injury was blunt in 79% (n = 12,041) and mortality was three percent (n = 513). Mean transport time was 21 minutes (range 0-1,439). Prehospital and first ED vital signs demonstrated good agreement for Glasgow Coma Scale (GCS) score (ICC 0.79; 95% CI, 0.77-0.79); fair agreement for heart rate (HR; ICC 0.59; 95% CI, 0.56-0.61) and systolic blood pressure (SBP; ICC 0.48; 95% CI, 0.46-0.49); and poor agreement for pulse pressure (PP; ICC 0.32; 95% CI, 0.30-0.33) and respiratory rate (RR; ICC 0.13; 95% CI, 0.11-0.15).
Despite challenges in prehospital assessments, field GCS, SBP, and HR correlate well with first ED vital signs. The data show that these prehospital measurements accurately predict initial ED vitals in an urban setting with short transport times. The generalizability of these data to settings with longer transport times is unknown.
The popliteal fossa is diamond-shaped and its borders are formed by the semimembranosus and semitendinosus muscles superiomedially, the biceps femoris muscle superiolaterally, the medial head of the gastrocnemius muscle inferiomedially, and the lateral head of the gastrocnemius muscle inferiolaterally. It contains the popliteal artery and vein, the tibial and common peroneal nerves, and is covered by subcutaneous tissue and skin.
The popliteal artery is the continuation of the superficial femoral artery after it passes through the adductor canal, an opening in the adductor magnus muscle, in the lower thirds of the thigh. It courses downward and laterally to the midline of the knee between the two condyles of the femur, into the popliteal fossa.
The popliteal artery has three segments: suprageniculate (above knee), midpopliteal (behind knee), and infrageniculate (below knee). Exposure to each segment of the popliteal artery is distinct.
The popliteal artery has superior and inferior genicular branches, which provide blood supply to the tissues surrounding the knee joint and provide important collaterals when there are occlusions of the superficial femoral or popliteal artery.
Below the knee, the popliteal artery branches into the anterior tibial artery, followed by the peroneal branch about 2–3 cm lower, which itself then branches into the peroneal and posterior tibial arteries.
The anterior tibial artery pierces the upper part of the interosseous membrane, courses in front of the membrane, under the extensor muscles of the anterior muscle compartment, and distally becomes the dorsalis pedis artery.
The tibioperoneal trunk is the direct continuation of the popliteal artery and, after approximately 3 cm, branches to form the peroneal artery laterally and the posterior tibial artery medially. The peroneal and posterior tibial arteries lie in the deep posterior compartment of the leg posteriorly of the fibula and tibia, respectively.
The posterior tibial artery continues directly to the ankle and lies superficially posterior to the medial malleolus, while the peroneal artery branches above the ankle to form collaterals to the dorsalis pedis and plantar branches of the posterior tibial artery in the foot.
The popliteal vein lies posterior to the artery (more laterally superiorly to more medially inferiorly). The tibial nerve is lateral and posterior to the artery.
Strict antiseptic precautions and personal protective equipment should be used during the procedure. A single dose of prophylactic antibiotics with Cefazolin should be administered before the procedure. There is no need for further prophylaxis.
Chest tubes can be inserted with an open or percutaneous dilational technique.
The site of insertion is the same for open or percutaneous insertion and for hemothorax or pneumothorax, at the fourth or fifth intercostal space, at the level of the nipple in males.
Autotransfusion should be considered in all cases with large hemothoraces.
On the right side, the subclavian artery originates from the innominate (brachiocephalic) artery, which branches into the right subclavian and right common carotid arteries. On the left side, it originates directly from the aortic arch. In some individuals, the left subclavian artery may have a common origin with the left common carotid artery.
The subclavian artery courses laterally, passing between the anterior and middle scalene muscles. This is in contrast to the subclavian vein, which is located superficial to the anterior scalene muscle.
The subclavian artery is divided into three parts on the basis of its relationship to the anterior scalene muscle. The first part extends from its origin to the medial border of the anterior scalene muscle, coursing deep to the sternocleidomastoid and the strap muscles. It gives rise to the vertebral, internal mammary (internal thoracic), and thyrocervical arteries. The second part lies deep to the anterior scalene muscle and superficial to the upper and middle trunks of the brachial plexus. Here, it gives rise to the costocervical artery (on the left side, costocervical artery comes off the first part of the subclavian artery). The third part is located lateral to the anterior scalene muscle, and courses over the lower trunk of the brachial plexus, usually giving rise to the dorsal scapular artery, although its branches are not constant.
The subclavian artery continues as the axillary artery, as it passes over the first rib. The external landmark for this transition is the lower border of the middle of the clavicle. The external landmark for the axillary artery is a curved line from the middle of the clavicle to the deltopectoral groove.
The subclavian vein is the continuation of the axillary vein and originates at the level of the outer border of the first rib. It crosses in front of the anterior scalene muscle, and at the medial border of the muscle, it joins the internal jugular vein to form the innominate (brachiocephalic) vein. The left thoracic duct drains into the left subclavian vein at its junction with the left internal jugular vein. The right thoracic duct drains into the junction of the right subclavian vein and right internal jugular vein.
The vagus nerve is in close proximity to the first part of the subclavian artery and it lies medial to the internal mammary artery. On the right side, it crosses in front of the artery and immediately gives off the recurrent laryngeal nerve (RLN), which loops behind the subclavian artery and ascends behind the common carotid artery into the tracheoesophageal groove. On the left side, the vagus nerve travels between the common carotid and subclavian arteries and immediately gives rise to the RLN, which loops around the aortic arch and ascends into the tracheoesophageal groove.
The abdominal aorta bifurcates into the two common iliac arteries at the level of the fourth to fifth lumbar vertebrae (surface landmark is the umbilicus). The common iliac arteries are about 5–7 cm in length.
At the level of the sacroiliac joint, the common iliac arteries bifurcate to the external and the internal iliac arteries.
The external iliac artery runs along the medial border of the psoas muscle and goes underneath the inguinal ligament to become the common femoral artery. It gives two major branches: the inferior epigastric artery, just above the inguinal ligament, and the deep iliac circumflex artery, which arises from the lateral aspect of the external iliac artery opposite the inferior epigastric artery.
The internal iliac artery is a short and thick vessel, about 3–4 cm in length. It divides into the anterior and posterior branches at the sciatic foramen. These branches provide blood supply to the pelvic viscera, perineum, pelvic wall, and the buttocks.
The ureter crosses over the bifurcation of the common iliac artery.
The common iliac veins lie medially and posterior to the common iliac arteries. They join to form the inferior vena cava at the level of the fifth lumbar vertebra, posterior to the right common iliac artery.
Negative pressure wound therapy (NPWT) provides a closed, moist environment with a regulated level of negative pressure to the wound bed, stimulating perfusion and granulation tissue formation, reduction of local edema, removal of infected fluid, and wound volume contraction.
NPWT can be used in a variety of wounds, including large traumatic wounds, fasciotomy sites, skin grafted wounds or burns, necrotizing soft tissue infections, infected orthopedic hardware or joints, and wounds with exposed or infected bone or tendon.
The recommended optimal negative pressure is 125 mmHg.
Veraflo therapy is a specialized wound dressing that combines negative pressure therapy with automated intermittent wound irrigation. The system instills irrigation fluid into the wound, allows soaking of the wound for determined period of time (usually 10–20 minutes), followed by negative pressure for a defined period of time (usually 3–4 hours). The settings and instillation volume can be customized as needed.
The principles of soft tissue wound management differ significantly based on whether or not infection is present.
For noninfected soft tissue defects, such as large traumatic wounds, operative management is guided by debridement of dead or ischemic tissues and wound approximation, where possible. Negative pressure therapy may be applied as an adjunct to stimulate granulation tissue formation and wound shrinkage.
For infected wounds, operative management is guided by debridement of all infected and necrotic tissue. Systemic antibiotics are often necessary for invasive infections. NPWT with intermittent irrigation (VAC Veraflo System) may be locally applied to enhance wound granulation and closure and decrease bacterial burden as well as frequency of debridements.
Appropriate surgical debridement and wound hemostasis are imperative prior to application of NPWT.
NPWT reduces the number of surgical debridements, is more comfortable than the traditional dressings, shortens the time to wound closure and hospital stay, and lowers costs.
The anterior compartment, which contains the biceps, the brachialis, and coracobrachialis, all innervated by the musculocutaneous nerve.
The posterior compartment, which contains the triceps, which is innervated by the radial nerve.
The forearm is divided into three muscle compartments:
The anterior or flexor compartment, which contains the muscles responsible for wrist flexion and pronation of the forearm. These muscles are innervated by the median and ulnar nerves and receive blood supply mainly from the ulnar artery.
The posterior or extensor compartment, which contains the muscles responsible for wrist extension. They are innervated by the radial nerve and the blood supply is provided mainly by the radial artery.
The mobile wad is a group of three muscles on the radial aspect of the forearm that act as flexors at the elbow joint. These muscles are often grouped together with the dorsal compartment. The blood supply is provided by the radial artery and the innervation by branches of the radial nerve.
The hand includes ten separate osteofascial compartments:
The transverse carpal ligament, over the carpal tunnel, is a strong and broad ligament. The tunnel contains the median nerve and the finger flexor tendons.
The inferior vena cava (IVC) is formed by the confluence of the common iliac veins, just anterior to the L5 vertebral body, and posterior to the right common iliac artery. As it courses superiorly towards the diaphragm, it lies to the right of the lumbar and thoracic vertebral bodies. It enters the thorax at T8, where the right crus of the diaphragm separates the IVC and aorta. In most individuals, there is a small segment of suprahepatic IVC, about 1 cm in length, between the liver and diaphragm, which is amenable to cross clamping.
The IVC receives four or five pairs of lumbar veins, the right gonadal vein, the renal veins, the right adrenal vein, the hepatic veins, and the phrenic veins. It is of practical importance to remember that all lumbar veins are below the renal veins and that between the renal veins and the hepatic veins, besides the right adrenal vein, there are no other venous branches. The left lumbar veins pass behind the abdominal aorta.
The confluence of the renal veins with the IVC lies posterior to the duodenum and the head of the pancreas.
The retrohepatic IVC is about 8–10 cm in length and is adhered to the posterior liver, helping to anchor the liver in place. In this liver “tunnel,” several accessory veins from the caudate lobe and right lobe drain directly into the IVC.
There are three major hepatic veins which drain the liver into the IVC. The extrahepatic portion of these veins is short, measuring about 0.5–1.5 cm in length. The right hepatic vein is the largest. In about 70% of individuals, the middle vein drains into the left hepatic vein to enter the IVC as a single vein.
The thoracic IVC is almost entirely in the pericardium.