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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 falciform ligament attaches the liver anteriorly to the diaphragm and the anterior abdominal wall above the umbilicus.
The coronary ligaments extend laterally to attach the liver to the diaphragm. Beginning at the suprahepatic inferior vena cava (IVC), the lateral extensions of the coronary ligaments form the triangular ligaments (right and left), which are also attached to the diaphragm.
The anatomical division of the liver into the eight classic Couinaud segments has no practical application in traumatic liver resection, where the resection planes are nonanatomical and are dictated by the extent of injury. However, the external anatomical landmarks may be useful in planning operative maneuvers.
The plane between the center of the gallbladder and IVC runs along the middle hepatic vein, and serves as the line of division between the right and left lobes.
The left lobe is divided by the falciform ligament into the medial and lateral segments.
Dissection along the falciform ligament should be performed carefully, so as to avoid injury to the portal venous supply to the medial segment of the left lobe inferiorly and the hepatic veins superiorly.
The retrohepatic IVC is approximately 8–10 cm long and is partially embedded into the liver parenchyma. In some cases, the IVC is completely encircled by the liver, further complicating exposure and repair.
There are three major hepatic veins (right, middle, and left), as well as multiple accessory veins. The first 1–2 cm of the major hepatic veins are extra-hepatic, with the remaining 8–10 cm intra-hepatic. In approximately 70% of patients, the middle hepatic vein joins the left hepatic vein before entering the IVC.
The common hepatic artery originates from the celiac artery. It is responsible for approximately 30% of the hepatic blood flow, but supplies 50% of the hepatic oxygenation. It branches into the left and right hepatic arteries at the liver hilum in the majority of patients. In a common anatomical variant, the right hepatic artery may arise from the superior mesenteric artery. Less frequently, the entire arterial supply may arise from the superior mesenteric artery. Alternatively, the left hepatic artery may arise from the left gastric artery in 15–20% of patients.
The portal vein provides approximately 70% of hepatic blood flow, and 50% of the hepatic oxygenation. It is formed by the confluence of the superior mesenteric vein and the splenic vein behind the head of the pancreas. The portal vein divides into right and left extrahepatic branches at the level of the liver parenchyma.
The porta hepatis contains the hepatic artery (medial), common bile duct (lateral), and portal vein (posterior, between the common bile duct and the hepatic artery).
The right hepatic duct is easier to expose after removal of the gallbladder.
The left hepatic duct, the left hepatic artery, and the left portal vein branch enter the undersurface of the liver near the falciform ligament.
The cervical esophagus extends from the cricopharyngeus muscle into the chest to become the thoracic esophagus.
The external landmark of the pharyngoesophageal junction is the cricoid cartilage. On esophagoscopy, this is at 15 cm from the upper incisors.
The esophagus lacks a serosal layer and consists of an outer longitudinal and inner circular muscle layer.
The cervical esophagus is approximately 5–7 cm long and lies posterior to the cricoid cartilage and trachea and anterior to the longus colli muscles and vertebral bodies. It is flanked by the thyroid gland and carotid sheath on either side.
Blood supply is primarily from the inferior thyroid artery, although significant collateral circulation exists.
The recurrent laryngeal nerves lie on either side of the esophagus in the tracheoesophageal groove.
A large operating room (OR) situated near the emergency department, elevators, and ICU should be designated as the Trauma OR to facilitate the logistics of patient flow and minimize transport. The room should be securable for high profile patients.
A contingency plan for multiple simultaneous operations should be in place with the operating rooms in sufficient proximity to allow nursing and anesthesia cross-coverage and facilitate supervision of the surgical teams. Direct lines of communication between the OR, resuscitation area, ICU, other ORs, blood bank, and laboratory should be in place.
All rooms should have ample overhead lighting as well as access to portable headlamps.
Multiple monitors to display imaging, vital signs, and laboratory such as thromboelastometry, should be in place.
Hybrid operating and interventional radiology teams should be familiar with operating in the hybrid room.
A dedicated family waiting room should be identified, and all family should be directed to this area for the postoperative discussion.