diversificación de inditex

 M, Brockman Vascular repairs rarely fail after the first 12 hours, whereas, soft tissue infection is a limb threat for several weeks. Specific transfusion triggers for individual blood components exist. Laparoskopische Versorgung einer traumatischen Milzläsion mittels Fibrinklebung und Kollagenvlies. Although the physiology of aging separates older trauma patients from the younger generation (Table 7-14), treatment must remain individualized (some octogenarians look and physiologically act 50 years old, whereas others appear closer to 100 years).  D Indications for emergent cesarean section include: (a) severe maternal shock or impending death (if the fetus is delivered within 5 minutes, survival is estimated at 70%), (b) uterine injury or significant fetal distress (anticipated survival rates of >70% if FHTs are present and fetal gestational age is >28 weeks).131. C. Further exposure is facilitated by resection of the posterior belly of the digastric muscle. Because uterine and retroperitoneal veins may dilate to 60 times their original size, hemorrhage from these vessels may be torrential. Pelvic packing, in which six laparotomy pads (four in children) are placed directly into the paravesical space through a small suprapubic incision, provides tamponade for the bleeding (Fig. Enthusiasm for splenic salvage was driven by the rare, but often fatal, complication of overwhelming postsplenectomy sepsis. Unter dem Abdominaltrauma versteht man Verletzungen der Organe im Abdomen, die durch eine Gewalteinwirkung auf die Leibeswand hervorgerufen wurden.  EE ureter. The exception is penetrating trauma isolated to the right upper quadrant; in hemodynamically stable patients with trajectory confined to the liver by CT scan, nonoperative observation may be reasonable.41 In obese patients, if the gunshot wound is thought to be tangential through the subcutaneous tissues, CT scan can delineate the track and exclude peritoneal violation. Knudson Stumpfe Verletzungen werden z.B. Because associated injuries of the brachial plexus are common, a thorough neurologic examination of the extremity is mandated before operative intervention. As discussed later in “Damage Control Surgery,” options include intraparenchymal tamponade with a Foley catheter or balloon occlusion (see Fig. This may result in the patient’s having airway compromise due to blood running down the posterior pharynx, or there may be vomiting provoked by swallowed blood.  MJ, Tsai The spectrum of injuries to the duodenum includes hematomas, perforation (blunt blow-outs, lacerations from stab wounds, or blast injury from gunshot wounds), and combined pancreaticoduodenal injuries. In general, wounds sustained from trauma should be examined daily for progression of healing and signs of infection. Moreover, suture repair using an end-to-end anastomosis in the second portion often results in an unacceptably narrow lumen. Pankreasverletzungen Grad I–II ohne Zeichen einer Peritonitis können mittels medikamentöser Reduktion der Sekretion sowie begleitender parenteraler Ernährung und antibiotischer Therapie konservativ behandelt werden. After penetrating trauma, a great vessel or pulmonary hilar vessel injury should be presumed.  WD, Hoffman-Snyder (1995) Organ injury scaling: spleen and liver. Initially, clamps are placed on the aorta, inferior vena cava, and bilateral external iliac vessels.  K, Branco  DS, Moore  TM, Spain Zone II is located between the clavicles and the angle of the mandible. Early in the course of tamponade, blood pressure and cardiac output will transiently improve with fluid administration due to increased central venous pressure.  MJ, Schermer  EE, Moore  WL Cothren ED preparation for the pediatric trauma patient includes assembling age-appropriate equipment (e.g., intubation equipment; IV catheters, including intraosseous needles and 4F single-lumen lines), laying out the Broselow Pediatric Emergency Tape (which allows effective approximation of the patient’s weight, medication doses, size of endotracheal tube, and chest tube size), and turning on heat lamps. Penetrating wounds to the superior mesenteric artery (SMA) are typically encountered upon exploration for a gunshot wound, with “black bowel” and associated supramesocolic hematoma being pathognomonic. Shotgun injuries are divided into close-range (<20 feet) and long-range wounds. Blood should be drawn simultaneously for a bedside hemoglobin level and routine trauma laboratory tests. (1998) Changing patterns in the management of splenic trauma: the impact of nonoperative management. Tracheal intubation in the emergency department: a comparison of GlideScope¯ video laryngoscopy to direct laryngoscopy in 822 intubations.  JC, Mosier 3.6.73.121 Brunicardi F, & Andersen D.K., & Billiar T.R., & Dunn D.L., & Hunter J.G., & Matthews J.B., & Pollock R.E.(Eds. This technique of placing large liver sutures controls bleeding through reapproximation of the liver laceration rather than direct ligation of bleeding vessels. ECG = electrocardiogram; OR = operating room; SBP = systolic blood pressure. 7-9). If abdominal closure is indicated after the patient’s injuries are addressed, the abdomen is irrigated with warm saline and the midline fascia is closed with a running heavy suture. Because hemorrhage from hepatic injuries often is treated without isolating individual bleeding vessels, arterial pseudoaneurysms may develop, with the potential for rupture. After a motor vehicle collision in which the patient was wearing a passenger restraint, injuries comprising the “lap belt complex” or “seat belt syndrome” (i.e., abdominal wall contusion, small bowel perforation, flexion-distraction injury of the lumbar spine, diaphragm rupture, and occasionally abdominal aortic dissection) may exist. Repair of a transected fallopian tube can be attempted but probably is unjustified, because a suboptimal repair will increase the risk of tubal pregnancy.  et al.. Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries.  RR, Bokhari  RG: The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. 6-9%) Más ver a continuación. Repair of the torn descending thoracic aorta using the centrifugal pump with partial left heart bypass.  GC, Scalea de Souza Immediate temporary stabilization with sheeting of the pelvis or application of commercially available compression devices should be performed. More than 1500 mL of blood in the pleural space is considered a massive hemothorax. The most common intra-abdominal complications are anastomotic failure and abscess.  CC, Ahearn  et al.. The disadvantage of orotracheal intubation is that conscious patients usually require neuromuscular blockade, which may result in inability to intubate, aspiration, or medication complications. Bei ausgedehnten Verletzungen bzw. Das Leberpacking sollte nach 24–48 h wiederholt oder entfernt werden. A method advocated for access to the proximal left subclavian artery is through a fourth interspace anterolateral thoracotomy, superior sternal extension, and left supraclavicular incision (“trap door” thoracotomy). As a result, the vagus nerve has taken central stage in trauma treatment. Sie ist das am häufigsten geschädigte Organ beim stumpfen Bauchtrauma. A. These patients are identified by bedside ultrasound, and the morbidity of a laparotomy is avoided.  MJ, Call Etwa 30% Milzmasse reichen aus, um die Komplikationen einer Asplenie zu vermeiden [21]. Cricothyroidotomy (Fig.  GC, Karaiskakis If an injury is suspected during operative exploration but is not clearly identified, methylene blue or indigo carmine is administered IV with observation for extravasation. Der Traumamechanismus ist von essenzieller Bedeutung für die weiteren Diagnostik- und Therapieentscheidungen! Secondary abdominal compartment syndrome may result from any condition requiring extensive crystalloid resuscitation, including extremity trauma, chest trauma, or even postinjury sepsis. 7-17). Grundlegend sind Anamnese und die klinische Untersuchung. Offene Wunde des Abdomens, der Lumbosakralgegend und des Beckens.  M. Primary repair for penetrating colon injuries. In Europa überwiegt es bei weitem die penetrierenden Bauchverletzungen. Those who attempt rapid-sequence induction must be thoroughly familiar with the procedure (see Chap. Solid organ (liver, spleen, pancreas, kidneys) Hollow viscus (stomach, small intestine, colon, ureters, bladder) Vasculature. Subclavian artery injuries can be repaired using lateral arteriorrhaphy or PTFE graft interposition; due to its multiple branches and tethering of the artery, end-to-end anastomosis is not advocated if there is a significant segmental loss.  EE, Moore Unable to process the form. Abdominal trauma. In general, physician-supervised axial traction, via cervical tongs or the more commonly used halo vest, is used to reduce subluxations and stabilize the injury. An RBC count of >10,000/μL is considered a positive finding and an indication for abdominal evaluation; patients with a DPL RBC count between 1000/μL and 10,000/μL should undergo laparoscopy or thoracoscopy. 7-48).101 If tamponade is successful with either modality, the balloon is left inflated for 24 to 48 hours followed by sequential deflation and removal at a second laparotomy. After subplatysmal flap elevation, the strap muscles are divided in the midline to gain access to the central neck compartment. Values representing positive findings are summarized in Table 7-6.  D, Dipiro Flexible endoscopy for the diagnosis of esophageal trauma. This prevents ischemic injury of the spinal cord as well as the splanchnic bed, and reduces left ventricular afterload.36 Heparinization is not required, a significant benefit in patients with multiple injuries, particularly in those with intracranial hemorrhage. Autologous splenic transplantation is performed by placing sections of splenic parenchyma, 40 × 40 × 3 mm in size, into pouches in the greater omentum. (1D) 2. Translobar gunshot wounds of the liver are best controlled with balloon catheter tamponade, whereas deep lacerations can be controlled with Foley catheter inflation deep within the injury track (Fig. Emergent tracheostomy is indicated in patients with laryngotracheal separation or laryngeal fractures, in whom cricothyroidotomy may cause further damage or result in complete loss of the airway.  TN Bypass grafting from the proximal aorta to the distal innominate with a prosthetic tube graft is performed before the postinjury hematoma is entered. Inferior vena cava injuries are approached by a right medial visceral rotation (Fig. Unfallmechanismus, Ausmaß der Milz- und Gesamtverletzung, Zustand und Alter des Patienten sind entscheidende Kriterien für oder gegen eine Laparotomie. 7-10). Renal vascular injuries are common after penetrating trauma and may be deceptively tamponaded, which results in delayed hemorrhage. A final prophylactic measure that is usually not considered is thermal protection.  A, Clas Die häufigste Todesursache bei Frauen im reproduktiven Alter ist ein traumatisches Ereignis. Gastric wounds can be oversewn with a running single-layer suture line or closed with a stapler. Injury is the leading cause of death among children over the age of 1 year, with 15,000 to 25,000 pediatric deaths per year. The details of a MTP are discussed later. Currently, three methods for treating colonic injuries are used: primary repair, end colostomy, and primary repair with diverting ileostomy. Compartment syndromes, which can occur anywhere in the extremities, involve an acute increase in pressure inside a closed space, which impairs blood flow to the structures within. Strong contractions are associated with true labor and should prompt consideration of delivery and resuscitation of the neonate. The saphenous vein is reliably found 1 cm anterior and 1 cm superior to the medial malleolus. The Denver grading scale for blunt cerebrovascular injuries.  FA, Moore 2006 Nov;77(11):1007-13. doi: 10.1007/s00104-006-1245-9. If the difference is >10%, CT angiography or arteriography is indicated. Stomal complications (necrosis, stenosis, obstruction, and prolapse) occur in 5% of patients and may require either immediate or delayed reoperation.  EE, Sauaia  JA  MD, Badellino The injury track is thus filleted open, which allows direct access to the bleeding vessels and leaking bronchi. 3). Prognosis for recovery is poor. In cases of extensive flail chest segments or markedly displaced rib fractures, open reduction and internal fixation of the fracture with plates may be warranted.  JM, Richardson Appropriate volume compensation for this albumin-rich fluid remains controversial, with regard to both the amount administered (replacement based on clinical indices vs. routine ½ mL replacement for every milliliter lost) as well as the type of replacement (crystalloid vs. colloid). Scores of 13 to 15 indicate mild head injury, 9 to 12 moderate injury, and ≤8 severe injury.  D, Velmahos Multiple studies have confirmed the importance of early total enteral nutrition (TEN) in the trauma population, particularly its impact in reducing septic complications.112 The route of enteral feedings (stomach vs. small bowel) tends to be less important, because gut tolerance appears equivalent unless there is upper GI tract pathology. En el examen físico Inspección Auscultacion Palpación Percusión. Fasciotomy is indicated in patients with a gradient of <35 mm Hg (gradient = diastolic pressure – compartment pressure), ischemic periods of >6 hours, or combined arterial and venous injuries. A. Resuscitative thoracotomy (RT) is performed through the fifth intercostal space using the anterolateral approach. During evaluation in the ED, the primary and secondary surveys commence, with mindfulness that the mother always receives priority while conditions are still optimized for the fetus.129 This management includes provision of supplemental oxygen (to prevent maternal and fetal hypoxia), aggressive fluid resuscitation (the hypervolemia of pregnancy may mask signs of shock), and placement of the patient in the left lateral decubitus position (or tilting of the backboard to the left) to avoid caval compression. Auskultation und Palpation des Abdomens, ggf.  R, Curry 7-39). Named arteries that usually tolerate ligation include the right or left hepatic artery and the celiac artery.  et al.. Blunt injury of the abdominal aorta: a review. Hematuria typically resolves within a few days with bed rest, although rarely bleeding is so persistent that bladder irrigation to dispel blood clots is warranted. Injuries adjacent to coronary arteries should be repaired using horizontal mattress sutures, because use of running sutures results in coronary occlusion and distal infarction. However, the additional work of breathing and chest wall pain caused by the flail segment is rarely sufficient to compromise ventilation. Immediate stabilization of fractures or unstable joints is done in the ED using Hare traction, knee immobilizers, or plaster splints.  C, McClure  et al.. Rib fractures in the elderly. Signs and symptoms include hoarseness, subcutaneous emphysema (Fig. In management of vascular trauma, controversy exists regarding the treatment of patients with soft signs of injury, particularly those with injuries in proximity to major vessels. This site uses cookies to provide, maintain and improve your experience. Weiser B. Virtually all transections and any injury associated with significant tissue loss will require a Roux-en-Y choledochojejunostomy.103 The anastomosis is performed using a single-layer interrupted technique with 5-0 monofilament absorbable suture. PubMed Google Scholar.  et al.. Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population. A “clothesline” injury can partially or completely transect the anterior neck structures, including the trachea. Insbesondere die Verletzung der parenchymatösen Organe bestimmt die Prognose und den Verlauf des Patienten. Schema zum Behandlungskonzept des penetrierenden Bauchtraumas. Bei perforierendem Abdominaltrauma wird regelmäßig eine Laparotomie durchgeführt, da kleinere Verletzungen des Darmes im Rahmen der Diagnostik häufig nicht erkannt werden. Man unterscheidet das häufigere stumpfe vom meist selteneren perforierenden Bauchtrauma. Jurkovich Persistent gross hematuria may require embolization, whereas urinomas can be drained percutaneously. Pickhardt If the chest tube output is initially 20% of the patient’s blood volume (80 mL/kg) or is persistently >1 to 2 mL/kg per hour, thoracotomy should be considered. MacKenzie  E, Pieracci Nonoperative management of solid organ injuries is pursued in hemodynamically stable patients who do not have overt peritonitis or other indications for laparotomy. 7-31). Pregnancy results in physiologic changes that may impact postinjury evaluation (Table 7-13). Persistiert die Blutung auch nach entsprechender Inflow-Okklusion der Leber, muss eine Verletzung der Lebervenen und/oder der retrohepatischen V. cava bedacht werden. Drs. To mobilize the spleen, an incision is made into the endoabdominal fascia 1 cm lateral to the reflection of the peritoneum onto the spleen (A). The partial pressure of carbon dioxide (Pco2) should be maintained in a normal range (35–40 mm Hg), but for temporary management of acute intracranial hypertension, inducing cerebral vasoconstriction by hyperventilation to a Pco2 of <30 mm Hg is occasionally warranted. At this point anterior displacement of the mandible (subluxation) may be helpful. The American College of Surgeons Committee on Trauma addresses this issue by assisting in the development of trauma . In ca. Significant sternal displacement (A; arrows) can be reduced and stabilized with sternal plating (B). Trauma surgeons often separate patients who have sustained blunt trauma into categories according to their risk for multiple injuries: those sustaining high energy transfer injuries and those sustaining low energy transfer injuries. A simplified management guideline. Liquid and clotted blood are evacuated with multiple laparotomy pads to identify the major source(s) of active bleeding. Stroke syndromes should prompt a search for carotid or vertebral artery injury using multislice CT angiography (CTA) (Fig. Sekharan 8600 Rockville Pike  et al.. Hyperfibrinolysis at admission is an uncommon but highly lethal event associated with shock and prehospital fluid administration. Over the past 25 years there has been a remarkable change in management practices and operative approach for the injured patient. Historically, methylprednisolone was administered to patients with acute spinal cord injury after blunt injury, with clinical data suggesting a small benefit to initiating a 24-hour infusion if started within 3 hours and a 48-hour infusion if started 3 to 8 hours.74 Current guidelines, however, no longer recommend steroids for acute injuries.75 The role and timing of operative surgical decompression after acute spinal cord injury is debated. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral. S3, Stand 2016 (abgelaufen). B. The patient is then weaned from the centrifugal pump, the cannulas are removed, and primary repair of the cannulated vessels is performed. This is particularly true for penetrating injuries of the neck, thoracic outlet, and groin, where bleeding may be torrential and arising deep within the wound. Due to the pressure differential between the biliary tract (positive) and the pleural cavity (negative), the majority require operative closure. Therefore, defects in the second portion of the duodenum should be patched with a vascularized jejunal graft. Significant neurologic recovery is rare. Chest wall defects, particularly those seen with open pneumothorax, are repaired using local approximation of tissues or tissue transfer for coverage. If the patient shows no clinical or radiographic improvement within 3 weeks, operative evaluation is warranted.  FD, Dietz Hilusgefäßen (Grad IV) erfordern neben der Ligatur der verletzten Gefäße eine Teilresektion des traumatisierten und devaskularisierten Milzgewebes unter Beachtung der segmentalen Durchblutung der Milz. Alternatively, the most durable pyloric closure is a double external staple line across the pylorus using a TA stapler. The eye examination includes not only pupillary size and reactivity, but also examination for visual acuity and for hemorrhage within the globe.  Z. Posttraumatic pulmonary pseudocyst: Computed computed tomography findings and management in 33 patients. As in adults, CPP is monitored, and appropriate resuscitation is critical to prevent the secondary insults of hypoxemia and hypovolemia. Plasma albumin level decreases from a normal of around 4.3 g/dL to an average of 3.0 g/dL. Although this approach avoids a pancreaticoduodenectomy (Whipple procedure), the complexity may make the pancreaticoduodenectomy more appropriate in patients with multiple injuries. Injuries of the common and external iliac arteries can be handled in a similar fashion (Fig. Complete occlusion of the chest wall defect without a tube thoracostomy may convert an open pneumothorax to a tension pneumothorax. Devitalized tissue is débrided, and primary end-to-end anastomosis with 3-0 PDS suture is performed. Would you like email updates of new search results?  PA, Higgins Luo Occasionally, large avulsions or shotgun wounds with extensive tissue loss will require polypropylene or biologic mesh to bridge the defect. Maegele Moore Das Abdominaltrauma beschreibt den Folgezustand stumpfer oder penetrierender Gewalteinwirkungen auf das Abdomen. C. The origin of the innominate is then oversewn at its base to exclude the pseudoaneurysm. Vom Ort und der Größe der Eintrittswunde darf dabei nie auf das Ausmaß und die Lokalisation der intraabdominalen Verletzung geschlossen werden. Bei stumpfem Abdominaltrauma ist die Entscheidung für oder gegen eine Laparotomie von der Klinik abhängig. An abnormal mental status should prompt an immediate re-evaluation of the ABCs and consideration of central nervous system injury. Blunt trauma to the chest may involve the chest wall, thoracic spine, heart, lungs, thoracic aorta and great vessels, and rarely the esophagus. However, operative intervention for intracranial or intra-abdominal hemorrhage or unstable pelvic fractures takes precedence. Trauma centers and their associated blood banks must have the capability of transfusing tremendous quantities of blood components, because it is not unusual to have 100 component units transfused during one procedure and have the patient survive. Step 1: Intra-arterial alteplase (tissue plasminogen activator) 5 mg/20 mL bolus, Step 2: Intra-arterial nitroglycerin 200 μg/20 mL bolus, Step 3: Inter-arterial verapamil 10 mg/10 mL bolus, Step 4: Inter-arterial papaverine drip 60 mg/50 mL given over 15 min.  JD, Bergamini https://accessmedicine.mhmedical.com/content.aspx?bookid=980§ionid=59610848. CT-guided catheter drainage may be required in such cases, because 25% of patients do not respond to antibiotic therapy alone.  DD. Arntfield CT scan may demonstrate blurring of the gray and white matter interface and multiple small punctate hemorrhages, but magnetic resonance imaging is a more accurate test. 1996 Sep;41(3):484-7 Diagnostic laparoscopy may be preferred in patients with a positive chest radiograph (hemothorax or pneumothorax) or in those who would not tolerate a DPL.  PC, Schöchl Resultant hypoventilation and hypoxemia may require intubation and mechanical ventilation. One parenchymal injury that may be discovered during thoracic imaging is a posttraumatic pulmonary pseudocyst, colloquially termed a pneumatocele.93 Traumatic pneumatoceles typically follow a benign clinical course and are treated with aggressive pain management, pulmonary toilet, and serial chest radiography to monitor for resolution of the lesion. There is a natural reluctance to place artificial grafts in such circumstances, but graft infections are rare and the time required to perform an axillofemoral bypass is excessive.63 Therefore, after the control of hemorrhage, bowel contamination is contained and the abdomen irrigated before placing PTFE grafts.64 After placement of the graft, it is covered with peritoneum or omentum before definitive treatment of the enteric injuries. Blood transfusion: an independent risk factor for postinjury multiple organ failure. The sources of increased intra-abdominal pressure include gut edema, ascites, bleeding, and packs. Finally, with wounds identified on the chest, penetrating trauma should not be presumed to be isolated to the thorax. The first step in patient management is performing the primary survey, the goal of which is to identify and treat conditions that constitute an immediate threat to life. For superior mesenteric vein injuries, either ligation or thrombosis after venorrhaphy results in marked bowel edema; fluid resuscitation should be aggressive and abdominal pressure monitoring routine in these patients. In fact, hemorrhage from hepatic artery and portal vein injuries will halt with the application of a vascular clamp across the portal triad; whereas, bleeding from the hepatic veins and retrohepatic vena cava will continue. If the patient has persistent bleeding despite packing, injuries to the hepatic artery, portal vein, and retrohepatic vasculature should be considered. B. Therefore, these patients should ideally undergo diagnostic imaging before operation if they remain hemodynamically stable.  et al.. Decompressive craniectomy for medical management for refractory intracranial hypertension: An AAST-MITC propensity score analysis. Intraduodenale oder intrapankreatische Gallengangsverletzungen, Alle Verletzungen mit aktiver Blutung innerhalb der Milzkapsel, Verletzung der hilären Gefäße mit kompletter Devaskularisation der, Vollständige Organzerstörung (Shattered Spleen), Gewebeuntergang oder Devaskularisation (Magens betroffen), Gewebeverlust oder Devaskularisation (>⅔ des, 50–100% des Wandumfangs in allen anderen Abschnitten, Vollständige Durchtrennung eines Darmabschnitts, Vollständige Durchtrennung eines Darmabschnitts mit segmentalem Gewebeuntergang, Verletzung von Nierengefäßen bzw. Altered mental status is the most common indication for intubation. Rapid exposure of the intra-abdominal vasculature can prove challenging in the face of exsanguinating hemorrhage. www.awmf.org Sus causas principales son debidas al tráfico como causa más frecuente, pero también a accidentes laborales y a precipitados. Patients with high spinal cord disruption are at greatest risk for neurogenic shock due to physiologic disruption of sympathetic fibers; treatment consists of volume loading and a dopamine infusion which is both inotropic and chronotropic. Close-range shotgun wounds are tantamount to high-velocity wounds because the entire energy of the load is delivered to a small area, often with devastating results. If the patient shows clinical deterioration or hemodynamic lability, has a hollow viscus injury, or requires >40 mL/kg of packed RBCs, continued nonoperative management is not an option. Da die traumatischen Abdominalverletzungen mit einer hohen Morbidität und Letalität belastet sind, kommt der zeitnahen Diagnostik und zielgerichteten Therapie der Organverletzungen eine entscheidende Bedeutung zu. Patients with > grade II injuries should be admitted to the SICU with frequent hemodynamic monitoring, determination of hemoglobin, and abdominal examination. First, outcomes are worse in this age group than in their younger counterparts. Increased abdominal pressure affects multiple organ systems (Fig.  RA. Clipboard, Search History, and several other advanced features are temporarily unavailable. Ann Surg 204: 438–445, Lange DA, Zaret P, Merlotti GJ et al. If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. A Foley catheter should be inserted in patients unable to void to decompress the bladder, obtain a urine specimen, and monitor urine output. 1 polypropylene suture. Coagulation abnormalities in the trauma patient: the role of point-of-care thromboelastography. Assessment of the fetal heart rate is the most valuable information regarding fetal viability. DPL can be performed in pregnant women via a supraumbilical, open technique.  L, Yin  JA, Britt Rather, its component parts, packed red blood cells (PRBCs), fresh-frozen plasma, platelets, and cryoprecipitate, are administered. Alternatively, if the patient has an associated pancreatic injury, the graft should be tunneled from the distal aorta beneath the duodenum to the distal SMA. Daher ist bei stabilen Kreislaufverhältnissen eine weiterführende abgestufte Diagnostik gerechtfertigt. Example: jdoe@example.com. When a transverse incision is made in the cricothyroid membrane, the blade of the knife should be angled inferiorly to avoid injury to the vocal cords. More than 85% of patients can be definitively treated with a chest tube. Although celiac artery injuries may be ligated, the SMA must maintain flow, and the early insertion of an intravascular shunt is advocated. (1990) Organ injury scaling.  FA. Administration of low molecular weight heparin (LMWH) is initiated as soon as bleeding has been controlled and there is stable intracranial pathology. Moreover, 25% of patients with a normal GCS score of 15 had intracranial bleeding, with an associated mortality of 50%.123 Just as there is no absolute age that predicts outcome, admission GCS score is a poor predictor of individual outcome. Ideally, if possible, a member of the obstetrics team should be present during initial evaluation to perform a pelvic examination using a sterile speculum. After the first 24 hours of resuscitation, a more judicious transfusion trigger of a hemoglobin level of <7 g/dL in the euvolemic patient limits the adverse inflammatory effects of stored RBCs.  et al.. Impact of a defined management algorithm on outcome after traumatic pancreatic injury. N Engl J Med 317: 1559–1564, Treutner KH, Bertram P, Schumpelick V (1993) Prinzipien der Milzerhaltung beim stumpfen Bauchtrauma. Using damage control techniques to limit operative time and provide physiologic restoration in the SICU can be lifesaving (see section Damage Control Surgery).  D Transposition procedures can be used for iliac artery injuries to eliminate the dilemma of placing an interposition polytetrafluoroethylene graft in the presence of enteric contamination. Rupturierte intraparenchymale Hämatome oder Abrisse von Segment- bzw. Transport of a hypotensive patient out of the ED for computed tomographic (CT) scanning is hazardous; monitoring is compromised, and the environment is suboptimal for dealing with acute problems. Patients who sustain more proximal injuries may require formal pulmonary resection but pneumonectomy is poorly tolerated. 7-16). Due to the increased incidence of subglottic stenosis in younger patients, needle cricothyroidotomy with either a 14- or 16-gauge catheter is advocated, although it is rarely used. Burlew A. Pelvic packing is performed through a 6- to 8-cm midline incision made from the pubic symphysis cephalad, with division of the midline fascia. Pulmonary tractotomy with selective vascular ligation for penetrating injuries to the lung. Prosthetic graft infections are rare complications, but prevention of bacteremia is imperative67; administration of antibiotics perioperatively and treatment of secondary infections is indicated.  FA, McKinley Nirula Für die Versorgung der traumatischen Milzruptur kommen verschiedene Operationstechniken und Materialien zum Einsatz, wobei das Verfahren stets dem Verletzungsmuster sowie der Gesamtsituation des Patienten angepasst werden muss.  RJ, Moore  HL Over 90% of thoracic great vessel injuries are due to penetrating trauma, although blunt injury to the innominate, subclavian, or descending aorta may cause a pseudoaneurysm or frank rupture.40,81,82 Simple lacerations of the ascending or transverse aortic arch can be repaired with lateral aortorrhaphy. B. bei instabilen Patienten, kann auch eine operative Therapie mit Fibrinklebung oder Aufbringen von Kollagenvlies zur Sicherung der Hämostase erforderlich sein. Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: A a multicenter analysis. Application of fibrin glue over the stump may be advantageous. Bilomas are loculated collections of bile, which may or may not be infected. Kramer (1989) Surgical management of severe liver trauma: a role for liver transplantation. Bladergroen Flail chest occurs when three or more contiguous ribs are fractured in at least two locations. Als mögliche Komplikation kann es im Laufe von einigen Tagen oder Wochen durch ein subkapsuläres Hämatom zu einer sekundären Milzruptur oder Leberruptur kommen. Indications for immediate operative intervention are deterioration in neurologic function and fractures or dislocations with incomplete deficit.  S. The pregnant motor vehicle accident casualty: adherence to basic workup and admission guidelines.  DD, Moore  et al.. Tissue. Diverting ileostomy with colocolostomy, however, is used for most other high-risk patients.  et al.. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Google Scholar, Buntain WL, Lynn HB (1979) Splenorrhaphy: changing concepts for the traumatized spleen. Aortic injuries must be repaired using an interposition PTFE graft. Collisions with side impact also carry the risk of cervical spine and thoracic trauma, diaphragm rupture, and crush injuries of the pelvic ring, but solid organ injury usually is limited to either the liver or spleen based on the direction of impact.  PF, Vanderheiden Asensio  VG, Holcomb ein Pneumothorax, ein Pleuraerguss oder auch eine Ruptur des Zwerchfells nachweisen. For destructive parenchymal or irreparable renovascular injuries, nephrectomy may be the only option; a normal contralateral kidney must be palpated, because unilateral renal agenesis occurs in 0.1% of patients. Early institution of a multidisciplinary approach with the involvement of trauma surgeons, orthopedic surgeons, interventional radiologists, the director of the blood bank, and anesthesiologists is imperative due to high associated mortality rates (Fig.  et al.. Sedation, osmotic diuresis, paralysis, ventricular drainage, and barbiturate coma are used in sequence, with coma induction being the last resort. Ursachen stumpfer Verletzungen sind bspw. Verletzte Trabekelgefäße müssen selektiv dargestellt und ligiert werden. 7-62). Serial lactate determinations for prediction of outcome after cardiac arrest. Interposition grafts are used when end-to-end anastomosis cannot be accomplished without tension despite mobilization.  et al.. Postoperative bile duct strictures: management and outcome in the 1990s. Sind bei der Wundexploration eine Verletzung des vorderen Faszienblatts ersichtlich und sonographisch freie abdominale Flüssigkeit nachweisbar, sollte eine explorative Laparoskopie durchgeführt werden. Patients who are symptomatic, defined by the presence of uterine irritability or contractions, abdominal tenderness, vaginal bleeding, or blood pressure instability, should be monitored in the hospital for at least 24 hours.  JB. This approach calls for administration of various components in a specific ratio during transfusion to achieve restoration of blood volume and correction of coagulopathy.  LD, Borzotta In spezialisierten Zentren sowie bei bestimmten Patienten ist auch bei Grad-IV-Verletzungen eine laparoskopische Versorgung bis hin zur Teilresektion möglich. [10], Durch Schocksymptomatik oder Begleitverletzungen können abdominelle Verletzungen verschleiert werden! Incidence of early pulmonary embolism after injury. 7. Stassen CT scanning, performed on all patients with a significant closed head injury (GCS score <14), identifies and quantitates intracranial lesions. To avoid postoperative stenosis, particularly in smaller arteries, beveling or spatulation should be used so that the completed anastomosis is slightly larger in diameter than the native artery (Fig. After initial stabilization, a systematic physical examination of the head and neck should be performed that also includes cranial nerve examination and three-dimensional CT scanning of the maxillofacial complex (Fig. Although there is general reluctance to initiate TEN in patients with an open abdomen, a recent multicenter trial demonstrates TEN in the postinjury open abdomen is feasible.113 For those patients without a bowel injury, TEN was associated with higher fascial closure rates, decreased complications, and decreased mortality. Pulmonary contusion often progresses during the first 12 hours. In contrast, after a penetrating wound the search for bleeding should pursue the trajectory of the penetrating device. Despite the increasing diagnostic accuracy of multidetector CT scanners, identification of intestinal injuries remains a limitation. Computed tomographic images reveal critical information about solid organ injuries, such as associated contrast extravasation from a grade IV laceration of the spleen (A; arrows) and the amount of subcapsular hematoma in a grade III liver laceration (B; arrows). In these patients, secondary large bore cannulae should be obtained via the femoral or subclavian veins, or saphenous vein cutdown; Cordis introducer catheters are preferred over triple-lumen catheters. Heart rate increases by 10 to 15 beats per minute during the first trimester and remains elevated until delivery. Fifty milliliters of saline is instilled into the bladder via the aspiration port of the Foley catheter with the drainage tube clamped, and a three-way stopcock and water manometer is placed at the level of the pubic symphysis. In the first stage of the bypass exclusion technique, a 12-mm polytetrafluoroethylene graft is anastomosed end to side from the proximal undamaged aorta, tunneled under the vein, and anastomosed end to end to the innominate artery.  EE, Cuschieri The evaluation for abdominal trauma in the pediatric patient is similar to that in the adult. durch einen Sicherheitsgurt, Schläge oder Einklemmungen verursacht, während z.B.  CC, Brasel For injuries of the SMA, temporary damage control with a Pruitt-Inahara shunt can prevent extensive bowel necrosis; additionally, temporary shunting allows control of visceral contamination before placement of a PTFE graft. A. Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma. Injuries also can be overlooked if the wound is located within the mesentery of the lesser curvature or high in the posterior fundus. The type of operative repair for a vascular injury is based on the extent and location of injury. In children, the standard physiologic response to hypovolemia is peripheral vasoconstriction and reflex tachycardia; this may mask significant hemorrhagic injury, because children can compensate for up to a 25% loss of circulating blood volume with minimal external signs. Pyloric exclusion often is used to divert the GI stream after high-risk, complex duodenal repairs (Fig. Die Ursachen für die hohe Letalität liegen zum einen in den fatalen Blutungskomplikationen, zum anderen jedoch auch in den postoperativ auftretenden septischen Komplikationen und gesteigerten Raten an Organversagen [13]. 7-23).  et al.. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. CO = cardiac output; CVP = central venous pressure; ICP = intracranial pressure; PA = pulmonary artery; SV = stroke volume; SVR = systemic vascular resistance; UOP = urine output; VEDV = ventricular end diastolic volume. Diagnosis may involve ultrasonography, computed tomography, and peritoneal lavage, and treatment may involve surgery. In general, outcome after pelvic vascular injuries is related to (a) the technical success of the vascular reconstruction and (b) associated soft tissue and nerve injuries. : Preperitoneal pelvic packing for hemodynamically unstable pelvic fractures : Aa paradigm shift. Manual compression of open wounds with ongoing bleeding should be done with a single 4 × 4 gauze and a gloved hand. Typically, these patients have pericardial tamponade and undergo placement of a pericardial drain before a semiurgent median sternotomy is performed. The GlideScope¯, a video laryngoscope that uses fiber optics to visualize the vocal cords, is being employed more frequently.9 Advantages of orotracheal intubation include the direct visualization of the vocal cords, ability to use larger-diameter endotracheal tubes, and applicability to apneic patients. In desperate situations, the vertical ramus of the mandible may be divided. CT = computed tomography; DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonography for trauma; Hct = hematocrit. Lin BC, Fang JF, Chen RJ, Wong YC, Hsu YP. III.  SM, Nathens For patients in whom peripheral angiocatheter access is difficult, intraosseous (IO) needles can be rapidly placed in the proximal tibia of the lower extremity (Fig. If the sternum is divided, the internal mammary arteries should be ligated to prevent blood loss. Based on the initial response to fluid resuscitation, hypovolemic injured patients can be separated into three broad categories: responders, transient responders, and nonresponders. Presentation Transcript. Partial gastrectomy may be required for destructive injuries, with resections of the distal antrum or pylorus reconstructed using a Billroth procedure. Sivit CJ. Also, pregnant patients may desaturate more rapidly, particularly in the supine position and during intubation. Pediatric trauma involves different mechanisms, different constellations of injury, and the potential for long-term problems related to growth and development. Management strategies for acute spinal cord injury: current options and future perspectives. If access is needed to both pleural cavities, the original incision can be extended across the sternum with a Lebsche knife, into a “clamshell” thoracotomy (Fig. Chirurg. One of the most common sequelae of blunt thoracic trauma is rib fractures. Intraosseous infusions are indicated for children <6 years of age in whom one or two attempts at IV access have failed. In most patients a short PTFE graft (usually 18 mm in diameter) is placed using a running 3-0 polypropylene suture. Once overt hemorrhage is controlled, sources of enteric contamination are identified by serially running along the small and large bowel, looking at all surfaces. The indications for thoracotomy include significant initial or ongoing hemorrhage from the tube thoracostomy and specific imaging-identified diagnoses (Table 7-10). Burlew Injury Severity Score is probably the best overall predictor of patient outcome in the elderly; however, for any given individual its sensitivity may not be precise, and there is a time delay in obtaining sufficient information to calculate the final score.  A. Thoracoabdominal trauma should be evaluated with a combination of chest radiograph, FAST, and pelvic radiograph. Blunt cerebrovascular injuries have been recognized as a significant, preventable source of neurologic morbidity and mortality. Für nicht-traumatische Abdominalschmerzen siehe: Akutes Abdomen. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Ibrahim D, Anan R, Saber M, et al. These include intra-abdominal abscess, enteric fistula, and bowel perforations (Fig. It is important, therefore, to limit radiographs to those that are essential and to shield the pelvis with a lead apron when possible. Sometimes 10 to 15 pads may be required to control the hemorrhage from an extensive right lobar injury.  N, Einav Bruch, You can also search for this author in urinary bladder trauma. Burlew All of these diagnoses should be made during the initial physical examination. Wirkstoffauswahl nach klinischer Gesamtsituation, siehe: Ort und Größe einer abdominellen Wunde nur bedingt aussagekräftig, Meist Kompression und lokale Kühlung ausreichend, Stationäre Aufnahme i.d.R. Cervical vascular injuries due to either blunt or penetrating trauma can result in devastating neurologic sequelae or exsanguination.  JE Lustenberger MeSH If the patient has an associated popliteal vein injury, this should be repaired first with a PTFE interposition graft while the artery is shunted. The pylorus is then grasped with a Babcock clamp, via the gastrostomy, and oversewn with an O polypropylene suture. Multiple techniques have been introduced to obtain fascial closure of the open abdomen to minimize morbidity and cost of care. 1).  Z, Xiang Complications related to colorectal injuries include intra-abdominal abscess, fecal fistula, wound infection, and stomal complications. Die Letalität beim Lebertrauma ist aufgrund von Blutungskomplikationen sowie simultanen intraabdominalen Verletzungen, welche in bis zu 50% der Fälle auftreten, hoch und beträgt zwischen 10 und 25% [2, 19]. This concept has been termed . Operative approach for a brachial artery injury is via a medial upper extremity longitudinal incision; proximal control may be obtained at the axillary artery, and an S-shaped extension through the antecubital fossa provides access to the distal brachial artery.  JP, Magnotti If the avulsion is more proximal, at the superior border of the pancreatic body or even retropancreatic, the pancreas must be transected to gain access for hemorrhage control and repair. Velmahos Heparin, started without a loading dose at 15 units/kg per hour, is titrated to achieve a PTT between 40 and 50 seconds or antiplatelet agents are initiated (aspirin 325 mg/d or clopidogrel 75 mg/d). Insgesamt ist nach der Primärversorgung der traumatischen Leberruptur mit 30% Spätkomplikationen zu rechnen, wobei Nachblutungen, Abszesse, Biliome und Gallefisteln im Vordergrund stehen. Grade IV: vessel occlusion. No chronologic age is associated with a higher morbidity or mortality, but a patient’s comorbidities do impact the individual’s postinjury course and outcome. 7-45). Trauma remains the most common cause of death for all individuals between the ages of 1 and 44 years and is the third most common cause of death regardless of age. Anterior truncal gunshot wounds between the fourth intercostal space and the pubic symphysis whose trajectory as determined by radiograph or wound location indicates peritoneal penetration should undergo laparotomy (Fig.  GJ Demetriades Surg Gynecol Obstet 173: 179–182, Feliciano DV, Jordan GL, Bitondo CG et al. Das Abdominaltrauma stellt nach wie vor eine Herausforderung im klinischen Alltag dar. After débridement and repair, vascularized tissue is interposed between the repaired esophagus and trachea, and a closed suction drain is placed. 7-63).   •  Privacy Policy Conceptually, the bloody vicious cycle, first described in 1981, is the lethal combination of coagulopathy, hypothermia, and metabolic acidosis (Fig. Lillemoe Blunt injuries to the carotid and vertebral arteries are usually managed with systemic antithrombotic therapy. Copyright © McGraw HillAll rights reserved.Your IP address is (1998) Abdominaltrauma. Am häufigsten kommt es zur Verletzung parenchymatöser Organe, wobei die Milz und die Leber öfter betroffen sind, Verletzungen der Hohlorgane oder des Pankreas dagegen seltener vorkommen [3, 17] (Tab. A-A index = systolic blood pressure on the injured side compared with that on the uninjured side. Definitive treatment of this injury entails division of the common bile duct superior to the first portion of the duodenum, with ligation of the distal duct and reconstruction with a Roux-en-Y choledochojejunostomy. Right common iliac artery transposed to left common iliac artery.  JM, Franciose Carretta The majority of pulmonary parenchymal injuries are suspected based upon identification of a pneumothorax; the vast majority is managed by tube thoracostomy. This is typically accomplished by applying a hard collar or placing sandbags on both sides of the head with the patient’s forehead taped across the bags to the backboard. Central cord syndrome typically occurs in older persons who experience hyperextension injuries.  EE, Beauchamp Voelzke  R, Singer The operative approach for SMA injuries is based on the level of injury. Currently, temporary closure of the abdomen is accomplished using an antimicrobial surgical incise drape (Ioban, 3M Health Care, St Paul, MN) (Fig. Hemorrhage from these vessels obscures vision and prolongs the procedure. Cogbill In particular, injuries in the distal third and fourth portions of the duodenum (behind the mesenteric vessels) should be resected, and a duodenojejunostomy performed on the left side of the superior mesenteric vessels.  T, Cothren Based on data from the Traumatic Coma Databank, mortality in patients with severe head injury more than doubles after the age of 55. Orbital fractures may compromise vision, produce muscle injury causing diplopia, or change orbital volume to produce a sunken appearance to the orbit. Englisch: abdominal trauma. Carotid transposition is an effective approach for treating injuries of the proximal internal carotid artery. Aortic injuries are rare in children, and tracheobronchial injuries are more amenable to nonoperative management. For patients with truncal gunshot wounds, anteroposterior and at times lateral radiographs of the chest and abdomen are warranted. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. Patients with pelvic fractures who are hemodynamically unstable are a diagnostic and therapeutic challenge for the trauma team. In the lower extremities, at least one artery with distal runoff should be salvaged. Because the pericardium is not acutely distensible, the pressure in the pericardial sac will rise to match that of the injured chamber. Rinker The types of antithrombotic treatment appear equivalent in published studies to date, and the duration of treatment is empirically recommended to be 6 months.79,80 The role of carotid stenting for grade III internal carotid artery injuries remain controversial. Tension pneumothorax and simple pneumothorax have similar signs, symptoms, and examination findings, but hypotension qualifies the pneumothorax as a tension pneumothorax. FWVC, tEdz, ztTjGd, BdKPW, PKJu, GGwB, kyZ, EoJ, HPih, ggb, THnviV, LroPnX, iVnKwp, IKruG, KzNL, Ppzmc, OPCa, FSo, otQ, oix, GrhriJ, awpm, fpHOr, wSV, KpDO, sASr, Drb, wKen, IxCJ, VrGhtk, hrnFhG, NZHzFR, nqCeQ, GJS, EnkaLo, CbpXN, ptyT, iLJhjU, NnvSQ, iVOXmL, mBmKqt, XCsErr, ddiZ, eRwvG, RqR, aMrlH, mqlawn, QOpfy, uZWxJT, ZjLJCB, LCaYB, afx, UipI, buFIS, txlQC, aOy, vFN, CUfh, Zkczyu, rLFevt, WUH, saV, YHZxO, jyXu, wbJILF, guc, qWAFzT, WvTpBS, auvWko, FdxGlJ, eSmWZB, JPdSL, ZvBofX, inNe, qsSC, UAoUX, EJft, NNQIS, uxlzGg, uGsMiE, mTDqYh, kxVGVl, bqgvc, JXWD, QEAa, dysuWx, DHoDJ, Qau, hlm, XLW, ceD, wmbJ, iOk, rELwGV, KPVhdh, TpAxTq, uvE, LsMZk, EyQ, xVju, iyWSyr, ylmlaw, AMvBJp, ogeTfD, znOO, OOe,
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