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2013 the trauma manual and acute care surgery

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THE TRAUMA MANUAL:
TRAUMA AND ACUTE
CARE SURGERY

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Fourth Edition

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THE TRAUMA MANUAL:
TRAUMA AND ACUTE
CARE SURGERY
Fourth Edition

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Editors

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Mark M. Ravitch Professor
Chief, Trauma and General Surgery
Department of Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA

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Andrew B. Peitzman, MD

Donald M. Yealy, MD

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Professor and Chair of Emergency Medicine
University of Pittsburgh/University of Pittsburgh Physicians
Pittsburgh, PA

Timothy C. Fabian, MD

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Harwell Wilson Alumni Professor and Chairman
Department of Surgery
University of Tennessee Health Science Center
Memphis, TN

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Michael Rhodes, MD

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Professor of Surgery
Thomas Jefferson University
Chair, Department of Surgery
Christiana Care Health Systems
Wilmington, DE

C. William Schwab, MD
Professor of Surgery
Department of Surgery
Perelman School of Medicine
University of Pennsylvania
Division of Traumatology, Surgical Critical Care & Emergency Surgery
Hospital of the University of Pennsylvania
Philadelphia, PA

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Acquisitions Editor: Brian Brown
Product Manager: Brendan Huffman
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©2013 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business
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Philadelphia, PA 19103 USA
LWW.com

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All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information
storage and retrieval system without written permission from the copyright owner, except
for brief quotations embodied in critical articles and reviews. Materials appearing in this
book prepared by individuals as part of their official duties as U.S. government employees
are not covered by the above-mentioned copyright.

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Printed in China

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Library of Congress Cataloging-in-Publication Data available upon request
ISBN-13: 978-1-4511-1679-3
ISBN-10: 1-4511-1679-3

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Care has been taken to confirm the accuracy of the information presented and to describe
generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in
this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in
a particular situation remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and
practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and
drug reactions, the reader is urged to check the package insert for each drug for any change
in indications and dosage and for added warnings and precautions. This is particularly
important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned
for use in their clinical practice.
To purchase additional copies of this book, call our customer service department at (800)
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This book is dedicated to those who have given their
lives, and those who daily risk their lives, in the care of
the injured.

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Contributors
Michel B. Aboutanos, MD, MPH, FACS
Professor of Surgery
Director, International Trauma System
Development Program
Division of Trauma, Critical Care &
Emergency Surgery
Department of Surgery
Virginia Commonwealth University
Medical Center
Richmond, VA
Syed M. Faisal Alam, MD
Vascular Surgery Fellow
Division of Vascular and Endovascular
Surgery
Department of Surgery
The University of Tennessee Health Science
Center
Memphis, TN
Louis H. Alarcon, MD
Medical Director, Trauma Surgery
Associate Professor of Surgery and Critical
Care Medicine
University of Pittsburgh School of Medicine
Pittsburgh, PA
Darwin Ang, MD, PhD, MPH
Associate Professor of Surgery
Trauma Medical Director, Ocala Regional
Director of Research USF/HCA Trauma
Network
University of South Florida
Tampa, FL
Derek C. Angus, MD, MPH, FRCP
Chair, Department of Critical Care
Medicine
The Mitchell P. Fink Endowed Chair in
Critical Care Medicine
Professor of Critical Care Medicine
University of Pittsburgh School of Medicine
Pittsburgh, PA
Juan A. Asensio, MD, FACS, FCCM, FRCS
Professor of Surgery
Department of Surgery
University of Miami Miller School of
Medicine
Director, Trauma Clinical Research,
Training and Community Affairs
Department of Surgery
University of Miami Miller School of
Medicine
Miami, FL

Vishal Bansal, MD, FACS
Assistant Professor of Surgery
Division of Trauma, Burns and Surgical
Critical Care
University of California San Diego Health
Sciences
San Diego, CA
Philip S. Barie, MD, MBA, FIDSA, FCCM, FACS
Professor
Departments of Surgery and Public Health
Weill Cornell Medical College
Chief
Preston A. (Pep) Wade Acute Care Surgery
Service
New York-Presbyterian Hospital/Weill
Cornell Medical Center
New York, NY
Tiffany K. Bee, MD
Associate Professor of Surgery
The University of Tennessee Health Science
Center
Memphis, TN
Matthew V. Benns, MD
Assistant Professor of Surgery
School of Medicine
University of Louisville
Louisville, KY
Timothy R. Billiar, MD, FACS
George Vance Foster Professor and
Chairman
Department of Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA
Thane A. Blinman, MD
Associate Director of Trauma
Division of General, Thoracic and
Fetal Surgery
The Children’s Hospital of Philadelphia
Philadelphia, PA
Deanna M. Blisard, MD
Department of Critical Care Medicine and
Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA
Amir Blumenfeld, MD, MHA
Former Chief, Trauma Branch
Israeli Defense Forces
Israel
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Contributors

Charles C. Branas, PhD
Professor of Epidemiology
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Benjamin Braslow, MD, FACS
Associate Professor of Surgery
Division of Trauma, Emergency General
Surgery & Surgical Critical Care
Section Chief of Emergency General
Surgery
Department of Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Susan Miller Briggs, MD, MPH
Associate Professor of Surgery
Harvard Medical School
Director, International Trauma and
Disaster Institute
Massachusetts General Hospital
Boston, MA
L.D. Britt, MD, MPH, FACS, FCCM, FRCSEng
(Hon), FRCSEd (Hon), FWACS (Hon),
FRCSI (Hon), FCS(SA) (Hon)
Brickhouse Professor and Chairman
Eastern Virginia Medical School
Department of Surgery
Norfolk, VA
Joshua B. Brown, MD
General Surgery Resident
Department of Surgery
University of Pittsburgh Medical
Center
Pittsburgh, PA
Jodie A. Bryk, MD
Chief Internal Medicine Resident
University of Pittsburgh School of
Medicine
Pittsburgh, PA
Christopher H. Byrne, MD
Assistant Professor of Surgery
Department of Surgery
The University of Tennessee Health Science
Center
Memphis, TN

Asim F. Choudhri, MD
Assistant Professor of Radiology and
Neurosurgery
The University of Tennessee Health Science
Center
Memphis, TN
Director of Neuroradiology
Le Bonheur Neuroscience Institute
Le Bonheur Children’s Hospital
Memphis, TN
William L. Chung, DDS, MD
Associate Professor
Department of Oral & Maxillofacial
Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA
Mark Cipolle, MD, PhD
Medical Director, Trauma Program
Christiana Care Health System
Wilmington, DE
Mitchell J. Cohen, MD
Associate Professor of Surgery
Division of General Surgery
Director of Acute Care Research
San Francisco Injury Center
University of California
San Francisco, CA
Raul Coimbra, MD, PhD, FACS
The Monroe E. Trout Professor of Surgery
Executive Vice-Chairman, Department of
Surgery
Chief Division of Trauma, Surgical Critical
Care, and Burns
UC San Diego Health System
San Diego, CA
David C. Cone, MD
Professor and EMS Section Chief
Department of Emergency Medicine
Yale University School of Medicine
New Haven, CT
Michael W. Cripps, MD
Assistant Professor of Surgery
UT Southwestern Medical Center
Dallas, TX
Martin A. Croce, MD
Professor of Surgery
Chief, Trauma and Surgical Critical Care
The University of Tennessee Health Science
Center
Memphis, TN

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Contributors
Frederick J. Denstman, MD
Section, Colon and Rectal Surgery
Christiana Care Health System
Wilmington, DE
Jennifer M. DiCocco, MD
General Surgery Chief Resident
Department of Surgery
The University of Tennessee Health Science
Center
Memphis, TN
Soumitra R. Eachempati, MD, FACS, FCCM
Professor of Surgery and Public Health
Weill Cornell Medical College
Chief, Trauma Services and Surgical
Intensive Care Unit
New York-Presbyterian Hospital
New York Weill Cornell Center
New York, NY
Philip A. Efron, MD
Assistant Professor of Surgery and
Anesthesiology
Co-director, Laboratory of Inflammation
Biology and Surgical Science
Associate Director, Trauma ICU
Program Director, Surgical Critical Care
Residency
Department of Surgery, Division of Acute
Care Surgery and Surgical Critical Care
College of Medicine
University of Florida
Gainesville, FL
Timothy C. Fabian, MD
Harwell Wilson Alumni Professor and
Chairman
Department of Surgery
University of Tennessee Health Science
Center
Memphis, TN
David V. Feliciano, MD
Professor
Department of Surgery
Emory University School of Medicine
Surgeon-in-Chief
Department of Surgery
Grady Memorial Hospital
Atlanta, GA
John Fildes, MD, FACS, FCCM
Professor and Vice Chair
Department of Surgery
Chief, Division of Acute Care Surgery
University of Nevada School of Medicine
Las Vegas, NV

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Abe Fingerhut, MD
Hippokration Hospital and Medical School
Athens, Greece
Gerard Fulda, MD, FACS, FCCM
Director, Surgical Critical Care and
Surgical Research
Christiana Care Health Systems
Associate Professor of Surgery
Jefferson Medical College
Newark, DE
Gary N. Galang, MD
Vice Chairman for Operations
UPMC Rehabilitation Institute
UPMC Mercy Hospital
Pittsburgh, PA
Frederick Giberson, MD, MS
Assistant Professor of Surgery
Jefferson Medical College
Program Director, General Surgery
Christiana Care Health Services
Newark, DE
Steven P. Goldberg, MD
Assistant Professor of Surgery
Division of Pediatric Cardiothoracic
Surgery
The University of Tennessee Health Science
Center
Le Bonheur Children’s Hospital
Memphis, TN
Daniel J. Grabo, MD
Division of Traumatology, Surgical Critical
Care and Emergency Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Vicente H. Gracias, MD
Professor of Surgery
Department of Surgery Chief
Trauma, Emergency Surgery, Surgical
Critical Care
UMDNJ-Robert Wood Johnson Medical
School
New Brunswick, NJ
Francis X. Guyette, MD, MPH
Assistant Professor, Department of
Emergency Medicine
Medical Director, STAT MedEvac
Pittsburgh, PA

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Contributors

Amy N. Hildreth, MD
Assistant Professor
Department of Surgery
Wake Forest School of Medicine
Winston-Salem, NC
William S. Hoff, MD, FACS
Clinical Professor of Surgery
Temple University School of Medicine
Trauma Program Medical Director
St. Luke’s University Health Network
Bethlehem, PA
Daniel N. Holena, MD
Assistant Professor of Surgery
Division of Traumatology, Surgical Critical
Care, and Emergency Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
James H. Holmes IV, MD, FACS
Director, WFBMC Burn Center
Associate Professor of Surgery
Department of General Surgery
Wake Forest University School of Medicine
Medical Center Blvd
Winston-Salem, NC
John A. Horton, III, MD
Assistant Professor
Department of Physical Medicine and
Rehabilitation
University of Pittsburgh School of Medicine
Pittsburgh, PA
Rao R. Ivatury, MD
Professor of Surgery
Chair, Division of Trauma, Critical Care
and Emergency Surgery
Virginia Commonwealth University
Richmond, VA
Steven A. Johnson, MD, FACS
Assistant Professor of Surgery
Jefferson Medical College
Director, Surgery and Surgical Critical Care
Capital Health, Hopewell Medical Center
Pennington, NJ
Gregory J. Jurkovich, MD
Chief of Surgery
Denver Health and Hospital Authority
Bruce M. Rockwell Distinguished Professor
and Vice Chairman
Department of Surgery
University of Colorado School of Medicine
Denver, CO

Michael Kalina, DO, FACOS
Assistant Professor of Surgery
Jefferson Medical College
Thomas Jefferson University
Associate Medical Director of
Trauma
Surgical Critical Care Associates
Christiana Care Health System
Newark, DE
John A. Kellum, MD
Professor and Vice Chair
Department of Critical Care
Medicine
University of Pittsburgh
Pittsburgh, PA
Mousa Khoursheed, MD, FRCS
Department of Surgery
University of Kuwait
Mubarak Al-Kabeer Hospital
Safat, Kuwait
Patrick K. Kim, MD
Assistant Professor of Surgery
Division of Traumatology, Surgical Critical
Care and Emergency Surgery
Department of Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Edward Kwon, MD
Trauma and Critical Care
Department of Surgery
University of Nevada School of
Medicine
Las Vegas, NV
Peter D. Le Roux, MD, FACS
Department of Neurosurgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Luke P.H. Leenen, MD, PhD, FACS
Professor of Trauma
Department of Surgery
University Medical Center Utrecht
Utrecht, The Netherlands
Ari K. Leppaniemi,
¨
MD, PhD
Chief of Emergency Surgery
Department of Abdominal Surgery
Helsinki University Hospital,
Meilahti
Helsinki, Finland

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Contributors
L. Scott Levin, MD, FACS
Paul B. Magnuson Professor of Bone and
Joint Surgery
Chairman, Department of Orthopaedic
Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Ryan M. Levy, MD
Assistant Professor of Thoracic Surgery
Department of Cardiothoracic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA
James D. Luketich, MD
Professor of Surgery
Chair, Department of Cardiothoracic
Surgery
Director, Heart Lung Esophageal Surgery
Institute
Chief, Division of Thoracic and Foregut
Surgery
Co-director, Minimally Invasive Surgery
Center
University of Pittsburgh Medical Center
Pittsburgh, PA
Robert C. Mackersie, MD, FACS
Professor of Surgery
University of California
San Francisco, CA
Director, Trauma Services
San Francisco General Hospital
San Francisco, CA
Louis J. Magnotti, MD
Associate Professor of Surgery
The University of Tennessee Health Science
Center
Memphis, TN
Neil R. Malhotra, MD
Assistant Professor
Department of Neurological Surgery
University of Pennsylvania
Philadelphia, PA
R. Shayn Martin, MD
Assistant Professor of Surgery
Department of Surgery
Wake Forest School of Medicine
Director, Surgical Critical Care
Wake Forest Baptist Medical Center
Winston-Salem, NC

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Federico N. Mazzini, MD
Attending Surgeon
Trauma & Emergency Surgery
General Surgery Department
Hospital Italiano de Buenos Aires
Buenos Aires, Argentina
Samir Mehta, MD
Assistant Professor, Department of
Orthopaedic Surgery
Perelman School of Medicine
University of Pennsylvania
Chief, Orthopaedic Trauma & Fracture
Service
Hospital of the University of Pennsylvania
Philadelphia, PA
Ali Y. Mejaddam, MD
Division of Trauma, Emergency Surgery,
and Surgical Critical Care
Massachusetts General Hospital and
Harvard Medical School
Boston, MA
J. Wayne Meredith, MD, FACS
Richard T. Myers Professor and Chair,
Department of Surgery
Director, Division of Surgical Sciences
Wake Forest School of Medicine
Winston-Salem, NC
Lyle L. Moldawer, PhD
Professor and Vice Chairman
Department of Surgery
College of Medicine
University of Florida
Gainesville, FL
Frederick A. Moore, MD
Professor
Department of Surgery
Head, Division of Surgical Critical Care &
Acute Care Surgery
Department of Surgery
University of Florida
Gainesville, FL
David Morris, MD
Senior Associate Consultant
Trauma, Critical Care, General Surgery
Department of Surgery
Mayo Clinic
Rochester, MN
A. James Moser, MD
Division of Surgical Oncology
Beth Israel Hospital
Boston, MA

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Contributors

Alan Murdock (Dr.) Col, USAF, MC
Chief, Acute Care Surgery
Department of Trauma and General
Surgery
UPMC PUH
Pittsburgh, PA

Andrew B. Peitzman, MD
Mark M. Ravitch Professor
Chief, Trauma and General Surgery
Department of Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA

Michael L. Nance, MD
Director, Pediatric Trauma Program
The Children’s Hospital of Philadelphia
Templeton Professor of Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA

Jean-Francois Pittet, MD
Professor and Vice Chair, Department of
Anesthesiology
Director, Division of Critical Care
Anesthesiology
University of Alabama School of Medicine
Birmingham, AL

Lena M. Napolitano, MD, FACS, FCCP, FCCM
Professor of Surgery and Associate Chair
Division Chief
Acute Care Surgery (Trauma, Burn, Critical
Care, Emergency Surgery)
Department of Surgery
University of Michigan
Ann Arbor, MI

Patrick M. Reilly, MD
Professor of Surgery
Chief Division of Traumatology, Surgical
Critical Care and Emergency Surgery
Department of Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA

Mayur Narayan, MD, MPH, MBA
Assistant Professor, Department of Surgery
Trauma/Critical Care/Acute Care &
Emergency General Surgery
Director, Center for Injury Prevention &
Policy
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine
Baltimore, MD
Matthew D. Neal, MD
Resident
Department of Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA
Juan B. Ochoa, MD, FACS
Professor of Surgery and Critical Care
University of Pittsburgh
Pittsburgh, PA
Medical and Scientific Director
Nestle Health Care Nutrition/Nestle
Health Science
North America
Mark W. Ochs, DMD, MD
Professor and Chair
Department of Oral and Maxillofacial
Surgery
University of Pittsburgh School of Dental
Medicine
Pittsburgh, PA

Michael Rhodes, MD
Professor of Surgery
Thomas Jefferson University
Chair, Department of Surgery
Christiana Care Health Systems
Wilmington, DE
Matthew R. Rosengart, MD, MPH
Associate Professor
Department of Surgery
University of Pittsburgh
Pittsburgh, PA
Ronald N. Roth, MD, FACEP
Professor, Department of Emergency
Medicine
Chief, Division of EMS
University of Pittsburgh School of Medicine
Pittsburgh, PA
Michael F. Rotondo, MD, FACS
Professor and Chairman, Department of
Surgery
The Brody School of Medicine, East
Carolina University
Greenville, NC
Chief of Surgery, Director of the Center of
Excellence for Trauma and Surgical
Critical Care
Vidant Medical Center, Vidant Health
System

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Contributors
Grace S. Rozycki, MD, MBA
Professor of Surgery
Emory University School of Medicine
Grady Memorial Hospital
Atlanta, GA
James M. Russavage, MD
Assistant Professor of Plastic Surgery
University of Pittsburgh
Pittsburgh, PA
Matthew Sanborn, MD
Assistant Professor
Department of Neurological Surgery
University of Pennsylvania
Philadelphia, PA
Babak Sarani, MD
Associate Professor of Surgery
Chief, Trauma and Acute Care Surgery
The George Washington University
Washington, DC
Thomas M. Scalea, MD
Physician in Chief, Shock Trauma Center
Francis X Kelly Professor of Trauma and
Director Program in Trauma
University of Maryland School of Medicine
Baltimore, MD
Vaishali D. Schuchert, MD
Clinical Assistant Professor of Surgery and
Critical Care
Associate Director of Acute Care Surgery
University of Pittsburgh School of
Medicine
Pittsburgh, PA
C. William Schwab, MD
Professor of Surgery
Department of Surgery
Perelman School of Medicine
University of Pennslyvania
Division of Traumatology, Surgical Critical
Care & Emergency Surgery
Hospital of the University of Pennsylvania
Philadelphia, PA

xiii

Lachlan J. Smith, PhD
Research Associate
Department of Orthopaedic Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Jason L. Sperry, MD, MPH
Assistant Professor of Surgery and Critical
Care Medicine
Division of Trauma and General Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA
S. Tonya Stefko, MD
Assistant Professor of Ophthalmology,
Otolaryngology, and Neurological
Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA
Glen Tinkoff, MD
Associate Vice Chair of Surgery
Christiana Care Health System
Newark, DE
Meredith S. Tinti, MD
Assistant Professor of Surgery
Associate Medical Director, Surgical
Intensive Care
UMDNJ-Robert Wood Johnson Medical
School
New Brunswick, NJ
Samuel A. Tisherman, MD
Professor
Departments of Critical Care Medicine and
Surgery
University of Pittsburgh
Pittsburgh, PA

Ayan Sen, MD, MSc
Critical Care Fellow
Department of Critical Care Medicine
University of Pittsburgh Medical Center
Pittsburgh, PA

Glenn Updike, MD, MMM
Medical Director
Magee-Womens Hospital Outpatient Clinic
Assistant Professor
Department of Obstetrics, Gynecology, and
Reproductive Sciences
University of Pittsburgh Magee-Womens
Hospital
Pittsburgh, PA

John P. Sharpe, MD, MS
General Surgery Resident
The University of Tennessee Health Science
Center
Memphis, TN

Cory J. Vatsaas, MD
Division of Acute Care Surgery
Department of Surgery
University of Michigan
Ann Arbor, MI

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Contributors

George C. Velmahos, MD, PhD, MSEd
John F. Burke Professor of Surgery
Harvard Medical School
Chief, Division of Trauma, Emergency
Surgery, and Surgical Critical Care
Massachusetts General Hospital
Boston, MA
Thai Vu, MD
Assistant Professor
Trauma and Surgical Critical Care
Penn State Hershey Medical Center and
Penn State College of Medicine
Hershey, PA
Brett H. Waibel, MD
Assistant Professor of Surgery
Trauma and Surgical Critical Care
The Brody School of Medicine at East
Carolina University
Greenville, NC
Henry E. Wang, MD, MS
Associate Professor and Vice Chair for
Research
Department of Emergency Medicine
The University of Alabama at
Birmingham
Birmingham, AL
Gregory A. Watson, MD, FACS
Assistant Professor of Surgery & Critical
Care
University of Pittsburgh School of
Medicine
Pittsburgh, PA
Hunter Wessells, MD, FACS
Professor and Nelson Chair
Department of Urology
University of Washington School of
Medicine
Seattle, WA
Harborview Injury Prevention and
Research Center
Seattle, WA

James F. Whelan, MD
Assistant Professor of Surgery
Division of Trauma, Critical Care, and
Emergency Surgery
Department of Surgery
Virginia Commonwealth University
Richmond, VA
Sean P. Whelan, MD
Chief Resident in Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA
J. Scott Williams, MD, PhD
Associate Professor of Radiology
Case Western Reserve University
Cleveland, OH
Donald M. Yealy, MD
Professor and Chair of Emergency
Medicine
University of Pittsburgh/University of
Pittsburgh Physicians
Pittsburgh, PA
Kent Zettel, MD
Chief Resident in Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA
Feihu Zhou, MD, PhD
The Clinical Research, Investigation, and
Systems Modeling of Acute Illness
(CRISMA) Center
Department of Critical Care Medicine
University of Pittsburgh School of Medicine
Pittsburgh, PA
Department of Critical Care Medicine
Chinese PLA General Hospital
Beijing, People’s Republic of China
Brian S. Zuckerbraun, MD
Associate Professor of Surgery
University of Pittsburgh School of Medicine
Attending Surgeon, University of
Pittsburgh Medical Center and VA
Pittsburgh Healthcare System
Pittsburgh, PA

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Preface
The 4th edition of The Trauma Manual reflects the maturation and evolution of the field.
Common to the patients for whom we provide care is their urgent presentation and often
time-dependent illness, whether from injury or non-trauma critical disease. The 4th edition
of The Trauma Manual has expanded its coverage of all components of the field: trauma,
critical care, and emergency surgery. The chapters are organized by disease processes and
based on the chronology of patient care. The emergency department and the trauma/acute
care surgery services at many hospitals are essentially the “safety nets” for the inpatients and
the critically ill outpatients. The Trauma Manual incorporates the diverse disease processes
and care that we deliver every day.
We have built upon the success of the first three editions of this book by expanding
the authorship of the chapters to more international and national experts. The chapters on
trauma care have been updated and revised. New chapters on critical care have been added
to this edition. Chapters on emergency general surgery have been expanded and reorganized.
As with the first editions, these chapters are written by experts in these fields. The
recommendations made are backed by the extensive clinical experience of the authors.
Rather than listing every option in a clinical situation, a consensus recommendation is
generally presented. We have attempted to keep the content of The Trauma Manual practical
and direct.
The goal of The Trauma Manual remains to serve as a ready pocket reference for all
who provide care for the patient with acute surgical diseases. The format of the book is
that of a user-friendly pocket manual rather than a comprehensive textbook. With that said,
this book contains a great deal of information covering all phases of trauma and acute care
surgery.

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Contents
Contributors vii
Preface xv

1

Introduction to Trauma Care

1

Amy N. Hildreth • R. Shayn Martin • J. Wayne Meredith

2

Physiologic Response to Injury 10
Luke P.H. Leenen

3

Airway Management and Anesthesia 22
Henry E. Wang • Jean-Francois Pittet • Donald M. Yealy

4

Initial Assessment and Resuscitation 35
Michael Rhodes • Michael Kalina

5

Shock 45
Joshua Brown • Jason L. Sperry • Timothy R. Billiar

6

Damage Control Surgery 51
Brett H. Waibel • Michael F. Rotondo

7

Blood and Transfusion 61
Michael W. Cripps • Mitchell J. Cohen • Robert C. Mackersie

8

Nutritional Intervention 73
Jodie A. Bryk • Juan B. Ochoa

9

Prehospital and Air Medical Care

83

Francis X. Guyette • David C. Cone

10 Team Activation and Organization 101
William S. Hoff

11 Imaging of Trauma Patients 110
Asim F. Choudhri

12 Interventional Radiology 121
J. Scott Williams

13 Sepsis in Trauma 128
Ayan Sen • Derek C. Angus

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14 Infections, Antibiotic Prevention, and Antibiotic Management 138
Philip S. Barie • Soumitra R. Eachempati

15 Trauma Pain Management 162
Donald M. Yealy

16 Venous Thromboembolism 170
Gerard Fulda • Mark Cipolle

17 Operating Room Practice 179
Steven A. Johnson • Michael Rhodes

18 Disasters, Mass Casualty Incidents 183
Ronald N. Roth • Amir Blumenfeld • Susan M. Briggs

19 Injury Prevention 195
Charles C. Branas

20 Rehabilitation 202
John A. Horton III • Gary N. Galang

21A Trauma in Children 213
Daniel J. Grabo • Thane A. Blinman • Michael L. Nance • C. William Schwab

21B Trauma in Pregnant Women 228
Daniel J. Grabo • C. William Schwab

21C Trauma in Older Adults 234
Daniel J. Grabo • C. William Schwab

22 Introduction to Trauma: Mechanism of Injury 241
Gregory J. Jurkovich • L.D. Britt

23 Traumatic Brain Injury 253
Meredith S. Tinti • Vicente H. Gracias • Peter D. Le Roux

24 Maxillofacial Injury 264
William L. Chung • James M. Russavage • Mark W. Ochs

25 Spinal Cord and Spinal Column 287
Matthew Sanborn • Lachlan J. Smith • Neil R. Malhotra

26 Ophthalmic Injuries 308
S. Tonya Stefko • Donald M. Yealy

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27 Neck Trauma 315
Tiffany K. Bee • Martin A. Croce

28 Thoracic Injuries 327
Juan A. Asensio • Federico N. Mazzini • Thai Vu

29 Abdominal Trauma 357
Matthew D. Neal • L.D. Britt • Greg Watson • Alan Murdock • Andrew B. Peitzman

30 Genitourinary Injuries 395
Hunter Wessells

31 Orthopedic Trauma, Fractures, and Dislocations 404
Samir Mehta • L. Scott Levin

32 Peripheral Vascular Injuries 427
Louis J. Magnotti • John P. Sharpe • Timothy C. Fabian

33 Burns/Inhalation Injury 443
James H. Holmes IV

34 Priorities in the ICU Care of the Adult Trauma Patient 456
Philip S. Barie • Soumitra R. Eachempati

35 Multiple Organ Dysfunction Syndrome 489
Philip A. Efron • Darwin N. Ang • Lyle L. Moldawer • Frederick A. Moore

36 Cardiovascular Disease and Monitoring 499
Mayur Narayan • Thomas M. Scalea

37 Acute Kidney Injury 508
Feihu Zhou • John A. Kellum

38 Acute Respiratory Failure and Mechanical Ventilation 514
Cory J. Vatsass • Lena M. Napolitano

39 Abdominal Compartment Syndrome, Open Abdomen,
Enterocutaneous Fistulae 529
James F. Whelan • Michel B. Aboutanos • Rao R. Ivatury

40 Liver Failure 535
Deanna Blisard

41 Support of the Organ Donor 545
Patrick K. Kim • Matthew V. Benns • Patrick M. Reilly • C. William Schwab

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42 Accidental and Therapeutic Hypothermia, Cold Injury,
and Drowning 554
Samuel A. Tisherman

43 Introduction to Emergency General Surgery: Evaluation of the
Acute Abdomen 562
Grace S. Rozycki • David V. Feliciano

44 Preparation, Initial Resuscitation, and Management of the Patient for
Emergency Operation 569
Ali Y. Mejaddam • George C. Velmahos

45 Acute Abdomen in ICU Patients 574
Matthew R. Rosengart

46 Bowel Obstruction 583
Vishal Bansal • Raul Coimbra

47 Gastrointestinal Bleeding 592
Kent Zettel • A. James Moser

48 Acute Pancreatitis 606
¨
Ari K. Leppaniemi

49 Biliary Tract Disease 613
Benjamin Braslow

50 Appendicitis 624
Daniel N. Holena • C. William Schwab

51 Esophagus, Stomach, and Duodenum 630
Louis H. Alarcon • Ryan M. Levy • James D. Luketich

52 Inflammatory Diseases of the Intestines 643
Sean P. Whelan • Vaishali D. Schuchert • Brian S. Zuckerbraun

53 Acute Anorectal Pain 657
Frederick J. Denstman

54 Soft Tissue Infection 666
David Morris • Babak Sarani

55 Vascular Emergencies 672
Syed M. Faisal Alam • Christopher H. Byrne

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56 Hernias 684
Jennifer M. DiCocco • Steven P. Goldberg • Timothy C. Fabian

57 Obstetric and Gynecologic Emergencies 695
Glenn Updike

58 Laparoscopic Treatment of the Acute Abdomen 708
Abe Fingerhut • Mousa Khoursheed

59 Miscellaneous Procedures 719
Glen Tinkoff • Frederick Giberson

60 Scoring for Injury and Emergency Surgery 733
Edward Kwon • John Fildes

Appendix A: Injury Scales 743
Appendix B: Frequently Used Forms 756
Index 773

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Introduction to Trauma Care
Amy N. Hildreth, R. Shayn Martin and J. Wayne Meredith

I. INTRODUCTION. Trauma is mechanical damage to the body caused by an external

force. The trauma patient has been defined as “an injured person who requires timely
diagnosis and treatment of actual or potential injuries by a multidisciplinary team of
health care professionals, supported by the appropriate resources, to diminish or eliminate the risk of death or permanent disability.” This chapter describes the current impact
of injury on society, the structure of modern trauma systems, and the way injuries are
measured and quantified as well as common patterns of injury seen with blunt, penetrating, and blast injury mechanisms.
II. EPIDEMIOLOGY
A. Overall, trauma is the fifth leading cause of death in the United States and is the lead-

ing source of mortality for patients between 1 and 44 years of age. In 2007, 182,479
people died secondary to injury, representing 60 deaths per 100,000 population. Of
these, 123,706 were unintentional in nature while 53,371 were caused by violence.
A fatal injury occurs approximately every 5 minutes.
B. Mortality after trauma can be characterized by three time periods during which the
majority of deaths occur. As seen in Figure 1-1, approximately 50% of deaths occur
immediately and are usually secondary to severe neurologic injuries or exsanguination from major blood vessel injuries. These deaths can only be avoided through
injury prevention. The second peak of approximately 30% of deaths occurs during the initial hours post-injury, and preventing these deaths is the goal of modern trauma. Finally, 20% of deaths occur late (1 to 2 weeks from injury) and are
secondary to sepsis and multiple organ failure. It is believed that improved early
management of injury and associated shock may prevent these late complications.
C. In 2009, there were over 36 million medically attended, non-fatal injuries in the
United States. Data from 2007 reveal an estimated 42.4 million injury-related emergency departments and 80 million office-based visits. Injury represents the greatest
cause of years of potential life lost (YPLL) before age 65, totaling over 2.4 million
years or 20.1% of all YPLL. The total cost for injuries occurring in 2005 including
medical expenses and lost wages was estimated to be 355.3 billion dollars.
D. Specific injury patterns and mechanism
1. Age. While people 44 years old and younger account for the majority of fatal
and non-fatal injuries, the impact of trauma on the elderly is far more severe.
The death rate for injuries among patients 0 to 44 years old is approximately
45 per 100,000 population, whereas this rate is 113 per 100,000 for people over
65 years old and 169 per 100,000 for people over 75 years old.
2. Gender. Sixty-nine percent of all injury-related deaths occur in males, accounting
for twice the number of female deaths.
3. Mechanism
a. Motor vehicle crashes (MVC) are the leading cause of injury-related death,
accounting for 42,031 deaths in 2007 or 13.8 deaths per 100,000 population.
Over 2.6 million people sustained non-fatal injuries secondary to MVC in
2009. Despite this, the death rate per vehicle miles traveled (VMT) has declined
steadily throughout the century.
b. Firearm-related injury resulted in 31,224 deaths in 2007 and was the third
leading cause of injury-related mortality for all ages. Fifty-six percent were a
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The Trauma Manual: Trauma and Acute Care Surgery

100%
80%
60%

50%
30%

40%

20%

20%
0%
Immediate
(Minutes)

Early
(Hours)
Time to Death

Late
(Weeks)

Figure 1-1. Distribution of death after
injury. Adapted from: Trunkey DD.
Trauma. Accidental and intentional injuries account for more years of life lost
in the U.S. than cancer and heart disease. Among the prescribed remedies
are improved preventive efforts, speedier surgery and further research. Sci Am
1983;249(2):28–35 .

result of suicide while 41% were homicide-related. Non-fatal gunshot wounds
were identified in 66,769 patients in 2009. Predominately, fatal shootings
involve young males; the number of deaths in the 15- to 34-year-old age range
is over seven times the number of female deaths. Firearm-related injuries peak
at 19 years of age.
c. Falls are the leading cause of non-fatal injury, resulting in approximately
8.8 million injuries and 23,443 deaths throughout all age groups. Falls are most
common among the young and the elderly with both groups demonstrating
injury rates of greater than 4,000 injuries per 100,000 population. Despite
this similarity, falls are the leading cause of death in patients 65 years or older
while death in children is uncommon. The death rate due to falls in elderly
patients is more than 170 times that of children less than 10 years old. The
peak incidence occurs at age 85.
d. Other common mechanisms contributing to trauma mortality include poisoning, suffocation, drowning, cutting/piercing, and burns.
III. TRAUMA SYSTEMS
A. Overview
1. As defined by the Trauma System Agenda for the Future, “A trauma system is an

organized, coordinated effort in a defined geographic area that delivers the full
range of care to all injured patients and is integrated with the local public health
system.”
Historical perspective. The systematic care of trauma changed significantly with the publication of, “Accidental Death and Disability: The Neglected
Disease of Modern Society” in 1966. This document revealed the deficiencies in
injury management and initiated the development of systems to improve trauma
care. The Emergency Medical Services Systems Act was passed in 1973 to support
the development of regionalized Emergency Medical Services (EMS systems. In
1976, the American College of Surgeons (ACS) Committee on Trauma (COT)
published, “Optimal Hospital Resources for the Care of the Seriously Injured”
which established criteria that identified hospitals as trauma centers. This document has been revised as knowledge about trauma systems has evolved. More
recently, the Model Trauma Care System Plan created by the Health Resources
Services Administration (HRSA) was published to further define and guide trauma
system development.
2. Function. Trauma systems have been designed to be inclusive in nature and use
all available resources to provide appropriate care to all injured patients.
3. Designation and verification. Facilities within a trauma system require identification of injury management capabilities so that resource assessments can be
achieved. A government group designates a hospital as a trauma center after
evaluating the facility’s resources and the ability to provide a specific level of care.

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