Laryngotracheal trauma is a rare and life-threatening injury, seen more commonly in multiple-trauma patients. It can often go unrecognized and undertreated due to its variable clinical presentation and the lack of experience in its diagnosis and treatment. Symptoms often do not correlate with the severity of the injury, and injuries may range from a minor perilaryngeal hematoma to complete tracheal transection. Diagnosis of the extent of the injury often requires a combination of multidetector, contrast, computed tomography, flexible fiberoptic laryngoscopy, and flexible bronchoscopy. Treatment ranges from observation with symptomatic management, reduction, and repair of laryngeal skeletal fractures to complete tracheal or laryngeal reconstruction. Endolaryngeal stents are reserved for use in cases of significant mucosal trauma or injuries that disrupt the anterior commissure of the larynx. The most important goal in management is to first secure and reconstruct the airway as needed. Once the airway has been secured, the goal of treatment is to restore voice and swallowing capabilities.
Human beings, as homeotherms, maintain their temperature within a narrow range around a core temperature of 37° C. Hypothermia can be classified as accidental/spontaneous or induced/therapeutic. Classical definition for hypothermia is a body core temperature less than or equal to 35° C. For trauma patients, however, Advanced Trauma Life Support (ATLS) defines hypothermia as any core temperature below 36° C (96.8° F). Hypothermia causes significant dysfunction to multiple organ systems and in combination with coagulopathy and acidosis (“lethal triad”) can worsen outcomes in critically ill trauma patients. Maintaining normothermia is a vital component to the management of the trauma patient. Studies have shown that trauma patients have a significantly higher mortality rate when suffering from hypothermia. Multifaceted management strategies focused on prehospital and hospital hypothermia prevention can avoid the physiologic consequences that can worsen the prognosis of trauma patients.
Cardiopulmonary physiology is complex. Although the Swan-Ganz catheter is now infrequently used, knowledge of its use and the hemodynamic parameters, both measured and calculated, remain useful knowledge for the care of critically ill and injured patients, especially in selected patients with multiple system organ failure (MSOF) and those requiring extracorporeal membrane oxygenation (ECMO).
Gastric Injuries most commonly occur following penetrating trauma. Physical findings are consistent with gastrointestinal perforation, mandate laparotomy, or in certain circumstances, laparoscopy. CT findings may support gastric penetration and also require operative intervention; this scenario is more common following blunt injury. Surgical management for gastric injury is relatively straightforward and is based on organ injury scoring. Morbidities are usually related to associate injuries but may occur due to a leak or bleeding following gastric repair. Mortalities are invariably related to shock severity and other injuries.
Although tracheobronchial injuries can be rapidly fatal, patients that survive the initial injury and reach definitive care have generally favorable outcomes. Penetrating trauma is the most common cause of this type of injury but it is seen with blunt trauma as well as during instrumentation of the airway. Signs of injury may include pain, hoarseness, stridor, hemoptysis, subcutaneous emphysema, and respiratory collapse. Mediastinal or intrapericardial air as well as pneumothorax may be seen on imaging. As in any trauma situation, evaluation and management of the airway takes priority. Definitive diagnosis can be made with computed tomography followed by bronchoscopy. Repairs should be done with absorbable suture in a tension-free fashion and should be buttressed with a vascularized pedicle of tissue when possible. Cervical tracheal injuries can be approached via collar incision and the majority of intra thoracic tracheobronchial injuries can be access through the right chest.
Resuscitative thoracotomy is a valuable tool in trauma surgeons′ armamentarium. It requires rapid decision, excellent surgical skills to rapidly carry out repair of injured thoracic organs, control of hemorrhage, cross clamping of the descending aorta, and rapid institution of open cardiopulmonary resuscitation. High mortality rates are associated with this procedure.
Approximately 3-4% of blunt trauma patients sustain fractures to the spinal column/axial skeleton. Most of these injuries result from high impact blunt forces secondary to motor vehicular collisions and accidental falls. Blunt force injuries can significantly disrupt the axial skeleton. The clinical presentation of these injuries can range from minimally symptomatic to injuries that present with partial neurological deficits or complete spinal cord injuries and transection with resultant paralysis manifesting as paraplegia or even quadriplegia. Penetrating injuries are usually the cause of gunshots, rarely knives and in military arenas of warfare as the results of automatic weapons, land mines or improvised explosive devices (IEDs). This chapter covers in great detail the clinical presentation as well as the necessary imaging required to diagnose these injuries.
Managing patients with thoracic vascular injuries requires technical expertise and surgical judgment. Patients with thoracic vascular injuries require careful preoperative planning. Because of the rigid chest wall, the appropriate choice of incisions can optimize the exposure for proximal/distal control of hemorrhage from thoracic vascular injuries. Endovascular repair requiring femoral or brachial access can avoid the morbidity of some of these thoracic exposures but demand skilled techniques. Although thoracic vascular injuries have one of the highest mortality rates of any trauma, surgical judgment along with operative precision will translate to improved patient care and outcome.
Pulmonary contusion and flail chest are the two most common anatomic complications of major blunt chest trauma. Each directly alters pulmonary physiology in a specific and unique fashion, with each contributing distinctly to pulmonary dysfunction and failure after trauma. Radiographically, flail chest is defined as fractures of three or more consecutive ribs or costal cartilages fractured in two or more places. The term may also apply to a costochondral disruption. This may be associated with a sternal fracture or when the fracture fault crosses the axillary line leading to a flail segment of the entire anterior chest. A pulmonary contusion is a bruise of the lung from alveolar and interstitial hemorrhage. This chapter will discuss these two chest injuries and the management strategies to best mitigate the resultant physiologic injury.
Injury triggers a complex immune response that involves a multitude of systems. It is markedly similar to that seen in response to a microbial infection. The individual’s immune system must balance the proinflammatory response, which is necessary to clear injured tissue, yet not cause overwhelming endogenous injury by allowing a downregulation of the inflammatory process to provide an environment that can nurture the cell proliferation and tissue remodeling needed for healing. This chapter discusses the main components of the immune response following trauma. It includes the role of danger (damage)-associated molecular patterns; cytokine response; leukocyte recruitment; protease and reactive oxygen species; complement, kinins, and coagulation; acute phase reactants; systemic inflammatory response syndrome (SIRS); compensatory anti-inflammatory syndrome (CARS); the two-hit model, and the persistent inflammation, immunosuppression, and catabolism syndrome (PICS).
Resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma is a novel method of hemorrhage control while supporting blood pressure. The indications for REBOA are evolving. This technique is a useful addition to the armamentarium of trauma surgeons.
The incidence of congestive heart failure is rising in the United States, and acute decompensated heart failure is a challenging problem in the intensive care unit. It requires a strong understanding of cardiac pathophysiology. There is also a wide variety of available diagnostic modalities, treatments, and medications, all of which are essential tools for the surgical intensivist when treating this disease. This chapter will discuss the available pharmacologic support of cardiac failure.
