Ebook Fundamentals of surgical practice (3/E): Part 2

(BQ) Part 2 book Fundamentals of surgical practice has contents: Assessment and early treatment of patients with trauma, fundamentals of thoracic surgery, fundamentals of endocrine surgery, surgical care of the paediatric patient,... and other contents.

Section Chapter 16 Common Surgical Conditions Assessment and early treatment of patients with trauma Ross Davenport and Nigel Tai Introduction Trauma continues to be a leading cause of death and disability worldwide, and exceeds all other cause mortality combined in persons under the age of 36 years old Globally each day 300 000 people are severely injured, with 10 000 trauma deaths In the UK over 17 000 people die each year from accident or injury, with approximately ten times as many incapacitated or permanently disabled The socio-economic burden to the country as a whole is difficult to quantify although estimates for trauma care in the USA are in the region of $500 billion per annum The caveat to this is the cost of quality adjusted life years (QALYs) for injured people, which are among the cheapest in healthcare Trauma patients are often young, fit and healthy with good potential to return to a normal life providing they receive high-quality timely intervention to enable optimal outcome from injury Severely injured patients have 20% higher inhospital mortality in England and Wales (E&W) than the USA and there has been a plateau in trauma outcomes since 1994 The 2007 NCEPOD report of the management of severely injured patients reported that 52% of trauma patients receive substandard care and there may be upwards of 3000 preventable deaths in E&W annually One model for the organization of trauma services is to provide a regional network, with specialist major trauma centres at the hub This has to be integrated with pre-hospital care providers and all other acute hospitals in the region as patients with major injuries would bypass the nearest available hospital facilities and be taken to specialist centres Organization of trauma care in this way has been shown to improve outcomes and reduce preventable death from trauma by up to 15–25% Regionalization of trauma care in some countries (e.g USA) is well-established but it has not yet been instituted nationwide in the UK Trauma care in London was regionalized in April 2010 and a UK national scheme is proposed within the next few years Trauma surgery requires rapid decision-making with good technical ability and leadership skills Involvement of a trauma surgeon begins at the point of injury and finishes when recovery is complete The so called ‘chain of survival’ is founded in pre-hospital care and continues through resuscitation, surgery, critical care and rehabilitation Successful outcomes from trauma are dependent on good teamwork, rapid recognition of problems, early intervention and constant reevaluation Over the past 20 years advances in trauma care such as ‘damage control surgery’, improved resuscitation strategies and the use of interventional radiology have revolutionized the management of the severely injured Clinicians providing trauma care must fully appreciate the relationship between mechanism of trauma, injury pattern, pathophysiological response and importance of timely treatment in order to produce optimal outcomes from major trauma It is impossible to provide a detailed overview of every aspect of trauma surgery in a single chapter and therefore we will provide some general principles of management with a focus on key treatments for common injury patterns Injury prevention and trauma epidemiology Up to 50% of deaths occur at the scene from nonsurvivable CNS or great vessel injury In most cases Fundamentals of Surgical Practice, Third Edition, ed Andrew N Kingsnorth and Douglas M Bowley Published by Cambridge University Press C Cambridge University Press 2011 253 Section 5: Common Surgical Conditions injury prevention is the only mechanism by which this percentage can be reduced Legislation is often required to bring about behavioural change with respect to preventative strategies but has proved extremely effective in reducing injury on the road, in the home and at the workplace; e.g r hard hats and machine safety on building sites r control of firearms r drink-driving campaigns r seat belts r airbags r cycle lanes (cycle helmets remain voluntary in the UK) r traffic-calming measures Trauma is still overwhelmingly a disease of young people and, in particular, males under the age of 40 years As the population ages, the number of elderly people injured is set to rise; older patients have more comorbidity but less physiological reserve; therefore they often require prolonged critical care intervention Despite improvements in management, death from major trauma still follows a trimodal distribution r Immediate (minutes) – death from catastrophic injury to the central nervous system (CNS) or great vessels often at the scene of the accident/ injury r Early (hours) – death from uncontrolled haemorrhage, e.g major pelvic fracture with rupture of pelvic vessels or hypoxia, e.g tension pneumothorax r Late (weeks) – patients who survive the initial injury insult are at risk of developing sepsis, acute lung injury, renal insufficiency and multi-organ failure due to the complex pathophysiological responses to trauma Injury mechanism Blunt injury in the form of road traffic collisions (RTCs) and falls or jumps from height account for the majority of the trauma workload in the UK Penetrating injury (gun or knife crime) is only responsible for 4% of trauma in this country although a large geographical divide exists, with rates exceeding 25% in some inner cities Eliciting the history of the accident or injury from the patient or bystanders is an essential part of recognizing the possible injury pattern The magnitude and direction of force sustained by the patient is a help- 254 ful guide to likely injury severity Markers of severe trauma include: r death of other occupants in same vehicle r ejection from vehicle r marked intrusion into the passenger compartment of the vehicle r fall from height (Ͼ5 metres) r fall under a train Certain mechanisms of trauma are associated with typical injury patterns A motorcyclist involved in a RTC hit from the left-hand side may present with fractured ribs and fractured left hemi-pelvis In this example the trauma surgeon must seek to actively exclude abdominal injury, e.g splenic rupture which, from this pattern of injury, is highly probable Blunt trauma The extent of tissue injury due to blunt trauma from external compression, crush or deceleration forces is usually far greater than that from penetrating injury Blunt trauma often involves the transfer of massive force to the body and results in multi-system injury which elicits a huge inflammatory response Abdominal viscera are at particular risk of injury from blunt trauma as there is little protection from the bony skeleton Clues to internal organ injury may be evident from skin marking such as the seat belt sign (Figure 16.1) Deceleration forces lead to shearing which causes viscera and vascular pedicles to tear, especially at relatively fixed points of attachment, e.g mesenteric vasculature and descending thoracic aorta Penetrating injury Gunshot wounds can be divided into either high or low energy transfer – the majority of injuries in civilian practice are from small-calibre low-velocity weapons, e.g pistols and air guns Low-velocity projectiles such as shotgun pellets and pistol bullets can follow an unpredictable course through the body and will often take the path of least resistance Direct injury occurs to structures in the trajectory of the projectile Projectiles from high-energy weapon systems, e.g rifles and close-range shotguns, dissipate energy into the surrounding tissues, causing massive disruption to viscera This process, known as cavitation, can suck in debris and clothing, leading to widespread contamination and associated infection Entry and exit wounds are not always related linearly – one should maintain Chapter 16: Assessment and early treatment of patients with trauma produces unique effects on specific organs, e.g blast lung, ruptured tympanic membrane Pathophysiology of blast injury is typically divided into r primary – shock front from blast damages air-filled structures, e.g lung, ear, bowel r secondary – objects energized by explosion impact upon the body, i.e shrapnel penetration r tertiary – high-energy explosions may cause buildings to collapse or people to be thrown through the air, e.g blunt injury, traumatic amputations r quaternary – burns, exposure to toxic components of explosive material or environment Injury severity scoring Figure 16.1 Seat belt sign a high index of suspicion that other body cavities may have been breached Knife injury is associated with low energy transfer, but direct damage to solid abdominal organs or major truncal or limb vasculature can result in catastrophic haemorrhage or cardiac tamponade The size of knife is an unreliable guide to depth of penetration and there is no benefit in routinely exploring wounds in the emergency department (ED) Patients with life-threatening injuries following penetrating trauma should be transferred to hospital for immediate assessment as a significant proportion will require surgical intervention, e.g intercostal chest tube drainage or haemorrhage control Blast injury Trauma from detonation of explosives has the capacity to cause life-threatening multi-system injuries in one or more casualties The mechanism of injury may be both blunt and penetrating although blast trauma Injury severity can be measured by extent of either anatomical injury or physiological derangement The limitation of both methods is they are unable to accurately define the extent of overall tissue trauma or take into account the patient’s physiological age, i.e premorbid state The most widely used anatomical scoring system is the Injury Severity Score (ISS) based on the Abbreviated Injury Scale (AIS) Injuries in each body region, e.g chest, head/neck etc., are scored using AIS from (minor) to (non-survivable) The three highest scores are then squared to give the ISS; severe injury is defined by an ISS Ͼ15 The main limitation of ISS is that it cannot be calculated in the acute phase of trauma care and does not take into account multiple injuries within the same body region, e.g unilateral humeral fracture has the same AIS (3) as bilateral femoral fractures GCS and the Revised Trauma Score (RTS) are the most widely used physiological scoring systems RTS utilizes respiratory rate, systolic BP and GCS to calculate a score from to 12, with lower scores associated with higher mortality The Trauma and ISS (TRISS) score is a combination of ISS, RTS and patient age and is a method by which trauma specialists have attempted to predict survival TRISS is limited for the reasons discussed above and hence a very crude measure as it does not provide any information of functional outcome Undoubtedly, a patient’s predetermined genetic response to trauma affects individual outcome Ongoing research suggests the prediction of outcome after trauma may be improved using a panel of plasma biomarkers for injury severity 255 Section 5: Common Surgical Conditions Metabolic response to trauma The acute physiological or stress response to trauma is a complex interplay of neuroendocrine, metabolic and inflammatory changes to maintain homeostasis Local and systemic effects are necessary to promote wound healing and tissue regeneration but, in excess, these responses can cause harm, e.g acute lung injury and multiple organ dysfunction In the early stages of injury the ‘fight or flight’ reaction predominates; central to this is the hypothalamic-pituitary-adrenal axis with activation of the sympathetic nervous system and the acute phase inflammatory response which leads to: r increased catabolism to mobilize energy resources r activation of the immune and coagulation systems r haemodynamic changes to preserve cardiovascular homeostasis The latter phase is characterized by increased metabolic rate, protein catabolism, reductions in lean body mass and immunosuppression Neuroendocrine Trauma induces release of both adrenocorticotrophin hormone (ACTH) via nociceptive stimuli (injured tissue) and vasopressin from the pituitary Plasma levels of these hormones are directly related to the extent of injury but severe trauma diminishes the cortisol response from the adrenal cortex, possibly as a consequence of adrenal hypoperfusion Hypovolaemia, e.g haemorrhage, specifically activates the renin-angiotensin-aldosterone axis to promote retention of sodium and water to maintain blood pressure Hypothalamic activation of the sympathetic nervous system by hypovolaemia and tissue damage promotes release of catecholamines from the adrenal medulla Adrenaline, noradrenaline and dopamine within the circulation cause tachycardia, an elevation in blood pressure and peripheral vasoconstriction to support the cardiovascular system and maintain blood flow to vital organs, e.g brain and kidney A prolonged and excessive sympathetic response as a result of severe injury and hypovolaemia will result in end organ hypoperfusion, giving rise to hepatic insufficiency and acute renal failure Adrenaline has additional effects on other hormones to effect mobilization of energy substrates ␣-Adrenergic inhibition of insulin release from the pancreas and ␤-adrenergic-mediated glucagon secretion significantly elevate plasma glucose In combination with growth hormone acting via insulin-like 256 growth factors glucose is preferentially taken up by neurons at this time of relative glucose shortage Metabolic Trauma produces a profound catabolic response to mobilize energy substrates from the breakdown of carbohydrate, fat and protein (late) The metabolic response to major trauma includes: r increased hepatic glycogenolysis and glucogenesis r reduced glucose utilization by skeletal muscle secondary to catecholamine-mediated suppression of insulin release and increased intracellular insulin resistance r conversion of triglycerides by lipolysis to free fatty acids and glycerol (substrate for hepatic gluconeogenesis) r skeletal muscle breakdown (release of amino acids for gluconeogenesis) r increased whole body turnover of protein – negative nitrogen balance Inflammatory Inflammation is critical to wound healing and survival but an overwhelming response in the face of severe trauma with systemic activation of the immune system may become self-destructive Trauma causes local non-specific activation of the ‘innate’ immune response to recruit white blood cells and macrophages with activation of the complement system at the site of injury Cytokines such as interleukin-6 cause hepatocytes to release acute-phase proteins such as fibrinogen and C-reactive protein which together with other proinflammatory mediators (TNF-alpha, IL-1, interferon and prostaglandins) define the immune response Circulating immunosuppressive factors, e.g suppressor T cells, attempt to keep the inflammatory process in check since overflow of cytokines into the systemic circulation is an important factor in the systemic inflammatory response syndrome (SIRS) Multiple organ failure (MOF) is an extreme form of SIRS and despite advances in critical care remains the leading cause of late death in trauma Following injury patients develop a hyper-inflammatory response, which is directly related to degree of shock, extent of tissue injury and host factors A low-level SIRS response permits recovery but if the injury load is extensive an augmented SIRS effect can precipitate early MOF Additionally any delayed Chapter 16: Assessment and early treatment of patients with trauma ED and continue until normovolaemia and haemostasis have been achieved DCR is defined as: Figure 16.2 Multi-factorial drivers of trauma-induced coagulopathy; from Hess et al 2008 immunosuppressive factors which keep SIRS at bay which escape the normal negative feedback loops will result in severe immunosuppression and infection The precise mechanism by which the immune balance is regulated and why trauma disrupts the equilibrium to predispose to sepsis and MOF is unknown Current hypotheses include impaired mitochondrial function in severe shock; reperfusion injury with release of free radicals; hypoperfusion of the gut allowing bacterial translocation and immunosuppression following massive blood transfusion Trauma-induced coagulopathy Our understanding of trauma-induced coagulopathy (TIC) has changed dramatically in recent years and continues to evolve rapidly TIC aetiology is multi-factorial (Figure 16.2) and more complex than the classic description of clotting factor loss (bleeding or consumption), dilution or dysfunction (hypothermia and/or acidaemia) Numerous studies have demonstrated an acute traumatic coagulopathy (ATC) present at admission in nearly 25% of trauma patients prior to the administration of significant volumes of fluid ATC appears to be an endogenous coagulopathy initiated by hypoperfusion and tissue injury Patients with ATC are four times more likely to die compared with non-coagulopathic patients Analysis of data from patients receiving massive blood transfusion (Ͼ10 units PRBC in 24 hours) from combat hospitals in Iraq and Afghanistan has changed trauma resuscitation recommendations These data suggest that for patients with exsanguination who require massive transfusion a high plasma to RBC ratio (Ͻ1:1.4) is independently associated with improved survival to hospital discharge These recent recommendations have been called Damage Control Resuscitation (DCR) and begin in the r maintaining systolic BP below 90 mmHg until haemorrhage control is achieved r transfusing PRBC (un-cross-matched type O until type-specific blood is available) and thawed fresh frozen plasma (FFP) as primary resuscitation fluids – aiming for a near equal ratio to correct hypovolaemia and promote haemostasis The pre-hospital phase and the trauma team The majority of pre-hospital trauma care continues to be provided by paramedic-trained ambulance crews in a ‘scoop and run’ approach On-scene treatment is kept to a minimum and the patient is rapidly transferred to the nearest hospital Increasing numbers of air ambulances are being deployed in both urban and rural locations to enable a trained pre-hospital care doctor to be transported to the scene The primary advantage of this strategy is definitive airway management, e.g endotracheal (ET) intubation, and the ability to temporarily control some life-threatening events Whatever approach is employed the time spent on scene must be kept to an absolute minimum Definitive treatment of injuries can only be accomplished within a hospital setting The concept of a ‘golden hour’ in the initial stage of trauma care is a useful reminder for clinicians of the need to expedite diagnosis and treatment of life-threatening injuries Prior to arrival of any severely injured trauma patient at hospital the pre-hospital care team must notify the ED in the receiving hospital If the patient is exsanguinating this pre-alert should be a trigger for activation of the in-hospital massive transfusion protocol to ensure blood and clotting products are immediately available on the patient’s arrival Patients who fulfil criteria for activation of a trauma team must be met by a fully assembled trauma team consisting of (but not limited to): r team leader r doctor with advanced airway skills, e.g anaesthetist r general surgeon r orthopaedic surgeon r nurse r radiographer 257 Section 5: Common Surgical Conditions Senior clinicians should be involved from the outset to ensure life-threatening conditions are identified early and definitive care is initiated as a priority Trauma team training through moulage-based scenarios facilitates an organized team structure The Advanced Trauma Life Support (ATLS R ) course has long been the mainstay of trauma team training around the world but similar European courses are now available Each member of the team should be assigned a specific role to ensure horizontal patient management – tasks are performed simultaneously by multiple personnel Meticulous recordkeeping is essential to document all injuries and treatment History-taking is (because of the context) difficult in major trauma, but the minimum background information should be obtained from the patient or a bystander; this has been called an AMPLE history: Allergies, Medications, Past medical history/Pregnancy, Last meal, Events leading up to injury Primary survey Initial assessment of the trauma patient All self-ventilating patients with major injury should receive high-flow oxygen via a non-rebreathing mask with reservoir to achieve an inspired oxygen concentration of around 85% Specific indications for ET intubation include those detailed below – the cervical collar can be removed prior to intubation but manual inline stabilization must be maintained at all times Indications for endotracheal intubation: r failure of basic techniques to maintain a patent airway r threatened airway, e.g patient with reduced conscious level, facial burns r poor respiratory function requiring artificial means of ventilation, e.g lung contusions The trauma team should be assembled prior to arrival of the patient in the resuscitation room and predefined roles allocated The pre-hospital care team should provide a structured but concise handover including mechanism of injury, vital signs and interventions performed The initial assessment termed a primary survey (as defined by ATLS R ) must be completed as a priority to enable rapid treatment of all life-threatening injuries All patients should be assessed in the same way utilizing the ABCDE approach: r r r r r Airway with cervical spine control Breathing Circulation and haemorrhage control Disability Exposure The team leader must oversee, co-ordinate and direct the team to ensure injuries are identified as soon as possible and treatment is implemented Following an intervention or deterioration in the patient’s condition it is essential to repeat the primary survey starting from A 258 A: airway management with cervical spine control Management of the airway with cervical spine immobilization is the first priority for all trauma patients A conscious, talking patient is, by definition, able to maintain their own airway whereas those who present with a reduced conscious level are unable to speak or are at risk of airway injury and may require: Basic techniques r Supplementary oxygen r Clearing of the airway – suctioning, chin lift, jaw thrust r Simple adjuncts, e.g oro- or naso-pharyngeal airway Advanced airway techniques (definitive airway) r Endotracheal (ET) intubation r Surgical airway – needle or surgical cricothyroidotomy The potential for cervical spine injury should be considered in all patients except a select number exposed to penetrating trauma only A well-fitted cervical collar should be fitted at the scene or on arrival in the ED to fully immobilize the cervical spine Sand bags on either side of the head and secured to the patient will achieve three-point immobilization and must be maintained until injury is excluded B: breathing One in four of trauma deaths are due to chest injury; therefore assessment of breathing requires a rapid but Chapter 16: Assessment and early treatment of patients with trauma comprehensive examination of the thorax and global tissue oxygenation It should be remembered the pleural cavity reaches 2.5 cm above the medial third of the clavicle and descends to the twelfth rib posteriorly Chest X-ray (CXR) forms an adjunct to the primary survey but clinical examination should not be delayed The following life-threatening injuries must be identified and treated immediately: r airway obstruction r massive haemothorax – thoracostomy with intercostal chest drainage (ICD) r tension pneumothorax – needle decompression or thoracostomy with ICD r open pneumothorax (sucking wound) – apply three-sided flap dressing; or sealing of wound and ipsilateral thoracostomy with ICD r cardiac tamponade – thoracotomy or sub-diaphragmatic incision to open pericardium r flail chest – supportive ventilation and analgesia Observe r Colour of the patient (cyanosis) r Distension of neck veins (obstructive cause of shock) r Confusion or agitation (hypoventilation will reduce cerebral oxygenation) r Elevated respiratory rate r Chest wall asymmetry (may indicate pneumothorax or rib fractures with flail segment) r Pulse oximetry – useful adjunct but unreliable in cold or vasoconstricted patients Palpate r Palpate thorax for any pain, crepitus or deformity indicative of bony injury r Tracheal deviation (late sign of tension pneumothorax) Percuss r Hyper-resonance – sign of pneumothorax but is often not audible at a trauma call Listen r Laboured breathing (respiratory compromise) r Stridor (obstructed airway) r Assess adequacy and equality of air entry to both lungs by auscultation C: cardiovascular status and haemorrhage control Approximately 40% of patients with major injuries who reach hospital alive subsequently die from uncontrolled bleeding Life-threatening haemorrhage must be identified at the outset of trauma resuscitation Military practitioners are taught to use a ϽCϾABC approach to ensure rapid control of catastrophic external bleeding as the first priority, e.g application of pressure to the bleeding point, limb tourniquets and topical haemostatic dressings In civilian trauma care catastrophic external haemorrhage is rare (1–3%) Successful outcomes after severe internal haemorrhage are dependent on prompt diagnosis and haemorrhage control by either radiological or surgical intervention, e.g angio-embolization (AE) of pelvic vasculature or ligation of damaged vessels Pathophysiology of shock Shock may be defined as inadequate tissue perfusion and oxygenation The first step in managing shock is to appreciate its presence and then determine the likely cause In the context of trauma, shock aetiology can be divided into haemorrhagic and non-haemorrhagic Causes of shock r Haemorrhage r Cardiogenic r r r cardiac tamponade blunt cardiac injury myocardial infarction r Tension pneumothorax r Neurogenic – loss of sympathetic tone from thoracic spinal cord injury r Sepsis – may arise 24–48 hours following injury as a result of systemic and inappropriate activation of inflammation (see Chapter 4) r Anaphylaxis r NB: isolated brain injury does not cause shock Haemorrhage is the most common cause of shock in trauma Blood loss leads to a progressive compensatory response of vasoconstriction Blood is diverted from the cutaneous, muscle and visceral vasculature to preserve blood flow to the brain, kidneys and heart Endogenous catecholamines increase peripheral vascular resistance with associated contraction of blood volume in the venous system Cardiac output is maintained in the early stages by a rise in heart rate but as 259 Section 5: Common Surgical Conditions the compensatory mechanisms fail and intravascular volume continues to be lost then blood pressure will begin to fall Cells deprived of oxygen switch to anaerobic metabolism and produce lactic acid, leading to a metabolic acidosis Prolonged hypoperfusion damages the cell membrane architecture, leading to fluid shift, swelling of the cell and eventual cell death The degree of circulatory shock is often difficult to determine as age, comorbidities and premorbid medication may mask true physiology Young people are able to compensate far longer and may not demonstrate hypotension until 30–40% of circulating volume has been lost, at which point a precipitous fall in blood pressure will occur Anti-hypertensive medication will limit the ability of an elderly person to mount a tachycardia or initiate vasoconstriction Clinical diagnosis is essential to the early recognition of shock and the following physiological changes are a rough stepwise approximation for the degree of shock: r sweaty and clammy skin r increased pulse pressure r elevated respiratory rate r tachycardia (a heart rate of 80–90 in a young fit person is a relative tachycardia) r altered mental status (anxious, confused) r hypotension r bradycardia, pallor and lethargy are late signs of haemorrhagic shock and indicate imminent cardiac arrest Source of haemorrhage Life-threatening blood loss may be external or concealed Common sites for major internal haemorrhage include: r thorax – each hemithorax can accommodate 2–3 litres of blood r abdomen – solid organ injury or mesenteric vessel rupture r pelvis – the retroperitoneum can accommodate the entire circulating volume, e.g pelvic fracture with associated vascular injury r limbs – long bone fractures, e.g femur (1–2 litres of blood) Investigations Recognition of haemorrhagic shock can be very difficult Some investigations can help determine the degree of shock and likely source of haemorrhage: r lactate and base deficit – (tissue hypoperfusion) 260 r haemoglobin and haematocrit – (unreliable indicators of blood loss) r CXR – (haemothorax) r pelvic X-ray (PXR) – (open book and vertical shear type fracture) r focused assessment with sonography in trauma (FAST) – (free fluid is intraperitoneal haemorrhage until proved otherwise) Resuscitation Initial treatment of severe shock is directed towards restoring end organ perfusion and securing haemorrhage control Multiple large-bore intravenous access must be obtained as soon as possible: r 14-gauge cannula in both antecubital fossa r rapid infusion catheter can be inserted into the internal jugular, subclavian or femoral veins Traditional ATLS R protocols advocated that fluid resuscitation should be with large volumes of crystalloid solutions This approach is now known to be associated with a transient rise in BP which may dislodge clots, precipitate a dilutional coagulopathy and reduce the patient’s core temperature Current recommendation is to give fluid boluses of 250 ml of crystalloid in patients without immediate life-threatening signs of shock to assess level of responsiveness: Responder = fluid bolus leads to sustained improvement in haemodynamic parameters Transient responder = pulse rate and BP improve after fluid boluses but then deteriorate Non-responder = fluid boluses have no effect and blood transfusion is required Resuscitation targets are controversial; for penetrating disease it is reasonable to aim at a systolic BP which is associated with cerebration or between 70 and 90 mmHg until haemostasis is achieved (permissive or hypotensive resuscitation) Although the evidence base is weaker for bluntly injured patients with shock, a similar approach is justified (at least until definitive haemorrhage control is achieved) In the context of traumatic brain injury (TBI), the threshold for permissive hypotension should be higher in order to prevent cerebral hypoperfusion (a systolic BP of least 100 mmHg should be maintained) Haemorrhage control Following diagnosis of life-threatening shock and identification of the source of bleeding it is vital to Chapter 16: Assessment and early treatment of patients with trauma gain haemorrhage control There should be no delay in order to ‘resuscitate the patient before theatre’ since no amount of resuscitation will arrest exsanguination Haemorrhage control can be achieved in the following ways: r splintage – stabilize the pelvic ring with a fabric pelvic binder or splint fashioned from a bed sheet to reduce the potential volume of the pelvis and tamponade any further; splint fractured long bones and apply traction, e.g femoral fracture r surgery – vessel repair or ligation; organ repair or resection; temporary packing for tamponade, e.g complex liver laceration r interventional radiology – angiographic embolization, e.g internal iliac artery in pelvic fracture D: neurological disability Traumatic brain injury (TBI) is the most common cause of early mortality following severe injury, accounting for two out of every five trauma deaths A rapid assessment of the CNS must be performed with early imaging of the brain and spinal cord to identify any injury Intracerebral haematoma (ICH) must be evacuated within hours to ensure optimal outcomes from TBI Shock, hypoxia, alcohol and drugs can mask underlying CNS pathology TBI and spinal cord injury (SCI) must be excluded before attributing an abnormal neurological examination to alcohol or drug intoxication Conscious level A reduced level of consciousness at any point after injury is a predictor of TBI Conscious level is determined by the Alert Voice Pain Unresponsive Scale (AVPU) or Glasgow Coma Scale (GCS) systems and the highest level should be recorded (Table 16.1) The best motor score is the most reliable predictor of outcome Pupillary response Assess both pupils for size, equality and reactivity A unilateral, dilated and non-reactive pupil suggests mass effect within the skull compressing the third cranial nerve An urgent CT scan of the brain is required Neurological examination A brief screening examination to check for hemiparesis/hemiplegia and the presence of reduced sensation Table 16.1 Neurological scoring systems A: AVPU provides a brief neurological assessment A V P U Alert Responds to verbal stimuli only Responds to painful stimuli only Unresponsive B: GCS is the sum of the best eye, motor and verbal responses Motor response (M) Spontaneous Localizes to pain Withdraws from pain Abnormal flexion Abnormal extension No response Verbal response (V) Oriented Confused Inappropriate words Incomprehensible sounds None Eye-opening response (E) Spontaneous Eyes open to speech Eyes open to pain No eye-opening should form part of the primary survey Limb weakness or altered sensation is indicative of either TBI or SCI and must be investigated as a priority In patients complaining of neck or back pain a more detailed neurological evaluation must be performed including rectal tone reflex E: exposure of the patient with environmental control A vital part of the primary survey is full external examination of the patient This mandates removal of the patient’s clothing and log rolls to examine the back of the patient Temperature control is important and, typically, an external warm air heating device will be placed over the patient to maintain normothermia Initial imaging and further examination X-ray As part of the primary survey an antero-posterior (AP) CXR and pelvic X-ray should be performed as they may detect life-threatening injuries and can aid identification of concealed haemorrhage X-ray imaging of the cervical spine in the initial evaluation 261 Section 5: Common Surgical Conditions Table 16.2 Zone of neck injuries Zone Anatomical borders Structures at risk of injury Surgical exposure I Clavicles to cricoid cartilage Vertebral and proximal carotid arteries Lung Trachea Oesophagus Spinal cord and major cervical nerve trunks Thoracic duct May require clavicle resection or median sternotomy II Cricoid cartilage to angle of mandible Jugular veins Vertebral and common carotid arteries Internal and external carotid arteries Trachea and larynx Oesophagus Spinal cord Easily accessible III Angle of mandible to base of skull Distal internal carotid arteries Jugular veins Pharynx May require disarticulation of the mandible or resection of the skull base remains controversial Lateral, AP and odontoid peg views are time-consuming, cannot be completed in the resuscitation room and are unable to reliably exclude injury Modern protocols for assessment of patients with major injury and the possibility of cervical spinal injury include CT scan with coronal and sagittal reconstruction Focused assessment with sonography in trauma (FAST) In recent years FAST has replaced diagnostic peritoneal lavage (DPL) for the assessment of intraabdominal injury FAST is an abbreviated ultrasound examination with the sole purpose of identifying the presence of free fluid, i.e blood, using four windows: perisplenic, perihepatic, pelvic and pericardial (for identification of tamponade) FAST is not a reliable modality for identifying specific injuries and does not replace the need for a subsequent (more sensitive and specific) CT scan of the torso Accuracy is excellent for patients with hypotension but FAST cannot be used to evaluate retroperitoneal injury, e.g pelvic haematoma It is operator-dependent and good views are not possible in obese patients or in the presence of extensive surgical emphysema In the shocked patient FAST examination may permit cavitary triage, i.e which body cavity requires immediate exploration for haemorrhage control, but a normal FAST scan does not exclude injury 262 Secondary and tertiary surveys The patient must be completely undressed to look for concealed injuries, e.g perineum, axilla and posterior scalp A formal secondary survey examination should be performed once all life-threatening injuries have been treated The aim of this systematic assessment is to identify and record all wounds, fractures and organ injury At this stage antibiotic prophylaxis and tetanus vaccination should be addressed Missed injuries are present in up to 50% of patients following major trauma and may lead to long-term functional deficit with associated medical litigation All patients should therefore receive a tertiary survey within 24 hours of admission This assessment should be undertaken by an experienced trauma nurse or clinician and must include a comprehensive review of the medical notes, appraisal of all investigations and a complete head-to-toe examination Traumatic brain injury (see Chapter 12) Neck injury The neck is relatively exposed and contains numerous vital structures; therefore it is at particular risk from penetrating injury (Table 16.2) Blunt neck trauma is rare, but injury to the cervical spine must be excluded as it can be equally life-threatening Blunt cerebrovascular injury (BCVI) has a 30% mortality rate Initial resuscitation should follow the ATLS R approach Index osteomyelitis, thoracic spine 296 osteoporosis distal humerus fractures 527 pathological fractures 526 proximal femoral fractures 531 proximal humerus fractures 527 spinal cord compression 295 tibial plateau fractures 532 wrist fractures 529 otitis externa 307 necrotizing (malignant) 307 otitis media acute 307–308 chronic suppurative 308, 308 ovarian ablation, breast cancer therapy 424 ovarian cysts 479 infants/children 605 ovarian mass, infants/children 605 overflow incontinence 457 ovotesticular dysgenesis 600 oxalate, urine levels 461 oxygen bound to haemoglobin 204 content in blood 203 dissolved in blood 204 transcutaneous monitoring 212 oxygen consumption (VO2 ) 204 oxygen delivery (DO2 ), shock 203–204 oxygen extraction ratio 204–205 oxygen saturation arterial 212 grafts 541 oxygen supplementation 10–11 preoxygenation for anaesthesia 136 oxygenation status 211 assessment 212 improvement 215 P wave 198 p53 mutation 604 packed red cells blood transfusion 234 massive blood loss 236 paediatrics see children; infants; neonates Paget’s cells 426 Paget’s disease of the nipple 402, 425, 425–426 654 pain acute 110–111 assessment 111, 112 bladder 458 bone 117, 171 breakthrough 114 cancer 111 bone metastases 171 causes 111 chronic 110–111 chronic pancreatitis 372–374 chronic regional pain syndrome with wrist fractures 529–530 classification 111, 110–111 control cancer 170–171 psychological methods 171 definition 110, 236 genitourinary 458 haematuria 458 hepatic capsule 117 incidence 111 incident 114 kidney 458 malignant bowel obstruction 121 management 113, 112–113, 114, 118 mechanisms 236 neuropathic 110, 117 nociceptive 110 opioid-resistant 170–171 palliative care 110–117 pathways 236 penile 458 postoperative 145, 236–237 management 236–237 pre-emptive treatment 236 prostate 458 scrotum 458 epididymo-orchitis 594 self-reported 111 ureter 458 see also analgesia; mastalgia palliative care 103–126 Advance Care Planning 105–108 best interest decisions 107 cachexia 124 cancer 170–171 communication 108–110 demographics 105 fatigue 124–125 formulary 118 hypercalcaemia of malignancy 122–124 malignant bowel obstruction 120–122 nausea and vomiting of cancer 117–119 pain 110–117 pathways 125–126 self care 104–105 strategy 105 symptom control 110 teamwork 104 WHO definition 103 Palliative Care Team (PCTeam) 104 pancreas 370–376 anatomical abnormalities 370 anatomy 370 annular 370, 577 calcification 373 children 588–589 cystic neoplasms 376 divisum 370 ectopic 370 endocrine tumours 389–390 infants 588–589 insulinoma 389–390 intraductal papillary mucinous neoplasm 376 mucinous cystic neoplasia 376 peripancreatic collection 373 physiology 370 transplantation 615 see also gastrinoma pancreatectomy 375 pancreatic cancer 374–376 ampullary adenocarcinoma 375 chemotherapy 375 ductal adenocarcinoma 374–375 head of pancreas tumour 375 lymphoma 376 multiple endocrine neoplasia I 391 neuroendocrine tumours 375–376 surgical management 374–375 pancreatic intraepithelial neoplasia (PanIN) 374 pancreatic pseudocyst 374, 374 pancreaticoduodenal trauma 376 pancreaticojejunostomy 372–374 pancreatitis acute 370–372 aetiology 370, 371 children 588 clinical presentation 370–371 diagnosis 370 phases 371–372 severity classification 371–372 treatment 372 chronic 372–374 pancreatic cancer association 374 pancuronium 143 panda eyes 602 panendoscopy 322 Index Panton–Valentine Leucocidin (PVL) 43 papilloedema 280 meningitis 304 paracetamol enhanced recovery 183 postoperative pain management 237 paraganglioma 389 paralytic ileus 184 children 565 paranasal sinus tumours 324 paraneoplastic syndromes 36, 161 parapharyngeal abscess 315, 316 parapharyngeal space 322 tumours 328 paraphimosis 478, 600 parasympathetic nervous system 283–285 parathyroid carcinoma 386 hypercalcaemic crisis 384–385 parathyroid hormone (PTH) 122–123 assay 385 hyperparathyroidism 384, 385 parathyroid/parathyroid disorders 384–386 anatomical relationships 386 damage in thyroid surgery 383 embryology 385 multiple endocrine neoplasia I 391 see also hyperparathyroidism parathyroidectomy 385 tertiary hyperparathyroidism 386 parathyroidism, primary 122–123 Par´e, Ambroise 181 parenteral nutrition children 565–566 home parenteral nutrition 173 infants 565–566 Parkland crystalloid formula 552–553 parotid gland, pleomorphic adenoma 326 parotitis 327 partial pressure of oxygen within alveolus (PAO2 ) 212 patella dislocation 535 fractures 532 pathogen-associated molecular patterns (PAMPs) 249 pathology 15–40 accumulations 31–32 cell death 16–17 cell injury 15–16 depositions 31–32 growth disorders 29–31 inflammation 17–21 neoplasia 32–38 surgical immunology 38–40 vascular disorders 24–29 patient care 230–246 activated protein C 234 appropriate provision 231 blood sugar control 233 communication 244–246 critical care 233 electrolyte balance 237–239 fluid balance 237–239 goal-directed therapy 233 operative severity 231 postoperative complications 239–244 preoperative physiological status 230–246 quality improvement programmes 246 recognition of ill surgical patient 231–234 safety factors 246 steroid therapy in severe sepsis 233–234 vital signs 231–233 see also blood transfusion; pain patient-controlled analgesia (PCA) 5, 145 laparoscopic surgery 184–185 opiate intermittent infusion 237 Patient Information Leaflet (PIL) 95 pattern recognition receptors (PRR) 249 fracture patterns 270 management 270 vertical shear fracture 273 penis 478–479 buried 600 degloving injury 478 developmental anomalies 456 fracture 478 inflammation 478 pain 458 squamous cell carcinoma 478 surgical anatomy 456 trauma 478 tumours 478 peptic ulcer 354–355 bleeding 348, 349 children 576 Helicobacter pylori 354–355 NSAID-induced 354 perforated 349–350 surgery 355 symptoms 354 perceived quality of life (PQoL) score 229 percutaneous imaging guided biopsy 63 percutaneous nephrolithotomy 467 percutaneous nephrostomy 63 percutaneous transhepatic biliary drainage 63 percutaneous transhepatic cholangiography (PTC) biliary obstruction 369 cholangiocarcinoma 369 perforated viscus 349–350 perforating vessel 549 perforator flaps 545–546 peak expiratory flow rate (PEFR), preoperative 132 perianal abscess 438–439, 587 pectineal ligament 485 perianal fistula 587 pelvi-ureteric junction 454 obstruction 465, 470, 471–472, 596–597 pericardiocentesis 200 cardiac tamponade 341 pelvic floor dysfunction 457 pelvic fractures 530, 531 antero-posterior compression 530 vertical shear 273, 530 pelvic kidney 454 pelvic pain syndrome 458 pelvic trauma 270 assessment 270 perianal disease, Crohn’s disease 441 perioperative management 181–182 peripheral nerve blockade, enhanced recovery 185–186 peripheral nerve injury 273 peristomal varices, lower gastrointestinal haemorrhage 437 peritoneal dialysis 469 peritoneum 486–487 655 Index peritonitis 52 meconium 580 pernicious anaemia 40 persistent hyperinsulinemic hypoglycemia of infancy (PHHI) 589 pethidine, patient-controlled analgesia 237 Peutz–Jeghers syndrome 587 Peyronie’s disease 458 phaeochromocytoma 388–389 diagnosis 388, 389 preoperative management 389 presentation 388 surgery 389 plastic surgery 537–559 burns 549–559 delay 537 flaps 537, 538 grafts 537–538, 539–542 head and neck reconstruction 548 mandibular reconstruction 548 negative pressure 539 principles 538 reconstructive ladder 539, 538–539 skin cancer 559–563 soft tissue cover 537 soft tissue reconstruction 537–538 Watson skin knife 540 see also breast reconstruction platelet concentrates 235 platelet trapping 567 phagocytosis 18–19 pleomorphic adenoma 328 phagosomes 18–19 pleomorphism 33 pharmacology 1–13 pleural conditions in children 572 phenylephrine 202 pleural effusion, malignant 339 phimosis 478, 600, 599–600 physiological 600 pleural fluid examination 333 phlegmasia 516 phosphodiesterase inhibitors 201, 478–479 photodynamic therapy 167 phrenic nerve 332 phyllodes tumour of the breast 426 physical activity, breast cancer prevention 410 physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) 230–231 phytobezoars 569 Pierre Robin syndrome 567–568 pilon fractures 533 PINNT (Patients on Intravenous and Nasogastric Nutrition Therapy) 179 pituitary gland 283, 299–301 adenomas 300, 300 management 300–301 investigations 300 management 300–301 pleural space 331 pleural tumours 339 pleurodesis, malignant pleural effusion 339 popliteal artery aneurysms 511 porphyria 128 portal hypertension 363 ascites 363 causes 363 portosystemic shunt see transjugular intra-hepatic portal–systemic shunting (TIPPS) positive end-expiratory pressure (PEEP) 139, 215, 216–217 positive pressure ventilators 138 positron emission tomography (PET) 59 chest 333–334 oesophago-gastric surgery 346 POSSUM (physiological and operative severity score for the enumeration of mortality and morbidity) 230–231 post-carotid endarterectomy hyperperfusion syndrome 513 post-cholecystectomy syndrome 366 post-exposure prophylaxis 48–49 post-transplant lymphoproliferative disease 624 Plummer’s disease 380 post-traumatic amnesia (PTA) 279, 291–292 pneumonectomy 336 postdural puncture headache 148 pneumonia postoperative 49–50, 239 ventilator-associated 50, 217 posterior sagittal anorectoplasty (PSARP) 586–587 pneumonitis, aspiration 50 pneumoperitoneum 85 insufflation pressures 85–86, 87 insufflation rate 87 insufflators 87 open technique 85, 86 optical access trochars 86 veress needle 85–86 pneumothorax catamenial 340 children 572 open 341 primary 339–340 recurrent 572 secondary 340 spontaneous 339–340 trauma 259, 264, 265 posterior urethral valve (PUV) 598 postoperative complications 239–244 abdominal adhesions 242–243 anastomotic leakage 241–242 cardiac 239–240 cognitive impairment 243 delirium 243 fever 243 respiratory 239 urinary retention 243 venous thromboembolism 243–244 wound 240–241 see also nausea and vomiting, postoperative postoperative monitoring, vital signs 231–233 plasma cells 20 polycyclic hydrocarbons 37 potassium bowel levels 176 infusions 238–239 measurement in renal failure 461 plastic spray 76, 78 polycystic disease, congenital 358 Potter’s syndrome 453 plain film radiography 54, 55 orthopaedics 535–536 656 polyclonal antibodies 621 Index povidone iodine 71 PQoL (perceived quality of life) score 229 pre-hospital care team 257–258 pre-malignant lesions 33–34 scoring systems 130, 133, 132–133 sickle cell disorders 128, 128 social history 129 suxamethonium apnoea 127 tracheal intubation difficulties 128, 130, 130 preauricular sinus 306, 306 children 567 preoperative physiological status 230–231 prednisolone 12, 12–13 immunosuppression in organ transplantation 619–620 side effects 619–620 toxicity 619–620 preoperative preparation, fasting 136, 136 pregabalin, neuropathic pain management 117 pregnancy anal incontinence 451 breast 395 breast cancer 427 ectopic 479 preload 192 premedication anaesthesia 135, 135 sedation 135 enhanced recovery 183 preoperative assessment 127–133 airway 130 AMPLE 130, 130 anaphylaxis 127–128 autonomic dysfunction 132 biochemistry 132 cardiac function 131–132 cardiac risk 131, 131 cardiovascular disease 129, 130–131 chest X-ray 132 drug history 129, 129 ECG 131 endocrine disorders 129 gastrointestinal disease 129 haematology 132 hepatic disease 129 history of previous anaesthesia 127 history taking 127 investigations 131–133 malignant hyperthermia/hyperpyrexia 127 musculoskeletal disease 129 obesity 131 past medical history 128 physical examination 130 porphyria 128 pulmonary function tests 132 renal disease 129 respiratory disease 128–129, 130, 132 preperitoneal space 486–487 prescribing nil by mouth perioperative pressure control ventilation (PCV) 215 pressure/electrosurgery 92 pressure support ventilation (PSV) 216 preterm infants herniotomy 592 inguinal hernia 591 respiration 566 prevesical space of Retzius 487 priapism 478–479 prilocaine 147 intravenous regional anaesthesia 148 topical anaesthesia 71 primary parathyroidism 122–123 primitive neuroectodermal tumours (PNET) 299 metastases 476 PSA testing 461, 466, 476 ureteric obstruction 470–471 prostate-specific antigen (PSA) 165, 476 testing 461 urine outflow obstruction 466 prostatitis 475 prosthetic biomaterials abdominal wall hernia repair 490–491, 499 femoral hernia 501 incisional hernia 502–503 umbilical hernia 500 indications for use 490 protein 176 protein C deficiency 25–26, 515–516 protein S deficiency 25–26, 515–516 prothrombin mutations 25–26 proto-oncogenes 36 proton pump inhibitors (PPI) 45 pseudoaneurysms, organ transplantation complication 622 pseudobulbar palsy 282 pseudohermaphroditism female 600 male 600 psoas abscess, groin swelling 497 pro-drugs 169 pulmonary artery catheter, floating 195 processus vaginalis persistence 591–592 pulmonary artery catheterization 195–196 professionalism 94–101 pulmonary contusions 263, 342 progestogens 13 pulmonary oedema 219–220 prolactin 300 pulmonary embolism 218–219, 516 clinical presentation 218 diagnosis 218–219 ECG 219 inferior vena cava filters 517 management 517 postoperative fever 243 prophylaxis 218 risk factors 218 risk with HRT 13 thrombolysis 219 treatment 219 warfarin 219 prolactinomas 300 propellor flaps 546, 548, 549 perforating vessel 549 propofol 141 prostate 475–476 anatomy 455 benign enlargement 456 continence mechanisms 455 inflammation 475 malignant enlargement 457 pain 458 ultrasound scanning 461–462 prostate cancer 476 androgen deprivation 476 asymptomatic 476 pulmonary function tests 213 preoperative 132 thoracic surgery 334 pulmonary resection 336 657 Index pulse contour analysis (PiCCO) 196 pulse oximetry 212, 232 anaesthesia monitoring 144 pulseless electrical activity (PEA) 149, 196, 198 pulsus paradoxus 200, 200 pupillary response advanced life support 552 trauma 261 pus culture 50 pyelonephritis 466 pyeloplasty 472 dismembered 597 pyloric atresia 575 pyloric stenosis, hypertrophic 577, 576–577 pyogenic granuloma 23 pyriform fossa squamous cell carcinoma 323 QRS complex 198 contrast agents 63–68 fluoroscopy 55–56 interventional 61–63 magnetic resonance imaging 58–59 nuclear medicine 59 plain film radiography 54, 55 questions for requesting imaging i65 ultrasound 59–61 radionuclides, bone pain 117 radiotherapy 166–167 adjuvant 166 bone pain 117 breast cancer treatment 418 axilla 419–420 morbidity 420 pregnancy 427 colorectal cancer 445, 446 palliative therapy 446 delivery 166–167 neoadjuvant 166 normal tissue effects 167 treatment planning 167 see also continuous peripheral nerve blocks (CPNB); epidural analgesia rehabilitation, intestinal failure 179 rejection, organ transplantation 617, 623 acute 623, 623 chronic 623, 623 effector phase 619 graft-versus-host disease 619 hyperacute 623, 623 induction phase 619 steps 619, 619 remifentanil 142 renal artery stenosis 513 renal calculi 467, 471 renal cell carcinoma 468, 467–468 renal colic 458 renal cysts 463 renal dysplasia 453 Ramstedt’s pyloromyotomy 576–577 renal ectopia, crossed 453 ranula 567 quality of life 170 rapid shallow breathing index (RSBI) 217 quinsy 309–310 parapharyngeal abscess 316 reconstructive ladder 538–539 renal failure 468–469 acute 223–226, 468–469 chronic 469 opioids 116 see also acute renal failure (ARF) recovery see enhanced recovery renal injury 271 racial groups, carcinogenesis 156–157 rectal injuries 439 racoon eyes 602 rectal polyps 587 renal replacement therapy (RRT), acute renal failure 224–225 radial head fractures 528–529 radial shaft fractures 529 rectal prolapse 449–450 age at presentation 450 infants/children 587 reduction 449 surgery 449–450 radiation, ionising 158–159 rectoanal inhibitory reflex 433–434 radical lymph node dissection, gastric cancer 353 rectum anatomy 431 foreign bodies 439, 439–440 physiology 431 quality improvement programmes 246 radial nerve palsy, humeral shaft fractures 527 radical neck dissection 320 modified 320 radiofrequency ablation 63 bone pain 117 radiofrequency coagulators 92 radiography CNS 287 plain film 54, 55 orthopaedics 535–536 radiology 54–68 clinical information 66 colorectal investigations 431 computed tomography 56–58 658 renal revascularization 513 renal transitional cell carcinoma 468 obstruction 471 renin–angiotensin system 388 renography 463 dimercaptosuccinic acid 464 nuclear isotope 463–464 renoscopy 465 renovascular disease 513 recurrent laryngeal nerve 322 damage in thyroid surgery 383 reproductive factors, carcinogenesis 157 red blood cells, measurement in urinary tract disease 461 Research Ethics Committees (REC) 94, 95 5-alpha-reductase inhibitors 475 residual volume 213 reflux oesophagitis 575 respiration 210 infants/children 566 preterm infants 566 regulation 210 regional anaesthesia 147–149 complications 147–148 contraindications 148 intravenous 73, 148 spinal blocks 148 respiratory acidosis 211, 232 respiratory alkalosis 232 Index respiratory centre 210 respiratory disease, preoperative assessment 128–129, 130, 132 respiratory distress of the newborn 568, 568 testicular in infants 478 rheumatoid arthritis 40 preoperative assessment 129 scrotum 476–478 empty 595 inflammation 477 pain 458 epididymo-orchitis 594 rhesus D sensitization 234–235 rhinitis 308 respiratory failure 213–214 causes 214 hypercapnic 214 hypoxaemic 213–214 pathophysiology 214 seat belt sign 255 rhinorrhoea, mucopurulent 309 seborrheic keratoses 317 rib fracture 263 nerve block 72 thoracic trauma 342 second signals 618 respiratory medication 10–11 ribavirin, hepatitis C virus treatment 49 sedatives, enhanced recovery 183 Richter’s hernia 493, 494 respiratory rate adolescents 566 children 566 respiratory system 210–221 acute lung injury 219–221 acute respiratory distress syndrome 219–221 care in spinal injuries 294 investigations 211–213 management in trauma 258–259 physiology 210–211 postoperative complications 239 pulmonary embolism 218–219 see also mechanical ventilation; multiple organ dysfunction syndrome (MODS); sepsis; systemic inflammatory response syndrome sedation, anaesthesia 135, 148–149 Seldinger technique 61 rights-based morality 99 selective decontamination of the digestive tract (SDD) 50 RNA viruses 38 self care for surgeons 104–105 robotic surgery 87 rocuronium 143 self-expanding metal stents (SEMS) 351 colonic obstruction 435 rotation flaps 544, 547 semilunar line 483 Roux-en-Y hepaticojejunostomy and gastrojejunostomy 375 seminoma 477 RTS (revised trauma score) 229 sentinel lymph node biopsy 419 Schistosoma haematobium (schistosomiasis) 459 bladder squamous cell carcinoma 472 sepsis 221, 221–223 activated protein C 234 acute respiratory distress syndrome 220 anorectal 438–439 children 566 definition 249, 248–249 diagnosis 250–251 endothelium 250 incisional hernia risk 502 infants 566 inflammatory mediators 249, 250 intestinal failure 177 intra-abdominal 52 management 248–252 management bundle 251–252 microcirculation dysfunction 250 neonatal 566 pathophysiology 249–250 presentation 248 resuscitation bundle 251 severe 233–234, 248 staging system 249 supportive care 222–223 Surviving Sepsis Campaign guidelines 248 treatment 222–223, 251–252 Reynolds’ pentad 367 sclerotherapy OK-432 for cystic hygroma 570 ultrasound-guided foam 514 septic embolism 26 rhabdomyolysis, traumatic 273–274 scrofula 326–327 rhabdomyosarcoma 604–605 scrotal oedema, acute idiopathic 594 restitution, intestinal failure 177–178 sacral agenesis 586 sacral nerve stimulation 451–452 sail sign 572–573 salivary gland disease 327–328 inflammation 327 resuscitation burns 551–553 cardiac arrest 197–198 damage control 257 intestinal failure 176–177 lower gastrointestinal haemorrhage 437 sepsis 222 shock 206–207, 260 trauma 260 upper gastrointestinal bleed 348 scalpel, harmonic 92–93 retching 117–118 scaphoid fractures 530 reticulo-endothelial system contrast agents 65 Scarpa’s fascia 483–484 retroperitoneal periurinary space 487 retropharyngeal abscess 315, 316 retroviruses 38 oncogenic 159 revised trauma score (RTS) 229 salivary gland tumours 320, 327–328 metastases 328 SBAR (situation–background– assessment–recommendation) 245–246 scalds 555, 556 scalp 276, 318 lacerations 291 scarring, burns 558–559 R Sepsis Six 251–252 septic shock 209, 221, 248 steroid therapy 233–234 trauma 259 659 Index Serial Halving, burns 554 serial transverse enteroplasty (STEP) 585 sevoflurane 140 sex development disorders 600–601 shaken baby syndrome 601 shaving of surgical site 71 sigmoidoscopy, flexible 447 rectal bleeding 449 silicone, breast reconstruction 421 single insertion laparoscopic surgery (SILS) 88 single photon emission tomography (SPECT) 59 shear injury, alveoli 217 single port laparoscopic surgery (SPLS) 88 Shimada classification of neuroblastoma 602–603 sinus formation 20 shock 203–209 airway, breathing, circulation 206 anaphylactic 209, 259 blood/blood products replacement 206 cardiogenic 205, 206, 207 intra-aortic balloon pump 202 trauma 259 causes 259 classification 206 definition 203 diagnosis 205 distributive 206, 206, 209 fluid replacement 206, 260 haemodynamic variables 207 haemorrhagic 208 trauma 260 hypovolaemic 205, 206, 207–208 reduced pulse pressure 232 neurogenic 209, 259 obstructive 206, 205–206, 208–209 inflow 208 outflow 208–209 pathophysiology 259–260 resuscitation 206–207, 260 septic 209, 221, 248 steroid therapy 233–234 trauma 259 trauma haemorrhagic 259 septic 259 types 205–206 short bowel anatomical 174 functional 174 short bowel syndrome 584–585 Shouldice, Earl 481, 481–482 Shouldice repair 481–482, 498, 497–498 shunting 214 sialadenitis, submandibular 327 sickle cell disorders 128, 128 sigmoid volvulus 434–435 660 sinus rhythm 198 sinus tachycardia 198–199 sinuses 308–309 sinusitis 308–309 acute 309 chronic 309 sirolimus 620–621, 623 Sistrunk’s operation 325, 384, 569 smoking avoidance 541 split skin 539–541 muscle flaps 548 stabilization 541–542 take 541–542 skull anatomy 276, 276 arteries on base 283 base 277 burr holes 291 foramina 276 fracture 289, 290 depressed 291 small bowel 430 anastomosis 178–179 anatomy 430 barium enema 55–56 compromised 434 distension 434 enteroclysis 432 obstruction 242 physiology 430 proximal atresia 579 situationbackgroundassessment recommendation (SBAR) 245246 small interfering RNA 169 Sjăogrens syndrome, salivary gland inflammation 327 smoking bladder cancer 459 breast cancer relationship 411 graft take 541 preoperative assessment 129 tobacco smoke carcinogenesis 157 skin blood supply 537 care in spinal injuries 294 head and neck surgery 317–318 preparation 71 protection in intestinal failure 178 tumours 37 skin cancer 317, 318 basal cell carcinoma 546, 559, 559, 560 immunosuppression complication 624 plastic surgery 559–563 squamous cell carcinoma 559, 559, 561, 561 well-differentiated 559 see also malignant melanoma skin grafts 537–538, 539–542 bacterial infections 542 basal cell carcinoma 560 blood count 541 blood supply 541 burns 551, 558 fluid balance 541 full thickness 541 negative pressure dressings 542 oxygen saturation 541 phases of take 541 small molecule kinase inhibitors 169 SNAPP (sepsis, nutrition, anatomy, protection of the skin, planned surgery) mnemonic 177 sodium depletion 175 excess administration 185 reabsorption 175 water balance 175–176 soft tissue cover 537 injury 272–273 reconstruction 537–538 soft tissue sarcoma 604–605 clinical features 604–605 diagnosis 605 non-rhabdomyosarcomatous 605 prognosis 605 rhabdomyosarcoma 604–605 testicular in infants 478 solar keratoses 317 solitary rectal ulcer syndrome (SRUS) 450 somatostatinoma 375–376, 390 Index SOWATS (sepsis, optimization of nutrition, wound care, anatomy, timing of surgery, surgical strategy) mnemonic 177 space of Bogros 486, 487 speech disorders 289 sphenopalatine artery, transnasal endoscopic ligation 314 sphincter of Oddi dysfunction 368 sphincterotomy chemical 448 surgical 448 Spigelian fascia 483 spina bifida 474 spinal blocks 148 complications 148 spinal concussion 293 spinal contusion 293 spinal cord anatomy 285 spinal cord compression 294–296 causes 295 decompression 294 intervertebral discs 295 intradural lesions 295 investigations 296 management 296 neurogenic bladder 295 subdural neoplasms 295 spinal cord injury 261, 293 cervical spine 258, 293 neurogenic shock 209 trauma 263–266 spinal injuries 292–296 cervical spine 258, 293 fracture dislocations 293 fractures 293 management 293–294 cervical spondylosis 293 fixation 294 management 293–294 surgery 294 thoracolumbar spine 293 trauma 263–266, 474–475 sputum examination 333 sputum retention postoperative 146 prevention 336 squamous cell carcinoma 559, 559, 561 bladder 472, 473 lung 33 metastases 561 pathology 561 prognosis 561 risk factors 561 secondary spread 561 treatment 561 well-differentiated 559 Staphylococcus aureus (staphylococcal infections) bacteriology testing 41 cellulitis 51 lactation 400 post-operative pneumonia 49–50 wound infection 50 staplers 89–90 circular 83–84 linear 84 mechanical for anastomosis 83–84 stimulant drugs, fatigue management 125 stitches 74–75 absorbable 75, 77 anastomosis 83 subcuticular 75, 76 stoma bags, intestinal failure 178 stomach anatomy 343, 344 strawberry capillary haemangioma 567 streptococci bacteriology testing 41 cellulitis 51 necrotizing fasciitis 52 stress incontinence 457, 466, 475 stroke 301 ischaemic 512 stroke volume 192–193 subarachnoid haemorrhage 302, 303 subdural neoplasms 295 subfertility undescended testes 595 varicocoele 596 staples 75–76 subglottic stenosis 569 Starling’s equation, burns 551 submandibular sialadenitis 327 Starling’s hypothesis, burns 551 subtraction angiography 61 statins sugammadex 143 stem cells bone marrow transplantation 168 cancer 153, 153–154 research 101 sulphonylureas 11 stenting biliary obstruction 369 carotid 513 cholangiocarcinoma 369 colonic 435 oesophageal 63 oesophageal cancer 351 ureteric 471 venous 62 superficial inguinal ring 485 superior laryngeal nerve 322 damage in thyroid surgery 383 suppuration 19, 21 supraglottic airway devices 137–138 supraglottitis, acute 310, 310 supraomohyoid neck dissection 320 supratentorial neoplasms 297 surgical emphysema 337, 350 sterilization 42–43 surgical field isolation 71 sternal fracture 342 surgical site, shaving 71 spinal nerves 285 sternotomy, median 335 spinal pathology 474–475 steroid therapy 12, 12–13, 202 incisional hernia risk 502 malignant bowel obstruction management 121 severe sepsis 233–234 toxicity 623 treatment regimen 13 surgical site infections (SSI) 50–53, 240–241 cellulitis 50–51 culture 50 gangrene 52 incision 74 intra-abdominal sepsis 52 management 50 necrotizing fasciitis 51–52 spinal shock 293 spleen, infants/children 589 trauma 601 split skin graft 539–541 muscle flaps 548 661 Index surgical site infections (SSI) (cont.) NICE guidelines for prevention/treatment 51 rates 240 tetanus 52–53 surgical technologies, innovative 101 T cells 39 activated 618 see also CD4+ cells; CD8+ cells T wave 198 tachycardia 198–199 broad-complex 199 narrow-complex 199 R testicular vessel division 596 testis 476–478 anatomy 455 developmental anomalies 455–456 failure to descend 455 inflammation 476–477 swellings 477–478 trauma 478 ultrasound scanning 462 Surviving Sepsis Campaign guidelines 248, 251–252 tacrolimus 620, 623 toxicity 623 suspensory ligaments of Cooper 392 tamoxifen breast cancer treatment 423–424 mastalgia 404 tetanus 52–53 treatment 53 vaccination 52, 53 fractures 524 target controlled infusion (TCI) systems 139 thelarche 395 sutures 77 abdominal wounds 76–77 absorbable 76–77 epidermoid cyst excision 80 haemostasis 79 incisional hernia 502 laparoscopic 90 mattress 74–75, 75 mechanical for anastomosis 83 metric gauge 76 non-absorbable 77 suxamethonium 142 swabs, culture 50 sympathetic nervous system 283–285 symptom control, palliative care 110 synapses 277 synchronized intermittent mandatory ventilation (SIMV) 216 pressure support ventilation 216 syringe drivers 119–120 malignant bowel obstruction 121 systemic inflammatory response syndrome (SIRS) 209, 221–223, 248 acute pancreatitis 371, 371 classification 221 definition 249, 248–249 diagnosis 250–251 multiple organ failure 256–257 non-infectious causes 221, 250 pathophysiology 249–250 treatment 222–223, 251–252 systemic lupus erythematosus (SLE), preoperative assessment 129 systemic thromboembolism 26 systemic vascular resistance (SVR) 193 systole 191–192 systolic dysfunction, cardiogenic shock 207 systolic pressure variation (SPV) 144 662 telesurgery 87 therapeutic intervention scoring system (TISS) 229 telomerase, bladder cancer urine molecular marker 460 thiazolidinediones 11 telomerase inhibitors 169 telomeres 154 temperature, body 232 children 565 TENS (transcutaneous electrical nerve stimulation) 171 Thiersch procedure 587 thigh, compartments 525 thiopental 141 thoracic aortic aneurysms 510–511 classification 510 endovascular repair 511, 511 open surgical repair 510–511 tension pneumothorax 341 children 572 obstructive shock 208 shock 259 trauma 259, 264 thoracic disease, blood tests 333 teratoid cysts 326 thoracic spine, pathological collapse fracture 295, 296 teratoma 573 neck 326 sacrococcygeal 606, 606 testicular 477 terminal care pathways 125–126 testes retractile 595 undescended 594–596 testicular appendage torsion 594 testicular torsion differential diagnosis 594 testicular dysgenesis 600 testicular torsion 455–456, 477 diagnosis 594 extravaginal 593, 593 infants/children 593–594 intravaginal 593, 593, 594 management 594 testicular tumours 477–478 germ cell 461 infants/children 605–606 undescended testes 595 thoracic endovascular aortic repair 266 thoracic lymph nodes, internal 419–420 thoracic surgery 330–342 bronchiectasis 338 complications 336–337 conditions 337–342 diaphragm 332 empyema 337–338 examination 332–333 history taking 332–333 infections 337–338 investigations 333–334 lung abscess 338 lung cancer 338–339 mediastinum 331 oesophagus 331–332 pleural space 331 procedures 334–336 spontaneous pneumothorax 339–340 surgical emphysema 337 symptoms/signs 332–333 thoracic trauma 340–342 emergency thoracotomy 342 tracheobronchial tree 330 Index thoracic trauma 263–266, 340–342 emergency thoracotomy 342 thoracolumbar spine injuries 293 spinal cord compression 295 thoracotomy anterior 335 clamshell incision 335 emergency 342 posterolateral 335, 336 throat 309–310 acute supraglottitis 310 haematological malignancy 309 quinsy 309–310 tonsillitis 309 thromboembolic deterrent (TED) graduated compression stockings 517–518 thromboembolism 26 acute limb ischaemia 506–507 obstructive shock 208–209 see also venous thromboembolism thrombolysis contraindications 508 pulmonary embolism 219 thrombomodulin 234 thrombophilia, secondary 516 thrombophlebitis, postoperative fever 243 thrombosis 24–26 acute limb ischaemia 506 organ transplantation complication 622 predisposing factors 25–26 see also deep vein thrombosis; pulmonary embolism thrombus appearance 24–25 mechanisms of formation 25 state 26 surgery 383 thyroidectomy 381 thyroid-stimulating hormone (TSH) 300 deficiency 301 euthyroid control 378 levels 379 thyroid cancer 383 thyroid-stimulating hormone (TSH) receptor complex 380 thyroid/thyroid disorders 378–384 autoimmune thyroid disease 379 children 569 clinical features 379 CT 381 cytology 381 ectopic 569 history taking 378–379 infants 569 investigations 381 isotope scan 381 lobectomy 381 natural history 379–380 neoplastic change 380, 381 nodule formation 379–380 presentation 378 sub-sternal 382 surgery 381–383 complications 383 retro-sternal goitre 382–383 thyroid cancer 383 ultrasound investigation 381 vocal cord checks 381 thyroidectomy 381–382 thyroid cancer 381, 383 thyroiditis children 569 chronic 382 subacute 382 tissue transplantation 608 TNM staging system 35–36, 164, 163–164 breast cancer 415 colorectal cancer 444–445 gastric cancer 353 lung cancer malignant melanoma 562 oesophageal cancer 352, 351–352 oral cavity 319 oropharynx 319 tobacco smoke carcinogenesis 157 tobacco use preoperative assessment 129 see also smoking tongue tie 567 tonsillitis 309 parapharyngeal abscess 316 topical negative pressure (TNP) 539 graft take 542 topoisomerase inhibitors 169 torticollis 570 total body surface area (TBSA), burns 552–554 total intestinal aganglionosis, short bowel syndrome 584 total intravenous anaesthesia (TIVA) 139 total lung capacity (TLC) 213 tourniquet 79 limb ischaemia 149 toxic megacolon 45 toxic shock syndrome, children 557 thyrotoxicosis 382 trachea 330 thyroxine (T4 ) levels 379 TSH suppression 383 tracheal intubation 138 difficulties 128, 130, 130 failed 149 tracheal stenosis 569 thyroglossal duct cyst 325, 569 tibial fractures distal 533 plateau 532 shaft 532–533 thyroglossal duct remnants 384 tidal volume 213 thyroid cancer 379, 383–384 children 569 follicular 383 medullary 384 multiple endocrine neoplasia I 391 papillary 383 prognosis 383–384 Tietze’s syndrome 403, 404, 405 thymic hyperplasia 572–573 thymidine kinase gene 169 thyroglobulin 383 tracheo-oesophageal fistula 573–574 anatomical types 573 complications 574 diagnosis 574 management 574 TISS (therapeutic intervention scoring system) 229 tracheobronchial rupture 341 tissue-extraction bags 90 tracheomalacia 569 tissue hypoxia, multiple organ dysfunction syndrome 250 tracheostomy, oropharyngeal surgery 324 tracheobronchial tree 330 663 Index transanal endoscopic microsurgery (TEM) 443 transarterial chemoembolization (TACE) 360–361 transcutaneous oxygen monitoring 212 transfer to specialist centres, infants/children 566 transient ischaemic attacks (TIAs) 301, 512 transjugular intra-hepatic portal– systemic shunting (TIPPS) 349, 363 transoesophageal echocardiography (TOE) 196 transthoracic echocardiography (TTE) 196 transuretero–ureterostomy 472 transurethral resection of the prostate (TURP) 455, 475–476 transverse rectus abdominis flap 422, 546, 548, 550 transversus abdominis plane (TAP) block 185–186 trauma 253–274 abdominal 266–270 quadrant packing 269 airway management 258 birth injuries 601 bladder 473–474 blast injury 255 blunt 254 abdominal 266 aortic 264–265 bladder 473–474 kidney 468 myocardial 266 breast 407 breathing management 258–259 cardiovascular status 259 chain of survival 253 chest to infants/children 601 children 601–602 coagulopathy 257 colorectal injury 439 compartment syndrome 272 conscious level 261 crush syndrome 273–274 damage control surgery 253 diaphragmatic injury 266 epidemiology 253–254 exposure of patient with environmental control 261 extremities 271 fractures 272–273 664 haemorrhage control 259, 260–261 haemorrhage source 260 haemorrhagic shock 259, 260 haemothorax 259, 264, 265, 341 history taking 258 hypovolaemia 256 imaging 261–262 incidence 253 infants 601–602 inflammation 256–257 initial assessment 258 injury mechanisms 254–255 kidney 468 laparotomy 267 listening to patient 259 liver injury 269, 363, 364 lower urogenital tract 271 major incidents 274 metabolic response 256–257 mortality distribution 254 in-hospital 253 multiple organ failure 256–257 neck injury 262–263 zone 262 neuroendocrine effects 256 neurological disability 261 neurological examination 261 neurological scoring systems 261 non-accidental injury 601 palpation 259 pancreaticoduodenal 376 patient observation 259 pelvic 270 assessment 270 fracture patterns 270 management 270 pelvic fractures 530, 531 antero-posterior compression 530 vertical shear 273, 530 penetrating injury 254–255 abdominal 266 of chest 265–266 kidney 468 penis 478 percussion 259 peripheral nerve injury 273 pneumothorax 259, 264, 265 pre-hospital phase 257–258 primary survey 258–259 pupillary response 261 rectal injuries 439 renal injury 271 resuscitation 260 seat belt sign 255 secondary survey 262 services 253 severe 254 shock 259–260 socio-economic burden 253 soft tissue injury 272–273 spine/spinal cord 263–266, 474–475 surgery 253 tertiary survey 262 testis 478 thoracic 263–266, 340–342 emergency thoracotomy 342 thoracic endovascular aortic repair 266 triage 274 ureter 471 urological injury 271 vascular injury 272, 271–272, 518–519 management algorithm see also abdominal trauma; burns Trauma and Injury Severity Score (TRISS) 255 trauma-induced coagulopathy 257 trauma team 257–258 traumatic brain injury (TBI) 261, 262–263, 288–292 analgesia 290 brain death 292 cerebrospinal fluid leak 291 clinical features 289 cognitive disorders 289 coma 290 contusions 288 craniectomy/craniotomy 291 epilepsy 290–291 haematoma 289 extradural 264 removal through burr holes 291 lacerations 288 management 289–290 missile injuries 291 neurological deficits 289 oedema 288–289 organ donation 292 pathology 288 primary lesions 288 rehabilitation 291–292 secondary lesions 288–289 skull fracture 291 speech disorders 289 surgery 291 triage 274 trichobezoars 569 trigeminal nerve 280–281 trisomy 18 602 trochlear nerve 280 Trousseau’s syndrome 25–26 Index tuberculosis meningitis 304 post-transplant infection 620 vertebral column 295 twins, conjoint 564 tumour(s) 32–33 benign 33, 34, 34 biopsy 35 children epithelial 605 germ cell 605–606 gonadal 605–606 liver 606–607 sex stromal 605 solid 602–605 stromal 605–606 classification 33–34 cytology 35 frozen sections 35 grading 35, 164, 163–164 hereditary 156 tumour suppressor genes 156 infants gonadal 605–606 liver 606–607 solid 602–605 initiation 157 laboratory diagnosis 35 local effects 160 malignant 34, 34 metastatic spread 34–35 spread 34–35 nomenclature 34, 34 pathological fractures 526 progressions 157 promotion 157 radiosensitivity 166 screening 36 staging 35–36 systemic effects 36 ulcerative colitis 440 children 587 colectomy 440 colorectal cancer risk 441–442 distal 440 extensive 440 lower gastrointestinal haemorrhage 436 management 440 severity 440 symptoms 440 tumour cells circulation 153 endothelial wall attachment 153 migration 152–153 tumour embolism 26 tumour markers 165 cancer-specific 165 predictive 165 prognostic 165 testicular germ cell tumours 461 tumour-specific 165 tumour necrosis factor (TNF) 618 tumour suppressor genes 36–37, 156 cell death regulation 37 hereditary tumours 156 mutations 37 tunica vaginalis 455–456 tympanoplasty, chronic suppurative otitis media 308 unconsciousness, prolonged postoperative 146–147 United Kingdom organ donation 614 organ transplant activity 614 upper arm compartments 525 upper gastrointestinal bleed 347–349, 437 balloon tamponade 349 causes 347 diagnosis 348 endoscopic management 348–349 resuscitation 348 Rockall scoring system 348 ulcers, chronic 159 upper gastrointestinal cancer, referral guidelines 353 ulna, fractures 529 urachal remnant 455 ultra-violet radiation 37 urea, serum levels 461 Ultrasmall Super Paramagnetic Iron Oxide (USPIO) 65 ureter anatomy 454 developmental anomalies 454 duplex 454, 597 ectopic 597, 598 pain 458 trauma 471 ultrasonic dissection 92–93 ultrasonography 59–61 anal 433 anorectal 433 bladder 461 chest 333 contrast agents 65 Doppler shift 60 frequency 60 genitourinary system 461–462 limitations 462 haematuria 465 interfaces 59–60 kidney 461 limitations 462 orthopaedics 536 prostate 461–462 testes 462 transducer 59 urinary incontinence 466 urine outflow obstruction 466 uses 60–61 vessel stenosis 60 see also endoscopic ultrasound (EUS) ureteric bud 597 ureteric obstruction 470, 470–471 ureteric reflux 470 ureteric stents 471 ureteric stones 467, 471 ureteric stricture/stenosis, organ transplantation 623 ureterocoele 597 ureterogram anterograde 463 retrograde 463 ureteroscopy 465 urethra 478–479 developmental anomalies 456 surgical anatomy 456 tumours 478 umbilical cord hernia 590 urethral meatus, hypospadias 599 umbilical granuloma 591 urethral obstruction 457 umbilical hernia in adults 500–501 incarceration 500–501 laparoscopic repair 501 strangulation 500–501 urethral stenosis 457 urethral stricture 457, 478 urethral valve, posterior 598 umbilical hernia in infants/children 591 urethrogram 463 umbilicus 483 urge incontinence 457 urethroplasty 478 665 Index uric acid, urine levels 461 urinary continence 455 male 455 urinary diversion 473, 598–599 chronic 456, 474 postoperative 243 urine tests 460 24-hour collection 461 haematuria 465 molecular markers 460 stone metabolites 461 urine outflow obstruction 466 urinary incontinence 475 anatomic 598 functional 599 infants/children 598–599 investigations 466 management 599 neurogenic 598–599 nocturnal 599 overflow 457 stress 457, 466, 475 urge 457 urological conditions caused by surgery 479 gynaecological origin 479 investigation 465–466 paediatric 564, 596–601 urinary output 232 urological history 458–459 urinary sphincter artificial 598–599 internal 455 urological injury 271 urinary stones 472 endoscopic fragmentation 465 investigations 466 urine tests for metabolites 461 urinary symptoms detrusor underactivity 457 filling 457 functional 456 haematuria 457–458 pain 458 pelvic floor dysfunction 457 storage 457 voiding 456–457 see also lower urinary tract symptoms (LUTS) urodynamics 457, 464–465 detrusor overactivity 466 urological symptoms 456–458 examination 460 family history 459 foreign travel 459 haemospermia 458 investigations 460–466 medical history 459 obstetric history 460 occupational history 459 presenting complaint 459 social history 459 surgical history 459–460 uterus, benign leiomyoma 33 utilitarian conduct 99 V to Y flap 544, 544–545, 547 urinary tract infection children 596 investigations 466 postoperative fever 243 VACTERL association 574, 586 urinary tract/urinary tract disease blood tests 461 fluoroscopy 56 urothelial malignancy 465 variceal banding 348 urine culture 460 urine cytology 460 urine flow test 464, 464 urine leak, organ transplantation 623 urine microscopy 460 urine outflow obstruction, investigations 466 urine pressure flow studies 464–465 urine retention acute 456 666 vaginal bleeding 479 vagus nerve 282, 332 varicocoele 477 infants/children 596 inguinal hernia differential diagnosis 495–496 varicose veins 513–515 classification 514 management 514–515 presentation 514 superficial venous reflux abolition 514–515 vascular access 61 vascular anastomosis 84, 84 vascular disorders 24–29 aneurysms 27–28 embolisms 26–27 groin swelling 496 infarction 27 intracranial 301–303 ischaemia 26–27 oedema 28–29 thrombosis 24–26 vascular injury 271–272 blunt 518 clinical signs 272 endovascular techniques 519 examination 519 management 272, 519 algorithm penetrating 518 trauma 272, 271–272, 518–519 management algorithm vascular repair 519 vascular intervention, complications 62 vascular intervention catheters 61 vascular malformations 567 vascular smooth muscle 193 vascular stenosis 622 vascular stents 62 vascular surgery 505–519 acute limb ischaemia 506–508 carotid artery disease 512–513 chronic lower limb ischaemia 505–506 chronic venous insufficiency 514, 515 lymphoedema 518 popliteal artery aneurysms 511 renovascular disease 513 thoracic aortic aneurysms 510–511 varicose veins 513–515 vascular trauma 518–519 venous thromboembolism 515–518 visceral arterial aneurysms 511–512 see also abdominal aortic aneurysms vasculitis 27 vasectomy 478 vasoconstriction 193 blood pressure effects 194 vasography 463 vasopressin 202 infusion for lower gastrointestinal haemorrhage 438 vasopressors 202 neurogenic shock 209 vasoregulatory agents 202 venlafaxine, neuropathic pain management 117 Index venous access 62 venous end diastolic pressure (VEDP) 195 venous gangrene 516 venous insufficiency, chronic 514, 515 management 515 video-assisted thorascopic surgery (VATS) 335–336 spontaneous pneumothorax 340 videourodynamics cystometrogram 465 VIPoma 375–376 warm ischaemia 611, 611 living donation 613 Warthin’s tumour 328 Watson skin knife 540 wetting (enuresis), infants/children 598–599 viral infections 48–49 acute liver failure 226 blood-borne 48 exposure 49 inoculation injuries 48–49 post-exposure prophylaxis 48–49 risk reduction strategies 48 vaccination 48 exposure prone procedures 48 meningitis 304 risk reduction strategies 48 transfusion-transmitted 235 wheeze 332 viral lymphadenitis 326 Virchow’s triad 25, 515, 516 Wingspread classification of anorectal anomalies 586 viruses, oncogenic 159 work of breathing 210 ventilation/perfusion (V/Q) mismatch 212–214 visceral arterial aneurysms 511–512 management 512 ventilator-associated pneumonia (VAP) 50, 217 vital capacity 213 postoperative 146 Ventilator Care Bundle 50 vital signs 231–233 ventilator-induced lung injury (VILI) 217 vitamins 176 World Health Organization (WHO) carcinoid tumour classification 390 lung cancer classification 338 pain ladder 6, 113, 112–113, 170 palliative care definition 103 safe surgery initiative 136 venous occlusion 27 venous stents 62 venous thromboembolism 26, 515–518 management 516–517 postoperative 243–244 prophylaxis 517–518 venous ulceration, chronic 515 management 515 ventilation 138–139 controlled 138 monitoring 232 spontaneous 138 status 211 see also mechanical ventilation venting procedures, malignant bowel obstruction 122 ventricular ejection fraction 131 ventricular fibrillation 196, 198 CPR 198 defibrillation 198 ventricular tachycardia CPR 198 defibrillation 198 pulseless 196 veress needle 86, 85–86 vertebral column infections 295 injury 293 malignancies 295 metastases 295 spinal cord compression 295 vitelline duct remnant 584 vocal cords 322, 330 damage in thyroid surgery 383 polyps 322 thyroid surgery preoperative checks 381 tumours 322 voiding symptoms 456–457 volvulus 434–435 short bowel syndrome 584 vomiting acute pancreatitis 370 bilious 578, 580 see also nausea and vomiting von Meyenburg complex 359 von Recklinghausen’s disease 327 vesicoureteric junction 454 obstruction 598 WAGR syndrome 603 vesicoureteric reflux 597–598 posterior urethral valve 598 Wallace’s rule of 9’s 554, 554 children 556 vesico–vaginal fistula 479 warfarin 9–10 pulmonary embolism 219 vessel stenosis, ultrasound 60 Waldeyer’s ring 318 Whipple’s pancreaticoduodenectomy 374–375 Whipple’s triad 389 Whitehead’s varnish 76, 78 Wilms’ tumour 468, 603–604 diagnosis 604 management 604 staging 604 varicocoele 596 wound(s) 21 classification 21 cleansing 22 compression 78 debridement 22 dehiscence 23, 241 drainage 78 haematoma 240 incisional hernia 241 malignant change 23 oedema 74 postoperative complications 240–241 protection 78 seroma 240 wound dressings 78–79 absorbent 78 burns 558 topical negative pressure 539 wound healing 21–24 angiogenesis 538–539 bone repair 24 burns 551, 558 central nervous system repair 24 collagen deposition 22 complications 23 667 Index wound healing (cont.) contraction 22 epithelialization 22 factors in repair 24 fibrosis 22 haemostasis 21 inflammation 21–22 natural process 538–539 primary closure 538–539 primary intention 22, 23 regeneration/repair 22 secondary intention 22, 23, 538–539 668 wound infections see surgical site infections (SSI) x-rays, trauma 261–262 xenografts 609 wound management abdominal wound closure 76–77 burns 556 Yellow Card scheme wound management bags, intestinal failure 178 Z-plasty flap 544, 547 wound protectors 90 Zenker’s diverticulum 327 wrist fractures 529–530 reduction 529 Zollinger–Ellison syndrome 355, 375, 390 Y to V flap 544–545, 548 ... massive transfusion J Trauma 20 07; 62: 1 12 119 Hess J et al The coagulopathy of trauma: a review of mechanisms J Trauma 20 08;65:748–754 Hoffman JR et al Validity of a set of clinical criterion to rule... Guideline (20 07) http://guidance.nice.org.uk/ CG56 World Health Organization Injury: a leading cause of the global burden of disease http://whqlibdoc.who.int/ publications /20 02/ 924 15 623 23.pdf .20 00... mortality J Trauma 20 02; 52( 2):374–380 Geeraerts T et al Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability Crit Care 20 07;11 :20 4 Gonzalez EA, Moore