Ebook Sabiston textbook of surgery - The biological basis of modern surgical practice (19th edition): Part 1

(BQ) Part 1 book Sabiston textbook of surgery - The biological basis of modern surgical practice presents the following contents: Surgical basic principles, perioperative management, trauma and critical care.

SABISTON TEXTBOOK OF SURGERY 19TH EDITION SABISTON TEXTBOOK OF SURGERY: THE BIOLOGICAL BASIS OF MODERN SURGICAL PRACTICE 19TH EDITION COURTNEY M TOWNSEND, JR., MD Professor and John Woods Harris Distinguished Chairman Robertson-Poth Distinguished Chair in General Surgery Department of Surgery The University of Texas Medical Branch Galveston, Texas R DANIEL BEAUCHAMP, MD J.C Foshee Distinguished Professor and Chairman, Section of Surgical Sciences Professor of Surgery and Cell and Developmental Biology and Cancer Biology Vanderbilt University School of Medicine Surgeon-in-Chief, Vanderbilt University Hospital Nashville, Tennessee B MARK EVERS, MD Professor and Vice-Chair for Research, Department of Surgery Director, Lucille P Markey Cancer Center Markey Cancer Foundation Endowed Chair Physician-in-Chief, Oncology Service Line UK Healthcare The University of Kentucky Lexington, Kentucky KENNETH L MATTOX, MD Professor and Vice Chairman Michael E DeBakey Department of Surgery Baylor College of Medicine Chief of Staff and Chief of Surgery Ben Taub General Hospital Houston, Texas with 1645 illustrations 1600 John F Kennedy Blvd Ste 1800 Philadelphia, PA 19103-2899 SABISTON TEXTBOOK OF SURGERY ISBN: 978-1-4377-1560-6 International Edition ISBN: 978-1-4557-1146-8 Copyright © 2012, 2008, 2004, 2001, 1997, 1991, 1986, 1981, 1977, 1972, 1968, 1964, 1960, 1956 by Saunders, an imprint of Elsevier Inc Copyright 1949, 1945, 1942, 1939, 1936 by Elsevier Inc Copyright renewed 1992 by Richard A Davis, Nancy Davis Regan, Susan Okum, Joanne R Artz, and Mrs Mary E Artz Copyright renewed 1988 by Richard A Davis and Nancy Davis Regan Copyright renewed 1977 by Mrs Frederick Christopher Copyright renewed 1973, 1970, 1967, 1964 by W.B Saunders Company All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Library of Congress Cataloging-in-Publication Data or Control Number Sabiston textbook of surgery : the biological basis of modern surgical practice.—19th ed / [edited by] Courtney M Townsend Jr … [et al.]    p ; cm   Textbook of surgery   Includes bibliographical references and index   ISBN 978-1-4377-1560-6 (hardcover : alk paper)   I.  Sabiston, David C., 1924-2009.   II.  Townsend, Courtney M.   III.  Title: Textbook of surgery   [DNLM:  1.  Surgical Procedures, Operative.   2.  General Surgery.   3.  Perioperative Care.  WO 500]   617—dc23 2011040621 Global Content Development Director: Judith Fletcher Content Developmental Manager: Maureen Iannuzzi Publishing Services Manager: Catherine Jackson Senior Project Manager: Rachel E McMullen Design Direction: Louis Forgione Printed in Canada  Last digit is the print number:  9  8  7  6  5  4  3  2  Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org DEDICATION t who grant us the privilege of practicing our craft; to our students, residents, and colleagues, from whom we learn; and to our wives—Mary, Shannon, Karen, and June—without whose support this would not have been possible O OUR PATIENTS, CONTRIBUTORS ANDREW B ADAMS, MD, PHD Associate, Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia Transplantation Immunobiology and Immunosuppression B TIMOTHY BAXTER, MD Professor of Vascular Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska The Lymphatics CHARLES A ADAMS, JR., MD Chief of Trauma and Surgical Critical Care, Rhode Island Hospital; Assistant Professor of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island Surgical Critical Care R DANIEL BEAUCHAMP, MD J.C Foshee Distinguished Professor and Chairman, Section of Surgical Sciences, Professor of Surgery and Cell and Developmental Biology and Cancer Biology, Vanderbilt University School of Medicine; Surgeon-in-Chief, Vanderbilt University Hospital, Nashville, Tennessee Perioperative Patient Safety AHMED AL-MOUSAWI, MD Clinical Fellow, Burns & Critical Care, Shriners Burns Hospital for Children, Department of Surgery, University of Texas Medical Branch, Galveston, Texas Metabolism in Surgical Patients WADDAH B AL-REFAIE, MD, FACS Co-Director, Minnesota Surgical Outcomes Workgroup, Associate Professor of Surgery and Staff Surgeon, Division of Surgical Oncology, Department of Surgery, University of Minnesota and Minneapolis VAMC, Minneapolis, Minnesota Exocrine Pancreas NANCY L ASCHER, MD, PHD Professor and Chair, Department of Surgery, University of California at San Francisco, San Francisco, California Liver Transplantation STANLEY W ASHLEY, MD Chief Medical Officer, Vice President for Medical Affairs, Brigham and Women’s Hospital; Frank Sawyer Professor of Surgery, Harvard Medical School, Boston, Massachusetts Acute Gastrointestinal Hemorrhage YOLANDA BECKER, MD, FACS Professor of Surgery, Director, Kidney and Pancreas Program, Division of Transplant Surgery, University of Chicago, Chicago, Illinois Kidney and Pancreas Transplantation PAUL R BEERY, MD Clinical Assistant Professor, Department of Surgery, Ohio State University Grant Medical Center, Columbus, Ohio Surgery in the Pregnant Patient DAVID H BERGER, MD Professor of Surgery and Vice-Chair, Michael E DeBakey Department of Surgery, Baylor College of Medicine; Operative Care Line Executive, Michael E DeBakey VA Medical Center, Houston, Texas Surgery in the Geriatric Patient JOSHUA I.S BLEIER, MD, FACS, FASCRS Assistant Professor, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania Colon and Rectum PAUL S AUERBACH, MD, MS, FACEP Redlich Family Professor of Surgery, Department of Surgery, Division of Emergency Medicine, Stanford University School of Medicine, Stanford, California Bites and Stings DANIEL BORJA-CACHO, MD HPB Fellow, Department of Surgery, University of Minnesota, Minneapolis, Minnesota Exocrine Pancreas BRIAN BADGWELL, MD Assistant Professor, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas Abdominal Wall, Umbilicus, Peritoneum, Mesenteries, Omentum, and Retroperitoneum HOWARD BRODY, MD, PHD Director, Institute for the Medical Humanities; John P McGovern Centennial Chair in Family Medicine, Family Medicine, University of Texas Medical Branch, Galveston, Texas Ethics and Professionalism in Surgery FAISAL G BAKAEEN, MD, FACS Chief of Cardiothoracic Surgery, The Michael E DeBakey VA Medical Center; Associate Professor, Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas Acquired Heart Disease: Coronary Insufficiency BRUCE D BROWNER, MD, MS, FACS Gray-Gossling Chair, Professor and Chairman Emeritus, Department of Orthopedic Surgery, New England Musculoskeletal Institute, University of Connecticut Health Center; Director of Orthopaedics, Hartford Hospital, Farmington, Connecticut Emergency Care of Musculoskeletal Injuries PHILIP S BARIE, MD, MBA, FIDSA, FCCM, FACS Professor of Surgery and Public Health, Weill Cornell Medical College; Chief, Preston A (Pep) Wade Acute Care Surgery Service, New York–Presbyterian Hospital–Weill Cornell Medical Center, New York, New York Surgical Infections and Antibiotic Use THOMAS A BUCHHOLZ, MD, FACR Head, Division of Radiation Oncology, The University of Texas M.D Anderson Cancer Center, Houston, Texas Diseases of the Breast vii BRIAN B BURKEY, MD, FACS Vice-Chairman and Section Head, Head and Neck Surgery and Oncology, Head and Neck Institute, Cleveland Clinic Foundation; Adjunct Professor, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee Head and Neck KATHLEEN E CARBERRY, BSN, RN, MPH Research Specialist—Clinical Outcomes, Center for Clinical Outcomes, Congenital Heart Surgery Service, Texas Children’s Hospital, Houston, Texas Congenital Heart Disease CHARLIE C CHENG, MD Assistant Professor, Division of Vascular Surgery and Endovascular Therapy, University of Texas Medical Branch, Galveston, Texas Peripheral Arterial Occlusive Disease KENNETH J CHERRY, JR., MD Professor, Department of Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia Aorta LORI CHOI, MD Assistant Professor, Division of Vascular Surgery and Endovascular Therapy, University of Texas Medical Branch, Galveston, Texas Peripheral Arterial Occlusive Disease DANNY CHU, MD Associate Chief of Cardiothoracic Surgery, Operative Care Line, Michael E DeBakey VA Medical Center; Assistant Professor of Surgery, Michael E DeBakey Department of Surgery, Texas Heart Institute/Baylor College of Medicine, Houston, Texas Acquired Heart Disease: Coronary Insufficiency DAI H CHUNG, MD Professor and Chairman, Janie Robinson and John Moore Lee Endowed Chair, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee Pediatric Surgery WILLIAM G CIOFFI, MD Surgeon-in-Chief, Department of Surgery, Rhode Island Hospital; Professor and Chairman of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island Surgical Critical Care MICHAEL COBURN, MD Professor and Chair, Scott Department of Urology, Baylor College of Medicine; Carlton-Scott Chair in Urologic Education; Chief of Urology, Ben Taub General Hospital, Houston, Texas Urologic Surgery MARION E COUCH, MD, PHD Associate Professor, Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina Head and Neck viii MICHAEL D’ANGELICA, MD Associate Member, Department of Surgery, Memorial SloanKettering Cancer Center; Associate Attending Surgeon, Department of Surgery, Memorial Hospital for Cancer and Allied Diseases; Associate Professor, Department of Surgery, Cornell University, Weill Medical College, New York, New York The Liver ALAN DARDIK, MD, PHD Associate Professor of Surgery, Yale University School of Medicine; Chief, Peripheral Vascular Surgery, VA Connecticut Healthcare System, West Haven, Connecticut Surgery in the Geriatric Patient MERRIL T DAYTON, MD Professor and Chairman, Department of Surgery, State University of New York–Buffalo; Chief of Surgery, Kaleida Health System, Buffalo General Hospital, Buffalo, New York Surgical Complications JOSE J DIAZ, MD, CNS, FACS, FCCM Professor of Surgery, Chief Acute Care Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland Bedside Surgical Procedures; The Difficult Abdominal Wall QUAN-YANG DUH, MD Professor of Surgery, University of California San Francisco; Surgical Service, San Francisco VA Medical Center, San Francisco, California The Adrenal Glands WILLIAM D DUTTON, MD, CDR, MC, USN Instructor of Surgery, Acute Care Surgery Fellow, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee The Difficult Abdominal Wall TIMOTHY J EBERLEIN, MD Bixby Professor and Chairman of the Department of Surgery, Spencer T and Ann W Olin Distinguished Professor and Director, The Alvin J Siteman Cancer Center, Barnes-Jewish Hospital and Washington University School of Medicine; Surgeon-in-Chief, Barnes-Jewish Hospital, St Louis, Missouri Tumor Biology and Tumor Markers JAMES S ECONOMOU, MD, PHD Beaumont Professor of Surgery, Chief of Division of Surgical Oncology, Professor of Microbiology, Immunology and Molecular Genetics, Professor of Molecular and Medical Pharmacology, UCLA School of Medicine; Vice Chancellor for Research, University of California, Los Angeles, California Tumor Immunology and Immunotherapy E CHRISTOPHER ELLISON, MD Robert M Zollinger Professor and Chair, Department of Surgery, Ohio State University Medical Center, Columbus, Ohio Surgery in the Pregnant Patient STEVEN R.T EVANS, MD Professor of Surgery, Chief Medical Officer and Vice President for Medical Affairs, Georgetown University Hospital, Washington, DC Biliary System B MARK EVERS, MD Professor and Vice-Chair for Research, Department of Surgery, Director, Lucille P Markey Cancer Center, Markey Cancer Foundation Endowed Chair, Physician-in-Chief, Oncology Service Line UK Healthcare, The University of Kentucky, Lexington, Kentucky Small Intestine FARHOOD FARJAH, MD, MPH Department of Surgery, University of Washington, Seattle, Washington Evidence-Based Surgery: Critically Assessing Surgical Literature MITCHELL P FINK, MD Professor, Departments of Surgery and Anesthesiology, ViceChair of Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California The Inflammatory Response NICHOLAS A FIORE, II, MD, FACS Cy-Fair Hand and Wrist, Houston, Texas Hand Surgery DAVID R FLUM, MD, MPH Professor of Surgery and Adjunct Professor of Health Services and Pharmacy, Director of the Surgical Outcomes Research Center, University of Washington, Seattle, Washington Evidence-Based Surgery: Critically Assessing Surgical Literature YUMAN FONG, MD Murray F Brennan Chair in Surgery, Department of Surgery, Division of Hepatopancreatobiliary Surgery, Memorial SloanKettering Cancer Center; Professor of Surgery, Weill Cornell Medical Center, New York, New York The Liver CHARLES D FRASER, JR., MD Chief and The Donovan Chair in Congenital Health Surgery, Surgeon-in-Chief, Texas Children’s Hospital; Professor of Surgery and Pediatrics, Susan V Clayton Chair in Surgery, Baylor College of Medicine, Houston, Texas Congenital Heart Disease JULIE A FREISCHLAG, MD The William Steward Halsted Professor and Chair, Department of Surgery, Johns Hopkins University, Baltimore, Maryland Venous Disease GERALD M FRIED, MD, CM, FRCS(C), FACS, FCAHS Adair Family Professor and Chairman, Department of Surgery, McGill University; Surgeon-in-Chief, McGill University Health Centre, Montreal, Quebec, Canada Emerging Technology in Surgery: Informatics, Robotics, and Electronics ROBERT D FRY, MD Emilie and Roland deHellebranth Professor of Surgery, Chief of the Division of Colon and Rectal Surgery, University of Pennsylvania Health System; Chairman, Department of Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania Colon and Rectum DAVID A FULLERTON, MD Head, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado Acquired Heart Disease: Valvular JAIME GASCO, MD Assistant Professor, Division of Neurological Surgery, University of Texas Medical Branch, Galveston, Texas Neurosurgery GERD G GAUGLITZ, MMS, MD Department of Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany Burns JASON P GLOTZBACH, MD Postdoctoral Research Fellow, Stanford University Department of Surgery, Stanford, California; General Surgery Resident, University of North Carolina Department of Surgery, Chapel Hill, North Carolina Regenerative Medicine S PETER GOEDEGEBUURE, PHD Research Associate Professor, Department of Surgery, Washington University School of Medicine, St Louis, Missouri Tumor Biology and Tumor Markers RAJA R GOPALDAS, MD Assistant Professor of Cardiothoracic Surgery, Hugh E Stephenson Department of Surgery, University of MissouriColumbia School of Medicine, Columbia, Missouri Acquired Heart Disease: Coronary Insufficiency MARJORIE C GREEN, MD Associate Professor of Medicine and Internist, Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas M.D Anderson Cancer Center, Houston, Texas Diseases of the Breast OLIVER L GUNTER, MD Assistant Professor, Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee Bedside Surgical Procedures GEOFFREY C GURTNER, MD, FACS Professor and Associate Chair of Surgery, Stanford University Department of Surgery, Stanford, California Regenerative Medicine FADI HANBALI, MD, FACS Assistant Professor of Neurosurgery, Texas Tech University Health Science Center, El Paso, Texas Neurosurgery ix JOHN B HANKS, MD C Bruce Morton Professor and Chief, Division of General Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia Thyroid ALDEN H HARKEN, MD Chairman, Department of Surgery, University of California at San Francisco (East Bay), San Francisco, California Acquired Heart Disease: Valvular JENNIFER A HELLER, MD Assistant Professor of Surgery, Director of Johns Hopkins Vein Center, Johns Hopkins Bayview Medical Center, Baltimore, Maryland Venous Disease DAVID N HERNDON, MD, FACS Chief of Staff, Shriners Burns Hospital for Children; Professor of Surgery and Jesse H Jones Distinguished Chair in Burn Surgery, The University of Texas Medical Branch, Galveston, Texas Burns; Metabolism in Surgical Patients MICHAEL S HIGGINS, MD, MPH Professor, Department of Anesthesiology, Surgery and Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee Perioperative Patient Safety ASHER HIRSHBERG, MD, FACS Professor of Surgery, State University of New York Downstate College of Medicine; Director of Emergency Vascular Surgery, Kings County Hospital Center, Brooklyn, New York The Surgeon’s Role in Mass Casualty Incidents ERIC H JENSEN, MD Assistant Professor of Surgery, University of Minnesota, Minneapolis, Minnesota Exocrine Pancreas MARC JESCHKE, MD, PHD, FACS, FRCSC Director, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre; Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Toronto; Senior Scientist, Sunnybrook Research Institute, Toronto, Ontario, Canada Burns HOWARD W JONES, III, MD Professor and Chairman, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee Gynecologic Surgery ALLAN D KIRK, MD, PHD Professor, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia Transplantation Immunobiology and Immunosuppression KIMBERLY S KIRKWOOD, MD, FACS Professor of Surgery, Department of Surgery, University of California at San Francisco, San Francisco, California The Appendix SAE HEE KO, MD Postdoctoral Research Fellow, Stanford University Department of Surgery, Stanford, California; General Surgery Resident, University of Pittsburgh Department of Surgery, Pittsburgh, Pennsylvania Regenerative Medicine GINGER E HOLT, MD Associate Professor, Department of Orthopaedic Surgery, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, Tennessee Bone Tumors TIEN C KO, MD Jack H Mayfield, M.D Distinguished Professor in Surgery; Vice Chairman for Harris County Hospital District, The University of Texas Health Science Center; Chief of Surgery, Lyndon B Johnson General Hospital, Houston, Texas Molecular and Cell Biology MICHAEL D HOLZMAN, MD, MPH Associate Professor of Surgery and Lester and Sara Jayne Williams Chair in Academic Surgery, General Surgery Division, Vanderbilt University Medical Center, Nashville, Tennessee The Spleen SETH B KRANTZ, MD Research Fellow, Robert H Lurie Comprehensive Cancer Center and the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois Stomach KELLY K HUNT, MD Hamill Foundation Distinguished Professor of Surgery, Chief of Surgical Breast Oncology, M.D Anderson Cancer Center, Houston, Texas Diseases of the Breast MAHMOUD N KULAYLAT, MD Associate Professor of Surgery, Department of Surgery, State University of New York–Buffalo, Buffalo General Hospital, Buffalo, New York Surgical Complications PATRICK G JACKSON, MD Chief of Gastrointestinal Surgery, Department of Surgery, Georgetown University Hospital, Washington, DC Biliary System TERRY C LAIRMORE, MD Professor of Surgery and Director, Division of Surgical Oncology, Scott and White Memorial Hospital and Clinic, Texas A&M University System Health Science Center College of Medicine, Temple, Texas The Multiple Endocrine Neoplasia Syndromes x Bedside Surgical Procedures  Chapter 24  601 Bronchoscopy Fiberoptic bronchoscopy of the surgical patient is indicated for diagnostic and therapeutic indications Under the therapeutic indication, bronchoscopy can be used to insert an endotracheal tube, remove foreign bodies inadvertently aspirated and mucous plugs, reversing atelectasis in mechanically ventilated patients, suctioning of thick tenacious secretions, and diagnosis of obstructive pneumonia.48 Diagnostic bronchoscopy is most commonly used for obtaining pulmonary specimens for the diagnosis and management of pneumonia.49 Quantitative cultures obtained via fiberoptic bronchoscopy have been demonstrated to eliminate the diagnosis of pneumonia in almost 50% of patients with clinical signs of pneumonia, decrease inappropriate antibiotic use, and improve mortality when compared with nonquantitative techniques Standardization of culture techniques should be undertaken.50 The risks associated with bronchoscopy are related more to the need for conscious sedation and to the medications required if performed in a nonintubated patient This could result in depressed mental status progressing to hypoventilation, airway vulnerability, and the risk of aspiration The risks of the pro­ cedure itself are pneumothorax, hypoxia, airway hyperreacti­ vity, pulmonary hemorrhage, and systemic hypotension or hypertension SELECTED REFERENCES Byhahn C, Wilke HJ, Halbig S, et al: Percutaneous tracheostomy: Ciaglia blue rhino versus the basic Ciaglia technique of percutaneous dilational tracheostomy Anesth Analg 91:882–886, 2000 Primary article describing the most common technique currently used for percutaneous dilational tracheostomy Delaney A, Bagshaw SM, Nalos M: Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: A systematic review and meta-analysis Crit Care 10:R55, 2006 This most current meta-analysis of PDT versus standard open surgical tracheostomy supports the benefits of PDT Diaz JJ, Jr, Mejia V, Subhawong AP, et al: Protocol for bedside laparotomy in trauma and emergency general surgery: A low return to the operating room Am Surg 71:986–991, 2005 Primary article examining outcomes of bedside laparotomy with a protocol for indications and support Fagon JY: Diagnosis and treatment of ventilator-associated pneumonia: Fiberoptic bronchoscopy with bronchoalveolar lavage is essential Semin Respir Crit Care Med 27:34–44, 2006 Review of the indications, benefits, and performance of bronchoscopy for the diagnosis of pneumonia Griffiths J, Barber VS, Morgan L, Young JD: Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation BMJ 330:1243, 2005 Meta-analysis of studies evaluating the timing of tracheostomy Early tracheostomy was defined as less than days Meduri GU, Chastre J: The standardization of bronchoscopic techniques for ventilator-associated pneumonia Chest 102:557S–564S, 1992 Extensive review of the techniques and limitations of quantitative culture in diagnosing pneumonia Moore AF, Hargest R, Martin M, Delicata RJ: Intra-abdominal hypertension and the abdominal compartment syndrome Br J Surg 91:1102–1110, 2004 Review of the pathophysiology and treatment of abdominal compartment syndrome Rumbak MJ, Newton M, Truncale T, et al: A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients Crit Care Med 32:1689–1694, 2004 SECTION III TRAUMA AND CRITICAL CARE gastric varices, and diffuse gastric cancer Anterior wall inflammation or infection should be treated prior to the procedure Ascites can be drained before the procedure and is not an absolute contraindication.41 PEG tubes may be placed in the presence of a ventriculoperitoneal shunt or a dialysis catheter; however, placement should be separated by to weeks or more.42,43 History of a previous or recent laparotomy is not a contraindication for PEG; however, a discrete indentation of the stomach when palpating the anterior abdominal wall and adequate transillumination should be ensured.44 PEG is thought to be a safe procedure whether it is performed in the gastrointestinal (GI) laboratory, OR, or at bedside in the ICU However, because PEG tube placement is frequently performed in debilitated or critically ill patients, complications are associated with a higher mortality than would be expected for most elective procedures.29 Free intraperitoneal air after PEG is common and can persist for as long as weeks.45 Abdominal wall infection can occur as an early complication of PEG placement; an ample skin incision that prevents creation of a closed space around the feeding tube and preprocedure antibiotics have both been demonstrated to decrease the incidence of PEG site infections.46,47 Dislodgment of the PEG tube from the stomach can occur and may be life-threatening This may occur acutely through the application of traction on the gastrostomy tube, thus pulling it partially or completely through the abdominal wall Alternatively, the tube may necrose through the stomach wall if the PEG flange or balloon applies too much pressure on the gastric wall If this complication occurs prior to development of a fibrous tract during the initial 10 to 14 days, it should be considered a surgical emergency, because gastric contents would spill into the abdominal cavity Operative closure of the gastrostomy is required To minimize the risk of this complication, methods that prevent inadvertent movement of the gastrostomy tube should be used and meticulously followed These include ensuring adequate fixation of the tube to the external abdominal wall, recording and routine verification of the immediate postprocedure gastrostomy tube position at the skin surface, and application of binders or other devices that limit the inadvertent application of traction of the tube 602  SECTION III  TRAUMA AND CRITICAL CARE Primary article examining the benefit of tracheostomy at 48 hours versus 14 days This study demonstrated a significant reduction in complications and mortality when performed early Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF: Damage control: Collective review J Trauma 49:969–978, 2000 Collective review of the history, indications, and performance of damage control laparotomy Van Natta TL, Morris JA, Jr, Eddy VA, et al: Elective bedside surgery in critically injured patients is safe and cost-effective Ann Surg 227:618–624, 1998 First report of the safety and effectiveness of bedside surgical procedures REFERENCES Diaz JJ, Jr, Mauer A, May AK, et al: Bedside laparotomy for trauma: Are there risks? Surg Infect (Larchmt) 5:15–20, 2004 Diaz JJ, Jr, Mejia V, Subhawong AP, et al: Protocol for bedside laparotomy in trauma and emergency general surgery: A low return to the operating room Am Surg 71:986–991, 2005 Porter JM, Ivatury RR, Kavarana M, et al: The surgical intensive care unit as a cost-efficient substitute for an operating room at a Level I trauma center Am Surg 65:328–330, 1999 Porter JM, Ivatury RR: Preferred route of tracheostomy— percutaneous versus open at the bedside: A randomized, prospective study in the surgical intensive care unit Am Surg 65:142–146, 1999 Van Natta TL, Morris JA, Jr, Eddy VA, et al: Elective bedside surgery in critically injured patients is safe and cost-effective Ann Surg 227:618–624, 1998 Bowen CP, Whitney LR, Truwit JD, et al: Comparison of safety and cost of percutaneous versus surgical tracheostomy Am Surg 67:54–60, 2001 Carrillo EH, Heniford BT, Osborne DL, et al: Bedside percutaneous endoscopic gastrostomy A safe alternative for early nutritional support in critically ill trauma patients Surg Endosc 11:1068– 1071, 1997 Freeman BD, Isabella K, Lin N, et al: A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients Chest 118:1412–1418, 2000 Freeman BD, Isabella K, Cobb JP, et al: A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients Crit Care Med 29:926–930, 2001 10 Beckmann U, Gillies DM, Berenholtz SM, et al: Incidents relating to the intra-hospital transfer of critically ill patients An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care Intensive Care Med 30:1579–1585, 2004 11 Pronovost PJ, Thompson DA: Reducing defects in the use of interventions Intensive Care Med 30:1505–1507, 2004 12 Haynes AB, Weiser TG, Berry WR, et al: A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 360:491–499, 2009 13 World Health Organization: Safe surgery saves lives: The Second Global Patient Safety Challenge, 2009 (http://www.who.int/ patientsafety/safesurgery/en) 14 Mayberry JC: Bedside open abdominal surgery Utility and wound management Crit Care Clin 16:151–172, 2000 15 Biffl WL, Moore EE, Burch JM, et al: Secondary abdominal compartment syndrome is a highly lethal event Am J Surg 182:645–648, 2001 16 Miller RS, Morris JA, Jr, Diaz JJ, Jr, et al: Complications after 344 damage-control open celiotomies J Trauma 59:1365–1371, 2005 17 Kirkpatrick AW, Balogh Z, Ball CG, et al: The secondary abdominal compartment syndrome: Iatrogenic or unavoidable? J Am Coll Surg 202:668–679, 2006 18 Leppaniemi A, Kemppainen E: Recent advances in the surgical management of necrotizing pancreatitis Curr Opin Crit Care 11:349–352, 2005 19 Moore AF, Hargest R, Martin M, et al: Intra-abdominal hyper­ tension and the abdominal compartment syndrome Br J Surg 91:1102–1110, 2004 20 Sugrue M: Abdominal compartment syndrome Curr Opin Crit Care 11:333–338, 2005 21 Shapiro MB, Jenkins DH, Schwab CW, et al: Damage control: Collective review J Trauma 49:969–978, 2000 22 Delaney A, Bagshaw SM, Nalos M: Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: A systematic review and meta-analysis Crit Care 10:R55, 2006 23 Heikkinen M, Aarnio P, Hannukainen J: Percutaneous dilational tracheostomy or conventional surgical tracheostomy? Crit Care Med 28:1399–1402, 2000 24 Griffiths J, Barber VS, Morgan L, et al: Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation BMJ 330:1–5, 2005 25 Arabi Y, Haddad S, Shirawi N, et al: Early tracheostomy in intensive care trauma patients improves resource utilization: A cohort study and literature review Crit Care 8:R347–R352, 2004 26 Rumbak MJ, Newton M, Truncale T, et al: A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients Crit Care Med 32:1689–1694, 2004 27 Ciaglia P, Firsching R, Syniec C: Elective percutaneous dilatational tracheostomy A new simple bedside procedure; preliminary report Chest 87:715–719, 1985 28 Byhahn C, Wilke HJ, Halbig S, et al: Percutaneous tracheostomy: Ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy Anesth Analg 91:882–886, 2000 29 Lockett MA, Templeton ML, Byrne TK, et al: Percutaneous endoscopic gastrostomy complications in a tertiary-care center Am Surg 68:117–120, 2002 30 Paran H, Butnaru G, Hass I, et al: Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance Chest 126:868–871, 2004 31 Polderman KH, Spijkstra JJ, de Bree R, et al: Percutaneous dilatational tracheostomy in the ICU: Optimal organization, low complication rates, and description of a new complication Chest 123:1595–1602, 2003 32 Heyrosa MG, Melniczek DM, Rovito P, et al: Percutaneous tracheostomy: A safe procedure in the morbidly obese J Am Coll Surg 202:618–622, 2006 33 Fikkers BG, Briede IS, Verwiel JM, et al: Percutaneous tracheostomy with the Blue Rhino trademark technique: Presentation of 100 consecutive patients Anaesthesia 57:1094–1097, 2002 Bedside Surgical Procedures  Chapter 24  603 42 Schulman AS, Sawyer RG: The safety of percutaneous endoscopic gastrostomy tube placement in patients with existing ventriculoperitoneal shunts JPEN J Parenter Enteral Nutr 29:442–444, 2005 43 Taylor AL, Carroll TA, Jakubowski J, et al: Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunts Br J Surg 88:724–727, 2001 44 Eleftheriadis E, Kotzampassi K: Percutaneous endoscopic gastrostomy after abdominal surgery Surg Endosc 15:213–216, 2001 45 Dulabon GR, Abrams JE, Rutherford EJ: The incidence and significance of free air after percutaneous endoscopic gastrostomy Am Surg 68:590–593, 2002 46 Ahmad I, Mouncher A, Abdoolah A, et al: Antibiotic prophylaxis for percutaneous endoscopic gastrostomy—a prospective, randomised, double-blind trial Aliment Pharmacol Ther 18:209– 215, 2003 47 Sharma VK, Howden CW: Meta-analysis of randomized, controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy Am J Gastroenterol 95:3133–3136, 2000 48 Labbe A, Meyer F, Albertini M: Bronchoscopy in intensive care units Paediatr Respir Rev Suppl A:S15–19, 2004 49 Fagon JY: Diagnosis and treatment of ventilator-associated pneumonia: Fiberoptic bronchoscopy with bronchoalveolar lavage is essential Semin Respir Crit Care Med 27:34–44, 2006 50 Meduri GU, Chastre J: The standardization of bronchoscopic techniques for ventilator-associated pneumonia Chest 102:557S– 564S, 1992 SECTION III TRAUMA AND CRITICAL CARE 34 Norwood S, Vallina VL, Short K, et al: Incidence of tracheal stenosis and other late complications after percutaneous tracheostomy Ann Surg 232:233–241, 2000 35 Walz MK, Peitgen K, Thurauf N, et al: Percutaneous dilatational tracheostomy—early results and long-term outcome of 326 critically ill patients Intensive Care Med 24:685–690, 1998 36 Gauderer MW, Ponsky JL, Izant RJ, Jr: Gastrostomy without laparotomy: A percutaneous endoscopic technique J Pediatr Surg 15:872–875, 1980 37 Adams GF, Guest DP, Ciraulo DL, et al: Maximizing tolerance of enteral nutrition in severely injured trauma patients: A comparison of enteral feedings by means of percutaneous endoscopic gastrostomy versus percutaneous endoscopic gastrojejunostomy J Trauma 48:459–464, 2000 38 Harbrecht BG, Moraca RJ, Saul M, et al: Percutaneous endoscopic gastrostomy reduces total hospital costs in head-injured patients Am J Surg 176:311–314, 1998 39 Shang E, Kahler G, Meier-Hellmann A, et al: Advantages of endoscopic therapy of gastrojejunal dissociation in critical care patients Intensive Care Med 25:162–165, 1999 40 Stein J, Schulte-Bockholt A, Sabin M, et al: A randomized prospective trial of immediate vs next-day feeding after percutaneous endoscopic gastrostomy in intensive care patients Intensive Care Med 28:1656–1660, 2002 41 Wejda BU, Deppe H, Huchzermeyer H, et al: PEG placement in patients with ascites: A new approach Gastrointest Endosc 61:178–180, 2005 CHAPTER 25 THE SURGEON’S ROLE IN MASS CASUALTY INCIDENTS Asher Hirshberg and Michael Stein key concepts mass casualty and modern trauma systems clinical aspects of hospital disaster plans surgeon’s role in natural disasters blast trauma: clinical patterns and system implications conclusion In the past decade, there has been a surge of interest among surgeons in the medical consequences of mass casualty incidents and civilian disasters The megaterrorist acts of 9/11 focused attention on the wave of urban terrorism that is sweeping across the globe, causing tens of thousands of casualties each year and challenging trauma and emergency systems from New York to Bali and from Madrid to Mumbai At the same time, a series of large-scale natural disasters, such as the 2004 tsunami in Southeast Asia, which claimed almost 250,000 lives in 10 countries, and Hurricane Katrina, which devastated New Orleans in August 2005, helped focus public attention on the medical consequences of natural catastrophes As this chapter is being written, the horrible consequences of the Haiti earthquake in January 2010 are becoming clear and the unique challenges facing medical teams and other relief workers are the center of much media attention Until recently, the medical response to mass casualty incidents and disasters has not been part of the traditional body of knowledge of general surgery However, as growing numbers of surgeons are involved in their institutions’ disaster planning, and treating casualties of urban bombings, school shootings, train accidents, or natural disasters, interest in this topic has grown Despite this increased interest, many surgeons remain unsure about their role in mass casualty incidents because they think of disasters primarily as logistic rather than medical challenges The prevailing view has always been that trauma care in disasters is similar to that in normal daily practice, only more of the same This is a dangerous misconception A mass casualty incident is a unique challenge to surgeons and trauma systems because the large number of casualties affects how individual patients are treated inside and outside the hospital Furthermore, urban terrorism and natural disasters confront surgeons with unusual injury patterns and unique clinical problems not seen in their daily practice Preparing for these challenges requires, therefore, not only special planning and training but, most importantly, a different way of thinking about trauma care The aim of this chapter is to provide a concise overview of the 604 medical response to civilian mass casualty incidents and disasters from the perspective of the clinical surgeon practicing in a hospital that is part of a modern trauma system KEY CONCEPTS Classification of Disasters and Implications for Trauma Care In a mass casualty incident (MCI), a medical system is suddenly confronted by a large number of casualties needing care within a short period of time This unexpected surge creates a discrepancy between the number of patients and the resources available to treat them An MCI can be classified by cause (natural versus man-made), duration, location, and many other characteristics, but there is no single universally accepted classification of disasters From the clinical perspective of medical care, it is important to distinguish among three classes of disaster scenarios and understand the implications for trauma care (Table 25-1).1,2 Multiple Casualty Incidents These involve dozens of casualties and can be effectively managed using local hospital resources In other words, the arriving casualties strain the hospital resources beyond normal daily operations, but not overwhelm them Mass Casualty Incidents These involve hundreds of casualties arriving at a single institution Despite an effective disaster response, this number exceeds the capacity of the emergency department (ED) and the hospital As a result, some severely wounded patients will not receive the level of care they require, and others will experience significant delays Therefore, the term mass casualty implies some degree of failure to provide optimal trauma care to all severe casualties Major Medical Disasters These typically result in many thousands of casualties and destruction of organized community support systems In this scenario, the resources to treat critically injured casualties have been largely destroyed External medical teams supported by appropriate logistic envelopes can make a difference in the management of severely injured survivors, although help usually arrives late and deals primarily with delayed complications In this chapter, MCI is used as a generic term describing a large-scale event When referring to a specific disaster class or scenario (e.g., multiple casualty incident), it is fully spelled out The Surgeon’s Role in Mass Casualty Incidents  Chapter 25  605 IMPLICATIONS FOR TRAUMA CARE Multiple casualty Less than ED capacity Standards of care are maintained for all severe casualties Mass casualty More than ED capacity Care of some severe casualties is delayed or suboptimal ED and hospital overwhelmed Most severely injured patients die or survive without any medical care Major disaster The magnitude of a MCI is inversely related to its frequency (Fig 25-1) The overwhelming majority of practicing surgeons will not encounter a major medical disaster in their communities, whereas most hospitals occasionally face limited multiple casualty incidents In fact, busy Friday nights, a single trauma team on call coping with a cluster of severely injured patients arriving together is situation that occurs frequently in every urban trauma center It represents the lowermost end of a spectrum of magnitudes, with a major earthquake or a devastating Tsunami at the other extreme The sad paradox of disaster preparedness is that the most time and effort is spent on preparing and training for the largest and least likely doomsday scenarios instead of improving the response to limited but more realistic threats Injury Severity Distribution A key feature of every MCI is the injury severity distribution of the casualties Regardless of the cause or magnitude of the MCI, only about 10% to 15% of survivors presenting to a hospital will be severely wounded, of whom roughly one third will have immediate life-threatening injuries (Fig 25-2) Most others sustain minor trauma or nonurgent injuries.3 For example, during the London subway bombings in July 2005, the Royal London Hospital received 194 casualties within hours, but only 27 (14%) were severely injured Of these, only casualties (4% of the total) were critically wounded.4 Although the death toll at the scene depends on the cause of the MCI, and is very high when structural collapse is involved, the injury severity distribution is a constant feature of MCIs This means that even though the total number of casualties may be high, the overwhelming majority will not require a high level of trauma care and are not urgent These considerations form the rationale for planning an effective medical response MASS CASUALTY AND MODERN TRAUMA SYSTEMS Goal of the Hospital Disaster Responses A well-known underlying principle of medical disaster response is to the greatest good for the greatest number of casualties, but it is crucial to understand the precise clinical implications of this principle for trauma care Bearing in mind the injury severity distribution, a MCI is “a needle in a haystack” situation in which a small group of Magnitude of event TOTAL NUMBER OF CASUALTIES DISASTER CLASS MAJOR DISASTER MASS CASUALTY Multiple casualty “Busy Friday night” 0% Probability of occurring within a year 100% FIGURE 25-1 Graphic depiction of the inverse relationship between the magnitude of disaster scenarios and their frequency Although most surgeons will not encounter a major natural disaster during their careers, busy Friday nights are a regular feature in most urban trauma centers Mild Severe noncritical Critical FIGURE 25-2 Generic injury severity distribution for disaster scenarios Of all survivors arriving in the hospital, the overwhelming majority (85%) will have only minor injuries Of the severely injured (ISS > 9), only one third, or in 20 arrivals, will be critically injured with lifethreatening injuries This injury severity distribution forms the basis for planning the hospital disaster response severely injured patients who require immediate high-level trauma care is immersed within a much larger group of casualties with minor injuries, who can tolerate delays and even suboptimal care without adversely affecting their outcome.1 The ultimate goal of the entire hospital disaster response is, therefore, to provide this small group of critically injured patients with a level of care that approximates the care provided to similarly injured patients on a normal working day This goal has never been formally declared by the American College of Surgeons2 or any other professional organization, but it has always been implicitly understood by surgeons and trauma care providers and is certainly an expectation of the public In a multiple casualty incident, this goal can be achieved by effective triage and priority-driven trauma care In a mass casualty incident, it can still be achieved by diverting trauma assets and resources from the less severely injured to the critically wounded—but at a cost Contrary to popular belief, the casualties whose management is delayed and compromised in a mass casualty scenario are not the mild ones but the severely injured patients with non–lifethreatening injuries SECTION III TRAUMA AND CRITICAL CARE Table 25-1  Classification of Disasters and Implications for Trauma Care 606  SECTION III  TRAUMA AND CRITICAL CARE CT OR 100 ICU FIGURE 25-3  Schematic depiction of the trauma service line of a hospital The service line consists of resource, assets, and facilities in which trauma care providers treat severely injured patients The typical flow of a severely injured patient is from the trauma resuscitation bay of the ED to imaging, usually the CT scanner, then to the OR, and finally to a surgical ICU bed Preserving this service line in the face of a large influx of severe casualties is the true goal of the hospital disaster response Level of trauma care (%) ED Surge capacity 80 60 40 20 0 The Trauma Service Line in Disasters There is a strange dissociation between the dramatic advances in trauma systems in the past 30 years and current disaster planning The U.S National Response Framework (NRF), which lays out the guiding principles for all levels of a unified national response to disasters, does not acknowledge the existence of trauma systems in the United States Furthermore, most hospital disaster plans (including those of level trauma centers) not refer specifically to the hospital trauma service or system, even though any effective disaster response must necessarily rely on them Simply put, hospitals with 21st century trauma services and facilities have disaster plans that are still based on concepts of trauma care from the 1970s Every modern trauma center establishes and maintains a dedicated trauma service line for severely injured patients during normal daily operations (Fig 25-3) This service line includes trauma teams, assets, and facilities (e.g., resuscitation bays and operating rooms), all readily available to treat seriously injured patients The trauma service line of a hospital provides the resources for optimal care of individual patients, but has limited capabilities to treat multiple badly injured patients simultaneously The goal of an effective disaster response is therefore to preserve the hospital trauma service line in the face of an unusually large number of casualties From the trauma care perspective, success in dealing with an MCI is not streamlining the flow of 40 or 60 casualties through the ED, but rather preserving the capability to provide optimal trauma care to the three or four critically injured (but salvageable) casualties among them.5 Casualty Load and Surge Capacity Many hospital administrators have an exaggerated view of the capacity of their institutions because hospital disaster planning is typically based on counting ED gurneys and hospital beds, rather than on the rate at which casualties are treated (or processed) by the hospital trauma system In reality, as the MCI unfolds and progressively more casualties arrive, finding an available resuscitation bay and staffing it with experienced trauma teams becomes increasingly difficult.1 From the trauma care perspective, the arrival rate of severe casualties is a more meaningful metric of the burden on a trauma system than the absolute number of casualties The casualty load is the arrival rate of severe casualties per hour, and an increasing casualty load eventually leads to degradation of trauma care as severely injured patients compete for the limited assets and resources An intact trauma service line provides each severe casualty with a trauma team, resuscitation bay, and other 10 15 20 Critical casualty load (patients/hour) FIGURE 25-4 Graphic depiction of the results of a computer simulation of the flow of casualties of urban bombing through the trauma service line of the Ben Taub General Hospital, a level trauma center in Houston The model predicts a sigmoid-shaped relationship between the casualty load and global level of trauma care The level of care for a single patient on a normal working day is defined as 100% The upper flat portion of the curve corresponds to a multiple casualty incident, the steep portion represents a mass casualty situation, and the lower flat portion represents a major medical disaster The surge capacity of the hospital trauma service line is the maximal critical casualty load that can be managed without a precipitous drop in the level of care This simulation is based on clinical profiles of casualties treated at the Rabin Medical Center in Petach Tikva, Israel (From Hirshberg A, Scott BG, Granchi T, et al: How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis J Trauma 58:686–693, 2005.) resources, such as an available computed tomography (CT) scanner, operating room, and intensive care bed The point beyond which this level of care cannot be maintained for new arrivals represents the surge capacity of the trauma service line of the hospital.6 Surge capacity is, therefore, a dynamic measure of the processing capacity of the trauma service line, and cannot be derived from static calculations of ED gurneys and staff Using a similar definition, a surge capacity can also be defined separately for each trauma-related facility in the hospital An increasing casualty load adversely affects the quality of trauma care for the severely injured because many casualties compete for the same limited trauma assets and resources Analysis using a computer model6 describes this relationship as a sigmoid-shaped curve (Fig 25-4) The upper flat portion of the curve represents an intact trauma service line, where the level of care for severe casualties approximates the care given to a single patient on a normal working day This is a multiple casualty incident The steep portion represents a gradually failing trauma service line, corresponding to a mass casualty scenario The lower flat portion represents a failed (or nonexistent) service line overwhelmed by a major medical disaster The surge capacity of the trauma service line is the point beyond which the level of care begins to drop An effective disaster response shifts the curve to the right, increasing the surge capacity and resulting in a more gradual degradation of the level of care An empirical estimate7 puts the surge capacity The Surgeon’s Role in Mass Casualty Incidents  Chapter 25  607 Mass Casualty and Modern Trauma Systems The overwhelming majority of urban terrorist bombings are multiple casualty incidents that not exceed the surge capacity of individual hospitals However, in the past decade, terrorist groups have made repeated attempts to increase the magnitude of these MCIs by coordinated multiple simultaneous bombings The two best documented examples were the Madrid trains bombing (March 2004)8 and the London subway bombing (July 2005).4 However, these incidents clearly demonstrated that modern emergency medical services (EMS) and trauma systems in large metropolitan areas serve as effective buffers that mitigate the medical impact of a large-scale event by distributing casualties among hospitals With 2253 casualties in Madrid and more than 700 in London, rapid dispersion of the casualties among several hospitals resulted in each participating hospital facing only a multiple casualty incident with a handful of critical patients This strong buffering mechanism was, however, conspicuously absent in the U.S Embassy bombing in Nairobi, Kenya, in 1998, where more than 4000 casualties flooded the Kenyatta National Hospital.9 This inadequately documented MCI is the only truly overwhelming urban mass casualty incident in recent history This is a key point that is worth reemphasizing: no hospital in a metropolitan area that has a functioning EMS system has ever been overwhelmed by a MCI A major difficulty in trying to learn useful lessons from past incidents is the paucity of clinical data Most published reports provide only global statistics, such as the total number of casualties and the mortality among the critically injured (critical mortality), with few clinical details about the trauma care of individual patients Difficulties and problems in trauma care must be inferred between the lines, such as an alarmingly high number of negative laparotomies, which are hidden in the data of the main reports from the Madrid and London bombings Interestingly, in the entire body of literature on disaster medicine, no hospital has ever reported having preventable morbidity and mortality In view of the high public profile and emotional impact of such incidents, factual detailed clinical reports about trauma care in MCIs are unlikely to be published The keys to an effective medical response to any MCI are robust trauma systems and well-functioning trauma centers Unfortunately, trauma centers in the United States are currently in the midst of a major crisis The public and its elected representatives simply not associate the well-being of trauma centers with the medical response to disasters Thus, while the national grid of functioning trauma centers is being eroded by lack of public support, huge resources are allocated to preparing hospitals for so-called all-hazard scenarios, which have become a top priority despite their extremely small likelihood The public clearly does not realize this dangerous paradox Without a strong national grid of trauma centers, no effective disaster response will be possible for doomsday scenarios or just plain civilian MCIs Medical Care at the Scene Most MCIs in an urban environment follow a typical timeline that can be divided into four distinct phases (Table 25-2).10 The initial chaotic phase begins immediately after the inciting event Table 25-2  Typical Timeline of Urban Mass Casualty Incident SCENE PHASE CHARACTERISTICS Chaotic No organized medical care; mild casualties go to nearest hospital Organized effort Key is effective triage; priority-driven transport of casualties Site clearing Remaining casualties transported Late Sporadic mild casualties IMPLICATIONS FOR THE ED First wave: A few walking wounded Second wave: Main body of casualties Third wave: Slow trickle of mild casualties Without any organized medical effort, many minor casualties and those with acute stress reaction run from the scene and find their way to the nearest hospitals The organized effort phase begins when a prehospital responder takes charge at the scene and initiates a systematic medical effort while also ensuring the safety and security of the medical teams The most important aspect of this phase is effective field triage, which allows prioritydriven transport of casualties to hospitals This is followed by the site-clearing phase, the duration of which depends on the specific circumstances of the incident (i.e., magnitude, structural collapse, or need for prolonged extrication) It ends when the last live casualty is transported from the scene The late phase is a poorly defined period when minor casualties who initially ran from the scene decide to seek medical attention, often after being persuaded by family and friends From the hospital perspective, this timeline translates into a characteristic casualty arrival pattern consisting of three waves (see Table 25-2) The first wave consists of a small cluster of casualties with minor injuries who arrive in hospital on their own After a variable interval, the main body of casualties begins to pour in, presenting a wide variety of injury severities Finally, a slow trickle of late arrivals with minor injuries or acute stress reaction continues over many hours.10 Because the time from injury to definitive care is a key determinant of mortality, the dominant approach of prehospital teams in an urban setting is to “scoop and run.” The emphasis is on triage and rapid transport; interventions are largely restricted to airway management and control of external hemorrhage However, in a rural or remote MCI, transport can be a bottleneck because of limited means or long distances and may mandate some form of trauma care at the scene Field triage schemes are based on a rapid assessment of clinical and physiologic parameters Until recently, the dominant algorithm in the United States was START (simple triage and rapid treatment), which sorts casualties into four categories—immediate, delayed, minor, and deceased.11 Criticism of START, which results in excessive overtriage, has led to the recent introduction of the SALT triage scheme (sort, assess, life-saving interventions, treatment and/or transport), which combines global assessment of the casualties (e.g., walking versus laying still) with a more detailed yet brief assessment of vital signs.12 SALT has been endorsed by the American College of Surgeons and other professional organizations dealing with mass casualty triage Although it is promoted as a universal triage SECTION III TRAUMA AND CRITICAL CARE at one severely injured patient per hour for every 100 hospital beds, providing a practical yardstick that can be used in disaster planning 608  SECTION III  TRAUMA AND CRITICAL CARE scheme for MCIs, its main usefulness is at the scene rather than for hospital triage at the ED door CLINICAL ASPECTS OF HOSPITAL DISASTER PLANS Hospital Disaster Response The ultimate goal of the hospital disaster plan is to rapidly augment the surge capacity of the trauma service line with its support elements, such as the blood bank and emergency laboratory An emergency operations center (EOC) coordinates the institutional effort Each service or facility in the hospital response envelope activates a facility-specific disaster protocol designed to increase the processing capacity (or surge capacity) of the facility quickly to accommodate a sudden large influx of casualties The underlying principle of these protocols is suspension of normal daily activities while rapidly mobilizing staff reinforcements Full activation of the entire disaster plan of a large hospital takes time, disrupts normal daily activities, is expensive, and is also usually unnecessary, because the overwhelming majority of MCIs that any hospital is likely to face are limited events It makes sense, therefore, to base the hospital disaster plan on a tiered response.13 The plan for a limited MCI centers primarily on the ED and relies on in-house staff and resources A plan for large-scale MCIs recruits reinforcement staff and additional facilities outside the ED Although this tiered approach is not yet a formal part of the hospital disaster planning in the United States, it makes clinical and administrative sense and is implicitly adopted by a growing number of institutions From the perspective of trauma care, the hospital response consists of two distinct phases.10 During the initial phase, the incident is still evolving, casualties are arriving, and their ultimate number is unknown Therefore, the key consideration is to preserve the trauma service line for the next critical arrival The definitive phase begins when casualties are no longer arriving, the overall casualty number is known, and the hospital response envelope has been fully deployed The clinical focus shifts to providing definitive care to all casualties in a graded, priority-oriented fashion Preparing to Receive Casualties The person authorized to initiate the hospital disaster response can be either a hospital administrator or a local decision maker in the ED (e.g., the charge nurse or the attending emergency physician) The former approach reflects a top-down command mentality and comes at a price of expediency, especially outside normal working hours The latter is in line with a flexible approach of empowering local managers to make decisions, facilitating a rapid response The characteristic time lag between the notification to expect incoming casualties and the actual arrival of the first wave is a window of opportunity to initiate the opening steps of the institutional response Actions taken during this brief window have a profound effect on the subsequent response Nowhere is this window more crucial than in the ED, where a rapid evacuation plan is activated to create empty gurneys and physical space for a large number of incoming casualties.14 Based on their medical condition, ED patients can be discharged, admitted to the floors, or transferred to a predesignated location within the hospital Other priorities are to position a triage officer outside (not inside) the ED and improvise additional trauma bays close to the trauma resuscitation area The command chain in the ED must be clear to all, and the entire staff must be briefed and given specific roles For example, in the trauma resuscitation area, staff members are assigned to specific teams and told explicitly who will take the first, second, and subsequent critical arrivals Emergency carts containing additional medical supplies are deployed in predesignated areas Incident Command and Clinical Decision Making Hospital disaster plans are traditionally based on a top-down organizational hierarchy stemming from the incident command structure developed in the 1970s to streamline the field management of large-scale incidents.3 However, the implementation of these top-down organizational structures during a real incident is problematic because most MCIs are brief and limited in scope The rapid dynamics of an urban MCI far outpace the deployment of the top-down hospital command structure, so that by the time the hospital has an incident command center up and running, the incident is long over More importantly, the topdown hierarchical tree means that when a problem arises, it is communicated upward in anticipation of a solution, which will inevitably be delayed In a real incident, local managers frequently solve problems by communicating horizontally among themselves The shortcomings of the rigid top-down command structure were glaringly obvious during the response to Hurricane Katrina in 200515 and stood in sharp contrast to many smallscale successes led by resourceful local managers who collaborated with peers in their professional or organizational networks It is becoming increasingly clear that an effective disaster response at any level must be based on such collaborative networks rather than on rigid top-down chains of command.16 Few hospital administrators realize that the major driving forces that propel the hospital disaster response are clinical decisions made at the bedside The movement of severe casualties among facilities is essentially flow between decision points, because no casualty enters (or leaves) a facility unless a clinical decision has been made by a trauma care provider In a traditional top-down command structure, executive decisions are made at the top and implemented by the lower echelons In a hospital coping with an MCI, the situation is reversed, because the crucial decisions are made at the bedside and the role of the higher organizational echelons is to support and facilitate the implementation of these clinical decisions.14 The effective response of every facility in the trauma service line to a sudden large casualty load always hinges on a small group of local managers whose clinical decisions drive the entire effort In the ED, these are the surgeon in charge, attending emergency physician, charge nurse, and triage officer These decision makers understand the overarching goals of the hospital plan and should be empowered to solve problems independently instead of merely reporting them They should be trained to improvise and communicate horizontally with other local managers Such collaborative network architectures provide flexibility, adaptability, and speed and are resilient when parts of the system fail unexpectedly Surgeons must also be aware of a fundamental change in the medical decision making process during an MCI In everyday clinical practice, trauma team leaders enjoy full autonomy in their clinical decisions regarding treatment priorities and the use of resources and facilities In an MCI, a large number of The Surgeon’s Role in Mass Casualty Incidents  Chapter 25  609 Hospital Triage Triage is the central element of the hospital disaster response with implications far beyond the ED door.18 There is a wide discrepancy between the theory of triage and the harsh reality of sorting arriving casualties on the ambulance dock Most hospital plans call for an experienced trauma surgeon to stand at the ED entrance and sort arriving casualties based on a brief assessment of physiologic parameters (e.g., palpable peripheral pulse or respiratory distress) Popular schemes divide casualties into five categories—immediate (life-threatening injuries), delayed (severe injuries that can wait for definitive care), minimal (walking wounded), dead, and expectant (hopeless; Table 25-3) Experience from real MCIs has shown that triage on the ambulance dock cannot be based on physiologic parameters simply because the triage officer has time for only a rapid cursory glance at each arrival The triage decision must therefore rely on a global impression of the patient’s clinical condition.19 Furthermore, it is often impossible to distinguish immediate from delayed casualties based on this rapid cursory glance, and pronouncing death on the ambulance dock without a thorough examination and cardiac monitor is also an unrealistic expectation Most problematic is the hopeless (or expectant) category, because such determinations often depend on the available resources; the same critical casualty may be deemed salvageable if the casualty load is light (or if the patient is an early arrival) or hopeless when the ED is overwhelmed.1 For all these reasons, realistic triage on the ambulance dock should be viewed as a screening test for severe casualties who require immediate access to the hospital trauma service line The quality of triage has traditionally been expressed in terms of overtriage and undertriage rates.19 The former is the erroneous assignment of nonsevere casualties to the trauma resuscitation area, whereas the latter is the erroneous assignment Table 25-3  Traditional Categories and Realistic Hospital Triage Triage Mode TRADITIONAL CATEGORIES SINGLE-STEP SEQUENTIAL Immediate Expectant Dead Severe (to shock room) Critical (to shock room) Delayed Minimal All others (to ED holding) Delayed (to ED holding) Minimal (treated outside ED) of severe casualties to a regular ED gurney Overtriage is a system problem because these patients compete with severe casualties for trauma teams and facilities Undertriage, on the other hand, is a medical error that may affect preventable morbidity and mortality It has been suggested recently that hospital triage should be viewed as any other diagnostic screening test, using specificity and sensitivity rates, which not directly correspond with overtriage and undertriage, as measures of triage accuracy.20 The major goal of effective triage is to facilitate better use of limited trauma resources The key resource most needed by a severely injured patient is the specific attention of a trauma team The price of inaccurate triage can therefore be quantified in terms of trauma team workload A recently published computer model has shown that increasing triage accuracy reduces this workload.20 It is important to underscore that triage does not end on the ambulance dock It is, in fact, a reiterative process whereby each casualty is sequentially and repeatedly assessed as he or she progresses along the trauma service line Each reevaluation increases the accuracy of the overall process and increases the likelihood that the patient will be triaged correctly and allocated the appropriate resources for the best possible clinical outcome Clinical Implications of Triage Modes From the perspective of the trauma service line of the hospital, there are two realistic modes for triage on the ambulance dock (see Table 25-3) Single-step triage is the simple binary decision mode whereby casualties are sorted into severe (roughly corresponding to an Injury Severity Score [ISS] of more than 9, or 15% of the casualties) and all others The former are assigned a trauma team in the trauma resuscitation area; the rest are treated in the ED holding area Sequential (two-step) triage further sorts severe casualties into critical (or immediate; ISS > 15) or urgent (or delayed; ISS = to15) categories The former (approximately 5% of the casualties) are assigned a full trauma team in a resuscitation bay to address immediate life-threatening injuries, whereas the latter are treated by one team per several casualties in the holding area In this mode, mild casualties (walking wounded) are directed to a designated area outside the ED Sequential triage can be performed by two triage officers working in sequence (one on the ambulance dock, the other inside the ED) or by a single officer making two triage decisions in rapid sequence The first decision separates mild casualties, who go to a designated area outside the ED, from the severely injuries, who enter the ED The second decision determines which casualties will receive a full dedicated trauma team Single-step triage works well in limited multiple casualty incidents, in which the total number of expected casualties is below the bed capacity of the ED Sequential triage is needed only in large-scale incidents that exceed this capacity It is important to emphasize that sequential triage is not merely a refined triage scheme with an additional category, but rather a dramatic qualitative change in trauma care In this mode, roughly two of every three severely injured patients will receive a lower level of trauma care than they would get on a normal working day The decision to use sequential triage is therefore the most important medical leadership decision during the early stages of a MCI Any disaster response entails a necessary compromise to the most good to the greatest number of casualties However, as sequential triage shows, it is in the treatment of urgent casualties SECTION III TRAUMA AND CRITICAL CARE severely injured patients compete for these same resources and facilities Key clinical decisions must therefore be made by the surgeon in charge, who can visualize the “big picture” of the institutional situation, and the autonomy of the individual team leader no longer exists.17 For example, the decision to take a patient with a penetrating abdominal injury and intra-abdominal bleeding to the operating room is not automatic nor can it be made by the trauma team leader alone, because it depends on other casualties and on the situation in the operating rooms The surgeon in charge is not merely a coordinator or supervisor but actually makes key clinical decisions about individual patients 610  SECTION III  TRAUMA AND CRITICAL CARE with severe (but not immediately life-threatening) injuries that this compromise is the most evident Although it is intuitively assumed that this lower level of care will not directly affect outcome, this crucial point has never been addressed in published reports of past MCIs Trauma Care in the Initial Phase During the initial phase of a MCI (Box 25-1), the hospital operates two parallel (but separate) service lines for incoming casualties.14 The first is a high-priority line with neither queues nor delays It is reserved for severe casualties and includes the staff and resources that treat severely wounded patients during normal daily operations, from the trauma resuscitation bay in the ED to the surgical intensive care unit (SICU; see Fig 25-3) This service line is staffed by the experienced trauma care providers who deal with severely injured patients daily The second service line is designated for the mildly injured, who require mostly treatment of trivial injuries and ruling out occult significant trauma Here, the role of trauma care providers is to supervise and guide hospital staff who are not trauma care providers but are called up to help in the ED It is interesting to note that the roles of the trauma surgeon and trauma-trained nurse in MCIs have never been formally defined in published guidelines, and are conspicuously absent from templates for hospital disaster plans Depending on the structure and size of the trauma service at a specific institution, surgeons and nurses with trauma experience may be assigned to perform triage, be in charge of the trauma resuscitation area, or have medical control of other parts of the hospital response envelope The underlying principle is that trauma surgeons and nurses should be positioned where they can have the most impact on the overall clinical result Their roles should be defined well in advance and incorporated into the institutional disaster plan Critical casualties who enter the trauma service line are treated in a fashion similar to that of everyday care, with an emphasis on expediency, rapid turnover times, and using smaller trauma teams The crucial difference is that all major clinical decisions are referred to the surgeon in charge who roams in the trauma resuscitation area and acts as coordinator and ultimate clinical decision maker.17 Clinical and administrative control are maintained through frequent rounding on all casualties in the ED by the surgeon in charge, charge nurse, and ED attending physician The product of these rounds is a list of casualties, their diagnoses, and their disposition (or plan) Knowing the total number of casualties and their injuries and dispositions, as well as the situation at each trauma service point, allows the surgeon in charge to consider clinical priorities against available resources and determine a feasible solution for each critical casualty BOX 25-1  Goals and Principles of Trauma Care in the Initial Phase Goals Optimal trauma care for critical casualties Minimal acceptable care for all others Principles Two parallel but separate service lines Conservation of trauma assets and resources Centralized clinical decision making Loss of continuity of care The guiding principle for the care of noncritical casualties during the initial phase is minimal acceptable care, which means empirical trauma care along the line of first aid in the field.21 The aim is to buy time, conserve trauma resources, and delay definitive care while offloading the trauma service line This concept of minimal acceptable care is based on experience with civilian casualties of war, in which some two thirds of casualties survive for week after injury without any medical care, and nonoperative management buys time and improves survival.22 Thus, the clinical suspicion of a long bone fracture is treated by empirical splinting and analgesia and the patient is rapidly admitted to a floor bed without imaging Penetrating abdominal trauma with peritoneal signs but no hemodynamic compromise is treated with IV fluids, antibiotics, nasogastric suction, analgesia, and admission to a floor bed until the definitive care phase One of the hallmarks of this temporizing philosophy is to limit access to the CT scanner only to patients for whom the scan is absolutely essential or potentially lifesaving (e.g., a head injury with lateralizing signs or a deteriorating level of consciousness) Another distinguishing feature of trauma care in disasters is discontinuity of care, because in most real-life events, teams are assigned to service points rather than to individual critical patients Thus, a critical casualty may be resuscitated in the shock room by one team, the imaging studies reviewed by a second team, and the operation performed by a third Few hospital disaster plans currently address this crucial issue and incorporate solutions (e.g., case managers) to mitigate the potential adverse effects of this loss of continuity of care.23 Although the CT scanner is a classic bottleneck in the flow of casualties along the trauma service line, operating room availability is not a major concern because only very few casualties require emergency surgery during the initial phase.21,24 Even in large-scale MCIs, such as the simultaneous terrorist bombings in Madrid (2004) and London (2005), there was a time window of more than hour between activation of the disaster response and the first operative procedure Contrary to the situation in the operating room (OR), the availability of ICU beds is a source of grave concern This is especially true in urban bombing incidents, in which approximately one of every four admitted casualties will need an intensive care bed This high demand comes in the face of a severe SICU bed shortage in most trauma centers The hospital disaster response must therefore include protocols for rapidly generating a substantial number of vacant intensive care beds available for incoming casualties.25 This is typically accomplished by transferring nonventilated patients to floor beds or by using nonsurgical intensive care facilities within the hospital The postanesthesia care unit is often the first to be used to accommodate an overflow of ventilated patients Critically injured nonoperated patients from an urban bombing will need an SICU bed approximately to hours after arrival in the hospital, and operated casualties take even longer.4 These long intervals allow the hospital to prepare beds, transfer patients, and mobilize staff reinforcements to achieve a substantial surge in intensive care capacity Definitive Care Phase During this phase, casualties are no longer arriving, their ultimate number is known, and the disaster response envelope of the hospital is fully deployed It is now possible to take The Surgeon’s Role in Mass Casualty Incidents  Chapter 25  611 SURGEON’S ROLE IN NATURAL DISASTERS The medical aid stampede during the first few weeks after the Haiti earthquake in January 2010 demonstrated how little surgeons know about their role in natural disasters, as many volunteers with good intentions rushed to the stricken country in improvised teams, only to discover how little good intentions and surgical skills alone can achieve There are fundamental differences between the medical response to an urban MCI and organizing medical aid to a major natural disaster In the former, a functioning trauma system is coping with an unusually large casualty load over a brief period (from hours to several days) In the latter, the catastrophic event compromises or destroys infrastructure and community support systems (including trauma and health care systems) in the disaster area External medical assets and resources must therefore be imported into the disaster area to reinforce, support, or replace compromised local assets over a period of many weeks, months, and sometimes years.28 The vulnerability of the population affected by a major natural disaster is determined primarily by its poverty level because poor countries have a weaker infrastructure, and hence suffer more devastation, but have fewer resources with which to cope Thus, the 2010 Haiti earthquake, with some 230,000 dead, stands in dramatic contrast to the 1989 earthquake near San Francisco, which was of a similar magnitude yet resulted in only 63 deaths Injury Patterns in Natural Disasters It is important to know the typical injury patterns seen in various types of natural disasters.29 In a major earthquake, the most important wounding mechanisms are falling debris and entrapment underneath collapsed buildings Immediate search and rescue efforts by survivors in their immediate vicinity save more lives than the organized (but delayed) rescue efforts of external agencies During the first few hours after an earthquake, survivors present with a wide variety of extremity and visceral injuries, but later the prevailing patterns are extremity injuries and a high incidence of crush injuries Only a small fraction of the overall number of casualties is extricated alive after 48 hours underneath the rubble, approximately 300 patients in the Haiti earthquake of January 2010 that killed 250,000 Delayed extrication translates into a high incidence of crush syndrome and acute renal failure, as seen after the Marmara earthquake in Turkey in 1999.30,31 The 2004 tsunami in Southeast Asia caused twice as many dead than injured survivors, in whom the dominant injury patterns were extremity fractures and soft tissue wounds.32 In a volcanic eruption, injuries are caused by falling rocks, exposure to ash (a strong respiratory irritant), and inhalation injury from volcanic gases The leading cause of death is suffocation Knowing the characteristic injury patterns for each type of natural disaster is an obvious prerequisite for planning a medical relief effort Initiating the Medical Relief Effort Contrary to the popular notion of the heroic medical volunteer racing to the rescue, there is a formal methodology for initiating a medical response to a natural disaster The crucial first step is a rapid needs assessment, a formal mission that is carried out as soon as possible after the catastrophe.28,33 A United Nations Disaster Assessment and Coordination (UNDAC) SECTION III TRAUMA AND CRITICAL CARE stock and proceed with definitive care for all admitted casualties.10,21,25 The central tool in this phase is a series of detailed rounds by members of the trauma service on all admitted casualties, making a detailed and priority-driven treatment plan for each one The deliverables of these rounds are prioritized lists of patients in need of imaging, consults, operative procedures, and transfer to other institutions In other words, the minimal acceptable care of the initial phase now transforms into prioritydriven definitive care in which the more urgent clinical problems are addressed first The definitive care phase consumes considerable time and resources,26 so even limited multiple casualty incidents may disrupt the normal daily activities of the trauma service line and related facilities for 24 to 48 hours after the last casualties have arrived Return to normal daily activities is therefore gradual and the timeline differs among facilities The ED can return to normal relatively quickly, but the intensive care unit (ICU) often requires additional staffing and support for several days The Israeli experience with urban bombings contains useful descriptions of the a general ICU coping with multiple casualty incidents, the importance of planning to relieve staff at regular intervals, and the use of staff reinforcements, nursing students, and volunteers.25,27 During the definitive care phase, consideration should be given to the need for secondary distribution of casualties by transferring some of them to other institutions Interhospital transfer of burn patients to burn centers is a self-evident example Such transfers are more problematic when the indication is mostly logistic, such as the desire to shorten waiting times for nonurgent operations (e.g., internal fixation of long bone fractures) Financial and administrative issues, as well as considerations of institutional prestige, often create barriers to interhospital transfer—to the detriment of patients An urban bombing is an example of a short MCI, in which the main body of casualties arrives within approximately hours of the explosion When structural collapse is involved, prolonged extrication and site-clearing activities extend the initial phase, but there is still a clear distinction between the initial and definitive care phases However, in some types of MCIs, such as natural disasters or civilian trauma care in areas of conflict, an ongoing stream of casualties blurs the distinction between the phases and poses an ongoing challenge to the hospital trauma service line and its logistic supply chains The hospital disaster response must therefore include plans for such a rolling MCI, in which maintenance of capabilities and preservation of resources over time become a central issue Strict rationing of staff working hours, maintaining a supply chain for critical items such as blood products, and preparing for the need to have hospital personnel reside in-house for many days are all elements of such a plan for a rolling MCI A crucial final step before return to normal daily operations is a formal debriefing This activity takes place as soon as possible after the incident Ideally, all staff (hospital and prehospital) who took part in the effort should participate The debriefing should be carefully structured to cover all key areas of clinical and administrative activity while allowing free input from any participant who wishes to make a point The aim is to learn lessons and identify barriers to the hospital response that can later be incorporated into the hospital disaster plan 612  SECTION III  TRAUMA AND CRITICAL CARE team, typically composed of two to six experts, travels quickly to the disaster area to assess the immediate needs and report them to the international community The rapid needs assessment, conducted in close collaboration with local authorities and facilities, defines not only the extent of the damage to local infrastructure and medical resources, but also estimates the numbers of casualties, types of injuries, and key priorities for disaster relief Medical needs are often assigned a lower priority than essentials such as water, food, and shelter Without an expert needs assessment and subsequent careful planning of the mission tailored to the specific profile of the disaster, the effort will not be effective Improvised initiatives of enthusiastic individuals are likely to end up as part of the problem rather than part of the solution Trauma Care in the Disaster Area The medical response to a major natural disaster consists of two distinct phases.28 During the immediate phase, the first days and weeks following the catastrophe, the main goal is to provide trauma care to the injured In the late phase, in the subsequent months or even years, the focus is on supporting the reconstruction of local medical services and facilities in the disaster area During the immediate phase, by the time outside medical help with surgical capabilities arrives, casualties with severe visceral injuries have either been treated already or have not survived Therefore, the clinical focus shifts to the management of extremity and soft tissue injuries that may be neglected or infected and to specific complications, such as renal failure from crush syndrome Another important component of the work of outside medical teams is to provide solutions to ongoing surgical emergencies in the afflicted population In the absence of surgical facilities in the disaster area, even simple, straightforward, nontrauma emergencies such as an incarcerated hernia or an obstetric condition requiring an urgent cesarean section may lead to preventable mortality In the immediate phase, the surgical management of extremity injuries follows the well-established principles of the management of war wounds The focus is on simple and traightforward procedures rather than on complex reconstructions, which are not a feasible option Muscle compartments should be decompressed liberally and early nonviable or heavily contaminated tissue must be excised while carefully preserving intact skin and viable soft tissue Wounds are left open for delayed primary closure or reexcision if needed Nonsalvageable or mangled extremities should undergo early amputation, with the stump left open for delayed primary closure.28 The composition and surgical capabilities of a team deployed to a disaster area must be carefully considered in view of the clinical needs in the field A typical team consists of torso and extremity surgeons with trauma experience More important than specific surgical skills is the ability to work in an austere environment in a spirit of collaboration with local and other external medical teams Here, again, the trained professional team with disaster relief experience, supported by a robust logistic, security, and communications envelope has a much better chance of rendering effective medical care than an ad hoc team of enthusiastic volunteers Such an effort relies on datadriven planning based on a competent rapid needs assessment, is limited in scope and duration, and has well-defined realistic goals Table 25-4  Classification of Blast Trauma CLASS OF   BLAST INJURY MECHANISM Primary Wounding of air-filled viscera as direct result of the blast wave Secondary Penetrating trauma from bomb fragments and other projectiles of varying mass and velocity Tertiary Casualties propelled by the blast wind, resulting in standard patterns of blunt trauma Quaternary Burns, crush, and all other trauma mechanisms that are not included above BLAST TRAUMA: CLINICAL PATTERNS AND SYSTEM IMPLICATIONS Urban bombing incidents result in unusually severe and challenging patterns of injury, where up to one third of casualties admitted to hospital have an ISS higher than 15, a rate three times higher than that seen in a typical civilian trauma practice The overall number of casualties and rate of immediate on-scene mortality are determined by the size of the explosive charge, structural failure of the building, and indoor detonation, which results in a greatly amplified blast wave Suicide bombers are particularly devastating weapons of urban terror because they specifically target crowded indoors locations or large open space gatherings to maximize the effect of the explosion.21 Blast trauma is viewed by trauma surgeons as a multidimensional injury because it often combines blast, penetrating, blunt, and burn mechanisms in the same casualty The results are injury patterns of higher severity and complexity and a greater burden on the trauma service line of the hospital The classification of blast injuries is given in Table 25-4 Primary Blast Injury The most common clinical sign of blast injury is eardrum perforation These perforations usually heal spontaneously but may result in various degrees of hearing loss in up 25% of patients Eardrum perforation is a useful marker of the proximity of the patient to the detonation but is not a reliable predictor of lung injury.34 All arriving casualties should therefore be screened for tympanic membrane rupture in the ED; those with a perforation should undergo an audiometric assessment for hearing loss within 24 hours, regardless of symptoms Although it is customary to admit otherwise asymptomatic patients with eardrum perforation for overnight observation because of their proximity to the detonation and concerns over the insidious onset of a blast lung injury, this practice is not evidence-based The blast wave from the detonation disrupts the alveolarcapillary interface of the lung, resulting in a spectrum of blast lung injury ranging in severity from mild pulmonary contusion with intra-alveolar hemorrhage to severe and rapidly evolving acute respiratory distress syndrome (ARDS).35 Blast lung injury is uncommon, occurring in only 5% to 8% of live casualties in urban bombings, but its severity is the key determinant of mortality among early survivors Blast may also cause barotrauma (pneumothorax and bronchoalveolar fistula), air embolism, and upper airway mucosal damage Mild blast lung injury presents with localized infiltrates on chest x-ray It is managed similarly to a mild lung contusion and has a good outcome Patients with severe lung injury typically The Surgeon’s Role in Mass Casualty Incidents  Chapter 25  613 Secondary Blast Injury Penetrating trauma from fragments of the bomb casing or from metal projectiles added to an improvised explosive device (IED) can cause a wide array of injuries, ranging from superficial skin lacerations to lethal visceral wounds From the perspective of the hospital trauma service line, the key consideration is the need for extensive imaging to locate penetrating fragments and define their trajectories because a physical examination is a poor predictor of the depth of penetration The most expedient method is to use a helical CT scan to locate multiple projectiles rapidly and delineate their trajectories.39 However, this makes the CT scanner a bottleneck to patient flow24 and requires setting priorities and rationing access to the scanner during the initial phase of the hospital response Penetrating trauma by multiple projectiles may result in deep soft tissue wounds that bleed profusely Because these wounds are typically located on the posterior aspect of the torso and extremities, the associated blood loss is often underestimated In patients who are taken to the OR for emergency surgery (e.g., for celiotomy) it is therefore advisable to log-roll the patient and rapidly pack the wounds with gauze before the main surgical procedure.40 Whereas classic management principles for traumatic wounds have called for débridement of each wound and removal of embedded foreign bodies, this is often not a realistic option in casualties with multiple (sometimes dozens) of asymptomatic penetrating wounds These multiple débridements consume OR time and resources and end up causing more tissue damage than the original injury A common sense approach is to address only symptomatic or infected projectiles and those in problematic locations (e.g., intra-articular) Tertiary and Quaternary Blast Injuries When casualties are propelled against stationary objects by the explosion, the results are standard patterns of blunt trauma However, these tertiary blast injuries are typically combined with other types of trauma caused by the blast This complicates the clinical picture and presents unusual dilemmas in terms of treatment priorities and resource allocation.21 Quaternary blast trauma refers mostly to burns and crush injuries.35 Superficial flash burns, typically involving large body areas, are caused by the explosion itself, and are markers of proximity to the blast They are common among casualties found dead at the scene and have also been shown to be predictors of blast lung injury.41 The ignition of flammable materials and clothes causes deep burns of variable extent, sometimes in conjunction with inhalation injury A large number of burn casualties, many of them brought initially to hospitals that not have a dedicated burn service, pose an extraordinary burden on regional burn systems that generally have a limited surge capacity, even during normal daily operations Secondary distribution of these patients to other, often geographically remote, burn centers outside the immediate vicinity of the bombing site is a key feature of MCIs involving a large number of burned casualties, such as the Bali nightclub bombing in Indonesia in 2002.42 CONCLUSION The central message of this chapter is that amidst the wailing sirens of approaching ambulances, the terrible sights on television, the hectic activity of medical teams, and the emotional outrage of the public, surgeons must not forget their core mission in disasters This core mission is to preserve the trauma service line of the hospital and remain focused on providing optimal trauma care to the next critical casualty Contrary to the tendency among disaster planners and hospital administrators to prepare for nightmare megascenarios that surgeons are unlikely ever to encounter in their professional careers, the emphasis should be to on preparing for realistic MCIs that affect every institution from time to time Surgeons must remember that the ultimate goal of the entire hospital disaster plan is to provide a small group of critically injured casualties with a level of trauma care comparable to the care given to similarly injured patients on a normal working day The many mildly injured patients are the noise, the casualties that are seen and heard on the evening news The surgeon’s role is to focus on the few casualties who are silent, those whose battle for survival unfolds away from the cameras, in the shock room, operating room, and ICU Strange as it may seem, it is these very few critically injured patients who are the crux of the entire effort SELECTED REFERENCES Aylwin CJ, Konig TC, Brennan NW, et al: Reduction in critical mortality in urban mass casualty incidents: Analysis of triage, surge, and resource use after the London bombings on July 7, 2005 Lancet 368:2219–2225, 2006 SECTION III TRAUMA AND CRITICAL CARE present with rapidly worsening hypoxia, develop bilateral diffuse infiltrates, and require early aggressive respiratory support along the lines of managing ARDS Pneumothorax should be actively sought and immediately decompressed in these patients Mortality is in excess of 60% in these severe cases.36 Blast lung injury in the setting of an urban bombing poses an exceptional burden on the surgical ICU.25,27 The trauma service line encounters several patients with severe and rapidly worsening hypoxia who arrive within a short time of each other Each of these patients requires emergency endotracheal intubation in the trauma resuscitation area and subsequent advanced ventilatory support, and sometimes invasive hemodynamic monitoring in an ICU This logistic nightmare scenario is almost unique to urban bombing incidents and translates into a huge medical, organizational, and staffing challenge.14 The presence of associated injuries (e.g., burns or penetrating visceral trauma) adds to the complexity of an already difficult situation These patients require not only an intensive care bed but, more importantly, the personal and undivided attention of a team of experienced critical care providers Intestinal blast trauma varies in severity from subserosal hemorrhage to full-thickness perforation.37 Clinically important bowel blast injury is rare in urban bombings, occurring in less than 2% of live casualties, but is the most common form of trauma in an immersion blast from an underwater explosion The clinical pitfall with these injuries is a delayed presentation, with some casualties developing peritoneal signs 48 hours or more after the explosion The injury may affect any portion of the bowel but a propensity for the terminal ileum has been described.38 Intraoperatively, a common dilemma is how much contused but nonperforated bowel to resect The concern is that traumatized bowel may eventually progress to a delayed perforation This decision is an operative judgment call 614  SECTION III  TRAUMA AND CRITICAL CARE This report paints a detailed picture of the hospital response to the London subway bombings, including individual timelines for severe casualties although it shows how a modern trauma centers copes with a large-scale event, it does not provide details on preventable morbidity and mortality Cushman JG, Pachter HL, Beaton HL: Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City J Trauma 54:147–154, 2003 A classic report of the main hospital response to the World Trade Center destruction on 9/11 with a discussion of the tiered hospital response plan Frykberg ER: Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma 53:201–212, 2002 This is the first overview of the medical response to urban terrorism that emphasizes the role of effective triage and looks at the medical response in quantitative terms Hirshberg A, Scott BG, Granchi T, et al: How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis J Trauma 58:686–693, 2005 A computer model was used to simulate the response of a major U.S trauma center to an urban bombing using casualty profiles from an Israeli hospital The model predicts the now classic sigmoid-shaped relationship between the level of trauma care and increasing casualty load and defines surge capacity of the hospital trauma service line Welling DR, Ryan JM, Burris DG, et al: Seven sins of humanitarian medicine World J Surg 2010;34:466–470 A must-read for any surgeon contemplating participation in a humanitarian disaster relief effort, this editorial explains how good intentions can end up causing more damage than good REFERENCES Hirshberg A, Holcomb JB, Mattox KL: Hospital trauma care in multiple-casualty incidents: A critical view Ann Emerg Med 37:647–652, 2001 Committee on Trauma, American College of Surgeons: Disaster planning and management In Committee on Trauma, American College of Surgeons: Resources for optimal care of the injured patient, Chicago, 2006, American College of Surgeons, pp 125– 131 O’Neill PA: The ABC’s of disaster response Scand J Surg 94:259– 266, 2005 Aylwin CJ, Konig TC, Brennan NW, et al: Reduction in critical mortality in urban mass casualty incidents: Analysis of triage, surge, and resource use after the London bombings on July 7, 2005 Lancet 368:2219–2225, 2006 Hirshberg A: Multiple casualty incidents: Lessons from the front line Ann Surg 239:322–324, 2004 Hirshberg A, Scott BG, Granchi T, et al: How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis J Trauma 58:686–693, 2005 De Boer J: Order in chaos: modelling medical management in disasters Eur J Emerg Med 6:141–148, 1999 Gutierrez de Ceballos JP, Turegano Fuentes F, Perez Diaz D, et al: Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings Crit Care Med 33:S107–S112, 2005 Macintyre AG, Weir S, Barbera JA: The international search and rescue response to the U.S Embassy bombing in Kenya: The medical team experience Prehosp Disaster Med 14:215–221, 1999 10 Stein M, Hirshberg A: Medical consequences of terrorism The conventional weapon threat Surg Clin North Am 79:1537–1552, 1999 11 Kahn CA, Schultz CH, Miller KT, et al: Does START triage work? An outcomes assessment after a disaster Ann Emerg Med 54:424– 430, 430 e421, 2009 12 SALT mass casualty triage: Concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association Disaster Med Public Health Prep 2:245– 246, 2008 13 Cushman JG, Pachter HL, Beaton HL: Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City J Trauma 54:147–154, 2003 14 Hirshberg A, Stein M: Trauma care in mass casualty incidents In Feliciano DV, Mattox KL, Moore EE, editors: Trauma, ed 6, New York, 2008, McGraw Hill 15 McSwain N, Jr: Disaster preparedness perspective from 90.05.32w, 29.57.18n Crit Care 10:108, 2006 16 Mattox KL: Hurricanes Katrina and Rita: Role of individuals and collaborative networks in mobilizing/coordinating societal and professional resources for major disasters Crit Care 10:205, 2006 17 Almogy G, Belzberg H, Mintz Y, et al: Suicide bombing attacks: Update and modifications to the protocol Ann Surg 239:295– 303, 2004 18 Frykberg ER: Medical management of disasters and mass casualties from terrorist bombings: How can we cope? J Trauma 53:201– 212, 2002 19 Frykberg ER: Triage: Principles and practice Scand J Surg 94:272–278, 2005 20 Hirshberg A, Frykberg EF, Mattox KL, Stein M: Triage and trauma workload in mass casualty: A computer model J Trauma 69:1074–1081, 2010 21 Stein M: Urban bombing: A trauma surgeon’s perspective Scand J Surg 94:286–292, 2005 22 Coupland RM: Epidemiological approach to surgical management of the casualties of war BMJ 308:1693–1697, 1994 23 Einav S, Schecter WP, Matot I, et al: Case managers in mass casualty incidents Ann Surg 249:496–501, 2009 24 Hirshberg A, Stein M, Walden R: Surgical resource utilization in urban terrorist bombing: A computer simulation J Trauma 47: 545–550, 1999 25 Shamir MY, Rivkind A, Weissman C, et al: Conventional terrorist bomb incidents and the intensive care unit Curr Opin Crit Care 11:580–584, 2005 26 Einav S, Aharonson-Daniel L, Weissman C, et al: In-hospital resource utilization during multiple casualty incidents Ann Surg 243:533–540, 2006 The Surgeon’s Role in Mass Casualty Incidents  Chapter 25  615 35 Born CT: Blast trauma: The fourth weapon of mass destruction Scand J Surg 94:279–285, 2005 36 Pizov R, Oppenheim-Eden A, Matot I, et al: Blast lung injury from an explosion on a civilian bus Chest 115:165–172, 1999 37 Cripps NP, Cooper GJ: Risk of late perforation in intestinal contusions caused by explosive blast Br J Surg 84:1298–1303, 1997 38 Paran H, Neufeld D, Shwartz I, et al: Perforation of the terminal ileum induced by blast injury: Delayed diagnosis or delayed perforation? J Trauma 40:472–475, 1996 39 Sosna J, Sella T, Shaham D, et al: Facing the new threats of terrorism: radiologists’ perspectives based on experience in Israel Radiology 237:28–36, 2005 40 Bala M, Rivkind AI, Zamir G, et al: Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury Ann Surg 248:303–309, 2008 41 Almogy G, Luria T, Richter E, et al: Can external signs of trauma guide management? Lessons learned from suicide bombing attacks in Israel Arch Surg 140:390–393, 2005 42 Fisher D, Burrow J: The Bali bombings of 12 October, 2002: Lessons in disaster management for physicians Intern Med J 33:125–126, 2003 SECTION III TRAUMA AND CRITICAL CARE 27 Aschkenasy-Steuer G, Shamir M, Rivkind A, et al: Clinical review: The Israeli experience: Conventional terrorism and critical care Crit Care 9:490–499, 2005 28 Ryan JM: Natural disasters: the surgeon’s role Scand J Surg 94:311–318, 2005 29 Redmond AD: Natural disasters BMJ 330:1259–1261, 2005 30 Erek E, Sever MS, Serdengecti K, et al: An overview of morbidity and mortality in patients with acute renal failure due to crush syndrome: The Marmara earthquake experience Nephrol Dial Transplant 17:33–40, 2002 31 Sever MS, Erek E, Vanholder R, et al: Lessons learned from the catastrophic Marmara earthquake: Factors influencing the final outcome of renal victims Clin Nephrol 61:413–421, 2004 32 Dries D, Perry JF, Jr: Tsunami disaster: A report from the front Crit Care Med 33:1178–1179, 2005 33 Redmond AD: Needs assessment of humanitarian crises BMJ 330:1320–1322, 2005 34 Leibovici D, Gofrit ON, Shapira SC: Eardrum perforation in explosion survivors: Is it a marker of pulmonary blast injury? Ann Emerg Med 34:168–172, 1999 ... 97 8 -1 -4 55 7 -1 14 6-8 Copyright © 2 012 , 2008, 2004, 20 01, 19 97, 19 91, 19 86, 19 81, 19 77, 19 72, 19 68, 19 64, 19 60, 19 56 by Saunders, an imprint of Elsevier Inc Copyright 19 49, 19 45, 19 42, 19 39, 19 36... Tait (18 4 5 -1 899), William Macewen (18 4 8 -1 924), and Frederick Treves (18 5 3 -1 923); German-speaking surgeons, including Theodor Billroth (18 2 9 -1 894; Fig 1- 5 ), Theodor Kocher (18 4 1- 1 917 ; Fig 1- 6 ),... (18 6 4 -1 943), Alfred Blalock (18 9 9 -1 964; Fig 1- 1 2), Dallas Phemister (18 8 2 -1 9 51) , and Charles Huggins (19 0 1- 1 997) became world-renowned surgeon-scientists Much as the ascendancy of the surgeon-scientist