TEXTBOOK OF POLYTRAUMA MANAGEMENT : a multidisciplinary approach.

Foreword
Preface
Contents
Part I: General Aspects of Trauma Care
	1: Impact of Trauma on Society
		1.1	 Introduction
			1.1.1	 Definitions
			1.1.2	 Case Load of Trauma
			1.1.3	 What Type of Trauma/Injury? Polytrauma—Potentially Life-Threatening Combination of Injuries
			1.1.4	 Sport and Fun
			1.1.5	 Impact
			1.1.6	 Conclusion
		References
	2: Economic Aspects of Trauma Care
		2.1	 Introduction
		2.2	 Cost of Injury
		2.3	 Implications of Economic Prosperity
		2.4	 Prevention
			2.4.1	 Road Traffic Injuries
			2.4.2	 Osteoporosis
		2.5	 Economical Impact of Osteosynthesis in Trauma Care
		2.6	 Conclusion
		References
	3: Evidence-Based Trauma Care
		3.1	 Principles of Evidence-Based Management
		3.2	 Quality of Evidence and the Hierarchy of Evidence
		3.3	 Presentation of Research Findings
		3.4	 Making Recommendations
		3.5	 Conclusion
		References
Part II: Acute Period (1–3 h)/Prehospital Phase and Trauma Bay
	4: Trauma System and Rescue Strategies
		4.1	 Trauma Systems
			4.1.1	 Definition of Trauma System
			4.1.2	 Trauma System Components
			4.1.3	 Implementing, Monitoring, and Improving Trauma Systems
				4.1.3.1	 Education and Training
				4.1.3.2	 System Evaluation and Quality Management
				4.1.3.3	 Hospital Resources
				4.1.3.4	 Interhospital Transfer
		4.2	 Rescue Strategies
			4.2.1	 First Tier: First Responders
			4.2.2	 Second Tier: Basic Prehospital Trauma Care
			4.2.3	 Third Tier: Advanced Prehospital Trauma Care
			4.2.4	 “Scoop and Run” Versus “Stay and play”
			4.2.5	 Prehospital Endotracheal Intubation
			4.2.6	 Prehospital Fluids
			4.2.7	 Field Triage Scores
		4.3	 Conclusion
		References
	5: Preclinical Management/Rescue
		5.1	 Introduction
		5.2	 The Basic Concept
		5.3	 Special Features of Individual Body Regions
			5.3.1	 Skull and Brain Trauma
			5.3.2	 Thoracic Injuries
			5.3.3	 Abdominal Injuries
			5.3.4	 Spinal and Pelvic Injuries
			5.3.5	 Extremity Injuries
			5.3.6	 Soft Tissue Injuries and Burns
		5.4	 Other Special Features
			5.4.1	 Strategic Aspects
			5.4.2	 Mass Casualty Incident
			5.4.3	 Principles for Drug Therapy in the Out-of-Hospital Phase
		5.5	 Case Report
		5.6	 Take-Home-Message and Conclusion
		References
	6: Initial Assessment and Diagnostics
		6.1	 Introduction
		6.2	 The Primary Survey
			6.2.1	 A—Airway
			6.2.2	 B—Breathing
			6.2.3	 C—Circulation
				6.2.3.1	 “Is the Patient in Shock?”—Clinical Assessment
					Stable
					Borderline (“At Risk”)
					Unstable
					In Extremis
				6.2.3.2	 “Is the Patient in Shock?”—Laboratory Tests
				6.2.3.3	 Postinjury Coagulopathy
				6.2.3.4	 Imaging Studies
				6.2.3.5	 Monitoring Resuscitation
			6.2.4	 D—Disability
			6.2.5	 E—Exposure
		6.3	 Secondary and Tertiary Survey
		6.4	 Conclusion
		References
	7: Volume and Blood Management
		7.1	 Introduction
		7.2	 Volume Therapy
		7.3	 Transfusion Management
		7.4	 Coagulation Management
		7.5	 Management of Anticoagulated Trauma Patients
			7.5.1	 Screening for Oral Anticoagulants
			7.5.2	 Reversal and Treatment of Oral Anticoagulants
				7.5.2.1	 Reversal of Vitamin K-Dependent Oral Anticoagulants
				7.5.2.2	 Reversal of Factor Xa Inhibitors
				7.5.2.3	 Reversal of Direct Thrombin Inhibitors
				7.5.2.4	 Reversal of Platelet Inhibitors
		7.6	 Conclusion
		References
	8: Resuscitative Endovascular Balloon Occlusion of the Aorta
		8.1	 Introduction
		8.2	 REBOA for Pelvic Fractures and Refractory Shock
		8.3	 An FDA Approved Device for Trauma
		8.4	 Procedural Steps
		8.5	 Treatment Algorithm
		8.6	 Techniques to Reduce Ischemia
		8.7	 Potential Complications
		8.8	 Future Directions
		8.9	 Conclusion
		References
	9: Preperitoneal Pelvic Packing
		9.1	 Background
		9.2	 Initial Evaluation and Management of the Pelvic Fracture Patient
		9.3	 Indications for Preperitoneal Pelvic Packing
		9.4	 Operative Approach
		9.5	 Role of Angiography
		9.6	 PPP Outcomes
		9.7	 Conclusion
		References
Part III: Primary Period (First 72 h)/Clinical Phase
	10: Pathophysiology: Trauma-Induced Coagulopathy
		10.1	 Introduction
		10.2	 Cell Mediated Hemostasis
		10.3	 Diminished Thrombin Generation
		10.4	 Platelet Dysfunction
		10.5	 Endotheliopathy
		10.6	 Hypofibrinogenemia
		10.7	 Fibrinolysis Dysregulation
		10.8	 Conclusion
		References
	11: The Inflammatory and Barrier Response After Polytrauma
		11.1	 Sensing of Danger After Polytrauma by the Immune System
			11.1.1	 Sensing of DAMPs
			11.1.2	 Sensing of MAMPs
		11.2	 Innate Immune Response After Polytrauma Drives Inflammation
			11.2.1	 Fluid Phase
			11.2.2	 Cellular Phase
		11.3	 Monitoring of the Posttraumatic Immune Response
			11.3.1	 Static Immune Monitoring
			11.3.2	 Functional Immune Monitoring
		11.4	 Posttraumatic Immune and Organ Dysfunction is Driven by Haemorrhagic Shock
		11.5	 Polytrauma-Induced Barrier Dysfunction
			11.5.1	 Macrobarriers
			11.5.2	 Microbarriers
		11.6	 Barrier Breakdown Drives Organ Failure After Polytrauma
		11.7	 Conclusion/Outlook
		References
	12: Pathophysiology: Remote Organ Injury
		12.1	 Introduction
		12.2	 Danger Associated Molecular Patterns
			12.2.1	 Protein DAMPs
			12.2.2	 Non-protein DAMPs
		12.3	 Immune Cells and Organ Dysfunction After Trauma
			12.3.1	 Polymorphonuclear Granulocytes
			12.3.2	 Monocytes/Macrophages
			12.3.3	 Lymphocytes
		12.4	 Humoral Factors and Organ Dysfunction After Trauma
			12.4.1	 Complement System
			12.4.2	 TNF-Alpha
			12.4.3	 Interleukin-1β
			12.4.4	 Interleukin-6
			12.4.5	 Interleukin-10
		12.5	 Conclusion
		References
	13: Polytrauma Scoring
		13.1	 Introduction
		13.2	 Anatomically Based Scoring Systems
			13.2.1	 Abbreviated Injury Scale (AIS)
			13.2.2	 Injury Severity Score (ISS)
			13.2.3	 New Injury Severity Score (NISS)
		13.3	 Pre-Hospital Scoring Systems
			13.3.1	 Revised Trauma Score (RTS)
			13.3.2	 Trauma and Injury Severity Score (TRISS)
			13.3.3	 Revised Injury Severity Classification RISC
			13.3.4	 The AdHOC Score
		13.4	 In-Hospital Scoring Systems
			13.4.1	 Early Appropriate Care (EAC) Protocol
			13.4.2	 Clinical Grading Scale (CGS)
			13.4.3	 Polytrauma Grading Score (PTGS)
		13.5	 Summary of Scoring Systems
			13.5.1	 Pre-Hospital Scoring Systems
			13.5.2	 In-Hospital Scoring Systems
		13.6	 Conclusion
		References
	14: Head Injuries
		14.1	 Introduction
		14.2	 The Quest for a Serum Biomarker
		14.3	 Hypoxia and Hypotension: The “Lethal Duo”
		14.4	 Classification of Head Injuries
			14.4.1	 Severity of Injury (GCS)
			14.4.2	 Morphology of Injury (CT)
				14.4.2.1	 Skull Fractures
				14.4.2.2	 Intracranial Lesions
		14.5	 Initial Assessment and Management
		14.6	 Pharmacological Therapy
		14.7	 Surgical Management
			14.7.1	 Scalp Wounds
			14.7.2	 Depressed Skull Fractures
			14.7.3	 Intracranial Mass Lesions
		14.8	 The “Polytrauma Conundrum”: TBI with Associated Femur Fracture
		14.9	 Conclusion
		References
	15: Chest Trauma: Classification and Influence on the General Management
		15.1	 Introduction
		15.2	 Injuries After Chest Trauma
			15.2.1	 Chest Wall Injuries
			15.2.2	 Injuries of the Intrathoracic Organs
				15.2.2.1	 Pleural Injuries
				15.2.2.2	 Diaphragm Injuries
				15.2.2.3	 Lung Injuries
				15.2.2.4	 Injuries to the Mediastinum
			15.2.3	 The Deadly Dozen
			15.2.4	 Pediatric Chest Trauma
		15.3	 Diagnostics
			15.3.1	 Plain Chest X-Ray
			15.3.2	 Computed Tomography
			15.3.3	 Thoracic Ultrasonography
			15.3.4	 Bronchoscopy
			15.3.5	 3D Printing for Surgical Stabilization of Rib Fractures
		15.4	 Classification
			15.4.1	 Abbreviated Injury Scale
			15.4.2	 Pulmonary Contusion Score
			15.4.3	 Computed Tomography-Dependent Wagner Score
			15.4.4	 Thoracic Trauma Severity Score
		15.5	 Treatment
			15.5.1	 Airway Management
			15.5.2	 Mechanical Ventilation
			15.5.3	 Positioning Therapy
			15.5.4	 Fracture treatment in multiple-trauma patients with thoracic trauma
			15.5.5	 Surgical Chest Wall Stabilization
			15.5.6	 Video-Assisted Thoracoscopic Surgery
		15.6	 Conclusion
		References
	16: Blunt Abdominal Trauma
		16.1	 Introduction
		16.2	 Clinical Evaluation
		16.3	 Diagnostic Testing
			16.3.1	 Focused Assessment by Sonography for Trauma
			16.3.2	 Diagnostic Peritoneal Aspiration (DPA)
			16.3.3	 Computed Tomography (CT)
		16.4	 Conduct of the Exploratory Laparotomy for Trauma
			16.4.1	 General Considerations and Setup
			16.4.2	 Initial Priorities
			16.4.3	 Systematic Exploration
		16.5	 Specific Organ Injury
			16.5.1	 Diaphragm
			16.5.2	 Hollow Viscus
			16.5.3	 Duodenum and Pancreas
				16.5.3.1	 Duodenum
				16.5.3.2	 Pancreas
			16.5.4	 Spleen
			16.5.5	 Liver
		16.6	 Conclusion
		References
	17: Penetrating Injuries of the Thorax
		17.1	 Introduction
		17.2	 Resuscitative Thoracotomy
			17.2.1	 Indications and Contraindications
			17.2.2	 Technique and Staff Safety
		17.3	 Tension Pneumothorax
			17.3.1	 Needle Decompression
				17.3.1.1	 Hemopneumothorax
			17.3.2	 Tube Thoracostomy
		17.4	 Cardiac Injury
			17.4.1	 Identification and Imaging
			17.4.2	 Indications to Intervene
			17.4.3	 Operative Exposure
			17.4.4	 Repair Options
			17.4.5	 Complications
		17.5	 Lung Injury
			17.5.1	 Identification and Imaging
			17.5.2	 Indications to Operate
			17.5.3	 Techniques for Exposure
			17.5.4	 Repair Options
		17.6	 Esophageal Injury
			17.6.1	 Identification and Imaging/Endoscopy
			17.6.2	 Indications for Operative Management
			17.6.3	 Exposure
			17.6.4	 Repair Options
			17.6.5	 Complications
		17.7	 Conclusion
		References
	18: Penetrating Abdominal Trauma
		18.1	 Introduction
		18.2	 Mandatory Laparotomy
		18.3	 Selective Nonoperative Management
			18.3.1	 Thoracoabdomen
			18.3.2	 Back/Flank
			18.3.3	 Anterior Abdomen
			18.3.4	 Gunshot Wounds
		18.4	 Conclusion
		References
	19: Pelvic Ring Injuries
		19.1	 Introduction
		19.2	 Classification of Pelvic Ring Injuries
		19.3	 The 2017 WSES Classification
		19.4	 The Role of Pelvic Binders
		19.5	 “Damage Control” External Pelvic Fixation
		19.6	 Pelvic Packing
		19.7	 Novel Innovative Concepts
			19.7.1	 Examination Under Anesthesia
			19.7.2	 Percutaneous Pelvic Ring Fixation
		19.8	 Conclusion
		References
	20: Spine Fractures
		20.1	 Introduction
		20.2	 Spine Fracture Classification
		20.3	 Spine Fracture-Dislocations
		20.4	 Diagnostic Workup
		20.5	 Spinal Precautions
		20.6	 Spinal Clearance
		20.7	 Initial Management
			20.7.1	 General Principles
			20.7.2	 Subaxial Cervical Spine
			20.7.3	 Thoracic and Lumbar Spine
			20.7.4	 Specific Injury Patterns
				20.7.4.1	 Occipital Condyle and Atlas Fractures
				20.7.4.2	 Odontoid Fractures
				20.7.4.3	 “Hangman’s Fracture”
				20.7.4.4	 “Chance” Fracture
				20.7.4.5	 Sacral Fractures
		20.8	 Surgical Timing
		20.9	 Postoperative Rehabilitation
		20.10	 Conclusion
		References
	21: Spinal Cord Injury
		21.1	 Introduction
		21.2	 Pathophysiology
		21.3	 Diagnostic Workup
		21.4	 Neurologic Evaluation
		21.5	 Terminology and Specific Injury Patterns
		21.6	 Neurogenic Versus Spinal Shock
		21.7	 Decision-Making and Treatment Options
		21.8	 Surgical Considerations
		21.9	 Surgical Timing
		21.10	 Principles of Postoperative Care
		21.11	 Special Considerations
			21.11.1	 The Role of Steroids Revisited
			21.11.2	 Riluzole
			21.11.3	 Blood Pressure Augmentation
			21.11.4	 Thromboembolic Prophylaxis
			21.11.5	 Timing of Tracheostomy
			21.11.6	 Gunshot Injuries
		21.12	 Conclusion
		References
	22: Urological Injuries in Polytraumatized Patients
		22.1	 Introduction
		22.2	 Renal Trauma
			22.2.1	 Clinical Symptoms
			22.2.2	 Imaging Studies
			22.2.3	 Treatment
			22.2.4	 Selective Angioembolizsation
		22.3	 Ureteral Trauma
			22.3.1	 Clinical Symptoms
			22.3.2	 Imaging
			22.3.3	 Management
		22.4	 Bladder Trauma
			22.4.1	 Clinical Symptoms
			22.4.2	 Imaging
			22.4.3	 Treatment
		22.5	 Urethral Trauma
			22.5.1	 Clinical Symptoms
			22.5.2	 Radiographic Examination
			22.5.3	 Treatment
				22.5.3.1	 Treatment for Urethral Injuries in Males
				22.5.3.2	 Treatment of Urethral Injuries in Females
		References
	23: Gyn. Injuries/Pregnant Patient in Polytrauma
		23.1	 The Pregnant Polytrauma Patient
		23.2	 Anatomic and Physiologic Changes During Pregnancy
		23.3	 The Right Patient to the Right Hospital
		23.4	 General Assessment of the Injured Pregnant Patient
			23.4.1	 Primary Survey
			23.4.2	 Guideline Recommendation During Primary Survey [28]
			23.4.3	 Secondary Survey
		23.5	 Radiological Assessment
			23.5.1	 Radiation Effects During Intrauterine LIFE
			23.5.2	 Cancer Risk After Intrauterine Irradiation
			23.5.3	 Genetic Effects After Irradiation
			23.5.4	 Imaging of the Pregnant Patient
		23.6	 General Recommendations for Surgical Interventions
			23.6.1	 Intraoperative Radiology
		23.7	 General Orthopedic Surgical Management
		23.8	 General Outcomes
		23.9	 Pelvic Fractures in Pregnant Polytrauma Patient
			23.9.1	 Pelvic Ring Injuries in Pregnant Patients
				23.9.1.1	 Pelvic Joint Changes During Pregnancy
				23.9.1.2	 Data on Pelvic Ring Fractures
			23.9.2	 Acetabular Fractures in Pregnant Patients
		23.10	 Special Features in treating Pregnant Women with Pelvic Ring Fractures
		23.11	 Vaginal Delivery After Pelvic Fractures
			23.11.1	 The Value of Implant Removal
		23.12	 Special Gynecological Injuries
			23.12.1	 Vulva Trauma
			23.12.2	 Vaginal Injury
				23.12.2.1	 Treatment
			23.12.3	 Rectal Injuries
			23.12.4	 Uterus Trauma
		23.13	 Summary
		References
	24: Vascular Injuries
		24.1	 Damage Control in Vascular Injury
		24.2	 REBOA
			24.2.1	 Indications
			24.2.2	 Technique
			24.2.3	 Complications
			24.2.4	 Courses
		24.3	 Hybrid Rooms
			24.3.1	 General Operative Techniques
			24.3.2	 Temporary Occlusion
			24.3.3	 Flow Restoration
				24.3.3.1	 Shunts
				24.3.3.2	 Lateral Repair
				24.3.3.3	 Stents
				24.3.3.4	 Complex Repairs and Grafts
			24.3.4	 Definitive Occlusion
				24.3.4.1	 Ligation
				24.3.4.2	 Coiling
				24.3.4.3	 Hemostatic Agents and Glues
				24.3.4.4	 Amputation
		References
	25: Compartment Syndrome: Pathophysiology, Diagnosis, and Treatment
		25.1	 Introduction
		25.2	 Diagnosis
		25.3	 History and Physical Examination
		25.4	 Interpretation of Intra-compartmental Pressures
		25.5	 Laboratory Measures
			25.5.1	 Treatment: Upper Extremity—Arm
			25.5.2	 Fasciotomies: Authors Preferred Technique
			25.5.3	 Treatment: Upper Extremity—Forearm
			25.5.4	 Fasciotomies: Authors Preferred Technique
		25.6	 ACS of the Hand
			25.6.1	 Fasciotomies: Authors Preferred Technique
		25.7	 Treatment: Lower Extremity
			25.7.1	 ACS of the Gluteal Compartment
			25.7.2	 Fasciotomies: Authors Preferred Technique
		25.8	 ACS of the Thigh
			25.8.1	 Fasciotomies: Authors Preferred Technique
		25.9	 ACS of the Leg
			25.9.1	 Fasciotomies: Authors Preferred Technique
		25.10	 ACS of the Foot
			25.10.1	 Fasciotomies: Authors Preferred Technique
			25.10.2	 Prognosis
			25.10.3	 Well Leg Compartment Syndrome (WLCS)
		25.11	 Wound Management After Fasciotomies
			25.11.1	 Authors Preferred Technique
		25.12	 Systemic Morbidity of ACS
			25.12.1	 Missed Compartment Syndrome
			25.12.2	 Author’s Preferred Technique
			25.12.3	 Morbidity of Properly Timed Fasciotomy
		25.13	 Outcomes
		25.14	 Summary
		References
	26: Damage Control in Abdomen and Thorax
		26.1	 Statement of Problem and Historical Context
		26.2	 Damage Control Resuscitation in the Pre-operative Phase: Initiation of Goal-Directed Resuscitation Without Delaying Surgery
		26.3	 Abdominal Damage Control Surgery and Organ-Specific Damage Control Maneuvers
			26.3.1	 Hollow Viscus
			26.3.2	 Liver
			26.3.3	 Spleen
			26.3.4	 Pancreas
			26.3.5	 Kidney/Ureter/Bladder
			26.3.6	 Intra-Abdominal Vascular
			26.3.7	 Management of the Open Abdomen
		26.4	 Thoracic Damage Control
			26.4.1	 Cardiac
			26.4.2	 Intra-Thoracic Vascular
			26.4.3	 Pulmonary
			26.4.4	 Chest Wall
			26.4.5	 Aerodigestive
			26.4.6	 Temporary Chest Closure
		26.5	 Damage Control Resuscitation in the Operating Room and Post-operatively
		26.6	 Conclusions
		References
	27: Fracture Management
		27.1	 Introduction
		27.2	 Assessment of the Fracture
			27.2.1	 Soft Tissue Injury in Closed Fractures
			27.2.2	 Open Fractures
		27.3	 Fracture Treatment
			27.3.1	 Upper Versus Lower Extremity Injuries
			27.3.2	 Fracture Care in Serial Extremity Fractures
		27.4	 Stages in Polytrauma
			27.4.1	 Acute Phase (1–3 h After Admission): Resuscitation/Hemorrhage Control
			27.4.2	 Primary Phase (1–48 h): Stabilization of Fractures
			27.4.3	 Secondary Period (2–10 Days): Regeneration
			27.4.4	 Tertiary Period (Weeks to Months after Trauma): Reconstruction and Rehabilitation
		27.5	 Assessment of the Patient
		27.6	 Physiology of Staged Treatment
			27.6.1	 Stable Condition
			27.6.2	 Borderline Conditions
			27.6.3	 Unstable
			27.6.4	 In Extremis Condition
		27.7	 Patient Assessment for Initial Definitive Surgery Versus Temporizing Orthopedic Surgery
		27.8	 Special Situations
			27.8.1	 Surgical Priorities in the Presence of Additional Head Injuries
			27.8.2	 Surgical Priorities in the Presence of Additional Chest Injuries
			27.8.3	 Surgical Priorities in the Presence of Additional Pelvic Ring Injuries
		27.9	 Conclusion
		References
	28: Mangled Extremity: Management in Isolated Extremity Injuries and in Polytrauma
		28.1	 Introduction
		28.2	 Mechanism of Injury
		28.3	 Common Injury Patterns
		28.4	 Scoring Systems
		28.5	 Management
		28.6	 Complications
		28.7	 Predictive Ability of Scoring Systems to Predict Final Outcome
		28.8	 Outcomes Following Limb Salvage Versus Amputation
		28.9	 Cost of Care
		28.10	 The Mangled Upper Extremity
		28.11	 The Mangled Extremity and Polytrauma
		28.12	 Conclusions
		References
	29: Surgical Management: Elderly Patient with Polytrauma
		29.1	 Introduction
		29.2	 Physiologic Differences between Younger Adults and Older Adults in the Trauma Situation
			29.2.1 Physiologic Differences
			29.2.2 Medical Comorbidities
		29.3	 Common Mechanisms of Injury
		29.4	 Frequent Patterns of Injury
			29.4.1 Pelvic Ring Injuries
				29.4.1.1	 Representative Case: Non-op Pelvic Fracture Can Have Significant Bleeding Risk
			29.4.2 Acetabular Fractures
				29.4.2.1	 Representative Case: Medium Energy Injury, High-Energy Fracture
			29.4.3 Spine Fractures
			29.4.4 Hip Fractures
			29.4.5 Traumatic Brain Injury
			29.4.6 Rib Fractures
		29.5	 Relevance of Scoring Systems
		29.6	 Appropriate Triage of the Older Adult Involved in Trauma
		29.7	 Initial Evaluation and Resuscitation
		29.8	 Pain Control/Anesthesia
		29.9	 Co-Management with Geriatrics and Palliative Care Specialists
		29.10	 Timing of Surgery
			29.10.1 Representative Case: Timing of Surgery and Appropriate Team-Based Clearance
		29.11	 Initial Operative Management
		29.12	 Secondary Operative Management
			29.12.1 Open Fractures
			29.12.2 Osteoporotic Fractures
			29.12.3 Peri- and Intra-Articular Fractures
			29.12.4 Periprosthetic Fractures
				29.12.4.1	 Representative Case: Open Fractures and Osteoporotic Bone (High Energy Leads to Devastating Injury Complex)
		29.13	 Post-op Complications
		29.14	 Secondary Fracture Prevention and Fracture Liaison Services
		29.15	 Outcomes of Care and Expectations for the Patient and Family
		29.16	 Conclusions
		References
	30: Pediatric Polytrauma Management
		30.1	 Initial Assessment and Resuscitation
		30.2	 Head Injuries
		30.3	 Chest Injuries
		30.4	 Abdominal Injuries
			30.4.1	 Liver and Splenic Injuries
			30.4.2	 Hollow Viscus Injuries
			30.4.3	 Pancreatic Injuries
		30.5	 Pelvic Injuries
			30.5.1	 Pelvic Ring Fractures
			30.5.2	 Acetabulum Fractures
			30.5.3	 Associated Injuries
		30.6	 Spine Injuries
			30.6.1	 Cervical Spine Fractures
			30.6.2	 Thoracolumbar Spine Fractures
		30.7	 Extremity Trauma
			30.7.1	 Principles of Care
		30.8	 Pediatric Critical Care
		30.9	 Conclusion
		References
	31: Surgical Management: Management of Traumatic Bone Defects
		31.1	 Introduction
			31.1.1	 Epidemiology
			31.1.2	 Initial Patient Management
			31.1.3	 Reconstruction Versus Amputation
		31.2	 Skeletal Fixation and Soft Tissue Coverage
		31.3	 Management of Bone Defects
			31.3.1	 Definition of “Critical”-Sized Bone Defect
			31.3.2	 Autologous Bone Grafts
			31.3.3	 Distraction Osteogenesis (Ilizarov Technique)
			31.3.4	 Vascularized Bone Grafts (VBG)
			31.3.5	 Induced Membrane Technique (IMT)
			31.3.6	 Titanium Mesh Cages
			31.3.7	 Arthroplasty—Megaprosthesis
		31.4	 Conclusion
		References
	32: Surgical Management: Acute Soft Tissue and Bone Infections
		32.1	 Introduction
		32.2	 Classification of SSTIs
		32.3	 Specific Types of SSTIs
			32.3.1	 Traumatic Wound Infections
			32.3.2	 Surgical Site Infections (SSIs)
				32.3.2.1	 SSI Prevention
				32.3.2.2	 Microbiology of SSIs
				32.3.2.3	 Closed Long Bone Fractures
				32.3.2.4	 Open Fractures
			32.3.3	 Necrotizing Soft Tissue Infections (NSTIs)
				32.3.3.1	 Aids to Diagnosis of NSTIs
				32.3.3.2	 Diagnostic Imaging in NSTIs
				32.3.3.3	 Microbiology of NSTIs
			32.3.4	 Pyomyositis
				32.3.4.1	 Fracture-Related Infection (FRI)
			32.3.5	 Osteomyelitis
				32.3.5.1	 Microbiology of Osteomyelitis
				32.3.5.2	 Surgical Treatment of Osteomyelitis
			32.3.6	 Four Important Steps in SSTI Treatment
				32.3.6.1	 Early Diagnosis and Differentiation of Necrotizing Vs. Non-necrotizing SSTI
				32.3.6.2	 Early Initiation of Appropriate Empiric Broad-Spectrum Antimicrobial Therapy with Anti-MRSA Coverage and Consideration of Risk Factors for Specific Pathogens
					Epidemiology and Microbiology of SSTIs
				32.3.6.3	 “Source Control,” I.E., Early Aggressive Surgical Intervention for Drainage of Abscesses and Debridement of Necrotizing Soft Tissue Infections
				32.3.6.4	 Pathogen Identification and Appropriate Escalation or de-Escalation of Antimicrobial Therapy
		32.4	 Conclusion
		References
Part IV: Secondary Period (3–8 Days)
	33: ICU Management: Disseminated Intravascular Coagulation (DIC)
		33.1	 Introduction
		33.2	 Trauma-Induced Coagulopathy and DIC
		33.3	 The Definition and Diagnosis
			33.3.1	 The Definition
			33.3.2	 The Diagnosis
		33.4	 Phenotypes and Time Courses
			33.4.1	 Phenotypes
			33.4.2	 Time Courses
		33.5	 Pathophysiology
			33.5.1	 Cytokines
			33.5.2	 Protease-Activated Receptors (PARs)
			33.5.3	 DAMPs and NETs
				33.5.3.1	 Cytokines and SIRS
				33.5.3.2	 Platelets and Coagulation
				33.5.3.3	 Anticoagulant Systems and Endothelial Cells
				33.5.3.4	 Activation and Impairment of Fibrinolysis
				33.5.3.5	 Brief Summary
			33.5.4	 Multiple Actions of Thrombin
		33.6	 MODS and the Prognosis
			33.6.1	 Microvascular Thrombosis
			33.6.2	 Histones and NETs
		33.7	 Management
			33.7.1	 Rationale
				33.7.1.1	 Why
				33.7.1.2	 To Whom
				33.7.1.3	 When
		33.8	 Underlying Disorders
		33.9	 Substitution Therapy
			33.9.1	 Anticoagulants
				33.9.1.1	 Heparin
				33.9.1.2	 Anticoagulant Factor Concentrates
			33.9.2	 Antifibrinolytics
			33.9.3	 Histones and NETs
		33.10	 Conclusions
		References
	34: Early ICU Management of Polytrauma Patients Who Develop Sepsis
		34.1	 Introduction
		34.2	 The Evolving Definition of Sepsis
		34.3	 Historic Perspective of Early Evidence-Based Sepsis Care
		34.4	 Current SSC EBG Care of Sepsis as It Pertains to Polytrauma Patients
		34.5	 Conclusion
		References
	35: Polytrauma and Multiple Organ Dysfunction
		35.1	 Introduction to Multiple Organ Dysfunction
			35.1.1	 Overview
			35.1.2	 Definitions of Multiple Organ Dysfunction
			35.1.3	 Scoring Systems
			35.1.4	 Epidemiology
			35.1.5	 Phenotypes
			35.1.6	 Intensive Care Utilization and Cost
		35.2	 Pathophysiology
			35.2.1	 Historical Context
			35.2.2	 Pathophysiologic Mechanisms and Host Responses to Injury
		35.3	 Actors Implicated in MOD Pathophysiology
			35.3.1	 Complement
			35.3.2	 Leukocytes
			35.3.3	 Platelets
			35.3.4	 Cytokines
			35.3.5	 The Gut
			35.3.6	 Secondary Insults
				35.3.6.1	 Transfusion
				35.3.6.2	 Infection and Sepsis
				35.3.6.3	 Surgery and Damage Control
		35.4	 Interventions to Prevent MOD
			35.4.1	 Damage Control Resuscitation
			35.4.2	 Judicious Use of Blood and Blood Product Transfusion
			35.4.3	 Timing of Secondary Interventions
			35.4.4	 Prevention of Ventilator-Induced Lung Injury
			35.4.5	 Immunonutrition
		35.5	 Long-Term Outcomes
		35.6	 Conclusion
		References
	36: ICU Management: General Management in the Elderly in ICU
		36.1	 Background
			36.1.1	 Frailty
			36.1.2	 Preexisting Conditions
			36.1.3	 Trauma Mechanism
			36.1.4	 Injury Severity
		36.2	 ICU Treatment for Geriatric Polytrauma
			36.2.1	 General Considerations
			36.2.2	 Development of Consensus Group
			36.2.3	 Therapeutic Options
				36.2.3.1	 Option A
				36.2.3.2	 Option B
				36.2.3.3	 Option C
		36.3	 Summary
		References
	37: ICU Management: Clearing Patients for Surgery
		37.1	 Introduction
		37.2	 Clinical Status After 24–48 h After ICU Admission
		37.3	 Clinical Status Following Day 2 After ICU Admission
		References
	38: ICU Management: Venous Thromboembolism
		38.1	 Definition and Epidemiology of Venous Thromboembolism
		38.2	 Risk Factors of VTE
		38.3	 VTE in Polytrauma Patients
		38.4	 Goal of VTE Care for Polytrauma Patients
		38.5	 Screening of VTE for Polytrauma Patients
		38.6	 VTE Prophylaxis for Polytrauma Patients
		38.7	 Mechanical Thromboprophylaxis
		38.8	 Chemical Thromboprophylaxis
			38.8.1	 Heparins
			38.8.2	 Fondaparinux
		38.9	 Inferior Vena Cava Filter
		38.10	 The American College of Chest Physicians Guidelines, 9th Edition
		38.11	 Treatment of VTE
		38.12	 Case Studies
			38.12.1 Case 1: A 57-Year-Old Man
			38.12.2 Case 2: A 71-Year-Old Man
		38.13	 Conclusion
		References
Part V: Tertiary Period (After 8 Days)/Rehabilitation
	39: Rehabilitation Strategies in Polytrauma
		39.1	 Introduction
		39.2	 Aims of Rehabilitation in Polytrauma
		39.3	 Phases of Rehabilitation
		39.4	 Outcome
		References
	40: Treatment of Fracture-Related Infections
		40.1	 Introduction
		40.2	 Pathogenesis
		40.3	 Definition and Diagnosis
			40.3.1	 Clinical Features
			40.3.2	 Laboratory Examination
			40.3.3	 Imaging Procedures
			40.3.4	 Microbiology and Histopathology
		40.4	 Treatment
			40.4.1	 General Considerations
			40.4.2	 Surgical Concepts
			40.4.3	 Antimicrobial Concepts
				40.4.3.1	 Empiric Antibiotic Therapy
				40.4.3.2	 Targeted Antibiotic Therapy
		40.5	 Follow-Up
		40.6	 Conclusion
		References
	41: Management of Aseptic Malunions and Nonunions
		41.1	 Introduction
		41.2	 Patient Evaluation and Diagnosis
		41.3	 Classification of Nonunion
		41.4	 Diagnosis of Nonunion
		41.5	 Treatment of Nonunion
		41.6	 Non-operative Treatment of Nonunion
		41.7	 Surgical Treatment of Aseptic Nonunion
		41.8	 Surgical Treatment of Malunion
		41.9	 Bone Grafting
		41.10	 Implantable Bone Stimulator
		41.11	 Conclusion
		References
	42: Strategies for Visceral Complications
		42.1	 General Considerations and Definitions
		42.2	 Deviation from an Ideal Postoperative Course
			42.2.1	 Postoperative Bleeding
			42.2.2	 Wound Healing Disorders
			42.2.3	 Small Bowel Obstruction
			42.2.4	 Anastomotic Leakage
			42.2.5	 Fistula Following Small Bowel Injuries
			42.2.6	 Abdominal Compartment Syndrome (ACS)
			42.2.7	 Incisional Hernia (Fig. 42.5)
			42.2.8	 How to Go on with Visceral Complications in Polytraumatized Patients?
			42.2.9	 Role of Laparoscopy
		42.3	 Examples
			42.3.1	 Example 1
				42.3.1.1	 What Happened, What Was Going Wrong?
			42.3.2	 Example 2
		42.4	 Conclusions
		References
	43: Rehabilitation: Soft Tissue Coverage
		43.1	 Timing of Soft Tissue Reconstruction and Patient Selection
		43.2	 The Trauma Zone
		43.3	 The Role of Negative Pressure Therapy
		43.4	 Definite Soft Tissue Reconstruction of the Lower Extremity
			43.4.1	 Skin Grafts
			43.4.2	 Local or Distant (Regional) Flaps
			43.4.3	 Free Tissue Transfer
			43.4.4	 Free Flap Choices
		43.5	 Postoperative Regime
			43.5.1	 Anticoagulation
			43.5.2	 Temperature
			43.5.3	 Nutritional Factors
			43.5.4	 Monitoring
			43.5.5	 Immobilization and Elevation
		43.6	 Outcome
		References
	44: Principles of Surgical Patient Safety
		44.1	 Introduction
		44.2	 From “Blame and Shame” to High Reliability
		44.3	 Effective Communication
			44.3.1	 Readbacks
			44.3.2	 SBAR
			44.3.3	 AIDET
		44.4	 Surgical Safety Checklists
			44.4.1	 Pre-procedure Verification
			44.4.2	 Surgical Site Marking
			44.4.3	 The Surgical “Time-Out”
		44.5	 The Next Frontier of Patient Safety: Individual Accountability
		44.6	 Conclusion
		References
	45: Psychiatric Issues in the Treatment of Severe Trauma
		45.1	 Introduction
		45.2	 Research Approaches to Psychiatric Disorders in Patients Receiving Treatment for Traumatic Injuries
		45.3	 Psychiatric Illness in Patients with Traumatic Injuries
			45.3.1	 Psychiatric Illness in Adult Patients with Traumatic Injuries
			45.3.2	 Psychiatric Illness in Pediatric Patients with Traumatic Injuries
			45.3.3	 Clinical Implications of Psychiatric Illness in Patients Receiving Treatment for Traumatic Injuries
		45.4	 Identification of Psychiatric Illness in Patients with Traumatic Injuries
		45.5	 Mental Health Care for Patients with Traumatic Injuries
		45.6	 Conclusions
		References
	46: Rehabilitation: Long-Term Outcome and Quality of Life
		46.1	 Introduction
		46.2	 Validity of Outcome Data
		46.3	 Level of Evidence
		46.4	 Outcome Measures
		46.5	 Patient Follow-Up
		46.6	 Numerical Results
		46.7	 Size of Treatment Effect
		46.8	 Precision of the Estimated Treatment Effect
		46.9	 Statistical Significance
		46.10	 Implications for the Clinical Practice
		46.11	 Outcome After Lower Extremity Injuries
		46.12	 Outcome After Upper Extremity Injuries
		46.13	 Conclusions
		References