L

Language Disorders Lateral Epicondyle Fractures

Traumatic Brain Injury: Cognitive/Speech- Pediatric Fractures About the Elbow

Language Issues

Lawsuit

Laparostomy Litigation

Prolonged Open Abdomen

Laxation

Bowel Active Agents in the ICU

Latent Period of Baudet

Delayed Splenic Rupture

Laxatives

Bowel Active Agents in the ICU

Lateral Condyle Fractures of the

Humerus Lean

Pediatric Fractures About the Elbow Performance Improvement

# Springer-Verlag Berlin Heidelberg 2015

P.J. Papadakos, M.L. Gestring (eds.), Encyclopedia of Trauma Care,
DOI 10.1007/978-3-642-29613-0
870
Lean Body Mass Wasting
Khanjan H. Nagarsheth
R Adams Cowley Shock Trauma Center,
University of Maryland School of Medicine,
Baltimore, MD, USA
Synonyms
Cachexia; Loss of lean body mass; Muscle
wasting
Definition
Lean body mass wasting is a syndrome affecting
many critically ill and trauma patients where
there is a significant loss of skeletal muscle,
which is the bodys major protein store (Fagan
et al. 1996). This condition is the result of a shift
in the equilibrium between protein synthesis and
protein catabolism.
Preexisting Condition
Background
About one-half of a persons total body weight is
made of lean body mass in the form of skeletal
muscle. It has been shown that the average 70-kg
person makes and breaks down about 280 g of
protein per day (Mitch and Goldberg 1996).
Skeletal muscle is composed of about 75 %
water, 20 % protein, and 5 % salts and pigments.
When protein breakdown is accelerated and
synthesis is not increased, muscle atrophy results.
In the critical care and trauma patient, many
will be immobile due to their illness or injuries and
will undergo disuse atrophy. This phenomenon
occurs quickly, usually within the first week after
being immobile. It has been noted that strength and
endurance are decreased by 20 % in the first week
and by 50 % after about 2 months (Jagmin 2002).
Studies have shown that trauma patients and crit-
ically ill septic patients will lose about 16 % of
their total body protein and 17 % of their total body
Lean Body Mass Wasting
water during a 3-week period (Finn et al. 1996).
Cachexia is associated with the release of tumor
necrosis factor-alpha and other proinflammatory
cytokines such as interleukin-1 and interleukin-6.
These inflammatory mediators are associated with
systemic inflammatory response syndrome (SIRS)
and multiple organ dysfunction syndrome
(MODS). This makes it easier to understand why
lean muscle wasting can be particularly devastat-
ing in the critically ill or trauma patient.
Pathophysiology
Multiple myofibrils, which are the contractive
component to skeletal muscle, are arranged to
make up muscle fibers. Skeletal muscle fibers
are organized into bundles known as fascicles.
Muscle function is based on its orientation and
shape. Some of the shapes of skeletal muscle
include fusiform, parallel, and bipennate. Muscle
fibers are surrounded by connective tissue known
as endomysium. Fascicles are surrounded by
similar fibrous tissue known as perimysium and
whole muscle groups are surrounded by
connective tissue known as epimysium. These
connective tissues coalesce into tendons that are
the boney insertions for muscles and allow for
forceful contraction and movement of joints.
Skeletal muscle fibers are designated as either
type 1 or type 2, depending on function. Type 1
fibers are also known as slow-twitch or red
muscle fibers; are responsible for slow, forceful
contractions; and are resistant to fatigue. These
fibers require energy in the form of adenosine
triphosphate (ATP) which is obtained through
oxidative phosphorylation. Type 2 fibers are
also known as fast-twitch or white muscle fibers.
They are responsible for high strength fast
contractions and are very susceptible to fatigue.
Type 2 fibers have higher glycogen content than
type 1 fibers and are able to undergo anaerobic
metabolism in order to obtain ATP.
As stated, lean muscle wasting occurs when
there is more proteolysis than protein catabolism.
This can be due to inadequate intake of nitrogen-
rich foods and resultant malnutrition. Depletion of
glutamine leads to lack of production of glutathi-
one, which plays an important role as a free radical
scavenger, thereby preventing the damage caused
Lean Body Mass Wasting
by reactive oxygen species. Malnutrition and pro-
teolysis also results in the liberation of cytokines,
reactive oxygen species, and proinflammatory
mediators that result in SIRS and MODS. These
states result in further anorexia and a worsened
hypermetabolic state. This then causes increased
gluconeogenesis and lipidogenesis, where lean
muscle and protein are the substrates that are
catabolized (Childs 2003).
Lean body wasting causes weight loss, anemia,
thrombocytopenia, impaired wound healing, and
poor humoral and cell-mediated immune response,
thereby resulting in an immunocompromised state.
Patients who areprofoundly susceptible to these
problems are those of advanced age and those
who have chronic systemic diseases of the
cardiac, pulmonary, and gastrointestinal systems.
Preexisting cancers, such as those of the pancreas
and lung, are associated with a hypermetabolic state
and some will secrete hormones that will cause
increased protein catabolism (Fearon et al. 1999).
Application
Diagnostics
In healthy individuals, total body potassium is
considered the gold standard for assessing lean
body mass. This is performed with either 40K or
NaBr dilution, but these tracers require a constant
body concentration of water and the critically ill
trauma patient is subjected to significant fluid
shifts and problems with kidney and intestinal
function, so these tests are not applicable
(Speakman 1990). Bioelectrical impedance anal-
ysis is a noninvasive method to assess fat-free
mass in patients and has been used with varying
success in critically ill patients. The problem with
this method is that the results are misleading for
fluid overloaded patients. Dual-energy X-ray
absorptiometry (DEXA) is able to more accu-
rately assess body composition but the downsides
include needing to transport patients to the
scanner, which in critically ill patients can be
a treacherous endeavor (Kyle et al. 1998). There
are also proponents of bedside clinical measure-
ments as an assessment of nutritional adequacy
and body cell mass. These include height, trunk
871
length, leg circumference, and changes in weight.
The Nutrition Risk Screening and Subjective
Global Assessment are tools that were created to
identify patients who would most benefit from
nutrition interventions based on bedside clinical
scoring parameters of nutritional status, like
those mentioned above (Kondrup et al. 2003).
Treatment
Trauma and critical illness both greatly increase
the metabolic demands for patients. This results
in skeletal muscle breakdown to make substrate
for gluconeogenesis, as noted earlier. So after
a patients caloric needs are calculated, it is
important to begin nutritional supplementation
when possible and tolerable by the patient.
Nutritional support is given in either an enteral
form or parenteral form. The standard thinking
has long been to use the gastrointestinal tract
when possible, since this has been shown to
decrease morbidity and mortality in critically ill
patients. Enteric feeding results in better mucosal
integrity and mucosal immunity. It has also been L
shown that early feeding, within 48 h, results in
better outcomes and decreased morbidity for the
patient. Enteral nutrition can be held up to 8 days
in patients before parenteral nutrition should be
started. Delayed start of parenteral nutrition has
been shown to decrease infectious complications
in critically ill patients (Casaer et al. 2011).
Patients who are receiving enteral feeds
should be monitored for feed tolerance, and
those who have significant abdominal distention
or discomfort may be showing signs that they are
not tolerating feeds. Gastric residual volumes
have long been used to assess whether a patient
is tolerating feeds, but recent work has shown that
500 mL of nasogastric aspirate is acceptable as
a residual volume, and more recent work has
questioned the need to check gastric residuals at
all, citing no increase in aspiration events. Those
patients who receive more goal nutrition have
better outcomes, less infectious complications,
and less overall morbidity.
Summary
Lean body mass wasting is a problem seen in
critically ill patients as they have an increased
872 Legal Action

metabolic demand. Their skeletal muscle is bro-

ken down to provide fuel for gluconeogenesis Legal Action
in the liver. Lean body mass wasting results
from multiple factors and processes, and there Litigation
are several diagnostic modalities that can be
used to identify patients who are at risk for
malnourishment and loss of skeletal muscle.
Early enteric feeding is preferred as it imparts LEMON
immunologic benefits, versus parenteral
nutrition. Airway Assessment

Cross-References
Lethal Triad
Nutritional Deficiency/Starvation
Nutritional Support Damage Control Resuscitation

References
Leukoreduced Red Blood Cells
Casaer MP, Mesotten D, Hermans G et al (2011) Early
versus late parenteral nutrition in critically ill adults.
N Engl J Med 365(6):506617
Harvey G. Hawes1, Bryan A. Cotton1 and
Childs SG (2003) Muscle wasting. Orthop Nurs Laura A. McElroy2
1
22(4):251257 Department of Surgery, Division of Acute Care
Fagan JM, Ganguly M, Tiao G, Fischer JE, Hasselgren PO Surgery, Trauma and Critical Care, University of
(1996) Sepsis increases oxidatively damaged proteins
Texas Health Science Center at Houston,
in skeletal muscle. Arch Surg 131:13261332
Fearon KC, Barber MD, Falconer JS, McMillan DC, Ross The University of Texas Medical School at
JA, Preston T (1999) Pancreatic cancer in a model of Houston, Houston, TX, USA
inflammatory mediators, acute-phase response, and 2
Department of Anesthesiology, Critical Care
cancer cachexia. World J Surg 23:584588
Medicine, University of Rochester Medical
Finn PJ, Plank LD, Clark MA, Connolly AB, Hill GL
(1996) Progressive cellular dehydration and proteoly- Center, Rochester, NY, USA
sis in critically ill patients. Lancet 347:654656
Jagmin MG (2002) Assessment and management of
immobility. In: Maher A, Salmond S, Pellino T (eds)
Orthopaedic nursing, 3rd edn. W. B. Saunders,
Synonyms
Philadelphia, pp 100129
Kondrup J, Hjgaard Rasmussen H, Hamberg O, Sanga Z, White blood cell reduced red blood cells
Ad Hoc ESPEN Working Group (2003) Nutrition Risk
Screening (NRS 2002): a new method based on an
analysis of controlled clinical trials. Clin Nutr
22(3):321336 Definition
Kyle UG, Pichard C, Rochat T, Slosman DO, Fitting JW,
Thiebaud D (1998) New bioelectrical impedance Leukoreduction, or the removal of white blood
formula for patients with respiratory insufficiency:
comparison to dual-energy X-ray absorptiometry. Eur
cells (WBCs) from blood products, has been stud-
Respir J 12:960966 ied as a means to reduce some the complications
Mitch WE, Goldberg AL (1996) Mechanisms of muscle associated with allogeneic blood transfusion. Cur-
wasting. N Engl J Med 335(25):18971905 rently, the literature supports leukoreduction of
Speakman JR (1990) Principles, problems and a paradox
red blood cells as a means to reduce the risk of
with the measurement of energy expenditure of
free-living subjects using doubly-labelled water. Stat febrile nonhemolytic transfusion reactions, HLA
Med 9:13651380 alloimmunization, and cytomegalovirus infection,
Life Support Training
though there may be other yet to be proven benefits
including reduction in viral infection and cancer
cell transmission (King et al. 2004). Currently,
leukoreduction of red blood cells is routine in
most developed countries, except the United
States, where only approximately half of RBC
units transfused are leukoreduced. It has been esti-
mated that the cost of leukoreduction is approxi-
mately $35 US dollars per unit of blood product
(Gorgas and Kaide 2013).
Leukoreduction can be achieved by a number
of methods including leukofiltration, sedimenta-
tion and freeze thawing, and apheresis of red
blood, with filtration being the most common.
Leukoreduction is preferably done prior to PRBC
storage and within 72 h of collection, rather than
by bedside filtration at the time of transfusion. This
standard practice evolved as a means of avoiding
transfusion of the soluble components of leuko-
cyte production, such as oxygen free radicals. By
American Association of Blood Bank definition,
a unit of PRBCs is said to be leukoreduced if it
contains less than 5  106 residual donor WBCs
(Glenister and Sparrow 2010).
There has been recent interest in the trauma
literature looking at leukoreduced blood products
in severely injured patients as a potential means
of reducing a host of complications including
Acute Respiratory Distress Syndrome (ARDS)
(Plurad et al. 2008; Silliman et al. 2011) and
infection (Friese et al. 2008), as well as studies
showing that prestorage leukoreduction of
blood products decreases the detrimental
effects of transfusing aged banked blood (Phelan
et al. 2010).
Cross-References
Blood Bank
Packed Red Blood Cells
References
Friese RS, Sperry JL, Phelan HA et al (2008) The use of
leukoreduced red blood cell products is associated with
fewer infectious complications in trauma patients. Am
J Surg 196(1):5661. doi:10.1016/j.amjsurg.2007.08.063
873
Glenister KM, Sparrow RL (2010) Level of platelet-
derived cytokines in leukoreduced red blood cells is
influenced by the processing method and type of
leukoreduction filter. Transfusion 50(1):185189.
doi:10.1111/j.1537-2995.2009.02353.x
Gorgas DL, Kaide CG (2013) Roberts and Hedges clin-
ical procedures in emergency medicine, 6th edn.
pp 498500, Chap 28
King KE, Shirley RS, Thoman SK et al (2004) Universal
leukoreduction decreases the incidence of febrile
nonhemolytic transfusion reactions to RBCs. Transfu-
sion 44(1):2529
Phelan HA, Gonzalez RP, Patel HD et al (2010) Prestorage
leukoreduction ameliorates the effects of aging on
banked blood. J Trauma 69(2):330337
Plurad D, Belzberg H, Schulman I et al (2008)
Leukoreduction is associated with decreased incidence
of late onset acute respiratory distress syndrome after
injury. Am Surg 74(2):117123
Silliman CC, Moore EE, Kelher MR et al (2011) Identifica-
tion of lipids that accumulate during the routine storage
of prestorage leukoreduced red blood cells and cause
acute lung injury. Transfusion 51(12):25492554.
doi:10.1111/j.1537-2995.2011.03186.x
Life Support Training
L
Catherine L. Gaines
Emergency Medical Associates, Southeastern
Regional Medical Center, Lumberton, NC, USA
Synonyms
Advance life support; Advanced cardiac life
support (ACLS); Basic cardiac life support
(BCLS); Cardiopulmonary resuscitation (CPR);
Critical care support; Disaster management;
Pediatric advanced life support (PALS)
Definition
Life support refers to a spectrum of techniques,
devices, or technology used to maintain life after
the failure of one or more vital organs.
Preexisting Condition
A patient requires life support when one or more
vital organs fail, due to causes such as trauma,
874
infection, cancer, heart attack, or chronic disease.
Among the purposes of life support are to:
Establish and maintain the ABCs of
resuscitation airway, breathing, and
circulation.
Restore the patients homeostasis the inter-
nal chemical and physical balance of the body.
Protect the patient from complications of the
underlying disease and its treatment.
Contraindications to life support would
be patient preference as outlined in a DNR or
do-not-resuscitate order previously actuated
by the patient. Other contraindications include
the patients healthcare power of attorney
rescinding continued life support or if family
members and medical staff agreed to the futility
of further treatment and withdrawal of care.
Application
Application of cardiopulmonary resuscitation
(CPR) should begin at the earliest possible rec-
ognition of cardiopulmonary distress, regardless
of the skill level of the bystander. Emergency
medical service (EMS) should be activated, but
the closest bystanders should begin bystander
CPR. As soon as a defibrillator is on scene, this
should be used to determine the hearts rhythm
and if intervention with electricity would be
beneficial. Rapid transfer to a facility of higher
care is then initiated, all proven strategies to
improve outcomes.
Life Support Training
With the advent of basic life support (BLS) in the
1950s, a new era to life support training emerged.
Rather than having centers of excellence and luck
driving the patients chances of survival, an idea
of standardization as the norm began to take hold.
In this way no matter where the patient received
care, there would be a certain level of compe-
tence and treatment based on best practices
ensuring better outcomes. This theory was then
expanded to lay people in the field. This idea later
focused to specialization to pediatrics, obstetrics,
Life Support Training
advanced life support, and critical care support
and continues to grow from there. Disparities in
care seem to drive the next avenues of pursuit.
Rather than offer a set of cookie cutter
approaches to patient care, these modules offer
basic treatment strategies steeped in evidence-
based research that also offer algorithms to refer
to higher levels of care when needed.
Resuscitation was initially endorsed in 1740
by the Paris Academy of Sciences officially
recommended rescue breathing for drowning vic-
tims. However, it was not until the early 1900s
that the first use of closed compression cardiac
massage was initiated. When James Elam proved
in 1954 that expired air from a rescuer had oxy-
gen content high enough for a resuscitative effort,
the idea of cardiopulmonary resuscitation was
considered. Dr. Elam and Peter Safar went on to
invent mouth-to-mouth resuscitation. The US
Military quickly jumped on this idea and began
teaching mouth-to-mouth resuscitation for
unresponsive persons as part of their training
curriculum. By 1960, the American Heart Asso-
ciation began operating a training program for
physicians for closed-chest resuscitation called
cardiopulmonary resuscitation or CPR. Later
calls for standardization of training were
responded to with consensus statements from
key leaders in the field, and one method for
CPR was approved. Dr. Leonard Cobb of Seattle,
Washington, believed so completely in the pro-
cess that he advocated for teaching CPR to lay
people and in 1972 had the first mass teaching
program for the public. Advanced trauma life
support came into the consciousness of the Amer-
ican College of Surgeons in the mid-1970s, fol-
lowing a tragic airplane crash of a prominent
trauma surgeon and his family. The push to once
again raise a certain level of care regardless of
location spurred the college to create a program of
protocols offered in an easily memorized algo-
rithm. In 1979, the 3rd National Conference on
CPR generated discussion of a more advanced
approach to resuscitation, with the same goal of
standardization of care among medical personnel.
Shortly thereafter planning and training was initi-
ated for 911 Operator/Dispatcher directed CPR
Life Support Training
via phone with lay persons at the scene. By 1983,
the American Heart Association (AHA) met and
discussed standardization for pediatric life sup-
port in conjunction with the American Academy
of Pediatrics (AAP). From this meeting evolved
pediatric basic life support, advanced life support,
and neonatal resuscitation. By the early 1990s,
a movement was started to get the best chance
for survival for out-of-hospital cardiac arrest
(OHCA). There are over 300,000 OHCA in the
United States alone and extremely poor survival
statistics. How to get the defibrillator out of the
ambulance and into the hands of the public, but
safely? Early defibrillation machines and proto-
cols soon followed. Fine tuning of compression to
ventilation ratios was hammered out over succes-
sive years and committees. However, with the
realization of confusion over ventilation to com-
pression ratios in the lay public, a push came to
simplify out-of-hospital resuscitation. Therefore,
compression-only CPR was initiated to increase
involvement by stranger initiated CPR.
Despite these advances, resuscitation statistics
remain grim, and there is a wide variation in the
rates of recovery from region to region (Neumar
et al. 2011). However, in this disparity lies the
hope for improvement. How to take the best of
the best and translate that to a national average?
Through greater standardization and improved
communication, the possibility for improved
overall survival rates exists. Clearly, more work
remains to be done to raise overall standards of
care. Expanding the notion of team from the
bystander on the street to the intensivist in the
ICU with access to appropriate levels of training
might be a first step. This advances the idea that
the smarter the team, the better the outcome.
Courses: From Pre-hospital to ED Arrival
Basic Life Support (BLS)
Basic life support (BLS) as it is known today
consists of mouth to mouth, with closed-chest
compression and defibrillation when indicated
and available. Out-of-hospital cardiac arrest
survival rates are between 1 % and 6 %
(Engdahl et al. 2002). Rates improve with
875
immediate initiation of excellent CPR and early
defibrillation. Those treated by emergency med-
ical services personnel (EMS), fare better at
510 %, and if the underlying heart rhythm is
ventricular fibrillation, survival rises to 15 %
(Peberdy et al. 2003). The latest statistics from
the American Heart Association reveal that less
than 12 % of victims of sudden cardiac arrest
(SCA) survive to discharge from the hospital.
Effective bystander CPR can double or triple
survival chances.
Advanced Cardiac Life Support (ACLS)
Advanced cardiac life support (ACLS) guidelines
evolved over several decades through expert
panels that meet and make recommendations
based on the evidence at hand. Most data is col-
lected via retrospective studies, animal studies,
and expert consensus. The cornerstone for ACLS
is still the early initiation of excellent CPR
and defibrillation (Field et al. 2010). Addition-
ally, every effort should be made NOT to inter-
rupt CPR unless other vital procedures are L
necessary, and even then, for the briefest possible
interruption. Sudden cardiac arrest (SCA) is
a low-frequency, high-stress event and often
chaotic. ACLS seeks to teach the team to think
critically in a methodical, easy-to-remember set
of algorithms (Reznek et al. 2003). There are now
strong recommendations to use crisis resource
management (CRM) often used in aircraft emer-
gencies that focus on checklists, effective com-
munication, and leadership (Murray and Foster
2000). With cardiac rhythm-driven recommenda-
tions, and effective team dynamics, the chance to
improve survival is increased substantially.
Pediatric Advanced Life Support (PALS)
Pediatric advanced life support (PALS) was cre-
ated to simplify the approach to a child in dis-
tress. Out-of-hospital arrests and accidents for
most children age 6 months to a young adult
often occur at or very near their home. The most
common cause of death is from trauma, causing
respiratory compromise and shock (Fleegler and
Kleinman 2012). The goals of PALS are to assist
medical personnel with recognition and
876
management of respiratory distress and failure,
shock, cardiac dysrhythmias, and post resuscita-
tion management of all of the above (ECC
Committee 2005).
Advanced Trauma Life Support
Advanced trauma life support (ATLS) is the
brainchild of Dr. Jim Styner. Dr. Styners family
was involved in a plane crash that took the life of
his wife and critically injured three of his chil-
dren. From observations made regarding the level
of care they received, he began to formulate the
idea of a golden hour of care following massive
trauma, and algorithms available to every medi-
cal center, regardless of size or frequency of
dealing with major trauma. From this wellspring,
many more trauma courses have evolved, but the
mainstays of the golden hour and simplified,
stepwise care remain.
Other complementary courses for trauma
include the ATEMS is now called TEAM
(Trauma Evaluation and Management) for medi-
cal students, Advanced Trauma Care for Nurses
(ATCN) for registered nurses, and Pre-Hospital
Trauma Life Support for EMS. The Emergency
Nurses Association offers the Trauma Nursing
Core course (TNCC), and other major medical
centers have begun offering shorter courses on
management of trauma in the obstetric patient.
The idea of improved team training drives the
theory that this in turn creates a smooth transition
of care to ATLS and ATCN-trained providers in
hospitals. The overarching goal is to assess the
patients condition rapidly and accurately and
resuscitate and stabilize the patient according to
priority. Should the patients needs overwhelm
the resources of the facility, rapid transfer to
a higher level of care is initiated early, without
deterioration in care. The idea is to provide
a measurable, reproducible, and comprehensible
system of trauma care, regardless of facility size
or experience.
ATOM or Advanced Trauma Operative
Management course and ASSET or Advanced
Surgical Skill for Exposure in Trauma are
used to increase surgical competence and confi-
dence in the operative management of trauma.
Life Support Training
ATOM focuses on penetrating injuries to the
chest and abdomen. The lectures teach the man-
agement of penetrating trauma as related to
trauma laparotomy, spleen and diaphragm, liver,
pancreas and duodenum, genitourinary, and car-
diac and vascular. ASSET increases confidence in
exposure of anatomic structures that when injured
may pose a threat to life or limb. This course
provides an overview of key surgical exposures
in five key anatomic areas: neck, chest, abdomen,
pelvis, and extremities, upper and lower.
The next innovation has been the Rural
Trauma Team Development course. This course
was driven from rural trauma data collected that
revealed a startling fact. While only 25 % of the
US population lives in rural regions, more than
60 % of trauma deaths occur in remote geo-
graphic segments of the country. The main
focus of this course is organization of the medical
facilities trauma receiving area, utilization of
available resources, and regional system relation-
ships in a way that is straightforward.
In Hospital: (Recognition of Patients that Will
Need Critical Care in the Next 24-Hour Period)
Surgeons were not the only specialty working on
process improvement. Research had shown that
there was a 24-hour period of assessment and
evaluation for patients in hospitals that could
potentially prevent patient deterioration if recog-
nized early. Therefore, the intensivists at the
Society of Critical Care Medicine designed
a course that addressed fundamental manage-
ment principles for the first 24 hour of the criti-
cally ill patient. More importantly, they focused
on signs and symptoms of the deteriorating
patient, so that all levels of medical professionals
that come into contact with the patient in that
golden 24 hour might recognize and then drive
treatment for prevention of a critical illness. The
overall purpose of the course is to better prepare
the non-intensivist for the first 24 hour of man-
agement of the critically ill patient until transfer
or appropriate critical care consultation can be
arranged. It seeks to assist the non-intensivist in
dealing with sudden deterioration of the criti-
cally ill patient. From these efforts a course was
Life Support Training
developed to further evaluate and comprehend
the special circumstances involved in the pediat-
ric population via the Pediatric Critical Care
Support Course.
Disaster Management
As a response to large-scale disasters, either man
made or natural, several courses have been
developed to help hospitals deal with the
multitude of issues that crop up within the context
of a mass disaster. As with all of these courses,
communication and coordination are the
prevailing themes throughout. Offering life
support to a damaged community in the wake of
a disaster is a challenge for all involved.
Fundamentals of Disaster Management
Fundamental Disaster Management (FDM)
prepares healthcare professionals to treat victims
of natural or man-made mass casualty events.
It arms critical care professionals with the
expertise to manage the critical care response to
large-scale disasters. This one-day course
focuses on critically ill patients who are admitted
to your hospital and is a must for healthcare pro-
viders who may come in contact with critically
ill and/or injured patients after a mass casualty
event.
Disaster Management Emergency Preparedness
The American College of Surgeons (ACS)
sought to assist their surgeons to develop the
necessary skills, understand the language, and
appreciate the structural transformation for
effective response to mass casualties in disasters.
This program is designed to stimulate thinking
about how to become better prepared as individ-
uals, professionals, organizations, and healthcare
systems.
Local Programs
There have been several programs that focus on
standardization of care for a specific condition at
the local level. Generally, these are conditions
that occur frequently, are often misdiagnosed,
or failure to diagnose and treat rapidly leads to
significant morbidity and mortality.
877
RACE-ER
In 2005, Duke medical researchers designed the
RACE-ER program to coordinate and accelerate
heart attack treatment in hospitals across North
Carolina. Since its expansion in 2008, RACE-ER
has helped healthcare facilities reduce the time
between first contact with a patient and treatment
by 12 min an approximate 10 % reduction in
time. After witnessing the success of the program,
the American Heart Association has used RACE-
ER as a model for their national program, Mission
Lifeline, which focuses on the prompt treatment of
acute heart attack care. RACE-ER focuses on
improving the speed and efficiency of treatment
for heart attack patients. This includes equipping
and training paramedics to diagnose heart attacks,
in particular an ST-elevated heart attack, creating
a plan to communicate the results to the right
hospitals, taking patients to the most appropriate
hospitals, and assuring teams are ready for patient
arrival, Granger said (Mooney and Muoio 2012).
Code STEMI (ST Elevation Myocardial Infarction) L
For many hospitals there has been no systematic
process in place to identify, differentiate, and
treat patients with chest discomfort or anginal
equivalent symptoms suggesting ischemia. The
diagnosis of possible ACS must be made as
quickly as possible.
*A 12-lead ECG should be obtained within 5 min
of a patients arrival in the ED so that it can be
read within 10 min. Early ECG evaluation can
identify patients with STEMI, defined as an
ST-segment elevation of 1 mm in two or more
leads.
*Patients with STEMI should be considered for
immediate reperfusion therapy by either fibri-
nolytic therapy or percutaneous coronary
intervention (PCI).
*The guidelines for managing STEMI and
NSTEMI patients differ (Braunwald et al.
2000).
Code Sepsis
This program is designed specifically to help
emergency responders and hospital personnel
878
on how to spot the signs of sepsis and then
providing them with the tools that they need to
quickly treat patients. Standards include rapid
recognition of a patient in septic shock, rapid
administration of fluids, appropriate blood tests
ordered, to include blood cultures, and the timely
administration of appropriate antibiotics (Tejedo
et al. 2009).
Cross-References
Cardiopulmonary Resuscitation in Adult
Trauma
Cardiopulmonary Resuscitation in Pediatric
Trauma
Disaster Management
Disaster Preparedness
Life Support, Withholding and Withdrawal of
References
Braunwald E et al (2000) ACC/AHA guidelines for the
management of patients with unstable angina and non-
ST-segment elevation myocardial infarction: a report
of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines
(Committee on the Management of Patients with
Unstable Angina). J Am Coll Cardiol 36(3):9701062
ECC Committee, Subcommittees and Task Forces of the
American Heart Association (2005) American Heart
Association guidelines for cardiopulmonary resuscita-
tion and emergency cardiovascular care. Circulation
112:IV1
Engdahl J, Holmberg M, Karlson BW et al (2002) The
epidemiology of out-of-hospital sudden cardiac
arrest. Resuscitation 52:235
Field JM, Hazinski MF, Sayre MR et al (2010) Part I:
executive summary: 2010 American Heart Association
guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 122:S640
Fleegler E, Kleinman M (2012) Guidelines for pediatric life
support. www.uptodate.com. Accessed 6 Aug 2012
Mooney A, Muoio D (2012) NC accelerates heart attack
care. The Chronicle, 2 July 2012; http://www.
dukechronicle.com/article/nc-accelerates-heart-attack-
care
Murray WB, Foster PA (2000) Crisis resource management
among strangers: principles of organizing a multidis-
ciplinary group for crisis resource management. J Clin
Anesth 12:633
Neumar RW, Barhar JM, Berg RA et al (2011) Implemen-
tation strategies for improving survival after
Life Support Training
out-of-hospital cardiac arrest in the United States: con-
sensus recommendations for the 2009, American
Heart Association Cardiac Arrest Survival Summit.
Circulation 123:28982910
Peberdy MA, Kaye W, Ornato JP et al (2003) Cardiopul-
monary resuscitation of adults in the hospital: a report
of 14720 cardiac arrests from the National Registry of
Cardiopulmonary Resuscitation. Resuscitation 58:297
Reznek M, Smith-Coggins R, Howard S et al (2003) Emer-
gency medicine crisis resource management
(EMCRM): pilot study of a simulation-based crisis
management course for emergency medicine. Acad
Emerg Med 10:386
Tejedo AA, Eharte Pazos JL, Minguez Maso S et al
(2009) Emergency department implementation of
a severe sepsis code. Emergencias 21:255/261.sk
Force on Practice Guidelines (Committee on the Man-
agement of Patients with Unstable Angina). J Am Coll
Cardiol 36(3):9701062, September 2000
Recommended Reading
[ACS/DMEP] American College of Surgeons/Disaster
Management and Emergency Preparedness. http://
facs.org/trauma/disaster/index.html. Accessed 6 Aug
2012
[ACS] American College of Surgeons. History of the
ATLS program. http://facs.org/trauma/atls/history.
html. Accessed 6 Aug 2012
[AHA Guidelines] Sudden Cardiac Arrest (SCA) and
CPR Fast Facts. http://www.heart.org/HEARTORG/
CPRAndECC/WhatisCPR/CPRFactsandStats/CPR-
Statistics_UCM_307542_Article.jsp. American
Heart Association Guidelines 2012. www.
americanheart.org. Accessed 6 Aug 2012
[AHA, History] American Heart Association. Highlights of
the History of Cardiopulmonary Resuscitation (CPR).
http://www.heart.org/HEARTORG/CPRAndECC/What
isCPR/CPRFactsandStats/History-of-CPR_UCM_3075
49_Article.jsp
American Heart Association (2006). www.americanheart.
org. Accessed 6 Aug 2012
Emerg Med 2003: 10:386
[ENA] Emergency Nurses Association: Philosophy of
Trauma Nursing Core Course. http://www.ena.org/
coursesandeducation/ENPC-TNCC/tncc/Pages/aboutco
urse.aspx. Accessed 6 Aug 2012
[SCCM/FDM] Society of Critical Care Medicine/Funda-
mentals of Disaster Management Course Purpose.
http://www.sccm.org/FCCS_and_Training_Courses/FD
M/Pages/default.aspx. Accessed 6 Aug 2012
[SCCM/PCCS] Society of Critical Care Medicine/Pediat-
ric Critical Care Support. Pediatric Fundamentals of
Critical Care Course Purpose. http://www.sccm.org/
FCCS_and_Training_Courses/PFCCS/Pages/default.
aspx. Accessed 6 Aug 2012
[SCCM] Society of Critical Care Medicine: Fundamentals
of Critical Care Support Course Purpose. http://www.
sccm.org/FCCS_and_Training_Courses/FCCS/Pages/
default.aspx. Accessed 6 Aug 2012
Life Support, Withholding and Withdrawal of
Life Support, Withholding and
Withdrawal of
Younsuck Koh
Department of Pulmonary and Critical Care
Medicine, Asan Medical Center, University of
Ulsan College of Medicine, Seoul, South Korea
Synonyms
End-of-life care decision
Definition
Withdrawal (WD) of life support means the dis-
continuation of crucial life support, whereas
withholding (WH) of life support means that
life-sustaining treatments will be foregone.
A do-not-resuscitate order is an example of
the WH. WH/WD of life support does not seek
to hasten patient death: it is not euthanasia
or physician-assisted suicide. WH/WD of life
support shifts the critical care goals from cure
to comfort. This reduces unnecessary suffering
by patients and their families as death
approaches and avoids inappropriate patient
management.
Background
Continued intensive care may not be beneficial
for terminally ill patients. Issues with the
WH/WD of life support have attracted public
comment. Technological improvements in life-
sustaining measures now allow terminally ill
patients to survive longer in the intensive care
units (ICUs). Provision of optimal care for
dying patients and their families has become an
important feature of ICU quality improvement
efforts. Death in the ICU frequently follows
WH/WD of life support (Prendergast et al.
1998). In a North American study, the proportion
of patients dying after WH/WD of life support
increased from 51 % to 90 % during a 5-year
879
study period (Prendergast et al. 1998). The rea-
sons for limiting the application of life-sustaining
measures include patient refusal of such proce-
dures, a low probability of improvement, or
failure of a patient to get obtain any benefit
from a prior therapeutic procedure. WH/WD
decisions are always influenced by many factors.
The possibility of future medical improvement
and the nature of end-of-life (EOL) care feature
prominently in discussions between caregivers
and family members. Most societies have not
reached a consensus on how to balance possible
future medical improvement and apparent
present medical futility.
Ethical Principles Related to the WH/WD
of Life Support
Although not all clinicians agree, three ethical
principles relevant to the WH/WD of life support
are (Truog 2008):
1. Withholding and withdrawing of life support
are equivalent. L
2. There is an important distinction between kill-
ing and allowing to die.
3. The doctrine of the double effect provides
an ethical rationale for providing relief of pain
and other symptoms using sedatives, even
when this may have the foreseeable (but not
intended) consequence of hastening death.
Distributive justice in terms of scarce medical
resources is also frequently in play when
WH/WD decisions are made. The principles of
such justice include cost-effectiveness, cost util-
ity, and cost-benefit analyses that prohibit unfair
discrimination. In clinical situations, these ethi-
cal principles sometimes clash. Prioritizing the
probable best interests of a patient at any given
moment may be a useful approach.
Legal Aspects
The legal aspects of whether patients (or their
surrogates) have a right to refuse any kind of
medical intervention vary among countries.
Many countries do not allow physician to make
EOL care decisions based on a unilateral view of
patient best interests. Resource to a judicial solu-
tion is a last resort appropriate only when
880
repeated efforts, including referral to institutional
Ethics Advisory Committees, have failed to cre-
ate a consensus on WH/WD of life support.
Application
Clinical Settings
WH/WD of life support should be considered
when patient survival is highly unlikely even
with application of reasonable and available
treatments. Also, WH/WD should be considered
when the burden of interventions either being
delivered or that could potentially be given out-
weighs any benefit to a terminally ill patient. An
example of such a burden is inhumane suffering.
Method
Any decision to WD/WH life support is the con-
clusion of a complex process involving many
factors including the characteristics of patients
and their proxies. The process should begin
soon after ICU admission. The use of a medical
chart to identify indicators for employment of
end-of-life care is helpful to improve both the
quality and the nature of such care. ICU physi-
cians do not have the authority to WD/WH life
support, although such physicians are the appro-
priate professionals to evaluate possible clinical
benefits of present or future therapies. Respect for
the right of each patient to self-determination is
the first principle of a WH/WD decision. If
a patient retains analytical capacity, care levels
should ideally be discussed with that patient.
Patient autonomy can be expressed via the mak-
ing of a living will or an advance health directive.
To date, most ICU patients do not write advance
directives, even in countries advocating patient
autonomy in hospitals. If the care request
expressed by a patient is not appropriate, the
sharing of decision-making, in terms of end-of-
life care, by both caregivers and patient family
members, is important. The family must be given
sufficient time, and adequate clinical informa-
tion, to allow an appropriate decision to be
reached. Physicians must ensure that families do
not feel that a WH/WD decision is the only
Life Support, Withholding and Withdrawal of
choice; alternative treatments should be offered.
Effective communication is crucial to resolve
conflicts between attending physicians, trainee
doctors, nurses, and family members and to
establish efficient advance care planning.
A willingness to both listen and respond to family
members is essential if communication is to be
effective. The clinical care team should carefully
define the clinical benefits of current or potential
life support. The planned care should prioritize
the physical, social, and spiritual comfort of the
patient. All ICU therapies should be critically
evaluated in terms of patient comfort. The care-
giver team must deliver a pain-free death. Each
patient must receive enough painkiller to allevi-
ate pain and distress (Thompson et al. 2004). If
such analgesia hastens death, the double-effect
doctrine should not detract from the aim of ensur-
ing patient comfort. The family should be kept
informed throughout the entire process. Docu-
mentation of family conferences is extremely
important to facilitate progress at future meet-
ings, to improve advance care planning, and as
evidence if legal disputes occur. Organ and tissue
donation is an integral feature of end-of-life care
decisions (see Family Preparation for Organ
Donation). Any request for organ or tissue dona-
tion should be made in a private room; families
must be allowed to consider patient wishes in this
regard. The family must be given time to accept
the death prior to the posing of any such request.
No major ethical difference is evident between
WH and WD of life support. Treatment should be
based on patient benefit-burden assessment, and
not on the psychological burdens experienced by
clinicians and families. End-of-life care should
continue after death; at that time, the family
members become the patients.
Hospital Ethics Committee (HEC)
If a conflict in terms of end-of-life care arises
between caregivers and the family, and this can-
not be resolved via further communication, con-
sultation with ethicists may be helpful. The first
role of an HEC is to address the relevant ethical
issues. Suggestions made by HEC support the use
of best practice for each patient and such
Life Support, Withholding and Withdrawal of
comments sometimes play important roles in
countries in which WH/WD of life support is
not legally supported. HEC have no distinct
legal status in most countries; families are thus
free to challenge HEC decisions in court.
Outcome
Relevant Factors
End-of-life care practice varies widely among
countries and even among ICUs in the same
country. Decisions are influenced by uncer-
tainties in terms of patient outcome, patient pref-
erence, the extent of legal tolerance of WH/WD
of life support, economic and home care burdens
on patient families, and the extent of national
medical coverage. Such choices are also
influenced by aspects of medical culture such as
ICU admission and discharge policies, social
mores, and ethnic perceptions of death. More-
over, decisions are influenced by clinician expe-
rience and values; the availability of medical
resources; current practice; the religious, psycho-
logical, and relational context of the patient and
proxies; and the evolution of medical theories.
Some quality domains of end-of-life care have
been identified; these include (1) patient- and
family-centered decision-making, (2) excellent
communication, (3) continuity of care, (4) emo-
tional and practical support, (5) symptom man-
agement and comfort care, (6) spiritual support,
and (7) emotional and organizational support for
ICU clinicians (Clarke et al. 2003). Poor commu-
nication between ICU staff and patient surrogates
constitutes a major barrier to a desirable outcome.
Family Acceptance of WH/WD of Life Support
Conflicts between family members and medical
staff are not infrequent during discussion of end-
of-life decisions. Posttraumatic stress is common
among those who share in such decisions
(Azoulay et al. 2005). Proactive consultation
with ethicists, advance care planning including
discussion of palliative care, and regular well-
planned ICU staff/family conferences improve
family satisfaction. Longer intervals prior to
881
life-support WD for patients with longer ICU
stays (Gerstel et al. 2008) and provision of spir-
itual support were both associated with increased
family satisfaction with care, as was extubation
before death (Gerstel et al. 2008). However,
unnecessary prolongation of dying creates family
dissatisfaction. Uncertainty in terms of outcomes
is a frequent cause of such prolongation, and
unclear recommendations from physicians
discussing end-of-life decisions are the principal
source of dissatisfaction among family members.
The use of imprecise and insensitive terminology
during family discussions and a failure to under-
stand the wishes of the family frequently create
family dissatisfaction. The final levels of family
and caregiver satisfaction are probably the best
measure of end-of-life care practice. Encourag-
ing caregivers to view acquisition of end-of-life
skills as a lifelong educational process may
be essential if the quality of end-of-life care is
to be further improved.
L
Cross-References
Advance Directive
Autonomy
End-of-Life Care
End-of-Life Care Communication in Trauma
Patients
Hospice
Surrogate, Role in Decision-Making
References
Azoulay E, Pochard F, Kentish-Barnes N et al (2005) Risk
of post-traumatic stress symptoms in family members
of intensive care unit patients. Am J Respir Crit Care
Med 171(9):987994
Clarke EB, Curtis JR, Luce JM et al (2003) Quality indi-
cators for end-of-life care in the intensive care unit.
Crit Care Med 31(9):22552262
Gerstel E, Engelberg RA, Koepsell T, Curtis JR
(2008) Duration of withdrawal of life support in the
intensive care unit and association with family satis-
faction. Am J Respir Crit Care Med 178(8):798804
Prendergast TJ, Claessens MT, Luce JM, Prendergast TJ,
Claessens MT, Luce JM (1998) A national survey of
end-of-life care for critically ill patients. Am J Respir
Crit Care Med 158(4):11631167
882 Ligamentous Knee Injury

Thompson BT, Cox PN, Antonelli M et al (2004) Chal-

lenges in end-of-life care in the ICU: statement of the Lisfranc Injury
5th International Consensus Conference in Critical
Care: Brussels, Belgium, April 2003: executive sum-
mary. Crit Care Med 32(8):17811784 Midfoot Fractures
Truog RD (2008) End-of-life decision-making in the
United States. Eur J Anaesthesiol Suppl 42:4350

Ligamentous Knee Injury Litigation

Knee Dislocations Lesli T. Giglio

The Heart Center, St Francis Hospital, Roslyn,
NY, USA

Limb Loss
Synonyms
Amputation
Court case; Lawsuit; Legal action; Proceedings

Limited Crystalloid Definition

Damage Control Resuscitation, Military Litigation appears to be incident specific and

Trauma relates to the filing of a lawsuit for the purpose
of pursuing a right. In many instances, the types
of claims and resolutions that follow may be
controversial.
Line Infections

Catheter-Related Infections Pre-existing Condition

Historically, although medical care back in 1812

was completely different than what it is today,
Line Placement much about the legal system is completely the
same. The United States Supreme court was the
Ultrasound in the Trauma and ICU Setting highest court and the Bill of Rights was in exis-
tence. The concept that every person in a learned
profession needs to take a reasonable degree of
care and skills dates back to the laws of ancient
Liquid Plasma Transfusion Rome and England (Bal 2009). Under Roman
law, medical malpractice was a recognized
Plasma Transfusion in Trauma wrong and around 1200 AD, it was introduced
to continental Europe. The first notable case
Slater vs. Baker & Stapleton dates back to
England in 1767 (Annas 2012). Slater broke his
Lisfranc Fracture-Dislocation leg which did not heal well. He sought the treat-
ment of a surgeon named Baker who placed
Midfoot Fractures it in a heavy steel thing and he had a poor result.
Litigation
Slater brought litigation and the case went to
trial where the defendants were awarded 500.
Interestingly, this case was appealed and
the verdict was affirmed, citing that a radical
experiment could itself be considered malprac-
tice. Three surgeons testified at trial, which
seems to mirror what we call expert testimony
today.
Application
In the United States, medical malpractice suits
first began appearing with regularity in the
1800s (De Ville 1990). However, prior to
1960s, they were rare and did not have much
impact on the practice of medicine. In the United
States, medical malpractice law is under the
authority of the individual states and not
the Federal Government. It falls under the aus-
pices of civil litigation. Civil litigation is a legal
dispute between two or more parties that seek
monetary award rather than criminal sanctions.
Tort law is a combination of legislative enact-
ments and common law principles which
may vary from state to state as they are often
based on precedents from previous rulings
(Zane 2009). Medical malpractice litigation
revolves around the concept of negligence and
liability, making this type of litigation part of
tort law.
Medical malpractice is medical negligence or
professional negligence by act or omission by
a health care provider in which the treatment
provided falls below the accepted standard of
practice. There are four elements that need to be
present in order for a medical malpractice action
to be successful. There must be a professional
duty owed to the patient, a breach of duty, an
injury, and the breach of the duty must be the
proximate cause of the patients injury (Bal
2009). The breach of duty refers to what we call
the standard of care. The standard of care refers to
a duty to treat patients with a reasonable dili-
gence, skill, and competence. In general, the
standard of care is determined by the prevailing
standard of care practiced by other health care
professionals in their field.
883
Trauma Care
Clinicians perceive an increased risk associated
with trauma care because emergency patients
usually have a high acuity illness and delivery
of care is complex. Additionally, there is rarely
an ongoing relationship with their patients and
care is often handed off to another physician
(Kachalia et al. 2007).
Stewart et al. (2005) conducted a multicenter
study relating to trauma and malpractice risk. The
study period was from July 1992 to July 2004.
Patient groups were classified as trauma, elective,
or urgent. The study concluded that there was no
increased risk of litigation when caring for trauma
patients, despite the perceived increase of mal-
practice risk, which has discouraged participation
in taking call and possible career choice. Limita-
tions to the study may be due to hospital localiza-
tion and the regions unique malpractice climate.
McGwin et al. (2008) conducted a similar
study at the University of Alabama Health
System (20032006). This study compared all L
compensable medical events and actual lawsuits.
Interestingly enough the trauma service had the
fewest events and lawsuits per 10,000 patient
days and ranked 10th on a per capita basis and
9th in total estimated cost. Therefore, the
researchers concluded that trauma care had
a better claim experience than almost every
other clinical service.
There are several risk reduction strategies that
can be employed by health care professionals to
minimize your liability and decrease the likeli-
hood of a malpractice action being brought
against you. Communication is the cornerstone
to providing safe patient care. Several factors
have been linked to patients decisions to bring
malpractice claims, most notably patient
dissatisfaction, physician communication, and
his/her interpersonal skills (Hickson et al.
1994). Effective communication and teamwork
techniques are being used as a means of reducing
medical errors and preventing adverse patient
outcomes. Additionally, thorough and accurate
documentation is essential for patient care as the
medical record is a communication tool and will
also enable you to successfully defend a lawsuit
884 Liver Contusion

should one be brought against you. Lastly, as the Recommended Reading

standard of care is based on what a reasonable
practitioner in similar circumstances would do, it
is important to practice within the most recent
and acceptable guidelines. Recently, clinical
practice guidelines (CPGs) have begun to play
a role in medical malpractice claims. They play
a dual role as they can be used in litigation by the
defendant (exculpatory evidence) and by the
patients alleging a breach of the standard of care
(Mackey and Liang 2011). Frequent, open,
honest, and compassionate communication is
the single most important factor other than
excellent patient care in determining the overall
outcome (Morris et al. 2008).
Annas (2006) The patients right to safety improving the
quality of care through litigation against hospital.
N Engl J Med 354(19):20632066
Hickson GB, Federspiel CF, Pichert JW, Miller CS,
Gauld-Jaeger J, Bost P (2002) Patient complaints and
malpractice risk. JAMA 287:29512957
Stewart, Corneille, Johnston, Geoghegan, Myers, Dent,
McFarland, Alley, Pruitt Jr, Cohn (2006) Transparent
and open discussion of errors does not increase
malpractice risk in trauma patients. Ann Surg
243:645651
Liver Contusion
Abdominal Solid Organ Injury, Anesthesia for

Cross-References

Outcomes Liver Injury

Teamwork and Trauma Care
Abdominal Solid Organ Injury, Anesthesia for

References

Annas G (2012) Doctors, patients and lawyers two

centuries of health law. N Engl J Med 367:5
Liver Laceration
Bal B (2009) An introduction to medical practice in the
United States. Clin Orthop Relat Res 467:339347 Abdominal Solid Organ Injury, Anesthesia for
De Ville KA (1990) Medical malpractice in nineteenth-
century America: origins and legacy. NYU Press,
New York
Hickson GB, Clayton EW, Entman SS et al (1994)
Obstetricians prior malpractice experience and Liver Trauma
patients satisfaction with care. JAMA 272:15831587
Kachalia A, Gandhi TK, Puopolo A et al (2007) Missed
and delayed diagnoses in the emergency department:
Hepatic and Biliary Injuries
a study of closed malpractice claims from 4 liability
insurers. Ann Emerg Med 49(2):196405
Mackey T, Liang B (2011) The role of practice guidelines
in medical malpractice litigation. Am Med Assoc J Eth
13(1):3641
McGwin G, Wilson, Bailes, Pritchett, Rue LIII (2008) Locked Facets
Malpractice risk: trauma care versus other surgical
and medical specialties. J Trauma 64(3):607613 Dislocation, Facets
Morris S, Flint LM et al (2008) Trauma: contemporary
principles and therapy. Lippincott Williams and
Wilkins, Philadelphia
Stewart R, Johnston, Geoghegan, Anthony, Myers, Dent,
Corneille, Danielson, Root, Pruitt Jr, Cohn
(2005) Trauma surgery malpractice risk perception
versus reality. Ann Surg 241:969977
Locked Plating
Zane R (2009) The legal process. Emerg Med Clin North
Am 27(2009):583592 Principles of Internal Fixation of Fractures
Lung Injury 885

Lockjaw Lung Collapse

Tetanus Atelectasis

Long Bone Fractures Lung Injury

Orthopedic Trauma, Anesthesia for Ipshita Prakash1 and Dan L. Deckelbaum2

1
Resident, General Surgery, McGill University
Health Centre, Montreal, QC, Canada
2
Department of Trauma Surgery and Critical
Long-Term Care Care Medicine, Centre for Global Surgery,
The Montreal General Hospital Room L9-411,
Neurotrauma Rehabilitation and Long-Term Montreal, QC, Canada
Care

Synonyms

Loss of Lean Body Mass Lung trauma; Parenchymal lung injury; Pulmo-
nary trauma; Traumatic lung injury
Lean Body Mass Wasting L

Definition

Low Core Temperature Pulmonary injury results from a blunt or pene-

trating force causing a disruption of the pulmo-
Hypothermia, Trauma, and Anesthetic nary parenchyma in the form of contusion or
Management laceration manifesting varying degrees of physi-
ologic derangements including hemorrhagic
or obstructive shock, and respiratory failure.
Tracheobronchial tree injuries and chest wall
Lower Extremity Skeletal Trauma injuries are discussed separately.

Proximal Femoral Fractures

Preexisting Condition

The lungs occupy the majority of the thoracic

Lumbar Paraspinal volume making them susceptible to injury. The
complexity of pulmonary physiology is a stark
Compartment Syndrome contrast to the simplicity of its anatomy, and,
therefore, even though the anatomic extent of
the injury might be limited, pulmonary parenchy-
mal injuries can lead to severe respiratory failure
Lung Abscess and hemodynamic collapse. It is, therefore, cru-
cial to rapidly identify and appropriately manage
Empyema such injuries. This chapter will focus on the
886
diagnosis, management, and consequences of
parenchymal injuries of the lungs including pul-
monary lacerations and contusions.
While the initial clinical manifestation of pul-
monary injuries may be immediately life threat-
ening, as in the case of tension pneumothorax,
massive hemothorax, or severe hypoxia, in some
instances, the presentation may be more subtle as
in the case of simple pneumothorax or mild con-
tusions, requiring an elevated index of suspicion
for the diagnosis and guiding of management
considerations.
Pulmonary Lacerations
Mechanism of Injury
A pulmonary laceration is a frank tear of the lung
parenchyma secondary to blunt or penetrating
trauma. Pulmonary lacerations may result in sig-
nificant bleeding leading to hemodynamic insta-
bility and hemorrhagic shock. While most
pulmonary lacerations are caused by penetrating
injuries, rib fractures sustained during blunt
injury may also lacerate the lung (Moghissi
1971). In addition, mechanical shear forces
from a sudden compressive-decompressive
force, such as those generated upon direct impact
on a steering wheel, may lead to disruptions of the
pulmonary parenchyma (Moghissi 1971).
Classifications of pulmonary lacerations based
on the mechanism of injury have been described
and include alveolar rupture as a result of
increased pressure against a closed glottis, com-
pression of the pulmonary parenchyma against
a fixed structure such as the spine, direct lacera-
tion by a rib fracture, or tearing of a preexisting
pleuropulmonary adhesion (Wagner 1988). The
clinical significance of such a classification is
limited and is unlikely to alter patient manage-
ment, which should be guided by clinical mani-
festation of the injury.
Pathophysiology
The significance of pulmonary lacerations
depends on the extent of bronchioalveolar and
vascular disruption. While minor lacerations may
not cause significant parenchymal injury and ana-
tomic dysfunction, the resultant air leak may lead
Lung Injury
to obstructive shock from a tension pneumothorax
with imminent death if not treated appropriately.
Vascular disruption and hemorrhage may also lead
to tension physiology responsive to decompres-
sion but may also manifest as hemorrhagic shock
requiring surgical control. Mortality, in these
cases, is directly proportional to the amount of
blood loss (Hoth et al. 2010). Lung re-expansion
after drainage usually buffers the injury with only
a minority of cases producing persistent air leaks.
As pulmonary perfusion pressure is usually low,
most lung lacerations do not result in massive
hemorrhage.
Diagnosis
Initial management for pulmonary lacerations
should follow Advanced Trauma Life Support
(ATLS) protocol. Signs of airway compromise,
hypoxia, and hemorrhagic shock may indicate
a pulmonary etiology. Subsequently, the
physician must recognize the symptoms and
signs that raise suspicion for a pulmonary lacer-
ation. This entity most often presents with
a hemo-/pneumothorax, which can be detected
by the presence of decreased air entry over the
affected hemithorax. Chest wall tenderness,
abnormal chest wall movements, and subcutane-
ous emphysema can be telltale signs of rib frac-
tures or flail chest, which can cause pulmonary
lacerations. Patients with penetrating pulmonary
injuries may infrequently present with hemopty-
sis or symptoms and signs of associated medias-
tinal or cardiac injuries. Rarely, in these
situations, pneumomediastinum may be present,
and Hammans crunch, a crunching sound, syn-
chronous with systole may be detected upon aus-
cultation over the precordial space. They may
also rarely present with a pneumopericardium,
which can be detected by the presence of
Bricketeaus bruit, a loud metallic bruit also
heard over the precordium. Such a finding should
raise the suspicion of an associated pulmonary
injury in the setting of penetrating trauma
(Asensio and Petrone 2009). One can appreciate
that due to the auscultatory nature of these find-
ings, they can be quite difficult to detect as the
primary survey is often performed in the setting
of a busy trauma bay.
Lung Injury 887

Lung Injury, Fig. 1 Subcutaneous emphysema with

a pneumatocele demonstrating likely rib fracture causing
Lung Injury, Fig. 2 Blood tracking within the horizontal
a pulmonary laceration
fissure: a telltale sign of an underlying pulmonary paren-
chymal injury

Given the limitations of the clinical exam in

the compromised patient, a chest X-ray should be
at CT as a round or oval cavity, instead of having
obtained for all trauma patients to exclude pul-
the linear appearance typically seen in other solid
monary injury. Lung lacerations can usually be
organs (Kaewlai et al. 2008).
suspected on the initial chest X-ray due to the
usual sequelae of hemo- or pneumothorax. L
Pulmonary Contusions
Although a pulmonary laceration itself is difficult
to appreciate on a routine chest X-ray, the sur-
Mechanism of Injury
rounding pulmonary hemorrhage or contusion, or
Pulmonary contusions are exceedingly common
a pleural-based process such as a pneumothorax
in trauma, occurring in approximately 20 % of
or hemothorax, may be suggestive of such injury
patients with multiple injuries (ISS >15). Motor
(Moghissi 1971). On the other hand, if
vehicle collisions and falls are the most frequent
a hematoma develops, opacification is seen on
mechanisms of injury in the civilian setting,
X-ray with a blunting of the costophrenic angle
whereas high-velocity mechanisms such as mis-
or opacification (complete or partial) of the asso-
sile and blast injuries are predominant causes in
ciated hemidiaphragm (see Figs. 1 and 2).
the military setting (Hoth et al. 2010).
Computed tomography is more sensitive for
Injury to the pulmonary parenchyma results
delineating the presence and extension of pulmo-
from transmission of mechanical forces from
nary lacerations. Once the patient has been resus-
the chest wall, increased tissue pressure, or direct
citated and stabilized, a CT scan can be used to
laceration of the lung by rib fractures or penetrat-
definitively diagnose or further characterize the
ing injuries. In fact, rib fractures are associated
laceration. Nearly all acute lacerations can be
with underlying contusions in 2040 % of cases
detected by CT scans. The CT diagnosis of
(Nadalo 2011).
a pulmonary laceration can be based on the pres-
Three basic physical phenomena seem to con-
ence of a localized cavitary lesion with air within
tribute to the mechanism of pulmonary contu-
an area of airspace opacification, a cavitary lesion
sions according to early post-World War II
with an air-fluid level, and/or a pulmonary hema-
studies (Clemedson 1956):
toma. Because of the normal pulmonary elastic
recoil, the pulmonary parenchyma surrounding 1. The spalling effect: as the lungs are exposed to
a laceration is pulled back from the laceration shock waves stemming from high-energy
itself. This results in the laceration manifesting forces, the alveolus may rupture at the point
888
of its initial contact with the shock wave due to
this shearing effect.
2. The inertial effect: stripping effect that occurs
when structures with different moments of
inertia for instance, the lung parenchyma
and the hilum accelerate at different rates
in response to a force.
3. The implosion effect: rebound of gas bubbles
with passing pressure waves. This
overexpansion stretches and tears alveoli.
Pathophysiology
Cellular and subcellular insults, inflammatory
mechanisms, and interaction with other injuries
(e.g., gastric aspiration) are essential in the devel-
opment of the pathophysiologic entity.
The injury is characterized by capillary disrup-
tion that results in the presence of intra-alveolar
and interstitial hemorrhage. This causes the pul-
monary parenchyma to become rigid and lose its
normal elasticity. Over the first 72 h, pulmonary
water content increases and can lead to frank pul-
monary edema in severe cases. The innate inflam-
matory response to this direct parenchymal injury
includes recruitment of neutrophils, tissue macro-
phage activation, and the production of a series of
inflammatory mediators (chemokines, cytokines,
free radicals, arachidonic acid metabolites, and
components of the complement and coagulation
cascades). This rise in inflammatory mediators
correlates with increased neutrophil accumulation
in the pulmonary parenchyma. The levels of these
inflammatory mediators usually return to baseline
7 days post-contusion (Raghavendran et al. 2009).
The neutrophilic response predominates in the
first 24 h, followed by a largely monocytic
response by 48 h. Several studies have associated
this increase in alveolar macrophages with alve-
olar epithelial apoptosis and alveolar type II cell
apoptosis (Ganie 2013) which manifests as sur-
factant dysfunction. Voggenreiter et al.
(1999) reported abnormalities in surfactant lipid
composition in patients with traumatic pulmo-
nary contusion. In addition, Raghavendran et al.
(2009) demonstrated functionally important
qualitative and quantitative reductions in surfac-
tant in animal models of traumatic pulmonary
contusions. Several studies have shown that the
Lung Injury
administration of bovine surfactant in animal
models of pulmonary contusions may be benefi-
cial; however, studies in humans have yet to be
performed.
The physiological dysfunction observed in pul-
monary contusions is related, in large part, to these
significant inflammatory mechanisms. The release
of multiple inflammatory mediators results in the
development of pulmonary edema, the thickening
of alveolar septa, and the increased production of
mucous causing pulmonary dysfunction and lung
collapse. The dysfunction of and reduction in sur-
factant production can also lead to alveolar col-
lapse and consolidation. This type of segmental
lung damage can cause ventilationperfusion
mismatch. As the mismatch grows, oxygen satu-
ration is reduced. Pulmonary vasoconstriction
occurs as a response to the hypoxemia leading to
increased vascular resistance in the contused lung
segment. Blood is therefore shunted to better ven-
tilated areas. The clinical presentation of the
contused lung hypoxia, hypercapnia, increased
work of breathing reflects this pathophysiology.
The degree of hypercapnia itself is dictated by the
amount of physiologic and anatomic dead space
(dependent on the amount of lung parenchyma
injured), decreased thoracic compliance, impair-
ment of the respiratory drive (usually secondary to
central nervous system dysfunction), and muscu-
loskeletal fatigue, among others. These factors
vary from patient to patient, and usually, isolated
pulmonary contusions with limited compromise of
the pulmonary parenchyma tend to take a benign
course without hypercapnia (Johnson and Haenel
2013).
Diagnosis
Lung contusions can often be missed as the respi-
ratory failure that develops may not be immedi-
ately clinically or radiologically evident. In fact,
less than 50 % of lesions are detected on chest
radiographs at the time of admission (Cohn and
DuBose 2010). Therefore, it is essential that the
diagnosis be considered whenever there is signif-
icant direct impact to the chest wall or when
multiple injuries are sustained.
Plain radiography findings of parenchymal
consolidations typically appear within 46 h
Lung Injury
Lung Injury, Table 1 Severity of pulmonary contusions
based on CT scan findings (Wagner and Jamieson 1989)
Mild <18 % of lung volume affected
No intubation required
Moderate 1828 % of lung volume affected
Intubate on a case-by-case basis
Severe >28 % of lung volume affected
Intubation required
after the injury and may progress over the next
2448 h. These findings are not limited to the
anatomical boundaries of the lobes or the lung
segments. The presence of hemothorax or pneu-
mothorax may obscure the contusion on chest
X-ray. The exclusive use of plain chest X-rays
often contributes to pulmonary contusions being
frequently missed as only 47 % of lesions are
detected at the time of admission, whereas up to
92 % are seen 24 h after injury (Pape 2000).
CT scans can visualize parenchymal injury and
contusions that are not seen on initial chest X-ray
and are increasingly being used in stable patients
to diagnose and define pulmonary contusions.
Several studies have shown that occult pulmonary
contusions (i.e., pulmonary contusions present
only on CT) have minimal clinical significance
and are associated with better outcomes and
fewer complications than those visualized on ini-
tial chest X-ray (Cohn and DuBose 2010). There-
fore, in patients with mild pulmonary contusions
diagnosed by chest X-ray and few clinical symp-
toms, CT scanning may not be necessary. The
primary value of CT scanning lies in its ability to
quantify the injured pulmonary parenchyma and is
mostly of prognostic value. Wagner et al. deter-
mined that the size of pulmonary contusions could
be divided into mild, moderate, and severe based
on the size of the contused portion of the pulmo-
nary parenchyma and predicted the need for
ventilator support (see Table 1).
This and other studies showed that 100 % of
patients with greater than 28 % parenchymal
involvement required ventilator support. CT scan-
ning can be used to diagnose the disease earlier in
the course when compared to chest X-ray and may
improve visualization of other serious intratho-
racic injuries. However, while CT scanning is
889
more sensitive for detecting the injury, it does
not guide therapeutic interventions and is not
required for initial management of this entity.
Application
Patients with thoracic trauma should be rapidly
examined and treated in accordance with ATLS
protocols instituting measures aimed at correcting
hypoxemia and hypoperfusion. While up to 85 %
of patients with thoracic trauma can be managed
nonoperatively, 1015 % of blunt pulmonary
trauma requires operative management, and
1530 % of penetrating pulmonary trauma requires
open thoracotomy to manage life-threatening,
complex injuries, or those that fail conservative
management (Mayglothling and Legome 2013).
Pulmonary Contusion: Management and
Outcome
The mortality rate of pulmonary contusion is
estimated to range from 14 % to 40 %, depending L
on the severity of the contusion, ensuing compli-
cations and associated injuries. Most contusions
that are not complicated by infection or respira-
tory failure resolve within 35 days of supportive
care. The management of this entity rests upon
initial resuscitation, proper oxygenation and ven-
tilation, optimization of pain control, and resto-
ration of pulmonary mechanics with the goal of
preventing additional injury and/or infection. It
should be noted that an increase in size of the lung
contusions on X-ray during the first 24 h is gen-
erally a negative prognostic sign (Cohn and
DuBose 2010). A repeat chest X-ray should be
obtained in 1224 h for the stable patient with
mild to moderate symptoms. While some recom-
mend a CT scan to evaluate contusions in
a patient with worsening respiratory status, this
must be done with caution as it may subject the
patient to a transfer to a challenging treatment
environment in the radiology department without
changing the ultimate management.
Oxygenation and Ventilation
The primary goal in the management of
pulmonary contusions is the maintenance of
890
adequate oxygenation. The assurance of appropri-
ate oxygenation requires a multimodal approach
including oxygen and ventilation therapy as
needed, pain control, and pulmonary toilet. As
the physiologic effects of the contusion manifest
themselves over 2448 h, close monitoring is
essential to guide appropriate treatment, which
varies from inhaled oxygen by nasal prongs to
more advanced modes of positive pressure venti-
lation (Ganie et al. 2013). The successful use of
high-frequency oscillatory ventilation and extra-
corporeal membrane oxygenation (ECMO) has
also been reported in the literature (Madershahian
2007). The application of high-frequency oscilla-
tory ventilation for pediatric acute respiratory dis-
tress syndrome (ARDS) is well established;
however, its use in adult ARDS has been explored
and found to be equivocal when compared to
conventional ventilatory methods at this time.
Since patients with pulmonary contusions are
thought to be more likely to develop ARDS, it
has been hypothesized that high-frequency oscil-
latory ventilation might be useful in complicated
pulmonary contusions (Simon et al. 2005a). How-
ever, the use of high-frequency oscillatory venti-
lation needs to be further evaluated and, currently,
there are no strong recommendations for its use.
The literature clearly establishes that obligatory
mechanical ventilation is unnecessary for pulmo-
nary contusions. Patients who are mechanically
ventilated are usually sedated, are unable to par-
ticipate in chest physiotherapy, and cannot coop-
erate with pulmonary toilet. Several authors have
shown that mechanical ventilation lends itself to
a longer hospital stay, a higher complication rate,
and, subsequently, higher mortality (Trinkle et al.
1975). Therefore, the institution of mechanical
ventilation should be initiated on a case-by-case
basis with the clinical status of the patient as the
main determinant of the need for positive pressure
ventilation. When required, mechanical ventila-
tion strategies should be tailored to optimize oxy-
genation while minimizing the potential for
secondary lung injury by barotrauma or
volutrauma. Strategies that emphasize alveolar
recruitment maneuvers have been successful and
often adopted from the ventilation strategies used
in ARDS. These recruitment maneuvers rely on
Lung Injury
positive end-expiratory pressure (PEEP) to pre-
vent alveolar collapse (Cohn and DuBose 2010).
A few studies in the trauma population have
shown a benefit from increasing average PEEP
values from 10 cm H2O to 1521 cm H2O (Sladen
1973; Schreiter 2004). The titration of PEEP
should be based on the patients oxygenation sta-
tus with attempts made to minimize barotrauma
and its sequelae including alveolar rupture, air
embolism, and hemodynamic instability (Simon
et al. 2005a). When the compliance of the injured
lung differs significantly from that of the uninjured
one, the lungs can be ventilated independently
with two ventilators to prevent overinflation injury
of the uninjured lung. Initially developed to facil-
itate the anesthetic management of thoracic sur-
gery patients, independent lung ventilation has
been used sporadically in the trauma setting, and
its success has been highlighted only in case
reports and its role remains unproven (Anantham
2005; Katsaragakis 2005).
Fluid Resuscitation
Controversy exists regarding quantity, as well as
type of fluid resuscitation in patients with tho-
racic injuries, as intuition dictates that a balance
is necessary to prevent shock without exacerbat-
ing pulmonary edema. This dates back to World
War II when Burford and Burbank ascribed the
wet lung phenomenon in soldiers with thoracic
trauma to fluid resuscitation. The results of stud-
ies using animal models have been inconclusive
regarding the potential adverse effects of infused
fluids in the context of pulmonary contusions
(Trinkle et al. 1975), and relatively few human
clinical trials have addressed the impact of resus-
citation on pulmonary contusion and, when
they have, the results have been controversial
(Cohn and DuBose 2010).
Collins et al. (1978) studied Vietnam War
casualties and found that the volume of blood
transfusion seemed to be associated with the
increased incidence of hypoxemia in soldiers
with evidence of direct lung injury. A subsequent
study by Tranbaugh et al. (1982) measured pul-
monary interstitial fluid in 16 trauma patients
presenting with shock and found that interstitial
fluid was increased only in the patients with
Lung Injury
pulmonary contusions and not in those with hem-
orrhagic shock in the absence of pulmonary
parenchymal injury. However, other investiga-
tors have found no association between the
amount of fluid resuscitation and the extent of
pulmonary dysfunction after contusions (Johnson
and Haenel 2013).
The use of hypertonic saline in patients with
pulmonary contusions has yet to be elucidated.
Where some researchers have found that hyper-
tonic saline resuscitation for rats with pulmonary
contusion decreases the amount of pulmonary
inflammation and increases cellular protection,
others have failed to detect any benefit. No stud-
ies using hypertonic saline in human models of
pulmonary parenchymal injuries have demon-
strated a physiologic benefit (Cohn and DuBose
2010).
Similarly, the use of arginine vasopressin
(AVP) is also emerging as a potential treatment
adjunct for vasodilatation in the setting of shock.
Feinstein et al. (2005) showed that the early use of
vasopressin in a swine model of thoracic trauma
and pulmonary contusion was associated with
a decrease in the mortality rate, a reduction in
fluid requirements, and an improvement in pulmo-
nary function. Clinical trials examining the effects
of administering vasopressin specifically to
trauma patients, including those with pulmonary
contusion, are ongoing (Cohn and DuBose 2010).
Due to the amount of controversy surrounding
fluid resuscitation in the context of pulmonary
contusions, maintenance of euvolemia and judi-
cious use of crystalloids and colloids are the
current recommended standard of care (Simon
et al. 2005a).
Pain Control
Rib fractures are associated with pulmonary con-
tusions in over 40 % of cases. These injuries tend
to be excruciatingly painful and can hinder pul-
monary mechanics leading to hypoxia, atelecta-
sis, and respiratory compromise. Pain control,
chest physiotherapy, and early mobilization are
the mainstay of treatment of pulmonary contu-
sions and associated thoracic injuries.
Several different analgesic modalities exist
and contribute to different pain control strategies
891
including intravenous narcotics, local nerve
blocks, and epidural analgesia.
Intravenous narcotics are the most prevalent
mode of analgesia for surgical and traumatic
pain. However, they are often insufficient, and
their adverse effects, which include sedation,
cough suppression, and respiratory depression,
can impede clinical progress (Simon et al.
2005a). Intercostal nerve blocks can, at times,
provide dramatic relief; however, the effect only
lasts approximately 6 h, depending on the analge-
sics used (Simon et al. 2005a). Epidural anesthesia
is the standard of pain control in patients with rib
fractures, flail chest, and pulmonary contusions as
it provides immediate comfort, improves tidal vol-
ume and vital capacity, and enables the patient to
produce an efficient cough. Several studies have
shown epidural anesthesia to result in an increased
functional residual capacity (FRC); lung compli-
ance and, consequently, vital capacity; a decreased
airway resistance; and increased pO2 (Simon et al.
2005a). A study by Bulger et al. in 2004 showed
that the rate of pneumonia was 18 % for patients L
who received epidural analgesia compared to 38 %
for patients who were administered intravenous
opioid. Moreover, the same study, when stratified
for the presence of pulmonary contusion, showed
a twofold decrease in the number of ventilator
days required for patients with epidural anesthesia
when compared to patients on opioids (Bulger
et al. 2004).
Pulmonary Lacerations
Pulmonary lacerations can directly lead to two
situations in which immediate action is required
to appropriately stabilize and resuscitate the
patient: pneumothorax and hemothorax. Patients
in whom the primary survey reveals decreased air
entry on either or both lung fields and hemody-
namic instability necessitate a tube thoracostomy.
Those that display stable hemodynamics and an
equivocal physical exam may undergo a chest
X-ray to confirm the presence of a hemo-/pneu-
mothorax before further action is taken.
Most pneumothoraces and hemothoraces
resolve adequately with chest tube placement and
observation. However, well-defined indications
exist for immediate thoracotomy (see Table 2).
892
Lung Injury, Table 2 Indications for surgical manage-
ment (Hoth et al. 2010; Mowery et al. 2011)
1. Blood loss >1.5 L via chest tube upon insertion
2. Bleeding >200 mL/h for 24 h
3. Need for persistent blood transfusion to maintain
hemodynamic stability
4. Massive air leak preventing re-expansion of the lung
Approximately 1015 % of patients admitted
for penetrating thoracic trauma require thoracot-
omy, with less than 20 % of this subgroup requir-
ing lung resection. The numbers for blunt trauma
are considerably smaller (Hoth et al. 2010). The
surgical options for the management of pulmo-
nary lacerations include pneumorraphy (suture
repair), tractotomy, wedge resection, lobectomy,
and pneumonectomy. Typically, nonanatomic
lung-sparing techniques should be used rather
than anatomic resections whenever possible.
More extensive surgery may be required to con-
trol hemorrhage; however, it is associated with
higher mortality (see Table 3).
Pneumorraphy should be reserved for superfi-
cial and peripheral lacerations, which can be
oversewn with a running, locked suture (Asensio
and Petrone 2009). However, in penetrating lung
injuries, simple oversewing of the entrance and
exit sites is not recommended since it can leave
the central cavity as a potential source for
uncontrolled bleeding and air embolism. First
described by Wall et al. in 1994, pulmonary
tractotomy serves both diagnostic and therapeutic
purposes in rapidly controlling bleeding without
subjecting the patient to unnecessary lung resec-
tion. The entrance and exit wounds are defined,
and a stapling device is placed through them and
fired. This opens the tract exposing the injured
vessels and bronchi, which are then selectively
ligated with an absorbable suture. The lung
parenchyma can then be approximated with
a single running suture. Having the anesthesiolo-
gist inflate the lung tests the integrity of the suture
line, and any air leaks can be detected and
repaired (Asensio and Petrone 2009). This tech-
nique can be attempted initially for most injuries,
even in the setting of hemodynamic instability,
with more formal pulmonary resection reserved
Lung Injury
Lung Injury, Table 3 Mortality related to amount of
tissue resected (Hoth et al. 2010)
Type of repair Mortality (%)
Suture repair 9
Tractotomy (see Figs. 3 and 4) 13
Wedge resection 30
Lobectomy 43
Pneumonectomy 50
Lung Injury, Fig. 3 This figure demonstrates
a penetrating pulmonary injury with a clear tract forma-
tion. (Figure credit: Dr. Dan L. Deckelbaum)
for cases in which bleeding is not satisfactorily
controlled or has a more central source (see Figs. 3
and 4).
Incising the inferior pulmonary ligament and
clamping the pulmonary hilum can temporarily
control persistent large air leaks or major pulmo-
nary hemorrhage. This should be done slowly to
allow the contralateral lung to accommodate.
While the hilar twist has been previously
described, we prefer to manually clamp the
hilum as the twist may result in tearing of the
thin-walled pulmonary vasculature and disruption
of the bronchus. Ultimately, in patients with global
or hilar parenchymal lung injury, pneumonectomy
is an option of last resort. These special maneuvers
carry high mortality rates.
Complications
In addition to adverse events such as pneumonia
and respiratory failure, patients who sustain
Lung Injury
Lung Injury, Fig. 4 The tract created by the entrance and
exit wounds is divided with a stapling device. The lung
parenchyma is then oversewn to control bleeding and air
leaks. (Figure credit: Dr. Dan L. Deckelbaum)
thoracic trauma are at risk of more specific
complications such as retained hemothorax,
posttraumatic empyema, pulmonary abscess, and
bronchopleural fistula (Cohn and DuBose 2010).
Retained Hemothorax
A retained hemothorax, defined as the presence
of clotted blood within the pleural cavity despite
initial tube thoracostomy, can develop due to
several factors, such as failure to timely diagnose
and manage the hemothorax, inadequate place-
ment or inappropriate care of the chest tube, and
the use of tubes of inadequate diameter.
A multicenter prospective observational trial
conducted by the American Association for the
Surgery of Trauma (AAST) in 2012 identified
independent predictors of successful manage-
ment of these retained hemothoraces. See Table 4
for their classification of retained hemothoraces.
According to their study, small retained
hemothoraces could be managed successfully by
either observation or by insertion of an additional
chest tube/percutaneous drain in the majority of
cases. Moderately sized hemothoraces tended to
be successfully treated with evacuation by video-
assisted thoracoscopic surgery (VATS), and tho-
racotomy was required for patients who failed the
893
Lung Injury, Table 4 Classification of retained
hemothoraces (DuBose et al. 2012)
Small <300 mL
Moderate 300900 mL
Large >900 mL
more conservative measures and for patients
with large retained hemothoraces (DuBose et al.
2012).
Posttraumatic Empyema
Empyema, defined as the presence of pus in the
pleural cavity, is associated with significant
morbidity and mortality. The incidence of
posttraumatic empyema in patients who have
sustained thoracic trauma has been reported to
range anywhere from 2 % to 25 %. Retained
hemothorax, the presence of a pulmonary contu-
sion, the duration of tube thoracostomy, and the
length of intensive care unit stay have all
been identified as independent predictors of
posttraumatic empyema. Early treatment with L
VATS or thoracotomy should be encouraged for
improved patient outcomes. Surgical decortica-
tion allows complete debridement of pleural
peels, disruption of all loculations, and evacua-
tion of all fluid in the fibrinopurulent stage of
empyema. The use of fybrinolytic therapy has
also been recently encouraged as a management
option. These steps are essential to achieve
source control and full lung expansion that oblit-
erates the pleural space and leads to resolution of
the infectious process (Wozniak et al. 2009).
Pulmonary Abscess
A pulmonary abscess is defined as an area of
pulmonary parenchymal necrosis caused by an
infectious organism (Nason et al. 2010). Pulmo-
nary abscesses after pulmonary trauma can occur
as a result of aspiration, complications of venti-
lator-associated pneumonia, retained foreign
body, or infected traumatic injury. Systemic anti-
biotics directed against the causative organism
are the mainstay of therapy; however, external
drainage may be required in select cases where
medical management fails and can be
894
accomplished with tube thoracostomy or percu-
taneous drainage (DuBose et al. 2012). Since the
advent of effective antibiotics, the mortality rate
from lung abscesses has declined from 30 % to
50 % down to 520 % (Nason et al. 2010).
Bronchopleural Fistula
Patients sustaining thoracic trauma can develop
air leaks from injury to the pulmonary paren-
chyma, leading to a bronchopleural fistula.
A true bronchopleural fistula is a centrally
located communication between the pleural cav-
ity and the lobar or segmental bronchi. These
types of communications are uncommon follow-
ing trauma, unless the patient has undergone
a pulmonary resection and has developed a leak
from a closure of a proximal airway (DuBose
et al. 2012). Most posttraumatic leaks are com-
munications with the distal airway conduits. For
most peripheral air leaks, management is primar-
ily supportive. However, persistent, large air
leaks in patients who are mechanically ventilated
can be challenging to manage as standard alveo-
lar recruitment measures (increased PEEP) can
contribute to the loss of effective tidal volume,
resulting in increased ventilationperfusion
mismatch and respiratory failure. In this setting,
the management of the posttraumatic air leak
should focus on minimizing transpulmonary
pressures, using the minimum chest tube suction
necessary to keep the lung inflated and weaning
patients from positive pressure ventilation
(DuBose et al. 2012). Smaller, more peripheral
leaks that do not respond to supportive measures
can be treated via VATS using stapling devices.
Larger, proximal air leaks may require
a vascularized flap repair utilizing muscle, omen-
tum, diaphragm, or pericardium.
Summary
Pulmonary injuries constitute a majority of tho-
racic trauma and are a significant cause of mor-
bidity and mortality. It is imperative to promptly
identify patients who require immediate therapy,
Lung Injury
as these injuries can often be life threatening.
Failure to identify these injuries and their com-
plications in a timely manner and to manage them
aggressively can significantly impact outcomes
in trauma patients. In patients who have limited
injuries, literature shows that conservative man-
agement is often sufficient. A systematic
approach to pulmonary injuries is crucial in
improving patient outcomes.
Cross-References
Acute Respiratory Distress Syndrome
(ARDS), General
ARDS, Complication of Trauma
Blast Lung Injury
Chest Wall Injury
Empyema
Imaging of Aortic and Thoracic Injuries
Pulmonary Trauma, Anesthetic Management for
Sedation and Analgesia
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Lyophilized Fibrinogen Concentrate

Lung Trauma
Adjuncts to Transfusion: Fibrinogen
Lung Injury Concentrate