contractual relations of individual and collectivity (in the formof written ship’s articles specifying shares of booty and ratesof compensation for on-the-job injury

In patients with peripheral bronchial injuries, indicated by persistent air leaks from the chest tube and documented by endoscopy, bronchoscopically directed fibrin glue sealing may be useful.

Before repair of the injury is attempted, hemorrhage should be controlled; injuries to the atria can be clamped with a Satinsky vascular clamp, whereas digital pressure is used to occlude the majority of ventricular wounds. Foley catheter occlusion of larger stellate lesions is described, but even minimal traction may enlarge the original injury.

Subclavian artery injuries can be repaired using lateral arteriorrhaphy or PTFE graft interposition; due to its multiple branches and tethering of the artery, end-to-end primary anastomosis is not advocated if there is a significant segmental loss.

Innominate artery injuries are repaired using the bypass exclusion technique,96 which avoids the need for cardiopulmonary bypass. Bypass grafting from the proximal aorta to the distal innominate with a prosthetic tube graft is performed before the postinjury hematoma is entered. The PTFE graft is anastomosed end-to-side from the proximal undamaged aorta and anastomosed end-to-end to the innominate artery (Fig. 7-56). The origin of the innominate is then oversewn at its base to exclude the pseudoaneurysm or other injury.

The role of carotid stenting for grade II or III internal carotid artery injuries remain controversial; current literature suggests stenting be reserved for symptomatic patients or markedly enlarging pseudoaneurysms.

Vertebral artery injuries due to penetrating trauma are difficult to control operatively because of the artery’s protected location within the foramen transversarium. Although exposure from an anterior approach can be accomplished by removing the anterior elements of the bony canal and the tough fascia covering the artery between the elements, typically the most efficacious control of such injuries is angioembolization. Fogarty catheter balloon occlusion, however, is useful for controlling acute bleeding if encountered during neck exploration.

Prompt revascularization of the internal carotid artery, using a temporary Pruitt-Inahara shunt, should be considered in patients arriving in profound shock.

All carotid injuries should be repaired except in patients who present in coma with a delay in transport.

Attention, therefore, is focused on maintaining cerebral perfusion rather than merely lowering ICP.

Resuscitation efforts aim for a euvolemic state and a SBP of >100 mmHg.

The goal of resuscitation and management in patients with head injuries is to avoid hypotension (SBP of <100 mmHg) and hypoxia (partial pressure of arterial oxygen of <60 or arterial oxygen saturation of <90%).

Penetrating injuries to the head may require operative intervention for hemorrhage control, evacuation of blood, skull fracture fixation, or debridement.

Indications for operative treatment of thoracic injuries Initial tube thoracostomy drainage of >1000 mL (penetrating injury) or >1500 mL (blunt injury) Ongoing tube thoracostomy drainage of >200 mL/h for 3 consecutive hours in noncoagulopathic patients Caked hemothorax despite placement of two chest tubes Great vessel injury (endovascular techniques may be used in selected patients) Pericardial tamponade Cardiac herniation Massive air leak from the chest tube with inadequate ventilation Tracheal or main stem bronchial injury diagnosed by endoscopy or imaging Open pneumothorax Esophageal perforation Air embolism