Immobilization of injuries also is achieved with spinal orthoses (braces), particularly in those with associated thoracolumbar injuries.

In general, physician-supervised axial traction, via cervical tongs or the more commonly used halo vest, is used to reduce subluxations and stabilize the injury.

After initial stabilization, a systematic physical examination of the head and neck should be performed that also includes cranial nerve examination and three-dimensional CT scanning of the maxillofacial complex

Nose and nasoethmoidal fractures should be assessed carefully to identify damage to the lacrimal drainage system or to the cribriform plate producing cerebrospinal fluid rhinorrhea.

Temporizing measures include nasal packing, Foley catheter tamponade of posterior nasal bleeding, and oropharyngeal packing.

Fractures of tooth-bearing bone are considered open fractures and require antibiotic therapy and semiurgent repair to preserve the airway as well as the functional integrity of the occlusion (bite) and the aesthetics of the face.

High-impact kinetic energy is required to fracture the frontal sinus, orbital rims, and mandible, whereas low-impact forces will injure the nasal bones and zygoma.

Moderate hypothermia (32°–33°C [89.6°–91.4°F]) has been shown experimentally to improve neurologic outcomes, but clinical studies have not validated this concept.

The maxillofacial complex is divided into three regions; the upper face containing the frontal sinus and brain; the midface containing the orbits, nose, and zygomaticomaxillary complex; and the lower face containing the mandible.

The typical clinical course of an epidural hematoma is an initial loss of consciousness, a lucid interval, and recurrent loss of consciousness with an ipsilateral fixed and dilated pupil. While decompression of subdural hematomas may be delayed, epidural hematomas require evacuation within 70 minutes.

General surgeons in communities without emergency neurosurgical coverage should have a working knowledge of burr hole placement in the event that emergent evacuation is required for a life-threatening epidural hematoma

Patients with diffuse cerebral edema resulting in excessive ICP may require a decompressive craniectomy, although a recent AAST multicenter trial questioned the benefits.

Patients with open or depressed skull fractures, with or without sinus involvement, may require operative intervention.

The partial pressure of carbon dioxide (PCO2) should be maintained in a normal range (35–40 mmHg), but for temporary management of acute intracranial hypertension, inducing cerebral vasoconstriction by hyperventilation to a PCO2 of <30 mmHg is occasionally warranted.

Sedation, osmotic diuresis, paralysis, ventricular drainage, and barbiturate coma are used in sequence, with coma induction being the last resort.

The role of decompressive craniectomy for refractory ICH remains controversial.

Fullen zone II SMA injuries, extending from the pancreatic edge to the middle colic branch, on the other hand, are approached via the lesser sac along the inferior edge of the pancreas at the base of the transverse mesocolon; the pancreatic body may be divided to gain proximal vascular access.

n patients with abnormal findings on CT scans and GCS scores of ≤8, intracranial pressure (ICP) should be monitored using fiber-optic intraparenchymal devices or intraventricular catheters.

The final stages of this sequence are caused by blood accumulation that forces the temporal lobe medially, with resultant compression of the third cranial nerve and eventually the brain stem.

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

Cerebral perfusion pressure (CPP) is equal to the mean arterial pressure minus the ICP, with a target range of >60 mmHg.

CPP can be increased by either lowering ICP or raising mean arterial pressure.

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.

The burr hole is made on the side of the dilated pupil to decompress the intracranial space. After stabilization, the patient is transferred to a facility with neurosurgical capability for formal craniotomy.

A shift of >5 mm typically is considered an indication for evacuation, but this is not an absolute rule. Smaller hematomas that are in treacherous locations, such as the posterior fossa, may require drainage due to brain stem compression or impending herniation.

Indications for operative intervention to remove space-occupying hematomas are based on the clot volume, amount of midline shift, location of the clot, GCS score, and ICP.

The newest neurosurgery guidelines additionally recommend maintaining the cerebral perfusion pressure (CPP) at >60 mmHg.

Although an ICP of 10 mmHg is the upper limit of normal, therapy is targeted to maintain an ICP of <20 mmHg.

A venous injury behind the pancreas, from the junction of the superior mesenteric, splenic, and portal veins, is accessed by dividing the neck of the pancreas.

More distal SMA injuries, Fullen zones III and IV, are approached directly within the mesentery.

Fullen zone I SMA injuries, located posterior to the pancreas, are best exposed by a left medial visceral rotation.

Supracolic injuries (aorta, celiac axis, proximal superior mesenteric artery [SMA], and left renal arteries) are best approached via a left medial visceral rotation (Fig. 7-40). This is done by incising the lateral peritoneal reflection (white line of Toldt) beginning at the distal descending colon and extending the incision along the colonic splenic flexure, around the posterior aspect of the spleen, and behind the gastric fundus, ending at the esophagus.

When the spleen is mobilized, it should be gently rotated medially to expose the lateral peritoneum; this peritoneum and endoabdominal fascia are incised, which allows blunt dissection of the spleen and pancreas as a composite from the retroperitoneum anterior to Gerota’s fascia

if an aortic injury is supraceliac, transecting the left crus of diaphragm or extending the laparotomy via a left thoracotomy may be necessary.

After the source of hemorrhage is localized, direct digital occlusion (vascular injury) or laparotomy pad packing (solid organ injury) is used to control bleeding

If the liver is the source in a hemodynamically unstable patient, additional control of bleeding is obtained by clamping the hepatic pedicle with a vascular clamp or Rummel tourniquet (termed the Pringle maneuver)

If the liver is the source in a hemodynamically unstable patient, additional control of bleeding is obtained by clamping the hepatic pedicle with a vascular clamp or Rummel tourniquet (termed the Pringle maneuver)

If the patient has an SBP of <70 mmHg when the abdomen is opened, digital pressure or a clamp should be placed on the aorta at the diaphragmatic hiatus.

After blunt trauma, the spleen and liver should be palpated first and packed if fractured, and the infracolic mesentery should be inspected for zone I vascular injury

Posterolateral thoracotomies are used for exposure of injuries to the trachea or main stem bronchi near the carina or the upper esophagus (right posterolateral thoracotomy) and tears of the descending thoracic aorta or lower esophagus (left posterolateral thoracotomy).

. Care must be taken to avoid injury to the phrenic and vagus nerves that pass over the subclavian artery and to the recurrent laryngeal nerve passing posteriorly

Median sternotomy with cervical extension is used for rapid exposure in patients with presumed proximal subclavian, innominate, or proximal carotid artery injuries

Typically, these patients have pericardial tamponade and may undergo placement of a pericardial drain before a semiurgent median sternotomy is performed

through the supraclavicular incision. Emergent median sternotomy is optimal for anterior stab wounds to the heart

Similarly, without time for blood typing, AB plasma is the universal donor, although A plasma appears to be a safe option