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1600 John F. Kennedy Boulevard Suite 1800 Philadelphia, Pennsylvania 19103-2899 PARKLAND TRAUMA HANDBOOK ISBN: 978-0-323-05226-9 Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. Copyright © 1999 by Mosby International Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions. Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. Library of Congress Cataloging-in-Publication Data Parkland trauma handbook/edited by Alexander L. Eastman, David H. Rosenbaum, Erwin R. Thal. -- 3rd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-05226-9 1. Traumatology--Handbooks, manuals, etc. 2. Blunt trauma--Handbooks, manuals, etc. 3. Wounds and injuries--Handbooks, manuals, etc. I. Eastman, Alexander L. II. Rosenbaum, David H. III. Thal, Erwin R. IV. Parkland Memorial Hospital (Dallas, Tex.) V. Title: Trauma handbook. [DNLM: 1. Wounds and Injuries--diagnosis--Handbooks. 2. Wounds and Injuries--therapy-- Handbooks. WO 39 P2485 2009] RD93.P3 2009 617.1--dc22 2008041754 Acquisitions Editor: James Merritt Publishing Services Manager: Tina Rebane Design Direction: Gene Harris Printed in the United States of America Last digit is the print number: 9 87654321 http://avaxho.me/blogs/ChrisRedfield Contributors Adam C. Alder, MD Kousta I. Foteh, MD Resident in General Surgery Resident in General Surgery Severn Barloco, MD Joshua L. Gary, MD Resident in General Surgery Resident in General Surgery Adam W. Beck, MD Robert Garza, MD Resident in General Surgery Resident in General Surgery Christopher Bell, MD Makram Gedeon, MD Resident in General Surgery Resident in General Surgery Jennifer Blumetti, MD Richard M. Gillespie, MD Resident in General Surgery Resident in General Surgery Amy Brazda, MD Julie Grimes, MD Resident in General Surgery Resident in Obstetrics and gynecology Scott Brakenridge, MD Jason Hall, MD Resident in General Surgery Resident in General Surgery Harshal Broker, MD Alan E. Harzman, MD Resident in General Surgery Resident in General Surgery James A. Chambers, MD, MPH & TM Richard Hershberger, MD Resident in General Surgery Resident in General Surgery Kevin Crawford, MD Arsalla Islam, MD Resident in General Surgery Resident in General Surgery David Curtis, MD Radha lyengar, MD Resident in General Surgery Resident in General Surgery Nabil N. Dagher, MD Samuel Jacks, MD Resident in General Surgery Resident in General Surgery Sean Dineen, MD Kshama Jaiswal, MD Resident in General Surgery Resident in General Surgery Alexander Eastman, MD Lauren Kane, MD Resident in General Surgery Resident in General Surgery Henry Ellis, MD Jarrod King, MD Resident in Orthopaedic Surgery Resident in Orthopaedic Surgery vi Contributors Jorie Klein, RN Josh Roller, MD Director, Trauma and Disaster Resident in General Surgery Services David H. Rosenbaum, MD Rohit K. Khosla, MD Resident in General Surgery Resident in Plastic Surgery Frances Rosenbaum, MD Marc Labat, MD Resident in Obstetrics and Gynecology Resident in Emergency Medicine Kelly Schmidt, MD Lee Ann Lau, MD Resident in Neurological Surgery Resident in General Surgery Paul Schumacher, MD Avron Lipschitz, MD Resident in General Surgery Resident in General Surgery Tif Siragusa, MD Clifann McCarley, RN, BNS Resident in General Surgery Trauma Nurse-Clinician Stephen Smith, MD Jennifer L. McDougal, MD Resident in Vascular Surgery Resident in General Surgery Taylor Smith, MD Barbra S. Miller, MD Resident in General Surgery Resident in General Surgery Lance E. Stuke, MD Meredith Miller, MD Resident in General Surgery Resident in General Surgery Patrick T. Sweeney, MD Ian Mitchell, MD Resident in General Surgery Resident in General Surgery Hemangini Thakar, MD Brian Oleksy, DDS, MD Resident in Plastic Surgery Resident in Oral and Maxillofacial Surgery Steven A. Vela, MD Resident in General Surgery Craig Olson, MD Resident in General Surgery Krishna Venkatesh, MD Resident in General Surgery Matthias Peltz, MD Resident in Thoracic Surgery Lance Walsh, MD, PhD Resident in Urologic Surgery Damon S. Pierce, MD Resident in General Surgery Stacey Woodruff, MD Resident in General Surgery Christina Roland, MD Resident in General Surgery Foreword We are pleased to present the third edition of the Parkland Trauma Handbook. Again, the manual presents the basic tenets of trauma management and updates protocols to meet current standards. The treatment of multiply injured patients remains a team effort and is best provided by adhering to trauma systems that cover the spectrum from prevention to rehabilitation. This team includes physicians from all specialties and support personnel from several disciplines. Essential ingredients for success include the reflective assessment of outcomes based on registry-generated data, pristine performance improvement and patient safety activity, well-designed research projects, and administrative and professional commitment, all led by the general (trauma) surgeon who serves as the “captain of the ship.” This new handbook reflects the considerable changes that have occurred since the last edition. Improvements in imaging, proliferation of nonoperative management, the introduction of minimally invasive procedures, as well as improvements in the general overall care of the patient, have accelerated in recent years. Efforts in trauma prevention have been reflected in changing patterns of injury. Along with the advances in technology comes a responsibility to be cost effective as one travels down the diagnostic highway. The Parkland Trauma Handbook is designed to assist young surgeons in training, general and specialty surgeons who do not treat a large number of injured patients, support personnel, and other colleagues in the management of these difficult cases. The principles and guidelines are based on the experience of a large Level 1 trauma center and the text has been written in its entirety by our excellent surgical housestaff. The handbook is a practical guide to be used in the management of trauma patients. This edition has been edited by two of our excellent chief residents, Alex Eastman and David Rosenbaum, and facilitated by the ever-present, senior mentorship of Dr. Erwin Thal. The Parkland Trauma Handbook continues to emerge from the forefront of trauma care, written by those who deliver that care every day and every night at one of the country's busiest trauma centers. We are proud to present this fine piece of work. Robert V. Rege, MD Chair, Department of Surgery The University of Texas Southwestern Medical Center Dallas, Texas Preface The chief surgical resident is the most senior house officer at Parkland Memorial Hospital. His or her expertise is a sought-after commodity in the treatment of the severely injured, sick, or dying. As a result of their experiences at Parkland, the Parkland “trauma chief” tends to walk a little taller as he or she roams the wards and intensive care units at night. Since its inception, the Parkland Trauma Handbook has served as a guiding light, helping us transition from wide-eyed Interns to seasoned surgical professionals. Revision of a work of this nature is daunting, and as is the case with many other of our traditions, the work of those who have come before us is unparalleled. The original manual, from Mike Lopez, was genius. It was only improved by that of Fiemu Nwariaku, who set the standard high, making it challenging for us to revise and update his work. His guidance at the beginning of this process was invaluable. In terms of mentorship, the leadership of Dr. Thal is unparalleled. He is a true giant in the field and a fantastic mentor, advisor, and friend (not to mention a merciless editor). As we worked through the revisions, the contributions of several people made this book possible. First, the surgical residents of Parkland Memorial Hospital are an extraordinary group of men and women. We thank each of them for their contributions and persistence. Dianne Wynne, Dr. Thal’s right hand and more, deserves more thanks than we can offer. For pushing us to stay on track, and more importantly, for keeping Dr. Thal in line, we are indebted. We also owe Jim Merritt and Tina Rebane at Elsevier our sincere thanks, for without their guidance and tremendous patience this project would have never made it to completion. We talk so often of the days when surgical giants walked the halls of Parkland Memorial Hospital and other leading medical centers. Our giants include Dr. Jules Cahan, Dr. Stephen R.T. Evans, Dr. Joseph Minei, Dr. Erwin Thal, Dr. Mike Cornell, Dr. John Cargile, Dr. Kelvin Johnigan, Dr. William Cheadle, Dr. Hiram Polk and Dr. J. David Richardson. To each of you, who have invested your time, energy, and vast resources into shaping us as surgeons, we hope in some small way our efforts with this manual will show you the beginnings of the fruits of your labors.

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