Chapter 3: Trauma Surgery

Introduction

Trauma is the oldest surgical subspecialty. Prehistoric evidence demonstrates early techniques for suturing lacerations, performing amputations, and setting fractures. Trephined skulls hint at early surgical attempts to relieve intracranial pressure after traumatic brain injury. The oldest known treatise on trauma care, the Edwin Smith Papyrus, dates back to 1600 BC and consists of 48 case descriptions of injuries. Such archaeological evidence reveals that ancient civilizations, from the Egyptians, to the Babylonyians, to the Mayans, treated wounds sustained from hand-to-hand and projectile-based combat.

Advancements in trauma care have closely paralleled technological advances on the battlefield. Ambulances were first introduced during the Siege of Malaga in 1487. Ambroise Paré first described the use of ligatures for hemostasis during his term as a military surgeon in 16th-century France. The practice of triage was developed during the Napoleonic Wars in the early 19th century, and the association of aggressive fluid resuscitation with pulmonary failure was described during the Vietnam Conflict. The Gulf Wars enhanced our understanding of massive transfusion ratios, management of traumatic brain injury, and tourniquet use. As weapons evolved with the invention of gunpowder and mechanized transportation, so evolved the understanding of blast injury and polysystem trauma.

In the civilian sector, research has historically consisted of expert opinion and single-center case series. High-quality studies on injured patients are extremely difficult to conduct, due to barriers to informed consent in the emergent setting, poor patient follow-up, and other methodological issues. However, in the past few decades, professional organizations such as the American Association for the Surgery of Trauma (AAST), the Eastern Association for the Surgery of Trauma (EAST), and the Western Trauma Association (WTA) have made great strides in organizing multicenter trials to enrich the quality of the trauma literature. This expanding evidence has steadily invalidated prior surgical dogma. In this chapter, we present several benchmark trials that have dramatically contributed to the trauma surgery literature. As the field of trauma surgery encompasses not only traumatology but also emergency surgery and surgical critical care, the importance of these trials spans multiple disciplines, and should influence the practices of trauma surgeons, general surgeons, and surgical intensivists alike.

a. NEXUS C-Spine Criteria

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma.

SYNOPSIS

Takeaway Point: A decision instrument based on a set of five clinical criteria can help identify a subset of patients who, after blunt trauma, are at extremely low risk for cervical injury and can safely forego cervical spine (c-spine) imaging.

Commentary: The authors present the results of a large, multicenter observational study on imaging of the cervical spine after blunt trauma. The decision instrument identifies five criteria ...