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EliasDegiannis
DietrichDoll
GeorgeC.Velmahos
Editors
Penetrating
Trauma
APractical Guide onOperative Technique
and Peri-Operative Management
ThirdEdition
123

Penetrating Trauma

Elias Degiannis • Dietrich Doll
George C. Velmahos
Editors
Penetrating Trauma
A Practical Guide onOperative Technique
andPeri-Operative Management
Third Edition

Editors
Elias Degiannis
University of the Witwatersrand Medical School
Johannesburg, South Africa
George C. Velmahos
Massachusetts General Hospital, Harvard
University Medical School
Boston, MA, USA
Dietrich Doll
Saarland University, Medical School
Homburg / Saar, Germany
ISBN 978-3-031-47005-9 ISBN 978-3-031-47006-6 (eBook)
https://doi.org/10.1007/978-3-031-47006-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2017,
2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or
part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microlms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter
developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Paper in this product is recyclable.

To my parents who inspired me to do medicine and to my wife, Nellie, for her
https://t.me/medicina_free
unconditional love and support.
To my patients, who taught me a lot and to my teachers, who taught me
everything.
Elias Degiannis
To my parents and to Simone, our children and grand children, and to my
teachers. Time is love.
Dietrich Doll
To my parents, who lit my past, and to my wife and children, who light my
present and future.
George C.Velmahos

Preface
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This book provides clear practical guidance on all aspects of surgical treatment of penetrating
trauma and aims to foster the type of strategic thinking that can save patients’ lives. The coverage encompasses prehospital care, penetrating injuries to various body regions and specic
organs, orthopedic injuries, peripheral arterial injuries, injuries to special groups of patients,
including children and the elderly, military injuries, and a range of other topics. Based on their
extensive personal experience, expert authors provide step-by-step instructions on evaluation,
surgical techniques, and management of perioperative problems. Tips, tricks, and technical
pearls are highlighted, and each chapter includes a list of the most important points to observe.
This third edition of Penetrating Trauma has been extensively revised and updated—with
inclusion of some entirely new chapters—to take into account the most recent trends in resuscitation, diagnostics, and treatment. It will be an ideal resource for those looking for practical
solutions on how to treat injuries surgically.
Johannesburg, South Africa EliasDegiannis
Homburg, Saar, Germany DietrichDoll
Boston, MA, USA GeorgeC.Velmahos
vii

Contents
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Part I Prehospital Care, Diagnostic Tools and Resuscitation Strategies
1 Prehospital Care of Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
David Carlbom and Eileen M. Bulger
2 Airway Management in Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Pudkrong Aichholz, Andreas Grabinsky, and Eileen M. Bulger
3 Damage Control Resuscitation in Penetrating Trauma: Rules of the Game . . . . . . 31
Christopher Reed, Adrian Camarena, and Suresh Agarwal
4 BLS Versus ALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Dominik A. Jakob and Aristomenis K. Exadaktylos
5 Prehospital Care and Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Michael A. Frakes and Vahe Ender
6 Prehospital Monitoring During Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Kazuhide Matsushima and Heidi Frankel
7 Trauma Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Rachel Morris and Marc de Moya
8 ABC Heuristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Pantelis Vassiliu, George Konstantoudakis, Jason R. Degiannis,
and Asad Mushtaq
9 Pediatric Trauma Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Morgan L. Hennessy and Peter T. Masiakos
10 Fluids, Blood Substitutes, and New Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Sophia Tam, Lara Senekjian, and Ram Nirula
11 Emergency Department Thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Simin Golestani, Austin Eagleton, and Carlos V. R. Brown
12 Intensive Care: Principles and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Zachary M. Bauman and Terence O’Keeffe
13 Ventilation in the Trauma Patient: A Practical Approach . . . . . . . . . . . . . . . . . . . 109
Guy A. Richards, Timothy C. Hardcastle, and Richard E. Hodgson
14 ECMO in the Trauma Patient: A Practical Approach . . . . . . . . . . . . . . . . . . . . . . . 119
Jerome Crowley
15 Sepsis and Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Mervyn Mer and Martin W. Dünser
16 Endpoints of Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
David Muckart
ix

x
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17 Plain X-Rays for Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Simeng Wang, Donald J. Green, Mark Bernstein, and Marko Bukur
18 Computed Tomography in the Workup of Patients
with Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Mark E. Hamill
19 Portable Ultrasound as an Adjunct in Penetrating Trauma . . . . . . . . . . . . . . . . . . 165
Jim Connolly
20 Laparoscopy and Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Nicolas Melo and Daniel R. Margulies
21 Angiography and Interventional Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Marc Kalinowski
22 Imaging of Penetrating Urologic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Beat Schnüriger and Donald J. Green
23 Practical Approach to REBOA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Lauri Handolin, Ville Vänni, and Viktor Reva
24 Video-Assisted Thoracic Surgery in Penetrating Chest Trauma . . . . . . . . . . . . . . 203
François Pons, Henri de Lesquen, Charlotte Baltazard,
and Guillaume Boddaert
Contents
25 Diagnostic Peritoneal Lavage (DPL) Unplugged . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Keneeshia Williams and Terence O’Keeffe
26 Mass Casualties and Triage in Military and Civilian Environment . . . . . . . . . . . . 217
James M. Ryan, Dietrich Doll, and Christos Giannou
27 Ballistics in Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Maeyane S. Moeng and Kenneth D. Boffard
Part II Surgical Strategies in Penetrating Trauma to Head, Face, and Neck
28 Surgical Strategies in Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Toby P. Keeney-Bonthrone, Rachel M. Russo, Jessie M. Ho,
and Hasan B. Alam
29 Surgical Strategies in Trauma to the Head, Face, and Neck . . . . . . . . . . . . . . . . . . 249
Natalie Wall, Martha L. McCrum, and Heather L. Evans
30 Penetrating Injuries of the Face. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Rizan Nashef and Thomas B. Dodson
31 Operative Strategies in Penetrating Trauma to the Neck . . . . . . . . . . . . . . . . . . . . 271
Libby Schroeder and Marc de Moya
32 Access to the Neck in Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Jeffrey Ustin
33 Penetrating Trauma to the Larynx and the Cervical Trachea . . . . . . . . . . . . . . . . 281
Lisa M. Kodadek, Alicia Kieninger, and Elliott R. Haut
34 Penetrating Injury to the Pharynx and Cervical Esophagus . . . . . . . . . . . . . . . . . 289
Jessica A. Keeley and Angela L. Neville
35 Carotid, Jugular and Vertebral Blood Vessel Injuries . . . . . . . . . . . . . . . . . . . . . . . 297
Dirk Le Roux, Martin Veller, and Ian Grant

Contents
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xi
Part III Surgical Strategies in Penetrating Trauma to the Chest
36 Penetrating Trauma to the Subclavian Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Daniel F. Du Toit
37 Penetrating Trauma to the Thoracic Oesophagus . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Elias Degiannis, Tugba H. Yilmaz, and Martin Mauser
38 Penetrating Trauma to the Mediastinal Trachea and Main Bronchi . . . . . . . . . . . 327
Elias Degiannis, Georgy Ivakhov, and Alexander Sazhin
39 Operative Management of Pulmonary Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Katherine R. Iverson and Marc de Moya
40 Operative Management of Delayed Complications of Pulmonary
and Pleural Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
George V. Oosthuizen, Victor Y. Kong, and Ofer Merin
41 Penetrating Injuries to the Mediastinal Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Agneta Geldenhuys
42 Penetrating Cardiac Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .357
Elias Degiannis, Denzel P. Mogabe, Ioannis Massalis, and Dietrich Doll
43 Penetrating Injuries to the Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Elmin Steyn
44 Approach to Thoracoabdominal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Elias Degiannis, Thorsten Hauer, and Dietrich Doll
45 Loss of the Chest Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
John C. Mayberry
Part IV Surgical Strategies in Penetrating Trauma to the Abdomen and Pelvis
46 Access to the Abdomen: Emergency Laparotomy . . . . . . . . . . . . . . . . . . . . . . . . . . 383
George C. Velmahos
47 Damage Control Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Riaan Pretorius, Frank Plani, Kenneth D. Boffard, and Vicky Jennings
48 Beyond Damage Control Surgery: Abdominal Wall Reconstruction
and Complex Hernia Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Rifat Lati
49 Abdominal Esophagus and Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Chelsea R. Horwood and Clay Cothren Burlew
50 Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
George C. Velmahos
51 Penetrating Trauma to the Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Martin D. Smith, Dietrich Doll, and Elias Degiannis
52 Liver and Extrahepatic Bile Ducts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Frederick Millham
53 Large and Small Bowel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Jonathan E. Schoen and Herb A. Phelan

xii
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54 Injury of the Kidney, Ureter, and Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Brian I. Shaw and Suresh Agarwal
55 Lower Genitourinary Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .457
Donald Hannoun and Charles D. Best
56 Major Abdominal Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Peep Talving, Sten Saar, and Kenji Inaba
57 Major Abdominal Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Lydia Lam and Kenji Inaba
58 Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Ragavan Narayanan and Heena P. Santry
59 Penetrating Rectal Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Andrew J. Nicol and Pradeep H. Navsaria
60 Abdominal Compartment Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Osamu Yoshino, Nicholas Lee, and Zsolt J. Balogh
61 SNOM: Conservative Management of Solid Viscera . . . . . . . . . . . . . . . . . . . . . . . . 499
Pradeep H. Navsaria
62 Bleeding in the Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Edward Kelly and Francesca Izzo
Contents
Part V Neurological Trauma
63 Gunshot Injuries to the Head. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Ekkehard M. Kasper, Hanan Algethami, Radwan Takroni,
and Burkhard S. Kasper
64 Approach to Penetrating Injury of the Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . 523
Joachim M. K. Oertel and Jason R. Degiannis
65 Early Neurotrauma Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .529
Sara E. Cartwright, Kate E. Delaney, and Ronald E. Hirschberg
Part VI Surgical Strategies in Penetrating Trauma and Orthopedic Injuries
66 Introduction to Orthopedic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Thomas Scalea
67 Extremity Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
Jeffrey Ustin
68 Compartment Syndrome of the Extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
Mark W. Bowyer
69 Penetrating Trauma to the Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Sascha Flohé, Konstantinos Degiannis, and Tim Lögters
70 Penetrating Trauma to the Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Tobias Gehlen and Sven Märdian
71 Penetrating Trauma: Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Alexander Upll-Brown, Cyrus E. Taghavi, Nelson F. SooHoo,
and Areti Tillou
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