Emergency Surgery

Definition
Purpose
Description
Diagnosis/Preparation
Normal results

Definition

Emergency surgery is nonelective surgery performed when the patient’s life or well-being is in direct jeopardy. Largely performed by surgeons specializing in emergency medicine, this surgery can be conducted for many reasons but occurs most often in urgent or critical cases in response to trauma, mass casualties, cardiac events, poison episodes, brain injuries, and pediatric medicine.

Purpose

Most surgery is elective and is performed after a diagnosis based on a history and physical examination of the patient, with differential test results and the development of strategies for management of the condition. With emergency surgery, the surgical team as well as the surgeon may have less information about the patient than would ordinarily be required and must work under time-dependent conditions to save a patient’s life, help avoid critical injury or systemic deterioration of the patient, or alleviate severe pain. Because of the unique conditions for urgent acute surgery, operations are usually performed by a surgical team specially trained for management of a critical or life-threatening event.

Acute surgical emergencies include:

• invasive resuscitation for acute respiratory failure, pulmonary embolism, and pulmonary obstructions
• injuries resulting from blasts, explosions, or the release of dangerous chemicals, as in terrorist attacks, industrial accidents, pipeline leaks, or aviation accidents
• injuries resulting from buildings collapsing as a result of earthquakes, tornadoes, or hurricanes
• blunt or penetrating injuries to the head, chest, or abdomen, largely from automobile accidents and gunshot wounds
• injuries resulting in the loss or amputation of body parts (teeth, fingers, ears, toes, etc.) from human or animal bites, knife wounds, industrial accidents, etc.
• burns
• cardiac events, including heart attacks, cardiac shock, and cardiac arrhythmia
• aneurysms
• brain injuries and other neurological conditions
• complications of pregnancy
• abdominal disorders, including perforated ulcer, appendicitis, and peritonitis

Description

Emergency surgery can take place in any hospital or battlefield setting. However, trauma centers or trauma sections of hospitals handle most emergency surgeries. Forty-one states have ACS-verified trauma centers as of 2008, some states with better systems than others. There is an additional ACS-verified trauma center in Landstuhl, Germany.

One major difficulty remaining in the early 2000s is that trauma centers are unevenly distributed across the United States. A study published in the Journal of the American Medical Association reported in 2005 that 26.7% and 27.7% of the population of the United States had access to level I or II trauma centers by helicopter only within time periods of 45 and 60 minutes, respectively; and 1.9% and 3.1% of Americans had access only by helicopter to level I or II centers from trauma centers or base helipads outside their home states within those time periods. Most of these people live in rural areas. By contrast, 69.2% of people in the United States living in large cities can get to a level I or level II trauma center within 45 minutes, and 84.1% can reach a trauma center within 60 minutes.

Trauma centers in the United States are classified by the American College of Surgeons (ACS) as levels I, II, III, and IV, respectively. A level I trauma center, the most advanced of the trauma center system, is equipped to get the patient to surgery beginning with trained first responders. The system relies on available operating rooms, readily available laboratory personnel, anesthesiologists, x-ray and blood bank access, intensive care nurses, and ward nurses—all trained to take the patient to the operating room within 60 minutes of the incident. If patients are in surgery within an hour, they have a 25% chance of survival. Level I trauma centers also carry on research and maintain programs on trauma prevention.

Level II trauma centers work in collaboration with level I centers. They provide 24-hour availability of all essential specialties, personnel, and equipment but are not required to have research or residency programs. Level III centers do not have the full range of specialists, but have resources for emergency resuscitation, surgery, and intensive care of most trauma patients; they also have transfer agreements with level I and level II centers for the care of severely injured patients. Level IV centers stabilize and treat patients in remote areas where no other emergency care is available.

Diagnosis/Preparation

Emergency surgery follows a path from resuscitation and stabilization of the patient with a patient management team, to preparation of the patient for surgery, to postoperative and recovery procedures—all designed to deal quickly with the life-threatening situation. There is often little time or possibility for extensive diagnosis or the gathering of a patient history. Decisions are made quickly about surgery, often without family members present. The possibility of emergency surgery due to trauma, injury, emergency medical conditions, and cardiac events make it wise for all patients to have a living will detailing their medical care wishes and to carry it with them at all times.

Emergency surgery related to situations in which there are mass casualties, as in aviation disasters, railroad collisions, factory explosions, terrorist attacks, or such natural disasters as earthquakes, is often performed on site rather than in a trauma center, as there

KEY TERMS

Aneurysm— A bulge in the wall of a blood vessel caused by the weakening of the vessel wall. Aneur-ysms can be fatal if the affected blood vessel bursts.

Arrhythmia— An abnormal heart rhythm.

Embolism— The obstruction of a blood vessel by an air bubble or foreign particle.

First responder— A term used to describe the first medically trained responder to arrive on scene of an emergency, accident, natural or human-made disaster, or similar event. First responders may be police officers, fire fighters, emergency medical services personnel, or bystanders with some training in first aid.

Peritonitis— Inflammation of the layer of tissue that lines the inside of the abdominal cavity.

Trauma centers— Specialized hospital facilities that are equipped to deal with emergency life-threatening conditions.

Triage— Prioritizing the needs of patients according to the urgency of their need for care and their likelihood of survival.

may not be time to transport survivors to a hospital. In these situations, first responders typically carry out triage, which is the sorting out and giving medical assistance to patients in order to maximize the number of survivors. In most cases, triage involves focusing efforts on those whose survival depends on receiving prompt care rather than on those who will survive without immediate treatment and those who are past help. In mass casualty situations, survivors may need to be treated for burns, decontaminated from dangerous chemicals, or taken outside the immediate danger zone before surgical interventions can be carried out.

Normal results

Mortality rates are high for emergency surgeries For instance, the rupture of an abdominal aneurysm results in death in about 50% of cases due to kidney failure from shock or disrupted blood supply. Auntreated aneurysm is always fatal. Certain gastrointestinal disorders require emergency surgery, including bleeding in the digestive tract, obstructions, appendicitis and peritonitis (inflammation of the lining of the abdomen). Pediatric emergency surgery includes birth defect of the heart. One in 120 infants is born with a hear defect defect requiring surgery to unblock the flow of blood or to treat a malformed aortic valve. Heart attacks are very effectively treated with emergency surgery depending upon the part of the heart affected, on whether there is arterial blockage, and on the patient’s overall health. Arrhythmias can develop as well as stroke. The first 48 hours are the most crucial with cardiac events and whether there is immediate medical and surgical attention. Many cardiac surgeries result in bypass procedures, with a higher death rate associated with bypass surgery done on an emergency basis. Women have emergency heart bypass operations more often than men, probably due to lack of earlier cardiac care.

Resources

BOOKS

Marx, John A., ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed. Philadelphia: Mosby/ Elsevier, 2006.

Peitzman, Andrew B., ed. The Trauma Manual: Trauma and Acute Care Surgery, 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2007.

Wyatt, Jonathan P. Oxford Handbook of Emergency Medicine, 3rd ed. New York: Oxford University Press, 2006.

PERIODICALS

Branas, Charles C., Ellen J. MacKenzie, Justin C. Williams, et al. “Access to Trauma Centers in the United States.” Journal of the American Medical Association 293 (June 1, 2005): 2626–2633.

Cancio, L. C. “Airplane Crash in Guam, August 6, 1997: The Aeromedical Evacuation Response.” Journal of Burn Care and Research 27 (September-October 2006): 642–648.

Judy, M. B. “Planning for the Utilization of Air Medical Resources for Large-Scale Incidents.” Emergency Medical Services 36 (February 2007): 42–43.

Moore, E. E., M. M. Knudson, C. W. Schwab, et al. “Military-Civilian Collaboration in Trauma Care and the Senior Visiting Surgeon Program.” New England Journal of Medicine 357 (December 27, 2007): 2723–2727.

Vella, M., M. R. Masood, and W. S. Hendry. “Surgery for Ulcerative Colitis.” Surgeon 5 (December 2007): 356–362.

ORGANIZATIONS

American College of Emergency Physicians (ACEP). 1125 Executive Circle, Irving, TX 75038-2522. (800) 798-1822 or (972) 550-0911 http://www.acep.org (accessed March 19, 2008).

American College of Surgeons (ACS). 633 North St. Clair Street, Chicago, IL 60611. (800) 621-4111. http://www.facs.org/ (accessed March 19, 2008).

OTHER

DeNoon, D. “Trauma Centers: Life-or-Death Difference.” WebMD Medical News October 23, 2002 [cited June 17, 2003]. http://www.webmd.com (accessed March 19, 2008).

Smith, I. M. “U.S. Trauma Centers.” Virtual Hospital April 2003 [cited June 17, 2003]. http://www.vh.org/adult/patient/internalmedicine/aba30/2003/traumacenter.html (accessed March 19, 2008).

Stevens, Everett. “EMS and Terrorism.” eMedicine, March 10, 2005. http://www.emedicine.com/emerg/topic712.htm [cited January 10, 2008] (accessed March 19, 2008).

Nancy McKenzie, PhD

Rebecca Frey, PhD

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Endocardial resection seeMyocardial resection