How disease and injury work

1Why it matters

Much of surgery treats disease and injury. A surgeon removes a tumor, drains an abscessabscessAB-sesA closed pocket of pus in tissue, walled off by the body.Full entry Close, stops bleeding from an injured organ or corrects a defect a baby was born with. To follow an operation, and to see what comes next, you need to know what has gone wrong in the body and why. Pathologypathologypuh-THOL-uh-jeeThe study of disease and its causes and effects, or the disease changes found in a person or tissue.path/o disease-logy study ofFull entry Close is the study of disease.

Every operation is also an injury. The incision is a wound, and the body heals it the same way it heals a cut or a scrape. How well it heals depends on the patient's health, on what the surgeon finds inside, and on how the team handles the tissue, which is the part you control.

This chapter starts with the words used for disease, then the body's first answer to any injury (inflammation), problems with fluids and blood flow, including shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close, and tumors and cancer. Then it turns to wounds: their types, how they heal, how surgical wounds are classed, how they become infected, what helps or slows healing, and what can go wrong. It ends with trauma and with disorders present at birth.

Other chapters teach what it leaves out: cells, tissues and growth changes such as hyperplasiahyperplasiahy-per-PLAY-zhuhAn increase in the number of cells in a tissue or organ, making it larger.hyper- more than normal-plasia formation, growthFull entry Close and dysplasia in chapter 2; the layers of the skin and how a broken bone heals in chapter 3; germs, the immune system and how infection spreads in chapter 10; fluids, blood productsblood productBLUD PROD-uktAny part of donated blood prepared for transfusion, such as red cells, plasma or platelets.Full entry Close and drugs in chapter 12; shock, blood loss and body temperature under anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, and malignant hyperthermiamalignant hyperthermiamuh-LIG-nunt hy-per-THER-mee-uhA rare inherited reaction to certain general anesthesia drugs in which the muscles' metabolism speeds up out of control.mal- badhyper- above normaltherm heat-ia conditionFull entry Close, in chapter 13; suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close, staples, drains and wound closure in chapter 25; asepsisasepsisay-SEP-sisThe state of being free of germs that cause disease, and the practices used to keep things that way.a- withoutsep- decay or infection-sis conditionFull entry Close in chapter 26; setting up for a trauma case in chapter 28; bowel technique in chapters 29 and 32; dressings in chapter 30; preventing pressure injuriespressure injuryPRESH-er IN-juh-reeDamage to the skin and the tissue beneath it from pressure, or pressure with shear, usually over a bony area or under a device.Full entry Close during positioning in chapter 31; damage control surgery in chapter 32; and the diseases of each body system, with their operations, in chapters 32 to 42.

2The words of disease

Doctors, nurses and the chart use a small set of words to describe any disease. You will hear them at handoffshandoff reportHAND-off ree-PORTThe passing of information and responsibility for a client's care from one nurse or team to another.Full entry Close and read them in the history and physical.

Where a disease comes from

• Etiologyetiologyee-tee-OL-uh-jeeThe cause or origin of a disease, or the study of causes of disease.eti/o cause-logy study ofFull entry Close means cause. "Etiology unknown" in a chart means nobody knew the cause when the patient was examined. A disease can have one cause or many, from the environment and from inside the body.
• Idiopathicidiopathicid-ee-oh-PATH-ikHaving no known cause.idi/o one's own, separatepath/o disease-ic relating toFull entry Close describes a disease whose cause is unknown, one that seems to arise on its own.
• Pathogenesis is how a disease begins and develops.

How a disease shows itself

• Sign: evidence someone else can see or measure, such as a fever, a rash, swelling, an injury or loss of function.
• Symptom: what the patient feels and reports, such as pain or "my vision has been getting worse for five days."
• Syndrome: a group of signs that go together and point to a particular disease.
• Diagnosis: identifying the disease or injury a patient has, and its cause. It starts with an assessment, and tests and procedures confirm a diagnosis or rule it out.
• Invasive procedure: a test or treatment that breaks the skin or a mucous membrane, or puts a device into a body cavity. A noninvasive one touches only the skin, or nothing at all.
• Definitive diagnosis: a diagnosis confirmed by the usual investigations, such as imaging. In trauma, treatment often starts before one is made.

The course of a disease

• Acute: comes on suddenly. An acute illness is usually short, about 3 weeks or less.
• Chronic: long term, lasting weeks, months or years.
• Complication: a second problem that happens along with the main one or because of it, and usually makes the main problem more serious. An infection after an operation is a complication.
• Exacerbationexacerbationig-zas-er-BAY-shunA time when a long-term disease suddenly gets worse, or its symptoms flare up.Full entry Close: a worsening. A sudden flare of a chronic disease is called an acute exacerbation.
• Remissionremissionrih-MISH-unA period when the signs and symptoms of a disease lessen or disappear.Full entry Close: the disease subsides, and the symptoms lessen or disappear.
• RelapserelapseREE-lapsThe return of a disease or its symptoms after a period of improvement, or a return to substance use after a time without it.Full entry Close: the disease comes back after a remission.
• Prognosis: the expected outcomeexpected outcomeek-SPEK-tid OWT-kumA specific, measurable result the nurse and client aim for, used to judge whether care is working.Full entry Close of a disease or a treatment, usually given in words such as excellent, good or poor.
• Terminal: an illness that will end in death.
• Morbiditymorbiditymor-BID-ih-teeThe state of having a disease or health problem, or how often a disease occurs in a group of people.morb disease-ity state or conditionFull entry Close and mortalitymortalitymor-TAL-ih-teeDeath, or the rate of death in a group of people over a period of time.Full entry Close: the rates of illness and of death in a population. A common cold has high morbidity and low mortality. You will also hear that an operation carries a higher morbidity and mortality, meaning more complications and more deaths.

Treatment words

• Curative treatment is meant to cure the problem.
• PalliativepalliativePAL-ee-uh-tivDescribing care that eases symptoms and improves comfort and quality of life rather than curing the disease.Full entry Close treatment makes the condition easier to live with, by easing symptoms such as pain, without curing it.

3Inflammation: the body's first answer to injury

Whatever hurts tissue, whether germs, chemicals, a blow, heat or radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close, the body answers in the same way: with inflammation. Inflammation limits the damage, removes some or all of the cause, and starts the repair. It is part of the body's built-in (innate) defense.

The five signs

The four classic signs were written down in Roman times, and a fifth, loss of function, may join them. You may hear the old Latin names.

Notice that "tumor" here simply means swelling. Later in this chapter the word means a new growth.

What happens in the tissue

1. Right after an injury, the small vessels at the site clamp down for a moment. This slows bleeding and keeps any germ toxinstoxinTOK-sinA poison made by a living thing, such as a bacterium, plant or animal.Full entry Close from spreading.
2. Then the vessels widen. Injured cells release chemical signals, and mast cellsmast cellmast selAn immune cell in the tissues that releases histamine and other chemicals during allergic reactions and inflammation.Full entry Close release histaminehistamineHIS-tuh-meenA chemical released by certain immune cells that widens blood vessels, makes them leaky and tightens airway muscles.hist/o tissue-amine a type of nitrogen-containing chemicalFull entry Close, which opens the vessels further, so the area turns red and warm.
3. The capillary walls become leaky. PlasmaplasmaPLAZ-muhThe pale yellow liquid part of the blood, which carries the blood cells, proteins, nutrients and wastes.Full entry Close seeps into the tissue, which dilutes toxins and helps the blood clot, but it also causes swelling and pain.
4. White blood cells move out of the vessels into the tissue. NeutrophilsneutrophilNOO-truh-filThe most common type of white blood cell, which is first to reach and destroy bacteria at a site of infection.Full entry Close arrive within about 90 minutes, and macrophagesmacrophageMAK-roh-fayjA large white blood cell in the tissues that swallows and digests germs, dead cells and debris.macro- large-phage eaterFull entry Close within about 5 to 48 hours. Both engulf and digest germs and debris, a process called phagocytosisphagocytosisfag-oh-sy-TOH-sisThe process by which some white blood cells swallow and destroy germs, dead cells and debris.phag/o eatcyt/o cell-osis processFull entry Close.
5. Pus may collect: a mix of dead cells, white cells and living and dead germs.

Acute and chronic inflammation

Acute inflammation settles as the tissue heals. When it does not settle, it becomes chronic and causes disease of its own, as in arthritis or tuberculosistuberculosistoo-ber-kyoo-LOH-sisAn infection caused by the bacterium Mycobacterium tuberculosis, which most often attacks the lungs.tubercul/o small swelling-osis abnormal conditionFull entry Close. The suffix -itis means inflammation of a part: peritonitisperitonitispair-ih-tuh-NY-tisInflammation of the peritoneum, the thin membrane that lines the inside of the belly and covers the organs there.peritone/o peritoneum-itis inflammationFull entry Close is inflammation of the peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close, and meningitismeningitismen-in-JY-tisInflammation of the meninges, the membranes that cover the brain and spinal cord.mening/o meninges-itis inflammationFull entry Close of the meningesmeningesmuh-NIN-jeezThe three thin layers of tissue that cover and protect the brain and spinal cord.mening/o membraneFull entry Close, the membranes around the brain and spinal cord.

When macrophages cannot destroy something foreign, they surround and wall it off. The small mass that forms is a granuloma. Granulomas form in tuberculosis and some fungal infectionsfungal infectionFUNG-gul in-FEK-shunAn infection caused by a fungus, such as a yeast or a mold.Full entry Close, and around foreign material such as a suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close.

Inflammation and the surgical wound

A wound cannot heal without inflammation: it clears away bacteria, foreign material and dead tissue. In the first few days, the edges of a healing incision look a little swollen and red, and that is normal.

Inflammation that goes on too long slows healing. Many chronic wounds "stall" in this stage, and a film of bacteria on a wound (a biofilm) can keep it inflamed. Increased inflammation with fluid draining from the wound is one of the first signs of infection. Drugs that damp inflammation, such as steroidssteroidSTAIR-oydA fat-based chemical built from cholesterol; the group includes hormones such as cortisol and estrogen, and many drugs.ster/o solid-oid likeFull entry Close and nonsteroidal anti-inflammatory drugsnonsteroidal anti-inflammatory drugnon-STAIR-oy-dul an-tee-in-FLAM-uh-tor-ee DRUGA drug that relieves pain, fever and inflammation and is not a steroid, such as ibuprofen or naproxen.non- notanti- againstinflamm/o inflammationFull entry Close (NSAIDs), can slow healing too.

When the wound becomes infected

A wound always has some bacteria on it, but it becomes infected when the body's defenses can no longer keep the germs in check. An infected wound is painful, red and swollen, and drains pus; the drainage increases or changes color, and the patient may run a fever.

Infections differ in how far they spread:

• AbscessabscessAB-sesA closed pocket of pus in tissue, walled off by the body.Full entry Close: a pocket of pus in one place, walled off by macrophages, fibrin and granulation tissuegranulation tissuegran-yuh-LAY-shun TISH-ooNew, moist, red tissue that fills a healing wound from the bottom up.Full entry Close. Staphylococcus aureusStaphylococcus aureusstaf-uh-loh-KOK-us AW-ree-usA common round bacterium that often lives on the skin and in the nose and can cause infection.Full entry Close, including MRSAMRSAMUR-suh, or said as lettersMethicillin-resistant Staphylococcus aureus, a staph bacterium that many common antibiotics cannot kill.Full entry Close, is a common cause. A small abscess at an incision is usually easy to treat.
• Cellulitiscellulitissel-yoo-LY-tisA bacterial infection of the deeper layers of the skin and the tissue just under it.cellul small cell-itis inflammationFull entry Close: a spreading bacterial infection of the skin and the tissue under it, usually caused by streptococciStreptococcusstrep-tuh-KOK-usA group of round bacteria that grow in chains, some of which cause infections in people.strept/o twisted chain-coccus round bacteriumFull entry Close or staphylococciStaphylococcusstaf-uh-loh-KOK-usA group of round bacteria that grow in grape-like clusters and often live on the skin and in the nose.staphyl/o cluster, like grapes-coccus round bacteriumFull entry Close. Unlike an abscess, it has no single pocket of pus to drain.
• Spread to a cavity or the blood: infection that reaches a body cavity inflames its lining, as in peritonitis, and infection that reaches the bloodstream (septicemiasepsisSEP-sisA severe whole-body response to an infection that damages the body's own organs.Full entry Close) can damage organs throughout the body. Either can be fatal.

Infection slows healing in several ways. Fighting germs uses up the energy the body needs for repair, and bacteria release toxins that kill cells. Sutures break down faster in an infected wound, so the wound can split open. That is why an infected wound is usually not sutured closed but left open to heal.

4Fluid and blood flow disorders

The body's fluids and its blood flow are kept in a narrow range. When they slip out of it, every tissue suffers, the healing wound included.

Water and electrolytes

Body fluids hold electrolytes: substances that split into electrically charged particles. Positive ones (cations) include sodium, potassium, calcium and magnesiummagnesiummag-NEE-zee-umA mineral in the blood that the nerves, muscles and heart need, measured with a blood test.Full entry Close; negative ones (anions) include chloridechlorideKLOR-ideA negatively charged mineral (electrolyte) in the blood that works with sodium to keep fluid and acid-base balance.Full entry Close, bicarbonatebicarbonateby-KAR-buh-naytA base in the blood that balances acid; the kidneys control it, and its level is measured on blood gas and chemistry tests.Full entry Close and phosphate. Sodium is the main cation in the fluid outside the cells, and potassium the main one inside them.

Dehydration means the blood and tissues hold too little water. Repeated vomiting, diarrhea and not drinking enough all cause it, and an infant can become dangerously dehydrated very fast. Severe dehydration is an emergency: the person can lose consciousness, the kidneys can fail, and the person can die without fluids.

Surgical patients lose fluid in many ways: bleeding, fasting before surgery, fever and sweating, vomiting, diarrhea, suction through a nasogastric tubenasogastric tubenay-zoh-GAS-trik toobA thin, flexible tube passed through the nose and down the esophagus into the stomach.nas/o nosegastr/o stomach-ic having to do withFull entry Close, a bowel blockage or a fistulafistulaFIS-choo-luhAn abnormal passage between two organs or vessels, or between an organ and the skin.Full entry Close, and evaporation from an open abdomen. The very young and the very old are affected fastest. A large loss (more than about 500 mL), or a fast one, brings on shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close and needs fluid replaced at once.

Edema is extra water in the tissues, most often in the arms and legs. Fluid leaks out of the capillariescapillaryKAP-ih-lair-eeOne of the tiniest blood vessels, joining the smallest arteries to the smallest veins.Full entry Close because of an underlying disease (such as heart or kidney failurerenal failureREE-nul FAYL-yerLoss of the kidneys' ability to filter waste and extra fluid from the blood.ren kidney-al relating toFull entry Close), some drugs, pregnancy, a local injury or an allergic reaction. Swollen skin feels tight, and a finger pressed into it may leave a dent that lasts a few seconds, called pitting. Edema in a wound slows its healing.

Sodium controls how much water the body holds and how it moves between the cells and the fluid around them. Normal blood sodium is about 135 to 145 mEq/L.

• Hyponatremiahyponatremiahy-poh-nuh-TREE-mee-uhA blood sodium level below normal, under 135 mEq/L.hypo- belownatr sodium (from its Latin name, natrium)-emia in the bloodFull entry Close (low sodium, below 135) can follow long vomiting or diarrhea, some diureticsdiureticdy-yoo-RET-ikA drug that makes the kidneys pass more water and salt out of the body as urine.dia- throughur/o urine-etic relating toFull entry Close, suction through a nasogastric tube, and surgery itself. In a transurethral resection of the prostatetransurethral resection of the prostatetrans-yoo-REE-thrul rih-SEK-shun of the PROS-taytSurgery that removes part of the prostate gland with an instrument passed up through the urethra.trans- throughurethr/o urethra-al relating toresection cutting outFull entry Close (TURP), the patient can absorbabsorptionub-ZORP-shunThe taking in of a substance, such as a drug or a nutrient, into the bloodstream.Full entry Close so much irrigating fluid that the blood sodium is diluted.
• Hypernatremiahypernatremiahy-per-nuh-TREE-mee-uhA blood sodium level above normal, over 145 mEq/L.hyper- abovenatr sodium (from its Latin name, natrium)-emia in the bloodFull entry Close (high sodium) often comes from too little fluid replacement. It can cause confusion, lethargylethargyLETH-er-jeeA state of being very drowsy, slow and hard to keep awake, or having little energy.Full entry Close and seizuresseizureSEE-zherA sudden burst of abnormal electrical activity in the brain that changes movement, feeling, behavior or awareness.Full entry Close.

Potassium is needed for the nerve signals that make skeletal, smooth and heart musclemyocardiummy-oh-KAR-dee-umThe thick middle layer of the heart wall, made of heart muscle that contracts to pump blood.my/o musclecardi/o heart-um structureFull entry Close contract. Normal blood potassium is about 3.5 to 5.0 mEq/L.

• Hypokalemiahypokalemiahy-poh-kuh-LEE-mee-uhA blood potassium level below normal, under 3.5 mEq/L.hypo- belowkal potassium (from its Latin name, kalium)-emia in the bloodFull entry Close (low potassium, below 3.5) can follow vomiting and diarrhea, heavy tissue injury, shock, diuretics and heavy suctioningsuctioningSUK-shun-ingRemoving mucus, saliva or other secretions from the mouth, nose or airway with a tube connected to a suction source.Full entry Close of body fluids. It causes heart rhythm problems, muscle weakness and a bowel that stops moving (ileusileusIL-ee-usA slowing or stopping of the normal movement of the intestines, with nothing physically blocking them.Full entry Close).
• Hyperkalemiahyperkalemiahy-per-kuh-LEE-mee-uhA blood potassium level above normal, over 5.0 mEq/L.hyper- abovekal potassium (from its Latin name, kalium)-emia in the bloodFull entry Close (high potassium, above 5.0) can follow a massive transfusionblood transfusionBLUD trans-FYOO-zhunGiving blood, or a part of blood, from a donor into a person's vein.trans- acrossfus/o pourFull entry Close of stored blood, kidney failure, low blood volume, acidosisacidosisas-ih-DOH-sisA state in which the blood is more acidic than normal, with a pH below 7.35.acid -osis abnormal conditionFull entry Close, crush injuries, burns and some drugs, such as succinylcholinesuccinylcholinesuk-sih-nil-KOH-leenA fast, short-acting drug that relaxes and paralyzes the muscles, used to place a breathing tube.Full entry Close. It can stop the heart.

Normal ranges differ a little from one lab to another.

Blood in the wrong place

• Hyperemia: more blood than usual in a part. It is active when more blood flows in, as in inflammation, and passive when blood cannot drain away (congestion).
• HemorrhagehemorrhageHEM-uh-rijA large loss of blood from a blood vessel, inside the body or out of it.hem/o blood-rrhage bursting forthFull entry Close: bleeding, usually bleeding that goes on for more than a few minutes, starves tissue of blood or threatens life. Bleeding from an artery, inside the body or inside the skull is the most dangerous. The risk is highest after major trauma and in patients on anticoagulantsanticoagulantan-tee-koh-AG-yoo-luntA drug that slows the blood's ability to form clots.anti- againstcoagul/o clotting-ant an agent that doesFull entry Close or with a clottingclottingKLOT-ingThe process by which blood thickens into a gel to plug a damaged vessel and stop bleeding; also called coagulation.Full entry Close disorder. In surgery, kidney failure, liver diseaseliver diseaseLIV-er dih-ZEEZAny condition that damages the liver or keeps it from working normally.hepat/o liverFull entry Close and disseminated intravascular coagulationdisseminated intravascular coagulationdih-SEM-ih-nay-tid in-truh-VAS-kyuh-ler koh-ag-yuh-LAY-shunA disorder in which clotting is switched on throughout the blood vessels until the clotting factors are used up.intra- withinvascul/o vesselcoagul/o clottingFull entry Close (DIC) can cause catastrophic bleeding. Exsanguinating hemorrhage is bleeding that could drain the patient's whole blood volume.
• Hematomahematomahee-muh-TOH-muhA collection of blood, often clotted, that has leaked out of the blood vessels into the tissue.hem/o blood (here as hemat-)-oma swelling or massFull entry Close: a mass of blood, usually clotted, trapped in a tissue, organ or space after a vessel breaks.
• Thrombosisthrombosisthrom-BOH-sisThe forming of a blood clot (a thrombus) inside a blood vessel or the heart.thromb/o clot-osis conditionFull entry Close: a blood clot (thrombus) forming inside the blood vessels. A clot is lifesaving when it seals a bleeding vessel, but dangerous anywhere else, because it can block the blood supply to an organ.
• EmbolismembolismEM-buh-liz-umThe blocking of a blood vessel by a mass carried there in the blood (an embolus), such as a clot, fat or an air bubble.embol/o plug-ism conditionFull entry Close: a sudden blockage of a vessel by something carried in the blood (an embolus). An embolus can be a clot, a piece of plaqueplaquePLAKA deposit that builds up on a surface in the body, such as a sticky film of bacteria on teeth or a fatty buildup in an artery wall.Full entry Close, bacteria, cancer cells, amniotic fluidamniotic fluidam-nee-OT-ik FLOO-idThe fluid inside the amniotic sac that surrounds and protects the baby during pregnancy.Full entry Close, fat from a broken bone or an air bubble.

The classic embolism of surgery starts as a deep vein thrombosisdeep vein thrombosisDEEP VAYN throm-BOH-sisA blood clot in a deep vein, most often in the leg or pelvis.thromb/o clot-osis conditionFull entry Close (DVT): a clot forms in a deep vein, most often in the leg, breaks loose and lodges in the lungs as a pulmonary embolismpulmonary embolismPUL-muh-nair-ee EM-buh-liz-umA blockage of an artery in the lungs, usually by a blood clot that has traveled there from elsewhere in the body.pulmon/o lung-ary relating toembol/o plug-ism conditionFull entry Close (PEPEpee-EE (said as letters)An abbreviation that most often means pulmonary embolism; it can also mean physical examination or pleural effusion.Full entry Close). Three things set up a clot, together called Virchow's triadVirchow triadFEER-koe TRY-adThree conditions that together promote blood clots in vessels: slowed blood flow, damage to the vessel wall, and blood that clots too easily.Full entry Close: injury to the lining of a vessel, blood pooling in the legs, and blood that clots too easily (hypercoagulability), as after surgery, burns or a stroke and with cancer, sepsissepsisSEP-sisA severe whole-body response to an infection that damages the body's own organs.Full entry Close, pregnancy, estrogenestrogenES-truh-jenA female sex hormone, made mainly by the ovaries, and the group of drugs that act like it.Full entry Close use or diabetes. Blood that pools in an unmoving patient can clot. Trauma, fractures, burns, hip surgery that flexes and rotates the hip, a pneumatic tourniquet, obesity and circulatory disease all raise the risk. Antiembolism stockingscompression stockingkum-PRESH-un STOK-ingA tight elastic stocking that squeezes the leg, most firmly at the ankle, to help blood flow back toward the heart.Full entry Close, sequential compression devicessequential compression devicesih-KWEN-shul kum-PRESH-un dih-VYSInflatable leg sleeves that fill with air and squeeze the legs in turns to keep blood moving in the veins.Full entry Close (SCDs) and drugs help prevent it.

When blood cannot get through, tissue suffers in steps:

• Ischemiaischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close: too little blood flow to a tissue or organ. Tissue that is retracted, clamped or handled roughly can become ischemic during surgery.
• Necrosisnecrosisneh-KROH-sisThe death of cells or tissue in a part of the body.necr/o death-osis conditionFull entry Close: the death of cells or tissue, from a poor blood supply, germs, trauma, radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close or chemicals. A heart attackmyocardial infarctionmy-oh-KAR-dee-ul in-FARK-shunDeath of part of the heart muscle because its blood supply is blocked; a heart attack.my/o musclecardi/o heart-al having to do withinfarct area of dead tissueFull entry Close (myocardial infarction) is necrosis of heart muscle caused by ischemia.
• GangrenegangreneGANG-greenThe death of body tissue because its blood supply has been lost or because of severe infection.Full entry Close: necrosis of a body part, usually because its blood supply has failed. Gangrene with an infection by bacteria that grow without oxygen also decomposes the tissue.

Shock

Shock (circulatory shock) is a life-threatening state in which the circulation cannot deliver enough blood, and so enough oxygen and nutrients, to keep the cells working. It has nothing to do with emotional shock. Blood is shunted away from the organs, and cells begin to die.

A patient in shock usually has a fast heart rate, low blood pressure, fast breathing, cool and clammy skin and little urine, and may become confused or lose consciousness. Early on, the blood pressure can stay normal while the body compensates, so a fast pulse, cool skin and falling urine output may be the first clues. Shock feeds on itself: left uncorrected, each change makes the next one worse, until the patient dies.

Shock is named by its cause:

• Hypovolemic shockhypovolemic shockhy-poh-voh-LEE-mik SHOKShock from a large loss of blood or body fluid, so there is too little volume in the blood vessels to supply the organs.hypo- belowvol volume-emic relating to the bloodFull entry Close: too little volume in the vessels. In adults it is usually caused by bleeding (hemorrhagic shock), but vomiting, diarrhea, burns and large fluid shifts after trauma cause it too. Hemorrhagic shock is the most common cause of death in trauma.
• Cardiogenic shockcardiogenic shockkar-dee-oh-JEN-ik SHOKA type of shock in which the heart cannot pump enough blood to supply the body's organs.cardi/o heart-genic produced byFull entry Close: the heart cannot pump enough blood, most often after a heart attack.
• Obstructive shock: a blockage, such as a pulmonary embolism, stops the blood flow; some references group it with cardiogenic shock.
• Distributive shock (also called vascular shock): the vessels lose their tone and widen, so their resistance drops and blood pools. Its three main forms are the next three in this list; adrenaladrenaluh-DREE-nulHaving to do with the adrenal glands, the two small glands that sit on top of the kidneys.ad- nearren/o kidney-al relating toFull entry Close insufficiencyinsufficiencyin-suh-FISH-un-seeA state in which an organ or part does not work well enough to meet the body's needs.in- notsufficient enoughFull entry Close can also cause it.
• Septic shockseptic shockSEP-tik shokThe most severe stage of sepsis, in which the circulation fails and blood pressure stays low even after IV fluids.sept/o infection-ic relating toFull entry Close, a distributive shock: a severe infection, most often bacterial, that sets off an inflammatory responseinflammatory responsein-FLAM-uh-tor-ee rih-SPONSThe body's protective reaction to injury or infection, which brings blood, fluid and white cells to the area.Full entry Close in the whole body. It can kill quickly, and it can lead to DIC.
• Anaphylacticanaphylaxisan-uh-fuh-LAK-sisA sudden, severe allergic reaction that affects the whole body.ana- away, against-phylaxis protectionFull entry Close shock, a distributive shock: a severe allergic reactionsevere allergic reactionsuh-VEER uh-LUR-jik ree-AK-shunAn allergic reaction strong enough to affect breathing, circulation or several body systems at once, not just the skin.Full entry Close releases histaminehistamineHIS-tuh-meenA chemical released by certain immune cells that widens blood vessels, makes them leaky and tightens airway muscles.hist/o tissue-amine a type of nitrogen-containing chemicalFull entry Close, and vessels widen throughout the body.
• Neurogenic shock, a distributive shock: the autonomic nervous systemautonomic nervous systemaw-tuh-NOM-ik NUR-vus SIS-tumThe part of the nervous system that controls body functions without conscious thought, such as heart rate, breathing and digestion.auto- selfnom/o law, control-ic relating toFull entry Close can no longer hold the vessels' tone, after a spinal cord or brain injury, some drugs or anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close.

Treatment aims at the cause, and in every case at restoring circulation, oxygen to the tissues and the electrolyte balance, with fluids, blood productsblood productBLUD PROD-uktAny part of donated blood prepared for transfusion, such as red cells, plasma or platelets.Full entry Close and drugs. Chapter 13 covers shock and blood loss during anesthesia.

5Tumors and cancer

Surgery is used to diagnose cancer, to find out how far it has spread and to treat it, so the words of cancer come up in the OR all the time.

The words

• A neoplasm, or tumor, is an abnormal new growth. A tumor is either benign or malignant. Any word ending in -oma names a tumor, such as osteoma, leiomyomauterine fibroidYOO-ter-in FY-broydA noncancerous growth of muscle and fibrous tissue in or on the wall of the uterus.fibr/o fiber-oid likeFull entry Close or lymphomalymphomalim-FOH-muhA cancer of lymphocytes, the white blood cells of the lymph system.lymph/o lymph-oma tumorFull entry Close.
• Benign describes a tumor that cannot spread to other parts of the body. Its cells are of one tissue type and look like the tissue they came from.
• Malignant describes tissue that grows in a disorganized, uncontrolled way and can invade and spread. A malignant tumor is a cancer.
• The primary tumor is the one at the site where the cancer started.
• Metastasismetastasismuh-TAS-tuh-sisThe spread of cancer cells from where the cancer started to other parts of the body.meta- change, beyondstasis standing, placeFull entry Close is the spread of cancer cells to a nearby or distant part of the body, where they start new tumors. Cancer cells usually travel in the lymphlymphLIMFThe clear fluid that flows through the lymphatic vessels and carries white blood cells.Full entry Close or the blood.

Cancers are named by the tissue they start in:

• Carcinomacarcinomakar-sih-NOH-muhA cancer that starts in the cells that line the skin or the inside and outside surfaces of organs.carcin/o cancer-oma tumorFull entry Close: from epithelial cells, the tissue that covers surfaces (chapter 2).
• Sarcomasarcomasar-KOH-muhA cancer that starts in bone or in the body's soft tissues, such as muscle, fat or blood vessels.sarc/o flesh-oma tumorFull entry Close: from connective tissueconnective tissuekuh-NEK-tiv TISH-ooBody tissue that supports, binds together and protects other tissues and organs.Full entry Close such as bone or muscle.
• Leukemialeukemialoo-KEE-mee-uhA cancer of the blood-forming cells in the bone marrow, in which abnormal white blood cells are made in large numbers.leuk/o white-emia blood conditionFull entry Close: cancer of the white blood cells.
• Lymphoma: cancer of the lymphocyteslymphocyteLIM-foh-syteA type of white blood cell that targets specific germs and abnormal cells, including T cells, B cells and natural killer cells.Full entry Close, the white cells of the lymph system.
• Melanomamelanomamel-uh-NOH-muhA cancer that starts in melanocytes, the cells that give skin its color.melan/o black, dark-oma tumorFull entry Close: cancer of the skin's pigment cells (melanocytesmelanocytemuh-LAN-uh-syteA cell in the bottom layer of the skin's outer layer that makes melanin, the pigment that gives skin and hair their color.melan/o black-cyte cellFull entry Close), often starting in a mole, and able to spread aggressively.

Carcinoma in situ means abnormal cells that have stayed in the place they started ("in situ" is Latin for "in place") and have not spread. They can become an invasive cancer.

What causes cancer

Cancer starts when a cell's DNADNAdee-en-AY (said as letters)Deoxyribonucleic acid: the molecule in cells that carries the genetic instructions for growth and function.Full entry Close is damaged. Normally, a damaged cell repairs itself or dies on schedule (apoptosisapoptosisap-op-TOH-sisProgrammed cell death: an orderly process by which the body removes cells it no longer needs.apo- away from-ptosis fallingFull entry Close). When repeated damage leaves an error the cell does not repair, the cell keeps dividing instead of dying, and if the immune system fails to find and destroy it, a malignant growth begins.

A carcinogencarcinogenkar-SIN-uh-jenAnything that can cause cancer, such as tobacco smoke, asbestos, UV light or certain chemicals and viruses.carcin/o cancer-gen something that producesFull entry Close is a substance that causes cancer. The causes fall into three groups that can work together: problems inside the body, such as immune dysfunction or long-lasting inflammation; things in the environment; and genes.

• Chemicals: tobacco smoke is the classic example, full of carcinogens. Alcohol, a poor diet and work exposures such as asbestos, benzene and lead raise the risk too.
• Radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close: sun exposure and ionizing radiation, such as X-rays.
• Viruses: hepatitis Bhepatitis Bhep-uh-TY-tis BEEA liver infection caused by the hepatitis B virus.hepat/o liver-itis inflammationFull entry Close, the human papillomavirushuman papillomavirusHYOO-mun pap-ih-LOH-muh-vy-rusA common group of viruses spread by close skin-to-skin contact, most often during sex.Full entry Close (HPV), the Epstein-Barr virusEpstein-Barr virusEP-steen BAR VY-rusA common herpes virus that causes infectious mononucleosis.Full entry Close and HIVHIVaych-eye-VEE (said as letters)Human immunodeficiency virus: a virus that infects and destroys immune cells called CD4 T cells.Full entry Close. HPV causes the cell changes in the cervix that a Pap testPap testPAP testA screening test in which cells are gently scraped from the cervix and looked at under a microscope.Full entry Close looks for.
• Genes: some mutationsmutationmyoo-TAY-shunA change in the genetic code (DNA) of a cell.Full entry Close are inherited from a parent and present from birth, such as the BRCA1 and BRCA2 mutations linked to breast and ovarian cancerovarian canceroh-VAIR-ee-un KAN-serCancer that starts in the ovaries or in the nearby fallopian tubes.Full entry Close. Others are acquired over a lifetime.

Inactivity and obesity add to the risk. Some cancers have no risk factor anyone can find.

Finding cancer and sizing it up

Many cancers can be treated if they are found early, which is why screening testsscreening testSKREE-ning testA test given to people who have no symptoms, to find a disease or risk early.Full entry Close exist. Cutting down on the known risks, such as tobacco, alcohol and a diet high in fat and processed food, staying active, keeping a healthy weight and keeping vaccines up to date all lower the risk of cancer.

• Tumor markersmarkerMAR-kerSomething that can be measured, such as a substance in the blood, that shows a disease or body process is present.Full entry Close: substances that cancer cells put on their surface or release into the blood, such as prostate-specific antigenprostate-specific antigenPROS-tayt spuh-SIF-ik AN-tih-junA protein made by the prostate gland, measured in a blood test to screen for and follow prostate problems.Full entry Close (PSA) in prostate cancerprostate cancerPROS-tayt KAN-serCancer that starts in the prostate, the gland below the bladder in males that helps make semen.Full entry Close and CA-125CA-125see-ay wun-TWEN-tee-fyvA blood test for cancer antigen 125, a protein used as a tumor marker for ovarian cancer.Full entry Close in some ovarian cancers. Some benign tumors release markers too, so a marker cannot prove cancer; markers are most useful for tracking how well treatment is working.
• Nuclear medicine: a radioactive substance given by vein, by mouth or into the tissue, then traced to show the structure and work of an organ or tissue.
• Biopsy: removing tissue, cells or fluid to be examined for disease. Tissue can be cut out (an excisional biopsy), taken as a core with a hollow needle or trocartrocarTROH-karA sharp or bladed instrument inside a tube (cannula), used to pierce a body wall and leave the tube in place as a port.Full entry Close, through the skin or during surgery, or swept from a passage with a small brush. A cell washing or a smearsmearSMEERA thin layer of a sample, such as blood or cells, spread on a glass slide to be looked at under a microscope.Full entry Close can be a biopsy too.
• Frozen section: tissue frozen and examined under the microscope while the patient is still on the table. Its answer can decide whether the surgeon goes on to a larger operation. A permanent section is fixed on slides and read later. Chapter 29 covers handling specimens.

Once cancer is found, two systems describe it:

• Grading describes how abnormal the cancer cells look under the microscope. Well-differentiated cells still look like the tissue they came from; poorly differentiated and undifferentiated cells do not, and they tend to grow and spread fast. Grades run from G1 to G4 (some references use grades I to IV), with GX when the grade cannot be judged. The higher the grade, the more abnormal the cells and the more serious the disease.
• StagingstagingSTAY-jingWorking out how large a cancer is and how far it has spread in the body.Full entry Close describes how far the cancer has spread.

Most solid tumors are staged with the TNMTNMtee-en-em (said as letters)Tumor, Node, Metastasis: a system for describing how far a cancer has grown and spread.Full entry Close system, which has three parts:

• T (tumor): the size and extent of the main tumor, from T1 to T4; Tis is carcinoma in situ, T0 means no primary tumor is found, and TX means it cannot be assessed.
• N (nodes): whether the cancer has reached the nearby lymph nodeslymph nodelimf nohdA small, bean-shaped organ of the immune system that filters lymph fluid and holds white blood cells.Full entry Close; N0 means no, N1 to N3 mean more and more nodes.
• M (metastasis): whether it has spread to distant organs, such as the brain or liver; M0 means no, M1 means yes.

The T, N and M results are combined into a stage. For example, a bladder cancer that is T1 N0 M0 (an early tumor, no nodes, no distant spread) is stage I. Each kind of cancer has its own staging rules, published by the American Joint Committee on Cancer, and blood cancers such as leukemia are not staged with TNM. Staging guides the choice of treatment and the prognosis.

The nodes are often checked during surgery with a sentinel lymph node biopsy, which removes the first node the tumor drains to; chapter 5 explains how it is found, and chapter 32 the operation.

Sentinel Node/Lymph Node Dissection13 instruments · 2 photos

Treating cancer

The treatment plan depends on the kind of cancer and its stage, on the patient's overall health, and on the goal of treatment. Most plans combine several treatments.

Surgery can serve several goals:

A benign tumor may need nothing more than its removal. A malignant one needs prompt treatment to keep it from spreading.

Where the tumor is, its grade and its stage decide how big the operation is. In breast cancer, for example, a small tumor is often removed with a margin of normal tissue (breast-conserving surgery), followed by radiation, but breast-conserving surgery is not usually an option when cancer is found in two or more separate parts of the breast. In a modified radical mastectomy the whole breast is removed, with a sentinel node biopsy or an axillary node dissectiondissectiondy-SEK-shunA tear in the inner layer of an artery wall that lets blood split the layers apart; also, the cutting apart of tissue in surgery.Full entry Close.

Chemotherapyantineoplastican-tee-nee-oh-PLAS-tikA drug used to treat cancer by killing cancer cells or stopping them from growing and dividing.anti- againstneo- newplas growth, formation-tic relating toFull entry Close and radiation, which the Core Curriculum calls adjunct treatments, are often added to surgery:

• Chemotherapy: drugs that kill cancer cells. It can aim to cure, to shrink a tumor and stop it spreading, or to ease symptoms. Chemotherapy given after surgery to destroy cells left behind is adjuvantadjuvantAJ-uh-vuntAdded to a main treatment to help it work better; also a substance added to a vaccine to strengthen the immune response.ad- towardjuv helpFull entry Close therapy; chemotherapy given before surgery to shrink the tumor is neoadjuvant therapy.
• Radiation therapyradiation therapyray-dee-AY-shun THAIR-uh-peeTreatment that uses high-energy rays or radioactive material to kill cancer cells or shrink tumors.Full entry Close: ionizing radiation that destroys tumor tissue. It can be aimed at the body from outside, as for the whole breast after breast-conserving surgery, or placed inside it (brachytherapybrachytherapybrak-ee-THAIR-uh-peeRadiation treatment in which a radioactive source is placed inside the body, in or right next to a tumor.brachy- short (a short distance)-therapy treatmentFull entry Close) as radioactive seeds left in the tumor, needles or a catheter loaded with radioactive pellets, as in breast and prostate cancer. A single dose can also be given during surgery (intraoperativeintraoperativein-truh-OP-er-uh-tivHappening during surgery, from when the client is brought into the operating room until they are moved to recovery.intra- within, duringoperative of surgeryFull entry Close radiation therapy). Clips the surgeon leaves in the tumor bed help the radiation oncologist aim later.
• Targeted and biologic therapy: drugs that kill cancer cells while sparing normal cells, and treatments that help the immune system kill cancer cells.

Chapter 12 covers drugs on the field, and chapter 22 radiation safety.

What cancer does to the whole body

A cancer harms more than the organ it grows in.

• Anemiaanemiauh-NEE-mee-uhA lower than normal number of red blood cells or amount of hemoglobin in the blood.a- without, lacking-emia blood conditionFull entry Close: from bleeding inside the body and the body's failure to replace red cells.
• Bleeding: a cancer of the blood-forming cells, such as leukemia, can leave too few plateletsplateletPLAYT-litA tiny cell fragment in the blood that sticks together at a wound to help form a clot.Full entry Close, so the patient bruises and bleeds easily.
• Infections: such a cancer can also leave too few working white cells, and chemotherapy and radiation lower the white cell countwhite blood cell countwite blud sel kowntA blood test that counts the white blood cells, the cells that fight infection, in a sample of blood.Full entry Close too.
• Blood clots: the tumor can release clotting factorsclotting factorKLOT-ing FAK-terAny of the proteins in blood plasma that work together in a chain to form a blood clot.Full entry Close or press on vessels, so clots (thrombosisthrombosisthrom-BOH-sisThe forming of a blood clot (a thrombus) inside a blood vessel or the heart.thromb/o clot-osis conditionFull entry Close) form more easily.
• Pain: from tumor pressing on and destroying tissue, and from chemicals the tumor releases.
• Paraneoplastic syndromes: effects of a cancer far from the tumor, caused by hormones or other chemicals the tumor cells release. Lung cancers, especially small cell lung cancer, can cause a high calcium level, too much antidiuretic hormoneantidiuretic hormonean-tee-dy-yoo-RET-ik HOR-mohnA hormone from the pituitary gland that tells the kidneys to hold on to water, making the urine more concentrated.anti- againstdiuretic making urineFull entry Close or Cushing syndromeCushing syndromeKUSH-ing SIN-drohmA condition caused by too much cortisol in the body over a long time.Full entry Close this way, sometimes before the cancer is even diagnosed.
• Weight loss and cachexiacachexiakuh-KEK-see-uhSevere, ongoing loss of muscle and fat, with weakness, that eating more does not fully reverse.Full entry Close: cachexia is wasting of the body. The tumor takes the nutrients healthy tissue needs and changes the body's metabolismmetabolismmuh-TAB-uh-liz-umAll the chemical processes in the body's cells that make energy, build tissue and break substances down.Full entry Close.

These effects follow the patient into the OR. A wasted (cachectic) patient loses heat fast, and cancer is one of the risk factors for a wound that splits open.

6Wounds

A wound is any tissue damaged by surgery or by injury.

The words of wound healing

The Core Curriculum lists the terms below. Several also appear elsewhere in this chapter.

Types of wounds

The Core Curriculum sorts wounds into three groups by how they came about.

Intentional (surgical) wounds are planned. An incision or an excisionexcisionek-SIZH-unCutting out tissue, such as a growth or damaged area, during surgery.Full entry Close is made under sterile conditions, for a treatment, with clean edges that can be brought together, bleeding under control, and closure right after the procedure.

Unintentional (traumatic) wounds come from an accident or an assaultassaultuh-SAWLTIn law, a threat or act that makes a person afraid they are about to be touched in a harmful or unwanted way.Full entry Close. They are not made under sterile conditions, their edges are irregular, they may involve tissue loss and several injuries at once, and bleeding may not be under control. Traumatic wounds are described in several ways, and one wound can fit more than one:

• Closed or open: in a closed wound the skin stays intact over damaged tissue; in an open wound the skin is broken.
• Simple or complicated: a simple wound has no tissue loss and nothing left in it; a complicated wound has lost tissue or holds a foreign body.
• Clean or contaminated: a clean wound has edges that can be brought together and is expected to heal by first intention; a dirty object makes a wound contaminated, and it can become infected within a short time.

A traumatic wound comes from a mechanical force (a mechanical injury), from heat or cold, from chemicals, or from electricity or radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close. By its cause, it can be:

• Blunt: a force that does not break the skin, such as a blow, a fall or a crash, causing contusions and internal injuries.
• Penetrating: an object that goes through the skin, such as a knife (a puncture or laceration) or a bullet.
• Chemical: damage that depends on how long the chemical touched the tissue, how strong it was, how much tissue it reached and how it acts.
• Thermal: damage from heat or cold.
• Electrical and radiation injuries are covered with burns, below.

Chronic wounds last because of an underlying condition, such as pressure or poor circulation, or an infection. A chronic wound fails to move through the phases of healing on time; in the United States, a wound that has not closed or improved within 30 days is called chronic. It tends to have jagged edges and a higher risk of infection.

• A pressure injurypressure injuryPRESH-er IN-juh-reeDamage to the skin and the tissue beneath it from pressure, or pressure with shear, usually over a bony area or under a device.Full entry Close is damage to a patch of skin and the tissue beneath it, usually over a bony prominence, caused by pressure or pressure combined with shear. Older names include pressure ulcerulcerUL-serAn open sore where the skin or the lining of an organ has broken down.Full entry Close, pressure sore (the term in the Core Curriculum's wound outline), decubitus ulcer and bedsore. Pressure injuries are staged: Stage 1 is intact skin with redness that does not fade when pressed; Stage 2 is a partial-thickness loss of skin with the dermisdermisDER-misThe thick layer of skin under the epidermis that holds blood vessels, nerves, hair roots and glands.derm/o skinFull entry Close showing; Stage 3 is a full-thicknessfull-thicknessful-THIK-nisGoing through every layer of the skin, or every layer of another tissue such as the wall of an organ.Full entry Close skin loss with fat showing; Stage 4 exposes fascia, muscle, tendon, cartilagecartilageKAR-tih-lijFirm, smooth, rubbery tissue that cushions joints and gives shape to parts such as the ear, nose and windpipe.chondr/o cartilageFull entry Close or bone; and an injury covered by dead tissue so its depth cannot be seen is unstageable. A deep tissue pressure injury shows as a purple or maroon patch of intact skin, or a blood-filled blister, over tissue damaged beneath it. A pressure injury that starts during surgery may not show until several days later. Chapter 31 covers preventing pressure injuries during positioning.
• An ulcer is an open sore on a skin or mucous membrane surface. Venous ulcers, arterial ulcers and diabetic foot ulcers are common chronic wounds.

A partial-thickness wound involves the epidermisepidermisep-ih-DER-misThe thin outer layer of the skin.epi- on, uponderm/o skinFull entry Close, the dermis or both; a full-thickness wound goes through every layer of the skin and can reach fascia or bone.

Burns and other injuries from heat, cold, chemicals and radiation

Burns can be caused by heat (flames, hot liquids, steam, hot metal or tar), chemicals, electricity, radiation and breathing in smoke or hot gases. An electrical burnburnBURNAn injury to the skin or deeper tissues caused by heat, chemicals, electricity, radiation or friction.Full entry Close can look small on the skin while the current has destroyed much more tissue inside, all along its path through the body to the exit wound; doctors call this the iceberg effect.

Burns are graded by how deep they go:

• Superficial (first-degree): the epidermis only; red and painful, like a sunburn. It heals on its own in a few days (about 3 to 6).
• Superficial partial-thickness (second-degree): the whole epidermis and part of the dermis, with painful blisters. It heals in about 10 to 21 days.
• Deep partial-thickness (second-degree): deeper into the dermis. Partial-thickness burns often heal by second intention.
• Full-thickness (third-degree): all the way through the epidermis and dermis, destroying the tissue and damaging the nerve endings. These burns need debridement and skin graftsgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close.
• Deep full-thickness (fourth-degree): into the muscle and bone underneath.

The size of a burn is given as a percentage of the body's surface area. A quick estimate, the rule of nines, gives the head 9%, each arm 9%, the front and the back of the trunk 18% each, each leg 18% and the genital area 1%. An adult with more than 15% of the body burned (10% in a child) is likely to go into hypovolemic shockhypovolemic shockhy-poh-voh-LEE-mik SHOKShock from a large loss of blood or body fluid, so there is too little volume in the blood vessels to supply the organs.hypo- belowvol volume-emic relating to the bloodFull entry Close, because a burn shifts so much fluid out of the circulation. Chapter 38 covers burn surgery.

Other injuries in this group:

• Frostbite: tissue frozen by extreme cold. Ice forms inside the cells and the blood supply is blocked. Ears, cheeks, nose, fingers and toes are hit most often.
• Hypothermiahypothermiahy-poh-THER-mee-uhA body temperature that has fallen below the normal range.hypo- belowtherm/o heat-ia conditionFull entry Close: a body temperature that is too low. In surgery, AST defines it as a core temperature below 36°C. A general medical definition sets the line lower, at 35°C.
• Hyperthermiahyperthermiahy-per-THER-mee-uhA body temperature that is higher than normal because the body takes in or makes more heat than it can lose.hyper- abovetherm/o heat-ia conditionFull entry Close: a body temperature that is too high, as in heat stroke or a severe infection. Chapter 13 covers malignant hyperthermiamalignant hyperthermiamuh-LIG-nunt hy-per-THER-mee-uhA rare inherited reaction to certain general anesthesia drugs in which the muscles' metabolism speeds up out of control.mal- badhyper- above normaltherm heat-ia conditionFull entry Close, a reaction to anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close drugs.
• Radiation injury: from long exposure to the sun or to radiation sources such as X-rays and radiation therapyradiation therapyray-dee-AY-shun THAIR-uh-peeTreatment that uses high-energy rays or radioactive material to kill cancer cells or shrink tumors.Full entry Close. Radiation therapy can damage the blood vessels of the treated area, which slows healing there.

The skin's other diseases in the Core Curriculum's list, such as moles (nevi), warts, keratoses and the skin cancers (basal cell carcinomabasal cell carcinomaBAY-sul SEL kar-sih-NOH-muhThe most common type of skin cancer, which starts in the basal cells at the bottom of the skin's outer layer.Full entry Close, squamous cell carcinomasquamous cell carcinomaSKWAY-mus SEL kar-sih-NOH-muhA cancer that starts in squamous cells, the thin, flat cells of the skin's outer layer and the linings of some organs.Full entry Close and melanomamelanomamel-uh-NOH-muhA cancer that starts in melanocytes, the cells that give skin its color.melan/o black, dark-oma tumorFull entry Close), are taught with plastic and reconstructive surgery in chapter 38.

7How wounds heal

After an injury, the body either regenerates the tissue, adding new cells of the same kind, or fills the gap with scar. Some cells, such as those of muscle (heart musclemyocardiummy-oh-KAR-dee-umThe thick middle layer of the heart wall, made of heart muscle that contracts to pump blood.my/o musclecardi/o heart-um structureFull entry Close included) and nerves, cannot divide to replace themselves, so their injuries heal with scar tissue, which fills the gap but cannot do their special work.

The three phases

Healing moves through three phases that overlap. The Core Curriculum calls them the lag, proliferative and maturationmaturationmach-uh-RAY-shunThe process of becoming fully grown or developed.Full entry Close phases; you will also hear them called the inflammatory, proliferative and remodeling phases. Some references count stopping the bleeding (hemostasishemostasishee-moh-STAY-sisThe stopping of bleeding, either by the body's own clotting process or by medical or surgical methods.hem/o blood-stasis stopping, standing stillFull entry Close) as a phase of its own; others include it in the first.

1. Lag (inflammatory) phase. It starts within minutes of the injury and lasts about 3 to 5 days; one reference gives 1 to 4 days.

• Bleeding stops: vessels constrict, plateletsplateletPLAYT-litA tiny cell fragment in the blood that sticks together at a wound to help form a clot.Full entry Close clump, and a clot forms.
• An exudateexudateEKS-yoo-daytFluid, cells or other material that has leaked out of blood vessels into a wound or tissue.ex- outsud sweatFull entry Close of blood, lymphlymphLIMFThe clear fluid that flows through the lymphatic vessels and carries white blood cells.Full entry Close and fibrin clots in the wound and loosely glues the cut edges together, and a scab dries over it to keep fluid in and germs out.
• Inflammation clears the wound: white cells eat bacteria, fibrin and dead cell pieces for about 3 to 4 days, and macrophagesmacrophageMAK-roh-fayjA large white blood cell in the tissues that swallows and digests germs, dead cells and debris.macro- large-phage eaterFull entry Close stay on, releasing growth factors and calling in fibroblasts.
• The wound has almost no tensile strength yet. The skin edges look a little swollen and red.

2. Proliferative phase. It begins around day 3 to 5 and lasts until about day 20.

• Fibroblasts build collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close, and new capillariescapillaryKAP-ih-lair-eeOne of the tiniest blood vessels, joining the smallest arteries to the smallest veins.Full entry Close grow into the wound (angiogenesisangiogenesisan-jee-oh-JEN-uh-sisThe growth of new blood vessels.angi/o vessel-genesis creationFull entry Close). Together they form granulation tissuegranulation tissuegran-yuh-LAY-shun TISH-ooNew, moist, red tissue that fills a healing wound from the bottom up.Full entry Close.
• Healthy granulation tissue is pink or red, uneven in texture and does not bleed easily. Granulation tissue that is dark and bleeds easily (friable) can be a sign of infection.
• Epithelial cells grow in from the edges to cover the wound, and the scab falls off. They can travel only about 3 cm, so a large open wound may need a skin graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close.
• The wound begins to contract about day 5, most strongly at about 2 weeks. A firm ridge of new tissue can be felt under a healing incision.
• By the end of this phase, the wound has about 25 to 30 percent of its original strength, and skin suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close are usually removed.

3. Maturation (remodeling) phase. It begins at about 2 to 3 weeks and can last a year or longer.

• Collagen is broken down and rebuilt, above all where the wound takes stress, and it becomes denser and better organized.
• Fewer blood vessels remain, so the scar fades from red to pale, and it flattens and shrinks.
• The wound slowly gains strength. It reaches about 70 to 80 percent of its original strength by about the third month, and it never gets back more than about 80 percent.

First, second and third intention

A wound heals in one of three ways, depending on whether its edges are brought together and when. Chapter 25 covers these as a closing choice; here is what the tissue does in each.

• First intention (primary intention, or primary union): the edges of a clean wound are brought together with sutures, staples, tape or skin adhesive soon after it is made. Little tissue is lost, no dead space is left, and drainage is minimal. Epidermal cells seal the surface within 24 to 48 hours, little granulation tissue is needed, and the scar is thin and flat.
• Second intention (secondary intention, or granulation and contraction): the edges cannot be brought together, or are left apart, so the wound stays open and heals from its base upward. Granulation tissue slowly fills it, it contracts, and epitheliumepitheliumep-ih-THEE-lee-umThe tissue that covers the body's surfaces and lines its organs, vessels and cavities.Full entry Close grows over the top. Healing is slower, the scar (cicatrix) is wider, and infection is more likely. Infected and dirty wounds, chronic wounds such as pressure injuriespressure injuryPRESH-er IN-juh-reeDamage to the skin and the tissue beneath it from pressure, or pressure with shear, usually over a bony area or under a device.Full entry Close, and traumatic wounds with a lot of tissue loss heal this way, and a large one may need a skin graft.
• Third intention (tertiary intention, or delayed primary closure): a contaminated or infected wound is cleaned and left open, often packed, for about 3 days or more. Once no infection shows and clean granulation tissue has formed, the surgeon brings the two granulating surfaces together. The result has middling strength and scarring. It is used for heavily contaminated (Class III or IV) wounds and for trauma patients too unstableunstableun-STAY-bulDescribes a client whose condition is changing quickly or is hard to predict.Full entry Close for the wound to be closed during the operation.

A wound that heals by second intention can grow too much granulation tissue, called proud flesh, which bulges above the edges and blocks the skin from closing over it. Large gaps healed this way leave a weak area that can become a herniaherniaHER-nee-uhA bulge of an organ or tissue through a weak spot in the muscle or tissue wall that normally holds it in.Full entry Close.

Scars

A new scar is red or purple and later takes on the color of the skin around it. Scar tissue is less elastic than normal tissue and has none of its special functions.

• Hypertrophichypertrophyhy-PER-truh-feeAn increase in the size of an organ or tissue because its cells grow larger.hyper- above, excessive-trophy nourishment, growthFull entry Close scar: a scar with too much tissue, red or raised. It usually improves after about 6 months and may fade over years.
• KeloidkeloidKEE-loydA raised, firm overgrowth of scar tissue that spreads beyond the edges of the original wound.-oid like, resemblingFull entry Close: a scar that keeps growing and spreads beyond the edges of the original wound, made of a swirling mass of collagen. Keloids form most often on the shoulders, chest and back, develop more often in people with dark skin, and often come back after treatment.
• Contracturecontracturekun-TRAK-cherA lasting shortening and tightening of muscle, tendon, skin or joint tissue that keeps a joint from moving through its full range.Full entry Close: a scar that shortens as it matures and pulls the skin or a joint so it cannot move normally. Large burns on the back, the buttocks or the back of the neck are prone to it.

Bone heals by a similar process, only more slowly. Chapter 3 covers how a broken bone heals.

8Wound classes

Every surgical wound is given a class at the end of the operation, based on how contaminated it became and so how likely it is to become infected. The class guides how the wound is managed after surgery. The four classes come from the CDC.

The class follows what actually happens, so it can change during the case. Opening the bowel makes a clean case at least Class II, gross spillage of bowel contents makes it Class III, and so does a major break in sterile technique, such as using a nonsterile instrument in the wound. The final class is decided at the end of the procedure, discussed in the team's debriefing and recorded on the intraoperativeintraoperativein-truh-OP-er-uh-tivHappening during surgery, from when the client is brought into the operating room until they are moved to recovery.intra- within, duringoperative of surgeryFull entry Close record.

A laparoscopic cholecystectomy is Class II, because the biliary tract is entered. It becomes Class III if bile spills or the gallbladder is acutely inflamed without pus, and Class IV if infection, such as pus, is already present. The Core Curriculum's outline and one surgical technology textbook list an uncomplicated case as Class I, and Class II only when a cholangiogram is done.

Laparoscopic Appendectomy29 instruments · 3 photos

An appendectomy is Class II when the appendix is not perforated, and Class III when it is acutely inflamed without pus. A perforated (ruptured) appendix, or one with pus around it, is Class IV, because the germs were in the abdomen before the operation began. Some references class a perforated appendix as Class III.

The higher the class, the higher the risk of infection. One reference estimates the risk at about 1 to 5 percent for a clean wound and more than 27 percent for a dirty or infected one. Preventive antibiotics are given for clean-contaminated operations, and for clean ones when a prostheticprostheticpros-THET-ikDescribes an artificial part made to replace a missing or damaged body part, such as a limb, joint, eye or heart valve.prosthe an addition (from Greek)-tic relating toFull entry Close joint or prosthetic material in a blood vessel goes in or an infection would be a catastrophe; patients with contaminated and dirty wounds are often already on antibiotics to treat an infection.

The class also shapes how you handle instruments. Instruments that touch the open bowel, or a tumor that could shed cancer cells, are kept apart from the clean setup so they cannot carry germs or cells to the rest of the wound. In the same way, during an abdominal hysterectomyabdominal hysterectomyab-DOM-ih-nul his-ter-EK-tuh-meeSurgery to remove the uterus through a cut in the lower abdomen.hyster/o uterus-ectomy surgical removalFull entry Close, instruments that touch the cervix and vagina are taken off the field so they cannot contaminate the abdominal incision. Chapters 29 and 32 teach this isolation (bowel) technique, and chapter 33 the hysterectomyhysterectomyhis-tuh-REK-tuh-meeSurgery to remove the uterus.hyster/o uterus-ectomy surgical removalFull entry Close.

9Surgical site infection

A surgical site infection (SSISSIes-es-EYE (said as letters)An abbreviation that can mean surgical site infection or sliding scale insulin.Full entry Close) is an infection of the incision, or of the organ or space that was operated on, after surgery. It is one of the most common infections patients pick up in a hospital, and the most common cause of delayed healing in surgical patients. About 2 to 4 percent of operations are complicated by one.

The three depths

The CDC's National Healthcare Safety Network sorts SSIs by how deep they go:

• Superficial incisional SSI: involves only the skin and the subcutaneous tissuesubcutaneous tissuesub-kyoo-TAY-nee-us TISH-ooThe layer of fat and loose connective tissue under the skin that attaches the skin to muscle.sub- undercutane/o skin-ous relating toFull entry Close of the incision. It counts if it starts within 30 days after the operation.
• Deep incisional SSI: involves the deep soft tissue of the incision, the fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close and muscle layers. It counts if it starts within 30 or 90 days, depending on the type of operation.
• Organ or space SSI: involves any part of the body, deeper than the fascia and muscle, that was opened or handled during the operation, such as an abscessabscessAB-sesA closed pocket of pus in tissue, walled off by the body.Full entry Close inside the abdomen, an infection of a joint or of bone (osteomyelitisosteomyelitisos-tee-oh-my-uh-LY-tisAn infection of bone.oste/o bonemyel/o marrow-itis inflammationFull entry Close), or mediastinitis, an infection in the middle of the chest. It too counts within 30 or 90 days, depending on the operation.

Each depth has signs that confirm it, such as pus draining from the incision or from a drain placed in the organ or space; germs grown from fluid or tissue taken from the site; pain, tenderness, swelling, redness or heat with the incision opened by the surgeon; a deep incision that splits open, with a fever above 38°C (100.4°F); or an abscess found on examination or imaging.

Deep and organ or space infections together make up one third to one half of all SSIs, and they usually keep the patient in the hospital or bring them back. A superficial SSI is often found after the patient has gone home.

Where the germs come from

• From the patient (endogenous): the patient's own germs, from the skin, the mucous membranes and the hollow organs such as the bowel, are the main source of SSI germs. Most are staphylococciStaphylococcusstaf-uh-loh-KOK-usA group of round bacteria that grow in grape-like clusters and often live on the skin and in the nose.staphyl/o cluster, like grapes-coccus round bacteriumFull entry Close from the skin, but an incision near the groin or perineumperineumpair-ih-NEE-umThe area of skin and muscle between the genitals and the anus.perine/o perineumFull entry Close, or an opened bowel, adds bowel germs. Skin prep lowers these germs but cannot get rid of them, which is why drapes wall off the rest of the patient's skin. Germs can also seed the wound from an infection somewhere else in the patient's body, especially when an implant is placed.
• From outside the patient (exogenous): the surgical team, the OR environment and its air, and every tool, instrument and material brought onto the sterile fieldsterile fieldSTAIR-ul feeldAn area set up with sterile drapes and supplies, kept free of all germs, for a sterile procedure.Full entry Close.

The germs found most often in SSIs are Staphylococcus aureusStaphylococcus aureusstaf-uh-loh-KOK-us AW-ree-usA common round bacterium that often lives on the skin and in the nose and can cause infection.Full entry Close, coagulase-negative staphylococci, Enterococcus and Escherichia coliEscherichia coliesh-uh-RIK-ee-uh KOH-lyeA rod-shaped bacterium that normally lives in the human intestine, some strains of which cause infection.Full entry Close, and more and more of them resist antibiotics, such as methicillinmethicillinmeth-ih-SIL-inAn older penicillin-type antibiotic, no longer used in treatment, whose name lives on in MRSA.Full entry Close-resistant S. aureus (MRSAMRSAMUR-suh, or said as lettersMethicillin-resistant Staphylococcus aureus, a staph bacterium that many common antibiotics cannot kill.Full entry Close).

Whether contamination becomes an infection depends on how many germs reach the wound, how dangerous they are, and how well the patient can resist them. Foreign material, such as suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close and implants, lets far fewer germs start an infection, which is one reason they raise the risk.

What makes an SSI more likely

Some patients start with a higher risk:

• older age, because the immune system responds less and tissue heals more slowly
• poor nutrition, which leaves out the proteins needed for healing and defense
• diabetes, which harms the circulation that the immune system depends on
• substance or alcohol abuse, which often comes with malnutrition, liver damage and a weakened immune system
• a weakened immune system from disease, cancer treatment or high doses of steroidssteroidSTAIR-oydA fat-based chemical built from cholesterol; the group includes hormones such as cortisol and estrogen, and many drugs.ster/o solid-oid likeFull entry Close
• a long stay in the hospital before surgery, which lets the patient pick up hospital germs, including resistant ones

The operation itself adds risk when the wound class is higher and when the procedure is long, because a long case means more time exposed to germs in the air and on devices.

What the team does about it

The CDC's 2017 guideline focuses on a few measures:

• Preventive antibiotics: given only when guidelines call for them, and timed so the drug is already in the blood and tissues when the incision is made. In clean and clean-contaminated operations, no more doses are given after the incision is closed, even when a drain is left in. Chapter 12 covers the drugs.

• Blood sugar control: high blood sugarhyperglycemiahy-per-gly-SEE-mee-uhA blood glucose level above normal, over 100 mg/dL when fasting.hyper- aboveglyc/o sugar-emia in the bloodFull entry Close harms healing, immunityimmunityih-MYOO-nih-teeThe body's ability to resist or fight off a particular infection or disease.immun/o protection-ity stateFull entry Close and the blood vessels. The CDC's target around surgery is below 200 mg/dL, in patients with and without diabetes.

• Normal body temperature (normothermia): a cold patient's vessels constrict, so less oxygen reaches the wound and infection becomes more likely.
• Oxygen to the tissues: helped by keeping the patient warm and the blood volume replaced.
• An antiseptic bath: the patient showers or bathes with soap or an antiseptic at least the night before surgery.

Beyond these, every SSI rule you learn elsewhere works toward the same goal: skin prep (chapter 31), sterile techniquesurgical asepsisSUR-jih-kul ay-SEP-sisPractices that keep an area or object completely free of microorganisms; also called sterile technique.a- withoutsepsis decay, infectionFull entry Close (chapter 26), drapes and attire (chapter 28), and hand hygiene by everyone who is not scrubbed.

When an SSI happens

Infection shows first as more inflammation than expected and drainage from the wound. A superficial infection is treated at its first signs: a sample of the drainage is sent for culture, and antibiotics may be started. A deep infection may not show for days and brings pain and fever. If it does not settle, the surgeon reopens the wound to drain pus and remove dead tissue (incision and drainageI&Deye-and-dee (said as letters)Incision and drainage: cutting open an abscess or collection so pus or fluid can drain out.Full entry Close, I&D), and the wound may be irrigatedirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close and left open to heal.

10What helps or slows healing

The Core Curriculum sorts what helps or slows healing into three groups: the patient's own condition, outside factors such as drugs and smoking, and surgical technique, which is how the team handles the tissue and keeps the field sterile. Together they affectaffectAF-ekt (stress on the first syllable)In mental health, the outward expression of a person's emotions, as seen in the face, voice and body language.Full entry Close how fast a wound heals, how strong it becomes and whether it gets infected.

The patient

• Age: an older patient's cells renew more slowly, the collagencollagenKOL-uh-jenThe main structural protein of the body, which gives strength to skin, bones, tendons, ligaments and scar tissue.coll/a glue-gen producingFull entry Close is less elastic, blood flow is poorer and the immune system is weaker, and many older patients are short of nutrients or fluids. Very young and very old patients may also have a poorer blood supply or weak muscle tone.
• Disease and comorbiditiescomorbiditykoh-mor-BID-ih-teeA disease or condition that a person has at the same time as another, main condition.co- togethermorbid disease-ity state ofFull entry Close: diabetes harms the circulation that brings oxygen and nutrients to the wound, and high blood sugarhyperglycemiahy-per-gly-SEE-mee-uhA blood glucose level above normal, over 100 mg/dL when fasting.hyper- aboveglyc/o sugar-emia in the bloodFull entry Close weakens the white cells that fight bacteria. Heart and lung disease, poor circulation, anemiaanemiauh-NEE-mee-uhA lower than normal number of red blood cells or amount of hemoglobin in the blood.a- without, lacking-emia blood conditionFull entry Close, cancer and infection all slow healing too, and so does a weakened immune system.
• Nutrition, when the patient is malnourished: new tissue is built from protein, and a shortage of vitamins C and A, zinc or iron is linked to infection and weaker wounds. A thin patient with little body fat also loses heat more easily.
• Nutrition, when the patient is obese: fat tissue has a poor blood supply, so it heals slowly, and its weight strains the closure, which makes the wound more likely to split open or become an incisional herniaherniaHER-nee-uhA bulge of an organ or tissue through a weak spot in the muscle or tissue wall that normally holds it in.Full entry Close.
• Fluid and electrolyte balance: low blood volume makes the vessels constrict and starves the wound of the oxygen and glucose it needs, so keeping the blood volume replaced is part of preventing infection. Edema in the wound slows healing as well.
• Oxygen: low oxygen in the wound slows the fibroblasts and the collagen they build, so the wound is weaker, and it leaves the wound more open to infection.

Outside factors

• Chemotherapyantineoplastican-tee-nee-oh-PLAS-tikA drug used to treat cancer by killing cancer cells or stopping them from growing and dividing.anti- againstneo- newplas growth, formation-tic relating toFull entry Close: it can slow or stop the growth of the new cells a wound needs, and it weakens the immune system.
• Prescription medications: steroidssteroidSTAIR-oydA fat-based chemical built from cholesterol; the group includes hormones such as cortisol and estrogen, and many drugs.ster/o solid-oid likeFull entry Close damp the inflammatory phase, and long-term steroid use raises the risk that a wound will split open. NSAIDsnonsteroidal anti-inflammatory drugnon-STAIR-oy-dul an-tee-in-FLAM-uh-tor-ee DRUGA drug that relieves pain, fever and inflammation and is not a steroid, such as ibuprofen or naproxen.non- notanti- againstinflamm/o inflammationFull entry Close can interfere with the inflammatory stage, anticoagulantsanticoagulantan-tee-koh-AG-yoo-luntA drug that slows the blood's ability to form clots.anti- againstcoagul/o clotting-ant an agent that doesFull entry Close raise the risk of bleeding and of the wound splitting open, and long courses of antibiotics can let a second infection take hold.
• Illicit drugs and alcohol: patients who abuse them are often malnourished, may have liver damage that limits how the body makes energy for its cells, and often have a weakened immune system.
• Smoking: nicotine constricts the vessels and cuts the oxygen reaching the wound, and the cough it brings strains a fresh incision. Patients are urged to stop.
• Radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close: tissue treated with radiation has a poorer blood supply, radiation lowers the white cell countwhite blood cell countwite blud sel kowntA blood test that counts the white blood cells, the cells that fight infection, in a sample of blood.Full entry Close by depressing the bone marrowbone marrowbone MAIR-ohThe soft, spongy tissue inside bones that makes blood cells.Full entry Close, and earlier radiation is a risk factor for a wound splitting open.

Surgical technique

This is the group the surgical team controls, and the scrub has a hand in every part of it.

• Principles of asepsisasepsisay-SEP-sisThe state of being free of germs that cause disease, and the practices used to keep things that way.a- withoutsep- decay or infection-sis conditionFull entry Close: any germs that get into the wound can cause infection. Chapter 26 teaches sterile techniquesurgical asepsisSUR-jih-kul ay-SEP-sisPractices that keep an area or object completely free of microorganisms; also called sterile technique.a- withoutsepsis decay, infectionFull entry Close.
• Bowel technique: keeping instruments that touched the open bowel away from the clean closure, taught in chapters 29 and 32.
• Dissectiondissectiondy-SEK-shunA tear in the inner layer of an artery wall that lets blood split the layers apart; also, the cutting apart of tissue in surgery.Full entry Close technique: cutting tissue cleanly and precisely, sharp or blunt, and saving as many blood vessels as possible, because tissue without a blood supply cannot heal.
• Duration of surgery: a long operation leaves the wound exposed longer to germs in the air and on devices, so working efficiently matters.
• Hemostasishemostasishee-moh-STAY-sisThe stopping of bleeding, either by the body's own clotting process or by medical or surgical methods.hem/o blood-stasis stopping, standing stillFull entry Close: small bleeding vessels form clots and hematomashematomahee-muh-TOH-muhA collection of blood, often clotted, that has leaked out of the blood vessels into the tissue.hem/o blood (here as hemat-)-oma swelling or massFull entry Close that block healing and invite infection. Chapter 29 covers the methods of controlling bleeding.
• Tissue approximation: the edges are brought together accurately and without tension. Tension on a suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close line squeezes the capillariescapillaryKAP-ih-lair-eeOne of the tiniest blood vessels, joining the smallest arteries to the smallest veins.Full entry Close at the wound edge and causes swelling and pain, and sutures tied too tightly strangle the tissue.
• Tissue handling: tissue is handled as little and as gently as possible, retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close press no harder than they must, and exposed tissue is kept moist. Rough handling bruises tissue and causes swelling, bleeding, ischemiaischemiais-KEE-mee-uhToo little blood flow to a part of the body, so the tissue does not get enough oxygen.isch- hold back-emia blood conditionFull entry Close and necrosisnecrosisneh-KROH-sisThe death of cells or tissue in a part of the body.necr/o death-osis conditionFull entry Close.
• Tissue perfusionperfusionper-FYOO-zhunThe flow of blood through the body's tissues, bringing them oxygen and nutrients.per- throughfus pour-ion processFull entry Close: tissue heals only with a good blood supply. Cold, pain, fear, nicotine and low blood volume all constrict the vessels, so keeping the patient warm helps.
• Drains: dead space left in a wound fills with blood and serumserumSEER-umThe clear, yellow liquid left from blood after it clots and the cells are removed.Full entry Close and can become infected. Careful suturing closes it, and a drain keeps fluid from collecting where it cannot be closed. Chapter 25 covers drains.
• Irrigationirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close: keeps exposed tissue moist and washes debris and germs out of a contaminated wound.

Many of these are Halsted's principles of surgery, which chapter 25 teaches in full.

11When healing goes wrong

Wound complications can come at any point in healing, but most show up in the first week after surgery. Some stay at the surface; others reach deep tissue and can break the wound open.

Infection

Infection, covered above under surgical site infection, is the most common cause of delayed healing in surgical patients. Its germs come from the patient (endogenous) or from outside the patient (exogenous).

Bleeding, hematoma and seroma

• HemorrhagehemorrhageHEM-uh-rijA large loss of blood from a blood vessel, inside the body or out of it.hem/o blood-rrhage bursting forthFull entry Close: some bleeding from a wound is normal; heavy bleeding is not. It can come from a clot that breaks loose, a suturesutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close that slips or a vessel worn through, and dressings are checked often in the first 48 hours. Bleeding at the surgical site is an abnormal finding you report.
• Hematomahematomahee-muh-TOH-muhA collection of blood, often clotted, that has leaked out of the blood vessels into the tissue.hem/o blood (here as hemat-)-oma swelling or massFull entry Close: blood collects in the wound because bleeding was not fully stopped during surgery or small vessels keep oozing. It raises the risk of infection, a large one presses on vessels and starves the tissue around it, and it may need another operation to drain.
• Seroma: serousserousSEER-usThin, watery and clear to pale yellow, like the fluid part of blood.Full entry Close fluid collects in the wound, from tissue injured during surgery or bleeding into it, often where dead space was left. It sits between the wound edges and keeps them from healing, and it too may need surgery.

Necrosis

Tissue that has lost its blood supply dies. Dead tissue blocks healing and harbors bacteria, so it is removed by debridementdebridementdih-BREED-muntThe removal of dead, damaged or infected tissue from a wound so it can heal.Full entry Close.

Tissue disruption

• Dehiscencedehiscencedee-HIS-ensThe splitting open of the edges of a wound that had been closed, such as a surgical incision.Full entry Close: the layers of a wound separate, partly or completely. It happens when the pull on the wound overcomes the strength of the suture or the knot, and it often comes between the 5th and 10th days after surgery. Serosanguineousserosanguineousseer-oh-san-GWIN-ee-usDescribes drainage that is thin and watery with a little blood in it, so it looks pale pink.sero- serum, the clear part of bloodsanguin- blood-ous havingFull entry Close fluid may drain from the wound first, and the patient may feel that "something has given way." Obesity, older age, male sex, lung disease, coughing, cancer, earlier radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close, trauma, poor nutrition and long-term steroidssteroidSTAIR-oydA fat-based chemical built from cholesterol; the group includes hormones such as cortisol and estrogen, and many drugs.ster/o solid-oid likeFull entry Close raise the risk, and so do infection, too much tension, sutures placed too close to the edge or to each other, sutures tied too tight, and knots that are loose or cut too short.
• Eviscerationeviscerationih-vis-er-AY-shunThe pushing out of internal organs, usually loops of bowel, through a surgical wound that has come open.e- outviscer/o internal organs-ation processFull entry Close: dehiscence of an abdominal wound with the abdominal contents, such as bowel or omentum, pushing out through it. It is an emergency. The organs are covered with a sterile towel soaked in sterile saline to keep them moist, the patient lies with the head slightly raised and the knees bent to ease the pressure on the wound, nothing is given by mouth, and the surgeon is called, because the patient goes back to the OR.
• Herniationherniationher-nee-AY-shunThe bulging or pushing of an organ or tissue through an opening or weak spot into a place where it does not belong.herni/o hernia, rupture-ation processFull entry Close: a scar that formed after a wound broke down is much weaker than healthy tissue, and contaminated or infected wounds are more likely to leave a herniaherniaHER-nee-uhA bulge of an organ or tissue through a weak spot in the muscle or tissue wall that normally holds it in.Full entry Close. Abdominal contents can bulge through the weak spot, an incisional hernia, usually found 2 to 3 months after surgery, and bowel can become trapped (incarcerated) in it.
• Re-injury: a wound that is still weak can be torn open again, which is why patients restrict their activity, avoid heavy lifting and protect the site after surgery.
• Rejection: tissue or an organ taken from another person can be attacked by the patient's immune system as foreign. A graftgraftGRAFTTissue or a man-made material moved into place in surgery to replace or repair a damaged part.Full entry Close of the patient's own tissue (an autograft) is not rejected. An implant brings a risk of its own: as foreign material, it lets far fewer germs start an infection.

Suture complications and tensile strength

A suture holds the wound until the wound can hold itself, and a wound gains strength slowly. If the suture breaks, a knot slips, or the suture loses its strength in an infected wound, the wound can split open. Suture is also foreign material: it can form a granuloma, and it lowers the number of germs needed to start an infection. Chapter 25 covers choosing a suture that keeps its strength long enough for the tissue.

Adhesions, fistulas and sinus tracts

• Adhesionsadhesionad-HEE-zhunA band of scar tissue that joins two surfaces inside the body that are normally separate.ad- towardhes stick-ion conditionFull entry Close: bands of scar tissue that join abdominal or pelvic organs to each other or to the peritoneumperitoneumpair-ih-toh-NEE-umThe thin membrane that lines the belly cavity and covers most of the organs inside it.peri- aroundton stretched-eum a structureFull entry Close. They follow infection, repeated operations, rough handling of tissue, and foreign bodies such as lint or glove powder. They can cause pain or a bowel obstructionbowel obstructionBOW-ul ub-STRUK-shunA partial or complete blockage that stops food, fluid and gas from moving through the small or large bowel.Full entry Close, and they make the next operation riskier.
• FistulafistulaFIS-choo-luhAn abnormal passage between two organs or vessels, or between an organ and the skin.Full entry Close: an abnormal passage from one organ or vessel to another, or to the skin.
• SinussinusSY-nusA hollow space in the body, most often one of the air-filled spaces in the skull bones around the nose.Full entry Close tract: a draining channel from an infection inside the body out to the surface.

12Trauma

Trauma means injury. It is the leading cause of death for people from about 1 to 45 years old, and the third leading cause at all ages. Most trauma patients arrive outside regular working hours or on a weekend, when fewer staff are working, so hospitals organize their care as a system.

How injuries happen

The way an injury happened, its mechanism of injury, predicts what injuries the patient is likely to have. Crashes, falls and assaultsassaultuh-SAWLTIn law, a threat or act that makes a person afraid they are about to be touched in a harmful or unwanted way.Full entry Close produce injury patterns that are fairly predictable.

• Blunt injury: a force that damages deep tissue without breaking the skin. Most blunt injuries come from motor vehicle crashes, falls and assaults. Speeding up, slowing down, shearing and crushing forces tear tissue inside; in a crash, the aorta can tear where it is fixed in the chest as the body stops and the aorta keeps moving. Because blunt injuries are hidden, they can be harder to find, and deadlier, than penetrating ones. A contusioncontusionkun-TOO-zhunA bruise: an injury that breaks small blood vessels under the skin or in an organ without breaking the skin.Full entry Close is a bruise.
• Penetrating injury: something pierces the skin and goes into the body, or the body is thrown onto something sharp, opening a wound with deeper injuries under it. Gunshots and knife attacks cause most of them. A high-speed bullet damages far more tissue than a slow one, and the exit wound is usually larger than the entry. A wound at or below the nipple line can reach both the chest and the abdomen. An impaled object stays in until the patient is in the OR, where the bleeding it may be holding back can be controlled.
• Blast injury: the pressure wave of an explosion injures gas-filled organs such as the lungs, bowel and middle ear; flying debris causes penetrating wounds; and the blast throws the victim.
• Burns and electrical and inhalationinhalationin-huh-LAY-shunBreathing in; also, a way of giving a drug as a mist or powder that is breathed into the lungs.in- inhal breathe-ation the act ofFull entry Close injuries, covered above, can come from an explosion or on their own.
• An occult injury is one the normal assessment does not find, such as hidden bleeding.

An open traumatic wound is contaminated. A fresh one is Class III, and an old one with dead tissue left in it is Class IV; some references use about 4 hours after the injury as the line between the two. Traumatic wounds were not made under sterile conditions, so they are usually debrideddebridementdih-BREED-muntThe removal of dead, damaged or infected tissue from a wound so it can heal.Full entry Close and irrigatedirrigationeer-ih-GAY-shunWashing out a wound, body cavity, tube or eye with a steady flow of liquid.Full entry Close, and many are left open to heal by second or third intention.

Trauma systems

In the United States, hospitals equipped to treat severe injuries are designated as trauma centers by the state or local government and verified by the American College of Surgeons (ACS), whose Committee on Trauma sets the criteria along with state laws. The levels vary from state to state, running from Level I, the highest, to Level IV or, in some systems, Level V.

• Level I: total care for every kind of injury, from prevention through rehabilitation, with specialists and equipment ready 24 hours a day.
• Level II: care for all injuries, but without some of the specialists and resources a Level I center has.
• Level III: prompt evaluation, resuscitationresuscitationrih-sus-ih-TAY-shunEmergency treatment to restore breathing, heartbeat or blood circulation.Full entry Close, emergency surgery and stabilization, then transfer to a higher level.
• Level IV: advanced trauma life support before transfer, often in a rural clinic or hospital.

The criteria include the number and kinds of trauma specialists, the equipment, fast transport, real-time communication with rescue teams and teaching the community about injury prevention. Emergency medical services (EMS) decide where to take a patient by field triagetriageTREE-ahzhSorting clients by how urgently they need care, to decide who is seen first.Full entry Close: for example, a patient whose Glasgow Coma ScaleGlasgow Coma ScaleGLAS-goh KOH-muh SKAYLA scoring tool that rates a person's level of consciousness by their eye opening, verbal response and movement, from 3 to 15.Full entry Close score is 13 or lower, whose systolicsystoleSIS-tuh-leeThe part of each heartbeat when the heart muscle squeezes and pumps blood out.Full entry Close blood pressure is under 90 mm Hg, or whose breathing rate is under 10 or over 29 goes to the highest-level center available.

The American College of Surgeons also runs Advanced Trauma Life Support (ATLS), the course that teaches physicians its protocols for trauma care. Only licensed physicians can be certified, though other staff may audit it in some places.

What severe injury does to the body

Deaths after injury come in three waves. Some patients die at the scene, within minutes, from tears of the heart or aorta or injuries to the brain stembrain stemBRAYN STEMThe lowest part of the brain, which connects it to the spinal cord and controls breathing, heart rate and other automatic functions.Full entry Close or spinal cord. Others die in the first hours, about half of them from bleeding, often from the spleenspleenspleenAn organ in the upper left abdomen that filters the blood and helps fight infection.splen/o spleenFull entry Close, liver or lungs: these are the patients fast, aggressive care in the golden hour can help most. The rest die days or weeks later, in intensive care, from complications and organ failure. Overall, bleeding is the main cause of death after injury.

HemorrhagichemorrhageHEM-uh-rijA large loss of blood from a blood vessel, inside the body or out of it.hem/o blood-rrhage bursting forthFull entry Close shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close is the failure of the circulation caused by heavy, prolonged bleeding. As blood is lost, the vessels of the limbs, muscles and gut clamp down to keep blood flowing to the heart, brain and kidneys, and hormones such as epinephrineepinephrineep-ih-NEF-rinA hormone and drug, also called adrenaline, that raises heart rate and blood pressure and opens the airways.Full entry Close, norepinephrinenorepinephrinenor-ep-ih-NEF-rinA hormone and nerve messenger that narrows blood vessels and raises blood pressure, also given as an IV drug.Full entry Close, vasopressinvasopressinvay-zoh-PRES-inA man-made form of antidiuretic hormone, given by IV mainly to raise blood pressure in shock.Full entry Close and cortisolcortisolKOR-tih-solA steroid hormone made by the adrenal glands that helps control blood sugar, blood pressure, stress and inflammation.Full entry Close pour out. At first this works, and the blood pressure can stay normal, but the starved tissues swell, small clots form and cells die. Losing about 20 percent of the blood volume causes mild shock, 20 to 40 percent moderate shock, and 40 percent or more severe shock.

The lethal triangle

Patients who survive the first hour face three conditions that the trauma team watches above all, called the lethal triangle (or lethal triadtriadTRY-adA group of three things, such as three signs that occur together.Full entry Close, or triangle of death):

• Hypothermiahypothermiahy-poh-THER-mee-uhA body temperature that has fallen below the normal range.hypo- belowtherm/o heat-ia conditionFull entry Close: a core temperature that stays too low. Tissues starved of blood stop making heat, and the patient loses more heat when clothing is removed, during transport and on the table. Nearly every critically injured patient is cold by the time care begins.
• Metabolic acidosismetabolic acidosismet-uh-BOL-ik as-ih-DOH-sisA state in which the blood is too acidic because the body has too much acid or has lost too much bicarbonate.metabol change, the body's chemical work-ic relating toacid -osis abnormal conditionFull entry Close: blood that is too acidic (a low pH). Cells without oxygen switch to a way of making energy that leaves lactic acidlactateLAK-taytA substance made when cells break down glucose for energy; its blood level is a common lab test.lact/o milk (lactic acid was first found in sour milk)-ate a salt of an acidFull entry Close, and without good circulation the acid builds up.
• Coagulopathy: the blood's clottingclottingKLOT-ingThe process by which blood thickens into a gel to plug a damaged vessel and stop bleeding; also called coagulation.Full entry Close system fails. Cold and shrinking capillariescapillaryKAP-ih-lair-eeOne of the tiniest blood vessels, joining the smallest arteries to the smallest veins.Full entry Close shift fluid that dilutes the blood, IV fluids dilute the plateletsplateletPLAYT-litA tiny cell fragment in the blood that sticks together at a wound to help form a clot.Full entry Close and clotting factorsclotting factorKLOT-ing FAK-terAny of the proteins in blood plasma that work together in a chain to form a blood clot.Full entry Close further, and the clotting factors get used up in the organs (disseminated intravascular coagulationdisseminated intravascular coagulationdih-SEM-ih-nay-tid in-truh-VAS-kyuh-ler koh-ag-yuh-LAY-shunA disorder in which clotting is switched on throughout the blood vessels until the clotting factors are used up.intra- withinvascul/o vesselcoagul/o clottingFull entry Close, DIC), so the patient keeps bleeding even after the main bleeding is stopped.

Each one makes the others worse: a cold patient clots poorly, acid blood clots poorly, and more bleeding deepens the shock that causes the cold and the acid. That is why the team warms the patient and treats the triad along with replacing blood.

Compartment syndrome

Injured tissue swells. When it swells inside a closed space, such as a muscle group wrapped in fasciafasciaFASH-ee-uhA sheet or band of tough connective tissue that covers and separates muscles and organs.fasci/o bandFull entry Close, the abdomen or the skull, the pressure rises until blood can no longer get in, and the tissue dies. This is compartment syndromecompartment syndromekum-PART-ment SIN-drohmA buildup of pressure inside a closed group of muscles that cuts off their blood supply.Full entry Close. It is most common in the limbs, the abdomen and brain injury.

• In a limb, the signs are severe pain, especially when the muscles are moved passively, numbness or tingling, and weakness. Normal pressure in a compartment is under 20 mm Hg; above 30 mm Hg, the surgeon cuts the fascia open to relieve it, a limb-saving operation called a fasciotomyfasciotomyfash-ee-OT-uh-meeSurgery that cuts open the fascia, the tough tissue around a group of muscles, to relieve pressure inside it.fasci/o fascia, a band of connective tissue-tomy cutting intoFull entry Close.
• In the abdomen, swollen bowel and organs raise the pressure until organs begin to fail (abdominal compartment syndrome). The treatment is opening the abdomen (decompressive laparotomylaparotomylap-uh-ROT-uh-meeSurgery that opens the abdomen through a large cut to reach the organs inside.lapar/o abdomen-tomy cutting intoFull entry Close), and the swelling can leave it too full to close.

ATLS principles of trauma care

Trauma care follows its own rules:

1. The problem most likely to kill the patient is treated first.
2. Treatment starts even before a definitive diagnosis is made.
3. Treatment may start without a detailed history.

Hospitals use algorithms, set treatment pathways, so care is systematic and consistent, but a badly injured patient often forces the team to step outside them.

The golden hour is the first critical hour after an injury, when fast, definitive care does the most to prevent death and disability. It starts at the scene, where EMS judges how badly the patient is hurt, begins treatment and chooses the hospital.

The primary survey finds and treats the threats to life, in order, following ABCDEABCDEay-bee-see-dee-EE (said as letters)A memory aid with two common uses: the warning signs of melanoma in a mole, and the order of the first check of a seriously ill or injured client.Full entry Close. First responders begin it in the field, and the trauma team repeats it on arrival. Each threat is corrected before the next step.

• A, airway with cervicalcervicalSER-vih-kulRelating to the neck, or to the cervix, the lower end of the uterus.cervic/o neck, cervix-al relating toFull entry Close spine protection: the airway is secured, and the neck is held still in a rigid collar until an exam and X-rays rule out a neck injury.
• B, breathing: the chest is checked for injuries that stop breathing, such as a pneumothoraxpneumothoraxnoo-moh-THOR-aksAir in the space between a lung and the chest wall, which lets part or all of that lung collapse.pneum/o air, lungthorac/o chestFull entry Close, a hemothorax (blood in the chest) or a flail chest.
• C, circulation: bleeding is controlled early, to prevent coagulopathy and exsanguination, and IV lines are placed for blood tests, fluids and drugs.
• D, disability: a quick neurologic check for a brain injury.
• E, exposure and environment: the clothing is removed to see every injury, and the patient is kept warm.

The order matters. A patient with a penetrating wound and bowel outside the abdomen still gets the airway and breathing secured first, because an eviscerationeviscerationih-vis-er-AY-shunThe pushing out of internal organs, usually loops of bowel, through a surgical wound that has come open.e- outviscer/o internal organs-ation processFull entry Close can wait minutes and a blocked airway cannot.

Neck injuries, blunt, penetrating or from a near-hanging, can damage the airway, the larynxlarynxLAIR-inksThe voice box: the part of the airway in the neck, above the windpipe, that holds the vocal cords.laryng/o larynxFull entry Close and the great vessels. The neck is treated as broken until cleared, and the airway is secured first, by rapid sequence intubationendotracheal intubationen-doh-TRAY-kee-ul in-too-BAY-shunPutting a breathing tube through the mouth or nose into the windpipe (trachea).endo- withintrache/o windpipe-al relating toFull entry Close through the mouth or, when that is not possible, a surgical airway. In the OR the patient lies supine, prepped and draped as for a wide thyroidectomythyroidectomythy-roy-DEK-tuh-meeSurgery to remove all or part of the thyroid gland in the neck.thyr/o thyroid-ectomy surgical removalFull entry Close, with vascular instruments and suturessutureSOO-cherA stitch, or the thread used to stitch, that holds the edges of a wound or incision together.Full entry Close as for carotidcarotidkuh-ROT-idHaving to do with the carotid arteries, the two large arteries on each side of the neck that carry blood to the head and brain.Full entry Close surgery (chapter 40), fine dissecting instruments and thyroid and carotid retractorsretractorrih-TRAK-terA surgical instrument that holds back tissue or organs so the surgeon can see and reach the operative site.Full entry Close. Vessels are repaired directly or with a patch, and the airway is repaired, often with a tracheostomytracheostomytray-kee-OS-tuh-meeA surgical opening through the front of the neck into the windpipe, usually holding a tube that the person breathes through.trache/o windpipe-stomy surgical openingFull entry Close (chapter 36).

The FAST exam (focused assessment with sonography for trauma) adds a bedside ultrasound to the primary survey in an unstableunstableun-STAY-bulDescribes a client whose condition is changing quickly or is hard to predict.Full entry Close patient with blunt trauma. It looks for blood around the heart and free fluid in the abdomen, and if it finds fluid in such a patient, they go straight to the OR for an exploratory laparotomy.

Exploratory Laparotomy32 instruments · 1 photo

Resuscitation means restoring the body's balance after severe injury: the blood volume, the flow to the tissues and the tone of the vessels. It begins as soon as help arrives and goes on through the emergency department, the OR and intensive care. It is a balancing act: too much IV fluid dilutes the blood and its clotting factors, and raising the blood pressure too far speeds bleeding and can knock loose the clots already formed. At least two large IV lines are placed, and fluids and blood are given through a pump that warms them. Many hospitals have a massive transfusionblood transfusionBLUD trans-FYOO-zhunGiving blood, or a part of blood, from a donor into a person's vein.trans- acrossfus/o pourFull entry Close protocol that gives red cells, plasmaplasmaPLAZ-muhThe pale yellow liquid part of the blood, which carries the blood cells, proteins, nutrients and wastes.Full entry Close and platelets in equal (1:1:1) amounts. Chapters 12 and 13 cover blood productsblood productBLUD PROD-uktAny part of donated blood prepared for transfusion, such as red cells, plasma or platelets.Full entry Close and anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close care.

The secondary survey comes once the patient is stable enough to move. It is a head-to-toe exam for less obvious injuries, with imaging such as ultrasound, X-rays and MRImagnetic resonance imagingmag-NET-ik REZ-uh-nunts IM-uh-jingAn imaging test that uses a strong magnet and radio waves to make detailed pictures of the inside of the body.Full entry Close, more IV lines, a urinary catheter and a nasogastric tubenasogastric tubenay-zoh-GAS-trik toobA thin, flexible tube passed through the nose and down the esophagus into the stomach.nas/o nosegastr/o stomach-ic having to do withFull entry Close, and a history from the patient or witnesses. A patient who needs surgery to save their life may go straight to the OR after the primary survey, and every patient with multiple injuries recovers in intensive care.

A definitive procedure is a planned operation that repairs injured structures and restores their function. A patient in the lethal triangle may be too unstable for one, and gets damage control surgery instead: stop the bleeding and the contamination, and leave the repair for later. Chapter 32 teaches damage control and staged closure of the abdomen, chapter 28 setting up for a trauma case, and chapters 39 to 42 the injuries of the bones, vessels, chest and nervous system.

13Disorders present at birth

A congenitalcongenitalkun-JEN-ih-tulPresent at birth.con- withgen birth, origin-al relating toFull entry Close disorder is present at birth; it develops during fetal life. Much of pediatric surgery corrects structural defects that formed before birth.

• A genetic abnormality is inherited, passed down in the genes.
• An acquired abnormality develops in fetal life because of something in the environment.

The body's organs form in embryonic life, the first 8 weeks of development; after that the developing baby is called a fetus. The first 60 days are the most vulnerable, because tissues are forming so fast.

• A teratogenteratogentuh-RAT-uh-jenAnything a pregnant person is exposed to that can cause birth defects in the developing baby.terat/o malformation-gen producingFull entry Close is anything that harms the developing embryo or fetus, such as alcohol, environmental mercury, some drugs, radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close and infections such as rubellarubellaroo-BEL-uhA contagious illness caused by the rubella virus; also called German measles.Full entry Close, cytomegaloviruscytomegalovirussy-toh-meg-uh-loh-VY-rusA common virus of the herpes family that stays in the body for life after infection.cyt/o cellmegal/o largevirus Full entry Close and syphilissyphilisSIF-uh-lisA bacterial infection, spread mainly through sex, caused by Treponema pallidum.Full entry Close.
• A mutagenic substance (a mutagen) changes the genes themselves. X-rays are both mutagenic and teratogenic.
• Diet matters too: too little folic acidfolic acidFOH-lik AS-idA B vitamin (vitamin B9) that the body needs to make DNA and red blood cells.Full entry Close in the mother's diet causes neural tubeneural tubeNOOR-ul TOOBThe hollow structure in an early embryo that develops into the brain and spinal cord.neur/o nerve-al relating toFull entry Close defects such as spina bifidaspina bifidaSPY-nuh BIF-ih-duhA birth defect in which the bones of the spine do not close completely around the spinal cord.spina spinebifida split in two (Latin)Full entry Close.

Some genetic disorders affectaffectAF-ekt (stress on the first syllable)In mental health, the outward expression of a person's emotions, as seen in the face, voice and body language.Full entry Close the whole body: cystic fibrosiscystic fibrosisSIS-tik fy-BROH-sisAn inherited disease in which the body makes thick, sticky mucus that clogs the lungs, pancreas and other organs.cyst/o sacfibr/o fiber-osis abnormal conditionFull entry Close involves several systems and needs long-term care, and muscular dystrophydystrophyDIS-truh-feeA condition in which a muscle or other tissue weakens and wastes away over time.dys- bad-trophy nourishment or growthFull entry Close causes muscle weakness that gets worse over time. In Down syndromeDown syndromeDOWN SIN-drohmA genetic condition in which a person has a third copy of chromosome 21.Full entry Close, an extra chromosomechromosomeKROH-muh-sohmA thread-like structure in the nucleus of a cell that carries the genes, made of tightly packed DNA.chrom/o color-some body (they take up colored stains easily)Full entry Close 21 gives the person 47 chromosomes instead of the usual 46.

Surgery treats many congenital defects, and each is taught with its specialty: pyloric stenosispyloric stenosispy-LOR-ik steh-NOH-sisA narrowing of the outlet of the stomach in a young infant, caused by thickening of the pylorus muscle.pylor/o pylorussten/o narrow-osis conditionFull entry Close and omphalocele in chapter 32; an undescended testiscryptorchidismkrip-TOR-kih-diz-umA condition in which one or both testicles have not moved down into the scrotum.crypt/o hiddenorch/o testis-ism conditionFull entry Close (cryptorchidism) in chapter 34; choanal atresia in chapter 36; cleft lipcleft lipkleft lipA split or opening in the upper lip that is present at birth.Full entry Close and palate in chapter 37; syndactyly in chapter 38; clubfootclubfootKLUB-fuutA birth defect in which one or both feet are twisted inward and downward.Full entry Close in chapter 39; heart defects, esophagealesophagusih-SOF-uh-gusThe muscular tube that carries food and liquid from the throat to the stomach.esophag/o esophagusFull entry Close atresia and pectus excavatum in chapter 41; and spina bifida (myelomeningocele) and hydrocephalushydrocephalushy-droh-SEF-uh-lusA buildup of too much cerebrospinal fluid inside the spaces (ventricles) of the brain.hydr/o watercephal/o head-us noun endingFull entry Close in chapter 42.

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