Management of Penetrating Neck Trauma

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Management of Penetrating Neck Trauma

• Ottawa Civic

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MVA, aphasia, R hemiplegia
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Types of Weapons

• Low velocity knives, ice picks, glass
• High velocity handguns, shotguns, shrapnel

K1/2mv2
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Guns
lt
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Ballistics
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Anatomy
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Anatomy
Zone III
Zone II
Zone I
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Incidence and Mortality
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Signs of Injury
Shock, Profuse bleeding, Evolving
stroke, Expanding hematoma, hemoptysis,
hematemesis, unequal pulses, bruits or thrills
Vascular
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Signs of Injury
Subcutaneous emphysema, Hoarseness, Respiratory
distress, Stridor
Larynx/Trachea
Neck pain, Blood in saliva, Fever, Odynophagia
Esophagus
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Initial Management
Airway
Intubation vs. Surgical Airway
Breathing
Circulation
IV access, Immediate Exploration
Examination
Determine weapon trajectory
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Management of the Stable Patient
The Standard
Wound Penetrates Platysma?
No
Yes
Immediate Neck Exploration
Observation/Discharge
Laryngoscopy Esophagoscopy
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The Standard

• Based on wartime experiences
• Fogelman et al (1956)
• immediate neck exploration-gt better outcomes in
  vascular injuries.
• negative neck explorations in gt 50
• Arteriogram?
• screening tool before exploration
• zone 1 and 3 injuries
• hard to detect on physical
• Safe answer on board exam

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Arteriogram

• Flint et al (1973)
• negative P.E. in 32 of pts. with major zone 1
  vascular injury.
• Arteriogram can be accompanied by treatment (e.g.
  embolization).

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A Newer Algorithm
Mansour et al 1991 retrospective study
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Newer Algorithm (Mansour)

• 63 of the study population was in the
  observation group.
• Overall mortality 1.5
• similar to those in more rigorous treatment
  protocols.
• Similar results obtained in other large studies
  with similar protocols (e.g. Biffi et al 1997).
• NOTE Arteriogram in asymptomatic patients with
  zone 1 injury.

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Points of Controversy

• Most trauma surgeons accept observation of select
  patients similar to the Mansour algorithm.
• Study by Eddy et al
• questions the necessity for arteriogram /
  esophagoscopy in asymptomatic zone 1 injury (use
  of P.E. and CXR resulted in no false negatives).
• Other noninvasive modalities than arteriogram
  exist for screening patients for vascular injury.

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CT scan

• Can id weapon trajectory and structures
• only in stable patients.
• Gracias et al (2001)
• CT scan in stable patients
• able to save patients from arteriogram indicated
  by other protocols 50 of the time
• avoid esophagoscopy in 90 of tested patients who
  might otherwise have undergone it.

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Duplex Ultrasonography

• Requires the presence of reliable technician and
  radiologist.
• A double blinded study by Ginsburg et al (1996)
  showed 100 true negative, 100 sensitivity in
  detecting arterial injury, using arteriography as
  the gold standard.

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Is this really wise??
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Incision for Neck Exploration
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Incisions for Neck Exploration
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Management of Vascular Injuries

• Common carotid
• repair preferred over ligation in almost all
  cases.
• Saphenous vein graft may be used.
• Shunting is rarely necessary.
• Thrombectomy may be necessary.
• Internal carotid
• Shunting is usually necessary
• Vertebral
• Angiographic embolization
• proximal ligation can be used if the
  contralateral vertebral artery is intact.
• Internal Jugular Repair vs. ligation.

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Esophageal Injury

• Diagnosis
• esophagoscopy and esophagram in symptomatic
  patients.
• Injection of air or methylene blue in the mouth
  may aid in localizing injuries.
• Controlled fistula with T-tube
• exteriorization of low non-repairable wounds
• Small pharyngeal lesions above arytenoids can be
  treated with NPO and observation 5-7 days
• All patients should be NPO for 5-7 days.

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Laryngeal/Tracheal Injury

• Thorough Direct Laryngoscopy for suspicious
  wounds
• Tracheotomy for suspected laryngeal injury

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Thoracic Trauma
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Thoracic Trauma

• 2nd leading cause of trauma deaths
• after head injury
• 10-20 of all trauma deaths
• Many deaths are preventable

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Thoracic Trauma

• Mechanisms of Injury
• Blunt Injury
• Deceleration
• Compression
• Penetrating Injury
• Combination

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Thoracic Trauma

• Anatomical Injuries
• Thoracic Cage (Skeletal)
• Cardiovascular
• Pleural and Pulmonary
• Mediastinal
• Diaphragmatic
• Esophageal
• Penetrating Cardiac

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Thoracic Trauma

• Hypoxia
• hypovolemia
• pulmonary V/P mismatch
• ? in intrathoracic pressure relationships
• Hypercarbia
• ? in intrathoracic pressure relationships
• ? level of consciousness
• Impairments to cardiac output
• blood loss
• increased intrapleural pressures
• blood in pericardial sac
• myocardial valve damage
• Acidosis final result
• hypoperfusion of tissues

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Thoracic Trauma

• Initial exam directed toward life threatening
• Injuries
• Open pneumothorax
• Flail chest
• Tension pneumothorax
• Massive hemothorax
• Cardiac tamponade

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Thoracic Trauma

• Assessment Findings
• Mental Status
• decreased
• Pulse
• absent, tachy or brady
• BP
• narrow PP, hyper- or hypotension, pulsus
  paradoxus
• Ventilatory rate effort
• tachy- or bradypnea, labored, retractions
• Skin
• diaphoresis, pallor, cyanosis, open injury,
  ecchymosis

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Thoracic Trauma

• Assessment Findings
• Neck
• tracheal position, SQ emph, JVD, open injury
• Chest
• contusions, tenderness, asymmetry, abN a/e, bowel
  sounds, abnormal percussion, open injury, impaled
  object, crepitus, hemoptysis
• Heart Sounds
• muffled, distant, regurgitant murmur
• Upper abdomen
• contusion, open injury

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Thoracic Trauma

• Assessment Findings
• ECG (ST segment abnormalities, dysrhythmias)
• History
• Dyspnea
• Pain
• Past hx of cardiorespiratory disease
• Restraint devices used
• Item/Weapon involved in injury

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Thoracic Trauma

• Specific Injuries

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Rib Fracture

• MC chest wall injury from direct trauma
• More common in adults than children
• Especially common in elderly
• Most commonly 5th - 9th ribs
• Poor protection

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Rib Fracture

• Fractures of 1st and 2nd second require high
  force
• Frequently have injury to aorta or bronchi
• Occur in 90 of patients with tracheo-bronchial
  rupture
• May injure subclavian artery/vein
• 30 will die

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Rib Fracture

• Fractures of 10 to 12th ribs can cause damage to
  underlying abdominal solid organs
• Liver
• Spleen
• Kidneys

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Rib Fracture

• Management
• PPV
• Analgesics for isolated trauma
• Non-circumferential splinting
• Monitor elderly and COPD patients closely
• Broken ribs can cause decompensation
• Patients will fail to breathe deeply and cough,
  resulting in poor clearance of secretions

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Sternal Fracture

• Uncommon, 5-8 in blunt chest trauma
• Large traumatic force
• Direct blow to front of chest by
• Deceleration
• steering wheel
• dashboard
• Other object

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Sternal Fracture

• 25 - 45 mortality due to associated trauma
• Disruption of thoracic aorta
• Tracheal or bronchial tear
• Diaphragm rupture
• Flail chest
• Myocardial trauma
• High incidence of
• myocardial contusion, cardiac tamponade or
  pulmonary contusion

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Sternal Fracture

• Management
• Establish airway
• High concentration oxygen
• Assist ventilations as needed
• IV NS/LR
• Restrict fluids
• Rule out associated injuries

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Flail Chest

• Usually secondary to blunt trauma
• Most commonly in MVA
• Also results from
• falls from heights
• industrial accidents
• assault
• birth trauma
• More common in older patients

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Flail Chest

• Mortality rates 20-40 due to associated injuries
• Mortality increased with
• advanced age
• seven or more rib fractures
• three or more associated injuries
• shock
• head injuries

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Flail Chest

• Consequences of flail chest
• Respiratory failure due to
• pulmonary contusion
• inadequate diaphragm movement
• Paradoxical movement of the chest
• must be large to compromise ventilation
• Increased work of breathing
• decreased chest expansion
• pain

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Flail Chest

• Suspect spinal injuries
• Establish airway
• Assist ventilation
• Treat hypoxia from underlying contusion
• Promote full lung expansion
• Consider need for intubation and PEEP
• Mechanically stabilize chest wall
• questionable value

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Flail Chest

• Management
• IV of LR/NS
• Avoid rapid replacement in hemodynamically stable
  patient
• Contused lung cannot handle fluid load
• Monitor EKG
• Chest trauma can cause dysrhythmias

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Simple Pneumothorax

• Incidence
• 10-30 in blunt chest trauma
• almost 100 with penetrating chest trauma
• Morbidity Mortality dependent on
• extent of atelectasis
• associated injuries

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Simple Pneumothorax

• a rib lacerates lung
• Usually well-tolerated in the young healthy
• Severe compromise can occur in the elderly or
  patients with pulmonary disease
• Degree of distress depends on amount and speed of
  collapse

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Simple Pneumothorax

• HDI and respiratory distress
• High index of suspicion
• Chest tube when in doubt before CXR

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Open Pneumothorax

• If the trauma patient does not ventilate well
  with an open airway, look for a hole
• May be subtle
• Abrasion with deep punctures
• Opening in the chest wall
• Sucking sound on inhalation
• HDI/resp distress
• SQ Emphysema

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Open Pneumothorax

• Profound hypoventilation may occur
• communication between pleural space and
  atmosphere
• Prevents development of negative intrapleural
  pressure
• Results in ipsilateral lung collapse
• inability to ventilate affected lung

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Open Pneumothorax

• V/Q Mismatch
• shunting
• hypoventilation
• hypoxia
• large functional dead space
• Pressure may build within pleural space
• Return from Vena cava may be impaired

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Open Pneumothorax

• Cover chest opening with occlusive dressing
• Assist with positive pressure ventilations prn
• Monitor for progression to tension pneumothorax

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Tension Pneumothorax

• Incidence
• Penetrating Trauma
• Blunt Trauma
• Morbidity/Mortality
• Severe hypoventilation
• Immediate life-threat if not managed early

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Tension Pneumothorax

• Pathophysiology
• One-way valve forms in lung or chest wall
• Air enters pleural space, but cannot leave
• Pressure collapses lung on affected side
• Mediastinal shift to contralateral side
• Reduction in cardiac output
• Increased intrathoracic pressure
• deformed vena cava reducing preload

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Tension Pneumothorax

• Severe dyspnea ? extreme resp distress
• Restlessness, anxiety, agitation
• Decreased/absent breath sounds
• Worsening or Severe Shock
• Cardiovascular collapse
• Tachycardia
• Weak pulse
• Hypotension
• Narrow pulse pressure

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Tension Pneumothorax

• Jugular Vein Distension
• absent if also hypovolemic
• Hyperresonance to percussion
• Subcutaneous emphysema
• Late
• Tracheal shift away from injured side
• Cyanosis

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Tension Pneumothorax

• Recognize Manage early
• Establish airway
• Needle thoracostomy then chest tube

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Tension Pneumothorax

• Decompress with 14g (lg bore), 2-inch needle
• Midclavicular line 2nd intercostal space
• Midaxillary line 4-5th intercostal space
• Go over superior margin of rib to avoid blood
  vessels
• Be careful not to kink or bend needle or catheter
• If available, attach a one-way valve

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Hemothorax

• Most common result of major trauma to the chest
  wall
• Present in 70 - 80 of penetrating and major
  non-penetrating trauma cases
• Associated with pneumothorax
• Rib fractures are frequent cause

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Hemothorax

• Each can hold up to 3000 cc of blood
• Life-threatening often requiring chest tube
  and/or surgery
• If assoc. with great vessel or cardiac injury
• 50 die immediately
• 25 live five to ten minutes
• 25 may live 30 minutes or longer
• Blood loss results in
• Hypovolemia
• Decreased ventilation of affected lung

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Hemothorax

• Accumulation of blood in pleural space
• penetrating or blunt lung injury
• chest wall vessels
• intercostal vessels
• myocardium
• Massive hemothorax indicates great vessel or
  cardiac injury
• Intercostal artery can bleed 50 cc/min

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Hemothorax

• Chest tube, go to OR if
• 1000 cc out on insertion
• 200 cc/h for 4 hours

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Pulmonary Contusion

• Pathophysiology
• Blunt trauma to the chest
• Rapid deceleration forces cause lung to strike
  chest wall
• high energy shock wave from explosion
• high velocity missile wound
• low velocity as with ice pick
• Most common injury from blunt thoracic trauma
• 30-75 of blunt trauma
• mortality 14-20

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Pulmonary Contusion

• Pathophysiology
• Rib Fx in many but not all cases
• Alveolar rupture with hemorrhage and edema
• increased capillary membrane permeability
• Large vascular shunts develop
• Gas exchange disturbances
• Hypoxemia
• Hypercarbia

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Pulmonary Contusion

• Assessment Findings
• Evidence of blunt chest trauma
• Cough and/or Hemoptysis
• Apprehension
• Cyanosis
• CXR changes late

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Pulmonary Contusion

• Management
• Supportive therapy
• Early use of positive pressure ventilation
  reduces ventilator therapy duration
• Avoid aggressive crystalloid infusion
• Severe cases may require ventilator therapy

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Myocardial Contusion

• Most common blunt injury to heart
• Usually due to steering wheel
• Significant cause of morbidity and mortality in
  the blunt trauma patient

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Myocardial Contusion

• Pathophysiology
• Behaves like acute MI
• Hemorrhage with edema
• Cellular injury
• vascular damage may occur
• Hemopericardium may occur from lacerated
  epicardium
• May produce arrhythmias
• hypotension unresponsive to fluid or drug therapy

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Myocardial Contusion

• Cardiac arrhythmias following blunt chest trauma
• Angina-like pain unresponsive to nitroglycerin
• Precordial discomfort independent of respiratory
  movement
• Pericardial friction rub (late)

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Myocardial Contusion

• ECG Changes
• Persistent tachycardia
• ST elevation, T wave inversion
• RBBB
• Atrial flutter, Atrial fibrillation
• PVCs
• PACs

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Myocardial Contusion

• IV LR/NS
• Cautious fluid administration due to injured
  myocardium
• ECG
• Standard drug therapy for arrhythmias
• 12 Lead ECG if time permits
• Admit to monitored evironment

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Pericardial Tamponade

• Incidence
• Usually associated with penetrating trauma
• Rare in blunt trauma
• Occurs in lt 2 of chest trauma
• GSW wounds have higher mortality than stab wounds
• Lower mortality rate if isolated tamponade

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• Tamponade is hard to diagnose
• Hypotension is common in chest trauma
• Heart sounds are difficult to hear
• Bulging neck veins may be absent if hypovolemia
  is present
• High index of suspicion is required

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Pericardial Tamponade

• Pathophysiology
• Space normally filled with 30-50 ml of
  straw-colored fluid
• lubrication
• lymphatic discharge
• immunologic protection for the heart
• Rapid accumulation of blood in the inelastic
  pericardium

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Pericardial Tamponade

• Pathophysiology
• Heart is compressed decreasing blood entering
  heart
• Decreased diastolic expansion and filling
• Hindered venous return (preload)
• Myocardial perfusion decreased due to
• pressure effects on walls of heart
• decreased diastolic pressures
• Removal of as little as 20 ml of blood may
  drastically improve cardiac output

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Pericardial Tamponade

• Becks Triad
• Resistant hypotension
• Increased central venous pressure
• distended neck/arm veins in presence of decreased
  arterial BP
• Small quiet heart
• decreased heart sounds

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Pericardial Tamponade

• Signs and Symptoms
• Narrowing pulse pressure
• Pulsus paradoxicus
• Radial pulse becomes weak or disappears when
  patient inhales
• Increased intrathoracic pressure on inhalation
  causes blood to be trapped in lungs temporarily

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Pericardial Tamponade

• Management
• ECHO if stable to diagnose
• In ER
• consider pericardiocentesis
• Pericardial window followed by sternotomy in OR

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Traumatic Aortic Dissection/Rupture

• Caused By
• Motor Vehicle Collisions
• Falls from heights
• Crushing chest trauma
• Animal Kicks
• Blunt chest trauma
• 15 of all blunt trauma deaths

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Traumatic Aortic Dissection/Rupture

• 1 of 6 persons dying in MVCs has aortic rupture
• 85 die instantaneously
• 10-15 survive to hospital
• 1/3 die within six hours
• 1/3 die within 24 hours
• 1/3 survive 3 days or longer
• Must have high index of suspicion

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Traumatic Aortic Dissection/Rupture

• Separation of the aortic intima and media
• Tear 2 high speed deceleration at points of
  relative fixation
• Blood enters media through a small intima tear
• Thinned layer may rupture
• Descending aorta at the isthmus distal to left
  subclavian artery most common site of rupture
• ligamentum arteriosom

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Traumatic Aortic Dissection/Rupture

• Assessment Findings
• Retrosternal or interscapular pain
• Pain in lower back or one leg
• Respiratory distress
• Asymmetrical arm BPs
• Upper extremity hypertension with
• Decreased femoral pulses, OR
• Absent femoral pulses
• Dysphagia

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CXR
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Work up

• CTA
• Angio is rarely used
• Address other injuries first
• Ideally, repaire when stable
• Stent vs open

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Diaphragmatic Penetration

• Suspect intra-abdominal trauma with any injury
  below 4th ICS
• Suspect intrathoracic trauma with any abdominal
  injury above umbilicus

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Diaphragmatic Rupture

• Usually due to blunt trauma but may occur with
  penetrating trauma
• Usually life-threatening
• Likely to be associated with other severe injuries

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Diaphragmatic Rupture

• Pathophysiology
• Compression to abdomen resulting in increased
  intra-abdominal pressure
• abdominal contents rupture through diaphragm into
  chest
• bowel obstruction and strangulation
• restriction of lung expansion
• mediastinal shift
• 90 occur on left side due to protection of right
  side by liver

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Diaphragmatic Rupture

• Assessment Findings
• Decreased breath sounds
• Usually unilateral
• Dullness to percussion
• Dyspnea or Respiratory Distress
• Scaphoid Abdomen
• Usually impossible to hear bowel sounds
• Management
• suspect
• NG tube
• CT
• Laparoscopy
• Sensitive and specific

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Esophageal Injury

• Penetrating Injury most frequent cause
• Rare in blunt trauma
• Can perforate spontaneously
• violent emesis
• carcinoma

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Esophageal Injury

• Assessment Findings
• Pain, local tenderness
• Hoarseness, Dysphagia, Respiratory distress
• Mediastinal esophageal perforation
• mediastinal emphysema / mediastinal crunch
• SQ Emphysema
• Shock
• Abx
• resuscitation
• Early diagnosis
• Gastrographin -gt dilute Ba
• Repair vs exclude

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Tracheobronchial Rupture

• Uncommon injury
• less than 3 of chest trauma
• Occurs with penetrating or blunt chest trauma
• High mortality rate (gt30)
• Respiratory Distress
• Obvious SQ emphysema
• Hemoptysis
• Especially of bright red blood
• Signs of tension pneumothorax unresponsive to
  needle decompression

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Tracheobronchial Rupture

• Majority (80) occur at or near carina
• rapid movement of air into pleural space
• Tension pneumothorax refractory to needle
  decompression
• Consider early intubation
• intubating right or left mainstem may be life
  saving
• If arrest and suspect air embolysm, may have to
  do ERT

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Damage control
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Damage control principle
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ED Thoractomy

• Thoracotomy performed in ER
• for resuscitation of patients arriving in
  extremis
• Plan to take to OR afterwards
• AIM
• Expeditious control of hemorrhage
• Maximization of coronary and cerebral perfusion
• Release of pericardial tamponade
• Tx of massive air-embolysm

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Procedure Left Anterolateral Thoracotomy
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Clamshell Thoracotomy
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Release Pericardial Tamponade
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Control Intrathoracic Hemorrhage
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Eliminate massive air embolism or bronchopleural
fistula

• Post intubation positive pressure ventilation
• Get air transfer across traumatic alveolovenous
  channels
• Pulmonary hilar cross clamping
• Air aspirated from L ventricular apex and aortic
  root
• Cardiac massage

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Perform Open Cardiac Massage

• Bimanual internal massage with hands in a hinged
  clapping motion
• Ventricular compression proceeding from apex to
  base of heart

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Occlude Descending Thoracic Aorta
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Futile?

• Overall survival 4-5
• Little to Lose
• risk to Health care workers
• Risk blood contact
• 26 trauma pts HIV or Hepatitis
• Health care costs
• J Trauma. 1998 Jul45(1)87-94

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Selective Application of ED Thoracotomy

• Mechanism of Injury
• Presence of Vital Signs
• Location of Injury
• Other Signs of Life

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Survival based on mechanism
J Trauma. 1998 Jul45(1)87-94
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Presence of vital signs
J Trauma. 1998 Jul45(1)87-94
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Survival based on organ injured
JACS 2000 Mar190(3)288-98.
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Other Signs of Life (SOL)
JACS 2000 Mar190(3)288-98.
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What about PEA?
26/62 (42) ED Thoracotomy survivors had PEA
requiring CPR
JACS 199211-215, 2004
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Conclusions

• ER thoracotomy considered in pts w/
• Presence of vital signs in field or hospital
• Better results in penetrating cardiac injury
• Results w/ Blunt trauma poor, but survivors exist
• PEA after penetrating trauma from stabs
• Up to 70 good outcomes
• Contraindicated in pts with
• No vital signs, prolonged asystole and
  unwitnessed arrest/loss of SOL
• JACS 199211-215, 2004

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Finally

• PEA after blunt trauma?
• Typically poor outcome, but occasionally will
  have a survivor
• If CPR gt 5 min, contraindicated

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References and thanks

• Thank God for internet and Google
• several websites specifically
• http//www.adhb.govt.nz/trauma/presentations/Forum
  s/major20chest20injuries/sld001.htm
• http//www.templejc.edu/dept/ems/Pages/PowerPoint.
  html
• http//www.mssurg.net
• www.nordictraumarad.com/Syllabus06/mo2015/NORDTER
  penetrating.pdf
• www.iformix.com/spu/chest_trauma.ppt
• Greenfield textbook of surgery