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Management of Penetrating Neck Trauma

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Title: Management of Penetrating Neck Trauma


1
Management of Penetrating Neck Trauma
  • Ottawa Civic

2
MVA, aphasia, R hemiplegia
3
Types of Weapons
  • Low velocity knives, ice picks, glass
  • High velocity handguns, shotguns, shrapnel

K1/2mv2
4
Guns
lt
5
Ballistics
6
Anatomy
7
Anatomy
Zone III
Zone II
Zone I
8
Incidence and Mortality
9
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10
Signs of Injury
Shock, Profuse bleeding, Evolving
stroke, Expanding hematoma, hemoptysis,
hematemesis, unequal pulses, bruits or thrills
Vascular
11
Signs of Injury
Subcutaneous emphysema, Hoarseness, Respiratory
distress, Stridor
Larynx/Trachea
Neck pain, Blood in saliva, Fever, Odynophagia
Esophagus
12
Initial Management
Airway
Intubation vs. Surgical Airway
Breathing
Circulation
IV access, Immediate Exploration
Examination
Determine weapon trajectory
13
Management of the Stable Patient
The Standard
Wound Penetrates Platysma?
No
Yes
Immediate Neck Exploration
Observation/Discharge
Laryngoscopy Esophagoscopy
14
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

15
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).

16
A Newer Algorithm
Mansour et al 1991 retrospective study
17
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.

18
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.

19
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.

20
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.

21
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22
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23
Is this really wise??
24
Incision for Neck Exploration
25
Incisions for Neck Exploration
26
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.

27
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.

28
Laryngeal/Tracheal Injury
  • Thorough Direct Laryngoscopy for suspicious
    wounds
  • Tracheotomy for suspected laryngeal injury

29
Thoracic Trauma
30
Thoracic Trauma
  • 2nd leading cause of trauma deaths
  • after head injury
  • 10-20 of all trauma deaths
  • Many deaths are preventable

31
Thoracic Trauma
  • Mechanisms of Injury
  • Blunt Injury
  • Deceleration
  • Compression
  • Penetrating Injury
  • Combination

32
Thoracic Trauma
  • Anatomical Injuries
  • Thoracic Cage (Skeletal)
  • Cardiovascular
  • Pleural and Pulmonary
  • Mediastinal
  • Diaphragmatic
  • Esophageal
  • Penetrating Cardiac

33
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

34
Thoracic Trauma
  • Initial exam directed toward life threatening
  • Injuries
  • Open pneumothorax
  • Flail chest
  • Tension pneumothorax
  • Massive hemothorax
  • Cardiac tamponade

35
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

36
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

37
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

38
Thoracic Trauma
  • Specific Injuries

39
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

40
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

41
Rib Fracture
  • Fractures of 10 to 12th ribs can cause damage to
    underlying abdominal solid organs
  • Liver
  • Spleen
  • Kidneys

42
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

43
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

44
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

45
Sternal Fracture
  • Management
  • Establish airway
  • High concentration oxygen
  • Assist ventilations as needed
  • IV NS/LR
  • Restrict fluids
  • Rule out associated injuries

46
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

47
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

48
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

49
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

50
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

51
Simple Pneumothorax
  • Incidence
  • 10-30 in blunt chest trauma
  • almost 100 with penetrating chest trauma
  • Morbidity Mortality dependent on
  • extent of atelectasis
  • associated injuries

52
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

53
Simple Pneumothorax
  • HDI and respiratory distress
  • High index of suspicion
  • Chest tube when in doubt before CXR

54
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

55
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

56
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

57
Open Pneumothorax
  • Cover chest opening with occlusive dressing
  • Assist with positive pressure ventilations prn
  • Monitor for progression to tension pneumothorax

58
Tension Pneumothorax
  • Incidence
  • Penetrating Trauma
  • Blunt Trauma
  • Morbidity/Mortality
  • Severe hypoventilation
  • Immediate life-threat if not managed early

59
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

60
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

61
Tension Pneumothorax
  • Jugular Vein Distension
  • absent if also hypovolemic
  • Hyperresonance to percussion
  • Subcutaneous emphysema
  • Late
  • Tracheal shift away from injured side
  • Cyanosis

62
Tension Pneumothorax
  • Recognize Manage early
  • Establish airway
  • Needle thoracostomy then chest tube

63
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

64
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

65
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

66
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

67
Hemothorax
  • Chest tube, go to OR if
  • 1000 cc out on insertion
  • 200 cc/h for 4 hours

68
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

69
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

70
Pulmonary Contusion
  • Assessment Findings
  • Evidence of blunt chest trauma
  • Cough and/or Hemoptysis
  • Apprehension
  • Cyanosis
  • CXR changes late

71
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

72
Myocardial Contusion
  • Most common blunt injury to heart
  • Usually due to steering wheel
  • Significant cause of morbidity and mortality in
    the blunt trauma patient

73
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

74
Myocardial Contusion
  • Cardiac arrhythmias following blunt chest trauma
  • Angina-like pain unresponsive to nitroglycerin
  • Precordial discomfort independent of respiratory
    movement
  • Pericardial friction rub (late)

75
Myocardial Contusion
  • ECG Changes
  • Persistent tachycardia
  • ST elevation, T wave inversion
  • RBBB
  • Atrial flutter, Atrial fibrillation
  • PVCs
  • PACs

76
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

77
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

78
  • 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

79
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

80
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

81
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

82
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

83
Pericardial Tamponade
  • Management
  • ECHO if stable to diagnose
  • In ER
  • consider pericardiocentesis
  • Pericardial window followed by sternotomy in OR

84
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85
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86
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

87
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

88
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

89
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

90
CXR
91
Work up
  • CTA
  • Angio is rarely used
  • Address other injuries first
  • Ideally, repaire when stable
  • Stent vs open

92
Diaphragmatic Penetration
  • Suspect intra-abdominal trauma with any injury
    below 4th ICS
  • Suspect intrathoracic trauma with any abdominal
    injury above umbilicus

93
Diaphragmatic Rupture
  • Usually due to blunt trauma but may occur with
    penetrating trauma
  • Usually life-threatening
  • Likely to be associated with other severe injuries

94
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

95
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

96
Esophageal Injury
  • Penetrating Injury most frequent cause
  • Rare in blunt trauma
  • Can perforate spontaneously
  • violent emesis
  • carcinoma

97
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

98
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

99
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

100
Damage control
101
Damage control principle
102
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103
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104
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105
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

106
Procedure Left Anterolateral Thoracotomy
107
Clamshell Thoracotomy
108
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109
Release Pericardial Tamponade
110
Control Intrathoracic Hemorrhage
111
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

112
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113
Perform Open Cardiac Massage
  • Bimanual internal massage with hands in a hinged
    clapping motion
  • Ventricular compression proceeding from apex to
    base of heart

114
Occlude Descending Thoracic Aorta
115
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

116
Selective Application of ED Thoracotomy
  • Mechanism of Injury
  • Presence of Vital Signs
  • Location of Injury
  • Other Signs of Life

117
Survival based on mechanism
J Trauma. 1998 Jul45(1)87-94
118
Presence of vital signs
J Trauma. 1998 Jul45(1)87-94
119
Survival based on organ injured
JACS 2000 Mar190(3)288-98.
120
Other Signs of Life (SOL)
JACS 2000 Mar190(3)288-98.
121
What about PEA?
26/62 (42) ED Thoracotomy survivors had PEA
requiring CPR
JACS 199211-215, 2004
122
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

123
Finally
  • PEA after blunt trauma?
  • Typically poor outcome, but occasionally will
    have a survivor
  • If CPR gt 5 min, contraindicated

124
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
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