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Penetrating Injury

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Fig 1- Diagnostic Evaluation for Esophageal Injury A OR^ D No Manage Other Injuries WTA Penetrating Neck Trauma Algorithm Neck CTA Neck Periesophageal – PowerPoint PPT presentation

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Title: Penetrating Injury


1
Fig 1- Diagnostic Evaluation for Esophageal Injury
A
OR
D
No
Manage Other Injuries
WTA Penetrating Neck Trauma Algorithm
Neck
Periesophageal Air / Fluid
CTA Neck
Penetrating Injury
E
Chest
Potential Transmediastinal Trajectory
Yes
Yes
Stable?
CTA Chest
C
Observe
Hypopharynx
B
No
F
OR
Manage Injury
Cervical
H
Yes
Yes
OR
G
D
()
Thoracic
Indications for Immediate Neck Exploration
Neck
Periesophageal Air / Fluid
CTA Neck
Esophagoscopy / Esophagography
Blunt Injury, Iatrogenic, Spontaneous
No
Indications for Immediate Thoracotomy
Chest
No
(-)
CTA Chest
No
Manage Other Injuries
Yes
OR
If extensive tissue damage, consider operative
management If clinical suspicion is low and
findings are subtle, proceed to esophagoscopy
and/or esophagography See Figure 2, Management
2
Fig 2- Management of Esophageal Injury
L
K
I
J
NG Tube Consider Drain
Primary Repair /- Buttress
Yes
Cervical Injury
Cervical Incision /- Endoscopy Debridement
Amenable to Primary Repair?
Drain /- Esophagostomy Gastrostomy / Jejunostomy
Tube
M
No
N
Yes
Stable patient, Contained perforation
Thoracic Injury
NPO, Abx, PPI, Re-Imaging
O
No
Thoracoscopic Debridement and Drainage Consider
Gastrostomy and/or Jejunostomy
Yes
Yes
Consider endoscopic stenting or clipping if
expertise available
Stable Patient, Early (lt24 hr) Small (lt2 cm) Free
Perforation
Q
No
No
Buttress Drain NG Tube
Yes
Primary Repair
Thoracotomy Endoscopy Debridement
P
Amenable to Primary Repair?
R
Repair Over T-Tube Gastrostomy Tube Jejunostomy
Tube
No
No
Significant Tissue Loss
If exploring specifically for esophageal
injury, left anterior cervical incision is
preferred otherwise exploration is on the side
of penetrating injury Anterolateral
thoracotomy if patient unstable Posterolateral
if injury is localized and patient is stable
Right thoracotomy for upper esophagus Left
thoracotomy for lower esophagus
Esophageal Diversion Cervical Esophagostomy Gastro
stomy Tube Jejunostomy Tube
S
Yes
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