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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 eapons
!ow velocity " knives, ice picks, glass #igh velocity " han$guns, shotguns, shrapnel
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%uns
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&allistics
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Anatomy
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Anatomy
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'nci$ence an$ Mortality
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(igns of 'n)ury*
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(igns of 'n)ury*
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'nitial Management
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Management of the (ta+le Patient*
The Standard:
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The (tan$ar$*
&ase$ on wartime eperiences -ogelman et al ./0123 * imme$iate neck eploration45 +etter outcomes in
vascular in)uries6 negative neck eplorations in 5 178
Arteriogram9 screening tool +efore eploration :one / an$ ; in)uries
har$ to $etect on physical
(afe answer on +oar$ eam<
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Arteriogram
-lintet al
./0=;3* negative P6>6 in ;?8 of pts6 with ma)or :one /
vascular in)ury6
Arteriogram can +e accompanie$ +y
treatment .e6g6 em+oli:ation36
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A Newer Algorithm
Mansour et al 1991 retrospective study
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Newer Algorithm .Mansour3
2;8 of the stu$y population was in theo+servation group6
Overall mortality /618 similar to those in more rigorous treatment
protocols6 (imilar results o+taine$ in other large
stu$ies with similar protocols .e6g6 &i@ et
al /00=36 NOT>* Arteriogram in asymptomatic patients
with :one / in)ury6
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Points of Controversy*
Most trauma surgeons accept o+servation ofselect patients similar to the Mansouralgorithm6
(tu$y +y >$$y et al uestions the necessity for arteriogram B
esophagoscopy in asymptomatic :one / in)ury.use of P6>6 an$ CR resulte$ in no falsenegatives36
Other noninvasive mo$alities than
arteriogram eist for screening patients forvascular in)ury6
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CT scan
Can i$ weapon tra)ectory an$ structures
only in sta+le patients6
%racias et al .?77/3 CT scan in sta+le patients*
a+le to save patients from arteriogram in$icate$ +y otherprotocols 178 of the time
avoi$ esophagoscopy in 078 of teste$ patients who mightotherwise have un$ergone it6
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Duple Eltrasonography
Reuires the presence of relia+le technicianan$ ra$iologist6
A $ou+le +lin$e$ stu$y +y %ins+urg et al ./0023 showe$ /778 true negative, /778
sensitivity in $etecting arterial in)ury, usingarteriography as the gol$ stan$ar$6
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's this really wise99
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'ncision for Neck >ploration*
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'ncisions for Neck >ploration*
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Management of Vascular 'n)uries*
Common caroti$* repair preferre$ over ligation in almost all cases6 (aphenous vein graft may +e use$6 (hunting is rarely necessary6 Throm+ectomy may +e necessary6
'nternal caroti$* (hunting is usually necessary
Verte+ral* Angiographic em+oli:ation proimal ligation can +e use$ if the contralateral verte+ral
artery is intact6
'nternal Fugular* Repair vs6 ligation6
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>sophageal 'n)ury*
Diagnosis* esophagoscopy an$ esophagram insymptomatic patients6
'n)ection of air or methylene +lue in the mouthmay ai$ in locali:ing in)uries6
Controlle$ Gstula with T4tu+e eteriori:ation of low non4repaira+le woun$s
(mall pharyngeal lesions a+ove arytenoi$s
can +e treate$ with NPO an$ o+servation14= $ays All patients shoul$ +e NPO for 14= $ays6
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!aryngealBTracheal 'n)ury
Thorough Direct !aryngoscopy for suspicious woun$s
Tracheotomy for suspecte$ laryngeal in)ury
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Thoracic Trauma
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Thoracic Trauma
?n$
lea$ing cause of trauma $eaths after hea$ in)ury
/74?78 of all trauma $eaths
Many $eaths are preventa+le
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Thoracic Trauma
Mechanisms of 'n)ury &lunt 'n)ury
Deceleration
Compression Penetrating 'n)ury
Com+ination
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Thoracic Trauma
Anatomical 'n)uries Thoracic Cage .(keletal3
Car$iovascular
Pleural an$ Pulmonary
Me$iastinal
Diaphragmatic
>sophageal Penetrating Car$iac
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Thoracic Trauma
#ypoia hypovolemia pulmonary VBP mismatch ∆ in intrathoracic pressure relationships
#ypercar+ia ∆ in intrathoracic pressure relationships ↓ level of consciousness
'mpairments to car$iac output +loo$ loss increase$ intrapleural pressures
+loo$ in pericar$ial sac myocar$ial valve $amage
Aci$osis " Gnal result hypoperfusion of tissues
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Thoracic Trauma
'nitial eam $irecte$ towar$ lifethreatening* 'n)uries
Open pneumothora
-lail chest Tension pneumothora
Massive hemothora
Car$iac tampona$e
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Thoracic Trauma
Assessment -in$ings Mental (tatus $ecrease$
Pulse
a+sent, tachy or +ra$y &P narrow PP, hyper4 or hypotension, pulsus para$ous
Ventilatory rate H eIort tachy4 or +ra$ypnea, la+ore$, retractions
(kin $iaphoresis, pallor, cyanosis, open in)ury,
ecchymosis
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Thoracic Trauma
Assessment -in$ings Neck tracheal position, (J emph, FVD, open in)ury
Chest contusions, ten$erness, asymmetry, a+N aBe,
+owel soun$s, a+normal percussion, openin)ury, impale$ o+)ect, crepitus, hemoptysis
#eart (oun$s
muKe$, $istant, regurgitant murmur Epper a+$omen contusion, open in)ury
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Thoracic Trauma
(peciGc 'n)uries
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Ri+ -racture
-ractures of /st an$ ?n$ secon$reuire high force -reuently have in)ury to aorta or
+ronchi
Occur in 078 of patients with tracheo4+ronchial rupture
May in)ure su+clavian arteryBvein;78 will $ie
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Ri+ -racture
-ractures of /7 to /?th ri+s can cause$amage to un$erlying a+$ominalsoli$ organs* !iver
(pleen
Li$neys
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Ri+ -racture
Management PPV
Analgesics for isolate$ trauma
Non4circumferential splinting
Monitor el$erly an$ COPD patientsclosely Broken ribs can cause decompensation
Patients will fail to breathe deeply and cough,
resulting in poor clearance of secretions
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(ternal -racture
Encommon, 148 in +lunt chesttrauma
!arge traumatic forceDirect +low to front of chest +y Deceleration
steering wheel
$ash+oar$
Other o+)ect
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(ternal -racture
Management >sta+lish airway
#igh concentration oygen
Assist ventilations as nee$e$
'V N(B!R Restrict ui$s
Rule out associate$ in)uries
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-lail Chest
Esually secon$ary to +lunt trauma Most commonly in MVA
Also results from falls from heights
in$ustrial acci$ents
assault
+irth trauma
More common in ol$er patients
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-lail Chest
Mortality rates ?7478 $ue toassociate$ in)uries
Mortality increase$ with a$vance$ age
seven or more ri+ fractures
three or more associate$ in)uries
shock hea$ in)uries
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-lail Chest
Conseuences of ail chest Respiratory failure $ue to
pulmonary contusion
ina$euate $iaphragm movement
Para$oical movement of the chest must +e large to compromise ventilation
'ncrease$ work of +reathing
$ecrease$ chest epansionpain
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-lail Chest
(uspect spinal in)uries >sta+lish airway
Assist ventilation
Treat hypoxia from underlying contusion Promote full lung expansion
Consi$er nee$ for intu+ation an$ P>>P
Mechanically sta+ili:e chest wall uestiona+le value
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-lail Chest
Management 'V of !RBN(
Avoid rapid replacement in hemodynamicallystable patient
Contused lung cannot handle uid load Monitor >L%
Chest trauma can cause dysrhythmias
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(imple Pneumothora
'nci$ence /74;78 in +lunt chest trauma
almost /778 with penetrating chesttrauma
Mor+i$ity H Mortality $epen$ent on etent of atelectasis
associate$ in)uries
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(imple Pneumothora
a ri+ lacerates lung
Esually well4tolerate$ in the young Hhealthy
(evere compromise can occur in theel$erly or patients with pulmonary$iseaseDegree of $istress $epen$s on amount
an$ spee$ of collapse
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(imple Pneumothora
#D' an$ respiratory $istress
#igh in$e of suspicion
Chest tu+e when in $ou+t +efore CR
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Open Pneumothora
'f the trauma patient $oes not ventilatewell with an open airway, look for a hole
May +e su+tle A+rasion with $eep punctures
Opening in the chest wall
(ucking soun$ on inhalation
#D'Bresp $istress (J >mphysema
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Open Pneumothora
Profoun$ hypoventilation may occur
communication +etween pleural space
an$ atmosphere Prevents $evelopment of negativeintrapleural pressure
Results in ipsilateral lung collapse
ina+ility to ventilate aIecte$ lung
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Open Pneumothora
VBJ Mismatch shunting
hypoventilation
hypoia
large functional $ea$ space
Pressure may +uil$ within pleuralspace
Return from Vena cava may +e
impaire$
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Open Pneumothora
Cover chest opening with occlusive$ressing
Assist with positive pressureventilations prn
Monitor for progression to tensionpneumothora
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Tension Pneumothora
'nci$ence Penetrating Trauma
&lunt Trauma
Mor+i$ityBMortality (evere hypoventilation
'mme$iate life4threat if not manage$early
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Tension Pneumothora
Pathophysiology One4way valve forms in lung or chest wall Air enters pleural space, +ut cannot leave
Pressure collapses lung on aIecte$ si$e
Me$iastinal shift to contralateral si$e Re$uction in car$iac output
'ncrease$ intrathoracic pressure$eforme$ vena cava re$ucing preloa$
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Tension Pneumothora
(evere $yspnea ⇒ etreme resp$istress
Restlessness, aniety, agitation
Decrease$Ba+sent +reath soun$s
orsening or (evere (hock
Car$iovascular collapse
Tachycar$ia eak pulse
#ypotension
Narrow pulse pressure
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Tension Pneumothora
Fugular Vein Distension a+sent if also hypovolemic
#yperresonance to percussion
(u+cutaneous emphysema
!ate Tracheal shift away from in)ure$ si$e
Cyanosis
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Tension Pneumothora
Recogni:e H Manage early
>sta+lish airway
Nee$le thoracostomy then chest tu+e
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Tension Pneumothora
ecompress with !"g #lg bore$, %&inch needle
'idclavicular line( %nd intercostal space
'idaxillary line( "&)th intercostal space
*o over superior margin of rib to avoid bloodvessels
Be careful not to kink or bend needle orcatheter
+f available, attach a one&way valve
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#emothora
Most common result of ma)or traumato the chest wall Present in =7 4 78 of penetrating an$
ma)or non4penetrating trauma cases
Associate$ with pneumothora
Ri+ fractures are freuent cause
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#emothora
>ach can hol$ up to ;777 cc of +loo$ !ife4threatening often reuiring chest tu+e
an$Bor surgery 'f assoc6 with great vessel or car$iac in)ury
178 $ie imme$iately
?18 live Gve to ten minutes
?18 may live ;7 minutes or longer
&loo$ loss results in ypovolemia
ecreased ventilation of a-ected lung
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#emothora
Accumulation of +loo$ in pleural space penetrating or +lunt lung in)ury
chest wall vessels
intercostal vessels
myocar$ium
Massive hemothora in$icates greatvessel or car$iac in)ury
'ntercostal artery can +lee$ 17 ccBmin
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#emothora
Chest tu+e, go to OR if /777 cc out on insertion ?77 ccBh for hours
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Pulmonary Contusion
Pathophysiology &lunt trauma to the chest
Rapi$ $eceleration forces cause lung to strike chestwall
high energy shock wave from eplosion
high velocity missile woun$
low velocity as with ice pick
Most common in)ury from +luntthoracic trauma ;74=18 of +lunt trauma
mortality /4?78
P l C i
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Pulmonary Contusion
Pathophysiology Ri+ - in many +ut not all cases
Alveolar rupture with hemorrhage an$
e$ema increase$ capillary mem+rane permea+ility
!arge vascular shunts $evelop %as echange $istur+ances
#ypoemia
#ypercar+ia
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Pulmonary Contusion
Assessment -in$ings >vi$ence of +lunt chest trauma
Cough an$Bor #emoptysis
Apprehension
Cyanosis
CR changes late
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Pulmonary Contusion
Management (upportive therapy
>arly use of positive pressureventilation re$uces ventilator therapy
$uration Avoi$ aggressive crystalloi$ infusion
(evere cases may reuire ventilatortherapy
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Myocar$ial Contusion
Most common +lunt in)ury to heart
Esually $ue to steering wheel
(igniGcant cause of mor+i$ity an$mortality in the +lunt traumapatient
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Myocar$ial Contusion
Pathophysiology &ehaves like acute M'
#emorrhage with e$ema Cellular in)ury
vascular $amage may occur #emopericar$ium may occur from
lacerate$ epicar$ium May pro$uce arrhythmias
hypotension unresponsive to ui$ or$rug therapy
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Myocar$ial Contusion
Car$iac arrhythmias following +luntchest trauma
Angina4like pain unresponsive to
nitroglycerin Precor$ial $iscomfort in$epen$ent of
respiratory movement
Pericar$ial friction ru+ .late3
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Myocar$ial Contusion
>C% Changes Persistent tachycar$ia
(T elevation, T wave inversion
R&&&
Atrial utter, Atrial G+rillation
PVCs
PACs
M $i l C t i
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Myocar$ial Contusion
'V !RBN( Cautious ui$ a$ministration $ue to in)ure$
myocar$ium
>C% (tan$ar$ $rug therapy for arrhythmias
/? !ea$ >C% if time permits
A$mit to monitore$ evironment
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Pericar$ial Tampona$e
'nci$ence Esually associate$ with penetrating trauma
Rare in +lunt trauma
Occurs in Q ?8 of chest trauma
%( woun$s have higher mortality than sta+
woun$s
!ower mortality rate if isolate$ tampona$e
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Tampona$e is har$ to $iagnose #ypotension is common in chest trauma
#eart soun$s are $i@cult to hear
&ulging neck veins may +e a+sent if
hypovolemia is present #igh in$e of suspicion is reuire$
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Pericar$ial Tampona$e
Pathophysiology (pace normally Glle$ with ;7417 ml of
straw4colore$ ui$ lu+rication
lymphatic $ischarge immunologic protection for the heart
Rapi$ accumulation of +loo$ in theinelastic pericar$ium
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Pericar$ial Tampona$e
Pathophysiology #eart is compresse$ $ecreasing +loo$
entering heart Decrease$ $iastolic epansion an$ Glling
#in$ere$ venous return .preloa$3 Myocar$ial perfusion $ecrease$ $ue to
pressure eIects on walls of heart
$ecrease$ $iastolic pressures
Removal of as little as ?7 ml of +loo$may $rastically improve car$iac output
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Pericar$ial Tampona$e
&ecks Tria$.esistant hypotension +ncreased central venous
pressuredistended neck/arm veins inpresence of decreased arterial BP
0mall 1uiet heart
decreased heart sounds
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Pericar$ial Tampona$e
(igns an$ (ymptoms Narrowing pulse pressure
Pulsus para$oicus
.adial pulse becomes weak ordisappears when patient inhales
+ncreased intrathoracic pressureon inhalation causes blood to be
trapped in lungs temporarily
Pericar$ial Tampona$e
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Pericar$ial Tampona$e
Management
>C#O if sta+le to $iagnose 'n >R " consi$er pericar$iocentesis
Pericar$ial win$ow followe$ +ysternotomy in OR
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T i A i Di i BR
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Traumatic Aortic DissectionBRupture
Cause$ &y* Motor Vehicle Collisions
-alls from heights
Crushing chest trauma Animal Licks
&lunt chest trauma
/18 of all +lunt trauma $eaths
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Traumatic Aortic DissectionBRupture
/ of 2 persons $ying in MVCs hasaortic rupture 18 $ie instantaneously
/74/18 survive to hospital /B; $ie within si hours
/B; $ie within ? hours
/B; survive ; $ays or longer
Must have high in$e of suspicion
T ti A ti Di ti BR t
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Traumatic Aortic DissectionBRupture
(eparation of the aortic intima an$ me$ia Tear ?S high spee$ $eceleration at points of
relative Gation
&loo$ enters me$ia through a smallintima tear Thinne$ layer may rupture
Descen$ing aorta at the isthmus $istal to
left su+clavian artery most common siteof rupture ligamentum arteriosom
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Traumatic Aortic DissectionBRupture
Assessment -in$ings Retrosternal or interscapular pain Pain in lower +ack or one leg
Respiratory $istress Asymmetrical arm &Ps Epper etremity hypertension with
Decrease$ femoral pulses, OR A+sent femoral pulses
Dysphagia
CR
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CR
k
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ork up
CTA Angio is rarely use$
A$$ress other in)uries Grst
'$eally, repaire when sta+le
(tent vs open
Di h ti P t ti
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Diaphragmatic Penetration
(uspect intra4a+$ominal trauma with any
in)ury +elow th 'C( (uspect intrathoracic trauma with any
a+$ominal in)ury a+ove um+ilicus
Di h ti R t
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Diaphragmatic Rupture
Esually $ue to +lunt trauma +utmay occur with penetrating trauma
Esually life4threatening
!ikely to +e associate$ with othersevere in)uries
Diaphragmatic Rupture
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Diaphragmatic Rupture
Pathophysiology Compression to a+$omen resulting inincrease$ intra4a+$ominal pressure a+$ominal contents rupture through $iaphragm into
chest +owel o+struction an$ strangulation
restriction of lung epansion
me$iastinal shift
078 occur on left si$e $ue toprotection of right si$e +y liver
Diaphragmatic Rupture
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Diaphragmatic Rupture
Assessment -in$ings Decrease$ +reath soun$s
Esually unilateral Dullness to percussion
Dyspnea or Respiratory Distress (caphoi$ A+$omen Esually impossi+le to hear +owel soun$s
Management suspect N% tu+e CT
!aparoscopy (ensitive an$ speciGc
> h l ' )
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>sophageal 'n)ury
Penetrating 'n)ury most freuentcause Rare in +lunt trauma
Can perforate spontaneously violent emesis
carcinoma
>sophageal 'n)ury
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Assessment -in$ings Pain, local ten$erness #oarseness, Dysphagia, Respiratory
$istress Me$iastinal esophageal perforation
me$iastinal emphysema B me$iastinal crunch (J >mphysema
(hock A+
resuscitation >arly $iagnosis %astrographin 45 $ilute &a Repair vs eclu$e
Tracheo+ronchial Rupture
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Tracheo+ronchial Rupture
Encommon in)uryless than ;8 of chest trauma
Occurs with penetrating or +lunt chesttrauma
#igh mortality rate .5;783Respiratory Distress
O+vious (J emphysema
#emoptysis 2specially of bright red blood
(igns of tension pneumothoraunresponsive to nee$le $ecompression
Tracheo+ronchial Rupture
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Tracheo+ronchial Rupture
Ma)ority .783 occur at or near carina
rapi$ movement of air into pleuralspace
Tension pneumothora refractory to
nee$le $ecompression Consi$er early intu+ation
intu+ating right or left mainstem may +e life saving
'f arrest an$ suspect air em+olysm, may have to $o>RT<
Damage control
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Damage control
Damage control principle
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Damage control principle<
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>D Thoractomy
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>D Thoractomy
Thoracotomy performe$ in >R
for resuscitation of patients arriving inetremis
Plan to take to OR afterwar$s
A'M* >pe$itious control of hemorrhage
Maimi:ation of coronary an$ cere+ral perfusion
Release of pericar$ial tampona$e
T of massive air4em+olysm
Proce$ure " !eft AnterolateralThoracotomy
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Thoracotomy
Clamshell Thoracotomy
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Clamshell Thoracotomy
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Release Pericar$ial Tampona$e
Control 'ntrathoracic #emorrhage
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Control 'ntrathoracic #emorrhage
>liminate massive air em+olism or+ronchopleural Gstula
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+ronchopleural Gstula
Post intu+ation H positive pressureventilation
%et air transfer across traumaticalveolovenous channels
Pulmonary hilar cross clamping Air aspirate$ from ! ventricular ape an$
aortic root
Car$iac massage
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Perform Open Car$iac Massage
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Perform Open Car$iac Massage
&imanual internal massage with han$s in ahinge$ clapping motion
Ventricular compression procee$ing fromape to +ase of heart
Occlu$e Descen$ing Thoracic Aorta
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Occlu$e Descen$ing Thoracic Aorta
-utile9
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-utile9
Overall survival 418 !ittle to !ose
risk to #ealth care workers Risk +loo$ contact ?28 trauma pts #'VU or #epatitisU
#ealth care costs
F Trauma6 /00 Ful1./3*=40
(elective Application of >DThoracotomy
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Thoracotomy
Mechanism of 'n)ury
Presence of Vital (igns !ocation of 'n)ury
Other (igns of !ife
(urvival +ase$ on mechanism
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(urvival +ase$ on mechanism
F Trauma6 /00 Ful1./3*=40
Presence of vital signs
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Presence of vital signs
F Trauma6 /00 Ful1./3*=40
(urvival +ase$ on organ in)ure$
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(urvival +ase$ on organ in)ure$
FAC( ?777 Mar/07.;3*?406
Other (igns of !ife .(O!3
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O e ( g s o e .(O 3
FAC( ?777 Mar/07.;3*?406
hat a+out P>A9
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FAC( /00*?//4?/1, ?77
?2B2? .?83 >D Thoracotomy survivors ha$ P>A reuiring CPR
Conclusions
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>R thoracotomy consi$ere$ in pts wB*
Presence of vital signs in Gel$ or hospital &etter results in penetrating car$iac in)ury Results wB &lunt trauma poor, +ut survivors eist P>A after penetrating trauma from sta+s
Ep to =78 goo$ outcomes
Contrain$icate$ in pts with* No vital signs, prolonge$ asystole an$ unwitnesse$
arrestBloss of (O!
FAC( /00*?//4?/1, ?77
-inally<
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y
P>A after +lunt trauma9
Typically poor outcome, +ut occasionallywill have a survivor
'f CPR 5 1 min, contrain$icate$
References an$ thanks
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Thank %o$ for internet an$ %oogle
several we+sites speciGcally* http*BBwww6a$h+6govt6n:BtraumaBpresentationsB-orumsBma)or8?7
chest8?7in)uriesBsl$77/6htm http*BBwww6temple)c6e$uB$eptBemsBPagesBPowerPoint6html http*BBwww6mssurg6net
www6nor$ictraumara$6comB(ylla+us72Bmo8?7/1BNORDT>Rpenetrating6p$f www6iformi6comBspuBchest3trauma4ppt *reen5eld textbook of surgery