10/1/2018

Outline

● Emergency Department Thoracotomy ● REBOA ● Lung ● Trachea Thoracic Trauma ● Esophagus ● Heart Tessa Woods, DO ● Thoracic Vascular Injuries

EAST Practice Management Guidelines

● EDT Survival Predictors ○ 1. Injury mechanism ○ 2. Anatomic injury location ○ 3. Presence of life on presentation ED Thoracotomy

EAST Scenarios EAST Scenarios

● Patient 1: Pulseless to ED with signs of life after penetrating thoracic injury? ● Patient 5: Pulseless to the ED with signs of life after blunt injury? ○ Yes ○ Yes, Conditionally ● Patient 2: Pulseless to ED without signs of life after penetrating thoracic ● Patient 6: Pulseless to the ED without signs of life after blunt injury? injury? ○ No ○ Yes, conditionally ■ Some voting “conditionally” ● Patient 3: Pulseless to the ED with signs of life after penetrating extrathoracic ■ Low quality of evidence injury? ○ Yes, conditionally ■ Does not pertain to cranial injuries ● Patient 4: Pulseless to the ED without signs of life after penetrating extrathoracic injury? ○ Yes, conditionally ■ Low quality of evidence

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Resuscitative Endovascular Balloon Occlusion of the Aorta2-12

● Benefits: ○ Maximizes cerebral and coronary perfusion ○ Limits infradiaphragmatic hemorrhage REBOA ○ Avoids thoracotomy ● Limitations/complications: ○ Vascular injury ○ Time consumptive? ○ Learning curve ○ Appropriate setting/provider ● https://youtu.be/L3z5utZvnq4

Upcoming studies ● EPR-CAT (Emergency Preservation and Resuscitation for Cardiac Arrest From Trauma) ○ Compares pulseless penetrating trauma victims with scene signs of life who undergo standard resuscitative efforts including EDT compared to arterial cath placement to induce hypothermia followed by resuscitative surgery then cardiopulmonary bypass Lung Trauma

Intro Lung Trauma

● Mechanism ● Injury to the bony thorax? ○ Blunt thoracic trauma ○ Suspect possible pulmonary injury ■ 8% of all thoracic trauma admits in US1 ○ Opposite in children due to greater chest wall elasticity ○ Penetrating thoracic trauma ● Alveoli rupture - pneumothorax 2 ■ 7% of all thoracic trauma admits and 16% of penetrating trauma admissions overall ○ Larger injuries - continued air leak ● Management ● Lung parenchyma damage ○ 18-40% managed with chest tube alone ○ Bleeding ■ 3-9% require thoracotomy ○ Bruising ● 30% will require pulmonary resection ● Chest wall bleeding ○ Intercostal arteries ○ Mammary arteries

1. Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl Surg. 2004;41(3): 211-380. 2. Demetriades D, Velmahos GC. Penetrating injuries of the chest: indications for operation. Scand J Surg. 2002;91(1)41-45.

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Lung Trauma Lung Trauma

● Pneumothorax ● Presentation/Evaluation ○ Large - tension physiology ○ Distended neck veins ■ Increased intrathoracic pressure ○ Tracheal deviation ■ Decreased venous return ○ Subcutaneous emphysema ■ Decreased cardiac output ○ Chest wall instability ■ Cardiac arrest ○ Absent breath sounds ● Hemothorax ○ Muffled heart sounds ○ Large ● Monitor vitals ■ Hypovolemia ○ Work of breathing, sats ■ Eventually tension physiology ● No time for radiographs

Lung Trauma Lung Trauma

● Penetrating trauma in hemodynamically unstable patient ● CT imaging ○ Generally go to OR ○ Three dimensional recon ● Workup: ■ Aorta, great vessels ○ ABG ○ Pneumothorax on ct? 1 ■ Oxygenation, ventilation, shock ■ Small and asymptomatic - observation ○ E-FAST ● Maybe 15.9 mm - not found to be an independent predictor for failure ○ CXR ● Positive pressure ■ Though some question in the stable patient1 ○ Still monitor ● E-FAST as sensitive ○ Hemothorax on ct? ○ CT ■ Moderate or large - drain ○ If indicated ● Blood in pleural cavity may progress to fibrothorax with lung entrapment or ■ thoracic us, esophagoscopy, bronchoscopy, echocardiogram infection leading to empyema

1. Simon B, Ebert J, et al. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery. 1. Moore, F. O., Goslar, P. W., Coimbra, R., Velmahos, G., Brown, C. V. R., Coopwood, T. B., … Haan, J. M. (2011). Blunt traumatic occult pneumothorax: Is observation safe?-results of a prospective, AAST multicenter study. Journal of 2012;73(5):S351-S361. Trauma - Injury, Infection and Critical Care, 70(5), 1019–1025. https://doi.org/10.1097/TA.0b013e318213f727

Lung Trauma Lung Trauma

● Lung lacerations ● Rib fractures ○ Symptoms ○ Flail chest - 3 or more adjacent ribs are segmentally fractured ■ Large air leaks ■ Leading to paradoxical chest wall motion ■ Hemoptysis ■ High rate of resp failure, underlying pulm contusion, infection ○ Dx ○ Tx: supportive ■ Bronchoscopy ■ Plating - still determining role ● Careful control of airway - double lumen tube, etc ● EAST practice management guidelines 20171 ■ OR ○ Meta-analysis with 22 studies, 3 prospective randomized trials ○ Tx ○ Flail chest - conditional recommendation to: ■ Majority - non-op ■ Decrease mortality, hospital LOS, ICU LOS, duration of mechanical ● Tube thoracostomy for air/blood ventilation, incidence of pneumonia, need for mechanical ventilation ■ Symptomatic - OR ■ Bleeding: transcatheter embolization if poor operative candidate 1. Kasotakis, G., Hasenboehler, E. A., Streib, E. W., Patel, N., Patel, M. B., Alarcon, L., … Como, J. J. (2017). Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 82(3), 618–626. https://doi.org/10.1097/TA.0000000000001350

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Lung Trauma Lung Trauma

● Pulmonary contusion ● Indications for operation ○ Symptoms ○ Massive hemothorax ■ Clinically silent to severe ■ 1500 cc or more upon initial tube placement ■ Evolve over 3 days - resolve at about 1 week ■ 200-250 cc/hr over 3 consecutive hours ○ May exacerbate hypoxia and shunting ○ Thoracic trauma with persistent hemodynamic instability ■ Upright positioning ● Monitor chest tubes closely ■ IS ○ Cessation of bleeding - clotted chest tube, poor positioning ■ Analgesia - epidural, medications ■ Consider CXR ● Early VATS/thoracotomy

Lung Trauma Lung Trauma

● Operative notes ● Operative Notes ○ Single lung ventilation not warranted in hemodynamically unstable patients ○ Lung repair ■ Unless massive hemoptysis ■ Pneumorrhaphy - running simple or mattress suture ○ Evacuate blood and clot ■ Resection ○ Incise inferior pulmonary ligament ● Tractotomy ○ Lyse adhesions ● Excision ○ Control bleeding ○ Hilar Injuries ■ Finger compression ■ Proximal ■ Hilar bleeding ● Need inflow occlusion to assess extent of injury ● Finger occlusion ○ Open pericardium and control intrapericardial pulmonary artery and vein ● Penrose around hilum ■ May require pneumonectomy ● Hilar vascular clamp ● Mortality approaches 100% if in shock ● Twist on itself ● Perform early and treat right heart failure ○ Occludes pulmonary artery, vein and mainstem bronchus ○ Maybe ECMO - some improvement in outcomes

Lung Trauma Lung Trauma

● Resection complications ● Damage Control in the Chest ○ Bronchial stump dehiscence ○ Pack and leave chest open ■ Devastating complication ■ Does not interfere with cardiac or pulmonary function ■ Some reinforce bronchial stump with viable tissue ■ Series of 44 patients1 ● Muscle ● Mean pH 7.07, ISS 29 ○ Intercostal muscle flap ● Mortality 23% ○ Diaphragmatic flap ● All physiologically normal at time of chest closure ○ Pedicled pericardial flap ○ Average 2-3 days ○ Pericardial fat pad ○ Mediastinal pleura ● Later ○ Omentum ○ Lat dorsi flap 1. O’Connor JV, DuBose JJ, Scalea TM. Damage-control thoracic surgery: Management and outcome. J Trauma Acute Care Surg. 2014;77(5):660-665.

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Lung Trauma Lung Trauma

● Video-Assisted Thoracoscopic Surgery ● Complications ○ Indications ○ Pneumonia ■ Alternative for diaphragm repair ■ Thoracic injury requiring intubation? ■ Empyema, retained hemothorax, persistent air leak ● 7 times more likely to develop pneumonia ■ Similar to open ■ Pulm contusion? ○ Lung isolate ● 50% will develop pneumonia, barotrauma, and or major atelectasis ○ First port - 4th or 5th intercostal space in mid or anterior axillary line ● 25% ARDS ■ Tip of scapula - good landmark ○ Retained hemothorax ○ Additional ports under visualization ■ Failed to be drained by tube in 5% ■ Repeat chest CT ● Less than 300 cc retained? Monitor ● Early VATS

Lung Trauma Lung Trauma

● Complications ● Complications ○ Empyema ○ Persistent air leak and bronchopleural fistula ■ Dx - positive pleural cultures or frank purulence in the pleural space ■ True bronchopleural fistula - centrally located communication between a lobar or ■ Develops in around 26.8% of patients with a retained traumatic hemothorax1 segmental bronchi and the pleural cavity ■ Stages ■ Most resolve by 7 days ● Exudative ■ Dx: bronch ● Fibrinopurulent ■ Tx: autologous blood pleurodesis, sealants, endobronchial one-way valves, Heimlich ● Organizing valves, OR ■ Tx: VATS/thoracotomy ○ Chylothorax ■ Milky chest tube output ● Triglyceride level greater than 110 ■ Tx

1 . DuBose J, Inaba K, Okoye O, et al. Development of post-traumatic empyema in patients with retained hemothorax: Results of a prospective, observational AAST Study. J Trauma Acute Care Surg. 2012:73(3):752- ● Nonop: tpn, enteral medium-chain triglycerides, octreotide 757. ● Beyond 7 days: operative - maybe embolize thoracic duct or direct ligation

Tracheobronchial Injuries Tracheobronchial Injuries

● Be aware of cervical tracheal injuries ● TX ○ Underlying esophageal, vascular thoracic duct and nerve injuries ○ OR ● Presentation/eval ■ Suture - interrupted absorbable ○ Subcutaneous air ● Distal half of trachea, right main stem, prox l main stem bronchus ○ Resp distress ○ Right posterolateral thoracotomy ■ Be careful during intubation of disruption ■ Double ligate and divide azygous vein ● Dx ■ Bougie or ngt in esophagus ● Distal left main stem bronchus ○ Bronch ○ Left posterolateral thoracotomy ■ 3/4 of blunt injuries occur within 2 cm of the carina ■ Arch will be in the way ■ Carefully back up ett over bronch and then slide back over to avoid missed injury ■ Consider muscle flap to protect esophagus ○ CT ○ Highly selected group - stents ■ May be helpful if penetrating trajectory far from site ● Generally less than 2 cm, nontransmural tears

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Tracheobronchial Injuries Esophageal Injuries

● Complications ● Rare ○ Tracheal stenosis ○ Very critical to identify ■ Wheezing from narrowed airway ● More common in neck than thorax ■ Dx ○ No bony protection ● Bronch ● 34 trauma center in US large multicenter trial1 ● CT ○ Penetrating esophageal injuries - 405 ■ Tx ○ High morbidity and mortality ● Control airway if high grade ● Rigid or balloon dilation under direct visualization ● OR only if very severe and short segment ○ End to end anastomosis

1. Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001:50(2):289-296.

Esophageal Injuries Esophageal Injuries

● Dx ● TX ○ Symptoms in less than 1/4 with an injury ○ More prone to postoperative leak due to lack of serosal layer ○ Pneumothorax or hemothorax ■ Easily treated in neck ■ Tube with saliva or food contents ■ Mediastinal - more morbidity ○ CT scan ○ Two layer ■ Oral contrast ■ Mucosa interrupted sutures with absorbable or nonabsorbable ■ Static exam ■ Muscular layer - interrupted nonabsorbable sutures ○ Contrast esophagography ○ EGD

Esophageal Injuries

● Pearls ○ Appropriate debridement ○ Preservation of esophageal length ○ Buttress the repair ○ Wide drainage ○ Enteral feeding access Heart Injuries ○ Side of access: ■ Right sided access for most of intra-thoracic esophagus ■ Left - distal esophagus, thoracoabdominal ● Laparotomy, left thoracotomy ● Consider fundal wrap ○ Controlled esophageal fistula with T tube if needed ■ With wide drainage ■ Retrograde esophageal drainage ○ EJ months later

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Heart Heart

● Epidemiology ● Blunt Injury ○ Difficult to ascertain true quantity due to low volumes ○ Replaced term “cardiac contusion” ● Mechanism ■ Insignificant bruising to cardiac rupture ○ Area most prone to injury: right and left ventricles ■ Direct energy to the heart or by compression (between sternum and vertebral column) ○ Be weary of: ■ Can occur from cpr ■ Coronary arteries ○ Manifests as a spectrum: ■ Valves ■ Septal rupture, free wall rupture, coronary artery thrombosis, cardiac failure, ■ Intracardiac fistulas (ventricular septal defects) dysrhythmia, rupture of chordae tendineae or papillary muscles ○ Foreign bodies ○ Pericardial tear ■ Remove if greater than 1 cm in size, contaminated or symptomatic1 ■ Right - can lead to twisting of heart and prevention of venous return ■ Generally okay to leave intracardiac missiles ■ Left - heart can herniate through - strangulation ● Right sided can embolize to PA then be removed with cath based technique if ● Sudden loss of pulse when the patient is repositioned or placed on a stretcher large ● Rare - embolize through a pfo or atrial septal defect

1. LeMaire SA, Wall MJ Jr, Mattox KL. Needle embolus causing cardiac puncture and chronic constrictive pericarditis. Ann Thorac Surg. 1998;65:1786.

Heart Heart

● Iatrogenic cardiac injury ● Electrical Injury ○ CVC, cardiac cath, endovascular interventions, pericardiocentesis ○ Acute myocardial necrosis with or without ventricular failure ○ SVC/atrial perforations - more common with left sided lines ○ Myocardial ischemia ■ Be weary of tamponade ○ Dysrhythmia ● Pericardiocentesis ○ Conduction abnormalities ● Subxiphoid pericardial window ○ Acute htn with peripheral vasospasm ● Median sternotomy ○ Ecg abnormalities ■ May be hard to find the injury

Heart Heart

● Overall Injury Presentation ● Dx ○ 60-100 ml blood in pericardial sac to induce clinical picture ○ Beck’s triad, Kussmaul’s sign - present in only 10% of patients with cardiac tamponade ○ Best sign of pericardial tamponade: narrowing of pulse pressure ○ FAST ○ Blunt ○ CXR - for hemothorax, pneumothorax ■ Dysrhythmia ○ CT scan for trajectory ● Most common: pvcs (unclear etiology), sinus tach ○ Laparoscopy for diaphragm injury ● Ventricular tach, fib ○ ECG ● Supraventricular tachydysrhythmias ■ Level 1 recommendation by EAST ○ Cardiac enzymes ■ Minimal evidence ○ ECHO ■ Often limited by chest wall injury ● TEE in OR

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Heart Heart

● TX ● Results ○ Left anterior thoracotomy ○ Mortality rate ■ Decompress right side with blunt dissection across anterior mediastinum ■ Overall for penetrating ■ Can extend to clamshell ● 30-90% ○ Median sternotomy ■ Limits access to posterior mediastinal structures and descending thoracic aorta for cross clamping ○ Cardiorrhaphy ■ Place sutures deep to the artery

Thoracic great vessel injury Thoracic great vessel injury

● 90% due to penetrating injuries1 ● Shear force, compression or profound intraluminal hypertension ○ Iatrogenic included ○ Pericardial attachments of pulmonary veins and vena cava and fixation of the descending ■ Cvc thoracic aorta at the ligamentum arteriosum and diaphragm ■ Chest tubes ○ Innominate artery pinched between sternum and vertebra ● Increased rate with pigtails ■ ED thoracotomy - aortic injury ■ Swan-ganz ■ Esophageal/tracheal stents

1. Mattox KL, Feliciano DV, Beall AC JR. et al. Five thousand seven hundred sity cardiovascular injuries in 4459 patients. Epidemiologic evolution. 1958-1987. Ann Surg. 1989;209:268.

1. Dumfarth J, Plaikner M, Krapf C, et al. Bovine aortic arch: predictor of entry site and risk factor for neurologic injury in acute type A dissection. Ann Thorcic Surg. 2014.

Thoracic great vessel injury Thoracic great vessel injury

● Aortic ● Physical exam ○ Blunt usually full thickness - similar to ruptured AAA ○ Upper extremity hypertension ■ Consider same tx - permissive hypovolemia ○ Unequal blood pressures ○ Dissection - longitudinal separation of the media extending along the length of the aorta ○ Sternal fx ■ Rare ○ Intra-scapular murmur ■ Blunt aortic injury better term ○ Left flail chest ○ Hemodynamically stable aortic injury patients rarely die from aortic rupture ● CXR ■ this subgroup that does die is usually from cns injury ○ Most reliable signs: ■ Loss or “double shadowing” of the aortic knob contour ■ Mediastinal widening - suggestive of innominate artery injury ● Mediastinal hematoma

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Thoracic great vessel injury Thoracic great vessel injury

● Dx ● Tx ○ Chest tube output ○ Consider nonop in: ○ ED thoracotomy ■ Severe head injury ■ Subclavian - pack, clamp at thoracic apex or insert balloon catheter ■ Risk factors for infection ■ Pulmonary hilum - cross clamp hilum or twist lung 180 degrees after releasing inferior ● Major burns pulmonary ligament ● Sepsis ○ CT chest ● Heavily contaminated wounds ■ Dx and operative planning ■ Severe multisystem trauma with hemodynamic instability and or poor physiologic reserve ○ Aortography ■ Careful follow up with serial imaging ● Permissive hypotension acceptable (sbp 60-90) ○ Endograft repair ● BB for aortic injury? ■ Need aortic diameter of greater than 18 mm ● Can use intravascular ultrasound to accurately measure in systole ○ Not proven in big studies ■ Seal zone length of 1-2 cm

Thoracic great vessel injury Thoracic great vessel injury

● Open repair ● Arterial injuries ○ Complications: ○ Blunt ascending aortic injuries - rarely survive transport to hospital ■ paraplegia, stroke, recurrent nerve and brachial plexus injuries ■ Generally require bypass ○ Vessels greater than 5 mm - prosthetic graft ○ Aortic arch ■ Especially in contaminated wounds (concern for saphenous vein graft being susceptible ■ Generally need extension of the median sternotomy to the neck to collagenase) ● Expose brachiocephalic branches ○ Damage control ● Can also divide innominate vein for better exposure ■ Pneumonectomy ○ Innominate artery ■ Shunts ■ Median sternotomy ■ Pulmonary tractotomy ■ Can divide vein if needed ■ Temporary chest closure ■ Emergent management - compression through tracheotomy ● 25% risk of neurologic complications but.... ○ Do not attempt revasularization

Thoracic great vessel injury Thoracic great vessel injury

● Arterial injuries ● Arterial injuries ○ Thoracic aorta ○ Left carotid artery ■ Clamp and direct reconstruction ■ Similar to innominate artery injury ■ Posterolateral thoracotomy through 4th intercostal space ● Median sternotomy with a left cervical extension ■ Generally at level of the ligamentum arteriosum ○ Pulmonary artery ■ Concern: paraplegia ■ Intrapericardial? Median sternotomy ● Debate on bypass, pumps ● Minimal dissection needed ● Benefit of endograft ○ Right - exposed by dissecting between svc and ascending aorta ○ Subclavian artery ● Posterior injuries generally require cardiopulmonary bypass ■ Access ■ Distal - generally posterolateral thoracotomy ● Right - Cervical extension of the median sternotomy ● Massive hemothorax ● Left - Anterolateral thoracotomy ○ Internal mammary artery ○ Possible supraclavicular incision separately for distal control ■ 300 ml/min in young patients ■ Some endovascular repair ○ Intercostal - circumferential sutures

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Thoracic great vessel injury Thoracic great vessel injury

● Venous Injuries ● Venous Injuries ○ Thoracic vena cava ○ Pulmonary veins ■ Thoracic vena cava exposure extremely difficult ■ Difficult through anterior incision ● Total cardiopulmonary bypass ■ Managed via resection of appropriate lobe ● Repair achieved from inside the cava via right atrium ○ Subclavian veins ○ Superior vena cava ■ Parallels arterial injuries ■ Lateral venorrhaphy ○ Azygous vein ● Shunt if needed ■ Not typically a thoracic great vessel...but similar in size and flow ○ Ptfe, Dacron ● Difficult to diagnose ○ Vein ○ Dark blood from posterior chest, right ■ Tx: suture ligated ● Make sure no concomitant injury to esophagus/injury

Special Problems Special Problems

● Mediastinal Traverse Injuries ● Thoracic duct injury ○ High probability of injury to thoracic great vessels and other critical vessels ○ Devastating morbidity due to marked nutritional depletion ■ Past mandatory exploration ○ Chylous material ○ Imaging ■ Chest tube ■ Aortography ■ Diet devoid of long chain fatty acids ■ Bronchoscopy ■ Generally spontaneous closure in a few weeks ■ Echo ● Beyond three weeks - minimal evidence that it will close ■ Esophagoscopy ○ OR ■ CT scan ■ Can do a fatty meal or heavy cream to increase chylous flow and ID fistula ● Ligate with 6-0 monofilament suture ● Recur? ○ Mass ligation at the thoracic duct at the diaphragm and perform pleurodesis

Special Problems References

1. Moore E, Feliciano D, Mattox K. Trauma. 8th Edition. 2017. ● Systemic Air Embolism 2. Seamon M, Haut E, Arendonk V, et al. Emergency Department Thoracotomy. 2015. J Trauma. 79(1);159-173. 3. Davidson, A. J., Russo, R. M., Reva, V. A., Brenner, M. L., Moore, L. J., Ball, C., … Group, B. S. (2018). The pitfalls of resuscitative endovascular balloon occlusion of the ○ Fistula between a pulmonary vein and bronchiole aorta: Risk factors and mitigation strategies. Journal of Trauma and Acute Care Surgery, 84(1), 192. https://doi.org/10.1097/ta.0000000000001711 4. DuBose, J. J., Scalea, T. M., Brenner, M., Skiada, D., Inaba, K., Cannon, J., … Group, A. (2016). The AAST prospective Aortic Occlusion for Resuscitation in Trauma and ■ Due to penetrating lung injury Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). Journal of ■ Bubbles enter left heart and embolize to systemic circulation (includes coronary and Trauma and Acute Care Surgery, 81(3), 409. https://doi.org/10.1097/ta.0000000000001079 5. Moore, L. J., Martin, C. D., Harvin, J. A., Wade, C. E., & Holcomb, J. B. (2016). Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible cerebral arteries) truncal hemorrhage in the abdomen and pelvis. The American Journal of Surgery, 212(6), 1222–1230. https://doi.org/10.1016/j.amjsurg.2016.09.027 6. Joseph, B., Ibraheem, K., Haider, A. A., Kulvatunyou, N., Tang, A., O’Keeffe, T., … Rhee, P. (2016). Identifying potential utility of resuscitative endovascular balloon occlusion ○ Seizures, cardiac arrest of the aorta: An autopsy study. Journal of Trauma and Acute Care Surgery, 81(5), S128. https://doi.org/10.1097/ta.0000000000001104 7. Tran, T. L. N., Brasel, K. J., Karmy-Jones, R., Rowell, S., Schreiber, M. A., Shatz, D. V, … Namias, N. (2016). Western Trauma Association Critical Decisions in Trauma: ○ Thoracotomy, clamp pulmonary hilum to prevent further air embolization Management of pelvic fracture with hemodynamic instability—2016 updates. Journal of Trauma and Acute Care Surgery, 81(6), 1171. ■ Aspirate air from left ventricle and ascending aorta https://doi.org/10.1097/ta.0000000000001230 8. Bisulli, M., Gamberini, E., Coccolini, F., Scognamiglio, G., & Agnoletti, V. (2018). Resuscitative endovascular balloon occlusion of vena cava: An option in managing traumatic ■ Consider cardiopulmonary bypass vena cava injuries. Journal of Trauma and Acute Care Surgery, 84(1), 211. https://doi.org/10.1097/ta.0000000000001707 9. Reynolds, C. L., Celio, A. C., Bridges, L. C., Mosquera, C., O’Connell, B., Bard, M. R., … Toschlog, E. A. (2017). REBOA for the IVC? Resuscitative balloon occlusion of the ○ Very few survivors inferior vena cava (REBOVC) to abate massive hemorrhage in retrohepatic vena cava injuries. Journal of Trauma and Acute Care Surgery, 83(6), 1041. https://doi.org/10.1097/ta.0000000000001641 10. Davidson, A. J., Russo, R. M., Reva, V. A., Brenner, M. L., Moore, L. J., Ball, C., … Group, B. S. (2018). The pitfalls of resuscitative endovascular balloon occlusion of the aorta: Risk factors and mitigation strategies. Journal of Trauma and Acute Care Surgery, 84(1), 192. https://doi.org/10.1097/ta.0000000000001711 11. Brenner, M., Hoehn, M., Pasley, J., Dubose, J., Stein, D., & Scalea, T. (2014). Basic endovascular skills for trauma course: Bridging the gap between endovascular techniques and the acute care surgeon. Journal of Trauma and Acute Care Surgery, 77(2), 286. https://doi.org/10.1097/ta.0000000000000310 12. Stannard, A., Eliason, J. L., & Rasmussen, T. E. (2011). Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct for Hemorrhagic Shock. Journal of Trauma and Acute Care Surgery, 71(6), 1869. https://doi.org/10.1097/ta.0b013e31823fe90c 13. Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl Surg. 2004;41(3): 211-380. 14. Demetriades D, Velmahos GC. Penetrating injuries of the chest: indications for operation. Scand J Surg. 2002;91(1)41-45.

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References

15. Simon B, Ebert J, et al. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery. 2012;73(5):S351-S361.

16. Moore, F. O., Goslar, P. W., Coimbra, R., Velmahos, G., Brown, C. V. R., Coopwood, T. B., … Haan, J. M. (2011). Blunt traumatic occult pneumothorax: Is observation safe?-results of a prospective, AAST multicenter study. Journal of Trauma - Injury, Infection and Critical Care, 70(5), 1019–1025. https://doi.org/10.1097/TA.0b013e318213f727 17. Kasotakis, G., Hasenboehler, E. A., Streib, E. W., Patel, N., Patel, M. B., Alarcon, L., … Como, J. J. (2017). Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 82(3), 618–626. https://doi.org/10.1097/TA.0000000000001350 18. O’Connor JV, DuBose JJ, Scalea TM. Damage-control thoracic surgery: Management and outcome. J Trauma Acute Care Surg. 2014;77(5):660-665.

19. DuBose J, Inaba K, Okoye O, et al. Development of post-traumatic empyema in patients with retained hemothorax: Results of a prospective, observational AAST Study. J Trauma Acute Care Surg. 2012:73(3):752-757.

20. Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001:50(2):289-296.

21. LeMaire SA, Wall MJ Jr, Mattox KL. Needle embolus causing cardiac puncture and chronic constrictive pericarditis. Ann Thorac Surg. 1998;65:1786.

22. Mattox KL, Feliciano DV, Beall AC JR. et al. Five thousand seven hundred sity cardiovascular injuries in 4459 patients. Epidemiologic evolution. 1958-1987. Ann Surg. 1989;209:268.

23. Dumfarth J, Plaikner M, Krapf C, et al. Bovine aortic arch: predictor of entry site and risk factor for neurologic injury in acute type A dissection. Ann Thorcic Surg. 2014.

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