Incidence

. Thoracic trauma mortality is 10% Thoracic Trauma . Accounts for 1 of every 4 trauma deaths Zonal Injuries of the Neck

Initial Assessment and Pathophysiology Management . Hypoxia . Primary survey – Hypovolemia . Resuscitation of the vital functions . Hypercarbia- inadequate ventilation . Detailed secondary survey . Metabolic acidosis . Definitive care

Primary Survey Assessment Parameters

. Find and treat the major life threats . Respiratory rate,depth,quality . ABC’s . Obvious chest trauma . Neck veins/trachea . Palpation . Percussion . Auscultation

1 Tension Pneumothorax Open Pneumothorax

. Definition . Definition . S&S . S&S . Treatment . Treatment

Flail Chest Massive Hemothorax

. Definition . Definition >1500 cc . S&S . S&S . Treatment . Treatment

Emergency Resuscitative Bony Injuries Thoracotomy . Indications: Trauma patient’s who exhibit . Rib Fractures profound refractory shock regardless of the – S&S mechanism and those with penetrating – Treatment injuries who exhibit vital signs in the field or . Sternal Fractures the resuscitation area – S&S . Prevent rather than treat cardiac arrest – Treatment

2 Pleural Injuries Thoracic Tissue Injury

. Simple Pneumothorax . Tracheobronchial Tree most die at scene – S&S – S&S – Treatment . Hemothorax – Treatment – S&S . Pulmonary contusion – Treatment – S&S

– Treatment

Cardiovascular Trauma Zonal Injuries of the Neck

. Cardiac tamponade . Blunt cardiac injury (myocardial contusion) – S&S – Treatment . Aorta (great vessel injury)

Zonal Injuries of the Neck Kinematics

. Earliest known writings – 5000 years ago . WWI military surgeons . Mostly due to penetrating injuries recognized zones . Zonal injuries defined

by Roon & Christensen

3 The Zones The Zones

. ZONE I . ZONE II – Base of neck from the clavicles – Area between the cricoid to the cricoid cartilage. cartilage to inferior border . Subclavian arteries of the mandible. . Vertebral arteries . Subclavian arteries . Subclavian and innominate veins . Carotid arteries (common . Carotid artery (common and and internal) internal) . Internal jugular veins . Trachea . Trachea . Esophagus . Esophagus

The Zones Assessment

. ZONE III . HARD SIGNS – Area from inferior border of the – Active bleeding mandible to the base of the skull. – Large expanding hematoma . Carotid arteries (common and internal) . Internal jugular veins – Distal ischemia . Vertebral arteries – Bruit/thrill . Basilar arteries . Spinal cord . Cervical vertebrae

Assessment Assessment

. SOFT SIGNS . ZONE I – Shock responding to fluid resuscitation – Unable to palpate and observe due to bony – Small, stable hematoma skeleton – Associated nerve injuries – Highest mortality of 3 zones – Dyspnea – Mortality due to vascular injury – Subcutaneous emphysema – Hoarseness – Dysphagia – Minor hematemesis

4 Assessment Assessment

. ZONE I (cont) . ZONE II – Evaluate for shock – Physical exam is possible – Hematoma resulting in respiratory compromise – Most common finding = vascular injury – Hoarseness/stridor – Subcutaneous emphysema – Hematemesis – Bruit – Dysphagia – Neuro deficit

Assessment Assessment

. ZONE II . ZONE III – Obvious hemorrhage – Difficult to assess with out ancillary diagnostic – Subcutaneous emphysema tests – Hoarseness/stridor – Hematemesis . Assess for neuro deficit . Signs and symptoms of shock – Bruit . Bruit – Dysphagia – Neuro deficit

Diagnostics Diagnostics

. ANGIOGRAPHY . COLOR FLOW DOPLER – Considered for Zone I and III – Less expensive than angiography – Invasive, costly, doesn’t always give you the – Difficult to diagnose internal carotid injuries due answer – many injuries found spontaneously to inability flex, extend or turn head if c-spine heal themselves injury is present. – Can help determine best surgical approach for repair

5 Diagnostics Diagnostics

. CAROTID DUPLEX ULTRASONOGRAPHY . ESOPHAGRAMS – Used instead of angiography – Used as indicated by dysphagia, hematemesis, – Sensitive or clinical exam – Completion of test ½ time of angiography – Less expensive

Diagnostics Treatment Plans

. FLEXIBLE BRONCHOSCOPY . Based on physical assessment and patient – When indicated by stridor, hoarseness, stability respiratory distress, crepitus, subcutaneous . Remember ABCs emphysema or clinical exam that correlates with tracheal injury. . Profound Shock = IVs, OR, consider angiography for Zone I and/or III . Digital pressure for active bleeding with Zone II

Treatment Plans Treatment Plans

. Every patient with ‘true’ penetrating neck . Evaluation and treatment of penetrating trauma should, at a minimum, be admitted neck injuries remains controversial for 23 hour observation and serial clinical exams . Selective versus Mandatory exploration of . Many vascular injuries can repair penetrating neck injuries themselves . Operative intervention is less frequent and indicated primarily with ZONE I injuries

6 Any Questions?

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