jason davis, md. blunt arterial injuries usually managed non-operatively operative tx similar to...
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Jason Davis, MDJason Davis, MD
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Blunt arterial injuries Usually managed non-operatively
Operative tx similar to penetrating injuries (rare)
Almost always diagnosed by angiography Blunt airway injuries
Managed similar to penetrating injuries Occasionally surgical emergencies
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Categorized into 6 groups Airway compromise Isolated laryngotracheal injuries Carotid artery injuries Jugular vein injuries Esophogeal injuries Pharyngeal injuries
Helps in choosing incision, operative priorities
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Establish airway first Orotracheal intubation Cricothyrotomy (emergent) Tracheotomy (less emergent) Nasotracheal not advised in most trauma
settings
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Establish airway first Cricothyrotomy (emergent)
Landmarks: Thyroid & Cricoid cartilages Stabilize thyroid cartilage (notched superiorly)
Transverse incision at Cricothyroid membrane Vertical incision in emergencies w/ unknown injury
Extend through subcutaneous tissue, cricothyroid Avoid injury to posterior tracheal wall
Twist 11-blade scalpel 900 to enlarge Insert No. 4 – 6 (largest for most adults) airway
Convert to tracheotomy 48 – 72hrs
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Establish airway first Tracheotomy (less emergent)
Incision 1 – 2 fingerbreadths inferior to cricothyroid
Skin incision to anterior border of SCM bilaterally May use wound. Mediasternotomy for distal injuries. Conversion Cricothyrotomy to Tracheotomy
Believed less likely to stricture or cause tension Literature does not support such a difference
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Traditional cervical neck divisions Zone 1: Zone 2: Zone 3:
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Traditional cervical neck divisions Zone 1: thoracic inlet to cricoid cartilage superiorly Zone 2: cricoid cartilate to angle of mandible Zone 3: angle of mandible and base of skull
Zone 2 – mandatory exploration if injury violates platysma
Zones 1, 3 - imaging studies, endoscopy to assess injuries
Consider injury depth, pt stability
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Most common for unknown injuries associated w/ penetrating neck trauma
Anterior sternocleidomastoid incision offers rapid access to most vital neck structures Carotid sheath, pharynx, cervical esophagus Particularly important for bleeding, neuro deficits May be lengthened for proximal/distal exposure Include anter chest in prep for poss prox control
Greasy feel may indicate salivary amylase
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Most commonly not recognized pre-op, though laryngoscopy / bronchoscopy can be useful in the context of a suspicious history
Initial focus on establish airway, min debridement Repair small trachea injury w/ 3.0 - 4.0 absorbable Post-op monitor for mediastinitis +cxr for
pneumo-mediastinum, leaks or missed pharyngoesoph injury
Reconstruction / definitive repair semi-elective
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*Curved posteriorly at mandible
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Dissection comparable to CEA Prox/distal control, protect nerves Proximal exposure occasionally may require
subluxation of mandible and division of stylohyoid lig, styloglossus/pharyngeus muscles at styloid process
May occlude more distal injuries w/ 4-5F fogarty Repair vs ligation as per hemodynamic
stability, complexity of injuries, and back-bleeding
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Repair w/ 3.0 – 4.0 absorbable suture, 1-2 layers and drain (closed/penrose) x1 wk
Several doses post-op antibiotics (oral flora)
UGI & feeding before drains removed
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Median sternotomy for inominate or R subclavian injuries
Left thoracotomy for L subclavian
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Median sternotomy for inominate or R subclavian injuries
Left thoracotomy for L subclavian
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Most vertebral artery injuries dx w/ angiography and may be embolized
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Most often hyperextension w/ MVC Blunt injury to cervical arteries ~rare Angio or CTA dx if cervical bruit <50yo,
evidence of cerebral infarct on CT, basilar skull fx involving carotid canal, neurologic sx not explained by CT, or as per mechanism
Anticoag typically for dissection/aneurysm