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Thoracic Trauma
Zonal Injuries of the Neck
Incidence
Thoracic trauma mortality is 10%
Accounts for 1 of every 4 trauma deaths
Pathophysiology
Hypoxia
– Hypovolemia
Hypercarbia- inadequate ventilation
Metabolic acidosis
Initial Assessment and
Management
Primary survey
Resuscitation of the vital functions
Detailed secondary survey
Definitive care
Primary Survey
Find and treat the major life threats
ABC’s
Assessment Parameters
Respiratory rate,depth,quality
Obvious chest trauma
Neck veins/trachea
Palpation
Percussion
Auscultation
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Tension Pneumothorax
Definition
S&S
Treatment
Open Pneumothorax
Definition
S&S
Treatment
Flail Chest
Definition
S&S
Treatment
Massive Hemothorax
Definition >1500 cc
S&S
Treatment
Emergency Resuscitative
Thoracotomy
Indications: Trauma patient’s who exhibit
profound refractory shock regardless of the
mechanism and those with penetrating
injuries who exhibit vital signs in the field or
the resuscitation area
Prevent rather than treat cardiac arrest
Bony Injuries
Rib Fractures
– S&S
– Treatment
Sternal Fractures
– S&S
– Treatment
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Pleural Injuries
Simple Pneumothorax – S&S
– Treatment
Hemothorax – S&S
– Treatment
Thoracic Tissue Injury
Tracheobronchial Tree most die at scene
– S&S
– Treatment
Pulmonary contusion
– S&S
– Treatment
Cardiovascular Trauma
Cardiac tamponade
Blunt cardiac injury (myocardial contusion)
– S&S
– Treatment
Aorta (great vessel injury)
Zonal Injuries of the Neck
Zonal Injuries of the Neck
Earliest known writings
– 5000 years ago
WWI military surgeons
recognized zones
Zonal injuries defined
by Roon & Christensen
Kinematics
Mostly due to penetrating injuries
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The Zones
ZONE I
– Base of neck from the clavicles
to the cricoid cartilage.
Subclavian arteries
Vertebral arteries
Subclavian and innominate veins
Carotid artery (common and
internal)
Trachea
Esophagus
The Zones
ZONE II
– Area between the cricoid cartilage to inferior border of the mandible. Subclavian arteries
Carotid arteries (common and internal)
Internal jugular veins
Trachea
Esophagus
The Zones
ZONE III
– Area from inferior border of the
mandible to the base of the skull.
Carotid arteries (common and internal)
Internal jugular veins
Vertebral arteries
Basilar arteries
Spinal cord
Cervical vertebrae
Assessment
HARD SIGNS
– Active bleeding
– Large expanding hematoma
– Distal ischemia
– Bruit/thrill
Assessment
SOFT SIGNS
– Shock responding to fluid resuscitation
– Small, stable hematoma
– Associated nerve injuries
– Dyspnea
– Subcutaneous emphysema
– Hoarseness
– Dysphagia
– Minor hematemesis
Assessment
ZONE I
– Unable to palpate and observe due to bony
skeleton
– Highest mortality of 3 zones
– Mortality due to vascular injury
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Assessment
ZONE I (cont)
– Evaluate for shock
– Hematoma resulting in respiratory compromise
– Hoarseness/stridor
– Subcutaneous emphysema
– Hematemesis
– Bruit
– Dysphagia
– Neuro deficit
Assessment
ZONE II
– Physical exam is possible
– Most common finding = vascular injury
Assessment
ZONE II
– Obvious hemorrhage
– Subcutaneous emphysema
– Hoarseness/stridor
– Hematemesis
– Bruit
– Dysphagia
– Neuro deficit
Assessment
ZONE III
– Difficult to assess with out ancillary diagnostic
tests
Assess for neuro deficit
Signs and symptoms of shock
Bruit
Diagnostics
ANGIOGRAPHY
– Considered for Zone I and III
– Invasive, costly, doesn’t always give you the
answer – many injuries found spontaneously
heal themselves
– Can help determine best surgical approach for
repair
Diagnostics
COLOR FLOW DOPLER
– Less expensive than angiography
– Difficult to diagnose internal carotid injuries due
to inability flex, extend or turn head if c-spine
injury is present.
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Diagnostics
CAROTID DUPLEX ULTRASONOGRAPHY
– Used instead of angiography
– Sensitive
– Completion of test ½ time of angiography
– Less expensive
Diagnostics
ESOPHAGRAMS
– Used as indicated by dysphagia, hematemesis,
or clinical exam
Diagnostics
FLEXIBLE BRONCHOSCOPY
– When indicated by stridor, hoarseness,
respiratory distress, crepitus, subcutaneous
emphysema or clinical exam that correlates with
tracheal injury.
Treatment Plans
Based on physical assessment and patient
stability
Remember ABCs
Profound Shock = IVs, OR, consider
angiography for Zone I and/or III
Digital pressure for active bleeding with
Zone II
Treatment Plans
Every patient with ‘true’ penetrating neck
trauma should, at a minimum, be admitted
for 23 hour observation and serial clinical
exams
Many vascular injuries can repair
themselves
Operative intervention is less frequent and
indicated primarily with ZONE I injuries
Treatment Plans
Evaluation and treatment of penetrating
neck injuries remains controversial
Selective versus Mandatory exploration of
penetrating neck injuries
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Any Questions?