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13 Trauma
Esophageal injury
Diagnosis Diagnostic modality Characteristics Radiology
CT scan of chest CT Findings: collection
around the esophagus;
esophageal wall thickening,
pleural effusion,
pneumocardium, and
pneumoperitoneum
Contrast esophagogram Gastrogran is used initially if
study result is negative →
Barium is used
443
Endoscopy
Endoscopy combined with contrast esophagogram is the gold standard to rule out any
esophageal injury (100% sensitivity)
Staging AAST Esophagus Injury Scale
Grade Injury description
Grade I Contusion/hematoma or partial thickness laceration
Grade II Laceration <50% of circumference
Grade III Laceration >50% circumference
Grade IV Segmental loss or devascularization <2cm
Grade V Segmental loss or devascularization >2cm
Advance one grade for multiple lesions up to grade III
Flexible endoscopy → less
sensitive for proximal injuries
Rigid endoscopy →more
sensitive for proximal injuries
Fluoroscopic image of the chest
with water- soluble oral contrast
demonstrates extra- luminal
contrast (arrow) adjacent to the
mid/distal esophagus, indicating
an esophageal perforation
444
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Esophageal injury
Management
R. C. Gooding et al.
Management of esophageal injury
1. Resuscitate, NPO, antibiotics
2. Control of the leak
3. Debridement of devitalized tissues
4. Repair of injury if possible
5. Buttress
6. Wide drainage
7. Nutritional support
Esophageal injury Management
Key steps for
esophageal repair
Acute esophageal injury
(<24 h from injury
Delayed recognition of
esophageal injury
Destructive injuries that
cannot be repaired primary
Destructive injuries with
signicant necrosis
Contained perforation in
patients that are poor
surgical candidates
Debride all devitalized tissue
Extend myotomy to inspect mucosa because mucosal defect is usually more extensive than
muscularis injury
Repair in two absorbable layers
Buttress: Omohyoid, sternocleidomastoid, intercostal, anterior serratus, and strap muscles
Wide drainage
Primary repair
Resuscitate and control contamination
Repair over T tube to create a controlled stula; wide drainage
Diversion with cervical esophagectomy
Esophageal stents
n
Cr
13 Trauma
Surgical approaches to repair esophageal injuries
Esophageal injury
location Figure Approach Buttress options
445
Cervical esophagus
(from cricoid to
suprasternal notch
Right
posterolateral
thoracotomy
Left
cervical incisio
Left collar incision or
incision along the
anterior border of the
sternocleidomastoid
muscle
Divide the omohyoid
muscle, perform blunt
Omohyoid,
sternocleidomastoid, and
strap muscles
posterior tracheal
Left
thoracotomy
dissection to avoid injury
of recurrent laryngeal
nerve
Upper thoracic
(suprasternal notch to
the carina)
Distal third (carina to
the gastroesophageal
junction)
Right posterolateral
thoracotomy at the fth
intercostal space
Left thoracotomy at the
seventh intercostal space
Pericardium, intercostal,
anterior serratus
Thal patch, partial
fundoplication,
omentum, and
diaphragm
Neck injuries
Triangles of the Neck Anterior: Borders are the sternocleidomastoid laterally, the mandible superiorly, and the
clavicles and sternal notch inferiorly
Posterior: Borders are the sternocleidomastoid anteriorly, the nuchal line of the occipital
bone superiorly, and the trapezius inferiorly
Zones of the neck Zones of the neck
Zone I: sternal notch to
cricoid
Zone II: cricoid to angle of
mandible
Zone III: angle of mandible
to skull base
icoid cartilage
Trachea
Carotid artery
Esophagus
Zone III
Zone II
Zone I
Presentation Hard signs of neck injury: active or brisk bleeding from the wound, expanding or
pulsatile hematoma, massive subcutaneous emphysema, hematemesis, air bubbling
through wound, neurologic decit, hemorrhagic shock, absent peripheral pulse on affected
side
Soft signs: Dysphagia/odynophagia, dysphonia, hemoptysis, pulse abnormality on
affected side, non-expanding hematoma, wide mediastinum, chest tube air leak,
oropharyngeal blood
446
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Neck injuries
R. C. Gooding et al.
Mechanisms of injury: extreme hyperextension and rotation, direct blow to the vessel,
vessel laceration by adjacent bone fractures
Denver criteria Memphis criteria
Risk factors for blunt
cerebrovascular
injury (BCVI)
Signs and symptoms Arterial hemorrhage or
expanding hematoma
Cervical bruit Horner syndrome
Neurologic
Examination
inconsistent with CT
head ndings
Stroke on follow up
head CT
Focal neurologic
decit
Le Fort II/III Le Fort II/III
Basilar skull fracture
Risk factors
with involvement of
the carotid canal
C1–C3 cervical spine
fracture, cervical spine
fractures extending
into a transverse
foramen, cervical
subluxation
DAI with GCS <6
Neck soft tissue injury
Neurologic examination
inconsistent with CT head
ndings
Basilar skull fracture with
involvement of the carotid canal
Cervical spine fracture
Near hanging with
anoxic injury
IF at least one screening criteria is met, 16-slice CTA neck is performed. If abnormal
ndings are observed, ndings are conrmed with DSA
Neck injuries
management
Hemodynamic instability and hard signs of injury → operating room
Hemodynamically stable and no hard signs →Imaging and selective management
Unexplained subcutaneous or mediastinal emphysema → laryngoscopy and bronchoscopy
For suspected esophageal injuries → esophagoscopy and contrast esophagogram
For suspected BCVI → CT angiography of the neck
tilage
Angle of the
Zone
13 Trauma
Surgical approaches to neck injuries
Injury
location Surgical approach
447
Zone I
injury
Supraclavicular incision with extension to trap door
incision
Sternotomy (±extension to anterior
sternocleidomastoid incision) for proximal control of
common carotid and right subclavian artery
Trap Door incision (Clavicular + Upper Median
Sternotomy + Anterior Left Thoracotomy (3rd or 4th
Intercostal Space) → for control of proximal left
subclavian artery
Zone III
Zone II
I
Supraclavicular incision → distal subclavian artery
Stable patients → endovascular approach
Zone II Incision through the anterior border of the
sternocleidomastoid
Collar incision—Two ngerbreadths above sternal
notch; extends to medial borders of SCMs; central
injury (thyroid, trachea, or larynx)
Zone III
injury
Sublaxation/dislocation/resection of the mandible to
access the distal carotid and vertebral arteries
Stable patients → endovascular approach
Blunt cerebrovascular injury (BCVI) Grading and their management
mandible
Cricoid car
Grade Description Management
Grade I <25% lumen narrowing Aspirin
Repeat CTA in 7 days
Grade IIa
Grade IIb
Grade III Pseudoaneurysm Heparin gtt for carotid artery injury
Grade IV Occlusion Heparin gtt for carotid artery injury
Grade V Transections of the carotid
Dissection or intramural
hematoma creates >25%
narrowing of the lumen
artery
Aspirin
Aspirin/Plavix for IIa (carotid artery injury) and IIb (vertebral
artery injury)
Repeat CTA in 7 days
ASA/Plavix for vertebral artery injury
Vascular surgery/IR consult for angiography ± embolization
Repeat CTA in 7 days
ASA/Plavix for vertebral artery injury
Vascular surgery consult for angiography
Repeat CTA in 7 days
Surgical repair → if it is inaccessible → ligate
448
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Neck injuries and their management
Injury to Management Key steps
R. C. Gooding et al.
Carotid artery
Vertebral artery Endovascular repair except in life- threatening
Internal jugular
Esophagus
Trachea Nonoperative treatment for lesions <1/3
Thyroid Debride
Thoracic duct
injury
Neurologically intact + HS → Repair
Ligate minor branches of the carotid without
consequences
Comatose patient or uncontrolled hemorrhage
→ temporary shunt or ligate
Uncontrolled bleeding from distal internal
carotid → Fogarty catheter/balloon occlusion
hemorrhage
Hemodynamically unstable → ligate IJ
Hemodynamically stable → lateral
venorrhaphy vs. reconstruction with spiral vein
graft or externally reinforced PTFE
Massively devitalized esophagus → cervical
esophagostomy + feeding enterostomy
Nonsurgical treatment for small, contained
perforations with limited leak
Stent
circumference or < 4cm
Minor injury → Primary repair
Extensive injury → tracheostomy
Usually diagnosed late
May cause unexplained pleural effusion
Clean laceration → primary repair
Destructive lesion → reconstruction with
shunt (GSV, ECA transposition, SFA)
V1 is visualized by transecting the SCM
from sternum and clavicle for ligation
Monitor for cerebral edema
Repair with venorrhaphy has a high rate of
thrombosis → anti-coagulate
Debride
Close in 2 layers (absorbable for mucosa)
Buttress with healthy tissue
Repair with monolament absorbable
sutures
Avoid lobectomy
Resolves spontaneously
Ligate
Research
Reference Findings
Inaba K, Byerly S, Bush LD, Martin MJ, Martin DT,
Peck KA, Barmparas G, Bradley MJ, Hazelton JP,
Coimbra R, Choudhry AJ, Brown CV, Ball CG,
Cherry-Bukowiec JR, Burlew CC, Joseph B, Dunn J,
Minshall CT, Carrick MM, Berg GM, Demetriades D;
WTA C-Spine Study Group. Cervical spinal clearance:
a prospective Western Trauma Association Multiinstitutional trial. J Trauma Acute Care Surg.
2016;81(6):1122–30
• CT was effective for ruling out clinically signicant
injury with a sensitivity of 98.5%
• If a neurological exam is deemed abnormal, upgraded
imaging in the form of MRI is warranted to ensure no
overt injury is present
13 Trauma
Chest Injury
Chest wall and pleura space injuries
Characteristics Chest injuries are caused by blunt and penetrating mechanisms equally
More than 65% of blunt traumas to the chest causes rib fractures → chest wall injuries are the
most common thoracic injury
Mechanism Blunt chest trauma is more common than penetrating chest trauma
Large amounts of energy transferred to the chest wall results in a ail segment
Flail segment: occur when ≥3 ribs are broken in at least two places
Presentation Pneumothorax, hemothorax, lung contusion
Diagnosis Diagnostic modality Findings Radiology
CXR White lung
Hemothorax
Main stem intubation
Pneumothorax: lucency
peripheral to lung
markings
449
Diaphragmatic injury:
attening of diaphragm,
presence of NGT in the
chest, left hemithorax
AP chest radiograph demonstrates
near- complete whiteout of the left lung
(arrow) with rightward mediastinal
deviation (arrowhead)
AP chest radiograph demonstrates the
endotracheal tube projecting over the right
mainstem bronchus (arrow)
450
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Chest wall and pleura space injuries
Thoracic CT scan Higher sensitivity for
detecting pneumothorax,
hemothorax, for
identifying rib fractures
and sternal fractures,
evaluating the
mediastinum, the lung
parenchyma, and the aorta
Rib fractures and sternal
fractures: CT is more
sensitive for detecting rib
fractures
Pulmonary contusions
R. C. Gooding et al.
a
b
Axial chest CT image with IV contrast
demonstrates posterior lateral left lower lobe
lung contusions (arrow), best seen on (a)
lung window. Overlying rib fractures (black
circle) are best visualized on (b) bone
windows
Axial chest CTA image demonstrates a high
attenuating right-sided pleural uid (arrow),
indicating a hemothorax
eFAST Additional chest views to
evaluate for pneumothorax
(marching ants → No Lung
sliding)
13 Trauma
Chest wall and pleura space injuries
Injury Management
451
Management
Hemothorax 28 French chest tube
Occult
pneumothorax
Moderate to large
pneumothorax
Massive
hemothorax (output
>1500ml on initial
placement of chest
tube or >250 ml/h
for 3 consecutive
hours) or signs of
ongoing bleeding
Rib fractures
Sternal fracture Aggressive pulmonary toilet, incentive spirometry, and multimodal pain
Observation and repeat CXR
28 French chest tube
Take the patient to the operating room for control of bleeding
Aggressive pulmonary toilet, incentive spirometry, and multimodal pain
management
Indications for Rib xation:
– Respiratory failure due to ail chest or severely displaced rib fractures
– Failure to wean from ventilator
– Chest wall instability or deformity due to rib fractures
management
Stable patient + isolated sternal fracture → nonoperative management of
sternal fracture
Tracheobronchial and lung injury
Denition Injuries that occur between cricoid cartilage and right and left mainstem bifurcation
Result from penetrating, blunt traumatic mechanisms or iatrogenic injuries
Mechanisms
Presentation Most common presentation is subcutaneous emphysema and pneumothorax
Diagnosis Rigid or exible bronchoscopy
Penetrating injuries have a higher incidence than blunt trauma
Iatrogenic injuries happen after airway instrumentation (it can happen up to 15% after
emergency intubation)
Patients can also present with airway obstruction, mediastinal emphysema, hoarseness,
hemoptysis, and persistent pneumothorax and air leak after chest tube placement
452
posterolateral
y
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Tracheobronchial and lung injury
Airway management:
For signicant injury that is causing respiratory distress → denitive airway endobronchial
intubation over a exible bronchoscope with placement of the endotracheal tube distal to
the injury
R. C. Gooding et al.
Management
Key operative steps
Avoid rapid sequence intubation, because it may result in airway transection or creation of
false passage for the endotracheal tube
Maintain spontaneous breathing until a safe airway has been established
Check for coexisting injuries because tracheobronchial injuries are often associated with
concomitant injuries that determine survival
Tracheobronchial injury Management
Injuries < 4cm or involve <1/3 of
circumference of trachea
Nonoperative management (humidied air,
voice rest, antibiotics, a proton pump inhibitor,
and repeat bronchoscopy) if patient is
hemodynamically stable, air leak is controlled,
and there is no associated esophageal injury
Difculty of intubation or mechanical
Operative management
ventilation
Patient with ongoing risk for airway
Operative management
obstruction, massive air leak, or
mediastinitis
Debride devitalized tissues
Small injuries → repair with interrupted 4-0 absorbable sutures with knots on outside of
trachea
Complex injuries → resection of the injured portion of the trachea with tension-free
anastomosis
Buttress with an intercostal tissue ap
Surgical approaches to tracheobronchial injuries
Injury location Surgical approach
Tracheobronchial injuries
above the clavicle
Tracheobronchial injuries
from clavicle to 2cm above
carina
For tracheobronchial injuries
involving carina or proximal
right and left mainstem
bronchus
For injures to the distal left
airways
Transverse collar incision or
incision along the anterior border
of the sternocleidomastoid muscle
Median sternotomy
Right posterolateral thoracotomy
Left thoracotomy
Right
thoracotomy
Cervival incision
Median sternotom
Left
posterolateral
thoracotomy
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