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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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13 Trauma
Research
453
Reference Findings
Farzanegan R, Alijanipour P, Akbarshahi H, etal.
Major airways trauma, management and long term
results. Ann Thorac Cardiovasc Surg.
2011;17(6):544–51
Neifert SN, Chapman EK, Rothrock RJ, Gilligan J,
Yuk F, McNeill IT, Rasouli JJ, Gal JS, Caridi
JM.Lower mortality and morbidity with lowmolecular- weight heparin for venous
thromboembolism prophylaxis in spine trauma.
Spine. 2020;45(23):1613–8
Panossian VS, Nederpelt CJ, El Hechi MW, Chang
DC, Mendoza AE, Saillant NN, Velmahos GC,
Kaafarani HMA.Emergency resuscitative
thoracotomy: a nationwide analysis of outcomes and
predictors of futility. J Surg Res. 2020;255:486–94
Haac BE, O’Hara NN, Manson TT, Slobogean GP,
Castillo RC, O’Toole RV, Stein DM; ADAPT
Investigators. Aspirin versus low-molecular-weight
heparin for venous thromboembolism prophylaxis
in orthopaedic trauma patients: a patient- centered
randomized controlled trial. PLoS One.
2020;15(8):e0235628
Diaphragmatic injuries
Penetrating injuries (65% of diaphragmatic injuries): any penetrating injury to the
abdomen or chest trauma below the nipple
Early airway stabilization and transfer to facilities
equipped to manage major airway trauma leads to
improved outcomes
There is lower mortality when receiving LMWH for VTE
prophylaxis in patients with spine trauma
No benet of conduction of ERT in the setting of blunt
trauma
ERT had the highest survival rates in patients younger than
60 y who present with SOL after penetrating trauma
LMWH demonstrated a 60.5% VTE prevention benet in
the weighted time to event analysis
No difference in the benet of VTE prophylaxis between
Aspirin and LMWH specically in fracture patients
Mechanism of injury
Blunt injuries → high-velocity and quick deceleration that cause a sudden increase in
intra-abdominal pressure that is sufcient to overcome the strength of the diaphragmatic
tissue
The left diaphragmatic is more likely than the right diaphragm to be injured with blunt
trauma
Blunt diaphragm injuries → causes large radial tears of the diaphragm
Penetrating injuries → causes smaller defects that approximate the size of the penetrating
body
• Maintain high index of suspicion
– In penetrating injuries, based on location
– In blunt injuries, based on mechanism
– In all high-energy injuries
454
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Diaphragmatic injuries
Diaphragmatic injury
severity scale
Diagnosis
R. C. Gooding et al.
Grade Injury
Grade I Contusion
Grade II
Laceration ≤2cm
Grade III Laceration 2–10cm
Grade IV
Laceration >10cm or tissue loss ≤25cm
Grade V Laceration or tissue loss >25cm
2
2
Diagnosis is usually made on CT scan coincidentally while ruling out other injuries
Small injuries are not usually seen on imaging
If there is high index of suspicion for diaphragmatic injury and imaging is inconclusive
→ diagnostic laparoscopy
Left-sided diaphragmatic injuries → operative management
Right-sided diaphragmatic injuries → nonoperative management (if hemodynamically
stable)
Case scenario Management
Management
Key operative steps
Acute diaphragmatic hernia Abdominal approach for repair
Chronic diaphragmatic
Thoracic approach for repair
hernia
Primary repair not possible Incise the peripheral attachments of the diaphragm from
their costal origins and reattach diaphragm two interspaces
cephalad to the original attachment
Primary repair not possible
+ no contamination in the
Nonabsorbable mesh (polytetrauoroethylene,
polyethylene)
abdomen
Primary repair not possible
Autologous tissue ap (omentum or latissimus dorsi)
+ contamination in the
abdomen
Reduce any herniating organs
Debride any devitalized diaphragmatic tissue
Eversion of borders for adequate approximation
Repair diaphragm with nonabsorbable suture (e.g., 2-0 Prolene) in a running or
interrupted fashion (airtight closure)
13 Trauma
Cardiac injury
Anatomy 15–20% of penetrating injuries to the cardiac box, are associated with cardiac injury
Cardiac box borders: Lateral → midclavicular lines, superior → sternal notch, inferior → tip of
xiphoid
Mechanism Penetrating injuries to the heart occur more commonly than blunt injuries
Injuries to the right side of the heart is more common than the left side of the heart
Right atrium/ventricle are the most common injured due to anterior position chamber
455
Presentation Patient may present with pericardial tamponade, hemi-thoraces, septal rupture, arrythmias,
Diagnosis Diagnostic modality Characteristics Radiology
cardiac dysfunction, and cardiac herniation through pericardium (presents as positional
hypotension)
FAST Quickly assess pericardium for uid
High risk of false negative ndings
Echocardiogram Detects structural injuries
Should be done if there is any
hemodynamic instability to evaluate
the valves
EKG
Cardiac enzymes Elevated cardiac enzymes + EKG
CT scan of chest Detects transmediastinal injuries
Pericardiocentesis High risk of false-positive and
Pericardial window
(subxiphoid or
transdiaphragmatic
window)
Sinus tachycardia →Most common
nding
changes conrm blunt cardiac
injury
false-negative ndings
Gold standard for diagnosing
pericardial tamponade
Axial abdominal CT image with
IV contrast demonstrates a large
malignant loculated pericardial
effusion (arrows), with extrinsic
compression of the ventricles,
concerning for tamponade
456
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Cardiac injury
Management
Injury Management
Denition:
• Hypotension in the absence of bleeding and neurogenic cause
Blunt cardiac injury
(BCI)
• Cardiac arrhythmias
• Depressed cardiac index (<2.5 L/min/m2)
• Anatomic abnormalities diagnosed on ECHO
Classication
• Cardiac free wall rupture
• Septal rupture
• Coronary artery injury
• Complex arrhythmias
• EKG or cardiac enzyme abnormalities
Nonoperative management except if they develop cardiac tamponade or
disrupted cardiac valves
EKG and normal troponin level → no BCI → no further management
EKG → new abnormality (arrhythmia, ST changes, ischemia, heart
block) → admit for ECG monitoring
R. C. Gooding et al.
Hemodynamic instability or persistent new arrhythmia →
echocardiogram (TEE) and admit to ICU
Penetrating injury to
atria
Penetrating injury to
ventricle
Cardiac injury in
close proximity to
coronary artery
For temporary control of bleeding from an atrial injury: A satinsky
clamp can be placed on the defect
For permanent repair: close with running or interrupted permanent
monolament sutures
Close with horizontal mattress sutures with pledgets for friable tissues
Intra-op or post-op TEE
For temporary control of bleeding from a ventricular injury: skin
staples or passage of a foley catheter through the wound and ination of
the balloon
For permanent repair: close the defect with horizontal mattress sutures
reinforced with pledgets
Intra-op or post-op TEE
Repair with horizontal mattress deep to the coronary
Intra-op or post-op TEE
Surgical approaches to repair cardiac injuries
Approach Indication
Left anterolateral thoracotomy Cardiac injuries that cause cardiovascular collapse (patient in
extremis)
Median sternotomy Unclear location of injury (median sternotomy gives the best
exposure)
13 Trauma
Cardiac tamponade
Pathophysiology
457
First phase: pericardial pressure increases → decreases ventricular diastolic lling →
reduces subendocardial blood ow → tachycardia
Second phase: decreased diastolic lling, stroke volume, and coronary perfusion →
anxiety, diaphoresis, and pallor
Third phase: loss of coronary perfusion → cardiac arrest
Diagnostic modality Characteristics
FAST High false negative rate
Diagnosis
Management Repair of cardiac injuries to control bleeding
Complication of
pericardiotomy
(pericarditis)
Echocardiogram unreliable with left pleural effusion
Thoracic CT scan Pericardial effusion
Deformity and compression of the cardiac chambers
Angulation or bowing of the interventricular septum
Acute pericarditis
Presentation: fever, chest pain, and pericardial rub
EKG changes: diffuse ST segment elevation with reciprocal ST depression in leads aVR and
V1; elevation of PR segment in lead aVR and depression of the PR segment in other leads
Management: anti-inammatory medications
Surgical approaches for diagnosing cardiac tamponade
Approach Key steps Indications
Subxiphoid window Make a small upper midline subxiphoid incision
Resect the xiphoid
Open pericardium at the inferior border of sternum
Transdiaphragmatic
pericardial window
Grasp the central tendon of the diaphragm
Open the peritoneum to access the pericardium
Open pericardium
Hemodynamically stable
with suspicion for cardiac
tamponade (FAST
inconclusive)
When abdomen is
explored for another
reason in a
hemodynamically stable
patient
Do not close the defect in the pericardium and central tendon
Median sternotomy Mark landmarks: sternal notch and xiphoid
Incision between sternal notch and tip of xiphoid process
Divide the subcutaneous tissue and the underlying pectoral
fascia between the bers of the pectoralis major muscle
Perform blunt digital dissection of the posterior side of the
sternum from the underlying sternoclavicular ligament, and
blunt digital dissection of the xyphoid process from the
underlying tissue of the diaphragm
Sternum is divided with a sternal saw
Hemodynamically
unstable patient with
suspected cardiac
tamponade
458
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Pulmonary injuries
Characteristics Lung injuries are common after blunt and penetrating chest trauma
A pulmonary contusion result from transfer of energy through the chest wall to lung parenchyma
Mechanism of
injury
Diagnosis
→ leading to edema and hemorrhage in the lung →this causes physiologic shunt → hypoxemia,
carbon dioxide retention, and respiratory acidosis
Pulmonary contusions are sometimes associated with ail segment, but the contusion usually has
more clinical signicance than the rib fractures
Most common cause of penetrating lung injury is gunshot wounds
Diagnostic modality Characteristics Radiology
CXR Acutely shows hemothorax
or pneumothorax
Contusions require time to
be visualized
R. C. Gooding et al.
eFAST Demonstrate pneumothorax
and hemothorax
Thoracic CT scan Difcult to differentiate
contusion from atelectasis
Atelectasis does not cross
pulmonary ssure
Contusions cross ssure
PA chest radiograph demonstrates
a large right-sided pneumothorax
(arrow) with mediastinal
deviation to the left (arrowhead),
concerning for tension
pneumothorax
Axial chest CT image without IV
contrast demonstrates posterior
left lower lobe and medial right
lower lobe ground-glass
opacication with
intraparenchymal air (arrows),
consistent with pulmonary
contusion and laceration. Not
shown is an acute posterior left
11th rib fracture
13 Trauma
Pulmonary injuries
Management Injury Management
459
Massive hemothorax (output
>1500ml on initial placement
of chest tube or >250 ml/h for
three consecutive hours) or
signs of ongoing bleeding
Injury to periphery of the lung
causing bleeding
Injury to the central portion of
the lung that is causing
bleeding
Massive hemorrhage from the
lung that is difcult to control
Moderate or large
pneumothorax
Hemothorax
Pulmonary contusion Supportive care
Thoracic aortic injuries
Take patient to operating room for control of bleeding
Wedge resection
Tractotomy and oversewing of bleeding tissues
Hilar clamping or hilar twisting
Chest tube
Chest tube → if retained hemothorax within 24 h → non-contrast
CT chest → if retained hemothorax → VATS or urokinase/TPA if
not a surgical candidate
Aggressive pulmonary toilet
Intubate only if dictated by respiratory function
Characteristic Thoracic injuries from blunt trauma are responsible for 8% of trauma admissions. Penetrating
thoracic injuries are also commonly encountered at 7% of admissions
Most of these patients will not require thoracic operative intervention though vascular injury
within the thorax has a high mortality
First or second rib fracture or scapula fracture indicates severe trauma and possibility of
traumatic aortic injury
Mechanism Blunt injuries are often from rapid deceleration injury, which tears the aortic wall in the vicinity
of the ligamentum arteriosum, from motor vehicle crashes
Presentation Physical examination ndings of distended neck veins, tracheal deviation, subcutaneous
emphysema, chest wall instability, absent breath sounds, mufed heart sounds, and absence of
upper extremity pulse suggest thoracic vascular injury
Penetrating thoracic trauma + hemodynamic instability → OR
460
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Thoracic aortic injuries
Diagnostic modality Findings Radiology images
CXR Widened
Diagnosis
R. C. Gooding et al.
mediastinum
Apical capping
Obliteration of aortic
knob
Deviation of trachea
to the right
Depression of left
mainstem bronchus
Fractures of 1st rib or
2nd rib or scapula
AP radiograph demonstrates a widened
mediastinum (arrows)
CT angiography
TEE for the unstable
patient
Periaortic hematoma
Axial and sagittal chest CT images with
IV contrast performed shortly after
demonstrates aortic transection
(arrowhead) at the level of the isthmus,
with active extravasation of blood. Note
the already developed hematoma (stars)
extending along the descending aorta
from the diaphragm, and along the aortic
arch branches
IVUS Useful for evaluation
in cases with
equivocal CTA
Right subcla
Left
13 Trauma
Thoracic aortic injuries
Management Emergent operation for thoracic exploration
• Shock with a penetrating chest injury
• Initial chest tube output 1500 cc
• Persistent chest tube output 250 cc/h for 3 h
Blunt aortic injury grade Management
I: Intimal tear Medical management
II: Intramural hematoma TEVAR vs. OR
III: Pseudoaneurysm TEVAR vs. OR
IV: Rupture TEVAR vs. OR
Medical Management:
Aggressive blood pressure and heart rate control with IV Esmolol or calcium channel blocker to
keep BP at or below 100 mmHg or mean below 80 mmHg and heart rate below 100
Open repair (OR) with interposition graft for unfavorably anatomy:
• Inadequate proximal landing zone
– Left subclavian artery coverage in 40%
• Small or diseased iliofemoral vessels <7mm diameter
MC BTAI located in region of isthmus → posterolateral thoracotomy
461
Surgical approaches to expose proximal great vessels
Approach Great vessels exposed Figure
Median sternotomy Proximal right subclavian
Innominate, proximal left
carotid, ascending aorta,
Left anterolateral
thoracotomy
Trap door incision (left
anterolateral
thoracotomy, partial
sternotomy, and left
supraclavicular
incision)
Extension of a median
sternotomy incision to
the anterior neck
Left posterolateral
thoracotomy
Supraclavicular
incision
aortic arch, proximal left
subclavian artery
Left subclavian artery
descending thoracic aorta
Left subclavian artery
Carotid arteries
Descending aorta
Right subclavian artery and
the distal left subclavian
artery
Right vertebral
artery
artery
Brachiocephalic
artery
Median
sternotomy
Superior
vena cava
vian
Right
common
carotid artery
common
carotid artery
Left vertebral
artery
Left
subclavian
artery
Left
anterolateral
thoracotomy
Aorta
Pulmonary
artery trunk
462
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R. C. Gooding et al.
Abdominal Exploration forTrauma
Abdominal exploration for trauma
Penetrating abdominal injuries with hemodynamic instability
Indications for
abdominal
exploration
Diagnosis Diagnostic modality Characteristics
Management Preoperative preparation: Intravascular access (two large-bore IVs) or intraosseous access
Peritonitis
Evisceration
FAST Limited value in penetrating trauma
CT scan For hemodynamically stable patients
DPL Have been largely replaced by the FAST
Used if FAST is equivocal
Diagnostic laparoscopy Used for diagnosis and treatment of stable
patients typically to evaluate for diaphragmatic
injuries
Minimize the use of intravenous uids in the resuscitation of trauma patients (transfuse blood after
1L of crystalloid if the patient is still hypotensive. Transfuse blood products as soon as the need
(PRBCs, plasma, and platelets in a 1:1:1 ratio)
Key steps to
exploratory
laparotomy
Activate massive transfusion protocol if the patient has sustained signicant blood loss
Permissive hypotension should be used until hemorrhage is controlled
Control of bleeding Packing (pack all four quadrants)
Profoundly hypotensive → supraceliac aortic
control
Central or peripheral vascular control
Major bleeding sites controlled (includes suture
repair, ligation, and shunting)
Identication of injury Run small bowel from ligament of Treitz to
ileocecal valve
Examine the intraperitoneal colon and rectum
Open lesser sac to examine posterior wall of
stomach and distal pancreas
Control of contamination Primary repair or stapled resection of bowel
Denitive repair versus damage control Strategy of damage control laparotomy: control
hemorrhage →control contamination
→temporary abdominal closure → resuscitation
and rewarming in intensive care unit→ return
to operating room in 24–48 h for denitive
repair
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