Jason Davis, MDJason Davis, MD

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

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

Establish airway first Orotracheal intubation Cricothyrotomy (emergent) Tracheotomy (less emergent) Nasotracheal not advised in most trauma

settings

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

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

Traditional cervical neck divisions Zone 1: Zone 2: Zone 3:

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

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

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

*Curved posteriorly at mandible

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

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

Median sternotomy for inominate or R subclavian injuries

Left thoracotomy for L subclavian

Median sternotomy for inominate or R subclavian injuries

Left thoracotomy for L subclavian

Most vertebral artery injuries dx w/ angiography and may be embolized

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