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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?