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Jason Davis, MD.  Blunt arterial injuries  Usually managed non-operatively  Operative tx similar to penetrating injuries (rare)  Almost always diagnosed.

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Presentation on theme: "Jason Davis, MD.  Blunt arterial injuries  Usually managed non-operatively  Operative tx similar to penetrating injuries (rare)  Almost always diagnosed."— Presentation transcript:

1 Jason Davis, MD

2  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

3  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

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

5  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 90 0 to enlarge  Insert No. 4 – 6 (largest for most adults) airway  Convert to tracheotomy 48 – 72hrs

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7  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

8  Traditional cervical neck divisions  Zone 1:  Zone 2:  Zone 3:

9  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

10  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

11  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/ absorbable  Post-op monitor for mediastinitis +cxr for pneumo-mediastinum, leaks or missed pharyngoesoph injury  Reconstruction / definitive repair semi-elective

12 *Curved posteriorly at mandible

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14  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

15  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

16  Median sternotomy for inominate or R subclavian injuries  Left thoracotomy for L subclavian

17  Median sternotomy for inominate or R subclavian injuries  Left thoracotomy for L subclavian

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

19  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


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