Trauma Anatomic Regions Elizabeth Gwinn MD 2014, updated 11/2015

Zones of the Neck

Zones of the Neck Anterior neck = above the clavicles, up to the TMJ and anterior to the posterior border of the SCM I = clavicles/sternum to cricoid cartilage II = cricoid cartilage to angle of mandible III = above angle of mandible to base of skull

Zones of the Neck – WTA algorithm

Penetrating neck trauma workup Zone I CTA arch and neck EGD and esophagram Consider bronchoscopy Zone II CTA neck Consider bronchoscopy/nasopharyngeal scope Zone III CTA neck and soft tissues Good visual inspection of oropharynx

Anterior Cardiac Box

Anterior Cardiac Box Superior = angle of Louis (sternomanubrial junction) Lateral = mid clavicular/nipple line Inferior = line drawn across the costal margin at the level of the mid clavicular line

Anterior cardiac box workup CXR Echo Fluid  pericardial window Suboptimal view  CT scan if stable or pericardial window

Posterior Box

Posterior Box Superior – top of scapula Lateral - medial to scapula Inferior - above costal margins

Posterior box workup Gunshot injuries Stab wounds CXR CT arch EGD and esophagram Consider bronchoscopy Stab wounds If CXR is completely normal  repeat CXR in 6 hours If PTX or effusion  chest tube If mediastinal air, consider esophageal injury If mediastinal widening, consider aortic injury

Thoracoabdomen

Thoracoabdomen Superior margin Inferior – inferior costal margin Anterior – nipples Posterior – tip of scapula Inferior – inferior costal margin

Thoracoabdominal trauma algorithm – Mattox, Kenneth, Moore Trauma 7th Edition

Penetrating thoracoabdomen trauma workup CXR DPL Positive if > 10,000 RBC If DPL cannot be done/won’t be done  diagnostic laparoscopy/laparotomy

Anterior Abdomen

Anterior Abdomen Superior – costal margins Lateral – mid axillary line Inferior – inguinal ligament

Penetrating anterior abdomen trauma workup Indications for operation Hemodynamic instability Pathway of the bullet Evisceration Retained stabbing implement Gross blood per orifice Peritonitis Pneumperitoneum Positive DPL GSW >10,000 RBC Anterior abd stab wound > 100,000 RBC Thoracoabdomen or black/flank stab wound > 10,000 Gunshot wounds All GSW that penetrating the peritoneal cavity require an operation Tangential GSW can be worked up with either DPL (positive > 10,000 RBC) or diagnostic laparoscopy Anterior abdomen stab wounds Only 50% penetrate the peritoneal cavity and of these, only 50% will have an injury that requires repair DPL is positive if >100,000 RBC for anterior abd stab wounds

Back and Flank

Back and Flank Anterior – mid axillary lines Superior – tip of scapula Inferior – iliac crest RETROPERITONEUM

Back and flank penetrating trauma workup Triple contrast (oral, rectal and IV) CT scan Positive triple contrast is a violation of the retroperitoneal fat plane +/- organ injury, contrast extravasation

Triple Contrast CT - Negative

Triple Contrast CT - Positive

Pelvis

Pelvis - blunt Pelvic fractures – if identified on xray will need CT pelvis Anterior pelvic fracture – RUG and cystogram

Pelvis - penetrating Bones, abdominal viscera and pelvic outflow tracts at risk Workup should include Iliac vessels - CTA pelvic vessels Extra-peritoneal rectum - Rigid proctosigmoidoscopy Urethra and bladder - Retrograde urethrogram and cystogram Females – vaginal exam, consider injury to uterus

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