Chapter 182 - Thoracic vascular trauma Flashcards
(28 cards)
Physical signs of thoracic vascular trauma
1) Distended neck veine
2) Tracheal deviation
3) subcutaneous emphysema
4) chest wall instability
5) absent breath sounds
6) muffled heart sounds
7) absent UE pulse
8) hemothorax/pneumothorax
BTAI CXR signs
1) widened mediastinum
2) apical capping
3) loss of normal radiographic cardiac/aortic arch silhouette
Sensitivity 41%
IVUS for BTAI advantage and disadvantages
1) no contrast
2) no radiation
1) cost
2) need large sheath
3) OR time use
Indications for emergency OR after BTAI
1) shock
2) chest tube output > 1500
3) chest tube output > 250/hr x 3 hours
Incisions for treating BTAI and indications
1) Median stenotomy with right and left neck extension –> injury to heart, proximal aorta, innominate
2) Left posteriorlateral thoracotomy –> descending thoracic aortic injury
3) Left anteriolateral thoracotomy –> left subclavian; can turn into clamshell modification by extenting posterior mid line
4) Book thoracotomy
Surgical treatment for lung injury in trauma
1) Pneumonorrhaphy
2) staple wedge resection
3) tractotomy and ligation of bleed
4) lobectomy
Key movement to expose lung
Inerior pulmonary ligament ligation
Techniques for hilar control of blled
1) lung torsion
2) manual compression
3) vascular clamp
BTAI is the cause of how much MCV death
1/3
Definition of widened mediastinum
1) 8cm at aortic knob
2) width exceed 25% of total chest width
Treatment of BTAI - BP control
Reduce stress on wall and reduce rupture risk from 12% to 1.5%
Betablock + vasodilator
Target for BTAI BP
SBP < 100
MAP < 80
1st approved TAAA endograft
Gore 2005
used for BTAI off label until 2008 became on label
Open approach exposure
left post-lat thoracotomy through 4th space
Left heart bypass cannulation sites
Left inferior pulmonary vein
Distal thoracic aorta
ACT for Left heart bypass
> 200 sec
ACT for full cardiopulmonary bypass
> 480 sec
Risks associated with spinal ischemia
1) cross clamp time
2) level and length of aorta
3) duration of hypotension
4) CSF pressure
5) distal aortic pressure
6) number of intercostal ligation
Methods to lower risk of spinal ischemia
1) steroids
2) CSF drain
3) localized hypothermia
4) reattach intercostal
TEVAR vs OPEN benefits for BTAI
Decrease early death, paraplegia, renal insufficiency, bleed, cardiac complication, pneumonia, LOC
2008 AAST BTAI landmark report
TEVAR reduce transfusion requirement and mortality
ATF study on BTAI
TEVAR also reduce aortic-related mortality
BTAI mortality 18.8%, aortic-related 6.5%
predictor of mortality: high injury severity and higher BTAI grade
Classification of BTAI
Grade 1: intimal tear
Grade 2: intramural hematoma
Grade 3: psuedoaneurysm
Grade 4: rupture
Timing of non-urgent BTAI repair
> 24 hour has better outcome
