Chapter 182 - Thoracic vascular trauma

Question 1

Physical signs of thoracic vascular trauma

Answer 1

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

Question 2

BTAI CXR signs

Answer 2

1) widened mediastinum
2) apical capping
3) loss of normal radiographic cardiac/aortic arch silhouette

Sensitivity 41%

Question 3

IVUS for BTAI advantage and disadvantages

Answer 3

1) no contrast
2) no radiation

1) cost
2) need large sheath
3) OR time use

Question 4

Indications for emergency OR after BTAI

Answer 4

1) shock
2) chest tube output > 1500
3) chest tube output > 250/hr x 3 hours

Question 5

Incisions for treating BTAI and indications

Answer 5

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

Question 6

Surgical treatment for lung injury in trauma

Answer 6

1) Pneumonorrhaphy
2) staple wedge resection
3) tractotomy and ligation of bleed
4) lobectomy

Question 7

Key movement to expose lung

Answer 7

Inerior pulmonary ligament ligation

Question 8

Techniques for hilar control of blled

Answer 8

1) lung torsion
2) manual compression
3) vascular clamp

Question 9

BTAI is the cause of how much MCV death

Answer 9

1/3

Question 10

Definition of widened mediastinum

Answer 10

1) 8cm at aortic knob

2) width exceed 25% of total chest width

Question 11

Treatment of BTAI - BP control

Answer 11

Reduce stress on wall and reduce rupture risk from 12% to 1.5%

Betablock + vasodilator

Question 12

Target for BTAI BP

Answer 12

SBP < 100

MAP < 80

Question 13

1st approved TAAA endograft

Answer 13

Gore 2005

used for BTAI off label until 2008 became on label

Question 14

Open approach exposure

Answer 14

left post-lat thoracotomy through 4th space

Question 15

Left heart bypass cannulation sites

Answer 15

Left inferior pulmonary vein

Distal thoracic aorta

Question 16

ACT for Left heart bypass

Answer 16

> 200 sec

Question 17

ACT for full cardiopulmonary bypass

Answer 17

> 480 sec

Question 18

Risks associated with spinal ischemia

Answer 18

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

Question 19

Methods to lower risk of spinal ischemia

Answer 19

1) steroids
2) CSF drain
3) localized hypothermia
4) reattach intercostal

Question 20

TEVAR vs OPEN benefits for BTAI

Answer 20

Decrease early death, paraplegia, renal insufficiency, bleed, cardiac complication, pneumonia, LOC

Question 21

2008 AAST BTAI landmark report

Answer 21

TEVAR reduce transfusion requirement and mortality

Question 22

ATF study on BTAI

Answer 22

TEVAR also reduce aortic-related mortality

BTAI mortality 18.8%, aortic-related 6.5%

predictor of mortality: high injury severity and higher BTAI grade

Question 23

Classification of BTAI

Answer 23

Grade 1: intimal tear
Grade 2: intramural hematoma
Grade 3: psuedoaneurysm
Grade 4: rupture

Question 24

Timing of non-urgent BTAI repair

Answer 24

> 24 hour has better outcome

Question 25

Second most common artery to be injured in thoracic cavity besides aorta

Answer 25

innominate artery

Question 26

Exposure of innominate

Answer 26

Median sternotomy with right cervical extension

Question 27

Exposure for LCCA injury

Answer 27

Sternotomy with left cervical extension

Question 28

Upcoming registry to look at thoracic trauma

Answer 28

Prospective vascular injury treatment PROOVIT registry