Moore Retreat: Neck Injuries

Mandatory Zone 2 neck exploration:

- was the surgical dogma dating from Korean and Vietnam war

- This dogma is now changing with improvements in CT imaging and additional diagnostic testing to rule out injuries

- Mandatory exploration carries a 60% negative exploration rate

Selective Zone 2 neck exploration:

- now the approach in most centres

Zone 1 injuries:
- Use CT imaging to determine trajectory of injury
- trajectory helps you to guide further management

Quadroscopy not mandatory anymore
- With improvements in imaging, CT can guide further investigations if the tract is in proximity to other structures

Airway injuries
- Supraglottic injuries: ENT
- Below cricothyroid membrane: general surgery in Denver repairs primarily with 2-0 PDS interrupted sutures
- large injuries can be managed with a tracheostomy tube

Esophageal Injuries:
- rare
- Drain
- place a muscle interposition with SCM flap
- air in the mediastinum more commonly from a tracheal injury
- flexible esophagoscopy is first test: if you make a hole larger it need operative repair anyways
In OR: if unsure
- do an air leak test
- instill methylene blue or charcoal into esophagus and look for leak in neck or chest tube

Carotid Artery Injuries:
- Be wary of using shunts: any debris that flies past shunt can cause a devestating stroke
- Dr. Moore believes ALL carotid artery injuries should be repaired
- doesn't feel risk of hemorrhagic stroke is significant: short presentation times

Internal jugular veins:
- unilateral injury can be ligated

Vertebral artery injuries:
- Angio is primary treatment modality
- if vessel bleeds continuously in ER, can take to OR: make incision at base of neck, place balloon tamponade to get the patient to angio

Moore Retreat: Damage Control Laparotomy

Identify who needs a damage control lap:
- Temperature, acidosis, coagulopathy
- temperature should be largely controlled: bear huggers in ER, warm fluids; in Denver not an issue as pts rarely get to OR with temp<36.  With longer transports most of our pts hypothermic, pre-hospital bear huggers?
- Acidosis can be controlled with bicarb, Denver is quite liberally with use of bicarbonate during trauma resuscitation
- Most significant factor is coagulopathy
- Need for resuscitation should not be indication of damage control. Can resuscitate as well or better in OR vs. ICU

Newer evidence to demonstrate that ARDS is better with isofluorane vs. propofol sedation
- pt in OR on volatile anesthetics may in fact be safer than in ICU from respiratory standpoint

30 Minute Time out:
- pack site of bleeding for 30 mins
- close abdomen with towel clips and then go back and check for further bleeding
- warm patient, resuscitate
- when you go back look for arterial bleeding
- better than sending back to ICU with arterial bleeding

Temporary Abdominal Closures:
- all pts in Denver get abdominal compartment syndrome
- Vac closure is preferred method of closure
- They even apply this to select abdominal sepsis patients
- Relaparotomy in 12-24 hours: especially if shunts used or contamination
- patients very quickly go from being hypocoaguable to hypercoaguable

Abdominal Closure techniques:
- staged tension closure
1) Plastic drape
2) Nylon retention sutures
3) Repeat laparotomy every 48hours and place interrupted sutures each time gradually closing the abdomen
(AJS 2007)

Diuresis:
- Gives a 10mg Lasix trial
- if the patient responds and diureses he then starts a lasix gtt to aggressively diurese for closure
- if pt doesn't respond then he waits

Pearls:
- Chest can also be closed temporarily with plastic drapes

Moore Retreat: Zone I retroperitoneal injuries

Important aspects of managing retroperitoneal injuries:
1) identify if the injury is arterial or venous?
- arterial: hematoma extends into mesentery, pulsatile

ACCESS: 
Supraceliac aortic injury - becuase of dense neural plexus network at celiac plexus unable to really get much above renal arteries with a Mattox maneuver
- therefore a thoracotomy to get supradiaphragmatic control of aorta necessary

"Mattox" maneuver - start incision 1 cm lateral to the white line of toldt: keeps you from damaging ?retroperitoneal structures
- leave kidneys in place generally

Superior Mesenteric Vessel injuries: 
Fullen's zones: (1-4) - describes areas of injury to SMA
Zone 1: proximal to infero-pancreaticoduodenal branch
Zone 2: between IPD and middle colic branches
Zones 1-2 are proximal and sit behind the pancreas
- access in trauma situation can be gained by simply cutting pancreas with scissors
Zone 3: between middle and ileocolic branches
Zone 4: distal to ileocolic
Moore advocates repairing ALL SMA injuries with possible exception of most distal SMA where you just accept some dead SB and resect it.
- this is a long process and a temporary shunt can be used

Inferior Vena Cava:
- control: use sponge sticks proximally and distally, a vascular clamp is likely to lacerate the IVC even further
- a posterior IVC injury can be difficult to access, enlarging your anterior injury to gain access to the posterior wall is probably your easiest option.
- try to close transversely as a longitudinal repair is likely to cause hourglass deformity

Pearls: - if you can't find your injury after exploring the hematoma, perform an immediate CTA as the injury is probably temporarily sealed but if it lets loose in ICU it will be catastrophic

Vascular Trauma AHD

Supraceliac Control
- Insert NG to help locate esophagus
- use mets or scrape with fingers to break through fascia over aorta
- use fingers ot dissect down to spine
- if visceral/aortic penetrating injury, thoracic aorta control much better

Abdo Injury
- Zone 3 injury: explore only if intra-op explanding hematoma
- get another pair of expert hands,

Mesenteric hematoma (expanding)
- Explore take off of SMA
- Can get angio next day to look for bleeding branch and embolize (vs. exploring each branch of SMA)

Packing pelvis:
- open space of retzius and pack anteriorly

CArotid Injury:
- shunts while repairing carotid: in line shunts, baloon shunts
- Safetste ALWAYS to shunt
- if no stents available then use: IV tubing, with bevel but no point
- keep in place with umbo tape
- tie shunt in middle

Indications: to repair carotid
- <4hrs
- hemiplegic
- >4hrs intact function
- otherwisenecrotic when hook up will bleed

14jun10

-Most common mets to the adrenal gland.
-Benign adrenal lesions.

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ED Thoracotomy

Source: Cameron

Discussion revolves around definition of Presence of Vital Signs vs. Signs of Life.
- vital signs include blood pressure, palpable pulse and spontaneous respirations
- signs of life include electrical cardiac activity, respiratory effort, pupillary reactivity.

Indications for EDT
1) salvagable post injury cardiac arrest
2) hypotension from
- cardiac tamponade
- intrathoracic hemorrhage
- air embolism
- active intra-abdominal hemorrhage

Relative indications:
1) refractory moderate hypotension from the same reasons as 2) above.

Incision:
- start just lateral to the sternum just inferior to the nipple.
- curvilinear incision following inferior border of pec major
- continue all the way down to the lattisimus dorsi
- using mayo scissors cut intercostal muscles just above the rib

Things you can do after chest accessed
1) pericardiotomy
- open longitudinally, parallel to phrenic nerve
- extend up to root of aorta and down to the apex
2) Aortic cross-clamping
- divide pulmonary ligmament with straight scissors
- bluntly dissect away mediastinal pleura from aorta and esophagus
- dissect away esophagus and prevertebral fascia to the point where you can encircle the aorta.
- with aorta encircled with left hand apply a curves aortic clamp with the right hand.
- be judicious about aortic cross clamping. It increases cardiac work and will result in post-clamp shock when reperfusion occurs.
3) Open cardiac massage
- begin bimanual cardiac massage if arrest has occured
4) control non cardiac hemorrhage
- great vessel damage is almost impossible to repair in ED. Apply pressure and get to the OR
- pulmonary hemorrhage can be controlled with Duvall clamp or vascular clamp
- last resort is to clamp or occlude inflow at the hilum. Which will require division of the pulmonary ligament. Similar to aortic clamping will result in increase in cardiac afterload and may supress cardiac index.

Risks assoated with EDT.
- HIV. Trauma pt 4%. EDT pt 14%
- acutely injured pt. HIV 4% HepB 20% HepC 14%

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Soft Tissue Sarcomas

Diagnosis:
Tissue diagnosis is the key - need to differentiate from other disease processes
1) FNA is rarely diagnostic
2) Core needle biopsy is the primary modality:
- try to follow straight tract to lesion - remember you'll have to resect the biopsy tract
- prior imaging will help to guide route of biopsy, image guided biopsy may also be useful
3) if core biopsy is not diagnostic then open incisional biopsy may be necessary
- <5cm can consider exicisonal biopsy
- if >5cm do incisional biopsy reducing flaps and ensuring hemostasis

Pathology:
LN Mets are rare (2-3%): Some subtypes do have a higher association with LN mets (~20-30%) and you should resect LNs if positive, some even advocate doing SLNB in these cases:
- Synovial
- Epitheliod
- Clear Cell
- Rhabdomyosarcoma

Most common subtype in Children: Rhabdomyosarcoma
Most common subtype in Adults: Malignant Fibrous Histiocytoma