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Gastric injuries

The stomach is a relatively thick-walled, well-vascularized organ that is variably positioned in the peritoneal cavity. Although partially protected by the lower rib cage, its size and location put the stomach at risk for injury, particularly with injury from penetrating trauma to the abdomen or lower chest. The generous blood supply to the stomach includes: (1) the left gastric artery, a branch of the celiac axis;…

Nonoperative management of blunt and penetrating abdominal injuries

Blunt abdominal injury Introduction The evaluation and management of the abdominal cavity in the blunt trauma patient has undergone radical change over the past several decades, due both to significant technological advances as well as a critical reappraisal of management techniques and their outcomes. Early and rapid diagnosis of injuries coupled with the application of modern trauma care principles has made successful nonoperative management of most…

Surgical anatomy of the abdomen and retroperitoneum

The abdominal cavity and the retroperitoneum lie immediately adjacent to one another, separated by a peritoneal lining. Some organs, such as the small bowel and the colon, have portions that lay within both the abdominal cavity and the retroperitoneum. Vascular structures such as the superior mesenteric artery (SMA) and vein course through both body compartments as well. A thorough knowledge of the anatomy of both the…

Diaphragmatic injury

Embryology, anatomy, and physiology The diaphragm is a musculotendinous organ that separates the thoracic cavity from the abdominal cavity. This important organ arises from the confluence of the abdominal peritoneum and the parietal pleural during the first trimester of pregnancy. The early muscular ingrowth is an extension from the circumference of the thoracic inlet, specifically, the posterior sternal border, the inner surfaces of the lower six…

Esophageal injuries: Principles of management

Incidence The incidence of esophageal injuries is low with most resulting from penetrating trauma. Esophageal trauma received little notice until the completion of World War II, with only 18 esophageal injuries recorded in the military records reviewed from that war and the Korean and Vietnam Wars combined. Numerous reports in the literature document the incidence of esophageal trauma to be less than 1%, with penetrating wounds…

Thoracic aortic injury

Thoracic aortic injury represents a highly lethal injury pattern following both blunt and penetrating trauma. The vast majority of patients will not survive to undergo assessment and treatment, with an estimated 80% of victims dying at the scene. For those patients having sustained thoracic aortic injury from a blunt mechanism, the majority will have concomitant injuries that inherently influence survivability. In this context, blunt traumatic aortic…

Thoracic vascular injury

The heart and aorta and its great vessels are encased in the chest cavity, protected by the vertebral bodies, rib cage, clavicle, manubrium, and sternum. One of the earliest reports of thoracic vascular injury was described by Vesalius in 1557 of a fatal, blunt traumatic rupture of the aorta in a man who was thrown from a horse. It was not until 1959 that Passaro and…

Cardiac injuries

Penetrating cardiac injuries Historical perspective Cardiac injuries have been described since ancient times. The earliest descriptions of a cardiac injury are found in the Iliad and in the Edwin Smith Papyrus , written in approximately 3000 bc . Hippocrates stated that all wounds of the heart were deadly. Ambrose Paré, the famous French trauma surgeon, described two cases of penetrating cardiac injuries, both detailed from autopsy…

Complications of pulmonary and pleural injury

Chest trauma is the primary cause of death in up to 25% of fatalities following traumatic injury and a major contributing factor in another 25%. As few as 5% to 15% of these patients require acute operative intervention. Based on these generalizations, it is accepted that overall chest injury is common, acute operative intervention is uncommon, and a significant, although ill defined, number of thoracic operations…

Operative management of pulmonary injuries: Lung-sparing and formal resections

Chest injuries were reported in the Edwin Smith Surgical Papyrus as early as 3000 bc . Ancient Greek chronicles reveal examples of penetrating chest wounds and pulmonary injuries; the Greeks had anatomic knowledge and were cognizant of the thoracic structures and the position of the lungs inside the hemithoracic cavities. In Homer’s Iliad , there is a vivid description of the death of Sarpedon by Patroclus:…

Tracheal and tracheobronchial tree injuries

Injuries to the tracheobronchial tree are uncommon. However, they are often lethal and associated with a high degree of morbidity. Many patients do not survive until arrival at a hospital but die from asphyxiation or due to concomitant injuries. If they are diagnosed and treated appropriately, however, generally good outcomes can be obtained if clinicians are familiar with signs and symptoms of injury, diagnostic techniques, appropriate…

Operative treatment of chest wall injury

Thoracic injury is a significant cause of morbidity and death. Rib fractures, one of the most common manifestations of thoracic injury, are frequently encountered in victims of trauma. For example, 94% of severely or fatally injured seatbelt wearers have rib fractures. Approximately 25% of all deaths due to trauma result from injury to the thorax. Despite this, most thoracic injuries are treated with simple interventions such…

Pulmonary contusion and flail chest

Pulmonary contusion was probably first described by Morgagni in the 18th century, but Laurent’s description in The Lancet in 1883 appears to be the first to recognize the possibility that plasticity of the chest wall, most notably in the young, can allow injury to the underlying lungs without disruption of the bony thorax. Conversely, patients in the sixth decade of life and beyond are prone to…

Diagnostic and therapeutic roles of bronchoscopy and video-assisted thoracoscopy in the management of thoracic trauma

Injuries to the chest are present in more than half of all polytrauma patients and can be a significant cause of mortality in up to 25% of these patients. Direct injury to the chest and pulmonary complications after any major trauma account for a significant proportion of trauma-related morbidity. Technical advances in fiberoptics and videoscopic imaging have led to rapid advances in the field of minimally…

Thoracic wall injuries: Ribs, sternal and scapular fractures, and hemothoraces and pneumothoraces

While many thoracic injuries are potentially lethal, most patients will survive. The earliest description of surviving blunt and penetrating chest trauma are Neanderthal skeletons showing evidence of a healed penetrating trauma and blunt rib fractures. The Edwin Smith Papyrus, written circa 3000 bc , gave explicit instructions for the management of chest injuries, including soft tissue and bony injuries. In fact, 8 of the 43 cases…

Pertinent surgical anatomy of the thorax and mediastinum

The thorax consists of the chest wall comprising the sternum, ribs, and thoracic vertebrae; the mediastinum containing the pericardium, heart, esophagus, trachea, great vessels, thoracic duct, and thymus; and the paired pleural cavities containing the lungs. This chapter will discuss the anatomy of these structures and spaces, as pertinent to trauma surgery and the surgical intensive care unit. Chest wall The muscular, tendinous, and bony structures…

Tracheal, laryngeal, and oropharyngeal injuries

Structural mobility and elasticity are characteristics of the upper airway that make injury to these structures infrequent. Skeletal protection is also provided anteriorly by the mandible and sternum and posteriorly by the bony spinal column ( Fig. 1 ). Upper airway injuries are identified in only 0.03% of patients admitted to major trauma centers. These injuries are frequently lethal, which explains their higher reported occurrence in…

Blunt cerebrovascular injuries

Over the past decade, a wealth of studies has provided the scientific rationale to warrant the early screening and preemptive antithrombotic management of blunt cerebrovascular injuries (BCVIs). In the 1990s, BCVIs were thought to have unavoidable, devastating neurologic outcomes, but several reports suggested anticoagulation improved neurologic outcome in patients suffering ischemic neurologic events (INEs). If untreated, carotid artery injuries (CAIs) have a stroke rate up to…

Penetrating neck injuries

The neck has been a source of tremendous interest in the trauma surgical literature for several hundred years. Its anatomic compactness places vital anatomic structures in close proximity to each other, making the patient prone to multisystem injuries as the result of a single traumatic event. The debate about the proper treatment of neck trauma has persisted since the 16th century when Ambroise Paré reportedly attended…