[Treatment of penetrating injuries of neck, chest and extremities]

Operating on penetrating trauma to the mediastinal vessels

BACKGROUND AND AIMS

Patients with penetrating trauma of the major vessels of the chest are infrequently encountered. This is due to the fact that the majority of these patients die on scene, as well as due to the overall dramatic decline in the incidence of penetrating trauma in the Western world. A certain proportion of survivors are physiologically stable and can be transferred to adequate care. Patients who are physiologically unstable must be dealt with by the surgeons available without delay. Rapid diagnosis and operation can salvage patients who would otherwise be lost, and all general surgeons should be capable of recognizing these injuries and intervening if a trauma and/or cardiothoracic surgeon is not immediately available.

MATERIAL AND METHODS

Technical description of practical emergency surgery approaches to patients bleeding to death from penetrating mediastinal vessel injuries.

RESULTS

The scope of this review familiarizes the "uninitiated" surgeon with the operative management of this rare and lethal type of injuries. Technical aspects are described, and pitfalls as well as tips and tricks of the trade are discussed.

CONCLUSIONS

Patients with penetrating injuries to the mediastinal vessels can be saved by swift and knowing operative management of this rare and lethal type of injuries, even if a trauma and/or cardiothoracic surgeon is not immediately available.

[Penetrating neck injury of a blacksmith by splitter projectile]

Laryngeal injuries are rare but potentially life-threatening injuries. Due to the topography of the neck, accompanying injuries of the greater blood vessels, cervical nerves, thoracic organs and spinal cord are common. Therefore in initial diagnostics, these must be excluded from injuries which determine the prognosis. A patient presented with ventral perforation of the larynx, initial dyspnea, hematemesis and left-sided emphysema of the neck. Cause of the findings, we treated the patient non-operatively in interdisciplinary consensus.

[Temporary treatment of uncontrolled intrathoracic hemorrhaging with abdominal towels in combination with a rescue procedure. Damage control procedure of the chest]

Case report of a 27-year-old patient who presented with a stab wound in the posterior aspect of the right chest. The patient was physiologically unstable and not responding to fluid resuscitation. A right intercostal drainage was inserted which immediately drained 1100 ml of blood. Thoracotomy was performed where a large clot was removed from the pleural cavity and followed by massive bleeding from the hilum of the lung as well as an intercostal artery posteriorly. Control of the hilar hemorrhaging necessitated right middle lobe resection. Attempts to control the bleeding from the intercostal artery were futile becoming technically more difficult due to a comminuted fracture of the ribs at the site of entry of the knife. During these attempts the patient became moribund. As a last resort the pleural cavity was packed with abdominal towels and the patient was transferred to the intensive care unit (ICU). The patient was returned to surgery after 48 h at which time the packing was removed with no further bleeding. On day 11 postoperatively drainage of the pleural collection was carried out and decortication of the right lower lobe. The patient was discharged 23 days after admission in a good general condition. This case report demonstrates that in exceptional circumstances packing of the pleural cavity to control bleeding can be considered as a method of damage control in penetrating chest trauma.

[Penetrating injuries in the face and neck region. Diagnosis and treatment]

Penetrating head and neck injuries often present with vascular lesions and airway compromise and may be life-threatening. Thus controlling bleeding and airway stabilisation take priority in emergency treatment. High-velocity projectiles, fragmentations from improvised explosive devices (IEDs) and shrapnel can cause severe tissue injury, representing a challenge for the head and neck surgeon. Since several organ structures, such as the eyes, midface, pharynx, larynx, trachea, esophagus, nerves, vessels and vertebral spine can be injured at the same time, patients should be referred to a specialized trauma center for interdisciplinary treatment following emergency treatment. High-speed ballistic injuries were once confined to the battle field and have been uncommon in Europe since World War II. For this reason, experience among civilian head and neck surgeons is at present limited. With the increased incidence of terrorism and the use of IEDs as the preferred weapon in terrorism it has become important for civilian head and neck surgeons to understand the role of ballistic injuries in mass casualty events. The present paper discusses current viewpoints in the diagnosis and treatment of penetrating head and neck injuries.

[Knife injury to the thoracic aorta and spinal cord. Report on an"almost-mistake"]

We report the surgical treatment of a thoracic knife injury with lesions of the aorta and the myelon. An initially incomplete revision of the wound nearly resulted in a critical situation. Complete revision of a wound is obligatory in a penetrating injury, when a relevant structure is possibly injured.

[Penetrating gunshot wound in the neck. Case report and review of the literature]

Penetrating gunshot neck injuries present a serious challenge for the primary attending surgeon. By means of a case treated in the German Field Hospital in Mazar-e-Sharif (northern Afghanistan) and a review of the literature, the principles of diagnosis and treatment of penetrating zone II neck injuries due to gunshots or shrapnel are presented.

Peripheral endografts for the treatment of traumatic arterial injuries

Catheter-based endovascular techniques for vascular trauma management are being increasingly reported. Covered stents may be inserted and deployed through a remote site of percutaneous access under local anesthesia and are ideal for treating arterial ruptures and pseudoaneurysms and to seal off arteriovenous communications. Advantages of endovascular stent-graft repair of peripheral traumatic arterial injuries include less blood loss and tissue damage, reduced operative time and morbidity, shortened hospital stay and recovery periods, and reduced healthcare costs. The present report provides an overview of the role of balloon-expandable and self-expandable covered stents in the minimally invasive treatment of various types of traumatic arterial injuries.

[Penetrating injuries to the pelvis]

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.