Thoracic Great Vessel Injuries Decision Algorithm Figure 1: Appropriate Incisions www.SurgicalReview.net Version 1.01

Plain Chest Xray findings that may be suspicious for thoracic great Vessel injuries Aplical pleural hematoma Massive left hemothorax Obvious blunt injury to the diaphragm Other findings Anterior displacement of the trachea Lost of the aortic and pulmonary window Lateral Chest X-Ray (if done) Obliteration of the Aortic knob Widening of the Mediastinum ( >8cm) Depression of the left mainstem bronchus Lost of the perivertebral pleural stripe Calcium layering at aortic knob “ funny looking “ mediastinum with no prior history of surgery Significant deviation of nasogastric tube once inserted Lateral Displacement of the trachea Mediastinal Sternum Scapula Multiple Left rib fractures Clavicule in multisystem injured patients First Ribs that are also Fractured Fractures Findings Location via Xray

Aplical pleural hematoma

Massive left hemothorax

Obvious blunt injury to the diaphragm

Anterior displacement of the trachea

Lost of the aortic and pulmonary window

Obliteration of the Aortic knob

Widening of the Mediastinum ( >8cm)

Depression of the left mainstem bronchus

Lost of the perivertebral pleural stripe

Calcium layering at aortic knob

“ funny looking “ mediastinum with no prior history of surgery

Significant deviation of nasogastric tube once inserted

Lateral Displacement of the trachea

Sternum

Scapula

Multiple Left rib fractures

Clavicule in multisystem injured patients

First Ribs that are also Fractured

H&P or CXR findings consistent with great vessel injury (see previous list ) If stable: Screening helical CT scan of the Chest with IV contrast (also known as Trauma Chest CT ) www.surgicalreview.net Highly suggestive and consistent with great thoracic great vessel injury Findings consistent with thoracic vascular injury Findings not consistent with thoracic Vascular injury Routine follow up Classification of injury and subsequent appropriate treatment Diagnostic Thoracic Aortogram No findings suspicious of a great vessel injury Questionable findings suggestive of great vessel injury Unstable With physical and or radiographic findings Treat immediately ie., with placement of Chest tubes, transfusions and immediately to OR for appropriate treatment (see next slide for appropriate approaches )

Appropriate incisions for Thoracic Great Vessel Injuries Median Sternotomy Left Antero/ posterio lateral Thoracotomy Ipsilateral posterolateral thoracotomy Right Antero/ postreo lateral Thoracotomy Median Sternotomy Intrathoracic vena cava Ipsilateral posterolateral thoracotomy Pulmonary Vein Right or left Hilar Main or intrapericardial Ipsilateral posterolateral thoracotomy Median Sternotomy Pulmonary artery Left anterolateral thoracotomy with possible separate left supraclavicular incision. Left Subclavian artery or vein Left posterolateral thoracotomy (4 th intercostal space) Descending Thoracic aorta Median sternotomy with possible right cervical extension Right subclavian artery or vein Median Sternotomy with right cervical extension Inominate artery / Vein Median Sternotomy Possible extension: neck extension Transverse Aortic Arch Median Sternotomy Ascending Aorta Left antero-lateral Thoracotomy with possible extensions: Transverse sternotomy Right anterolateral thoracotomy (clamshell) Unclear location of injury with hemodynamic instability Appropriate Incisions Injured Vessels*

Left anterolateral thoracotomy

with possible separate left supraclavicular incision.

Median Sternotomy

Possible extension: neck extension

Left antero-lateral Thoracotomy with

possible extensions:

Transverse sternotomy

Right anterolateral thoracotomy (clamshell)