2. ANATOMÍA
QUIRÚRGICA
• Tráquea longitud 10-12cms; 2-2.5cms
ancho;
• Extiende C6 a T5.
• Tráquea compone 16-20 anillos
incompletos; pared posterior plana –
músculo y tejido fibroso;
• Bordes anatómicos tráquea – istmo de
tiroides y músculos correa anteriormente.
• Arterias carótidas comúnes, lóbulos
tiroideos; nervios laríngeos recurrentes –
bordes laterales.
3. ANATOMÍA
QUIRÚRGICA
• Cartílago tiroides – suspendido
hueso hioides por membrana
tiroihioidea.
• Ligamento cricotiroideo conecta
porción inferior cartílago tiroideo
a cartílago cricoides.
• Inferiormente – primer anillo
traqueal.
4. • Tráquea divide – bronquio principal
izquierdo y derecho a nivel ángulo
esternal T4.
• Bronquio derecho más ancho, corto
y vertical.
• Bronquio derecho divide – 3
bronquios lobares; se divide lóbulo
superior, medio e inferior;
• Bronquio izquierdo – 2 bronquios
lobares.
5. • Arterias bronquiales originan
directamente aorta torácica;
• Pequeños en diámetro –
irrigan tráquea, árbol
bronquial y pleura
visceral
• Drenaje venoso – venas
pulmonares – origen
nivel de alveolos.
• 2 VENAS pulmonares
izquierdas y derechas;;
unión atrio izquierdo –
pericardio.
6.
7.
8.
9. • Lesión pared torácica ~ 10%
hospitalización- trauma.
• Marcador mortalidad, gravedad – lesion;
• Predictor –deterioro pulmonar y
complicaciones.
Bradley M. Dennis. Thoracic Trauma. Surg Clin N Am 97 (2017) 1047–1064 http://dx.doi.org/10.1016/j.suc.2017.06.009
GENERALIDADES
10. Contusión pulmonar
Frecuente ~ fracturas pared costal.
Parénquima incapaz – intercambio ventilatorio;
Volumen extenso Distress respiratorio.
Escasos signos clínicos; lesiones concomitantes
~sugestivo
Rx y TC
Bradley M. Dennis. Thoracic Trauma. Surg Clin N Am 97 (2017) 1047–1064 http://dx.doi.org/10.1016/j.suc.2017.06.009
11. • Efecto “astillamiento”
transmisión onda choque.
Disrupción alvéolo punto
contacto inicial.
• Efecto inercial tejido baja
densidad alveolar “denudado”
tejidos hiliares mayor peso;
desaceleración a diferentes tasas.
• Efecto implosión rebote o
expansión burbujas gas ~
transmisión ondas de presión.
Bradley M. Dennis. Thoracic Trauma. Surg Clin N Am 97 (2017) 1047–1064 http://dx.doi.org/10.1016/j.suc.2017.06.009
12. Lesión parénquima pulmonar – cambios fisiopatológicos;
desacoplamiento ventilación/ perfusión.
• Sangrado – segmentos sanos ~ broncoespasmo
~ compromiso
• Incremento producción moco; disminución
aclaramiento
• Disminución surfactante.
• Aumento cortocircuito intrapulmonar; pérdida
complianza.
• Hipoxemia, hipercarbia; roncus, sibilancias o
hemoptisis.
Bradley M. Dennis. Thoracic Trauma. Surg Clin N Am 97 (2017) 1047–1064 http://dx.doi.org/10.1016/j.suc.2017.06.009
13. • 1.- Hemorragia intersticial ~ 1-2 hrs tras edema.
• Infiltrado monocitos / neutrófilos;
• 2.- 24 hrs. Acúmulo eritrocitos; proteína; células
inflamatorias, fibrina; pérdida arquitectura y
edema masivo.
• 3.- 48 hrs consolidación fibrina, detritus celular;
granulocitos derivados células alveolares tipo 2,
neutrófilos y macrófagos. *
• 4. Días 7-10 reparación.
Bradley M. Dennis. Thoracic Trauma. Surg Clin N Am 97 (2017) 1047–1064 http://dx.doi.org/10.1016/j.suc.2017.06.009
14. Diagnóstico de imagen
• Infradiagnóstico Rx
• ~ 1000 pacientes; TAC –
100% contusiones
pulmonares vs 38% Rx.*
• Diagnóstico temprano
volumen total
contusion.
15. Manejo
• Soporte ventilatorio y observación; prehospitalario: O2 y abordaje vía
respiratoria.
• Restricción juiciosa líquidos.
• O2 suplementario y monitorización continua; ~ ventilación no invasive
con presión positiva – pacientes hypoxemia.
• Intubación solo si dificultad respiratoria; ~ optarse intubación
selectiva
16. Control analgésico ~
anestesia regional;
bloqueo intercostal
• Fijación costal
temprana ~
Uso antibiótico no
lugar
Corticosteroides no
juegan rol.
21. Síntomas clínicos ~ variar – region anatómica y mecanismo lesion;
Enfisema subcutáneo, disnea; distress respiratorio común
Fuga aérea peristente tras colocación SEP levanter sospecha
Patognomónico – pacientes con lesion penetrante cervical aire
a través de herida.
22. Diagnóstico
por imagen
Estudios de imagen
~enfisema subcutáneo,
neumotórax y
neumomediastino
más communes;
TAC – disrupción.
hew M, Boyd C, Kraft S (May 16, 2020)
Delayed Multifocal Tracheal Injury
Following Thyroidectomy: A Case Report
and Review of the Literature. Cureus
12(5): e8164. doi:10.7759/cureus.8164
23. Laceración
traqueal
• Suele tener trayecto vertical
(perpendicular a los anillos traqueales).
•Neumomediastino.
• Enfisema en partes blandas, cervical y
torácico.
• ~Neumotórax.
• Malposición tubo endotraqueal se
extiende a través defecto traqueal.
• ~Defecto en anillos cartilaginosos -
tráquea, tracto - aire entre luz de tráquea
y aire paratraqueal o deformidad traqueal.
24. Laceración
bronquial
• Disposición paralela - respecto
anillos cartilaginosos.
• Neumomediastino.
• Neumotórax, particularmente si
lesión distal - bronquio principal.
• Angulación bronquial.
• Signo bayoneta: aire rodeando
paredes bronquiales.
• Signo pulmón caído: caída
pulmón a región más declive
tórax*
31. • Reparación sutura realizada más pronto
posible;*
• Algunas heridas~ grandes para reparación primaria;
área dañada resección circunferencial y
anastomosis termino terminal.
• Disección cuidadosa necesaria – prevenir
desvascularización anastomosis. ~
• Si resección – pequeña porción tráquea requerida;
cuello debe flexionarse durante reparación y
mantenido**
32. A) TAC muestra bronquio izquierdo principal deformado; discontínuo
con aire alrededor de bronquios; además NT derecho y enfisema
subcutáneo al ingreso;
C tras día 50 TAC atelectasia izquierda e interrupción total bronquio
principal izquierdo.
33. • D y E imágenes
transquirúrgicas –
bronquio resecado
posteriormente
anastomosis
• F TAC posqx muestra
expansion pulmón
izquierdo y
desbloqueo bronquio
principal y bronquios
lobares
34. • A – C TAC prequirúrgica
15 días tras lesión
interrupción bronquio
izquierdo principal;
• D broncoscopía
fibróptica – estenosis
por granulación.
• E RX posquirúrgica con
expansión pulmón
izquierdo.
49. Incisiones
• Esternotomía media elección lesiones
penetrantes tórax anterior – sospecha lesión
vascular o mediastinal;
• Menor dolor posquirúrgico;
• NO permite exposición estructuras mediastinales
posteriores.
• Anterolateral – preferida mayoría lesiones
parénquima pulmonar.
• Clamshell – extensión toracotomía anterolateral
estándar; para sospecha lesiones parénquima
pulmonar – bilateral; lesiones vasculares
mediastinales; clamp aórtico.
50. Técnicas quirúrgicas.
• Neumorrafia reparar lesiones pequeñas, superficiales parénquima
pulmonar.
• Tras ligadura – vasos sangrado mayor o fugas aéreas laceración
reparada puntos en 8.*
• Casos hemorragia o fuga aérea – lesiones penetrantes profundas;
evitar sutura heridas entrada y salida riesgo embolismo aéreo;
hematoma intrapulmonar o hemorragia árbol bronquial Manejo
tractoctomía o resección segmentaria.
51. Tractoctomía pulmonar
• De elección casos –
hemorragia o fuga aérea
mayor heridas
penetrantes profundas;
• No indicada en sospecha
heridas hiliares¨*
• 1.- Trayecto herida abierto
con engrapadora GIA
• Ligadura – visión directa
sangrado significativo o
fugas; ~ pegamento
tisular.
52.
53. Resección en cuña
• Heridas periféricas mayores ~ resección no anatómica.
• Engrapadora GIA o puede colocarse tejido lesionado
entre clamps y seccionar tejido; los bordes- surgete.
• Clamps De Bakey
54. Resección lobar
no anatómica.
• ~ Lesiones extensas;
• Se aplica compresión digital/ clamp vascular
– estructuras hiliares;
• Disecan vasos;
En resecciones lóbulo inferior incide
ligamento pulmonar.
• Utilización engrapadora; antes de activación
– dos suturas p/ fijación o fórceps Allis
aplicadas en muñón prevenir retracción;
• Posteriormente línea de sutura – control
sangrado o fuga aérea.
• Cuidado desvascularización parénquima
remanente.
55.
56. Neumonectomía
• Neumonectomía total ~ necesaria – lesiones hiliares graves no aptas –
reparación o lobectomía;
• Lesión hiliar inestabilidad hemodinámica –hemorragia activa grave
• Compresión digital . Clamp vascular.
• Control vascular, prevención embolismo aéreo – estancamiento
hemorrágico árbol bronquial normal.
• Twist hiliar.
57. • Pacientes inestables – aislamiento individual división y
ligadura estructuras hiliares poco provechoso~
consumir tiempo – empeorar condición paciente.
• Neumonectomía en mass- engrapadora TA.
• Bronquio principal dividido lo más proximal a carina –
reducir riesgo desestructuramiento – muñón.
• Suturas fijas en 8 en dos bordes – muñón – prevenir
retracción;
• Colgajos musculares, adosar muñón a tejidos
circundantes, pleura parietal, grasa pericárdica ~ usarte
The paired strap muscles are in front of the trachea and larynx. These include the sternohyoid muscles and the underlying sternothyroid and thyrohyoid muscles
The paired strap muscles are in front of the trachea and larynx. These include the sternohyoid muscles and the underlying sternothyroid and thyrohyoid muscles
The larynx is composed of three paired (arytenoid, corniculate, and cuneiform), and three unpaired (cricoid, thyroid, and epiglottic) cartilages.
The lung has a unique dual blood supply. The pulmonary artery trunk originates from the right ventricle and gives the right and left pulmonary arteries. The right pulmonary artery passes posterior to the aorta and superior vena cava. The left pulmonary artery courses anterior to the left mainstem bronchus. The pulmonary arteries supply deoxygenated blood from the systemic circulation directly to alveoli where gas exchange occurs. These vessels are large in diameter, but supply blood in a low pressure system.
If large enough in volume, this condition can result in significant respiratory distress. In flail chest, pulmonary contusions are frequently present and contribute to respiratory compromise
Among civilian trauma populations, falls and rapid deceleration after vehicular crashes are the predominant mechanisms of lung injury. Recent reports from the Crash Injury Research and Engineering Network (CIREN) [3] demonstrated that two significant predictors of pulmonary contusion are an instantaneous change in velocity (delta V) of more than 45 mph (odds ratio [OR] = 1.9) and a frontal crash into a fixed object (OR = 1.8) [3]. Near-side lateral impact during a vehicular crash has also been implicated as an important mechanism leading to this lesion [3, 4]. In the combat setting, the shock wave produced by explosions and high-velocity projectiles may cause serious trauma to the pulmonary parenchyma.
Distensión excesiva ~ desgarro parénquima pulmonar.
spalling effect, the shearing or bursting effect that can occur at the interface between a gas and a liquid (or between other media with large differences in density). This phenomenon is visible when a shock wave from a depth charge reaches the surface of the ocean, resulting in a “spray dome.
Linfáticos dilatados y llenos de proteína.
Miller and associates56 found that patients with severe pulmonary contusions (contused lung 20% of total lung volume) developed acute respiratory distress syndrome at much higher rates (82% vs 22%; P
Bronquiales más frecuentes > traqueales.
~darse maniobras intubación
Accidentes vehiculares Tracheobronchial injury is a rare but morbid injury. In a large trauma autopsy series, 2% were found to have a tracheobronchial injury. Of those 81% died at the scene, mostly from associated injuries [1]. Motor vehicle accidents were the most frequent mechanism.
Trauma penetrante afecta normalmente tráquea extratorácica anterior – nivel cervical bajo
En trauma cerrado las lesiones se localizan más frecuentemente en los bronquios, preferentemente en el bronquio principal derecho a menos de 2,5cm de la carina.
Fig. 19: Varón de 19 años con una herida penetrante por barra de hierro tras caída en una obra. Reconstrucción volumétrica (A) y coronal (B) de TCMD. Se observa la barra metálica a nivel de la tráquea (flecha larga) con neumomediastino (flecha corta) y enfisema subcutáneo (punta de flecha). Aumentos de densidad bibasales por probable broncoaspiración (*)
. We report the case of a spontaneous posterior tracheal wall rupture following a cough. A 67-year-old woman with a history of longstanding treatment with corticosteroids (8 years) for Giant Cell Arteritis had general anesthesia for cataract removal. Surgery and anesthesia were uneventful. In the recovery room, the patient coughed and soon after developed subcutaneous emphysema of the neck. Chest radiography confirmed the clinical diagnosis of marked subcutaneous emphysema and showed huge pneumomediastinum and minor right pneumothorax. A thoracic CT scan revealed a large laceration of the posterior tracheal wall (a 4 cm longitudinal tear), extending from the middle of the trachea to the level of the carina. Surgical repair consisted in closure of the dilaceration using an autologous pericardial patch
Se queda anclado al mediastino únicamente por las estructuras vasculares. Es poco frecuente, pero patognomónico de rotura del bronquio principal.
• en ocasiones, la laceración bronquial también puede ser visualizada directamente como un defecto y/o deformidad focal en pared
tracheobronchial lesion may be also seen as a “bayonet sign” when a sharp angulation of the normal tracheal column or of the bronchial lumen occurs (Scaglione et al. 2002).
This is useful in spontaneously breathing patients who are at risk of airway loss with rapid sequence induction.98 Additionally, bronchoscopic intubation potentially allows for direct visualization of the injury. This can allow for both diagnostic and therapeutic interventions. Guiding the endotracheal tube beyond the injury can be safely accomplished with the aid of the bronchoscope. In patients with other significant injuries, this may potentially serve as a temporary, or occasionally a definitive, treatment until more concerning issues can be addressed.
For injuries without a large open wound, a collar incision is often the best approach for injuries in this area.*
Sternotomy offers no advantages in exposure owing to overlying cardiac and vascular structures**
*For penetrating wounds or large tears, the wound edges may require debridement before suture closure.
~ In particular, excessive circumferential dissection beyond area of injury can result in damage to the blood supply to the tracheobronchial tree, which can threaten the healing and lead to stenosis or leak.
**If resection of a small portion of the trachea is required, the neck should be flexed during repair and maintained postoperatively by using a chin-tochest stitch. I***
Tracheostomy is seldom required for these injuries if successful endotracheal intubation is performed. For patients unable to be intubated orally, a tracheostomy may be necessary for airway control. Tracheostomy is also indicated for proximal airway injuries near the vocal cords, where airway obstruction owing to edema can occur. For relatively small anterior penetrating cervical tracheal injuries, tracheostomy via the tracheal injury defect may be an alternative to primary repair
The choice of incision depends on the mechanism of injury (blunt or penetrating), the location of the injury, and the suspected presence of associated injuries (i.e. esophagus or major vessel). • Collar Incision • For tracheal injuries, a collar incision is made approximately 2 fingerbreadths above the sternal notch, extending to the medial borders of the sternocleidomastoid muscles.
After the collar skin incision is made, the platysma is divided, and subplatysmal flaps are created superiorly and inferiorly to expose the strap muscles. • The strap muscles are divided in the avascular plane along the midline to expose the trachea, larynx, and thyroid gland.
Strap infrahiodeos o suprahioideos
The thyroid isthmus will often need to be divided in order to fully expose the underlying trachea and larynx. This can be accomplished using electrocautery or suture ligation.
The larynx may also be accessed from the collar incision provided a generous superior extension of the subplatysmal flap is performed.
• Sternocleidomastoid Incision • In patients with suspected associated injuries to the esophagus or major vessels, an incision over the anterior border of the sternocleidomastoid is preferable (reference Chapter 13, Cervical Esophagus for images). • A neck incision is made through the skin and the platysma is divided. • The sternocleidomastoid muscle is retracted laterally to expose the carotid sheath. • Division of the omohyoid muscle allows exposure of the deep structures of the neck. • The carotid sheath is then retracted laterally with the sternocleidomastoid muscle to expose the trachea and esophagus. • Bilateral sternocleidomastoid incisions may be necessary for penetrating transcervical wounds
Sternotomy • For lower tracheal injuries, a median sternotomy or partial upper sternotomy may be necessary. This will usually be an inferior extension of the sternocleidomastoid or collar incision
Repair • Most penetrating laryngotracheal injuries without significant tissue loss can safely be managed by primary repair and without a tracheostomy. • All devitalized tissue must be debrided prior to repair or reconstruction. • Most injuries to the trachea can be primarily repaired using simple, interrupted, absorbable suture.
In the military arena, Zakharia et al [24] reported 1992 casualties during the Lebanon's conflict, with an incidence of 11%. Petricevic and associates [25] reported on 2547 casualties from the Balkan war experience, 16% of those sustained both blunt and penetrating chest wounds
The clinical presentation of patients sustaining penetrating pulmonary injuries ranges from hemodynamic stability to cardiopulmonary arrest.
Hamman’s sign (a.k.a. Hamman’s crunch) is a “mediastinal crunch” heard upon auscultation in the setting of mediastinal emphysema (air in the mediastinum).
With each heartbeat, the air is displaced creating this auscultatory finding. This sound is similar to “crackles” that can be heard in the lungs in patients with pulmonary fibrosis. Mediastinal emphysema can occur after esophageal rupture or after cardiac surgery.
A standard supine posteroanterior CXR is the most frequently used diagnostic modality in patients who sustain traumatic lung injury. Radiological diagnosis of traumatic pulmonary injuries is based on the presence of pneumothorax, pleural fluid collections, intrapulmonary hematomas, traumatic pneumatoceles, and pulmonary parenchymal contusion
About 80% to 85% of penetrating and more than 90% of blunt trauma to the lungs can safely be managed with thoracostomy tube drainage and supportive measures alone
Neumonectomía tras trauma asociado alta tasa mortalidad
The type of lung operation is determined by the site and severity of lung injury, the shape and direction of apenetrating lung wound, the hemodynamic condition of the patient, and the experience of the surgeon. The operative techniques may include suturing of the bleeding lung, lung tractotomy, wedge resection, lobectomy, and total pneumonectomy
Aplicación pegamento tisular ~ útil hemostasia y fuga aérea menor.
Éstas requieren lobectomía o neumonectomía.
A GIA 55 or 75 stapler with 3.8 mm staples is placed through the orifices of entrance and exit and fire This will open the tract traversed by the missile or other wounding agent effectively exposing the injured vessels and bronchi which are then selectively ligated utilizing absorbable suture (Figure 6). The lung parenchyma can then be approximated with a single running locked suture. The integrity of the suture line is tested by having the anesthesiologist inflate the lung, and the air leaks are then detected and repaired [11,46]
On rare occasions, tractotomy may devascularize segments of the lung, resulting in subsequent ischemic necrosis and lung abscess. The tractotomy should be performed parallel to the vascular supply whenever possible. The lung adjacent to the tractotomy should be always assessed for viability and any questionable tissue should be resected.
After resection of the lower lobe, avoid torsion of the remaining upper lobe. Failure to recognize this problem results in ischemic necrosis of the normal lobe. The remaining lung parenchyma can be tacked into place using superficially placed 3-0 sutures on a tapered needle.
e. Acute occlusion may aggravate the hemodynamic condition of the patient because of acute right sided cardiac strain. An alternative to clamping the hilum is to perform a “hilar twist” after release of the inferior pulmonary ligament. The whole lung is twisted 180° around the hilum.
* Requerirán manejo quirúrgico pero por suerte son infrecuentes.
