The importance of the thoracic aorta in ensuring the vital functions of the body. Emergency medical care for trauma Thoracic vessels

In 90% of cases, damage to the thoracic vessels is caused by penetrating wounds. Blunt aortic injuries occur in 10-15% of all car accidents; in 70-90% of patients with such injuries die before arriving at the hospital. Most often, such injuries damage the proximal part of the descending aorta. In typical cases, the aorta is damaged at the level of the ligamentum arteriosus, just distal to the orifice of the left subclavian artery. Blunt chest injuries occur in frontal collisions, although recent research suggests a role for side impacts. Collisions or compression may damage the brachiocephalic trunk, pulmonary veins, and vena cava.

Symptoms of thoracic vessel damage

Typically, patients with penetrating wounds associated with vascular injury exhibit hemodynamic instability, often with ongoing bleeding. Such patients should be taken immediately to the operating room for emergency thoracotomy. In this case, the diagnosis is clarified during the procedure, and then injury to the vessels of the chest is excluded or confirmed. In patients with blunt trauma, they may initially appear hemodynamically stable, and vascular injury is often masked by concomitant injury to other structures. A high probability of damage to large vessels of the chest is indicated by:

• — shock/hypotension;
• - difference in blood pressure or pulse between the two upper or lower limbs (in case of damage to the brachiocephalic trunk or subclavian artery);
• - difference in blood pressure between the upper and lower extremities (pseudocoarctation syndrome);
• - an increasing hematoma located at the level of the exit from the chest;
• - pathological mobility of the chest (“dangling” chest);
• - noise heard above the scapula;
• - palpable fracture of the sternum;
• - palpable fracture of the thoracic spine;
• - external signs of serious chest injury;
• - chest injury resulting from a collision or compression of the chest.

Diagnosis of thoracic vessel injuries

The possible scope of a diagnostic examination will depend on the severity of the general condition of the victim, as well as on the stability of hemodynamics, the nature of damage to the aorta and other structures.

Chest X-ray

AP radiography is an important screening test and should be performed in all patients with penetrating wounds or suspected blunt chest injuries. In patients with penetrating wounds, it is useful to use special radiopaque markers to mark the entry and exit wounds.

In 90% of cases, injuries to the thoracic aorta are combined with widening of the mediastinum on chest radiographs, while the sensitivity of this sign is 90%, and the negative predictive value is 95%. Other radiological signs of damage to the descending aorta:

• changes in the mediastinum:
• widening of the mediastinum by more than 8 cm;
• blurred contour of the aortic arch;
• descent of the left main lobar bronchus by more than 140 degrees;
• disappearance of the paravertebral pleural line;
• lateral displacement of the tracheal contour;
• bending of the contour of a gastric tube passed through the nose;
• calcification of the aortic arch;
• fractures of the sternum and scapula, as well as a fracture of the clavicle in a patient with polytrauma, multiple fractures of the ribs;
• other findings revealed on radiographs performed in a direct projection: apical pleural hematoma (in the area of ​​the apex of the lung shadow), massive left-sided hematoma, rupture of the diaphragm;
• findings revealed on a radiograph taken in a lateral projection: anterior displacement of the trachea, absence of an aortopulmonary window.

If these findings are identified on radiographs, a more in-depth examination of the patient is indicated. Angiography and spiral CT are usually necessary.

In case of damage to the thoracic vessels

Aortography allows you to identify, localize and determine the extent of damage to the aorta; it can be used for planning surgical intervention, because Depending on the type of aortic injury, different versions of thoracotomy may be required. Aortography is indicated in patients with penetrating chest wounds suspicious for possible injury to the innominate, carotid, or subclavian arteries, but only if they are hemodynamically stable. The proximity of the wound channel to the brachiocephalic vessels may be an indication for arteriography, even in the absence of any objective symptoms of vascular damage.

Spiral CT

Spiral CT is no longer used only for the purpose of screening examination and selection of patients for angiography. It is considered a decisive diagnostic procedure, allowing fairly accurate recognition of aortic injuries and ruptures.

Compared to arteriography, this research method is less invasive, faster and more accessible. In addition, it allows you to detect damage not only to blood vessels, but also to other important structures. However, the inability to contact the patient during the examination limits its use in unstable patients.

Other Imaging Techniques

In selected cases of thoracic vascular injury, transesophageal echocardiography and intravascular ultrasound scanning can be additionally used, but their use is currently limited.

Treatment of thoracic vessel injuries

Indications for emergency surgery in case of damage to the thoracic vessels are: hemodynamic instability, an increase in the volume of blood discharged from the chest, as well as radiological signs of an increasing hematoma.

Damage to the thoracic vessel is indicated by an initially large volume of blood released through the drainage at the time of its placement (>1500 ml) or continued release of blood at a rate exceeding 200-300 ml/hour. In these cases, thoracotomy is indicated. However, if the patient’s hemodynamics are stable, it is better to perform the operation at a later date.

In patients with stable hemodynamics, reconstructive intervention on the aorta should be delayed in cases where they have:

• - trauma to the central nervous system with coma,
• - respiratory failure due to pulmonary contusion,
• - burns to the surface of the body,
• - heart bruise,
• - damage to internal organs subject to conservative treatment,
• - retroperitoneal hematoma,
• - contaminated wounds,
• — hypothermia, coagulopathy and other conditions, the elimination of which will improve the outcome of the operation,
• - concomitant diseases, and the patient’s age exceeds 50 years.

In some situations, with minimal damage to the aorta, for example, intimal defects, small patch injuries, pseudoaneurysms, dynamic monitoring of the patient is possible. If conservative treatment tactics are initially chosen, the patient should be closely monitored and controlled hypotension should be carried out, maintaining systolic pressure below 120 mmHg. Hg, or mean arterial pressure below 80 mm. Hg Aronstam et al. reported a beneficial effect of beta blockers in patients with blunt aortic trauma, and many protocols now include intravenous titration of beta blockers under heart rate monitoring.

Surgical reconstruction

Adequate exposure of the proximal and distal segments of the damaged vessel is required, which makes it possible to control both central and retrograde blood flow. Before surgery, it is necessary to treat the skin of the anterior surface of the neck, chest, abdomen and lower extremities.

Surgical intervention for damage to the thoracic vessels can be performed using four approaches.

Left anterolateral thoracotomy is indicated for hypotensive, unstable patients with undiagnosed injuries. The patient is placed in the supine position and an anterolateral thoracotomy is performed in the fourth intercostal space. If necessary, the access can be expanded by extending it in the medial direction, crossing the sternum or posteriorly.

Posterolateral thoracotomy is performed in the fourth intercostal space and can be supplemented by resection of the fifth rib, resulting in excellent visibility of most of the left half of the chest. The incision can be extended medially across the sternum or towards the abdominal wall, which will allow for additional revision and exclude other injuries.

Median sternotomy is indicated for patients with damage to the ascending aorta, transverse aortic arch, innominate artery, and proximal segments of the carotid and subclavian arteries. For better exposure of the aortic arch and brachiocephalic branches, the incision can be extended into the neck.

To access the proximal segments of the subclavian artery, either a median sternotomy or an anterolateral thoracotomy at the level of the middle third of the intercostal space can be used. If necessary, to stop retrograde bleeding, the subclavian artery can be isolated from a separate supraclavicular approach.

The main debate concerns the need to use circulatory support to supply blood to organs located distal to the damaged segment of the thoracic aorta at the stage of reconstruction in case of damage to the thoracic vessel. Many still advocate a simple clamping technique without systemic administration of anticoagulants and without the use of auxiliary shunts. However, other authors prefer to use one of the options for circulatory support. In this case, the most promising are two options for bypass surgery: from the left atrium to the distal segment of the aorta or to the femoral artery. Regardless of the technique used, paraplegia occurs in approximately 8% of patients, and to date there have been no randomized trials regarding the benefit of either technique.

Endovascular reconstructions

Stent grafts have been successfully used to treat descending aortic aneurysms as well as type B aortic dissections. These techniques have been successfully used to treat traumatic injuries of the aorta and are associated with significantly fewer complications and less mortality.

In hemodynamically stable patients with suitable aortic anatomy, arthroplasty should be considered the preferred treatment option.

The thoracic cavity also contains visceral and parietal lymph nodes. Visceral lymph nodes, nodi lymphatici viscerales :

1. Anterior mediastinal lymph nodes, nodi lymphatici mediastinales anteriores . They are located in the anterior mediastinum, on the anterior surface of the superior vena cava and aortic arch. The lymphatic vessels of the s., pericardium, and thymus gland flow into these lymph nodes, i.e. organs of the anterior mediastinum.

2. Posterior mediastinal lymph nodes , nodi lymphatici mediastinales posteriores . Located in the tissue of the posterior mediastinum. Take lymph from the organs of the posterior mediastinum.

3. Bronchopulmonary lymph nodes , nodi lymphatici bronchopulmonales . Among them, intraorgan nodes are distinguished (located in each lung and in the places of branching of the bronchi) and extraorgan nodes (grouped around the main bronchus, in the area of ​​the hilum of the lung). The efferent lymphatic vessels of these nodes flow into the tracheobronchial lymph nodes, and sometimes directly into the thoracic duct.

4. Tracheobronchial lymph nodes , nodi lymphatici tracheobronchiales :

Lower tracheobronchial (bifurcation) lymph nodes , nodi lymphatici tracheobronchiales inferiores. They lie under the bifurcation of the trachea.

Upper tracheobronchial lymph nodes (right and left), nodi lymphatici tracheobronchiales superiores dextri et sinistri . Located on the lateral surfaces of the trachea. The efferent lymphatic vessels of the tracheobronchial lymph nodes participate in the formation of the right bronchomediastinal trunk, some of them flow directly into the thoracic duct.

Parietal lymph nodes, nodi lymphatici parietalеs . Among them are:

1. Superior diaphragmatic lymph nodes , nodi lymphatici phrenici superiores . Located on the diaphragm and around the pericardium. Lymph is collected from the diaphragm, pericardium, pleura and diaphragmatic surface of the liver. The efferent lymphatic vessels from these lymph nodes empty into the periosternal, posterior mediastinal and tracheobronchial lymph nodes.

2. Parasternal lymph nodes , nodi lymphatici parasternales .Lie to the right and left of the sternum, on the inner surface of the anterior chest wall. Lymph is collected from the tissues of the anterior chest wall, pleura, pericardium, from the mammary gland, as well as from the lower epigastric nodes. The efferent lymphatic vessels from the parasternal lymph nodes go to the anterior mediastinal lymph nodes, and can also flow directly into the thoracic duct or the left jugular trunk.

3. Intercostal lymph nodes , nodi lymphatici intercostales . They are located in the intercostal spaces, near the posterior intercostal vessels. Take lymph from the back wall of the chest cavity. The efferent lymphatic vessels of these lymph nodes empty into the thoracic duct and into the deep lateral cervical lymph nodes.

The blood vessels of the human upper back and chest include the main arteries and veins, as well as the heart. These vital structures are critical to the process of pumping venous blood to the lungs for gas exchange, as well as pumping oxygenated blood to the body's tissues to support their metabolic functions.

The heart is the pump of the body's circulatory system, which is responsible for moving blood throughout the body. The heart acts as a double action pump as it pumps venous blood to the lungs, and oxygenated blood to the body tissues with each heartbeat... [Read below]

• Chest and upper back

[Start at the top]… The heart is primarily composed of cardiac muscle tissue, which requires a constant supply of oxygen to the blood. The left and right coronary arteries provide this blood supply to meet the heart's own energy needs. A slight blockage in the coronary arteries leads to chest pain, this is called angina pectoris; Complete blockage of the coronary arteries leads to myocardial infarction, more commonly known as a heart attack.

Pulmonary arteries and veins

The pulmonary arteries and pulmonary veins provide vital conduits but only provide a short distance of blood flow between the heart and lungs. Leaving the heart from the right ventricle, venous blood flows through the greater pulmonary trunk before dividing into the left and right pulmonary arteries. The pulmonary arteries carry blood to a huge structure of small arterioles and capillaries in the lungs, where they release carbon dioxide and receive oxygen from the air in the alveoli of the lungs. These capillaries merge into larger venules, which further merge into the left and right pulmonary veins. Each pulmonary vein carries blood from the lungs back to the heart, where it returns through the left atrium.

Oxygenated blood leaves the left ventricle of the heart and enters the aorta, the largest artery in the human body. The ascending aorta, located above the heart, before it makes a 180-degree turn to the left, is called the aortic arch. From there it passes posteriorly from the heart of the thoracic aorta towards the abdominal cavity.

The branches of the aorta, passing through the chest, branch into several large arteries, as well as many small ones.
The left and right coronary arteries arise from the ascending aorta, which supplies the heart with its vital areas.

The arch of the aortic branches consists of three large arteries - the brachiocephalic trunk, the left common carotid artery and the left subclavian artery. These arteries collectively supply oxygen to the head and arms.

The thoracic aorta continues with many small arteries that supply blood to the organs, muscles and skin of the chest before entering the abdomen, the abdominal aorta.
Blood from the abdominal aorta supplies oxygen and nutrients to the vital organs of the abdominal cavity through the arteries of the celiac trunk and the common hepatic artery.

Completion of the circulatory cycle

At the end of the circulatory cycle, the veins of the upper body carry blood with waste products and carbon dioxide from the body tissues back to the heart, from where it again flows through the lungs to all organs of the body.

Blood returning to the heart from the lower torso and legs enters the upper torso into a large vein called the inferior vena cava. The inferior vena cava takes blood from the hepatic and phrenic veins before entering the right atrium of the heart. Blood returning from the head enters the torso through the left and right jugular veins, and blood returning from the arms exits through the left and right subclavian veins.

The jugular and subclavian veins on each side merge to form the left and right brachiocephalic trunks, which merge into the superior vena cava. Several small veins that carry blood from the organs, muscles, and skin of the upper torso also drain into the superior vena cava, which carries blood from the arms and head to the right atrium of the heart.

Lymph nodes and vessels of the chest. Topography, structure, location of the lymph nodes and vessels of the chest.

In the chest cavity there are parietal and visceral lymph nodes.

Parietal nodes located on the back wall of the chest - prevertebrates, nodi lymphatici prevertebrales, And intercostal, nodi lymphatici intercostales; on the front wall - circumthoracic, nodi lymphatici paramammarii, and periosternal, nodi lymphatici parasternals; on the bottom wall - superior diaphragmatic, nodi lymphatici phrenici superiores.

Among the visceral nodes there are prepericardial and lateral pericardial nodes, nodi lymphatici prepericardiales et pericardiales laterhles; anterior mediastinal nodes, nodi lymphatici mediastinals anteriores, And posterior mediastinal nodes, nodi lymphatici mediastinals posteriores.

The posterior mediastinal nodes lie at the hilum of the lung - bronchopulmonary (root) nodes, nodi lymphatici bronchopulmonales (hilares) around the tracheal bifurcation - upper and lower tracheobronchial nodes, nodi lymphatici tracheobronchites superiores et inferiores; along the esophagus - pulmonary juxta esophageal nodes, nodi lymphatici jucstaesophageales pulmonales.

Lymphatic vessels of the outer integument of the anterior and lateral walls of the chest are directed mainly to nodi lymphatici axillares, some of the trunks pass through the collarbone and flow into the deep cervical nodes.

From the inside of the chest and from the pleura, lymphatic vessels are directed through the nodi lymphatici intercostales to the ductus thoracicus, more anteriorly - in nodi lymphatici parasternales. The efferent lymphatic vessels of the mammary gland go from its lateral sections to the axillary nodes, from the posterior to the supraclavicular and subclavian, and from the superomedial to the parasternal. During pregnancy and lactation, the lymphatic channel of the gland expands, and in old age, as the gland inflates, it narrows.

Lymphatic vessels of the diaphragm drain into nodi lymphatici phrenici, located at the crura of the diaphragm, partly to the mediastinal nodes, partly to nodi lymphatici parasternales.

The lymphatic vessels of the viscera are described after describing the anatomy of the corresponding organ (see “Splanchnology”).

Lymph from the organs of the chest cavity is collected in two large trunks, trunci bronchomediastinales dexter et sinister that flow into: right - into ductus lymphaticus dexter, left - in ductus thoracicus.

The draining lymphatic vessels of individual organs of the thoracic, abdominal and pelvic cavities can either connect with each other on the way to regional nodes, or flow into common regional nodes, thereby establishing a connection between lymph flows from individual organs. These connections have practical implications for understanding how cancer spreads.

In the chest cavity, parietal (parietal) lymph nodes are distinguished, lying on the corresponding walls (anterior, lower and posterior), and visceral (internal), located in the chest cavity on the paths of lymph flow from its internal organs.

Parietal (parietal) lymph nodes are the periosternal lymph nodes (nodi lymphatici parasternales), no 2-20 on each side. They are located on the inner (posterior) surface of the anterior chest wall to the right and left of the sternum and are adjacent to the internal mammary arteries and veins; in rare cases, single nodes are located on the posterior surface of the sternum. Lymphatic vessels flow into the periosternal lymph nodes not only from the tissues of the anterior chest wall, pleura and pericardium, lower epigastric and upper phrenic lymph nodes, but also from the diaphragmatic surface of the liver (penetrate through the diaphragm) and from the mammary gland. The efferent lymphatic vessels of the right parasternal lymph nodes flow into the right jugular trunk and into the prevenous lymph nodes located in the upper mediastinum. The vessels of the left parasternal nodes go to the pre-aortic lymph nodes, and also flow directly into the thoracic duct and into the left jugular trunk.

In the intercostal spaces on each side of the spinal column, near the posterior intercostal vessels, there are posterior intercostal lymph nodes (nodi lymphatici intercostales, 1-7 in total). Lymphatic vessels from the posterior wall of the chest cavity are directed to these nodes. The efferent lymphatic vessels of the intercostal nodes flow into the thoracic duct, and from the upper nodes into the deep lateral cervical (internal jugular) lymph nodes located near the internal jugular vein.

The superior phrenic lymph nodes (nodi lymphatici phrenici superiores) lie on the diaphragm, to the left of the inferior vena cava and around the pericardium, at the points where the right and left phrenic nerves and musculo-phrenic arteries enter the diaphragm. Depending on their position in relation to the pericardium, this group is divided into non-permanent lateral pericardial, prepericardial and retropericardial lymph nodes. Paired lateral pericardial nodes (nodi lymphatici pericardiales laterales, 1-4 on the right and 1-2 on the left) are found more often (in 50% of cases) near the right phrenic nerve than near the left (10%). Prepericardial lymph nodes (nodi lymphatici prepericardiales, 1-7 in total) are located behind the xiphoid process, as well as near the musculophrenic arteries at the site of their entry into the diaphragm. Beneath the pericardium, near the inferior vena cava and anterior to the esophagus, lie the retropericardial lymph nodes (1-9). Lymphatic vessels from the diaphragm, pericardium, pleura and diaphragmatic surface of the liver are directed to the diaphragmatic nodes (perforate the diaphragm). The efferent lymphatic vessels of the upper diaphragmatic lymph nodes drain mainly into the periosternal, posterior mediastinal, lower tracheobronchial and bronchopulmonary lymph nodes.

The visceral (internal) lymph nodes include the anterior and posterior mediastinal, tracheobronchial and bronchopulmonary lymph nodes. The anterior mediastinal lymph nodes (nodi lymphatici mediastinales) are located in the upper mediastinum (in the upper part of the anterior mediastinum), on the anterior surface of the superior vena cava and brachiocephalic veins, the aortic arch and arteries branching from it, upward from the base of the heart. According to their position, these nodes (according to Rouvier-Zhdanov) are divided into precaval (prevenous) lymph nodes (1-11), which lie in front of the superior vena cava and right brachiocephalic veins; preaortocarotid (3-18), located on the anterior surface of the left brachiocephalic vein and brachiocephalic trunk.

The anterior mediastinal lymph nodes receive lymphatic vessels of the heart, pericardium, thymus and efferent lymphatic vessels of the bronchopulmonary and tracheobronchial lymph nodes. From the lymph nodes located in the upper and anterior parts of the mediastinum, several rather large lymphatic vessels emerge, heading up to the neck area - to the right and left venous angles. The efferent lymphatic vessels of the prevenous lymph nodes form a small-diameter short right lymphatic duct (truncus lymphaticus dexter), which is found in Va cases, as well as in the right lymphatic duct or in the right jugular trunk and peribronchial lymph nodes. The efferent lymphatic vessels of the preaortocarotid nodes flow into the thoracic duct, the left jugular trunk, and also go to the left lateral (internal) jugular lymph nodes. Thus, lymph from the lymph nodes of the anterior (upper) mediastinum can flow towards both the right and left venous angle.

The posterior mediastinal lymph nodes (nodi lymphatici mediastinales posteriores, 1-15 in total) are located in the tissue near the thoracic aorta and near the esophagus, receiving lymph from the organs of the posterior mediastinum. Lymph nodes lying next to the esophagus (in front of it) and on the sides - paraesophageal, as well as those located between the aorta and esophagus - interaortotitis (1-8), occur in approximately 60% of cases. Behind the aorta and to the side of it, peri-aortic lymph nodes are found even less frequently - in less than 30% of cases. The efferent lymphatic vessels of these nodes flow directly into the thoracic duct, as well as into the lower tracheobronchial and, rarely, into the left extraorgan bronchopulmonary lymph nodes.

On the paths of the lymphatic vessels of the lung there are bronchopulmonary lymph nodes, 4-25 in total. Intraorgan bronchopulmonary nodes are located in each lung in places where the main bronchi branch into lobar and lobar into segmental, and extraorgan (root) nodes are grouped around the main bronchus, near the pulmonary arteries and veins. The efferent lymphatic vessels of the right and left bronchopulmonary nodes are directed to the lower and upper tracheobronchial lymph nodes. Sometimes they flow directly into the thoracic duct, as well as into the prevenous nodes (right) and preaortocarotid nodes (left).

The lower tracheobronchial (bifurcation) lymph nodes (nodi lymphatici tracheobronchiales inferiores, total 1-14) lie under the bifurcation of the trachea, and the upper tracheobronchial (right and left) lymph nodes (nodi lymphatici tracheobronchiales superiores dextri, 3-30, et sinistri, 3-24 ), located on the lateral surface of the trachea and in the tracheobronchial angle formed by the lateral surface of the trachea and the upper semicircle of the main bronchus of the corresponding side. The efferent lymphatic vessels of the bronchopulmonary nodes, as well as other visceral and parietal nodes of the thoracic cavity, are directed to these lymph nodes. The efferent lymphatic vessels of the right upper tracheobronchial nodes participate in the formation of the right bronchomediastinal trunk and the right lymphatic duct. There are also pathways for lymph outflow from the right upper tracheobronchial lymph nodes towards the left venous angle. The efferent lymphatic vessels of the left upper tracheobronchial lymph nodes empty into the thoracic duct.