Scholarly article on topic 'Combined tracheoesophageal transection after blunt neck trauma'

Combined tracheoesophageal transection after blunt neck trauma Academic research paper on "Clinical medicine"

Share paper
OECD Field of science

Academic research paper on topic "Combined tracheoesophageal transection after blunt neck trauma"

Review Article

Combined tracheoesophageal transection after blunt neck trauma

Umar Imran Hamid, James Mark Jones

Department of Cardiothoracic Surgery, Royal Victoria Hospital, Grosvenor road, Belfast, UK BT12 6BA


Survival following tracheoesophageal transection is uncommon. Establishing a secure airway has the highest priority in trauma management. Understanding the mechanism of the incident can be a useful adjunct in predicting the likelihood and severity of specific anatomical patterns of injuries. We discuss published literature on combined tracheoesophageal injuries after blunt neck trauma and their outcome. A search of MEDLINE for papers published regarding tracheoesophageal injury was made. The literature search identified 14 such articles referring to a total of 27 patients. Age ranged from 3-73 years. The mechanism of injury was secondary to a rope/wire in 33%, metal bar in 4% of cases and unspecified in 63%. All of the patients were managed surgically. A number of tissues were used to protect the anastomosis including pleural and sternocleidomastoid muscle flaps. There were no reported mortalities. Patients with combined tracheoesophageal injury after blunt neck trauma require acute management of airway along with concomitant occult injuries.

Key Words: Esophageal injury, neck trauma, tracheal injury


Combined blunt traumatic injuries of the trachea and esophagus are infrequent and most patients with complete tracheal transection probably die at the scene due to loss of the airway.[1] The few who survive and arrive at a hospital will pose a challenge to the trauma team in terms of acute management of the airway and diagnosis of occult injuries. These patients may suffer fatal outcomes if misdiagnosed or long-term complications if improperly treated. The signs and symptoms require a high index of clinical suspicion. In patients with a transected trachea utmost care must be taken not to convert a partial injury to a complete transection. If unrecognized it is likely to result in a fatal outcome if the distal segment is not intubated. Fiber optic intubation should be used in patients in whom airway trauma is suspected.[2,3]

Address for correspondence:

Mr. Umar Imran Hamid, E-mail:

METHODS Selection

A search of MEDLINE for papers published regarding tracheoesophageal injury was made. The following MeSH headings were used: Tracheal injury, esophageal injury, tracheoesophageal transection and aero digestive injuries. The search was limited to combine tracheal and esophageal injuries after blunt neck trauma and was confined to articles published in English.

Data extraction

The data extracted from each publication was: First author, publication year, age, time to surgery, mechanism of injury, level of injury, type of interposition tissue used, type of repair and outcome.

Outcomes of interest

The outcomes of interest were survival and post-operative complications.


Publications included

The literature search identified 14 such articles referring to a total of 27 patients [Table 1].[4-17] Age ranged from 3-73 years, 46% of the patients were under 25 years of age.[4-7,9,11-17] This may be

Access this article online

Quick Response Code: Website:

DOI: 10.4103/0974-2700.110774

due to the prevalence of use of motorbikes in this age group where the neck is exposed and therefore prone to trauma from wires and hyperextension injuries.[18] The mechanism of injury was secondary to a rope/wire in 33%, metal bar in 4% of cases and unspecified in 63%. At the time of presentation symptoms and signs included neck abrasions, laceration, sub-cutaneous emphysema, dysphonia and respiratory compromise. All of the patients were managed surgically. A number of tissues were used to protect the anastomosis including pleural and sternocleidomastoid muscle flaps. In 88% (n = 24) of the cases, primary repair was carried out at the time of surgery with good outcome. No mortalities were reported in the current literature review, airway was promptly established and associated injuries were identified at the time of surgery [Table 1].


Combined tracheoesophageal injury is rare and most trauma or emergency centers would have limited experience. The true incidence of combined tracheoesophageal injury is difficult to discern as most succumb at the scene due to compromised airway. Blunt neck trauma is also associated with cervical spine injury and only rarely with injury to the carotid artery.


Patients with these injuries account for less than 1% of patients presenting to the hospital following trauma. Over 2,000 people in the United Kingdom die of neck trauma every year.[19]

Mechanism of injury

Blunt trauma to the neck not only occurs during motor vehicle accidents but also occurs with sports-related injuries and strangulation. In motor vehicle accidents where driver is not belted, the driver may be thrust forward with the head extended, forcing the anterior neck against the steering column. The mechanisms of tracheal transection as proposed by Kirsh, et aL are as follows:[20]

1. Impact to the exposed anterior aspect of the neck may crush the larynx or the trachea, particularly at the cricoid ring, and compress the esophagus against the posterior spinal column.

2. Rapid deceleration can also produce a shearing force that disrupts the trachea, which is fixed at the carina and cricoid cartilage.

3. Direct compression of the trachea between the sternum and vertebral column may produce a focal point for transection in association with other forces.

4. Reflex closure of glottis with an associated increase in intra-thoracic pressure may cause barotraumatic rupture.

Initial assessment and management

Standard principles governing assessment and management of a polytrauma patient should follow the advance trauma life support (ATLS®) guidelines.[21] The primary goal should be establishment of a secure airway with cervical spine immobilization followed by assessment of the associated injuries. Fiber optic bronchoscopy can be used to direct the endotracheal tube safely into the distal segment of the trachea thus avoiding extra-tracheal intubation

within the soft tissues of the neck. During the resuscitation and initial assessment phase, the cervical spine should be assumed to be injured and should be splinted using a cervical spine collar, two sandbags and a forehead tape.

Signs and symptoms

Clinical examination has a key role in trauma patients despite the routine use and advancement of radiological imaging.

Various signs associated with tracheal injury include aphonia, hoarseness, hemoptysis and subcutaneous emphysema.[22] These result from air escaping from the trachea into the surrounding tissues and a lack of air passing through the glottic region. Undiagnosed tracheal injury may become evident by presence of massive subcutaneous emphysema. An air leak on chest drain insertion may not be present unless there is breaching of the mediastinal pleura or an additional bronchopleural fistula.

Esophageal injuries may have more subtle signs and symptoms including vague chest pain, odynophagia and subcutaneous emphysema at the thoracic outlet. The presence of mediastinal pneumatosis with associated pleural effusions on chest films should raise such suspicion.[23]

Of the few patients with associated carotid artery injury, most remain asymptomatic or develop neurologic deficits shortly after injury. Typical symptoms of carotid artery injury are pain in the ipsilateral face or neck, followed by contralateral weakness or sensory loss. Horner's syndrome associated with pain is characteristic of carotid artery injury. The interval between blunt cervical injury and neurological deficits may be hours, days, or even months.[24]

Cervical spine injury is associated with presence of neck pain and tenderness with neurological deficit in the extremities.


Performing whole body imaging on patients has become an accepted protocol in many trauma centers in the fear of missing an injury. Recent studies have shown that whole-body CT is associated with increased probability of survival in patients with polytrauma.[25]

Apart from clinical signs, radiological imaging indicating the presence of tissue pneumatosis with associated fracture of the upper ribs should raise the suspicion of an underlying airway injury. Endoscopic and CT assessment of the airway is indicated to ascertain the level and nature of injury.[3]

Esophageal injuries may require a combination of endoscopy and water-soluble contrast studies to detect any perforations. When a swallow is technically impossible or where a high index of suspicion remains despite a negative contrast study, flexible endoscopy may be used allowing direct visualization of the esophageal mucosa but care should be exercised in order to avoid exacerbation of an esophageal perforation.[26

Table 1: Summary of published cases of tracheoesophageal transection due to neck trauma

Reference Time to Year No.of Age Mechanism Airway Associated injuries Interposition tissue Site of injury Repair Morbidity

surgery patients of injury management

Odell PFW 8 hrs 1980 1 18 Cable on neck Orotracheal intubation Recurrent laryngeal 2 layer closure of 2ndTracheal ring Primary anastomosis None

nerve esophageal injury

Glatterer MS Jr[sl 41/2 hrs 1985 2 10-69 Blunt neck Not specified Recurrent laryngeal Pleural flap/2 layer Not specified Primary anastomosis Pneumonia

trauma nerve, fractured closure of esophageal

mandible injury

Kelly JP[6] Not specified 1987 2 22-48 Blunt neck Not specified Not specified Muscle flaps/2 layer Not specified Primary anastomosis None

trauma closure of esophageal


Wei man DS[7] Not specified 1988 1 15 Wire on neck Initial failed Recurrent laryngeal None 4th tracheal ring Cervical Esophageal

orotracheal intubation nerve eso ph ag osto my+de 1 ayed strict ure+Cervical

followed by immediate closure abscess


Khiew KF[8] Not specified 1990 1 Not specified Attempted suicide Tracheostomy Nil Not specified Not specified Primary anastomosis None

Ayabe Not specified 1991 1 21 Wire on neck Tracheostomy Nil 2 layer closure of 3rd tracheal ring Primary repair None

esophageal injury

Vassiliu P[10] Not specified 2001 7 Not specified Blunt neck Tracheostomy (i), Not specified Not specified Not specified Primary Repair None

injuries Orotracheal

intubation (6)

DaviesG[11] Not specified 2001 1 10 Jet ski line Crico-thyroidotomy Recurrent laryngeal None Not specified Stoma+Delayed Repair Esophageal

between boats nerve, cervical vertebral stricture


Johansson K[12] ih 2001 1 18 Rope against Tracheostomy Recurrent laryngeal None Cricoid Two stage repair Sub glottic

neck nerve stenosis

SokolovVV[13] Not specified 2001 6 3-73 Blunt neck Not specified Not specified Sternocleidomastoid Not specified Primary anastomosis None

Bernat RA[Hl Not specified 2005 1 22 Clothes line Intubation through Nil 2 layer closure of Cricothyroid plane Primary anastomosis None

neck wound esophageal injury

O'Connor AE[15] 4hrs 2006 1 10 Wire against Orotracheal intubation Nil Not specified Sub cricoid transection Primary anastomosis None

Mukherjee K[l6] Not specified 2009 1 10 Handlebar of Orotracheal intubation Nil Sternothyroid Posterior tracheal Primary anastomosis None

cycle wall+esophageal tear

Hamid Ul[1?] 6 hrs 2011 1 15 Wire on neck Initial failed orotracheal Recurrent laryngeal Thyroid Complete tracheal Primary anastomosis None

intubation followed by nerve transection+esophageal tear

fibreoptic intubation

Conventional carotid angiography is considered the gold standard in diagnosis of carotid artery injury.[27] However, CT angiography allows for rapid and safe evaluation of the carotid artery.[28]

The 2007 NICE guidelines on imaging of head injuries[29] also contain guidance on cervical spine imaging in trauma patients. A three-view plain radiography series (lateral, anteroposterior and odontoid process projections) remains the initial investigation of choice. It is recommended that patients with a glasgow coma score (GCS) below 13, intubated patients or patients being scanned for multi-region trauma should have CT scans rather than plain radiographs. Interestingly the American College of Radiology appropriateness criteria[30] recommend thin-section CT, not plain radiography, as the investigation of choice in adults.


The repair of tracheoesophageal transection poses a challenge to the trauma surgeon, as these injuries are uncommon. A multidisciplinary approach is advocated.

Esophageal injuries

The time of presentation to institution of management has an important bearing in management of thoracic esophageal injuries. It has been shown that delayed diagnosis adversely affects outcome following esophageal perforation.[31]

Esophageal injuries may be managed conservatively with or without drainage procedures or by primary repair depending upon the extent of the laceration and the site of esophageal injury.[16] Oral intake should be avoided and nutrition maintained either by a feeding jejunostomy or parenterally via central line. If the nature of the esophageal injury is such that a primary repair is not achievable or the tissues are beyond repair then a staged reconstructive procedure is advisable.[32] Initial management in these cases would be to form diversion stomas in order to minimize mediastinal contamination. A neo-esophagus can then be fashioned using either a gastric or colonic conduit at an appropriate time as dictated by the clinical state of the patient.

Tracheal injury

The principal anesthetic consideration is ventilation. Early surgical repair is the preferred treatment for most patients with a transmural tear exceeding 2 cm in length.[33] Conservative treatment may be a viable alternative for some patients. This would include those with short lacerations in the upper third of the trachea, especially if they do not involve the entire thickness of the tracheal wall.[34] The use of local muscle flaps to buttress the trachea and separate the trachea from the esophagus is an important technique in the management of combined injuries of the trachea and esophagus.[35]

Recurrent laryngeal nerve injury

Recurrent laryngeal nerve injury can be expected in approximately 60% of patients with complete transection of the cervical

trachea.[36] Bilateral vocal cord paralysis causes midline fixation and may lead to respiratory obstruction and thus threatens life. Tracheostomy is needed in such patients, while waiting for the return of function and in the perioperative period to allow edema to subside. If the vocal cord paralysis is permanent then several options to regain function is available one of which includes augmenting the glottic aperture.[37] This involves simultaneous bilateral resection of the posterior one third of the vocal folds including the vocal process. A posterior cordectomy allows for decanulation with preservation of respiratory function and phonation.

Carotid artery injury

Treatment options in carotid artery injury include observation, antithrombotic therapy, and endovascular stenting.[38,39] The need for surgical intervention is rare. The requirement for surgical reconstruction is determined by the thrombogenicity of the injured carotid artery, the state of the collateral circulation to the brain, the presence of an expanding hematoma or worsening neurological symptoms despite anticoagulation.[39]

Cervical spinal injury

The management of spinal trauma ranges from dealing with patients with trivial injuries through to major complex, spinal cord trauma which may be life threatening. Many patients can be managed conservatively. The options for non-operative treatment of the cervical spine range from the application of a lightweight orthosis through to a reduction with halo traction and rigid stabilization with a halo jacket. The principles of treatment are to decompress neurological structures and restore vertebral column integrity. Indications for surgical stabilization in sub-axial fractures include failure of closed reduction, unstable injuries and progressive neurological deterioration.[40]


Complications of tracheoesophageal transection include esophageal strictures and tracheoesophageal stenosis.[13] Ischemia and anastomotic leaks are known risk factors in esophageal stricture formation.[41] Three patients in the current literature review underwent delayed repair of their injuries and of these two patients developed esophageal stricture formation[7,11] and one developed subglottic stenosis.[12] None of these patients developed anastomotic leak during their post-operative period. Stricture formation in these patients may be contributed by the severity of local tissue damage and ischemia at the time of the injury which had necessitated the staged reconstruction during their initial surgery. However, no stricture formation was seen in the group that underwent primary repair.

Tracheoesophageal fistula (TOF) is a rare complication. High cuff pressures, infection and ischemia are known factors that may be implicated in fistula formation.[42,43] Two layered closure of esophageal injury and re-enforcement with tissue flaps are protective of TOF formation^ as inferred from the current literature review where none of the patients undergoing this type of repair developed delayed TOF.

Symptoms in TOF usually develop 3 to 10 days after the initial blunt trauma.[44] Coughing after swallowing, Ono's sign is the classic symptom in TOF but other symptoms include hemoptysis, increased tracheal secretions, copious production of sputum, dysphagia, hoarseness, and odynophagia. The diagnosis is typically established with the use of contrast studies, endoscopy, and bronchoscopy. However, the false-negative rates are up to 33% for endoscopy and 12.5% for contrast studies.[45] Surgical repair should be carried out as soon as possible after diagnosis. Non-operative management carries a high mortality of 80%, while operative mortality is only 9.3%.[46] The repair is best carried out through a right posterolateral thoracotomy, which allows access to all levels of the trachea and esophagus. The use of interposition tissue is recommended not only to protect the suture line but also to prevent recurrence of TOF.[47] Temporary esophageal stenting may be an alterative option in patients who are critically ill and unable to undergo corrective surgery.[48]

In conclusion, presentation of patients to hospital with combined transection of the trachea and esophagus is rare after blunt trauma. Once an airway is secured in the acute setting a high index of clinical suspicion with appropriate contrast or endoscopic examination should be present to diagnose occult injuries including those to the esophagus.


1. Dertsiz L, Arici G, Arslan G, Demircan A. Acute tracheobronchial injuries: Early and late term outcomes. Ulus Trauma Acil Cerrahi Derg 2007;13:128-34.

2. Baumgartner FJ, Ayres B, Theuer C. Danger of false intubation after traumatic tracheal transsection. Ann Thorac Surg 1997;63:227-8.

3. Lee WT, Eliashar R, Eliachar I. Acute external laryngotracheal trauma: Diagnosis and management. Ear Nose Throat J 2006;85:179-84.

4. Odell PF, LeBrun CJ. Tracheo-esophageal disruption. J Otolaryngol 1980;9:433-7.

5. Glatterer MS Jr, Toon RS, Ellestad C, McFee AS, Rogers W, Mack JW, et al. Management of blunt and penetrating external esophageal trauma. J Trauma 1985;25:784-92.

6. Kelly JP, Webb WR, Moulder PV, Moustouakas NM, Lirtzman M. Management of airway trauma. II: Combined injuries of the trachea and esophagus. Ann Thorac Surg 1987;43:160-3.

7. Weiman DS, Dunham ME, Almond CA, Friedman HI, Bowe EA. Combined tracheal and esophageal transection from blunt trauma to the neck. J S C Med Assoc 1988;84:111-3.

8. Khiew KF, Huang CJ, Ohta I. Complete transection of trachea and esophagus. Two-case report. Zhonghua Yi Xue Za Zhi 1990;45:64-8.

9. Ayabe H, Tsuji H, Akamine S, Tagawa Y, Kawahara K, Tomita M. Combined transection of the trachea and esophagus following cervical blunt trauma. Thorac Cardiovasc Surg 1993;41:193-5.

10. Vassiliu P, Baker J, Henderson S, Alo K, Velmahos G, Demetriades D. Aerodigestive injuries of the neck. Am Surg 2001;67:75-9.

11. Davies G, Leighton S, Hayward R, Spitz L. Jet-ski injury: Severe blunt neck trauma with survival. J R Soc Med 2001;94:402-3.

12. Johansson K, Ananda N, Campbell P, Durmush K, Edwards K, Harrison K, et al. Blunt tracheo-oesophageal transection. Eur J Surg 2001;167:795-7.

13. Sokolov VV, Bagirov MM. Reconstructive surgery for combined tracheo-esophageal injuries and their sequelae. Eur J Cardiothorac Surg 2001;20:1025-9.

14. Bernat RA, Zimmerman JM, Keane WM, Pribitkin EA. Combined laryngotracheal separation and esophageal injury following blunt neck trauma. Facial Plast Surg 2005;21:187-90.

15. O'Connor AE, Cooper J. Case of the month: Complete transection of the trachea and oesophagus in a 10 year old child: A difficult airway problem. Emerg Med J 2006;23:156-7.

16. Mukherjee K, Isbell JM, Yang E. Blunt posterior tracheal laceration and esophageal injury in a child. J Pediatr Surg 2009;44:1292-4.

17. Hamid UI, McGuigan JA, Jones JM. Transection of the aerodigestive tract after blunt neck trauma. Ann Thorac Surg 2011;92:1896-8.

18. Bener A, Rahman YS, Mitra B. Incidence and severity of head and neck injuries in victims of road traffic crashes: In an economically developed country. Int Emerg Nurs 2009;17:52-9.

19. The annual mortality statistics published by the Office for National Statistics in 2010. Available from: [Last accessed on 2011].

20. Kirsch MM, Orringer MB, Behrendt DM, Sloan H. Management of tracheobronchial disruption secondary to non penetrating trauma. Ann Thorac Surg 1976;22:93-101.

21. American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support for Doctors, Student Course Manual (8th ed.). American College of Surgeons, Chicago, IL (2008).

22. O'Neill JP, Shine N, Timon C. Complete traumatic laryngo-tracheal separation. Iran Med J 2009;102:291-2.

23. White RK, Morris DM. Diagnosis and management of esophageal perforation. Am Surg 1992;58:112-9.

24. Biffl WL, Moore EE, Offner PJ, Burch JM. Blunt carotid and vertebral arterial injuries. World J Surg 2001;25:1036-43.

25. Huber-Wagner, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, et al. Effect of whole-body CT during trauma resuscitation on survival: A retrospective, multicentre study. Lancet 2009;373:1455-61.

26. Flowers JL, Graham SM, Ugarte MA, Sartor WM, Rodriquez A, Gens DR, et al. Flexible endoscopy for the diagnosis of esophageal trauma. J Trauma 1996;40:261-6.

27. Kraus RR, Bergstein JM, DeBord JR. Diagnosis, treatment, and outcome of blunt carotid arterial injuries. Am Surg 1999;178:190-3.

28. Berne JD, Keuland KS, Villarreal DH, McGovern TM, Rowe SA, Norwood SH. Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury. J Trauma 2006;60:1204-9.

29. National Institute for Clinical Excellence. Head injury: Triage, assessment, investigation and early management of head injury in infants, children and adults. Clinical Guideline 4 (partial update); 2007.

30. Daffner RH, Hackney DB. American College of Radiology appropriateness criteria on suspected spine trauma. J Am Coll Radiol 2007;4:762-75.

31. Muir AD, White J, McGuigan JA, McManus KG, Graham AN. Treatment and outcomes of oesophageal perforation in a tertiary referral centre. Eur J Cardiothorac Surg 2003;23:799-804.

32. Triggiani E, Belsey R. Oesophageal trauma: Incidence, diagnosis, and management. Thorax 1977;32:241-9.

33. Gabor S, Renner H, Pinter H, Sankin O, Maier A, Tomaselli F, et al. Indications for surgery in tracheobronchial ruptures. Eur J Cardiothorac Surg 2001;20:399-404.

34. Beiderlinden M, Adamzik M, Peters J. Conservative treatment of tracheal injuries. Anesth Analg 2005;100:210-4.

35. Flynn AE, Thomas AN, Schecter WP. Acute tracheobronchial injury. J Trauma 1989;29:1326-30.

36. Chen FH, Fetzer JD. Complete cricotracheal separation and third cervical spinal cord transection following blunt neck trauma: A case report of one survivor. J Trauma 1993;35:140-2.

37. Dennis DP, Kashima H. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1989;98:930-4.

38. Harrigan MR, Weinberg JA, Peaks YS, Taylor SM, Cava LM, Richman J, etal. Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice. World J Emerg Surg. 2011;6:11.

39. Edwards NM, Fabian TC, Claridge JA, Timmons SD, Fischer PE, Croce MA. Antithrombotic therapy and endovascular stents are effective treatment for blunt carotid injuries: Results from longterm followup. J Am Coll Surg 2007;204:1007-13.

40. Singh RR, Barry MC, Bouchier Hayes D. Current Diagnosis and Management of Blunt Internal Carotid Artery Injury. Eur J Vasc Endovasc Surg 2004;27:577-84.

41. Briel JW, Tamhankar AP, Hagen JA, DeMeester SR, Johansson J, Choustoulakis E, et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: Gastric pull-up versus colon interposition. J Am Coll Surg 2004;198:536-41-2.

42. Cherveniakov A, Tzekov C, Grigorov GE, Cherveniakov P. Acquired

benign esophago-airway fistulas. Eur J Cardiothorac Surg 1996;10:713-6.

43. Yalgin Ciftci AO, Karnak I, Tanyel FC, £enocak ME. Management of acquired tracheoesophageal fistula with various clinical presentations. J Pediatr Surg 2011;46:1887-92.

44. O'Riordan JM, Hickey N, Ilinski O, Keeling P, Walsh TN. Successful early repair of a traumatic tracheoesophageal fistula after blunt chest trauma. J Thorac Cardiovasc Surg 2006;132:1495-6.

45. Gcrzic Z, Raki S, Randjelovic T. Acquired benign esophago-respiratury fistula: Report of 16 consecutive cases. Ann Thorac Surg 1990;50:724-7.

46. Reed WJ, Doyle SE, Aprahamian C. Tracheoesophageal fistula after blunt chest trauma. Ann Thorac Surg 1995;59:1251-6.

47. Feliciano DV, Bitondo CG, Mattox KL, Romo T, Burch JM, Beall AC Jr, et al. Combined tracheoesophageal injuries. Am J Surg 1985;150:710-5.

48. Eleftheriadis E, Kotzampassi K. Temporary stenting of acquired benign tracheoesophageal fistulas in critically ill ventilated patients. Surg Endosc 2005;19:811-5.

How to cite this article: Hamid UI, Jones JM. Combined

tracheoesophageal transection after blunt neck trauma. J Emerg

Trauma Shock 2013;6:117-22.

Received: 04.12.11. Accepted: 25.08.12.

Source of Support: Nil. Conflict of Interest: None declared.

Staying in touch with the journal

1) Table of Contents (TOC) email alert

Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to

2) RSS feeds

Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal's website. You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add as one of the feeds.

Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.