chest trauma3

Chest Chest TraumaTraumaDr. Ronald McLean, B.D.S., Dr. Ronald McLean, B.D.S., M.D.M.D.

- St. Barnabas Regional Trauma - St. Barnabas Regional Trauma CenterCenter

- Bronx, New York- Bronx, New York

Chest Trauma Chest Trauma -- BLUNTBLUNT

Chest Trauma Chest Trauma -- PENETRATINGPENETRATING

Chest Trauma Chest Trauma -- INCIDENCEINCIDENCE Sudden and dramaticSudden and dramatic

Directly => 20 – 25% (1 in every 4)Directly => 20 – 25% (1 in every 4) trauma deathstrauma deaths

Contribute to 25-50% of the remainingContribute to 25-50% of the remaining deathsdeaths

=> 16,000 deaths per year in => 16,000 deaths per year in USAUSA

Chest Trauma Chest Trauma - CARE- CARE

Improved pre-hospital & peri-operative Improved pre-hospital & peri-operative carecare

=> More pts getting to ER alive=> More pts getting to ER alive

Many die after coming to hospitalMany die after coming to hospital

Deaths Deaths possibly preventablepossibly preventable

=> by => by prompt Dx and Txprompt Dx and Tx

Chest Trauma Chest Trauma - HISTORY- HISTORY

3000 BC3000 BC – treating gladiators chest injuries – treating gladiators chest injuries 16351635 - De Vacca => removal of arrowhead - De Vacca => removal of arrowhead

from chest wallfrom chest wall 18141814 -Larrey reported injuries to subclavian -Larrey reported injuries to subclavian

vesselsvessels 19021902 - Hill performed first cardiorrhaphy in - Hill performed first cardiorrhaphy in

USUS 19341934 - Blalock first American to - Blalock first American to

successfully successfully repair an aortic injuryrepair an aortic injury

BOUNDARIES of ChestBOUNDARIES of Chest

SuperiorlySuperiorly

=> clavicles=> clavicles InferiorlyInferiorly

=> => diaphragm diaphragm

LaterallyLaterally

=> rib cage=> rib cage

BOUNDARIES of ChestBOUNDARIES of Chest

AnteriorlyAnteriorly

=> sternum=> sternum PosteriorlyPosteriorly

=> => vertebral vertebral bodies & ribsbodies & ribs

STRUCTURES InjuredSTRUCTURES Injured

Any organ in chest Any organ in chest potentially susceptiblepotentially susceptible

– especially to penetrating traumaespecially to penetrating trauma

CONTENTS CONTENTS - Thoracic - Thoracic cavitycavity - Chest wall and - Chest wall and

ribsribs - Lungs and - Lungs and

pleurapleura - Great and - Great and

thoracic thoracic vesselsvessels - Heart and - Heart and

mediastinal mediastinal structuresstructures

- Diaphragm- Diaphragm

CONTENTS CONTENTS - Thoracic - Thoracic cavitycavity

EsophagusEsophagus Thoracic ductThoracic duct

Tracheobronchial Tracheobronchial systemsystem

OTHER ORGANS OTHER ORGANS at riskat risk

Thoraco-Thoraco-abdominal injuryabdominal injury

any woundany wound below nipples below nipples in front andin front and

inferior scapula inferior scapula angles angles dorsallydorsally

may result inmay result in intra abdominal intra abdominal injuryinjury

OTHER ORGANS OTHER ORGANS at riskat risk

Peritoneal visceraPeritoneal viscera– LiverLiver– SpleenSpleen– StomachStomach– Colon & small Colon & small

intest.intest.– Biliary systemBiliary system

Retro-peritoneumRetro-peritoneum kidneyskidneys

RESULTING INJURIESRESULTING INJURIES

– Rib fracturesRib fractures– Sternal fracturesSternal fractures

– Open or Closed Pneumothorax Open or Closed Pneumothorax

- unilateral / bilateral- unilateral / bilateral

– HemothoraxHemothorax– HemopneumothoraxHemopneumothorax

RESULTING INJURIESRESULTING INJURIES

– Pneumo-mediastinumPneumo-mediastinum

– Pulmonary contusionPulmonary contusion

– Myocardial contusionMyocardial contusion

– Diaphragmatic ruptureDiaphragmatic rupture

RESULTING INJURIESRESULTING INJURIES

Subcutaneous emphysemaSubcutaneous emphysema

CLINICAL CONSEQUENCIESCLINICAL CONSEQUENCIES

RELATED TO :RELATED TO :

Mechanism of injuryMechanism of injury– Location of injuryLocation of injury– Associated injuriesAssociated injuries– Co-morbiditiesCo-morbidities

Mechanism Mechanism of Injuryof Injury

BLUNTBLUNT

Mostly managed non-operativelyMostly managed non-operatively

– Simple intubation & ventilation orSimple intubation & ventilation or– chest tube placementchest tube placement

Mechanism Mechanism of Injuryof Injury

PENETRATINGPENETRATING

Low energyLow energyMedium energyMedium energyHigh energyHigh energy

Penetrating Penetrating (Low energy)(Low energy)

ImpalementsImpalements Knife woundsKnife wounds

=> disrupts only => disrupts only structures structures

penetratedpenetrated

Penetrating Penetrating (Medium (Medium energy)energy) Bullet woundsBullet wounds from most from most

handgunshandguns

=> primary tissue damage=> primary tissue damage

< than higher velocity < than higher velocity forcesforces

Penetrating Penetrating (High energy)(High energy)

From From rifles and military weaponsrifles and military weapons

+ Shotguns+ Shotguns (low velocity) (low velocity) Transfers kinetic energy to tissuesTransfers kinetic energy to tissues

=> => cavitationcavitation

=> => high velocityhigh velocity..

Amount of tissue damage Amount of tissue damage proportionalproportional to amount of energy exchanged to amount of energy exchanged between the penetrating object and the between the penetrating object and the body part.body part.

PathophysiologyPathophysiology

Quite serious Quite serious

1.1. HYPOXIA / HYPO-HYPOXIA / HYPO-

VENTILATIONVENTILATION Primary acute killer of trauma Primary acute killer of trauma

patientspatients

inadequate delivery of O2inadequate delivery of O2 to tissuesto tissues

Signs of HYPOXIASigns of HYPOXIA

Increased RRIncreased RR Change in breathing pattern Change in breathing pattern

(shallow)(shallow) Anxious behaviorAnxious behavior Poor air movementPoor air movement DiaphoresisDiaphoresis Dilated pupilsDilated pupils Cyanosis – (late sign)Cyanosis – (late sign)

2.2. Hypovolemia Hypovolemia

Inadequate intravascular Inadequate intravascular volumevolume

=> => BLOOD LOSSBLOOD LOSS

3.3. Ventilation / Perfusion Ventilation / PerfusionMismatchMismatch

ContusionContusion HematomaHematoma Alveolar collapseAlveolar collapse

4.4. CHANGES IN INTRATHORACIC CHANGES IN INTRATHORACIC

PRESSURE RELATIONSHIPSPRESSURE RELATIONSHIPS

- Tension pneumothorax- Tension pneumothorax

- Open pneumothorax- Open pneumothorax

5.5. METABOLIC ACIDOSIS METABOLIC ACIDOSIS

Hypo perfusion of tissues Hypo perfusion of tissues (shock)(shock)

MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma ABCsABCs PRIMARY SURVEYPRIMARY SURVEY

– Most important feature of chest injury evaluationMost important feature of chest injury evaluation

=> Aim to identify & treat => Aim to identify & treat immediately life threateningimmediately life threatening conditions conditions

MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma

EARLY INTERVENTIONSEARLY INTERVENTIONS geared towards geared towards– identifying / correcting / preventingidentifying / correcting / preventing problems problems

Tension pneumothoraxTension pneumothorax Massive hemothoraxMassive hemothorax Open pneumothoraxOpen pneumothorax Cardiac tamponadeCardiac tamponade Flail chestFlail chest

MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma

Resuscitation of vital functionsResuscitation of vital functions

REMEMBER :REMEMBER :

- Most life threatening injuries txd - Most life threatening injuries txd byby

- Airway control - Airway control

- Chest tube- Chest tube

MANAGEMENT - MANAGEMENT - Chest Chest TraumaTrauma - Detailed - Detailed Secondary Secondary SurveySurvey

Influenced by:Influenced by: Mechanism of Mechanism of

injuryinjury High level of High level of

suspicionsuspicion

May show:May show: Simple pneumothoraxSimple pneumothorax HemothoraxHemothorax Pulmonary contusionPulmonary contusion Myocardial contusionMyocardial contusion Blunt aortic injuryBlunt aortic injury Rib fracturesRib fractures Diaphragmatic Diaphragmatic

rupturerupture

MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma

Definitive careDefinitive care

Usually operativeUsually operative

MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma AdjunctsAdjuncts

CXRCXR=> basis for initiating other investigations=> basis for initiating other investigations

ALLALL wounds to thoracic cavity bounded back & front by wounds to thoracic cavity bounded back & front by

Neck & umbilicusNeck & umbilicus for stabs for stabs Neck & pelvis Neck & pelvis for GSWfor GSW

– MUST HAVE CXRMUST HAVE CXR

=> => UPRIGHUPRIGHTT if possible if possible

Adjuncts Adjuncts - FAST- FAST

Focused AbdominalFocused Abdominal

Sonography forSonography for

Trauma (Trauma (FASTFAST))

- All - All hemodynamically hemodynamically unstableunstable blunt blunt trauma ptstrauma pts

Adjuncts - Adjuncts - Cat ScanCat Scan- (CT angio)- (CT angio)

Becoming a Becoming a primary diagnostic toolprimary diagnostic tool fast (spiral)fast (spiral) allow for reconstruction etcallow for reconstruction etc

SPECIFIC CHEST INJURIESSPECIFIC CHEST INJURIES

Chest WallChest Wall Rib fracturesRib fractures Most common sign of blunt chest Most common sign of blunt chest

injuryinjury– Fx scapula, first rib, sternum suggest Fx scapula, first rib, sternum suggest

massive force of injurymassive force of injury– 1st & 2nd rib fx associated with serious 1st & 2nd rib fx associated with serious

other injuriesother injuries– Upper ones => Upper ones => suspect vascular injurysuspect vascular injury

Rib FracturesRib Fractures

Rib fracturesRib fractures

Signs and SymptomsSigns and Symptoms

- Deformity- Deformity

- Localized pain- Localized pain

- Tenderness- Tenderness

- Crepitus- Crepitus

Rib FracturesRib Fractures

TreatmentTreatment

Analgesia (PCA)Analgesia (PCA) Pulmonary toiletPulmonary toilet Observe for possible Observe for possible

pneumothoraxpneumothorax

Flail ChestFlail Chest

Segment of chest wallSegment of chest wallthat does not havethat does not havecontinuity with rest of continuity with rest of

thoracicthoraciccagecage Usually 2 fractures per Usually 2 fractures per

rib in at least 2 ribsrib in at least 2 ribs Segment does not Segment does not

contribute to lung contribute to lung expansionexpansion

Disrupts normal Disrupts normal pulmonary mechanicspulmonary mechanics

Accompanied by Accompanied by pulmonary contusion in pulmonary contusion in 50%50% of patients with flail of patients with flail chestchest

Flail Chest Flail Chest - - PathophysiologyPathophysiology

A major problem is theA major problem is the injury injury toto

thethe underlying lung underlying lung

=>=> Pulmonary ContusionPulmonary Contusion

Flail Chest Flail Chest – – Signs & Signs & SymptomsSymptoms

DyspneaDyspnea Chest painChest pain Paradoxical chest Paradoxical chest

wall movementwall movement Poor air movementPoor air movement CrepitusCrepitus HypoxiaHypoxia CyanosisCyanosis

Flail ChestFlail Chest - Treatment- Treatment

Pain controlPain control Humidified O2Humidified O2 Close observation for respiratoryClose observation for respiratory

decompensationdecompensation Aggressive pulmonary & physicalAggressive pulmonary & physical

therapytherapy

Flail ChestFlail Chest - Treatment- Treatment

Selective intubation and ventilationSelective intubation and ventilation:: significant other injuriessignificant other injuries respiratory rate > 35respiratory rate > 35 paO2 < 80paO2 < 80 paCO2 > 66 paCO2 > 66

Other treatmentsOther treatments:: tight fluid resuscitationtight fluid resuscitation

Flail ChestFlail Chest - Treatment- Treatment

Operative fixationOperative fixation not usually required not usually required (historical)(historical)

Lung InjuriesLung Injuries

Pneumothorax or HemothoraxPneumothorax or Hemothorax– most treated with simple tube most treated with simple tube

thoracostomythoracostomy

PneumothoraxPneumothoraxLess than Less than 1-2 cm1-2 cm may be observed in otherwise may be observed in otherwise healthy pts if stable on f/u CXR 6-8 hrs afterhealthy pts if stable on f/u CXR 6-8 hrs after

Open PneumothoraxOpen Pneumothorax

Open sucking chestOpen sucking chestwoundwound if opening if opening 2/3 of 2/3 of

diameter of tracheadiameter of trachea air will come through air will come through wound wound (preferentially)(preferentially)

allows free passage allows free passage of air into and out of air into and out pleural cavitypleural cavity=> effective ventilation => effective ventilation

impairedimpaired=> hypoxia & => hypoxia &

hypercarbiahypercarbia

Open PneumothoraxOpen Pneumothorax

Signs & Signs & SymptomsSymptoms

Penetrating chest Penetrating chest woundwound

Decreased breath Decreased breath soundssounds

Sucking sounds Sucking sounds on on inspirationinspiration

Open PneumothoraxOpen Pneumothorax

Treatment :Treatment :

3 sided occlusive 3 sided occlusive dressingdressing

Observe for Observe for tension tension pneumothoraxpneumothorax

OperativeOperative

Tension PneumothoraxTension Pneumothorax

One way valve allows air leak One way valve allows air leak from lung or chest wallfrom lung or chest wall

=> air forced into chest cavity=> air forced into chest cavity

without escapewithout escape

Tension PneumothoraxTension Pneumothorax

Collapses ipsilateral Collapses ipsilateral lunglung

Tension PneumothoraxTension Pneumothorax

Displaces mediastinum to opposite Displaces mediastinum to opposite sideside

Tension PneumothoraxTension Pneumothorax

Compresses opposite lungCompresses opposite lung

Tension PneumothoraxTension Pneumothorax

Decreases venous returnDecreases venous return

Tension PneumothoraxTension Pneumothorax

Signs & SymptomsSigns & Symptoms

– air hungerair hunger– chest painchest pain– respiratory distressrespiratory distress– tachycardiatachycardia– hypotensionhypotension– tracheal deviationtracheal deviation– absent breath soundsabsent breath sounds– hyper-resonant percussionhyper-resonant percussion– JVDJVD

Tension PneumothoraxTension Pneumothorax- Treatment- Treatment

Immediate decompressionImmediate decompression– large bore needlelarge bore needle

2nd intercostal space2nd intercostal space midclavicular linemidclavicular line

– chest tube as definitive txchest tube as definitive tx

NOTENOTE – – may mimicmay mimic a collapsed lung on the a collapsed lung on the other sideother side – - i.e. trachea deviates - i.e. trachea deviates towardstowards the collapsed lung the collapsed lung– - however, one - however, one resonanresonant (empty), other t (empty), other tympanic tympanic (full)(full)

Pulmonary ContusionPulmonary Contusion

Largest # of pts are those withLargest # of pts are those with

blunt traumablunt trauma Most common chest injury in Most common chest injury in

childrenchildren Usually develops over 24 hoursUsually develops over 24 hours Can occur with or without Can occur with or without

laceration of laceration of parenchymaparenchyma

Pulmonary ContusionPulmonary Contusion

Results from:Results from:

Leakage of blood and fluid into Leakage of blood and fluid into interstitial interstitial spaces of lungspaces of lung

- Significant inflammatory - Significant inflammatory reaction reaction to blood to blood components in the lungcomponents in the lung

Pulmonary ContusionPulmonary Contusion - -

PathophysiologyPathophysiologyLoss of normal lung structure & Loss of normal lung structure & function leads tofunction leads to

- poor gas exchange- poor gas exchange

- increased pulmonary - increased pulmonary vascular vascular resistanceresistance

- decreased lung compliance- decreased lung compliance

Pulmonary ContusionPulmonary Contusion - Complications- Complications

– AtelectasisAtelectasis– PneumoniaPneumonia– ARDSARDS– Respiratory failureRespiratory failure

Pulmonary ContusionPulmonary Contusion- Diagnosis- Diagnosis

Parenchymal Parenchymal infiltrate seen infiltrate seen in in CXRCXR adjacent to adjacent to injured chest injured chest wallwall

Pulmonary ContusionPulmonary Contusion- Diagnosis- Diagnosis

No real clinical No real clinical findings especially findings especially

initiallyinitially dyspneadyspnea chest wall chest wall

contusions / contusions /

abrasionsabrasions increased RRincreased RR may have may have

cracklescrackles

Pulmonary ContusionPulmonary Contusion- Diagnosis- Diagnosis

Lung gets stiffer causing Lung gets stiffer causing dyspnea and increased dyspnea and increased RRRR

Blood gases worsen 2-3 Blood gases worsen 2-3 days as edema increasesdays as edema increases

CXRCXR changes may lag 12 - changes may lag 12 - 48hrs 48hrs

behindbehind May underestimate the May underestimate the

true extenttrue extent

CTCT - very sensitive – can - very sensitive – can

allow quantifyingallow quantifying

Pulmonary ContusionPulmonary Contusion- Treatment- Treatment

MOSTLY supportiveMOSTLY supportive - usually resolve - usually resolve in in 5-8 days5-8 days

- - O2O2 + + observationobservation in milder cases in milder cases- - Pain controlPain control to allow to allow::

- adequate ventilation and - adequate ventilation and better better management of secretionsmanagement of secretions

- - Fluid restrictionFluid restriction - - Intubation + mechanical ventilationIntubation + mechanical ventilation

if respiratory distress presentif respiratory distress present

Pulmonary ContusionPulmonary Contusion

Indications for intubationIndications for intubation

Respiratory distressRespiratory distress Co-morbidities esp. lung diseaseCo-morbidities esp. lung disease Other injuriesOther injuries

– – intra-intra-abdominalabdominal

Myocardial contusionMyocardial contusion

Physical bruising of Physical bruising of the cardiac musclethe cardiac muscle

Usually associated Usually associated with fractures with fractures

of of the sternumthe sternum Any severe anterior Any severe anterior

chest injurychest injury

Myocardial contusionMyocardial contusion

Difficult to dxDifficult to dx

=> HIGH LEVEL => HIGH LEVEL OF SUSPICIONOF SUSPICION

ALL pts with ALL pts with pattern of injury pattern of injury must have an must have an EKGEKG

Myocardial contusionMyocardial contusion- Diagnosis- Diagnosis

EctopyEctopy ST elevationST elevation TachycardiaTachycardia

Friction rubFriction rub Enzymes may be normalEnzymes may be normal

Myocardial contusionMyocardial contusion- Treatment- Treatment

Monitor in ICU & treat Monitor in ICU & treat dysrhythmiasdysrhythmias

Serial enzymesSerial enzymes AnalgesiaAnalgesia

Massive HemothoraxMassive Hemothorax

Pleural cavity hold 3 liters bloodPleural cavity hold 3 liters blood 200cc – 1L in chest cavity seen on CXR200cc – 1L in chest cavity seen on CXR 90% from internal mammary or intercostals90% from internal mammary or intercostals 10% from pulmonary vessels10% from pulmonary vessels

Massive HemothoraxMassive Hemothorax- Treatment- Treatment

– DecompressionDecompression– Chest tube Chest tube (most need just that)(most need just that)– Bleeding may stop when lung re-Bleeding may stop when lung re-

expandsexpands

Aortic Rupture / Aortic Rupture / Great Vessel InjuriesGreat Vessel Injuries Abrupt deceleration Abrupt deceleration

or compression or compression injuryinjury

Sudden motion of Sudden motion of heart / great vessels heart / great vessels within thoraxwithin thorax

Great vessel injury Great vessel injury may occur in 0.3 => may occur in 0.3 => 10% penetrating 10% penetrating traumatrauma

Often rapidly fatalOften rapidly fatal Only 10% survive to Only 10% survive to

hospitalhospital Only 20% survive > Only 20% survive >

1 hour1 hour 90% who reach 90% who reach

hospital will diehospital will die EARLY DX and EARLY DX and

aggressive tx aggressive tx best chancebest chance

Aortic RuptureAortic Rupture- Signs and - Signs and

SymptomsSymptoms

– Hypovolemic shockHypovolemic shock– Chest wall ecchymosisChest wall ecchymosis– Marked difference in BP b/l armsMarked difference in BP b/l arms– Fx 1st, 2nd, 3rd ribs especially on Fx 1st, 2nd, 3rd ribs especially on

leftleft

Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis

Consider Consider mechanism of mechanism of injuryinjury– widened widened

mediastinum on mediastinum on CXRCXR

– 40% normalizes 40% normalizes with sitting upwith sitting up

Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis

Mediastinum > 8cm wideMediastinum > 8cm wide Blurring of aortic knobBlurring of aortic knob

Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis

Deviation of NGT to rightDeviation of NGT to right

Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis

CT with contrast CT with contrast then angiogram then angiogram if abnormal if abnormal

Aortic Rupture Aortic Rupture - - TreatmentTreatment

Contained injuryContained injury

=> BP control=> BP control

Operative repairOperative repair

Cardiac InjuryCardiac Injury

Highly lethal : Highly lethal : fatality ratesfatality rates

- 70 => - 70 => 80%80%

Mostly Mostly ventricularventricular– right > leftright > left

Cardiac TamponadeCardiac Tamponade

=> Blood in pericardial sac=> Blood in pericardial sac

Occurs most frequently with Occurs most frequently with penetrating injuriespenetrating injuries

Cardiac TamponadeCardiac Tamponade- Signs and - Signs and

SymptomsSymptoms ShockShock JVDJVD DyspneaDyspnea PEAPEA Beck’s triadBeck’s triad = minority of pts = minority of pts

- Distended neck veins- Distended neck veins

- Muffled heart sounds- Muffled heart sounds

- Hypotension- Hypotension

Cardiac TamponadeCardiac Tamponade- Treatment- Treatment

Volume Volume resuscitationresuscitation

PericardiocentesisPericardiocentesis SurgerySurgery

- Pericardial - Pericardial windowwindow

- sternotomy- sternotomy

- thoracotomy- thoracotomy

Diaphragmatic RuptureDiaphragmatic Rupture

Traumatic Traumatic herniation of herniation of abdominal abdominal contents into the contents into the chestchest

Diaphragmatic RuptureDiaphragmatic Rupture

Mostly on Mostly on leftleft side side

Diaphragmatic RuptureDiaphragmatic Rupture

Liver “Liver “protectiveprotective” on right side ” on right side

Diaphragmatic RuptureDiaphragmatic Rupture

Frequent in thoracoabdominal Frequent in thoracoabdominal traumatrauma

– 15% stab wounds15% stab wounds– 46% GSW46% GSW– 15% greater than 2cm long15% greater than 2cm long

May be no immediate herniation of May be no immediate herniation of abdominal contentsabdominal contents

Diaphragmatic RuptureDiaphragmatic Rupture- Signs and - Signs and

symptomssymptomsNo distinctive signs / No distinctive signs /

symptoms seensymptoms seen

High index of suspicionHigh index of suspicion needed especially needed especially with mechanism of with mechanism of injuryinjury

dyspneadyspnea cyanosiscyanosis shoulder painshoulder pain bowel sounds in bowel sounds in

lower lower chestchest

Diaphragmatic RuptureDiaphragmatic Rupture- Treatment- Treatment

Up to 13% acute injuries missed initiallyUp to 13% acute injuries missed initially 85% presenting in 3 years as85% presenting in 3 years as

- obstruction or with- obstruction or with- decreased cardio / pulmonary reserve- decreased cardio / pulmonary reserve

Goal of treatmentGoal of treatment::- - Maintain adequate oxygenationMaintain adequate oxygenation => intubate=> intubate

- NG decompression of stomach- NG decompression of stomach

Diaphragmatic RuptureDiaphragmatic Rupture- Surgery- Surgery

Esophageal InjuriesEsophageal Injuries

Most due to penetrating traumaMost due to penetrating trauma

DiagnosisDiagnosis- Difficult- Difficult

- If delayed => - If delayed => rapid sepsis & high mortalityrapid sepsis & high mortality

- Requires aggressive investigation- Requires aggressive investigation

- Radiography- Radiography

- Endoscopy- Endoscopy

- Thoracoscopy- Thoracoscopy

TreatmentTreatment- Thoracotomy, etc.- Thoracotomy, etc.

Thoracic Duct InjuriesThoracic Duct Injuries

Accompany thoracic Accompany thoracic vessel injuriesvessel injuries

Noted much later i.e. not Noted much later i.e. not in acute phasein acute phase

Huge morbidity due to Huge morbidity due to severe nutritional severe nutritional depletiondepletion

MnMn – => initially aggressive => initially aggressive

and and nonoperative nonoperative = hyperalimentation = hyperalimentation

=> TPN=> TPN and if not sealed in 5-7 and if not sealed in 5-7

daysdays– surgical interventionsurgical intervention

Emergency Emergency ThoracotomiesThoracotomies““ACUTE” THORACOTOMYACUTE” THORACOTOMY Cardiac tamponade (relieved)Cardiac tamponade (relieved) Vascular injury to thoracic outletVascular injury to thoracic outlet Massive air leakMassive air leak Endoscopic/radiographic evidence of Endoscopic/radiographic evidence of

tracheal or bronchial injurytracheal or bronchial injury Esophageal injuryEsophageal injury Chest tube outputChest tube output

– immediate evacuation of 1500ml bloodimmediate evacuation of 1500ml blood– or > 250cc/ houror > 250cc/ hour– TREND MORE IMPORTANT TREND MORE IMPORTANT than initial outputthan initial output

““ER” THORACOTOMYER” THORACOTOMY – survival rates < – survival rates <

8%8%

““ER” THORACOTOMYER” THORACOTOMY- - To do or NOT to To do or NOT to

do…do…Type of CARDIACType of CARDIAC

ACTIVITYACTIVITY asystole asystole bradycardia bradycardia tachycardiatachycardia

““ER” THORACOTOMYER” THORACOTOMY- - To do or NOT to To do or NOT to

do…do…Type of VITAL Type of VITAL

SIGNSSIGNS electrical cardiac electrical cardiac

activity activity (PEA)(PEA)

palpable pulsepalpable pulse recordable blood recordable blood

pressurepressure

““ER” THORACOTOMYER” THORACOTOMY- - To do or NOT to To do or NOT to

do…do…LOCATION of LOSSLOCATION of LOSS

of vital signsof vital signs streetstreet in transit in transit

ambulance/helicopterambulance/helicopter unloading areaunloading area hallwayhallway resuscitation arearesuscitation area

““ER” THORACOTOMYER” THORACOTOMY- Unlikely to benefit - Unlikely to benefit

if ...if ... BLUNTBLUNT injury with injury with

arrestarrest Arriving without Arriving without

pulse/BPpulse/BPPenetratingPenetrating injury with injury with

arrestarrest Better chanceBetter chance High likelihood of High likelihood of

– isolated / isolated / correctablecorrectable intra- intra-thoracic injury (?GSW?)thoracic injury (?GSW?)

– still EXTREMELY RAREstill EXTREMELY RARE

““ER” THORACOTOMYER” THORACOTOMY- Bottom line- Bottom line

ER ER THORACOTOMYTHORACOTOMY

if presence of if presence of

MEASUREABLEMEASUREABLE – pulsepulse– blood pressureblood pressure– organized cardiac organized cardiac

activityactivity (or just lost IN (or just lost IN

trauma bay)trauma bay)

MUST consider MUST consider alsoalso– ageage– co-morbidities (ie co-morbidities (ie

infectious diseases) infectious diseases) AVOID AVOID if arrest if arrest

– occurs occurs OUTSIDEOUTSIDE OF OF RESUSCITATION RESUSCITATION AREA orAREA or

– due to due to BLUNTBLUNT trauma.trauma.

““ER” THORACOTOMYER” THORACOTOMY- -

Consider . . .Consider . . . Be mindful that circulatory arrestBe mindful that circulatory arrest

=> cerebral hypoxia=> cerebral hypoxia

=> permanent neurologic => permanent neurologic deficitsdeficits

=> => non-functionalnon-functional survivor survivor

occurs in 10 => 15% of survivorsoccurs in 10 => 15% of survivors

Chest tube Chest tube insertioninsertion Most common Most common

interventionintervention Relatively simple Relatively simple

procedureprocedure Definitively Definitively

manage > 85%manage > 85% of chest trauma : of chest trauma : penetrating or penetrating or bluntblunt

Has significant Has significant complication rate complication rate 2-19%2-19%

May be minor butMay be minor but May require May require

operative operative intervention andintervention and

Can result in Can result in deathdeath

Chest tube insertionChest tube insertion- Indications- Indications

Drain contentsDrain contents of of

pleural spacepleural space– airair– bloodblood– chylechyle– gastric contentsgastric contents

PreventPrevent development of development of pleural collectionpleural collection i.e. after i.e. after thoracotomythoracotomy

Prevent tension Prevent tension pneumothoraxpneumothorax in in ventilated pt with ventilated pt with rib fracturesrib fractures

Chest tube insertionChest tube insertion- Indications- Indications

Absolute Absolute indicationsindications pneumothorapneumothora

xx hemothoraxhemothorax traumatic traumatic

arrest - (b/l)arrest - (b/l)

Relative indicationsRelative indications– rib fractures and rib fractures and

positive pressure positive pressure ventilationventilation

– profound profound hypoxia/hypotensihypoxia/hypotension with on with penetrating chest penetrating chest injury injury

Placement may be Placement may be diagnostic or therapeuticdiagnostic or therapeutic

Bright red bloodBright red blood– suggest arterial injury = possible suggest arterial injury = possible

thoracotomythoracotomy Intestinal contentsIntestinal contents

esophageal, stomach, diaphragmesophageal, stomach, diaphragm intestinal injuryintestinal injury

Large air leakLarge air leak- bronchial disruption- bronchial disruption

Technique = importantTechnique = important to avoid to avoid complicationscomplications

Chest tube insertionChest tube insertion- Insertion - Insertion

SiteSite mid or anterior axillary linemid or anterior axillary line behind pectoralis behind pectoralis

majormajor above 5th ribabove 5th rib since on expiration diaphragm since on expiration diaphragm

rises rises that highthat high count down from sternomanubrial joint (2nd rib)count down from sternomanubrial joint (2nd rib)

Chest tube insertionChest tube insertion- Analgesia- Analgesia

PainfulPainful especially in muscular pts especially in muscular pts– Morpine IV or Ketamine 20mg in Morpine IV or Ketamine 20mg in

adultadult– 10-20 ml local analgesia10-20 ml local analgesia

along line of incisionalong line of incision perpendicularly thru all layers of chest perpendicularly thru all layers of chest

wall to wall to rib below spacerib below space up into pleural cavity after aspirating airup into pleural cavity after aspirating air

Chest tube insertionChest tube insertion- Procedure- Procedure

Prep and drapePrep and drape Incise along Incise along upper border of the ribupper border of the rib below the below the

intercostal space to be usedintercostal space to be used TrackTrack is to be directed is to be directed over top of lower ribover top of lower rib so so

as as to avoid intercostal vessels lying below to avoid intercostal vessels lying below each ribeach rib

should be big enough to fit fingershould be big enough to fit finger Use curved clamp to develop tract by blunt Use curved clamp to develop tract by blunt

dissection only – use to spread the dissection only – use to spread the muscle muscle fibers, develop tract with fingersfibers, develop tract with fingers

On reaching rib, clamp angled upward just On reaching rib, clamp angled upward just above above the rib and dissection continued the rib and dissection continued till pleural till pleural space enteredspace entered

Chest tube insertionChest tube insertion- Procedure- Procedure

Finger inserted Finger inserted into pleural into pleural space and area space and area palpatedpalpated

32-36 F tube 32-36 F tube attached to attached to clamp and clamp and inserted along inserted along track into the track into the pleural cavitypleural cavity

Chest tube insertionChest tube insertion- Procedure- Procedure

Connect tube toConnect tube to

underwater sealunderwater seal

and suture in and suture in placeplace

Examine chest toExamine chest to

check effectcheck effect CXR to checkCXR to check

placement andplacement and

positionposition

POSITION - Dependent on POSITION - Dependent on direction of tractdirection of tract

BluntBlunt chest trauma chest trauma pts lying flatpts lying flat– place drain place drain

anteriorlyanteriorly– prevents prevents

blockage of tube blockage of tube and development and development of tension of tension pneumothoraxpneumothorax

PenetratingPenetrating Posteriorly & basally Posteriorly & basally

directed draindirected drain Last hole should Last hole should

be INSIDE the be INSIDE the CHEST CAVITYCHEST CAVITY

If too far in could If too far in could cause severe cause severe intractable pain intractable pain when up against when up against mediastinummediastinum

Chest tube insertionChest tube insertion - Underwater - Underwater

SealSeal Allows air to Allows air to ESCAPE but NOT ESCAPE but NOT

RE-ENTERRE-ENTER chest cavity chest cavity Negative pressure dependent Negative pressure dependent

upon upon level of waterlevel of water Pleurovac must always be below Pleurovac must always be below

level level of patientof patient Persistent bubbling = air leak Persistent bubbling = air leak

from from lunglung

Chest tube insertionChest tube insertion - Underwater - Underwater

SealSeal May be May be

connected to connected to suction (water suction (water level 20cm H2O)level 20cm H2O)

Aid lung Aid lung re-expansion re-expansion especially if there especially if there is an air leakis an air leak

CHEST TUBES CHEST TUBES SHOULDSHOULD NEVER NEVER BE CLAMPED = BE CLAMPED =

TENSION TENSION PNEUMOTHORAPNEUMOTHORAXX

Chest Tube RemovalChest Tube Removal

When?When? When no air leakWhen no air leak No more fluid No more fluid

drainingdraining

How?How? Occlude hole while Occlude hole while

pulling tubepulling tube Remove at end of Remove at end of

expiration or at expiration or at peak of inspirationpeak of inspiration

Avoids air being Avoids air being drawn into cavitydrawn into cavity

Remove Remove rapidlyrapidly and and close wound quicklyclose wound quickly

Chest tube insertionChest tube insertion- -

ComplicationsComplications ““there is no organ in the thoracic or there is no organ in the thoracic or

abdominal cavity that has not been abdominal cavity that has not been pierced by a chest drain”pierced by a chest drain”

mainly historical since drains used to mainly historical since drains used to be inserted withbe inserted with

- a steel trocar - a steel trocar

- excessive force- excessive force

Chest tube insertionChest tube insertion - Acute - Acute

complicationscomplicationsHemothoraxHemothorax – usually – usually

laceration of laceration of intercostals vessel, intercostals vessel, may require may require thoracotomythoracotomy

Lung lacerationLung laceration especially when especially when adhesions presentadhesions present

Diaphragm / Diaphragm / abdominal cavity abdominal cavity penetrationpenetration - placed - placed too lowtoo low

Stomach colon injuryStomach colon injury - - diaphragmatic hernia diaphragmatic hernia not recognizednot recognized

TubeTube placed placedsubcutaneoussubcutaneouslyly – not – not

ininpleural cavitypleural cavity

Tube placed Tube placed too fartoo far = pain= pain

Tube falls outTube falls out = not = not secured properlysecured properly

Chest tube insertionChest tube insertion- Late - Late

complicationscomplications– blocked tubeblocked tube

= clot, lung= clot, lung– retained retained

hemothoraxhemothorax– empyemaempyema– pneumothoraxpneumothorax

after removalafter removal

= poor = poor techniquetechnique

Chest TraumaChest Trauma - - ConclusionConclusion Chest trauma isChest trauma is

– COMMONCOMMON– SERIOUSSERIOUS

AIM in TREATMENTAIM in TREATMENT– to to provide oxygen provide oxygen

to vital organsto vital organs– Be alert to Be alert to

changes in changes in clinical conditionclinical condition

Managed MOST Managed MOST of the time with a of the time with a CHEST TUBECHEST TUBE

CHEST TRAUMACHEST TRAUMA

ENDEND