Blunt Chest Trauma

Bradley M. Dennis, MD

09.21.15

Overview

• Rib Fractures

• Lung Injuries

• Tracheobronchial Injuries

• Cardiac Injuries

• Aortic Injuries

Overview

• Rib Fractures

• Lung Injuries

• Tracheobronchial Injuries

• Cardiac Injuries

• Aortic Injuries

Rib Fractures

• Often not clinically significant in isolation

• Harbinger of other injuries

• Most commonly associated with PTX, HTX, Pulm contusion

• R sided rib fx (including 8th rib or below) 19-56% chance of assoc. liver injury

• L sided rib fx 22-28% chance of splenic injury

Rib Fractures

• Worse in the elderly– 2x mortality and thoracic

morbidity• PNA, effusion, ARDS

– Mortality increases 19% for each add’l rib fx

– Longer hospital and ICU LOS

Bulger, E; Arneson, M; Mock, C; Jurkovich, G. J Trauma. 2000.

Flail Chest

• Fracture of 4+ consecutive ribs with fx in 2 places

• Paradoxical motion of the affected chest wall segment during respiration– Flail segment collapses

during inspiration

– Expands during expiration

From Mayberry J, Trunkey D. The fractured rib in chest wall trauma. ChestSurg Clin N Am 1997;7:253.

Management

• Options– Medical

• Opioids/NSAIDS—Monotherapy if 1-2 rib fx

• Pulmonary toilet/IPPV/IS/mobilization

• Mechanical ventilation

– Anesthesia• Epidural catheter

• Paravertebral infusion (On-Q pump)

• Intercostal block

– Surgical• Rib plating

Pain Management

• Epidural

– Ideal for ≥4 rib fx

– Excellent for bilateral fx

– Inserted at mid-level of fxs

– Typically infuse narcotic and local anesthetic• Fentanyl + bupivicaine

– Low risk of local anesthetic toxicity

Thoracic Epidural Analgesia

• Risks– Hypotension

– Pruritus

– Urinary retention-not an indication to keep foley

– Muscle weakness-not an indication for bedrest

• Contraindications– Hypotension/hypovolemia

– Spinal fracture

– Coagulopathy

– Sepsis

Pain Management

• Paravertebral infusion– Excellent for unilateral fxs

– Not limited by coagulopathy or spinal fx

– Low risk of hypotension or urinary retention

– Local anesthetic toxicity more common

Pain Management

• Intercostal block– Lasts 4-8 hours,

repeatable

– Requires injection at each level plus one rib above and below fractures

– Requires palpating fractured ribs to indentify landmarks

– Difficult to identify landmarks above T7

From Karmakar MJ, Anthony MH, Acute Pain Management of Patients withMultiple Rib Fractures. J Trauma 2003; 54: 615-625

Rib Fixation

From Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications,technical issues, and future directions. World J Surg. 2009;33:14-22.

Rib fixation

• Options

– Anterior plate with wire cerclage

– Anterior plate with cortical screws

– Intramedullary fixation

– Judet strut

– U-shaped plate (RibLoc®)

– Absorbable plates

Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications,technical issues, and future directions. World J Surg. 2009;33:14-22.Lafferty P, Anavian J, Will R, Cole P. Operative Treatment of Chest Wall Injuries: Indications, Technique, and Outcome. J Bone Joint Surg Am. 2011;93:97-110.

Rib Fixation

• Advantages

– Less vent days

– Less pneumonia

– Less pulmonary dysfunction

– Less inpatient hospitalization

– Less long-term pain and disability

Overview

• Rib Fractures

• Lung Injuries

• Tracheobronchial Injuries

• Cardiac Injuries

• Aortic Injuries

Pneumothorax

• Occult PTX

– Seen on CT, but not on CXR

– Can be observed without chest tube• Even if on postive pressure ventilation

Pneumothorax

• If large or clinically significant, place chest tube

– Sterile conditions

– Periprocedural antibiotics (Ancef)

– Large bore chest tube (28F-40F)

– Posterior and apical

– Leave in place until air leak resolved and drainage down (≤2mL/kg/day or ≤200mL/day)

Hemothorax

• Often associated with PTX and/or rib fractures

• Occurs in 30-40% of thoracic trauma pts

• Operative indications

– ≥1,500 mL of blood immediately evacuated Y

– Persistent bleeding from the chest, ≥150 mL/h for 2-4 hours

– Persistent blood transfusion to maintain hemodynamic stability

HTX Management

• If retained HTX present on CXR– Consider placing 2nd chest

tube• ? Right angle chest tube

– CT chest on Day 3 to evaluate volume• >300mL requires intervention

– VATS recommended on/before Day 7

– If poor surgical candidate, intrapleural t-PA

Intrapleural t-PA

• 50mg mixed in 100mL sterile NS

• Chest tube site prepped/draped sterilely

• Injected via chest tube into pleural cavity

• Chest tube clamped at skin x 1 hour

• Patient rolled in multiple positions to distribute fluid

• Unclamp and allow to drain

• Perform once daily x 3 days

Pulmonary Contusion

• Often associated with rib fx or other chest trauma

• Best diagnosed with CT– 100% vs 38% (CXR)

– Allows for quantifying amount of lung involved

• ARDS developed in 82% of those with >20% contused lung (vs 22% in those <20%)

• May require mechanical ventilation

• No benefit to steroids or fluid restrictionMiller PR, Croce MA, Bee TK, Qaisi WG, Smith CP, Collins GL, et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high risk patients. J Trauma 2001;51(2):223– 30.

Overview

• Rib Fractures

• Lung Injuries

• Tracheobronchial Injuries

• Cardiac Injuries

• Aortic Injuries

Tracheobronchial Injuries

• Very rare in blunt trauma

• Pneumothorax, subcutaneous emphysema and hemoptysis are most common symptoms

• Persistent PTX despite chest tube should raise suspicion

Airway Management

• Avoid double-lumen tube

• Intubate with long single-lumen tube

– Go beyond injury with ETT or mainstem contralateral bronchus

• Bronchial blocker if injury more distal

Management

• Injury <1/3 circumference can be watched

• Distal 1/3 of trachea, carina and R mainstem bronchus best approached via R thoracotomy

• L mainstem bronchus approached thru left chest

• Simple interrupted absorbable sutures

• Up to 50% of trachea can be resected and reconstructed and all of mainstem bronchi

• Repair carina

Overview

• Rib Fractures

• Lung Injuries

• Tracheobronchial Injuries

• Cardiac Injuries

• Aortic Injuries

Commotio Cordis

• Sudden cardiac death due to blunt trauma

• Primarily males (95%) of adolescent or young age (78%)

• 87% mortality rate

• Survival is directly correlated with

– Quick recognition

– Rapid initiation of resuscitation,

– Availability of AED

Chamber Rupture

• Ventricular rupture is highly lethal

• Atrial rupture can be successfully repaired

• Suspect if unexplained hypotension despite fluid resuscitation (cardiac tamponade)– Rule out

• Tension PTX

• Massive HTX

• TBI

• spinal cord injury

• Negative findings from abdominal evaluation (FAST/DPL)

Blunt Cardiac Injury

• Most common cardiac injury in blunt trauma

• Wide ranging manifestations

– Sinus tach to lethal arrhythmias

• No one best test for diagnosis

– EKG and Cardiac enzymes can be misleading

– Echo probably best test

• Treatment is supportive

– May require inotropes, beta blockers, even pacing

Overview

• Rib Fractures

• Lung Injuries

• Tracheobronchial Injuries

• Cardiac Injuries

• Aortic Injuries

Aortic Injuries

• Deceleration injuries

• Most are fatal injuries

– 70-80% die at scene

– 2-5% have delayed rupture

• Injuries most commonly occur just distal to left subclavian artery

• Can be repaired via open thoracotomy or endovascular stent graft

Aortic Injuries

• Preoperative anti-impulse therapy shown to be beneficial

– Using short-acting beta-blockade to reduce wall stress by reducing blood pressure and heart rate

– Goals usually HR<100, SBP<120

• Shown to reduce in-hospital aortic rupture rates without adversely affecting other injuries

TEVAR

Advantages

• No thoracotomy

• No single-lung ventilation

• No aortic cross-clamping

• No left heart or cardiopulmonary bypass

• Requires considerably less time

• Can be done quickly in relatively unstable patients

Disadvantages• Can be logistically as well as

technically challenging

• Off-label use of these devices

• Technical limitations in younger patients with smaller aortas

• Long-term side effects and durability of the repair remain unknown

• Often requires covering L subclavian artery with stent

Aortic Injuries

• Meta-analysis demonstrated nearly 70% reduction in operative mortality by using endovascular approach

• 30-day mortality reduced by over 50%

• Post-operative paraplegia rates significantly lower with endovascular repair (OR O.32)

Questions?