blunt thoracic trauma
TRANSCRIPT
Blunt Thoracic Trauma848th FST
Blunt Cardiac Injury (BCI)
• Cardiac injury may be the most common unsuspected fatal visceral injury
• Majority of BCI associated with motor vehicle crashes or other deceleration injuries
• Incidence in thoracic trauma: – 46% per autopsy have a BCI– 15% life threatening– Right side of heart injured more often.
Clinical Presentation of BCI
• Chest pain• SOB• Chest bruising,
crepitance, open chest wound
• Hemodynamic instability
• Auscultation may reveal a friction rub, gallop, murmur or lack of breath sounds
BCI Diagnosis
• EKG- 35 to 80% show ST segment changes.• SVT, PVC’s, AFIB, VT/VFIB, 2nd or 3rd AV Block
or Complete Heart Block are all possible• Alteration of R-wave amplitude is usually a key
sign of cardiac tamponade• A normal EKG is reassuring, b/c small risk of
any cardiac trauma– No EKG changes in 12 hours then contusion is ruled
out
Anesthetic Risk with BCI
• Ross stated that GENA is safe and no greater risk with BCI
• Flancbaum stated BCI pt’s with proper monitoring, aggressive fluid resuscitation and inotropic treatment to maintain CO had an 80% survival rate, if they entered surgery
Anesthetic Recommendations for BCI
• Invasive monitoring should be dictated by injury and type of surgery
• Avoid PEEP if cardiac tamponade is suspected (keep intrathoracic pressure low)
• Delay surgery, if possible, 24 to 48 hours to allow cardiac dysfunction to resolve (cardiac contusion)
• Maintain CO with fluids and/or pharmacological intervention
• Maintain tachycardia intra-op to maintain CO
Flail Chest and Pulmonary Contusion
• Rib Fx at least 2 locations on same rib
• Rib and sternum move independently of remaining thorax
• Hypoxia and respiratory failure usually due to pulmonary contusion (pulmonary edema), rather than flail chest
Treatment of Flail Chest and Pulmonary Contusion
• Ventilator if signs of pulmonary failure
• CPAP per mask
• Epidural narcotics for pain relief
• Intercostal nerve blocks for pain relief
• Methylprednisone 30mg/kg
• If severe pulm contusion:– Inhaled anesthesia may increase pulmonary
shunting b/c lungs loose ability to autoregulate blood flow effectively
Traumatic Pneumothorax
• Usually associated with blunt and penetrating thoracic injuries
• Most common cause is penetrating displacement of a rib fracture
• 40% of patients with rib fractures have a pneumothorax
Signs and Symptoms of Pneumothorax
• Subcutaneous emphysema is the most sensitive clinical sign, but may not be present
• Tracheal shift from midline• SOB, hypoxia, increased airway inflation
pressures, hypotension, tachycardia• Tension pneumothorax: does not lower CO or
preload, instead massive intrapulmonary shunting causes hypoxia, tachycardia, low bp and SOB
Treatment of Pneumothorax
• Needle thoracostomy placement (4th intercostal space) will reinflate lung
• Pre-hospital needle thoracostomy placement per EMS had 45% of needles not placed in pleural space
• Chest tube is gold standard treatment
Anesthesia Implications of Pneumothorax
• Unrecognized in OR with (+) pressure ventilation tension pneumo:– Cardiovascular collapse
– N2O may exacerbate problem
– Precipitous hypoxia, absent breath sounds, tracheal deviation and increased airway pressures are classic presentation
Traumatic Hemothorax
• Can occur with both penetrating and nonpenetrating thoracic trauma
• 40% of blood volume can be contained in thoracic cavity
• Initially, same signs and symptoms as pneumothorax
Treatment of Hemothorax• Chest tube placement allows continual blood
loss measurement
• Continued hypotension after aggressive fluid resuscitation may require emergent thoracotomy
• 1500cc immediate blood loss per chest tube indicates thoracotomy
• Anesthesia: intubate, ventilate with 100% oxygen, muscle relaxant and fluid resuscitate
Diaphragmatic Rupture
• Relatively uncommon: 2 to 3% of thoracic trauma patients
• Mortality approximately 20%
• 75% occur on LEFT side secondary to shielding effect of the liver
Anesthesia for Diaphragmatic Rupture
• Change in pulmonary compliance and increased inspiratory pressures may be noted
• Increased gastric suction per NGT
• Difficulty weaning pt off ventilator post-op should arouse suspicion of a missed diaphragmatic hernia/rupture
• Laparotomy/laparoscopy is best way to inspect integrity of diaphragm
Penetrating Trauma of Lung• Usually only require thoracostomy tube for
lung re-expansion
• Patient at risk for systemic air embolus with positive pressure ventilation– Animal studies indicate air emboli embed in
coronary arteries frequently
• Inspiratory pressures upto 100 cm H2O may be required during resuscitative thoracotomy
Tracheobronchial Injuries
• Usually due to shrapnel penetrating thorax, and usually within 2.5cm of carina
• Other mechanisms of injury include:– Rapid deceleration: shearing of airway tree– Increased interthoracic pressure b/c closed
glottis at time of blunt thoracic trauma• Causes traction on the pericardial portion of the
trachea
Signs and Symptoms of Tracheobronchial Injuries
• Dyspnea
• Cough
• Painful hemoptysis
• Subcutaneous emphysema
• 10% of patients are unsymptomatic initially
Anesthesia for Tracheobroncheal Injuries
• Intubating the traditional way is not recommended b/c posterior displacement of trachea is possible and will not be visualized
• Utilize fiberoptic scope and visualize right and lift bronchi for displacment or disruption
• Some recommend a long ETT or Double lumen to intubate the non-injured lung only
• May be able to use fiberoptic scope as a “stent” between disruption of the trachea, and pass ETT beyond the distal tracheal tear
Questions
David Reed, CPT