blunt thoracic trauma

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Blunt Thoracic Trauma 848 th FST

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Page 1: Blunt Thoracic Trauma

Blunt Thoracic Trauma848th FST

Page 2: Blunt Thoracic Trauma

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.

Page 3: Blunt Thoracic Trauma

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

Page 4: Blunt Thoracic Trauma

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

Page 5: Blunt Thoracic Trauma

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

Page 6: Blunt Thoracic Trauma

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

Page 7: Blunt Thoracic Trauma

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

Page 8: Blunt Thoracic Trauma

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

Page 9: Blunt Thoracic Trauma

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

Page 10: Blunt Thoracic Trauma

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

Page 11: Blunt Thoracic Trauma

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

Page 12: Blunt Thoracic Trauma

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

Page 13: Blunt Thoracic Trauma

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

Page 14: Blunt Thoracic Trauma

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

Page 15: Blunt Thoracic Trauma

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

Page 16: Blunt Thoracic Trauma

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

Page 17: Blunt Thoracic Trauma

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

Page 18: Blunt Thoracic Trauma

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

Page 19: Blunt Thoracic Trauma

Signs and Symptoms of Tracheobronchial Injuries

• Dyspnea

• Cough

• Painful hemoptysis

• Subcutaneous emphysema

• 10% of patients are unsymptomatic initially

Page 20: Blunt Thoracic Trauma

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

Page 21: Blunt Thoracic Trauma

Questions

David Reed, CPT