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GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Advanced Emergency Trauma Course

GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD

ThoracicTrauma

Presenter:PatrickCarter,MD

Objectives

  Epidemiology  ChestWallInjury  PulmonaryInjuries  CardiovascularInjuries  EsophagealInjuries


http://www.trauma.org/images/image_library/21223463721July_125.jpg


Epidemiology   Thoracictraumaresultsin20-25%ofdeathsduetotrauma

  Accountsformorethan16,000deathsannuallyintheUnitedStates

  Immediatetraumaticdeathisgenerallytheresultofruptureofmyocardialwallorthethoracicaorta.

  Earlydeathswithin30min–3hoursaretypicallyduetotensionpneumothorax,cardiactamponade,airwayobstructionoruncontrolledthoracichemorrhage

  EarlydeathsfromthoracicinjuryareoftenpreventableifappropriateEmergencyDepartmentandTraumacareisprovided.

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Chest Wall Injury   Epidemiology•  50%ofpatientswiththoracictraumahavechestwallinjury

  10%willhaveminortrauma  35%willhavemajortrauma  5%willhaveflailchestinjuries

  AnatomyandPhysiology•  Intactchestwallisnecessaryfornormalventilation

•  Respiratorymusclescauseoutwardexpansionofthoracicwallanddescentofdiaphragmcausingnegativepressureandpassiveairentryduringrespiration

•  Chesttraumawillimpactthenormalrespiratoryprocessandpreventadequateoxygenationandventilation

•  Patientsabilitytocompensateforinjurydependsonrespiratoryreserve

  ClinicalFeatures•  Inspectthechestfor:

  Adequatechestrise  Respiratoryrate  Tidalvolume

•  Palpatefor:  Deformity  Tenderness  Crepitus

•  Auscultatefor:  Lungsounds  Heartsounds

  SpecificInjuries•  RibFractures•  SternalFracture•  FlailChest•  Non-penetratingBallisticInjury


Rib Fractures   Epidemiology•  Simpleribfracturesaccountformorethan50%ofnon-penetratingtrauma•  Associatedinjuriesareimportanttoidentify-Pneumothorax/Hemothorax

  Pathophysiology•  Ribsbreakatpointofimpactorposteriorangle(weakeststructuralpoint)•  Ribs1-3=Relativelyprotected=Higherassociationwithsevereintrathoracicinjury

•  Ribs9-12=Moremobile=Higherassociationwithintra-abdominalinjury  Rightsidedribfractures=3Xaslikelytohavehepaticinjury  Leftsidedribfractures=4Xaslikelytohavesplenicinjury

•  Fracturesmorecommoninadultsduetoinelasticityofthechestwall•  Ribfractures=Highpotentialforpenetratinginjurytopleura,lung,liverorspleen

•  Multipleribfractures(2ormore)isassociatedwithhigherincidenceofinternalinjury

•  Elderlypatientswithmultipleribfractureshavefivefoldincreaseinmortalitycomparedwithyoungerpatients(<65)


Rib Fractures   ClinicalFeatures•  Clinicalsuspicionwithtenderness,bonycrepitus,ecchymosisandmusclespasmovertherib

•  Compressionoverthesiteofinjurytypicallycausespain  DiagnosticStrategies•  CXRismainstayofdiagnosis–Mainlytoevaluateforassociatedinjuries•  Dedicatedribfilmsareoflimitedutility•  Previouslyfracturesofribs1-2termedthehallmarkofseverechesttrauma

  Requiredarteriographytoevaluateintrathoracicinjury  Numerousstudieshavenowshownthatwithoutdirectevidenceofvascularorneurologiccompromisethatfractureof1stor2ndribisnotassociatedwithincreasedmortality

  However,multipleribfracturesthatincludethe1stor2ndribisassociatedwith10foldincreaseinmortality

•  HelicalCThaslargelyreplacedarteriographyfordiagnosisofmajorvascularinjuriesandpatientswithmultipleribfractureswithsuspectedvascularorintrathoracicinjuriesshouldundergoCTimaging


Rib Fractures   ClinicalCourse•  Ribfractureshealin3-6weeks•  Gradualdecreaseinpainovertimewithanalgesianeededforfirst1-3weeks

  Management•  Paincontrol(PONarcotics,IVNarcotics,IntercostalNerveBlocks)•  Maintenanceofpulmonaryfunction•  Binders,beltsandotherrestrictivedevicesshouldbeavoided.Theydecreasepainbutarenotedtohaveincreasedriskofhypoventilation,atelectasisandsubsequentpneumonia

•  ElderlypatientsmayrequireadmissionfortreatmentwithIVpaincontrolandmonitoringofrespiratorystatus

•  DisplacedribfracturesshouldbemonitoredandrepeatCXRat3hoursafterpresentationtoevaluatefordelayedpneumothoraxdevelopment


Rib fractures   1stand2ndRibfracture,Smallapicalcapindicatinglocalizedhemorrhage


http://anaesthesia-drzek.blogspot.com/2008/09/fracture-rib.html http://anaesthesia-drzek.blogspot.com/2008/09/fracture-rib.html


Sternal Fracture   Epidemiology•  Primarily,theresultofanteriorblunttrauma

•  E.g.Passenger’scheststrikessteeringwheel•  Increasedriskofsternalfracturewithuseofpassengerrestraint

  Threefoldincreasesincewidespreadseatbeltuse  Expectdecreasewithairbagdeployment(nodatayet)

•  SternalFracturesmorecommoninolderpatientssufferingblunttrauma(Lesselasticchestwalldoesn’tdistributeforceevenly)

  Pathophysiology•  Rapiddecelerationinjuryfromafrontalimpactresultsinsternalfractureatsiteofseatbelt

•  Isolatedsternalfracturesarerelativelybenignwithlowmortality(0.7%)

•  Complications  MyocardialContusion(1.5-6%ofcases)  SpinalFractures(<10%ofcases)  RibFractures(21%ofcases)  Noassociationbetweensternalfractureandbluntaorticinjury


Sternal Fracture   Pathophysiology(continued)•  Associatedmediastinalinjuriesshouldbeconsideredincludingmediastinalhematomafrominjurytounderlyingproximalgreatvessels

  ClinicalFeatures•  Anteriorchestpainandpointtendernessoverthesternum,softtissuedeformity

  DiagnosticManagement•  Lateralradiographismosthelpfulwithdiagnosisduetotransversenatureofmostfractures

•  PatientswithsternalfractureshouldbescreenedformyocardialcontusionwithEKGandserialcardiacenzymes

  Management•  Analgesia•  Withoutanyassociatedinjuries,patientswithisolatedsternalfracturescanbedischarged


Sternal Fracture   PectusExcavatum   SternalFracture


http://www.jssm.org/vol4/n3/14/F1.htm

www.radrounds.com


Flail Chest   Epidemiology•  Occursin1/3ofmajortraumapatientswithmajorchestinjuries

  Pathophysiology•  Threeofmoreadjacentribsarefracturedattwopoints,resultinginafreelymovingsegmentofchestwall

•  Segmentmovesinparadoxicalmotionwithunderlyingnormalchestmovement

•  Highassociationwithunderlyingpulmonarycontusion•  Underlyingpulmonarycontusionismajorcauseofrespiratoryinsufficiency

•  Severepainassociatedwithinjuryresultsinmuscularsplintingandresultantatelectasisandhypoxemia


Flail Chest   ClinicalFeatures•  Examineforparadoxicalsegmentmovement•  Pain,tendernessandcrepitusareoftenseen

  DiagnosticStrategies•  CXRwilloftenshowmultipleribfracturesandunderlyingpulmonarycontusion

•  CTscan–moreaccuratethanCXRandwillhelpdefineextentofunderlyinginjury

  Management•  Aggressivepulmonaryphysiotherapy•  Effectiveanalgesia•  Selectiveuseofmechanicalventilationandendotrachealintubation•  Closeobservationofrespiratorystatus•  Earlyoperativefixationofflailsegmentresultsinquickerrecovery,decreasedcomplicationsandimprovedcosmeticandfunctionalresults

•  Mortalityassociatedwithflailchest=8-35%andisdirectlyrelatedtounderlyinginjuries


Flail Chest


PulmonaryContusion

http://virtual.yosemite.cc.ca.us/lylet/rc211/Case1FlailChest.gif

Non-penetrating Ballistic Injury   Definition•  Non-penetratingballisticinjuryincludesinjuryfrom:

  Rubberbullets(Usedbypoliceforcrowdcontrol)  Beanbagshotgunshells  “BulletProofVests”=Bulletresistantvests

  Pathophysiology•  Projectileinjuryfrompenetratingbulletisinhibitedbynon-penetratingballisticinjuries

•  Kineticenergyofprojectilecanbetransmittedthroughtopatientandstillcauseinjury

  ClinicalFeatures•  Erythema,EcchymosisandTendernessoverimpactedarea•  Evaluateareaforanysubcutaneousemphysema,crepitisorbonystep-offs

  DiagnosticStrategies•  CXRtoevaluateforintra-thoracicinjuries,retainedforeignbodyorviolationofthebone

  Management=CloseobservationGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Non-Penetrating Ballistic Injury   RubberBulletInjuries


http://www.mindfully.org/Health/2002/Rubber-Bullets-Israeli-Arab25may02.htm

SourceUndeterminedGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Traumatic Asphyxia   Pathophysiology

•  Raresyndromecharacterizedbyseveresuddencompressionofthethoraxbyheavyobject

•  Causesmarkedincreaseinthoracicandsuperiorvenacavalpressure•  Retrogradeflowofbloodfromrightheartintogreatveinsofheadandneck

  ClinicalFeatures•  Deepvioletcolorofskinoftheheadorneck•  Bilateralsubconjunctivalhemorrhages,PetechiaeandFacialEdemaaretypicallypresent,indicativeofsuddenincreaseinbloodflow

•  BenignandSelf-limitedcondition  Diagnosis

•  Clinicalsignificanceisindiagnosingintrathoracicinjuryfromseverityofforcerequiredtocausetraumaticasphyxia

•  Chestwallandpulmonaryinjuriesaremostcommon•  Neurologicbleedingisrare•  CTImagingshouldbeobtained

  Management•  Neurologicmanifestationsresolvewithin24-48hours•  Mainstayoftreatmentistreatmentofunderlyinginjuriesandsupportivecare


Pulmonary Injuries

  SubcutaneousEmphysema  PulmonaryContusion  Pneumothorax  Hemothorax  TracheobronchialInjury


Subcutaneous Emphysema   Pathophysiology•  Subcutaneousemphysemainthepresenceofthechestwallisindicativeofamoreseriousthoracicinjury

•  Typeofairentry  Extrapleural

•  Tracheobronchialtreeinjuryallowsairtoleakintomediastinumandthenuptothesofttissuesofanteriorneck

  Intrapleural•  Intrapleuralleakagetypicallycreatesapneumothoraxandthenairleaksthroughtheparietalpleuraandintothethoracicwall

•  Location  Adjacenttopenetratingwound

•  Mayindicatelocalizedinfiltrationfromexternalenvironment  Localizedsubcutaneousairoverchestwall

•  Indicatespresenceoftraumaticpneumothorax  Localizedoversupraclavicularareaandanteriorneck

•  Typicallyindicatespneumomediastinum  Massivesubcutaneousairofthefaceandneck

•  TypicallytheresultofrupturedbronchusGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Subcutaneous Emphysema   Diagnosis•  Palpationofchestwallandneckrevealscrepitance•  AuscultationmayrevealHamman’scrunchindicativeofairinmediastinum

•  CXRmayshowsubcutaneousairtrackingthroughsofttissue

  Management•  Mostlysubcutaneousairisbenignandselflimitedandcanbetreatedwithhighflowoxygen

  Facilitatesre-absorptionofnitrogenfromtissues•  Keyisidentifyingunderlyinginjury•  Massiveaccumulationsmaybeuncomfortabletoapatient


Subcutaneous Emphysema


http://www.trauma.org/index.php/main/images/C11/

SourceUndetermined



Pulmonary Contusion   Epidemiology

•  Presentin30-75%ofpatientswithsignificantbluntchesttrauma•  Mostcommonsignificantchestinjuryinchildren

  Pathophysiology•  Directbruiseofpulmonaryparenchymawithassociatedalveolaredemaandhemorrhage

  ClinicalFeatures•  Dyspnea,Tachypnea,Cyanosis,Tachycardia,Hypotension,ChestwallBruising•  Hemoptysismaybepresentin50%ofpatients•  Associatedwithflailchest

  Diagnosis•  Radiographicfindingsappearwithinminutesofaninjury•  Patchyirregularalveolarinfiltratestofrankconsolidation•  Alwayspresentwithin6hoursofinjury•  CTisparticularlysensitiveatdiagnosis•  DifferentiatefromARDSbytimecourse

  Pulmonarycontusion<6hourspresent,resolvesin48-72hours  ARDSonsetis24-72hoursafterinjury


Pulmonary Contusion   Management•  RestrictionofIVFadministration•  Vigoroustracheopulmonarytoilet,Suctioning•  PainControl•  Judicioususeofrespiratorysupportwithendotrachealintubationandmechanicalventilation

  ConsiderdoublelumenETTwhenonlyonelungdamaged  Allowsforcompensationfordifferencesincompliancebetweenlungs  Avoidintubationifpossibleasincreasedmortalityfromintubationduetopneumonia,sepsis,pneumothorax,longerhospitalization

  Complication=Pneumonia•  Prophylacticantibioticsarenotrecommended

  Prognosis•  Mortalityofisolatedpulmonarycontusionis5-16%


Pulmonary Contusion


http://upload.wikimedia.org/wikipedia/commons/f/f2/Pulmonary_contusion.jpg


Pneumothorax   Definition=Accumulationofairinthepleuralspace  Epidemiology•  15-50%ofpatientswithseverechesttrauma

  Pathophysiology•  Traumaticpneumothoraxiscausedbyfracturedribthatisdriveninwardresultinginlacerationofpleura

•  Alsooccurswithoutafractureswhenimpactisdeliveredatfullinspirationwiththeglottisclosed,leasingtotremendousincreaseinintra-alveolarpressureandsubsequentruptureofthealveoli

•  Penetratingtraumasuchasagunshotwoundorknifeinjurymaycausedirecttraumatothepleura


Pneumothorax   TypesofPneumothorax•  SimplePneumothorax

  Nocommunicationwiththeatmosphereoranyshiftofmediastinalstructuresorthehemi-diaphragmfromaccumulatingair

  Pneumothoraxgrading•  SmallPneumothorax<15%•  ModeratePneumothorax=15-60%•  LargePneumothorax>60%

•  CommunicatingPneumothorax(OpenPneumothorax)  Pneumothoraxassociatedwithlossofintegrityofchestwall  Oftentermedsuckingchestwound  Resultsinlargefunctionaldeadspaceforthenormallungandsevereventilatorydisturbance


Tension Pneumothorax   TensionPneumothorax•  Progressiveaccumulationofairunderpressurewithinthechestcavitywithshiftofmediastinalstructurestooppositehemithorax•  Resultsincompressionofcontralaterallungandgreatvesselvenousreturn•  Resultsindecreaseddiastolicfillingoftheheartandsubsequentdecreasedcardiacoutput•  Leadstorapidonsetofhypoxia,acidosisandshock•  CardinalPhysicalExamFindings

  Tachycardia,JugularVenousDistension,Tachypnea  AbsentBreathsoundsonipsilateralside  HypoxiaandHypotension,followedbycardiacarrest


Pneumothorax   ClinicalFeatures•  Chestpainandshortnessofbreatharemostcommonsymptoms•  Spectrumofpresentation

  SmallPTX=Absentclinicallyonexam  TensionPTX=Acutelyillinminuteswithseverecardiovascularandrespiratorydistress

•  Signsandsymptomsdon’talwayscorrelatewithsizeofpneumothorax•  Physicalexam

  Absentbreathsoundsoveraffectedside  Hyperesonance  Tachycardia  Tachypnea


Pneumothorax   DiagnosticFeatures•  CXRispreferredinitialstudy•  Uprightfullinspiratoryfilmprovidesbestinitialstudy•  Ifnon-diagnostic,expiratoryfilmmaymakethepneumothoraxmorevisiblebydecreasingthelungvolume•  CTisverysensitiveatfindingsmallpneumothoraceseveninsupinepatient•  Bedsideultrasound

  Rapidminimallyinvasivewayofevaluatingforpneumothorax  Primarilyusedtoexcludediagnosis  Findingssuggestingthepresenceofapneumothoraxinclude

•  Absenceofpleuralline•  Absenceofpleuralsliding•  Presenceofalungpoint(exclusivehorizontallines)


Simple Pneumothorax



http://www.daviddarling.info/images/pneumothorax_radiograph.gif


Open Pneumothorax


http://www.trauma.org/index.php/main/images/C11/ https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/12617-1/ACCP/IS0877A/lsn4_files/image002.jpg


Tension Pneumothorax




Pneumothorax   Management•  PenetratingTrauma/NoPneumothorax

  IfCXRisnegative,Observationx3hrs,RepeatCXRpriortoD/c•  SimplePneumothorax

  Someauthorsadvocatechesttubeforalltraumaticpneumothoracies  SmallPneumothorax•  Somepeopleadvocatecarefulobservationifpatientissymptomsfreeanddoesnotneedanesthesiaorpositivepressureventilation•  Smallapicalpneumothorax<25%mayalsobeobservedclosely•  OccultCTdiagnosedPTXisalsosuggestedtobeamenabletoconservativetreatment•  Ifpatientistoreceivepositivepressureventilationorhasevidenceofmulti-systemtrauma,chesttubeshouldbeplaced

 Moderate/LargePneumothorax=ChesttubeGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Pneumothorax   Management–OpenPneumothorax•  Pre-hospitalsetting–Threesidedocclusivedressing  Avoidconversiontotensionpneumothorax

•  EDsetting–PlacementofChesttubeatsiteremotefromwalldeficit  Dressingcanbeocclusivedressingofpetroleumgauzeifchesttubeisinplace

  Neverpackthewound–dressingcanbesuckedintochestcavity

  Endotrachealintubationforrespiratorysupport•  Definitivesurgicalrepairofdeficit


Pneumothorax   Management–TensionPneumothorax•  NeedleThoracostomy

  2ndIntercostalSpace–Mid-clavicularLine•  TubeThoracostomy

  5thIntercostalSpace–AnteriorAxillaryLine


http://www.hcmc.org/manualHCMC/Procedure_Lab/thoracostomy_tube_files/image004.jpg

www.trauma.org/index.php/main/article/199/index.php?main/image/95/


Hemothorax   Definition=accumulationofbloodinthepleuralspaceafterbluntorpenetratingtraumaticinjury

  Pathophysiology•  Hemorrhagefrominjuredlungparenchymaismostcommoncausebutisusuallyself-limiting

•  Othervesselsmaybesiteofinjuryincludingintercostalandinternalmammaryarteries

•  Lesscommonly,majorvesselsorhilarvesselsaresiteofbleeding

  ClinicalFeatures•  Dependingonrateandquantityofhemorrhage,varyinglevelsofhemorrhagicshockareencountered

•  Diminishedorabsentbreathsoundsonaffectedside


Hemothorax   Diagnosis•  ClinicalDiagnosis–oftenenoughtoinitiatetreatment•  CXR–initialdiagnostictest

  200-300ccBloodrequiredtocausecostophrenicblunting  Supinefilm–typicallybloodwilllayerposteriorlyandgeneratediffusehazinessthatcanbesubtle

•  CT–mostsensitivetestbutoftennotabletobeobtainedifpatientunstable

  Management•  Tubethoracosomyfordrainageofaccumulatedblood

  Largeborechesttube=36-40French  Failuretoevaluatebloodmayleadtopleuraladhesions

•  Urgentthoracotomyisindicatedwithmorethan1500ccofbloodoutputoninitialplacementofchesttubeormorethan200cc/hrfor3hours

•  Restorationofcirculatingvolume•  Auto-transfusionisoptionforpatientswithbriskbleedingandrequirementoftransfusiontomaintaincirculatingvolume


Hemothorax




Tracheobronchial Injury   Epidemiology•  Occurwitheitherbluntofpenetratingtraumatothechestorneck•  MorethanhalfareresultofMVC•  Rareentity-occurringin<3%ofpatientswithsignificantchesttrauma

•  Mortality=10%  Pathophysiology•  Knifewounds=Injuryincervicaltracheawithtransectionoftrachealringsorcricoidcartilage

•  GSW=Injurytotracheobronchialtreeatanypoint•  MVC/BluntInjury=Suddendecelerationofthoraciccage,putstractionontracheaatthecarinaaslungsarepulledaway

  Aselasticityoftracheobronchialtreeisexceeded,itruptures  80%oftheseinjuriesoccurwithin2cmofthecarina


Tracheobronchial Injury   ClinicalFeatures•  Symptoms

 MassiveAirLeak,HemoptysisandSubcutaneousEmphysema

•  TwoclinicalPresentations Woundopensintopleuralspace–LargePTX•  Chesttubefailstoevacuatethespaceandre-expandthelungcharacterizedbybronchopleuralfistulaorpersistentairleak

  Completetransectionofthetracheobronchialtreebutlittlecommunicationwiththepleuralspace•  Presentwithunexplainedatelectasisorpneumoniadaystoweeksafterinjury


Tracheobronchial Injury   Diagnosis•  CXRmaydemonstratesecondaryfindings

  i.e.Pneumothorax,Pneumomediastinum,etc•  Definitivediagnosisismadewithbronchoscopy

  Management•  EndotrachealIntubation

  Preferableifdonewithbronchoscopetoallowvisualizationoftubepassingbeyondsiteofinjury

  Blindintubationrisksplacingendotrachealtubeintotransectedairway,falsepassageorconvertpartialtearintofulltear

•  SurgicalRepair(Thoracotomy)


Tracheobronchial Injury   Tracheobronchialinjuryresultinginbilateralpneumothorax,pneumomediastinumandsubcutaneousair


http://commons.wikimedia.org/wiki/File:Bilateral_pneumothorax_pneumomediastinum.jpg


Cardiovascular Injuries

  BluntCardiacTrauma•  MyocardialConcussion•  MyocardialContusion•  MyocardialRupture

  PenetratingCardiacInjury  AcutePericardialTamponade  BluntAorticInjury


Blunt Cardiac Trauma   Epidemiology•  TypicallyresultsfromhighspeedMVCwherechestwallstrikessteeringwheel•  Firstcharacterizedassignificanttraumaticentityin1930’sbyBrightandBeck•  Diagnosisisdifficultbecauseoflackofgoldstandardtestingformakingdiagnosis

  ClinicalSpectrum•  MyocardialConcussion•  MyocardialContusion•  TraumaticMyocardialInfarction•  MyocardialRupture


Myocardial Concussion   Definition•  CommotioCordis•  Bluntinjurytochestproducesastunningtothemyocardiumanddysrhythmia

•  Nopermanentcellularinjuryoccursbuttransientclinicaleffectsresult

  Mechanism=Sharpdirectblowtothemid-anteriorchest•  Resultsinabriefdysrhythmia,hypotensionandlossofconsciousness

  Ifpatientsurvivesinitialdysrhythmia,nolastingpathologicchangesanddifficulttomakediagnosis

  Myocardialconcussion=casesofsuddendeathafterablowtochestwithnochangesonautopsy

  Treatment=CasereportsofsuccessfultreatmentwithrapidapplicationofCPRandautomateddefibrillator


Myocardial Contusion   Epidemiology•  Poorlyunderstoodandnebulouscondition•  Reportedincidence=3-55%inreportsofsevereclosedchesttrauma

  Pathophysiology•  Directblowtothechesttransmitsenergythroughtheribstothespineandcompressestheheartbetweenthesternumandvertebrae,resultingincardiacinjury

•  Theseverityoftheinjuryisthoughttorelatetothephaseofthesystolic/diastoliccycleduringwhichthetraumaoccurs

•  Injuriesoccurringduringthemorerigidstagesoflaterdiastoleandearlysystole(whentheheartisfilledwithblood,lesselastic)aremoredamaging.


Myocardial Contusion   Pathophysiology(Continued)•  Rangeofmicrocellulardamageisseenfrommilddisruptionofmyofibrilstocompletelossofstructureandnecrosis

•  Edemaandcellularinfiltratesaccumulateinthewalloftheheartandresultsindecreasedventricularcompliance

•  Acutethrombusmayformandresultincoronaryarteryocclusionandmyocardialinfarction

•  Smallpericardialeffusionsoccurinmorethan50%ofallcontusions(notindicativeofsignificantcardiacinjuryorincreasedriskoftamponade)

•  Fibrousreactionmayoccuratthesiteofthemyocardialinjuryandsiteisatriskfordelayedrupture(typically2ndweekafterinjury)

•  Mostmyocardialcontusionshealspontaneouslywithresolutionofcellularinfiltrateandhemorrhageleadingtoscarformation.


Myocardial Contusion   ClinicalFeatures•  Mostpatientswithmyocardialcontusionwillhaveexternalsignsofthoracictraumaincludingcontusions,abrasions,ribfractures,etc.•  Absenceofthoraciclesionsdecreasessuspicionbutdoesnotexcludecardiacinjury•  Mostsensitivebutleastspecificsignofmyocardialcontusion=sinustachycardia

  Presentin70%ofpatientswithdocumentedmyocardialeffusion

•  Conductionblocksmayoccurbutisrarelyclinicallysignificant


Myocardial Contusion   DiagnosticStrategies•  Controversy

  Significantcontroversyexistsregardingtheimportanceofmakingthediagnosisinotherwisehemodynamicallynormalpatients

  Cannotbedefinitivelyidentifiedshortofabiopsyperformedatbiopsy

  Thepointofdiagnostictestingisnottodiagnosethepresenceofmyocardialcontusionbuttodefinealowriskpopulationthatcanbesafelydischargedfromtheemergencydepartment

•  EKG  EKGmaybenormalormaydemonstratenonspecificabnormalitiessuchassinustachycardia,RBBB(withinjuryofRV),AVBlock,Arrhythmias

  Mostfrequentlyseenabnormalitiesincludesinustachycardiaandatrialextrasystolicbeats


Myocardial Contusion   DiagnosticStrategies(Continued)•  CardiacEnzymes

  CK/CK-MBareoflittlediagnosticutilitybecauseitwillbenon-specificallyincreasedintraumapatientsasaresultofskeletalmuscleinjury

  Serumtroponinlevelsarehighlyspecificformyocardialinjuryandsomeauthorsrecommendtwosetsoftroponinmeasurements6hoursapartifnegativeisindicativeofalowriskstatus

•  Echocardiography  Echocardiographyisusefultoidentifywallmotionabnormalitiesandidentifyingassociatedlesionssuchasthrombi,pericardialeffusionandvalvulardisruption

•  Radionucleotidestudies  RarelyavailableintheEDandoflimitedbenefitbutwillidentifyunderperfusedareasoftheheartduetocontusion


Myocardial Contusion   Management•  Thereislittlevaluetoadmittingandcarefullymonitoringpatientswithsuspectedmildcardiaccontusions

•  Troponinissuggestedasameansofriskstratificationofpatientssuspectedofhavingamyocardialcontusion

•  Increasedtroponinlevelssuggestahigherriskofdevelopingcardiaccomplicationsandwarrantsfurthermonitoringwithechocardiography,serialEKG’sandserialtroponinlevels

•  NormalEKGandTroponinlevelat4-6hoursaftertheinjurycorrelateswithminimalriskofdevelopingcardiaccomplications

•  Elevatedtroponinlevelsshouldbetreatedwithoxygen,cardiacmonitoringandanalgesia

  Thrombolyticagentsandaspirinarecontraindicatedinthesettingofacutetrauma


Myocardial Rupture   Definition–Acutetraumaticperforationoftheventricles,atriabutincludespericardialrupture,lacerationorruptureofintraventicularseptum,papillarymusclesorvalves•  Delayedrupturemayoccurweeksafterblunttrauma,probablyresultingfromnecrosisofacontusedorinfarctedareaofmyocardium

  Epidemiology•  MostcommonlytheresultofhighspeedMVC•  15%ofallfatalthoracicinjuries•  Incidenceofcardiacruptureincasesofbluntchesttraumarangesfrom0.5%-2%

•  Autopsyreviewsuggest20%ofpatientswillsurvive30minutesormoresuggestingrapiddiagnosismayhaveallowedthissubsettoreachtheoperatingroom


Myocardial Rupture   Pathophysiology•  Ventriclesmostcommonlyrupture•  Multiplechamberrupturein30%ofpatients•  20%ofnon-survivorsalsohaveaorticrupture•  Proposedmechanismsofrupture

  Decelerationshearingforcesactingonfixedattachments(IVC/SVCandatrium)

  Upwarddisplacementofbloodandabdominalviscerafrombluntabdominalinjuryresultinginsuddenincreaseinintrathoracicpressure

  Directcompressionofheartbetweensternumandvertebralbodies  Lacerationfromriborsternalfracture  Complicationofmyocardialcontusionwithsubsequentrupture

•  Highassociationwithmulti-trauma–70%ofreportedsurvivorshadotherassociatedmajorinjuries

•  Immediatesurvivalisrelatedtotheintegrityofthepericardium  Intactpericardiumwithtamponadebleedingeffect  Violatedpericardiumwillresultinimmediateexsanguination


Myocardial Rupture   ClinicalFeatures•  Patientswilltypicallypresentwithevidenceofpericardialtamponadeandsubsequentrapiddeterioration

•  Auscultation=“bruitdemoulin”=harshmurmur=splashingmillwheel=hemopericardium

•  Findingssuggestiveofmyocardialrupture  Hypotensiondisproportionatetosuspectedinjury  Hypotensionunresponsivetofluidresuscitation  MassiveHemothoraxunresponsivetothoracotomyandfluidresuscitation

  Persistentmetabolicacidosis  PericardialEffusiononechocardiographywithhypotension

  Diagnosis•  EmergencyDepartmentUltrasound•  CXRsuggestiveofassociatedtraumaticinjuries


Myocardial Rupture   Management•  ImmediateDecompressionofcardiactamponadeandhemorrhagecontrol•  Pericardiocentesismaybeperformedastemporizingmeasureorasadiagnosticevaluationtool•  Emergencydepartmentthoracotomymayberequiredinpatientswithrapiddeteriorationandcardiacarrest  Hemorrhagecontrol=Fingerocclusion,FoleyCatheter,Vascularclamp GhanaEmergencyMedicineCollaborative

AdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Penetrating Cardiac Injury   Penetratingcardiacinjuriesisoneofleadingcausesoftraumaticdeathinurbansettings

  Rightventricle(43%)>Leftventricle(34%)duetoanatomiclocation

  1/3affectmultiplechambers  5%haveanassociatedlaceratedcoronaryartery  Outcomes•  ExsanguinatingHemorrhage

  Frequentlyexpirepriortoreachingemergencymedicalcare  E.g.Gunshotwoundtotheheart

•  CardiacTamponade  Incasesofpenetratingcardiacinjury,actuallyofferssomedecreeofprotectionbyprovidingtamponadeeffecttomassiveexsanguination

  Insomepatients,smallpericardialwoundcanactasawaytorelievepressurefromtamponadebyalsohelptamponadesevereexsanguination


Penetrating Cardiac Injury   PenetratingCardiacInjury•  Knives=LowerEnergy•  Bullets=HigherEnergy•  RVclosesttosurfaceofchest





Acute Pericardial Tamponade   Epidemiology•  Incidenceinpenetratingtraumatochestandupperabdomen=2%•  60-80%ofstabwoundstotheheartwillresultintamponade

  Pathophysiology•  Tamponaderesultsinincreasedintrapericardialpressureandvolume

•  Increasingvolumeandpressurelimitsabilityofatriaandventriclestofillwithblood,eventuallyleadingtodecreasedstrokevolumeanddecreasedcardiacoutput

•  Decreasedstrokevolumeandcardiacoutputresultinhypotensionanddecreasedpulsepressureresult

•  HeartattemptstocompensatewithincreasedHRandtotalperipheralresistanceinanattempttomaintainadequatecardiacoutputandbloodpressure

•  Clinicalpictureoftamponademayresultfromaslittleas60-100ccofbloodandclotsinthepericardium


Acute Pericardial Tamponade   ClinicalFeatures•  Beck’sTriad

  Hypotension  Distendedneckveins  Distantormuffledheartsounds

•  Threedistinctclinicalpresentations  Normotensive,tachycardicpatientwithelevatedCVP

•  Hemorrhageconfinedtopericardialsac

  Hypovolemicshockwithhypotension,tachycardiaandlowCVP•  Significanthemorrhageoutsideofpericardialsac

  Waxingandwaninghemodynamicmeasures•  Intermittentlydecompressingtamponade

  Diagnosis•  Ultrasound=pericardialeffusion+RVcollapse

  Ultrasound=98.1%Sensitive,99.9%specific•  Electrocardiography=ElectricalAlternans•  Radiography

  Nottypicallyhelpful,mayseewaterbottleshapedheartorairfluidlevel


Acute Pericardial Tamponade



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Acute Pericardial Tamponade   Management•  InitialResuscitation

  VolumeexpansionwithcrystalloidviatwolargeboreIVcatheters

  Bedsideechocardiographyfordiagnosis

•  Pericardiocentesis  Controversialtemporizingprocedure  5-10ccaspirationofbloodmayresultindramaticimprovementofclinicalcondition

  Notbenignprocedure–lacerationofcoronaryarteryorlung,inductionofcardiacarrhythmias

•  SurgicalRepair(Thoracotomy)  Definitivetreatment


Emergency Department Thoracotomy   Drasticpotentiallylife-savingprocedure  Indications

•  PenetratingTraumaticCardiacArrest  Cardiacarrestatanypointwithinitialsignsoflifeinthefield  Bloodpressure<50mmHgafterresuscitation  Severeshockwithclinicalsignsofcardiactamponade

•  BluntTrauma  Onlyifcardiacarrestintheemergencydepartment

•  SuspectedAirEmbolus  Goal=Determineifalife-threateningfixablelesionispresent

•  CardiacTamponade,CardiacRupture•  Vascularbleeding,Cross-ClampAorta

  SurvivalRates•  Cardiacarrestinthefield=0%•  Cardiacarrestinemergencydepartment=30%•  Agonalintheemergencydepartment=40%•  Unresponsiveshockinemergencydepartment=50%


Emergency Department Thoracotomy


http://www.trauma.org/index.php/main/image/900/ http://www.trauma.org/index.php/main/image/900/


Blunt Traumatic Aortic Injury   Epidemiology•  Mostcommonvesselinjuredbyblunttrauma•  IncreasingmortalityratesuggestingstrongassociationwithhighspeedMVC  <1%(1947),15%(Current)

•  10-20%ofpatientssustainingbluntaorticinjurywillsurvivetemporarily•  Meanage=33y/o,>70%aremen•  85%willsurviveifdiagnosisandsurgicalinterventionareprompt


Blunt Traumatic Aortic Injury   Pathophysiology•  SiteofRupture

  80-90%occurindescendingthoracicaortajustdistaltotheleftsubclavianartery•  25%incidenceofassociatedlethalcardiacinjuries

 Othercommonareasofinjury•  Distaldescendingaortaatlevelofthediaphragm•  Mid-thoracicdescendingaorta•  Originofleftsubclavianartery

  Descendingaorta>Ascendingaorta  Ascendingaortarupturehashighassociation(70-80%)withlethalcardiacinjuries•  SurvivallongenoughtobeevaluatedinEDrare


Blunt Traumatic Aortic Injury   Pathophysiology•  MechanismofInjury(DescendingAorta)

  Descendingaortaisfixedandimmobileduetotetheringeffectoftheintercostalarteriesandligamentousarteriosum

  Suddendeceleration,moremobileaorticarchmovesforwardproducingashearingforceontheaortaattheisthmus

  Bendingstressattheisthmuscreatedbylateralobliquecompressionmayalsoresultinrupturebyflexionoftheaorticarchontheleftmainbronchusandpulmonaryartery

  Otherauthorssuggestthatthesestressesarenotenoughtocausetheinjuryandtheinjuryresultsfrominferiorandposteriorrotationofanteriorthoracicosseousstructures(e.g.manubrium,clavicles,firstrib)thatsheartheaortaasitstrikesthevertebralcolumn


Blunt Traumatic Aortic Injury   Pathophysiology•  Ascendingaortamechanism

  Rapiddecelerationdisplacestheheartintoleftchestcausingashearingstressabovetheaorticvalvewithasuddenincreaseinintra-aorticpressure(waterhammereffect)

•  OthermechanismsofAorticInjury  Directlacerationbyfracturesofsternum,ribs,clavicle

  Complicationofexternalcardiacmassage  Fracturedislocationsofspine


Blunt Traumatic Aortic Injury   ClinicalFeatures•  Considerinanypatientwithsuddendecelerationinjury•  Clinicalmanifestationscanbedeceptiveandsubtle•  Co-existinginjuriescanmaskthesignsandsymptomsofaorticinjury

•  Mostcommonsymptomsareintrascapularorretrosternalpain•  Othersymptoms

  Dyspnea–trachealcompressionanddeviation  Stridororhoarseness–compressionofrecurrentlaryngealnerve  Dsyphagia-compressionoftheesophagus  Extremitypain–decreasedextremityperfusion

•  Signs–uncommonandnon-specific  Hypertension(reflexresponsetostretchingstimulus)  Harshsystolicmurmur  Swellingatbaseofneck(rare)


Blunt Traumatic Aortic Injury   Diagnosis•  Chestradiography

  Increasedwidthofsuperiormediastinum•  Seenin50-92%ofaorticruptures•  Specificity=10%

 Mediastinalwidth>8cminAPfilm Obscuredaorticknob  Leftapicalpleuralcap  PreviousbeliefthatnegativeCXRishighlypredicativeofnormalaortogramhasbeenrecentlychallengedandpatientswithsignificantmechanismsareatincreasedrisk


Blunt Traumatic Aortic Injury


http://www.trauma.org/index.php/main/images_keyword/aorta/

http://www.trauma.org/index.php/main/images_keyword/aorta/


Blunt Traumatic Aortic Injury   Diagnosis•  HelicalChestCT

  100%sensitivityandspecificity  PoorresultswithCTwerepreviouslyrelatedtoconventionalstyleCTscanners

•  TransesophagealEchocardiography  Fast,non-IVcontraststudythatcanbeperformedintheED(ifavailable)  Allowsidentificationofintimalflapandperiaortichematoma  Sensitivity=87%-100%  Specificity=98-100%

•  IntravascularUltrasound  Smallultrasoundprobethatcanbeinsertedthroughfemoralarteryandguideduptotheaortatofindsubtleinjuries

  Veryfewcentershavemodalityavailable

•  Aortography  Goldstandardforestablishingthediagnosis  Intra-arterialinjectionofIVcontrastandwaspreviouslyrecommendedforanypatientwithsignificantbluntchesttraumaandabnormalCXR(beforehelicalCTscans)

  RiskofcausingfurtherdamageifarterialcathetercrossessiteofinjuryGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Blunt Traumatic Aortic Injury   HelicalCTImaging•  Aorticarchdisruption

  Aortogram•  Pseudoaneuyrsmofdescendingaortaattheisthmus

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseSourceUndetermined

SourceUndetermined


Blunt Traumatic Aortic Injury   Management•  EmergencyDepartment

  Fixlifethreateninginjuriesfirst(ABCDE)  Makethediagnosis  Carefulregulationofbloodpressure(SBP=100-120mmHg)•  Decreasetheshearingeffectofelevatedpulsepressure•  IVBetablocker(Esmolol)

•  SurgicalIntervention  Definitivetherapy  Incidenceofmortalityduringsurgery=20-30%  Incidenceofparaplegia=5-7%  Endovascularrepairisdevelopingastoolformanagementandinitialliteratureispromising


Esophageal Perforation   Epidemiology•  MostrapidlyfatalperforationoftheGItractbecausedeathisnearly100%ifdiagnosisisdelayedpast24hours

•  ClassicdescriptionwasbyBoerhaavein1724•  Between1724–1940–Boerhaavesyndromewasnearly100%fatal•  Withimprovedsurgicaltechniques,mortalityhasnowbeendecreasedto30%

  Pathophysiology•  Esophagealperforationisassociatedwithhighmortalitybecauseofthelackofanyserosalcoveringtotheesophaguswhichallowsdirectaccesstomediastinum

•  Upperorcervicalperforations–extendintoretropharyngealspace•  MidorLoweresophagealperforations–extenddirectlyintothemediastinum

•  Drainageofesophagealcontentsresultsinchemicalandbacterialmediastinitis


Esophageal Perforation   Etiology•  Iatrogenic

  ComplicationofRigidorFlexibleEndoscopy  EsophagealDilatation  NasotrachealintubationorNasogastrictubeplacement  DifficultEndotrachealIntubations

•  ForeignBodies  Foreignbodiescauseesophagealperforationthroughdirectlacerationorpressurenecrosisorascomplicationofendoscopicremoval

•  CausticBurns  Intentionaloraccidentalingestionofacidoralkali  Perforationtypicallyoccurs4-14daysafteringestion  Strongalkaliburns=Liquefactionnecrosis=Higherpotentialofperforation

  Strongacidburns=Coagulationnecrosis=LowerpotentialofperforationGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Esophageal Perforation

  Etiology(continued)•  PenetratingandBluntTrauma

  EsophagealTraumaoccursin5%ofpatientswithinjuriestotheneckbutonly1%ofblunttraumaduetoposteriorlocationofesophagus

  Bluntesophagealtrauma<Penetratingesophagealtrauma

•  SpontaneousRupture  Boerhaave’sSyndrome  Morethan80%aremiddleagedmenwhohaveingestedlargemealsandalcohol


Esophageal Perforation   Diagnosis•  CXR–ClassicFeatures

  MediastinalAirwithorwithoutsubcutaneousair

  Left-sidedpleuraleffusion  Pneumothorax  Widenedmediastinum

•  Radiographicevidencemaynotbepresentinearlyphaseofdisease

•  Gastrografinesophagram(GoldStandard)

•  Endoscopy  Management•  Earlydiagnosisiskey•  Broadspectrumantibiotics•  SurgicalRepair GhanaEmergencyMedicineCollaborative

AdvancedEmergencyTraumaCourse

http://www.ispub.com/ispub/ijtcvs/volume_13_number_1_2/spontaneous_esophageal_perforation_presenting_as_pneumothorax_a_case_report/pneumo-fig1.jpg



Questions?

Dkscully(flickr)


References   Marx,JohnA.Rosen’sEmergencyMedicine6thEdition:ConceptsandClinicalPractice.NewYork.2006.

  Rivers,Carol.PreparingfortheWrittenBoardExaminEmergencyMedicine.5thEdition.January2006

  RobertsandHedges.ClinicalProceduresinEmergencyMedicine.4thEdition.Philadelphia.2004.

  Tintinelli,Judith.EmergencyMedicine:Acomprehensivestudyguide.6thEdition.McGrawHill.2004.

Download - Author(s): Patrick Carter, Daniel Wachter, Rockefeller ...€¦ · • Ribs break at point of impact or posterior angle (weakest structural point) • Ribs 1-3 ... • Primarily,

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