in thoracic trauma
TRANSCRIPT
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MANAGEMENT OF THORACIC
TRAUMA
Luis H. Tello MV, MS DVM, COS
Portland Hospital Classic
Banfield Pet Hospital - USA [email protected]
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Chest Trauma: Big threat !!!!
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CAUSES OF THORACIC TRAUMA
• Blunt Trauma • Motor vehicle accidents, intentional or non intentional blows, high-rise, etc.
• Penetrating injuries • Penetrating weapons, gun shots, small dogs v/s large dogs, etc.
• Multiple Trauma • Dog fights, animal-animal interaction, etc.
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GENERAL RULES IN THORACIC TRAUMA
Restore and insure permeable airway
Restore normal intra-pleural pressure
Preserve normal alveolar ventilation
Maintain effective circulation, blood
pressure, volemia and hemoglobinemia
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I.- PNEUMOTHORAX
• Air accumulation in the pleural space
• 47% of thoracic trauma in dogs and cats
• 63% of cats with high-rise syndrome
• Is is classified as “open” or “closed”
• Tension and/ or valve pneumothorax
• Not all have clinical transcendence
TRAUMA AFFECTING THE PLEURAL SPACE
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SHOULD BE RULE OUT IN EVERY TRAUMA PATIENT
THE DIAGNOSIS IS CLINIC, NOT RADIOGRAPHIC
(tap it before rad it!!)
PHYSICAL EXAMINATION - THORACOCENTESIS
PNEUMOTHORAX
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Pneumothorax : Radiographs… bad decision
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• PHYSICAL EXAMINATION
• Dyspnea - Silence at dorsal auscultation - Orthopneic position -
Cyanosis - Sat.O2 Hb< 90%
• THORACOCENTESIS
• Patient in sternal position
• 8°- 11° inter costal space as dorsally as possible
• 3 way stop-lock – butterfly/catheter 21 - 23 G
• More than 10 cc/kg of air? Repeat in 2 hours
• Avoid damage to pulmonary parenchyma
PNEUMOTHORAX
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II.- HEMOTHORAX
• Blood accumulation in the pleural space
• 8% of thoracic trauma in dogs and cats
• 5 % of cats with high-rise syndrome
• 12% of dogs in vehicle accidents
• Potentially volume entrapment
• Not all have clinical importance
• Of lousy prognosis when associated to shock
TRAUMA AFFECTING PLEURAL SPACE
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UNFREQUENT PRESENTATION BUT IT
SHOULD BE INVESTIGATED
PHYSICAL EXAM DIAGNOSIS (NOT RADIOGRAPHIC)
THORACOCENTESIS: Dx and therapeutic
SHOCK SIGNS ? SERIOUS !!!!
Pale mucous membranes, long CRT, cold limbs, tachycardia, etc.
BP<60 mm Hg, HR > 180 bpm (dogs), CVP< 3 cm H2O
HEMOTHORAX
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“HEMOTHORAX MYTH”
ACCUMULATED BLOOD PREVENTS EXPANTION
INTRAPLEURAL PRESSURE RISES
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• PHYSICAL EXAMINATION
• Dyspnea - Silence at ventral auscultation - Cardiac
silence - Painful respiration - Costal fracture?
• THORACOCENTESIS
• 8°- 11° intercostal space as ventrally as possible
• 3 way stop-cock - Butterfly catheter 21 - 23 G
• When and how much to drain?.... CONTROVERSIAL
• More than 20 cc/Kg? Auto-transfusion ?
• Continual hemorrhage SURGERY
HEMOTHORAX
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KEY IN HEMOTHORAX IF THERE ARE HYPOTENSION or
PENETRATING INJURIES or COSTAL FRACTURES,
SURGICAL EXPLORATION MUST BE DONE
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III.- DIAPHRAGMATIC HERNIA
Traumatic rupture of the diaphragm with
abdominal organs in the pleural space due
to an increase in abdominal pressure
• 28% of multiple trauma patients in dogs and cats
• 43% associated to other injuries (JAAHA, 1998)
• Not all have clinical transcendence
• It is an ABDOMINAL trauma
TRAUMA AFFECTING PLEURAL SPACE
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DIAPHRAGMATIC HERNIA
MOST PATIENTS SHOW
FEW CLINICAL SIGNS
DIAGNOSIS IS BY
PHISICAL
EXAMINATION AND
CONFIRMED BY X-RAYS
THORACIC
AUSCULTATION
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• SURGICAL MANAGEMENT
• CONTROVERSIAL
• MORTALITY IS GREATER IN THE FIRST 24
HOURS POST TRAUMA ***
• WHENEVER POSSIBLE, STABILIZE THE PATIENT
– BLOOD PRESSURE AND NORMAL HR
– Hb SATURATION and/or ARTERIAL GASES
– AVOID SIRS AND SEPSIS
DIAPHRAGMATIC HERNIA
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KEY IN DIAPHRAGMATIC HERNIA
EMERGENCY SURGERY IS RARE … DON´T RUN !!
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I.- PULMONARY CONTUSION • PARENCHYMA HAEMORRHAGE & EDEMA
• ENDS IN ALVEOLAR COLAPSE AND PULMONARY
CONSOLIDATION
• CAUSED BY SUDDEN THORACIC COMPRESSION
AND DECOMPRESSION
• CAUSES HYPOXEMIA DUE TO
– PERFUSION : VENTILATION INADEQUATE,
VASCULAR SHUNT, HYPOVENTILATION, DIFFUSION
FAILURE
TRAUMA AFFECTING PULMONARY PARENCHYMA
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• CLINICAL SIGNS
– DIFFERENCIATE BY HEMITHORAX
– HYPOXEMIA
– DYSPNEA - TACHYPNEA
– COUGH
– HEMOPTISIS
– THORACIC AUSCULTATION WITH MULTIPLE
SOUNDS
PULMONARY CONTUSION
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Pathophysiology and Significance
• Blunt force to lung parenchyma resulting in capillary damage
• Increased interstitial and intra-alveolar fluid
• Decreased pulmonary compliance
• Increased pulmonary shunt
• Hypoxemia
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• RADIOGRAPHICAL SIGNS
– STRONGLY UNDERESTIMATE REAL DAMAGE
– RADIOGRAPHICAL SIGNS APPEAR LATER THAN
CLINICAL SIGNS
– INTERSTITIAL and/or ALVEOLAR PATTERN
– “PATCHES” ALL OVER
– MANY OTHER TRAUMATIC INJURIES
PULMONARY CONTUSION
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• Lesión pulmonar aguda ALI
• Síndrome Distres Respiratorio Agudo SDRA
•Oxigenación: PaO2/FiO2 igual o menor a 300
•Rx de tórax: infiltrado pulmonar bilateral
•PaO2 Art. Pulmonar: igual o < de 18 mmHg
•Oxigenación: PaO2/FiO2 igual o menor de 200
•Los otros dos parámetros igual que la ALI
ALI ≠ RADS
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• TREATMENT
– MAINLY VITAL SUPPORT
– OXYGENTHERAPY 100 - 200 ml/Kg/min UNTIL
ACHIEVING SatO2 Hb > 95%
– CRISTALLOID + COLLOID FLUIDTHERAPY UNTIL
ACHIEVING Art Pr > 80 mm Hg & URINE
PRODUCTION OF 1 ml/Kg/hr
PULMONARY CONTUSION
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• My personal experience….
– Stabilize the patient
– Oxygen UNTIL GET SatO2 Hb>95% / PO2>60 mmHg
– Small amount of crystalloids + colloids and
– LOBECTOMY
PULMONARY CONTUSION
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• CONTROVERSIAL TREATMENTS
– FUROSEMIDE 0,5 - 2 mg/Kg
– NOT ACTUALLY RECOMMENDED
– CORTICOSTEROIDS
– NOT CURRENTLY RECOMMENDED
– ANTIBIOTICS
– SECONDARY PNEUMONIA IS MOST FREQUENT IN
HUMANS THAN ANIMALS
– REQUIERES ANTIBIOGRAM (BRUSHING OR LAVAGE)
– AMPICILLIN 15 mg/Kg TID + GENTAMICIN 2-3 mg/Kg BID
– DOXICICLIN IS MORE EFFECTIVE IN CATS
PULMONARY CONTUSION
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MECHANICAL VENTILATION
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LIQUID VENTILATION
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Secondary Issues in Thorax Trauma
• Pneumonia
• DIC
• RADS
• Cardiac contusion
• Arrhythmias
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THANKS