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Prof. of Cardio-Thoracic Surgery

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Presentation on theme: "Prof. of Cardio-Thoracic Surgery"— Presentation transcript:

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2 Prof. of Cardio-Thoracic Surgery
Chest Trauma By Dr. Samir Abdallah M.D Prof. of Cardio-Thoracic Surgery Cairo University

3 Chest Trauma Epidemiology
The fact that it has become possible in recent decades for millions of people to travel at high speed had led to a phenomenal increase in blunt injury to the chest - a most lethal type of injury.

4 All casualties, and particularly children who have been exposed to blunt chest injury may have sustained highly lethal internal lesions (rupture of the heart, the aorta or the major airway, for example, or contusion of the heart although the external stigmata of chest injury may be quite trivial or even absents altogether.

5 For this reason any causality who has sustained blunt trauma to the chest should be considered seriously injured until proved otherwise.

6 Frequency of Various Injuries In Motor Vehicle Accidents
Extremities 34% Head and neck 32% Chest 25% Abdomen 15%

7 Mechanism of Injury in Chest Trauma
Acceleration/deceleration (motor vehicle accident) Body compression (crush injury) High-speed impact (gunshot wound) Miscellaneous Low-velocity penetration (stab wound) Airway obstruction (suffocation) Caustic injury (poisoning) Burns Electrocution

8 Blunt or Penetration Trauma
Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosis Blunt or Penetration Trauma Chest wall injury Airway Obstruction Pneumothorax Hemorrhage Cardiac injury Pain, Restriction, Retention of Secretions, Atelectasis Flail Chest Hemothorax Hypovolemia Tamponade Myocardial dysfunction Diminished Cardiac Output Hypoventilation Hypoxemia Respiratory Acidosis Pulmonary Shunting Tissue Hypoxia Metabolic Acidosis

9 Multiple Organ Failure
TRAUMA DEATHS IMMEDIATE 50% Seconds or Minutes Spinal Cord Injuries Severe Brain Injuries Lesions to Great Vessels Prevention Optimum Prehospital Care EARLY 30%-35% Within Hours (Golden Hour) Thoracic Trauma Liver/Spleen Injuries Multiple Pelvic Fractures Others Optimum Initial Care LATE 15%-20% 2-3 Weeks Sepsis Multiple Organ Failure Optimum Initial Care (Future?)

10 Percentage of Specific Types of Thoracic Organ Injury
Chest wall 54 Flail chest 13 Pneumothorax 20 Hemothorax 21 Pulmonary Miscellaneous 18

11 Assessment of patient with Thoracic injury
The evaluation of thoracic injuries is only one aspect of the total assessment of severely injured patients. Both diagnosis and therapy go hand in hand. The basic principle of elective surgery - “First investigate and make the diagnosis, then treat the illness” - is a dangerous illusion.

12 Assessment of patient with Thoracic injury
The first step is to make a rough estimate of the status of the circulatory and respiratory systems. This provides the first diagnostic clues and often determines which therapeutic action is to be taken. Specific questions are then posed pertaining to individual injuries or their consequences.

13 threatening; diagnosis and therapy before taking
TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries     1. Hypovolemia?     2. Respiratory insufficiency?     3. Tension pneumothorax?     4. Cardiac tamponade Immediately life- threatening; diagnosis and therapy before taking roentgenograms

14 TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries
Multiple rib fractures? (Paradoxical respiration?) Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?) Hemothorax? Diaphragmatic rupture? Aortic rupture? Cardiac contusion?

15 Monitoring and evaluating the patient with Thoracic trauma
Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles). Mediastmum (wide or normal) shifted or not. Lung parenchyma (Contusion). The heart (cardiac tamponade). Diaphragm. Pneumothorax, hemothorax. ECG CVP Arterial blood gases. Urine output. Lab. Investigations. Others.

16 Management of patients with Thoracic Trauma
The treatment of polytraumatized patient must follow a certain protocol which includes. Adequate oxygenation. Fluid replacement. Surgical intervention. Treatment of septic complications. Adequate caloric and substrate supplementation. Prevention of stress bleeding. Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis.

17 Rib and Sternal Fracture Mechanism of Injury
Lung injuries are more common Indirect violence Direct Violence

18 Rib and Sternal fractures
Diagnosis Patient complains of localized pain that is aggravated by coughing deep breathing “Localised tenderness. Subcutaneous emphysema False motion, paradoxical respiration Rib fractures must be diagnosed clinically many rib fractures are not visible on X-ray chest.

19 Flail Chest

20 Therapy in multiple rib fractures (not taking companion injuries into consideration)
Stable thoracic wall Unstable thoracic wall Paradoxical respiration 1. Controlling pain Analgesics (morphine derivatives) every 4h even if there are “no pains” If necessary, intercostal nerve block If necessary, epidural anesthesia 2. Intensive breathing exercises Only in cases of respiratory insufficiency Mechanical ventilation; prophylactic insertion of a chest tube In exceptional cases, operative stabilization of the thoracic wall

21 Intercostal Blocks (Sites)

22 It is a tried and tested rule that a prophylactic chest tube should be inserted in every patient with multiple rib fractures who is to undergo an operation under general anaesthesia even when there is neither evidence of a hemothorax nor of a pneumothorax.

23 Pneumothorax and Hemothorax
Cases of pneumothorax and hemothorax can be provided with extremely effective therapy for the most part with simple methods, in more than 80% of cases. It must, however, be given early, furthermore the drainage of air and blood must be efficient.

24 Tension Pneumothorax (Life Threatening)
Every traumatic pneumothorax can develop into tension pneumothorax, however, this complication is rare with spontaneous breathing. Very frequently, in a more dangerous form by for, a tension pneumothorax occurs during mechanical ventilation. Treatment consists of immediate relief of pressure.

25 Open Pneumothorax Diagnosis:
A penetrating thoracic wound with a sucking sound of incoming and outgoing air “sucking wound” adds to the clinical and radiological evidence of pneumothorax Therapy: Immediate air tight closure of the thoracic wound. Immediate intubation and mechanical ventilation.

26 Hemothorax Diagnosis Diminished breath sound.
Muffled sound on percussion. X-ray chest: Clouding of the affected half of the thorax up to complete opacity. In the diagnosis of hemothorax formation of atelectosis and rupture of the diaphragm should be differentiated.

27 Hemothorax Sources of blood accumulating in the chest following blunt or penetrating trauma: Pulmonary parenchymal laceration. Rupture of pleural adhesions. Mediastinal injury with or without vascular injury. Cardiac injury with pericardio-pleural communication. Decompression of abdominal hemorrhage through a traumatic diaphragmatic injury.

28 Hemothorax Therapy The key to successful management of acute hemothorax is early aggressive care in the form of adequate pleural evacuation by thoracostomy or thoracotomy in order to minimize the morbidity. The rate and cessation of bleeding depends on the site and size of the bleeding wound.

29 Hemothorax Thoracotomy is done if the bleeding is constant and more than 300 ml per hour during the first three to four hours. However, tube thoracotomy is all what is needed if bleeding is less and decreasing without radiological evidence of clotted blood.

30 Insertion of Chest Tube
Development of subcutaneous tract Confirmation that lung is not adherent to chest wall at puncture site Incision over intercostal space Penetration of parietal pleura

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38 Lung Parenchymal Injuries
Clinical significant Therapy Lung laceration/ lung rupture Mostly harmless (exception: central lung rupture) Conservative Thoracic drainage in pneumothorax and hemothorax Operation only in exceptional cases because of bleeding or massive air loss

39 Lung Parenchymal Injuries
Clinical significant Therapy Intrapulmonary hematoma Harmless None

40 Lung Parenchymal Injuries
Clinical significant Therapy Traumatic lung pseudocysts Harmless Mostly none

41 Lung Parenchymal Injuries
Clinical significant Therapy Simple lung contusion Mostly harmless Can develop into lung contusion with respiratory insufficiency Breathing exercises Careful monitoring of progress

42 Lung Parenchymal Injuries
Clinical significant Therapy Lung contusion with respiratory insufficiency Progressive respiratory insufficiency: hypoxia, right-to-left shunt interstitial edema, considerable mortality Intubation and positive end-expiratory pressure ventilation (PEEP) Maintenance of a normal oncotic pressure (fluid infusion limited, human albumin 29%). Steroids

43 Lung Parenchymal Injuries
Clinical significant Therapy Blast injury Severest injury Progressive respiratory insufficiency Danger of arterial air embolism Hemothorax, pneumothorax, abdominal injuries (colonl) As in lung contusions with respiratory insufficiency

44 Abnormalities following bronchial rupture and methods of management
Immediate Acute respiratory insufficiency Acute Infections Early Bronchial Obstruction Mediastinitis Empyema Atelectasis Tubes Emergency Repair or Resection

45 Abnormalities following bronchial rupture and methods of management
Delayed Pulmonary Infection Late bronchial obstruction Pneumonia Abscess Bronchiectasis Pneumonitis Atelectasis Fibrosis Abscess Elective Pulmonary Resection Fibrosis

46 Pathologic courses following esophageal perforation
Entry into cervical or mediastinal fascial planes of: Air Gastric juice Bacteria and Saliva Mediastinitis Emphysema Pneumothorax Burn Abscess Empyema Sepsis Pneumonia Tension Fluid and electrolyte disturbance CV Collapse

47 Therapy non-operative
Essential components of and procedures used in management of esophageal perforation Therapy non-operative Fluid and Electrolytes Antibiotics Prevent further contamination High-dose IV Topical, Luminal Gast. Tube Plus Operative Prox. Tube Closure Or Exclusion Re-section Drainage of Mediastinal and/or fascial planes Only With reconstruction

48 Injuries of the diaphragm
Diaphragmatic Rupture: Incidence: In 3% of all sever thoracic injuries. Mechanism: Broad surface blow. Location: Left side in 85% of cases. Clinical picture. Acute: symptoms of companion injury and shock. Chronic: Intestinal obstruction or strangulation (usually)

49 Diaphragmatic ruptures (Cont.)
Radiological Ex.: Rupture of the diaphragm are frequently overlooked. Therapy: Is indicated for increasing impairment to respiration. Operative approach from chest or abdomen.

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51 Traumatic Diaphragmatic Rupture

52 Traumatic Emphysema Subcutaneous. Mediastinal Emphysema.
“Present in about 27% of patients with blunt or penetrating chest injury”

53 Traumatic Emphysema Therapy:
Despite its impressive appearance the treatment of subcutaneous emphysema it self is mostly unnecessary. Determite the site of origin. Treat underlying pneumothorax if present by tube thoracostomy. Treat tracheobronchial, or oesophageal rupture or tension pneumothorax in cases of mediastinal emphysema. Rarely, cervical mediastinotomy is needed for mediastinal enphysema.

54 Non-penetrating wounds of Heart

55 Cardiac Tamponade

56 Algorithm for the diagnosis and management of penetrating cardiac injuries
Precordial/Epigastric Wounds Hypotension Suspect Cardiac Injury Airway Control Central Venous Lines Volume Expansion Tube Thoracostomy Hemodymanic Instability Hemodymanic Stability Operating Capability In E.R. Yes No Immediate TRT Relief of Tamponade Cardiorrhaphy Pericardiocentesis Intrapericardial Catheter Constinous Aspiration Operating Room Transfer Subxiphoid Pericardial Window Diagnosis Confirmed Operating Room Transfer Definitive Casrdiorrhaphy Control of Other Injuries Closure of Incision

57 Penetrating cardiac injuries (Therapy)

58 Penetrating cardiac injuries (Therapy)

59 CARDIAC INJURY Repair Postoperative Period Asymptomatic Symptomatic
Electrocardiogram Chest X-ray Physical examination Normal Abnormal 2-D Echocardiogram Shunts Fistulae Equivocal intracardiac Defects Foreign Bodies Cardiac Catheterization Re-operation Follow-up

60 Other Injury Patterns in Thoracic Trauma
I. Traumatic asphyxia: Due to a severe compression of thorax with sudden increase of pressure in the venous system resulting in a characteristic injury pattern where small hemorrhages in the conjunctiva, the skin and the mucous membranes of the throat and head and reddish-blue discoloration in the latter region. Therapy: Is for the companion injuries and cerebral oedema if present.

61 Other Injury Patterns in Thoracic Trauma
II. Injuries of the thoracic duct: (Chylothorax) III. Cholothorax IV. Traumatic induced hernia of the chest wall V. Arterial air embolism VI. Blast injury

62 Indications for Thoracotomy: Decision to Operate
Excluding minor surgical procedures such as tracheostomy pericardiocentesis, tube thoracostomy, and suture of chest wall lacerations, formal operations are required in only 12 to 15 percent of patients with thoracic trauma.

63 Indications for thoracotomy: ACUTE
Post-traumatic cardiovascular collapse Pericardial tamponade Vascular injury to the thoracic outlet Traumatic thoracotomy Massive Air leak Proved tracheobronchial injury Proved Esophageal injury Great vessel injury Continuing Hemothorax Mediastinal traversing injury Bullet Embolism Air Embolism

64 Indications for thoracotomy: CHRONIC
Unevaluated clotted hemothorax Chronic traumatic Diaphragmic hernia Chronic cardiac septal or valvular lesions Chronic false Aneurysms Chronic non-closing thoracic duct fistula Infected intrapulmonary hematoma Missed trachobronchial injury Traumatic Arterio-venous fistula

65 Initial Assessment of the most important thoracic injuries
Suspected if there is Additional examination required Initial therapeutic measures Tension pneum- Othorax Inflated hemithorax with reduced mobility of thorax None  Immediate thoracic Hypersonorous auscultation Weakened breath sounds Venous congestion in creasing elevation of central venous pressure Open pneumothorax Thoracic wounds with sound of air rushing in and out (“sucking wound”) 1. Tight bandage +ICT or 2. Intubation mechanical ventilation Cardiac tamponade Location of wound in the precordium or corresponding tract of the bullet or knife Pericardioeentesis Operation

66 Initial Assessment of the most important thoracic injuries
Suspected if there is Additional examination required Initial therapeutic measures Rib fractures Local tenderness Chest roentgenogram Relief of pain Compression pain Intubation and mechanical ventilation when respiratory insufficiency occurs Possibly crepitation on auscultation Inspection: possibly paradoxical respiration Pneumothorax Hyperresonance Thoracic drainage Diminished breath sounds Hemothorax Dullness to percussion Subcutaneous emphysema

67 Initial Assessment of the most important thoracic injuries
Suspected if there is Additional examination required Initial therapeutic measures Rupture of bronchus Mediastinal emphysema Bronchoscopy Operation Pneumothorax or tension peneumothorax No expansion of lung during thoracic drainage Total atelectasis Rupture of esophagus Esophagography

68 Initial Assessment of the most important thoracic injuries
Suspected if there is Additional examination required Initial therapeutic measures Mediastinal emphysema Characteristic crunching sound above the heart, synchronous with the heart beat (Hamman’s sign) Chest roentgenogram Cervical mediastionotomy only when there is significant venous congestion and no rupture of bronchus or esophagus Central venous pressure Determination of possible cause by means of: Bronchoscopy Esophagography Diaphragmatic rupture Percussion: dampened or hypersonorous percussion Roentgenogram of thorax with possible use of nasogastric tube and/or contrast media Operation

69 Initial Assessment of the most important thoracic injuries
Suspected if there is Additional examination required Initial therapeutic measures Rupture of aorta Possibly pseudocoarctation syndrome Aortography Operation Possibly compression syndrome in the upper mediastinum Possibly systolic murmur Roentgenorgram: Wide mediastinum Tracheal displacement to the right Displacement of the left bronchus downward Possible left-sided hemothorax Cardiac contusion ECG: Irregularities in repolarization Disturbances in rhythm and conduction Infarct pattern Cardiac enzymes ECG monitoring Drug treatment of rhythm irregularities and of possible cardiac insufficiency

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