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Chest Trauma 19 th April 2013 Kenyatta National Hospital Dr. Josiah Ruturi Thoracic and Cardiovascular Surgeon.

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Presentation on theme: "Chest Trauma 19 th April 2013 Kenyatta National Hospital Dr. Josiah Ruturi Thoracic and Cardiovascular Surgeon."— Presentation transcript:

1 Chest Trauma 19 th April 2013 Kenyatta National Hospital Dr. Josiah Ruturi Thoracic and Cardiovascular Surgeon.

2 - Approximately 150,000 people die each year in the United States as a result of trauma. - 25% of the deaths can be directly related to thoracic injury. - Almost all patients with thoracic trauma are treated conservatively with a successful outcome. - urgent operative treatment was required in only: - 0.5% of blunt thoracic injuries % of blunt thoracic injuries % of penetrating thoracic injuries % of penetrating thoracic injuries.

3 OBJECTIIVES Identify and initiate treatment of life- threatening thoracic injuries Identify and initiate treatment of life- threatening thoracic injuries Primary survey Primary survey Secondary survey Secondary survey Procedures Procedures Special considerations Special considerations

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6 Immediate Life-Threatening Injuries Airway obstruction Airway obstruction Tension Pneumothorax Tension Pneumothorax Open Pneumothorax Open Pneumothorax Massive Hemothorax Massive Hemothorax Flail Chest Flail Chest Cardiac Tamponade Cardiac Tamponade

7 Potentially Life-Threatening Injuries: Pulmonary Contusion Pulmonary Contusion Myocardial Contusion Myocardial Contusion Aortic Disruption Aortic Disruption Traumatic Diaphragmatic Rupture Traumatic Diaphragmatic Rupture Tracheobronchial Disruption Tracheobronchial Disruption Esophageal Disruption Esophageal Disruption

8 An unstable hemodynamic state : 1. Traumatic cardiac arrest or near arrest and 1. Traumatic cardiac arrest or near arrest and an Emergency department thoracotomy. an Emergency department thoracotomy. 2. Cardiac tamponade 2. Cardiac tamponade 3. Persistent ATLS class III shock despite fluid 3. Persistent ATLS class III shock despite fluid resuscitation resuscitation (blood loss 1500–2000 mL, pulse rate > 120, (blood loss 1500–2000 mL, pulse rate > 120, blood pressure decreased) blood pressure decreased) 4. Chest Tube output > 1500 mL of blood on insertion 4. Chest Tube output > 1500 mL of blood on insertion 5. Chest Tube output > 500 mL/hour for the initial hour 5. Chest Tube output > 500 mL/hour for the initial hour 6. Massive hemothorax after chest tube drainage 6. Massive hemothorax after chest tube drainage

9 Primary Survey Airway: patency, retractions, obstruction Airway: patency, retractions, obstruction Breathing: exposure, rate, pattern, cyanosis Breathing: exposure, rate, pattern, cyanosis Circulation: *Pulses, color, *neck veins, monitor for arrythmias Circulation: *Pulses, color, *neck veins, monitor for arrythmias *hypovolemic patients might not exhibit

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11 Initial Management Airway - with cervical spine control - tracheobronchial tree disruption Airway - with cervical spine control - tracheobronchial tree disruption Breathing - tension/open pneumothorax, flail chest, lung contusion Breathing - tension/open pneumothorax, flail chest, lung contusion Circulation - cardiac tamponade, hemothorax, cardiac contusion, aortic disruption Circulation - cardiac tamponade, hemothorax, cardiac contusion, aortic disruption

12 Specific signs and symptoms Pneumothorax Tension Pneumothorax Tension Pneumothorax –Hypotension, tracheal deviation, distended neck veins Pneumothorax Pneumothorax –No signs, tachypnea, tachycardia, decreased breath sounds, hyperresonance, SQ emphysema Pneumomediastinum Pneumomediastinum –Hamman’s sign, SQ emphysema

13 Subcutaneous Emphysema Airway, Lung or Blast injury Airway, Lung or Blast injury esophageal injury: Boerhaave’s esophageal injury: Boerhaave’s Adjacent penetrating wound Adjacent penetrating wound Progression to tension pneumothorax Progression to tension pneumothorax

14 Pneumothorax

15 Pneumothorax -Treatment <15% -very small spontaneous can be given 100% O2 in ED and observed <15% -very small spontaneous can be given 100% O2 in ED and observed <25% - simple pneumothorax can be aspirated through a small catheter <25% - simple pneumothorax can be aspirated through a small catheter Larger pneumothoraces/ underlying lung dz –tube thoracostomy Larger pneumothoraces/ underlying lung dz –tube thoracostomy Pneumonediastinum – conservative Pneumonediastinum – conservative

16 Tension Pneumothorax “one-way valve”: air enters, can’t exit “one-way valve”: air enters, can’t exit displacement of mediastinum/trachea displacement of mediastinum/trachea decreases venous return, displaces opposite lung decreases venous return, displaces opposite lung Causes: spontaneous pneumothorax, blunt chest trauma, penetrating trauma Causes: spontaneous pneumothorax, blunt chest trauma, penetrating trauma

17 Tension Pneumothorax

18 LeftRight A: Air under tension in left thorax A B B: Collapsed right lung Pleural margin; partial lung collapse Tension Pneumothorax

19 Heart LeftRight B B B: pressure of tension pneumothorax pushing midline structures (heart, mediastinum) into patient’s left thoracic cavity A A: air, under tension, in thoracic cavity

20 Tension Pneumothorax Clinical manifestations in patient with Clinical manifestations in patient with –Spontaneous breathing –Respiratory distress –Florid face –Tracheal deviation –Distended neck veins –Tachycardia –Hypotension

21 Needle Thoracentesis Indication: Rapidly deterioration with tension pneumothorax. Indication: Rapidly deterioration with tension pneumothorax. Equipment Equipment –Povidone-iodine solution –14-gauge catheter-over-needle device Technique Technique –Cleanse overlying skin –Insert needle at 2nd or 3rd intercostal space, midclavicular line, over top of rib –Leave catheter in pleural space open to air

22 Sucking Chest Wound AKA communicating pneumothorax AKA communicating pneumothorax Large defects: if opening > 2/3 trachea, air will pass preferentially. Large defects: if opening > 2/3 trachea, air will pass preferentially. Cover immediately with cleanest occlusive dressing Cover immediately with cleanest occlusive dressing 3 sides vs 4 sides 3 sides vs 4 sides

23 Massive Hemothorax >1500 cc blood >1500 cc blood Mechanism: Mechanism: –Penetrating injury of systemic or hilar vessels, especially wounds medial to nipples, scapulas. –Blunt trauma Loss of Breath sounds, dullness to percussion Loss of Breath sounds, dullness to percussion

24 Flail Chest No bony continuity with rest of cage No bony continuity with rest of cage Multiple rib fractures, paradoxical movement Multiple rib fractures, paradoxical movement Hypoxia from injury to underlying lung Hypoxia from injury to underlying lung 30% missed in first 6 hours 30% missed in first 6 hours

25 Flail chest is a marker for significant injuries Retrospective analysis, 92 pat, L-1 center. Retrospective analysis, 92 pat, L-1 center. 46% had pulmonary contusion 46% had pulmonary contusion 70% had pneumo or hemothorax 70% had pneumo or hemothorax Great vessel, tracheobronchial injuries had no associated. Great vessel, tracheobronchial injuries had no associated. 27% developed ARDS 27% developed ARDS 69% required mechanical ventilation 69% required mechanical ventilation 33% mortality 33% mortality Ciraulo DL et al. J Am Coll Surg 1994;178(5):466. (Penn)

26 Traumatic Aortic Injury Retrosternal/intrascapular pain Retrosternal/intrascapular pain Dyspnea, hoarseness, dysphagia, HTN Dyspnea, hoarseness, dysphagia, HTN Pseudocoarctation syndrome Pseudocoarctation syndrome Hypotension Hypotension Harsh systolic murmur (AI) Harsh systolic murmur (AI) 50% without external findings 50% without external findings

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31 Cardiac Tamponade Penetrating injuries most common Penetrating injuries most common Beck’s Triad Beck’s Triad Kussmaul’s sign (rise in CVP with inspiration) Kussmaul’s sign (rise in CVP with inspiration) Mimic: tension pneumo on left side Mimic: tension pneumo on left side EKG: electrical alternans (rare) EKG: electrical alternans (rare)

32 Management of Tamponade: Cautious fluid management Cautious fluid management Pericardiocentesis: cc may immediately improve hemodynamics Pericardiocentesis: cc may immediately improve hemodynamics Open thoracotomy and inspection Open thoracotomy and inspection

33 Pericardiocentesis Indications Indications –Immediate threat to life –Severe hemodynamic impairment –Fall in systolic blood pressure >30 mm Hg

34 Pericardiocentesis Technique Technique –Patient in supine position, upper torso elevated –ECG limb leads attached to patient –Use echocardiography guided procedure (rarely: ECG-guided, V lead) –Subxiphoid approach –Continuous aspiration

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36 Pulmonary Contusion Determinants of outcome ISS > 25 ISS > 25 Initial GCS < 7 Initial GCS < 7 Transfusion > 3 U blood Transfusion > 3 U blood pO2/FiO2 < 300 pO2/FiO2 < 300 Not correlated to shock or IV fluid administration Not correlated to shock or IV fluid administration Extent of contusion seen on initial chest X-ray Extent of contusion seen on initial chest X-ray not predictive of mortality or intubation. Johnson JA et al. J Trauma 1986; 26(8):695.

37 Diaphragmatic Rupture Blunt trauma: large tears Blunt trauma: large tears Penetrating: small tears, subtle Penetrating: small tears, subtle More commonly diagnosed on the left More commonly diagnosed on the left

38 Tracheobronchial Tree Larynx Larynx –Hoarseness –Subcutaneous emphysema –Palpable Fracture –Crepitus Trachea: Trachea: –Noisy breathing –Penetrating injuries: esoph, carotid artery, jugular vein trauma

39 Scapular and Rib Fractures Splinting impairs ventilation Splinting impairs ventilation Majority – optimise pain mx Majority – optimise pain mx Scapula, often indicate major injury to the head, neck, spinal cord, lungs and great vessels: mortality > 50% Scapula, often indicate major injury to the head, neck, spinal cord, lungs and great vessels: mortality > 50% pain, tenderness, crepitus

40 Sternal Fractures Mortality 25-45% Mortality 25-45% Underlying injuries to myocardium Underlying injuries to myocardium Flail segment Flail segment

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45 Penetrating Cardiac Injury Ventricles: will self seal more commonly Ventricles: will self seal more commonly RV>LV>RA>LA RV>LV>RA>LA 56-66% overall survival 56-66% overall survival 87% survival in OR thoracotomy 87% survival in OR thoracotomy Positive predictors: VS on admission, short transport, SW Positive predictors: VS on admission, short transport, SW

46 penetrating cardiac injury A combination of: - unstable patient: aggressive operative intervention - unstable patient: aggressive operative intervention - stable patient: ultrasound evaluation - stable patient: ultrasound evaluation provided an overall survival of 40% in the patients with known cardiac injury. The diagnosis of a traumatic pericardial effusion can be made by the visualization of an echolucent region between the heart and pericardium, right ventricular diastolic collapse will confirm tamponade. ultrasound imaging appears to be with an accuracy, sensitivity, and specificity that exceeds 95%

47 Classification of Mediastinal Injuries M1= base of the neck into mediastinum or pleura M2= one pleural cavity and mediastinal violation (central hematoma, visceral or spinal cord injury,metallic fragments in the mediastinum) M3 = parasternal injury within the nipple line or < 4 cm from the sternum M4 = two pleural cavities and mediastinal traverse.

48 M4 - All of the mediastinal traverse injuries were caused by gunshot wounds by gunshot wounds - this trajectory had the highest rate of instability and - this trajectory had the highest rate of instability and subsequent operative intervention. subsequent operative intervention. - the highest observed mortality rate (60%), - the highest observed mortality rate (60%), M1 - Injuries from a cephalad direction were predominately stab wounds. wounds. - were responsible for the second highest incidence of instability - were responsible for the second highest incidence of instability and subsequent operative intervention. and subsequent operative intervention. The presence of a gunshot wound, was associated with significant risk of both instability and death.

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50 Penetrating Chest Trauma Low chest SW: 15% intraperitoneal, 15% require operative intervention (diaphragm) Low chest SW: 15% intraperitoneal, 15% require operative intervention (diaphragm)

51 Pediatric Chest Trauma Compliance = internal injury Compliance = internal injury Mobility = tension pneumos, flail chest Mobility = tension pneumos, flail chest Bronchial and diaphragmatic injuries Bronchial and diaphragmatic injuries Infrequent injuries to great vessels Infrequent injuries to great vessels

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58 Summary Thoracic trauma is common in multiply injured patients Thoracic trauma is common in multiply injured patients Life- threatening problems may be temporarily relieved by simple measures Life- threatening problems may be temporarily relieved by simple measures Injury recognition important Injury recognition important High index of suspicion for occult injuries High index of suspicion for occult injuries

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