1. Health-Process Evidence-Based Clinical Practice Guidelines for Trauma on Thoracic Area Jonathan Malabanan MD OMMC October 11, 2007

2. Thoracic Trauma A. Overview of the Problem Concept Common Types Common Causes B. General Management Guidelines Clinical Diagnosis Paraclinical Diagnosis Treatment

3. Clinical Questions 1.What is a operational concept of trauma on the thoracic area? Trauma -body injury produced by sudden force Thorax- region

4. Clinical Questions 2.What is a operational concept of “Non- Penetrating Thoracic Injury”? - Blunt trauma to the thoracic area

5. Clinical Questions 3.What is a operational concept of “Penetrating Thoracic Injury”? -Potential surgical patient

6. 4.How is head trauma classified in terms of mechanism of injury? -Blunt/ non- penetrating trauma -Penetrating trauma Clinical Questions

7. 5. What are the most common causes of penetrating thoracic injury? -Assault with sharp object -Gunshot Injury

8. Clinical Questions 7.What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury? - difficulty of breathing - decreased breath sounds on the affected lung field

9. Clinical Questions 7.What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury? - tachycardia - increased respiratory rate

10. Clinical Questions 7.What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury? - presence of paradoxical pulse

11. 8. If a paraclinical diagnostic procedure is needed for trauma to the thoracic area, the most cost effective would be: BenefitRiskCostAvailability X-Ray Pneumothorax: (+) Hemothorax:(+) Exposure to radiation P200available Ultrasound Pneumothorax: (++) Hemothorax:(+) No radiation exposure P600available CT-Scan Pneumothorax: (+++) Hemothorax: (+++) Exposure to radiation P6000 Not readily available http://www.diagnosticimaging.com

12. 9. What are the goals of treatment for the following? A.Non- Penetrating Thoracic Injury B.Penetrating Thoracic Injury

13. GOALS OF TREATMENT Resolution of hemothorax or pneumothorax Full re- expansion of left lung Monitor for ongoing bleeding

14. 11.What is the most cost-effective operative treatment for the following? A.Non- Penetrating Thoracic Injury B.Penetrating Thoracic Injury

15. Treatment Options BenefitRiskCostAvailability Tube Thoracostomy -Complete evacuation of fluid -can monitor ongoing bleeding -hemostatic - Injury to adjacent structure P10000available Thoracentesis-Useful in small hemothorax -incomplete evacuation - Injury to adjacent structure P5000available

16. Practice Level of Evidence Standards (I) need to be followed Guidelines (II) suggested Options (III) considered

17. Protocol on CTT May proceed to thoracotomy if: –initial output is ≥ 1000 cc of blood –There is continuous CTT output of more than 150cc/hour

18. Protocol on Prevention of Posttraumatic Retained Hemothorax Department of Surgery, OMMC Hemothorax CTT Thoracotomy >1 Liter >150cc/hr x 4 hrs Suctioning >1/3 retained Hemothorax by CXR Active Observation Gomco < 1/3 retained hemothorax Turiñgan H, Hernandez D, Joson O. Posttraumatic Retained Hemothorax – Incidence, Prevention and Management with Suctioning. Published PJSS,2004

19. What is the role of fluid resuscitation prior to surgery in the treatment of significant thoracic injury? Fluid resuscitation should be given to avoid hypotension (II)