Thoracic Trauma J William Finley, MD Trauma Director Providence Regional Medical Center

Thoracic Trauma Fourth Leading cause of death –150,000 Annual deaths Second only to head injury in cause of death –25% of trauma related deaths Often associated with other injuries Prevention Focus –Gun Control Legislation –Improved motor vehicle restraint systems Passive Restraint Systems Airbags

Anatomy Thoracic cavity –Thoracic inlet –Diaphragm Contains a lot of important stuff –Heart –Lungs –Mediastinal structures

Extensive Armor

There is no perfect protection…

It’s a Dangerous World Penetrating Injury –Low Energy Stab wounds –High Energy GSW Blunt Injury –Crush –Compression –Shear –Acceleration/Deceleration

Spectrum of Disease Chest Wall –Contusions –Rib fractures –Flail Chest Pulmonary –Pulmonary contusion –Pulmonary laceration –Hemothorax –Pneumothorax

Spectrum of Disease Cardiac –Contusion –Laceration –Avulsion –Tamponade Mediastinal –Great vessel –Tracheobronchial –Esophageal –Aortic

Keys To Diagnosis Index of suspicion Injury association Clinical signs/symptoms Diagnostic imaging –Xray –CT –Ultrasound

Basic Trauma Resuscitation Easy as A-B-C –A - Airway –B - Breathing –C - Circulation

October 24, 2011 Thanks to Jonathan Holbrook, Tall Taurus Media, LLC Real Heroes Breakfast 2011 Snohomish County, American Red Cross

Hemothorax Accumulation of blood in the pleural space Serious hemorrhage may accumulate 1,500 mL of blood –Mortality rate of 75% –Each side of thorax may hold up to 3,000 mL Blood loss in thorax causes a decrease in tidal volume –Ventilation/Perfusion Mismatch & Shock Typically accompanies pneumothorax –Hemopneumothorax

Hemothorax Blunt or penetrating chest trauma Diagnosis –Small to moderate Only seen on CXR or CT –Large May be diagnosed clinically –Dull to percussion over injured side –Decreased BS on affected side –Decreased chest expansion

Hemothorax

Management –Placement of tube thoracostomy 36 French tube or greater –Operative indications, thoracotomy Initial L blood Ongoing /hr losses

ED Thoracotomy Most surgeons hold a very pessimistic view Success rates vary Overall success rate 4- 5% The first successful 'prehospital' thoracotomy and cardiac repair was carried out by Hill on a kitchen table in Montgomery, Alabama in 1902.

Why? Abysmal Success rate Exposes medical personnel to risk There are survivors The main determinants for survivability –mechanism of injury –location of injury –presence or absence of vital signs

Mechanism of Injury Penetrating thoracic injury –Survival rate 18-33% stab wounds > gunshot wounds. Isolated thoracic stab wounds causing cardiac tamponade approach 70% survival Gun shot wounds injuring more than one cardiac chamber and causing exsanguination have a much higher mortality. Blunt trauma survival rates –Vary between 0 and 2.5%

Location of Injury Almost all survivors of emergency thoracotomy suffer isolated injuries to the thoracic cavity. Cardiac injuries have the highest survival –single chamber > multiple chamber –great vessels and pulmonary hila carry a much higher mortality

Presence of Vital Signs Survival related to –Presence of cardiac activity –Amount of time since loss of cardiac activity 0% for those patients arresting at scene, 4% when arrest occurred in the ambulance, 19% for emergency department arrest and 27% for those who deteriorated but did not arrest in the emergency department 1 1 Tyburski JG, J Trauma 2000.

Presence of Vital Signs Survival for blunt trauma patients who never exhibited any signs of life is almost uniformly zero. Survival for penetrating trauma patients without signs of life is between 0 and 5%.

ED Thoractomy - Why? Release pericardial tamponade Enable open cardiac massage Occlude the descending aorta Control intrathoracic hemorrhage

ED Thoracotomy - How Steps –Prep chest, generally left chest –Generous incision from sternal border to mid axillary line –Down to intercostal muscles –Divide chest along upper margin of 6 th rib –Spread ribs –Retract lung –Identify and incise the pericardium to release potential tamponade

ED Thoracotomy - How Steps –Recognize and repair any cardiac injury –Open cardiac massage using 2 hand technique –Cross clamp aorta –Incision can be extended to right side of chest (Clamshell) –Ongoing resuscitation –Closure in OR

Posterio-Lateral Thoractomy

Clamshell Thoracotomy

Thoracic Trauma Can create dramatic injuries Keep to resuscitation basics A-B-C Involve surgeons early ED thoracotomy does have some survivors