1. Sept 4/2003 Todd Ring Gord McNeil
CHEST TRAUMA
Sept 4/2003
Todd Ring
Gord McNeil

2. Overview Approach to patient with chest trauma Pulmonary injuries:
Management of occult pneumothorax
OR intervention for hemothorax
Imaging of pulmonary contusion
Traumatic aortic injury: imaging modalities
Blunt and penetrating cardiac injury
Role of ED Thoracotomy
Chest wall and other injuries
Gord’s chest trauma cases

3. Epidemiology
2nd commonest cause of traumatic death after head injuries (USA = 16,000 deaths per year)
25% of all trauma related deaths
10 % mortality
5 – 10 % of pediatric trauma admissions but higher mortalilty
5% mortality when isolated
25 % mortality with head or abdominal trauma
40 % mortality when head, abdominal and chest injury

4. Initial Management and Assessment
ABC’s
Six Immediately Life Threatening Injuries:
airway obstruction
flail chest
tension pneumothorax
open peumothorax
massive hemothorax
cardiac tamponade
All can be identified in the primary survey
CXR not necessary to make the diagnosis

5. Secondary Survey
More detailed examination including reassessment of items covered in primary survey
Appropriate investigations: CXR, pulse oximeter, EKG, ABG
Identify “potentially” lethal chest injuries
simple pneumothorax, hemothorax, pulmonnary contusion, tracheobronchial tree injury, blunt cardiac injury, traumatic aortic injury, diaphragmatic injury, wounds transversing the mediastinum

6. Classification 1) Chest wall injuries 50% 2) Pulmonary injuries 25%
rib fractures, flail chest, sternal fractures
2) Pulmonary injuries 25%
pulmonary contusion, hemothorax, pneumothorax, tracheo-bronchial disruption
3) Cardiovascular injuries 20%
myocardial contusion, aortic disruption, cardiac rupture/tamponade
4) Other 5%
esophageal/diaphragmatic injuries

7. Mr. C. Tube
22 yo male driver MVC. Unrestrained found 10 feet from vehicle. GCS 8 at scene. Intubated for airway protection. Hemodynamically stable. CXR normal. CT head and spine normal. CT abdomen demonstrates small pneumothoracies, no abdominal pathology.
What features on supine CXR useful in identifying pneumothoracies?
Does this patient require a chest tube?
Does he require antibiotic prophylaxis if he gets a chest tube?

8. Simple Pneumothorax No communication with atmosphere
No shift of mediastinum or hemidiaphragm
Mechanism
Fractured rib
Increased intrathoracic pressure with closed glottis

9. Open Pneumothorax
Open defect in chest wall; if > 2/3 diameter of trachea then path of least resistance for air
Paradoxical motion of affected lung
Large dead space = severe ventilatory disturbance
Cover with occlusive dressing
High risk of conversion to tension pneumothorax especially if PPV

10. Tension Pneumothorax Trapping of air created by one way valve
Cardinal signs
decreased BS and hyper-resonance on one side
distended neck veins
hypotension
tachycardia
Needle decompression 2nd ICS MCL then CT

11. Pneumothorax on CXR
Frequently missed (20-30%) on initial trauma CXR (small size or supine position)
If pneumothorax suspected:
sit patient up
expiration film
repeat in 3 hours
+/- indication for CT chest

12. Pneumothorax on Supine Film
Deep sulcus sign
deep lucent costophrenic sulcus
Depression of involved hemidiaphragm
Hyperlucency in lower chest
Double diaphragm sign
Seen at interface of dorsal and ventral pneumothorax with anterior and posterior aspects of hemidiaphragm

14. Pneumothoarx on CXR Estimation of size of pneumothorax
Generally inaccurate – varies with inspiratory effort and shift of mediastinum
From lateral chest wall (~4th rib) 1cm = 10%, 2cm = 20%
Generally intervention is indicated if >20%

15. Treatment of Occult Pneumothoracies
Occult pneumothoracies are often missed on CXR and found on abdominal CT scans—do these patients need chest tubes?
Brasel et al. conducted a prospective, randomized trial comparing CT to observation in 39 patients with pneumothoracies from blunt chest trauma (including 9 patients in each group with PPV)
there was no difference in overall complication rate (progression of pneumo or resp. distress)
no patient had respiratory distress related to the OPTX or required emergent CT
Brasel et al. Treatment of occult pneumothoraces from blunt trauma. Journal of Trauma-Injury Infection & Critical Care. 46(6):987-90

16. Occult Pneumothorax in MV Patients
Enderson et al. studied forty trauma patients with occult pneumothorax who were prospectively randomized to management with CT (n = 19) or observation (n = 21) in MV patients
8 of 21 patients observed had progression of their pneumothoraces on PPV with 3 developing tension pneumothorax
no patients with CT suffered major complications
hospital and ICU stays were not increased by CT
they concluded that patients with occult pneumothorax on PPV should undergo tube thoracostomy
Enderson et al. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. Journal of Trauma-Injury Infection & Critical Care. 35(5):726-9

17. Chest Tube Indications
Traumatic cause of pneumothorax
Moderate-to-large pneumothorax
Respiratory distress
Increasing size with conservative therapy
Recurrence after removal of chest tube
Patient requires ventilation
Hemothorax
Bilateral pneumothorax (regardless of size)
Tension pneumothorax
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.

18. Chest Tube Complications
neurovascular bundle damage, intrapulmonary insertion, subcutaneous emphysema, bronchopleural fistula
Bailey et al. performed a retrospective case series of all trauma patients who underwent chest tube over a one year period to determine rates of complications in trauma patients
57 CT’s placed in 47 patients with no insertional complications and only one major complication
they concluded no need to decrease rates of CT
Bailey et al. Complications of tube thoracostomy in trauma. Journal of Accident & Emergency Medicine. 17(2):111-4, 2000 Mar.

19. Antibiotic Prophylaxis in Patients with Chest Tubes
Reported incidence of empyema 1.6 – 26 % after chest tube
Mandal et al. recommend antibiotics for emergent or urgent thoracotomy, shotgun blast to chest wall, lung contusion with hemoptysis, exploratory lap, or open long bone fracture
5474 patients followed protocol with only 1.6% developed empyema
Mandal et al. Post traumatic empyema. Risk factor analysis. Arch Surg 1997; 132:

20. Antibiotics con’t…
Richardson’s review article from 7 RTC’s comparing antibiotics vs. none
Infection rate in placebo 20.9% vs. 4.5 % in treatment
Richardson. Thoracic infection after trauma. Chest Surg. Clin NA. 1997; 7:
No infectious complications in hemothoracies > 500 cc (often thought to be nidus for infection)
Staph aureus most common pathogen; gram negative, anaerobes also pathogens

21. Air Travel Following Pneumothorax
Aerospace Medicine Association recommends waiting 2-3 weeks after radiographic resolution of pneumothorax prior to air travel
Cheatham et al. conducted a prospective study of air travel following pneumothorax
12 patients who flew 14 days after pneumothorax resolved had no symptoms
2 patients who flew within 14 days; one patient developed symptoms
Cheatham et al. Air travel following traumatic pneumothorax. When is it safe? Am Surg. 1999; 65:1,

22. “Stick-em up!”
41 year old male, “minding his own business,” single GSW to R chest by small caliber handgun. Tachycardic. BP 90/50. Decreased BS to R chest. CXR opacification of R lung. CT on R initial drainage 1000cc.
Does this patient require immediate OR?

23. Hemothorax Accumulation of blood in pleural space
Can cause severe hypovolemia, shock, and decrease vital capacity
Generally due to injured lung parenchyma – usually self-limiting
More severe bleeding from intercostal and internal mammary arteries
Uncommonly from great vessels

24. Xray in Hemothorax
Poor ability to predicit amount of blood in chest cavity using CXR
250 ml required to cause blunting of costophrenic angle on upright
On supine film fluid layers posteriorly
increased density over hemithorax
25 % of cases associated with pneumothorax
may see air fluid level on upright CXR
CT more sensitive than CXR but generally clinically insignificant if not visible on CXR

25. Treatment #38 chest tube at midaxillary line
BIG PROBLEM = BIG CUT = BIG TUBE

26. Who needs the OR? initial drainage > 20 ml/kg of blood (1500ml)
persistent bleeding at > 7 ml/kg/hr (500ml/h)
increasing hemothorax on CXR
persistent hypotension despite adequate blood replacement and other sites ruled out as source
patient decompensates after initial resuscitation
15mg/kg of blood initially or 3-4mg/kg/h

27. Tracheo-bronchial Injury
Occur with either blunt or penetrating injuries
Relatively rare injury (<3 % of chest injuries)
Mortality rate of 30 % (50 % die within first hour)
Rare in children but high mortality
33% die in 1st hour

28. Clinical Presentation
Typically
Hoarseness, dyspnea, hemoptysis, blood in larynx, subcutaneous emphysema, pneumothorax not improving with chest tube and large air leak despite 2 chest tubes
Two clinical patterns depending on location of injury
wound opens in to pleural cavity
no communication with pleural cavity therefore no pneumothorax (occult presentation); identified at later date due to atelectasis/pneumonia from granulation tissue obstructing airway

29. Diagnosis and Management
X-ray
Lateral neck view – pretracheal or subcutaneous air
CXR – mediastinal air, pneumothorax
Fiberoptic bronchoscopy
Intubation over bronchoscopy to prevent extratracheal intubation into mediastinum (case reports of this occurring)

30. Pulmonary Contusion Most common injury following chest trauma
Often in combination with other injuries such as rib fracture or flail chest
Bleeding from laceration of lung parenchyma
Most common thoracic injury in pediatric trauma
Often isolated injury due to pliable chest wall

31. Imaging in Pulmonary Contusion
Contusion usually present on initial CXR and always appears within 6 hours
Appear as patchy or diffuse airspace disease
Can identify occult contusions on chest CT but clinically utility unclear
Guerro-Lopez et al. conducted a cohort study of 375 patients. One group received admission CT the other CXR.
Induced therapy changes in 30 % of patients but no effect on MV, ICU stay or mortality
Guerrero-Lopez F, Vazquez-Mata G, Alcazar-Romero PP, et al. Evaluation of the utility of computed tomography in the initial assessment of the critical care patient with chest trauma. Crit Care Med
2000;28:1370-5

34. Pulmonary Contusion vs. ARDS
Manifest within minutes (up to 6 hours)
Usually confined to one lobe
Apparent on initial CXR
Resolve on CXR by 48 –72 hours
ARDS
Development delayed
Diffuse
Onset between hours

35. Management Hospitalize for observation
Chest physio/incentive spirometry/ analgesia/supplemental O2
In patients who remain hospitalized greater than 48 h and have progression of CXR finding should prompt suspicion of other diagnosises including ARDS or aspiration

36. Mrs. Dee Sellaration
55 yo female. Driver of single vehicle MVC into telephone pole (approx 70 kph). Restrained. Airbag deployed. LOC at scene GCS 3. Intubated. Tachycardic but BP 90/50.
Findings on CXR to suggest TAI?
What is the next imaging study of choice?
How aggressive do you fluid resuscitate this patient?

37. Great Vessel Injury Injury of high speed MVC
mortality 1947 < 1%
mortality now 15 %
More frequent with penetrating trauma (90%)
Aorta most commonly injured; high mortality associated with this injury
Rare in pediatrics—almost all secondary to MVC

38. Aortic Anatomy

39. Pathologic Terminology
Traumatic aortic injury: generic term that covers all of the below; should be used to describe the lesion until injury fully defined
Aortic traumatic rupture: full thickness disruption of the wall
Aortic traumatic tear: partial thickness tear limited to intima and muscularis
Aortic traumatic intimal tear: disruption of the intima

40. Who cares about terminology?
Most patients presenting to the ED with TAI have a partial thickness injury
Of those patients suffering a complete TAI
80 – 85 % exsanguinate at the scene, 15-20% arrive in the ED alive
of these 50% exsanguinate in the first 24 hours; 80% by one week and 95% by four months
2 – 5 % long term survivors

41. Risk factors for Aortic Injury
Dyer et al. conducted a prospective study of 1561 patients with suspected aortic injury over 5 year period
Only significant RF was high speed MVC (>60kph)
No association for front vs. side impact, ejection, fatality, sudden deceleration, damage
No blunt TAI from fall < 10 feet
Concluded by recommended the liberal use of chest CT in blunt chest trauma
Dryer et al. Thoracic Aortic Injury: How Predictive Is Mechanism and Is Chest Computed Tomography a Reliable Screening Tool? Journal of Trauma 2000;48:

42. Location, location, location...
% involve proximal descending aorta
10-15% ascending aorta or arch
12% distal
13-18% multiple sites
Patients with ascending aorta tears have a 70-80% incidence of associated lethal injuries
pericarditis, tamponade, aortic valve tear, coronary artery injury

43. Prehospital Management
Good evidence to avoid military anti-shock trousers  elevates BP
No effective in field therapy for injuries to the great vessels therefore “scoop and run” best pre-hospital management
ATLS recommends 1-2 L fluid bolous for patients in shock to return BP to “normal” HOWEVER...

44. Fluid Restriction in TAI
Bickell et al. conducted a prospective trial of penetrating torso trauma in patients with SBP < 90
Fluid restricted group received no fluid rescusitation until arrival at OR
Control group received standard resuscitation
203/289 (70 %) patients in restricted group survived to hospital d/c compared to 193/309 (62 %) of control group
Bickell et al. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. NEJM 331:

45. Clinical Presentation
History
MVC: impact, duration of extraction, intrsuion, blood loss
Penetrating trauma: length of knife, firearm type, number of rounds fired and distance
Physical Examination
Do not disregard the possibility of aortic injury based on patients clinical apperance

46. Physical Findings that Increase Suspicion of Blunt Aortic Injury
Hypotension: Up to 50% of patients with proven aortic rupture present with hypotension.
• Hypertension: Up to 72% of patients may be hypertensive before fluid or vasoactive drug administration. The hypertension may result from a stretching stimulus of the sympathetic afferent nerve fibers, located in the area of the aortic isthmus.
• Pseudocoarctation syndrome: Acute onset of upper extremity hypertension, along with absent or diminished femoral pulses. Reported to occur in up to one third of the patients due to compression of the aortic lumen by the periaortic hematoma.
Expanding hematoma: At the thoracic outlet.
• Interscapular murmur: Reported in up to 31% of the patients.
• Palpable fracture:Of the sternum.
• Palpable fracture:Of the thoracic spine.
• Hemothorax:Chest tube with an initial “rush” of more than 1500 mL or more mL/h is suggestive of a major vessel injury and an indication for urgent thoracotomy.

47. Radiography in TAI Specific findings:
mediastinal widening
depression of left mainstem bronchus
loss of paravertebral stripe
NG deviation
lateral displacement of trachea
left apical cap
obscured aortic knob
widened paratracheal strip
Difficult to assess mediastinal widening in pediatrics because of thymus

48. Radiographic Findings
Table 3. Radiographic Findings of Mediastinal Hematoma
Finding
Sensitivity
Specificity
Mediastinal widening
50-90%
10%
Depression of the left mainstem bronchus
70-80%
80-100%
Deviation of nasogastric tube
23-71%
90-94%
Lateral displacement of trachea
12-100%
80-95%
Left apical pleural cap
20-63%
75-76%
Loss of paravertebral pleural stripe
Obscured aortic knob
Widened paratracheal stripe

49. CXR in TAI
Despite multiple suggestive findings on CXR not completely reliable
The CXR visualises the mediastinum not the aorta
Sensitivity of widened mediastinum only 89% and of any abnormality 92-98%
Take home message CXR will miss 2-11% of injuries

50. Aortography The “gold standard” with sensitivity of 100%
Also localizes the area of injury and can identify lesions in other vessels
BUT
time consuming
in location away from ED
not readily available
high contrast load
Complication rate of 2.6 % in series of trauma patients
Reid et al. The assessment of proximity of a wound to major vascular structures as an indication for arteriography. Arch Surgery 1988; 123:

51. Chest CT Many advantages over aortography
readily accessible in most most urban ED’s
low complication rate
less contrast
fast
gives information about structures other than the aorta

53. Evidence for CT in Blunt Trauma?
Early scanners (non-helical) were disappointing but new helical CT’s have sensitivities of 100% and specificity of 96 %
Mirvis et al. Traumatic aortic injury. Diagnosis with contrast enhanced thoracic CT—five year experience at a major trauma center. Radiology 1990; 176:
Garrant et al. Blunt traumatic aortic rupture. Detection with helical CT of the chest. Radiology 1995; 197:
Demetriades et al. concluded that “all trauma patients with high risk deceleration injuries undergo routine helical CT irrespective of CXR findings”
Demetriades et al. Routine helical CT evaluation of the mediastinum in the high risk trauma patient. Arch Surg 1998; 133:

54. Helical CT in Penetrating Trauma
In stable patients with a GSW to the torso, CT can be used to follow the trajectory of the bullet thereby decreasing the need for exploratory surgery
Grossman et al. Determining anatomical injury in selected torso gunshot wounds. J Trauma 1998;

55. TEE in TAI
Sturn et al. conducted a prospective, nonrandomized study of 160 patients with TAI and found a sensitivity and specificity of 100 % (3 studies unequivocal requiring aortography)
Sturn et al. Thoracic aortography following blunt chest trauma. A J of Emerg Med 1990; 8:192
Buckmaster et al. also found similar results with sensitivity of 100 % and specificity of 98 %
Buckmaster et al. Further experience with TEE in evaluation of thoracic aortic injury. J Trauma. 1994; 37:989
Patients who only had TEE as the diagnostic test had significantly shorter (30 vs. 71 min.) times to OR
Smith et al. TEE in the diagnosis of traumatic rupture of the aorta. NEJM 1995; 332:

56. TEE in TAI Advantages: Bedside application No contrast
Quick to perform
Gives additional information about heart function
Disadvantages:
Limited by experience and access to operator
Limited in evaluation of aortic branch arteries
Contraindicated in esophageal perforation and cervical trauma

57. The Bottom Line in Imagaing TAI
No clear algorithm to follow
Variation from center to center
Some centers use a widened mediastinum to prompt further investigation while others use mechanism of high velocity deceleration to advocate for aortography or helical CT
In pediatrics making the diagnosis crucial as high survival rate (70 – 90 % once diagnosis made)

58. Management Pharmacologic management similar to aortic dissection
Maintain systolic blood pressure between 100 – 120
Beta-blockers decrease pulse pressure and shear forces on the wall of the adventia
esmolol preferred because short acting and titrateable
Addition of nitroprusside as needed

59. Non-operative Management
Approach for patients with high intra-operative risk of death or injuries that are uniformly fatal
Giles et al.reported a case series of 42 patients with TAI
21 with immediate repair had a mortality rate of 19% vs. no deaths in 21 patients treated non-operatively

60. Indications for Conservative Management of TAI
Severe injury to the CNS
Major burns with high infection risk
Sepsis
Contaminated open wounds with high risk of infection
Severe respiratory insufficiency
Hemodynamic instability
Presence of a non-threatening lesion (an intimal defect only)
False aneuryms

61. Mr. Al Kohol
43 yo male. EtOH earlier in evening. Driving home, loses control of vehicle hits parked car head on (estimated speed 70 kph). Not wearing seat belt and no air bag. Hits steering wheel with chest. No LOC. Brought in by EMS complaining of chest pain. CXR and ECG normal.
What is the role of troponin in cardiac contusion?
Does this patient need admission?

62. Blunt Cardiac Trauma
Result of high speed MVC with chest wall striking the steering column
Less commonly from falls, crush injury, blast and direct blows
Importance of diagnosis lies in recognition of associated fatal conditions
dysrhythmias, CHF, cardiogenic shock, tamponade, cardiac rupture, intraventricular thrombi, coronary artery occlusion

63. Myocardial Concussion
“Commotio cordis”
An acute form of blunt cardiac trauma that stuns the myocardium and results in a brief dysrrhythmia, hypotension and LOC
No long lasting histopathological changes
Death can result from an initial non-perfusing rhythm such as VF that results in cardiac arrest

64. Myocardial Contusion Continuum from: concussionscontusioninfarct
Clinical picture varied and non-specific
73% have external signs of thoracic trauma
other associated injuries: pulmonary contusion, pneumothorax, hemothorax, external fracture, great vessel injury
sinus tachycardia most sensitive but least specific

65. Diagnosis Obvious at autopsy!
No true “gold standard” for making diagnosis
Normal ECG reassuring if no obvious clinical symptoms
Non-specific ECG findings include sinus tachy, PVC’s and PAC’s but also other conduction and rhythym disorders

66. Troponin in Blunt Cardiac Trauma
Collins et al. conducted a prospective evaluation of all blunt trauma patients admitted with the possible diagnosis of blunt cardiac injury to exclude diagnosis of cardiac contusion
72 patients enrolled, 40 normal ECG and Tnt, 16 abnormal ECG and normal troponin, 10 patients elevated Tnt2 died, 1 poor LV function on echo, 8 d/c’d home
Concluded that normal Tnt exclude contusion and elevated Tnt should require ongoing monitoring…BUT…
Collins et al. The usefulness of serum troponin levels in evaluating cardiac injury. American Surgeon. 67(9):821-5; discussion 825-6, 2001 Sep.

67. Troponin in Blunt Cardiac Injury
Berchinant studied Tnt in 96 chest trauma patients of which 26 were diagnosed with myocardial contusion (echo and/or ECG) over 18 months
23 % of patients with myocardial contusion had positive Tnt vs. 3 % of placebo
Sensitivity 23 %, specificity 97 %
Berchinant et al. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin. Journal of Trauma-Injury Infection & Critical Care. 48(5):924-31, 2000 May

68. Myocardial Rupture An acute perforation of the atria or ventricles
Also includes pericardial rupture or rupture or laceration of the interventricualr or atrial septum, papillary muscle, chrodae, or valves
MVC’s most common cause
0.5 – 2 % of cases of chest trauma accounting for 5% mortality of all chest traumas

69. Clinical Presentation
Usually that of cardiac tamponade
Less common hemothorax, hypotension, hypovolumeia suggesting pericardial rupture
Diagnosis of shock and elevated JVP in blunt chest trauma patient = pericardial tamponade (also consider tension pneumothorax, RV contusion, SVC obstruction, ruptures tricuspid valve, chronic pulmnonary disease)

70. Management EMS ED scoop and run
immediate decompression of tamponade and control of hemorrhage
emergency thoracotomy and percardiotomy then OR for definitive repair

71. Penetrating Cardiac Injury
Interpersonal violence vast majority of causes
GSW or SW
Two conditions may occur
exsanguinating hemorrhage: free communication with pleural space
cardiac tamponade: contained within the pericardium
Those with exsanguination often die or will meet criteria for ED thoracotomy
Those with tamponade provides some protection but require immediate attention

72. FAST Exam Focused Abdominal Sonography for Trauma 4 windows:
Pericaridial, perisplenic, perihepatic, pelvic
Purpose is for identification of hemopericardium and hemoperitoneum

73. FAST Exam in Penetrating Cardiac Injury
Rozycki et al. conducted a prospective multi-center trial of 261 patients to assess US identification of pericardial fluid
100 % sensitive, 96.9 % specific for identification of hemopericardium
Based on there findings recommend immediate OR for positive findings
Rozycki et al. The role of US in patients with possible penetrating cardiac wounds. J Trauma 1999; 46:

74. FAST Exam in Penetrating Cardiac Injury
Thourani et al conducted a retrospective chart review of 22 years for penetrating cardiac trauma at their institution; divided into two 11 year subgroups based on introduction of FAST exam
Current approaches impacting mortality are: shorter field time, more FAST exams in normotensive or moderately hypotensive patients and earlier OR
Mortality rate similar in both groups (25 %) but trend to better survivial in FAST group of normotensive and moderately hypotensive patients
Thourani et al. Penetrating cardiac trauma at an uran trauma center. Am Surgeon 1999; 65:

75. Indications for ED Thoracotomy
Penetrating trauma
cardiac arrest at any point with initial vitals at the scene (< 10 min transport time)
systolic blood pressure < 50 after fluid resuscitation
severe shock with signs of tamponade
Blunt trauma
cardiac arrest in ED
Miscellaneous
suspect air embolism
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.

76. Evidence for ED Thoracotomy
Rhee et al. completed a large review of 24 studies including 4,620 cases of EDT for blunt and penetrating trauma over past 25 years
Primary outcome was in hospital survival
EDT overall survival rate of 7.4 %
Normal neurological outcome 92.4 %
3 main factors affecting outcome:
MOI: penetrating 8.8 % vs. 1.4 % for blunt; of penetrating injuries GSW 4.3 % vs. SW 16.8 %
LOMI: 10.7 % thoracic, 4.5 % abdominal, 0.7 % multiple; if heart then 19.4 %
SOL: present on arrival to hospital 11.5 % vs. 2.6 % if absent; during transport 8.9 %; absent in field 1.2 %
Rhee et al. Survival after ED thoracotomy. J of Amer Col of Surgeons 2000; 190(3):

77. Poor Outcome in Blunt Chest Trauma
Martin et al. conducted a retrospective review of blunt trauma victims with prehospital PEA from 1997 to 2001
110 patients 79 with PEA at the scene, and 31 experienced PEA en route
CPR initiated when PEA was detected
Vital signs were regained en route or at the trauma center by 25 patients (23%)
Only one patient, who has significant residual neurologic impairment, survived
Conclusions in keeping with other studies– consideration should be given to allowing paramedics to declare blunt trauma victims with PEA dead at the scene
Martin et al. Blunt Trauma Patients with Prehospital Pulseless Electrical Activity (PEA): Poor Ending Assured. The Journal of Trauma: Injury, Infection, and Critical Care 2002; 53(5):

78. Favorable Prognostic Signs
Penetrating thoracic trauma
Isolated stab wound
Pericardial tamponade
Vital signs in ER
Mild shock
Short EMS transit time
Intubation in the field
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.

79. Adverse Prognostic Factors
Blunt thoracic trauma
Gunshot wound
Exsanguinating hemorrhage through pericardium
No signs of life
Extreme shock
Prolonged EMS transit time
Unsuccessful field intubation
Asystole as initial cardiac rhythm
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.

80. Overall Survival Overall survival from EDT 4 - 16 %
Of patients with SW who reach the OR survival %
Of patients with GSW who reach the OR survival %

81. ED Thoracotomy Scalpel incision in left 5th intercostal space
Divide muscle and soft tissue with scissors above rib margin
Insert rib spreaders and spread

82. Relief of Tamponade Make small incision in pericardium with scissors
Longitudinal blunt dissection to avoid phrenic nerve
Manually evacuate blood clot from pericardial cavity

83. Control of Hemorrhage
3-0 non-adsorbable suture – use mattress technique
Skin stapler
Finger
Foley catheter

84. Internal Cardiac Massage
Commence immediately following control of hemorrhage or relief of tamponade
Two handed technique produces better cardiac output (55% of baseline)

85. Cardiac Tamponade
2% of patients with penetrating thoracic trauma develop cardiac tamponade
Rarely seen in blunt trauma
% of stab wounds to heart develop tamponade
20% of GSW to heart

86. Cardiac Tamponade Collection of blood in indispensable pericardium
cc blood tolerated before decompensation begins (normal = 5 – 60 cc pericardial fluid)

87. Clinical Presentation
Beck’s triad:
hypotension
distended neck veins (>15mm H20 with hypotension is diagnostic)
muffled heart sounds (unlikely to be heard in trauma room)
Pulsus paradoxus – difficult to measure during resuscitation
No response to vigorous fluid resuscitation

88. Electrical Alternans

89. Pericardiocentesis Diagnostic and therapeutic
Many false positives / false negatives (clotted blood)
Improvement possible with small volume of blood removed
Complications
Pericardial tamponade
Laceration of coronary artery / lung
Induction of dysrhythmia
Continued deterioration may necessitate thoracotomy

90. Pericardiocentesis Technique
18 gauge, 10 cm spinal needle, 20 cc syringe
Continuous ECG monitoring
Needle enters subxyphoid area
Aim for left scapula
Aspirate every 1-2 mm
Stop if blood aspirated, cardiac pulsations felt, ECG changes
If more than 20 cc blood is removed easily you are probably in the RV

91. “He was trying to break up the fight…”
21 year old male, “brought fists to a knife fight.” Stabbed once in the abdomen with “long” knife. Hemodynamically stable. Mild SOB but O2 sat, vitals stable. CXR normal. To OR for laparotomy. Multiple abdominal lacerations including laceration of L diaphragm.
CXR findings suggestive of diaphragmatic injury?
Is there a role for DPL or CT scan?

92. Diaphragmatic Injuries
1-6% of people sustaining multiple trauma
55% from penetrating trauma and 45% from blunt trauma
High speed blunt trauma to the diaphragm or direct injury to diaphragm from penetrating trauma
Transmission of abdominal pressure through diaphragm
Left sided traumatic hernias 3-4x’s more common
liver acts as buffer

93. Diaphragmatic Injuries
Symptoms and signs variable and often over shadowed by associated injuries
30 % missed in acute phase
Often not accompanied by herniation of abdominal viscera

94. Radiography of Diaphragmatic Injury
Nonspecific but generally abnormal
Indistinct left hemidiaphragm, focal atelectasis in LLL, visualisation of viscera or NG tube above the left hemidiaphragm
15% of patients have normal CXR

95. Investigation of Diaphragmatic Injury
DPL found unreliable
False negative rate of 34 %
CT variable sensitivity % if no herniation of abdominal viscera and specificity of 76 – 99 %
Most common finding is defect in hemi-diaphragm
Seen in approx. 70 % of ruptures
CT collar sign 100 % specific but only 30 % sensitive

98. Latent Phase
Herniation can be intermittent making the diagnosis difficult
Requires serial examination if persistent symptoms
Contrast studies useful

99. Esophageal Injury
Result of blunt or penetrating trauma, barotrauma (blast), or ingestion of caustic material
Symptoms: chest, throat or neck pain, dysphagia or odynophagia
Signs: fever choking, subcutaneous emphysema, redness, swelling, shock

100. Diagnosis Clinical: subcutaneous crepitus
Neck and CXR: air in cervical tissue or mediastinum or pleural effusions
Diagnosis made by esophogram using gastrografin initially then barium if no lesion identified
Endoscopy identifies % of injuries but can enlarge the perforation

101. Management
Surgical management is definitive treatment if patient is stable
If patient is not a suitable surgical candidate and continuing to have ongoing leak then treat with IV antibiotics, NG suction, parenteral nutrion
High mortality with medical management with mortality rate 50 % or greater if surgery delayed > 24 hours

102. Rib Fractures Ribs 4-9 most commonly broken Ribs 1-3 well protected
marker for severe intrathoracic injury
Ribs 9-12 mobile anteriorly
marker for intra-abdominal injury (liver, spleen, kidney)
Rib Fractures less common in pediatric population because of chest wall compliance
Rib fractures in children less than 3 yo need to rule out NAT

103. Rib Fractures Single rib fracture Multiple rib fractures
May limit ventilation and cough reflex secondary to pain
Conservative management
Multiple rib fractures
More force = more injuries
Look for flail chest, pneumothorax, hemothorax, and extrathoracic injuries (liver, spleen, kidney – 30% of patients with 9-12th rib fractures)

104. Rib Fractures Clinical Radiological
Tenderness, bony crepitus, ecchymosis, muscle spasm
Radiological
best diagnosed using CXR but still miss 50%
CXR inadequate for evaluation of rib fractures, but valuable for seeing intrathoracic/ mediastinal injuries

105. Rib Views: Indications
Fractures suspected, ribs 1-2
Fractures suspected, ribs 9-12
Multiple rib fractures
Elderly patient
Preexisting pulmonary disease
Suspected pathologic fractures

106. Rib Fractures: Treatment
Pain relief
Medication/intercostal nerve block/epidural
Deep breathing exercises
Do not use
binders, belts, other restrictive devices as they promote atelectasis, pneumonia

107. Mr. Flail
65 yo male passenger in MVC. T-Bone collision at high speed. Restrained. No LOC. Complaining of L chest wall pain. Mild respiratory difficulty. RR 30. O2 sat 95 % on 5L. Tender on L chest wall. ? Palpable flail segment. CXR flail segment on L chest wall.
What are the indications for MV in flail chest?
Does this patient require prophylactic intubation?

108. Flail Chest > 2 adjacent ribs fractured at two points
Mortality %
Respiration adversely affected
Free segment moves paradoxically
Frequently associated with underlying pulmonary contusion
Intubation and ventilation can splint and mask flail chest

109. Flail Chest: Management
Observe for signs of underlying pulmonary injury/pathology
Conserstone of Rx: physiotherapy, analgesia, selective use of endotracheal intubation/MV, and observation for respiratory compromise

110. Who needs MV in Flail Chest?
Freedland et al. conducted a retrospective study to identify factors affecting outcome in 57 patients with flail chest
Factors correlating with need for MV
ISS > 22, blood transfusion in 1st 24 h, moderate to severe associated injuries
Factors correlating with adverse outcome (MV >2/52), death from sepsis or pneumonia
ISS >30, moderate or severe associated injuries or need for transfsuion
Freeland M, et al. The management of flail chest injury: Factors affecting outcome. J Trauma. 1990; 30:

111. Sternal Fracture Mechanism generally anterior blunt chest trauma
Usually MVC
More likely with restrained passengers
Associated with
myocardial contusion (1.5-6%)
rib fractures (21%)
spinal fractures (<10%)
mediastinal hematoma
no association with aortic rupture
Isolated sternal fractures – low mortality (0.7%)

112. Indications for MV in Flail Chest
Signs of respiratory fatigue
RR >35 or < 8 bths/min
PaO2 <60 (FiO2 > .5)
PaCO2 >55 (FiO2 > .5)
Evidence of shock
Associated severe head injury
Associated severe injury needing surgery

113. Sternal Fracture Clinical Radiological Treatment
Point tenderness on sternum, palpable deformity
Radiological
Lateral CXR; CT poor at picking up horizontal fractures
Treatment
Treat associated injuries
Isolated sternal injury can be discharged with analgesia

114. Sternoclavicular Dislocation
SC dislocation best studied with CT scan
Anterior (more common)
Lateral compressive force applied to shoulder
Medial end of clavicle prominent and palpable, may be visible on lateral CXR
Treat with closed reduction–apply pressure on medial end of clavicle

115. Posterior Dislocation
Rare
Direct blow to medial end of clavicle
Possible compression of airways or major blood vessels
CXR visible deformity along lateral sternum
If obstructing airway requires immediate intervention otherwise closed reduction under general anaesthesia