chest trauma3
TRANSCRIPT
Chest Chest TraumaTraumaDr. Ronald McLean, B.D.S., Dr. Ronald McLean, B.D.S., M.D.M.D.
- St. Barnabas Regional Trauma - St. Barnabas Regional Trauma CenterCenter
- Bronx, New York- Bronx, New York
Chest Trauma Chest Trauma -- BLUNTBLUNT
Chest Trauma Chest Trauma -- PENETRATINGPENETRATING
Chest Trauma Chest Trauma -- INCIDENCEINCIDENCE Sudden and dramaticSudden and dramatic
Directly => 20 – 25% (1 in every 4)Directly => 20 – 25% (1 in every 4) trauma deathstrauma deaths
Contribute to 25-50% of the remainingContribute to 25-50% of the remaining deathsdeaths
=> 16,000 deaths per year in => 16,000 deaths per year in USAUSA
Chest Trauma Chest Trauma - CARE- CARE
Improved pre-hospital & peri-operative Improved pre-hospital & peri-operative carecare
=> More pts getting to ER alive=> More pts getting to ER alive
Many die after coming to hospitalMany die after coming to hospital
Deaths Deaths possibly preventablepossibly preventable
=> by => by prompt Dx and Txprompt Dx and Tx
Chest Trauma Chest Trauma - HISTORY- HISTORY
3000 BC3000 BC – treating gladiators chest injuries – treating gladiators chest injuries 16351635 - De Vacca => removal of arrowhead - De Vacca => removal of arrowhead
from chest wallfrom chest wall 18141814 -Larrey reported injuries to subclavian -Larrey reported injuries to subclavian
vesselsvessels 19021902 - Hill performed first cardiorrhaphy in - Hill performed first cardiorrhaphy in
USUS 19341934 - Blalock first American to - Blalock first American to
successfully successfully repair an aortic injuryrepair an aortic injury
BOUNDARIES of ChestBOUNDARIES of Chest
SuperiorlySuperiorly
=> clavicles=> clavicles InferiorlyInferiorly
=> => diaphragm diaphragm
LaterallyLaterally
=> rib cage=> rib cage
BOUNDARIES of ChestBOUNDARIES of Chest
AnteriorlyAnteriorly
=> sternum=> sternum PosteriorlyPosteriorly
=> => vertebral vertebral bodies & ribsbodies & ribs
STRUCTURES InjuredSTRUCTURES Injured
Any organ in chest Any organ in chest potentially susceptiblepotentially susceptible
– especially to penetrating traumaespecially to penetrating trauma
CONTENTS CONTENTS - Thoracic - Thoracic cavitycavity - Chest wall and - Chest wall and
ribsribs - Lungs and - Lungs and
pleurapleura - Great and - Great and
thoracic thoracic vesselsvessels - Heart and - Heart and
mediastinal mediastinal structuresstructures
- Diaphragm- Diaphragm
CONTENTS CONTENTS - Thoracic - Thoracic cavitycavity
EsophagusEsophagus Thoracic ductThoracic duct
Tracheobronchial Tracheobronchial systemsystem
OTHER ORGANS OTHER ORGANS at riskat risk
Thoraco-Thoraco-abdominal injuryabdominal injury
any woundany wound below nipples below nipples in front andin front and
inferior scapula inferior scapula angles angles dorsallydorsally
may result inmay result in intra abdominal intra abdominal injuryinjury
OTHER ORGANS OTHER ORGANS at riskat risk
Peritoneal visceraPeritoneal viscera– LiverLiver– SpleenSpleen– StomachStomach– Colon & small Colon & small
intest.intest.– Biliary systemBiliary system
Retro-peritoneumRetro-peritoneum kidneyskidneys
RESULTING INJURIESRESULTING INJURIES
– Rib fracturesRib fractures– Sternal fracturesSternal fractures
– Open or Closed Pneumothorax Open or Closed Pneumothorax
- unilateral / bilateral- unilateral / bilateral
– HemothoraxHemothorax– HemopneumothoraxHemopneumothorax
RESULTING INJURIESRESULTING INJURIES
– Pneumo-mediastinumPneumo-mediastinum
– Pulmonary contusionPulmonary contusion
– Myocardial contusionMyocardial contusion
– Diaphragmatic ruptureDiaphragmatic rupture
RESULTING INJURIESRESULTING INJURIES
Subcutaneous emphysemaSubcutaneous emphysema
CLINICAL CONSEQUENCIESCLINICAL CONSEQUENCIES
RELATED TO :RELATED TO :
Mechanism of injuryMechanism of injury– Location of injuryLocation of injury– Associated injuriesAssociated injuries– Co-morbiditiesCo-morbidities
Mechanism Mechanism of Injuryof Injury
BLUNTBLUNT
Mostly managed non-operativelyMostly managed non-operatively
– Simple intubation & ventilation orSimple intubation & ventilation or– chest tube placementchest tube placement
Mechanism Mechanism of Injuryof Injury
PENETRATINGPENETRATING
Low energyLow energyMedium energyMedium energyHigh energyHigh energy
Penetrating Penetrating (Low energy)(Low energy)
ImpalementsImpalements Knife woundsKnife wounds
=> disrupts only => disrupts only structures structures
penetratedpenetrated
Penetrating Penetrating (Medium (Medium energy)energy) Bullet woundsBullet wounds from most from most
handgunshandguns
=> primary tissue damage=> primary tissue damage
< than higher velocity < than higher velocity forcesforces
Penetrating Penetrating (High energy)(High energy)
From From rifles and military weaponsrifles and military weapons
+ Shotguns+ Shotguns (low velocity) (low velocity) Transfers kinetic energy to tissuesTransfers kinetic energy to tissues
=> => cavitationcavitation
=> => high velocityhigh velocity..
Amount of tissue damage Amount of tissue damage proportionalproportional to amount of energy exchanged to amount of energy exchanged between the penetrating object and the between the penetrating object and the body part.body part.
PathophysiologyPathophysiology
Quite serious Quite serious
1.1. HYPOXIA / HYPO-HYPOXIA / HYPO-
VENTILATIONVENTILATION Primary acute killer of trauma Primary acute killer of trauma
patientspatients
inadequate delivery of O2inadequate delivery of O2 to tissuesto tissues
Signs of HYPOXIASigns of HYPOXIA
Increased RRIncreased RR Change in breathing pattern Change in breathing pattern
(shallow)(shallow) Anxious behaviorAnxious behavior Poor air movementPoor air movement DiaphoresisDiaphoresis Dilated pupilsDilated pupils Cyanosis – (late sign)Cyanosis – (late sign)
2.2. Hypovolemia Hypovolemia
Inadequate intravascular Inadequate intravascular volumevolume
=> => BLOOD LOSSBLOOD LOSS
3.3. Ventilation / Perfusion Ventilation / PerfusionMismatchMismatch
ContusionContusion HematomaHematoma Alveolar collapseAlveolar collapse
4.4. CHANGES IN INTRATHORACIC CHANGES IN INTRATHORACIC
PRESSURE RELATIONSHIPSPRESSURE RELATIONSHIPS
- Tension pneumothorax- Tension pneumothorax
- Open pneumothorax- Open pneumothorax
5.5. METABOLIC ACIDOSIS METABOLIC ACIDOSIS
Hypo perfusion of tissues Hypo perfusion of tissues (shock)(shock)
MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma ABCsABCs PRIMARY SURVEYPRIMARY SURVEY
– Most important feature of chest injury evaluationMost important feature of chest injury evaluation
=> Aim to identify & treat => Aim to identify & treat immediately life threateningimmediately life threatening conditions conditions
MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma
EARLY INTERVENTIONSEARLY INTERVENTIONS geared towards geared towards– identifying / correcting / preventingidentifying / correcting / preventing problems problems
Tension pneumothoraxTension pneumothorax Massive hemothoraxMassive hemothorax Open pneumothoraxOpen pneumothorax Cardiac tamponadeCardiac tamponade Flail chestFlail chest
MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma
Resuscitation of vital functionsResuscitation of vital functions
REMEMBER :REMEMBER :
- Most life threatening injuries txd - Most life threatening injuries txd byby
- Airway control - Airway control
- Chest tube- Chest tube
MANAGEMENT - MANAGEMENT - Chest Chest TraumaTrauma - Detailed - Detailed Secondary Secondary SurveySurvey
Influenced by:Influenced by: Mechanism of Mechanism of
injuryinjury High level of High level of
suspicionsuspicion
May show:May show: Simple pneumothoraxSimple pneumothorax HemothoraxHemothorax Pulmonary contusionPulmonary contusion Myocardial contusionMyocardial contusion Blunt aortic injuryBlunt aortic injury Rib fracturesRib fractures Diaphragmatic Diaphragmatic
rupturerupture
MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma
Definitive careDefinitive care
Usually operativeUsually operative
MANAGEMENT MANAGEMENT - - Chest Chest TraumaTrauma AdjunctsAdjuncts
CXRCXR=> basis for initiating other investigations=> basis for initiating other investigations
ALLALL wounds to thoracic cavity bounded back & front by wounds to thoracic cavity bounded back & front by
Neck & umbilicusNeck & umbilicus for stabs for stabs Neck & pelvis Neck & pelvis for GSWfor GSW
– MUST HAVE CXRMUST HAVE CXR
=> => UPRIGHUPRIGHTT if possible if possible
Adjuncts Adjuncts - FAST- FAST
Focused AbdominalFocused Abdominal
Sonography forSonography for
Trauma (Trauma (FASTFAST))
- All - All hemodynamically hemodynamically unstableunstable blunt blunt trauma ptstrauma pts
Adjuncts - Adjuncts - Cat ScanCat Scan- (CT angio)- (CT angio)
Becoming a Becoming a primary diagnostic toolprimary diagnostic tool fast (spiral)fast (spiral) allow for reconstruction etcallow for reconstruction etc
SPECIFIC CHEST INJURIESSPECIFIC CHEST INJURIES
Chest WallChest Wall Rib fracturesRib fractures Most common sign of blunt chest Most common sign of blunt chest
injuryinjury– Fx scapula, first rib, sternum suggest Fx scapula, first rib, sternum suggest
massive force of injurymassive force of injury– 1st & 2nd rib fx associated with serious 1st & 2nd rib fx associated with serious
other injuriesother injuries– Upper ones => Upper ones => suspect vascular injurysuspect vascular injury
Rib FracturesRib Fractures
Rib fracturesRib fractures
Signs and SymptomsSigns and Symptoms
- Deformity- Deformity
- Localized pain- Localized pain
- Tenderness- Tenderness
- Crepitus- Crepitus
Rib FracturesRib Fractures
TreatmentTreatment
Analgesia (PCA)Analgesia (PCA) Pulmonary toiletPulmonary toilet Observe for possible Observe for possible
pneumothoraxpneumothorax
Flail ChestFlail Chest
Segment of chest wallSegment of chest wallthat does not havethat does not havecontinuity with rest of continuity with rest of
thoracicthoraciccagecage Usually 2 fractures per Usually 2 fractures per
rib in at least 2 ribsrib in at least 2 ribs Segment does not Segment does not
contribute to lung contribute to lung expansionexpansion
Disrupts normal Disrupts normal pulmonary mechanicspulmonary mechanics
Accompanied by Accompanied by pulmonary contusion in pulmonary contusion in 50%50% of patients with flail of patients with flail chestchest
Flail Chest Flail Chest - - PathophysiologyPathophysiology
A major problem is theA major problem is the injury injury toto
thethe underlying lung underlying lung
=>=> Pulmonary ContusionPulmonary Contusion
Flail Chest Flail Chest – – Signs & Signs & SymptomsSymptoms
DyspneaDyspnea Chest painChest pain Paradoxical chest Paradoxical chest
wall movementwall movement Poor air movementPoor air movement CrepitusCrepitus HypoxiaHypoxia CyanosisCyanosis
Flail ChestFlail Chest - Treatment- Treatment
Pain controlPain control Humidified O2Humidified O2 Close observation for respiratoryClose observation for respiratory
decompensationdecompensation Aggressive pulmonary & physicalAggressive pulmonary & physical
therapytherapy
Flail ChestFlail Chest - Treatment- Treatment
Selective intubation and ventilationSelective intubation and ventilation:: significant other injuriessignificant other injuries respiratory rate > 35respiratory rate > 35 paO2 < 80paO2 < 80 paCO2 > 66 paCO2 > 66
Other treatmentsOther treatments:: tight fluid resuscitationtight fluid resuscitation
Flail ChestFlail Chest - Treatment- Treatment
Operative fixationOperative fixation not usually required not usually required (historical)(historical)
Lung InjuriesLung Injuries
Pneumothorax or HemothoraxPneumothorax or Hemothorax– most treated with simple tube most treated with simple tube
thoracostomythoracostomy
PneumothoraxPneumothoraxLess than Less than 1-2 cm1-2 cm may be observed in otherwise may be observed in otherwise healthy pts if stable on f/u CXR 6-8 hrs afterhealthy pts if stable on f/u CXR 6-8 hrs after
Open PneumothoraxOpen Pneumothorax
Open sucking chestOpen sucking chestwoundwound if opening if opening 2/3 of 2/3 of
diameter of tracheadiameter of trachea air will come through air will come through wound wound (preferentially)(preferentially)
allows free passage allows free passage of air into and out of air into and out pleural cavitypleural cavity=> effective ventilation => effective ventilation
impairedimpaired=> hypoxia & => hypoxia &
hypercarbiahypercarbia
Open PneumothoraxOpen Pneumothorax
Signs & Signs & SymptomsSymptoms
Penetrating chest Penetrating chest woundwound
Decreased breath Decreased breath soundssounds
Sucking sounds Sucking sounds on on inspirationinspiration
Open PneumothoraxOpen Pneumothorax
Treatment :Treatment :
3 sided occlusive 3 sided occlusive dressingdressing
Observe for Observe for tension tension pneumothoraxpneumothorax
OperativeOperative
Tension PneumothoraxTension Pneumothorax
One way valve allows air leak One way valve allows air leak from lung or chest wallfrom lung or chest wall
=> air forced into chest cavity=> air forced into chest cavity
without escapewithout escape
Tension PneumothoraxTension Pneumothorax
Collapses ipsilateral Collapses ipsilateral lunglung
Tension PneumothoraxTension Pneumothorax
Displaces mediastinum to opposite Displaces mediastinum to opposite sideside
Tension PneumothoraxTension Pneumothorax
Compresses opposite lungCompresses opposite lung
Tension PneumothoraxTension Pneumothorax
Decreases venous returnDecreases venous return
Tension PneumothoraxTension Pneumothorax
Signs & SymptomsSigns & Symptoms
– air hungerair hunger– chest painchest pain– respiratory distressrespiratory distress– tachycardiatachycardia– hypotensionhypotension– tracheal deviationtracheal deviation– absent breath soundsabsent breath sounds– hyper-resonant percussionhyper-resonant percussion– JVDJVD
Tension PneumothoraxTension Pneumothorax- Treatment- Treatment
Immediate decompressionImmediate decompression– large bore needlelarge bore needle
2nd intercostal space2nd intercostal space midclavicular linemidclavicular line
– chest tube as definitive txchest tube as definitive tx
NOTENOTE – – may mimicmay mimic a collapsed lung on the a collapsed lung on the other sideother side – - i.e. trachea deviates - i.e. trachea deviates towardstowards the collapsed lung the collapsed lung– - however, one - however, one resonanresonant (empty), other t (empty), other tympanic tympanic (full)(full)
Pulmonary ContusionPulmonary Contusion
Largest # of pts are those withLargest # of pts are those with
blunt traumablunt trauma Most common chest injury in Most common chest injury in
childrenchildren Usually develops over 24 hoursUsually develops over 24 hours Can occur with or without Can occur with or without
laceration of laceration of parenchymaparenchyma
Pulmonary ContusionPulmonary Contusion
Results from:Results from:
Leakage of blood and fluid into Leakage of blood and fluid into interstitial interstitial spaces of lungspaces of lung
- Significant inflammatory - Significant inflammatory reaction reaction to blood to blood components in the lungcomponents in the lung
Pulmonary ContusionPulmonary Contusion - -
PathophysiologyPathophysiologyLoss of normal lung structure & Loss of normal lung structure & function leads tofunction leads to
- poor gas exchange- poor gas exchange
- increased pulmonary - increased pulmonary vascular vascular resistanceresistance
- decreased lung compliance- decreased lung compliance
Pulmonary ContusionPulmonary Contusion - Complications- Complications
– AtelectasisAtelectasis– PneumoniaPneumonia– ARDSARDS– Respiratory failureRespiratory failure
Pulmonary ContusionPulmonary Contusion- Diagnosis- Diagnosis
Parenchymal Parenchymal infiltrate seen infiltrate seen in in CXRCXR adjacent to adjacent to injured chest injured chest wallwall
Pulmonary ContusionPulmonary Contusion- Diagnosis- Diagnosis
No real clinical No real clinical findings especially findings especially
initiallyinitially dyspneadyspnea chest wall chest wall
contusions / contusions /
abrasionsabrasions increased RRincreased RR may have may have
cracklescrackles
Pulmonary ContusionPulmonary Contusion- Diagnosis- Diagnosis
Lung gets stiffer causing Lung gets stiffer causing dyspnea and increased dyspnea and increased RRRR
Blood gases worsen 2-3 Blood gases worsen 2-3 days as edema increasesdays as edema increases
CXRCXR changes may lag 12 - changes may lag 12 - 48hrs 48hrs
behindbehind May underestimate the May underestimate the
true extenttrue extent
CTCT - very sensitive – can - very sensitive – can
allow quantifyingallow quantifying
Pulmonary ContusionPulmonary Contusion- Treatment- Treatment
MOSTLY supportiveMOSTLY supportive - usually resolve - usually resolve in in 5-8 days5-8 days
- - O2O2 + + observationobservation in milder cases in milder cases- - Pain controlPain control to allow to allow::
- adequate ventilation and - adequate ventilation and better better management of secretionsmanagement of secretions
- - Fluid restrictionFluid restriction - - Intubation + mechanical ventilationIntubation + mechanical ventilation
if respiratory distress presentif respiratory distress present
Pulmonary ContusionPulmonary Contusion
Indications for intubationIndications for intubation
Respiratory distressRespiratory distress Co-morbidities esp. lung diseaseCo-morbidities esp. lung disease Other injuriesOther injuries
– – intra-intra-abdominalabdominal
Myocardial contusionMyocardial contusion
Physical bruising of Physical bruising of the cardiac musclethe cardiac muscle
Usually associated Usually associated with fractures with fractures
of of the sternumthe sternum Any severe anterior Any severe anterior
chest injurychest injury
Myocardial contusionMyocardial contusion
Difficult to dxDifficult to dx
=> HIGH LEVEL => HIGH LEVEL OF SUSPICIONOF SUSPICION
ALL pts with ALL pts with pattern of injury pattern of injury must have an must have an EKGEKG
Myocardial contusionMyocardial contusion- Diagnosis- Diagnosis
EctopyEctopy ST elevationST elevation TachycardiaTachycardia
Friction rubFriction rub Enzymes may be normalEnzymes may be normal
Myocardial contusionMyocardial contusion- Treatment- Treatment
Monitor in ICU & treat Monitor in ICU & treat dysrhythmiasdysrhythmias
Serial enzymesSerial enzymes AnalgesiaAnalgesia
Massive HemothoraxMassive Hemothorax
Pleural cavity hold 3 liters bloodPleural cavity hold 3 liters blood 200cc – 1L in chest cavity seen on CXR200cc – 1L in chest cavity seen on CXR 90% from internal mammary or intercostals90% from internal mammary or intercostals 10% from pulmonary vessels10% from pulmonary vessels
Massive HemothoraxMassive Hemothorax- Treatment- Treatment
– DecompressionDecompression– Chest tube Chest tube (most need just that)(most need just that)– Bleeding may stop when lung re-Bleeding may stop when lung re-
expandsexpands
Aortic Rupture / Aortic Rupture / Great Vessel InjuriesGreat Vessel Injuries Abrupt deceleration Abrupt deceleration
or compression or compression injuryinjury
Sudden motion of Sudden motion of heart / great vessels heart / great vessels within thoraxwithin thorax
Great vessel injury Great vessel injury may occur in 0.3 => may occur in 0.3 => 10% penetrating 10% penetrating traumatrauma
Often rapidly fatalOften rapidly fatal Only 10% survive to Only 10% survive to
hospitalhospital Only 20% survive > Only 20% survive >
1 hour1 hour 90% who reach 90% who reach
hospital will diehospital will die EARLY DX and EARLY DX and
aggressive tx aggressive tx best chancebest chance
Aortic RuptureAortic Rupture- Signs and - Signs and
SymptomsSymptoms
– Hypovolemic shockHypovolemic shock– Chest wall ecchymosisChest wall ecchymosis– Marked difference in BP b/l armsMarked difference in BP b/l arms– Fx 1st, 2nd, 3rd ribs especially on Fx 1st, 2nd, 3rd ribs especially on
leftleft
Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis
Consider Consider mechanism of mechanism of injuryinjury– widened widened
mediastinum on mediastinum on CXRCXR
– 40% normalizes 40% normalizes with sitting upwith sitting up
Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis
Mediastinum > 8cm wideMediastinum > 8cm wide Blurring of aortic knobBlurring of aortic knob
Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis
Deviation of NGT to rightDeviation of NGT to right
Aortic Rupture Aortic Rupture - Diagnosis- Diagnosis
CT with contrast CT with contrast then angiogram then angiogram if abnormal if abnormal
Aortic Rupture Aortic Rupture - - TreatmentTreatment
Contained injuryContained injury
=> BP control=> BP control
Operative repairOperative repair
Cardiac InjuryCardiac Injury
Highly lethal : Highly lethal : fatality ratesfatality rates
- 70 => - 70 => 80%80%
Mostly Mostly ventricularventricular– right > leftright > left
Cardiac TamponadeCardiac Tamponade
=> Blood in pericardial sac=> Blood in pericardial sac
Occurs most frequently with Occurs most frequently with penetrating injuriespenetrating injuries
Cardiac TamponadeCardiac Tamponade- Signs and - Signs and
SymptomsSymptoms ShockShock JVDJVD DyspneaDyspnea PEAPEA Beck’s triadBeck’s triad = minority of pts = minority of pts
- Distended neck veins- Distended neck veins
- Muffled heart sounds- Muffled heart sounds
- Hypotension- Hypotension
Cardiac TamponadeCardiac Tamponade- Treatment- Treatment
Volume Volume resuscitationresuscitation
PericardiocentesisPericardiocentesis SurgerySurgery
- Pericardial - Pericardial windowwindow
- sternotomy- sternotomy
- thoracotomy- thoracotomy
Diaphragmatic RuptureDiaphragmatic Rupture
Traumatic Traumatic herniation of herniation of abdominal abdominal contents into the contents into the chestchest
Diaphragmatic RuptureDiaphragmatic Rupture
Mostly on Mostly on leftleft side side
Diaphragmatic RuptureDiaphragmatic Rupture
Liver “Liver “protectiveprotective” on right side ” on right side
Diaphragmatic RuptureDiaphragmatic Rupture
Frequent in thoracoabdominal Frequent in thoracoabdominal traumatrauma
– 15% stab wounds15% stab wounds– 46% GSW46% GSW– 15% greater than 2cm long15% greater than 2cm long
May be no immediate herniation of May be no immediate herniation of abdominal contentsabdominal contents
Diaphragmatic RuptureDiaphragmatic Rupture- Signs and - Signs and
symptomssymptomsNo distinctive signs / No distinctive signs /
symptoms seensymptoms seen
High index of suspicionHigh index of suspicion needed especially needed especially with mechanism of with mechanism of injuryinjury
dyspneadyspnea cyanosiscyanosis shoulder painshoulder pain bowel sounds in bowel sounds in
lower lower chestchest
Diaphragmatic RuptureDiaphragmatic Rupture- Treatment- Treatment
Up to 13% acute injuries missed initiallyUp to 13% acute injuries missed initially 85% presenting in 3 years as85% presenting in 3 years as
- obstruction or with- obstruction or with- decreased cardio / pulmonary reserve- decreased cardio / pulmonary reserve
Goal of treatmentGoal of treatment::- - Maintain adequate oxygenationMaintain adequate oxygenation => intubate=> intubate
- NG decompression of stomach- NG decompression of stomach
Diaphragmatic RuptureDiaphragmatic Rupture- Surgery- Surgery
Esophageal InjuriesEsophageal Injuries
Most due to penetrating traumaMost due to penetrating trauma
DiagnosisDiagnosis- Difficult- Difficult
- If delayed => - If delayed => rapid sepsis & high mortalityrapid sepsis & high mortality
- Requires aggressive investigation- Requires aggressive investigation
- Radiography- Radiography
- Endoscopy- Endoscopy
- Thoracoscopy- Thoracoscopy
TreatmentTreatment- Thoracotomy, etc.- Thoracotomy, etc.
Thoracic Duct InjuriesThoracic Duct Injuries
Accompany thoracic Accompany thoracic vessel injuriesvessel injuries
Noted much later i.e. not Noted much later i.e. not in acute phasein acute phase
Huge morbidity due to Huge morbidity due to severe nutritional severe nutritional depletiondepletion
MnMn – => initially aggressive => initially aggressive
and and nonoperative nonoperative = hyperalimentation = hyperalimentation
=> TPN=> TPN and if not sealed in 5-7 and if not sealed in 5-7
daysdays– surgical interventionsurgical intervention
Emergency Emergency ThoracotomiesThoracotomies““ACUTE” THORACOTOMYACUTE” THORACOTOMY Cardiac tamponade (relieved)Cardiac tamponade (relieved) Vascular injury to thoracic outletVascular injury to thoracic outlet Massive air leakMassive air leak Endoscopic/radiographic evidence of Endoscopic/radiographic evidence of
tracheal or bronchial injurytracheal or bronchial injury Esophageal injuryEsophageal injury Chest tube outputChest tube output
– immediate evacuation of 1500ml bloodimmediate evacuation of 1500ml blood– or > 250cc/ houror > 250cc/ hour– TREND MORE IMPORTANT TREND MORE IMPORTANT than initial outputthan initial output
““ER” THORACOTOMYER” THORACOTOMY – survival rates < – survival rates <
8%8%
““ER” THORACOTOMYER” THORACOTOMY- - To do or NOT to To do or NOT to
do…do…Type of CARDIACType of CARDIAC
ACTIVITYACTIVITY asystole asystole bradycardia bradycardia tachycardiatachycardia
““ER” THORACOTOMYER” THORACOTOMY- - To do or NOT to To do or NOT to
do…do…Type of VITAL Type of VITAL
SIGNSSIGNS electrical cardiac electrical cardiac
activity activity (PEA)(PEA)
palpable pulsepalpable pulse recordable blood recordable blood
pressurepressure
““ER” THORACOTOMYER” THORACOTOMY- - To do or NOT to To do or NOT to
do…do…LOCATION of LOSSLOCATION of LOSS
of vital signsof vital signs streetstreet in transit in transit
ambulance/helicopterambulance/helicopter unloading areaunloading area hallwayhallway resuscitation arearesuscitation area
““ER” THORACOTOMYER” THORACOTOMY- Unlikely to benefit - Unlikely to benefit
if ...if ... BLUNTBLUNT injury with injury with
arrestarrest Arriving without Arriving without
pulse/BPpulse/BPPenetratingPenetrating injury with injury with
arrestarrest Better chanceBetter chance High likelihood of High likelihood of
– isolated / isolated / correctablecorrectable intra- intra-thoracic injury (?GSW?)thoracic injury (?GSW?)
– still EXTREMELY RAREstill EXTREMELY RARE
““ER” THORACOTOMYER” THORACOTOMY- Bottom line- Bottom line
ER ER THORACOTOMYTHORACOTOMY
if presence of if presence of
MEASUREABLEMEASUREABLE – pulsepulse– blood pressureblood pressure– organized cardiac organized cardiac
activityactivity (or just lost IN (or just lost IN
trauma bay)trauma bay)
MUST consider MUST consider alsoalso– ageage– co-morbidities (ie co-morbidities (ie
infectious diseases) infectious diseases) AVOID AVOID if arrest if arrest
– occurs occurs OUTSIDEOUTSIDE OF OF RESUSCITATION RESUSCITATION AREA orAREA or
– due to due to BLUNTBLUNT trauma.trauma.
““ER” THORACOTOMYER” THORACOTOMY- -
Consider . . .Consider . . . Be mindful that circulatory arrestBe mindful that circulatory arrest
=> cerebral hypoxia=> cerebral hypoxia
=> permanent neurologic => permanent neurologic deficitsdeficits
=> => non-functionalnon-functional survivor survivor
occurs in 10 => 15% of survivorsoccurs in 10 => 15% of survivors
Chest tube Chest tube insertioninsertion Most common Most common
interventionintervention Relatively simple Relatively simple
procedureprocedure Definitively Definitively
manage > 85%manage > 85% of chest trauma : of chest trauma : penetrating or penetrating or bluntblunt
Has significant Has significant complication rate complication rate 2-19%2-19%
May be minor butMay be minor but May require May require
operative operative intervention andintervention and
Can result in Can result in deathdeath
Chest tube insertionChest tube insertion- Indications- Indications
Drain contentsDrain contents of of
pleural spacepleural space– airair– bloodblood– chylechyle– gastric contentsgastric contents
PreventPrevent development of development of pleural collectionpleural collection i.e. after i.e. after thoracotomythoracotomy
Prevent tension Prevent tension pneumothoraxpneumothorax in in ventilated pt with ventilated pt with rib fracturesrib fractures
Chest tube insertionChest tube insertion- Indications- Indications
Absolute Absolute indicationsindications pneumothorapneumothora
xx hemothoraxhemothorax traumatic traumatic
arrest - (b/l)arrest - (b/l)
Relative indicationsRelative indications– rib fractures and rib fractures and
positive pressure positive pressure ventilationventilation
– profound profound hypoxia/hypotensihypoxia/hypotension with on with penetrating chest penetrating chest injury injury
Placement may be Placement may be diagnostic or therapeuticdiagnostic or therapeutic
Bright red bloodBright red blood– suggest arterial injury = possible suggest arterial injury = possible
thoracotomythoracotomy Intestinal contentsIntestinal contents
esophageal, stomach, diaphragmesophageal, stomach, diaphragm intestinal injuryintestinal injury
Large air leakLarge air leak- bronchial disruption- bronchial disruption
Technique = importantTechnique = important to avoid to avoid complicationscomplications
Chest tube insertionChest tube insertion- Insertion - Insertion
SiteSite mid or anterior axillary linemid or anterior axillary line behind pectoralis behind pectoralis
majormajor above 5th ribabove 5th rib since on expiration diaphragm since on expiration diaphragm
rises rises that highthat high count down from sternomanubrial joint (2nd rib)count down from sternomanubrial joint (2nd rib)
Chest tube insertionChest tube insertion- Analgesia- Analgesia
PainfulPainful especially in muscular pts especially in muscular pts– Morpine IV or Ketamine 20mg in Morpine IV or Ketamine 20mg in
adultadult– 10-20 ml local analgesia10-20 ml local analgesia
along line of incisionalong line of incision perpendicularly thru all layers of chest perpendicularly thru all layers of chest
wall to wall to rib below spacerib below space up into pleural cavity after aspirating airup into pleural cavity after aspirating air
Chest tube insertionChest tube insertion- Procedure- Procedure
Prep and drapePrep and drape Incise along Incise along upper border of the ribupper border of the rib below the below the
intercostal space to be usedintercostal space to be used TrackTrack is to be directed is to be directed over top of lower ribover top of lower rib so so
as as to avoid intercostal vessels lying below to avoid intercostal vessels lying below each ribeach rib
should be big enough to fit fingershould be big enough to fit finger Use curved clamp to develop tract by blunt Use curved clamp to develop tract by blunt
dissection only – use to spread the dissection only – use to spread the muscle muscle fibers, develop tract with fingersfibers, develop tract with fingers
On reaching rib, clamp angled upward just On reaching rib, clamp angled upward just above above the rib and dissection continued the rib and dissection continued till pleural till pleural space enteredspace entered
Chest tube insertionChest tube insertion- Procedure- Procedure
Finger inserted Finger inserted into pleural into pleural space and area space and area palpatedpalpated
32-36 F tube 32-36 F tube attached to attached to clamp and clamp and inserted along inserted along track into the track into the pleural cavitypleural cavity
Chest tube insertionChest tube insertion- Procedure- Procedure
Connect tube toConnect tube to
underwater sealunderwater seal
and suture in and suture in placeplace
Examine chest toExamine chest to
check effectcheck effect CXR to checkCXR to check
placement andplacement and
positionposition
POSITION - Dependent on POSITION - Dependent on direction of tractdirection of tract
BluntBlunt chest trauma chest trauma pts lying flatpts lying flat– place drain place drain
anteriorlyanteriorly– prevents prevents
blockage of tube blockage of tube and development and development of tension of tension pneumothoraxpneumothorax
PenetratingPenetrating Posteriorly & basally Posteriorly & basally
directed draindirected drain Last hole should Last hole should
be INSIDE the be INSIDE the CHEST CAVITYCHEST CAVITY
If too far in could If too far in could cause severe cause severe intractable pain intractable pain when up against when up against mediastinummediastinum
Chest tube insertionChest tube insertion - Underwater - Underwater
SealSeal Allows air to Allows air to ESCAPE but NOT ESCAPE but NOT
RE-ENTERRE-ENTER chest cavity chest cavity Negative pressure dependent Negative pressure dependent
upon upon level of waterlevel of water Pleurovac must always be below Pleurovac must always be below
level level of patientof patient Persistent bubbling = air leak Persistent bubbling = air leak
from from lunglung
Chest tube insertionChest tube insertion - Underwater - Underwater
SealSeal May be May be
connected to connected to suction (water suction (water level 20cm H2O)level 20cm H2O)
Aid lung Aid lung re-expansion re-expansion especially if there especially if there is an air leakis an air leak
CHEST TUBES CHEST TUBES SHOULDSHOULD NEVER NEVER BE CLAMPED = BE CLAMPED =
TENSION TENSION PNEUMOTHORAPNEUMOTHORAXX
Chest Tube RemovalChest Tube Removal
When?When? When no air leakWhen no air leak No more fluid No more fluid
drainingdraining
How?How? Occlude hole while Occlude hole while
pulling tubepulling tube Remove at end of Remove at end of
expiration or at expiration or at peak of inspirationpeak of inspiration
Avoids air being Avoids air being drawn into cavitydrawn into cavity
Remove Remove rapidlyrapidly and and close wound quicklyclose wound quickly
Chest tube insertionChest tube insertion- -
ComplicationsComplications ““there is no organ in the thoracic or there is no organ in the thoracic or
abdominal cavity that has not been abdominal cavity that has not been pierced by a chest drain”pierced by a chest drain”
mainly historical since drains used to mainly historical since drains used to be inserted withbe inserted with
- a steel trocar - a steel trocar
- excessive force- excessive force
Chest tube insertionChest tube insertion - Acute - Acute
complicationscomplicationsHemothoraxHemothorax – usually – usually
laceration of laceration of intercostals vessel, intercostals vessel, may require may require thoracotomythoracotomy
Lung lacerationLung laceration especially when especially when adhesions presentadhesions present
Diaphragm / Diaphragm / abdominal cavity abdominal cavity penetrationpenetration - placed - placed too lowtoo low
Stomach colon injuryStomach colon injury - - diaphragmatic hernia diaphragmatic hernia not recognizednot recognized
TubeTube placed placedsubcutaneoussubcutaneouslyly – not – not
ininpleural cavitypleural cavity
Tube placed Tube placed too fartoo far = pain= pain
Tube falls outTube falls out = not = not secured properlysecured properly
Chest tube insertionChest tube insertion- Late - Late
complicationscomplications– blocked tubeblocked tube
= clot, lung= clot, lung– retained retained
hemothoraxhemothorax– empyemaempyema– pneumothoraxpneumothorax
after removalafter removal
= poor = poor techniquetechnique
Chest TraumaChest Trauma - - ConclusionConclusion Chest trauma isChest trauma is
– COMMONCOMMON– SERIOUSSERIOUS
AIM in TREATMENTAIM in TREATMENT– to to provide oxygen provide oxygen
to vital organsto vital organs– Be alert to Be alert to
changes in changes in clinical conditionclinical condition
Managed MOST Managed MOST of the time with a of the time with a CHEST TUBECHEST TUBE
CHEST TRAUMACHEST TRAUMA
ENDEND