Thoracic trauma

Dr Neisevilie NisaDept. AnaesthesiaAIIMS Hospital New Delhi

Overview Anatomy

Pathophysiology of thoracic trauma

Assessment and management

Flail chest

Pain management in thoracic trauma

Epidemiology

10-20% of polytrauma 2nd most common cause

of death after head trauma

25% of death in polytrauma

India Most common cause is

Motor vehicle injury 6% of global vehicular

accidents Male , mean age 21-40

years Violence ,industrial

accidents, falls, assaults, gunshot

AIIMS Trauma

HEAD & NECK916%

FACE/MF14910%

THORAX35824%

ABDOMEN&PELVIS40026%

ISOLATED PELVIS544%

EXTREM-ITY

+PELVIC &SHOUL

DER GIRDLE

25016%

EX-TER-NAL22014%

(N=1522)

Thoracic Trauma (n=358)Non-operative – 345 (95.3%) Operative n=13(4.7%)

With ICDT 280

INDICATION for

THORACOTOMY

Pneumonectomy 01

With out ICDT 65 Lobectomy 01

Bronchial repair 03

Massive Hemothorax 06

VATS 01

Epidural 82Descending thoracic aorta stenting 01

Diaphragmatic repair 09(6-Open abdominal approach; 3-Lap)

Etiology

624, 57%

189, 17%

122, 11%

32, 3%27, 3%

97, 9%

RTI

Assault

FFH

Railway

Suicidal

Unintentional

Anatomy

Etiology

BluntExplosion

Penetrating

Blunt Thoracic Trauma Globally = Road traffic accident represent the

most common cause Eastern mediterranean countries = Assault Other causes- Assault - Fall- Industrial - Sports - Animal attacks

Blunt trauma contd…… Results from kinetic energy forces

- Blast - Crush- Decelaration

Blast- Pressure wave - Tear blood vessels & disrupt alveolar tissue- Disruption of tracheobronchial tree- Traumatic diaphragm rupture

Crush (Compression)– Body compressed between an object and

a hard surface– Direct injury of chest wall and internal

structures Deceleration– Body in motion strikes a fixed object– Internal structures continue in motion– Force exceeds tissue tensile strength– Ligamentum Arteriosum shears aorta

Penetrating Trauma

Penetrating Trauma– Low Energy

Arrows, knives– High Energy

Military, hunting rifles & high powered hand guns

Extensive injury due to high pressure cavitation

Pathophysiology

Hypoventilation

Hypotension

Hypoxia

Injuries Associated withThoracic Trauma

Airway

Tension pneumothorax

Open pneumothorax

SecondarySimple pneumothorax

Hemothorax

Pulmonary contusion

Tracheabronchial tree

Blunt cardiac injury

Aortic disruption

Diaphragmatic injury

Mediastinal transversing wound

Flial chest

ATLSPrimary survey

Resuscitaion of vital functions

Secondary survey

Definitive care

Primary survey Airway

Laryngeal trauma Sternoclavicular joint

Listen Observe Palpate

Breathing Open pneumothorax

Tension pneumothoraxListen Observe Palpate

Circulation Pulse

Blood pressure

Skin

Neck veins

SPo2, ECG

Cardiac temponade

Massive hemothorax

Resuscitative Thoracotomy Release pericardial

tamponade

Control cardiac/great vessel

bleeding

Perform open cardiac

massage

Aortic cross clamping

Tracheobronchial injury Hemoptysis

Air escaping from neck

wound

Dyspnoea, resp distress

Hoarseness, dysphonia

Emphysema

Pneumothorax

Management Bronchoscopy : confirms diagnosis

Secure airway

Unstable patients : surgical intervention

Stable patients : After acute inflamation and

oedema resolve

Diaphragmatic Rupture

More common on left side

Commonly diagnosed during

laparatomy

Chest X-ray with gastric tube,

contrast study

Treatmant is direct repair

Esophageal Injury

Penetrating Injury

most frequent cause

Forceful expansion

of gastric contents

Esophageal Injury

Assessment Findings

- Pain/shock out of proportion to the apparent injury

- Dysphagia, Respiratory distress

- Particulate matter in the chest tube

- Mediastinitis, pneumomediastinum, emphysema

- Contrast study

- Direct repair

Traumatic Aortic Rupture Common cause of sudden

death

Slim chances of survival

Ligamentum arteriosum

Immediate survivors, early

diagnosis and treatment

Signs and symptoms Non specific : High index of suspicion

Burning or Tearing Sensation in chest or shoulder

Rapidly dropping Blood Pressure and increasing pulse

Decreased or loss of pulse or BP on left side compared to

right side

Rapid Loss of Consciousness

Management

ABC’s and RAPID TRANSPORT to higher center

Angiography is gold standard

Other investigation non specific

Primary repair or resection and grafting

Flail chest Flail chest has mortality of 10 – 20 % and typically

associated with pulmonary contusion

Traditional = Paradoxical movement and

“Pendelluft” “ Pulmonary contusion causes major respiratory

compromise and flail chest secondary problem of pain and splinting ”

Definition

Fracture of 2 or more ribs in 2 or more places

Pathophysiology

Paradoxical movement

Pathophysiology

Pulmonary contusion

Blood and plasma leakage into alveoli

Histology

Thickened alveolar septa with neutophillic infiltration

Clinical features

Symptoms Breathlessness Pain

Signs Hypoxia Bruising/Swelling Crepitus Increased pulmonary

vascular resistance

Investigations

Management Principles of fluid management ?

Invasive or non- invasive ventilation ?

Optimal mode of ventilation ?

Role of surgical fixation ?

Role of steroids ?

Rule of thumb = Adequate analgesia and chest physiotherapy

Management contd… Humidified oxygen

Analgesia

Ventilation and re-expansion of lung

Sandbag and extensive strapping

contraindicated

No role of steroids

Fluid management “Congestive atelectasis” - Aggressive fluid

resuscitation increase the size of lesion Trinkle et al 1973

Colloids better than crystalloids

Pulmonary dysfunction unrelated to hemodilution Mortality related to pulmonary function on

admission “ Fluid resuscitation should not be restricted to maintain adequate tissue perfussion”

Ventilatory support Initially = ‘ obligatory mechanical ventilation ‘

Longer hospital stay, increase mortality and

morbidity

“ Correct abnormalities of gas exchange rather to

overcome instability of chest wall ”

Indication for intubation

Severe head injury Several associated injury Shock Fracture of eight or more ribs Age > 65 years Previous pulmonary disease

RR > 35/mt Pao2 < 60mmHg PaCO2 > 55mmhg SPo2 < 90%

Which mode ? No difference between CMV and IMV

CPAP or PEEP of 10-15 cm H2O

Alveolar recruitment and increase FRC

Independent lung ventilation in severe unilateral

chest trauma

HFOV : Failure of conventional methods

Indication of surgical repair Thoracotomy

FC with respiratory insufficiency without

pulmonary contusion

Severe flail chest requiring prolonged ventilatory

support

Progressive dislocation of ribs

Summary“ Flail chest component causes short term respiratory

dysfunction, Pulmonary contusion responsible for

long term dyspnoea, low FRC , PaO2 ”

“ Adequate analgesia and chest physiotherapy is

mainstay of treatment ”

Pain management in thoracic trauma

History

Optimal pain control and chest physiotherapy

Modalities

Intravenous Thoracic

paravertebral

Intercostal Intrapleural analgesia

Epidural

Epidural

Intercostal Intrapleural

Paravertebral

Intravenous analgesia

Intravenous analgesicsAdvantages Disadvantages

Easy to administer and monitor Avoids invasive procedure Specialised personnel not required

Sedation Cough suppression Respiratory depression Hypoxemia

Epidural analgesiaAdvantages Disadvantages

Avoids sedation Improve PFT Decrease airway resistance Effective chest physiotherapy

Technically demanding Hypotension Infection Spinal chord trauma Mask symptoms of associated abdominal injury Monitoring required

Epidural superior to intravenous narcotics

Less ventilator daysLess tracheostomy rate Less ICU stayShorter hospital length of stay

Epidural contd….

Lumbar “OR” thoracic

Opiods “OR” LA

Infusion “OR” intermittent boluses

Epidural contd…. Equally effective pain scores but superior PFT

Cicala et al 1990

Combination therapy

Lower pain scores

IV narcotic sparing Logas et al 1997

Lower doses of both

Boluses has higher rate of complication

kurek et al 1997

Complications

Unsuccessful catheter

placement

Dural puncture

Neurological injury

Hypotension

Radicular pain

Pruritus

Respiratory depression

Urinary retention

Nausea

Vomitting

Paravertebral blockAdvantages Disadvantages

Ribs palpation not required Upper ribs fracture Avoids EDA side effects Unilateral block Less spinal chord trauma

Pleural puncture Pneumothorax Vascular puncture Higher failure rate

Intercostal nerve blockAdvantages Disadvantages

Increase PEFR ,lung volumes Less hypotension Bladder function preserved

Palpation of fractured ribs LA Toxicity Difficult for upper ribs Multiple infections Pneumothorax

Intrapleural anesthesiaAdvantages Disadvantages

Unilateral block Similar to intercostal

LA lost via chest tube Gravity dependent Pneumothorax Impair diffusion of LA Diaphragmatic function

Newer modalities 5 % lignocaine patch ( LIDODERM )

No opiod sparing versus placebo group Ingalls et al 2010

Summary Epidural analgesia: Optimal modality of pain

control and preferred technique after severe

blunt thoracic trauma

Safe with negligible complications

PVB when ED is contraindicated

Combination of narcotic and LA superior

Any query….????

Thank you