Blunt Chest Trauma Bradley M. Dennis, MD 09.21.15
Blunt Chest Trauma
Bradley M. Dennis, MD
09.21.15
Overview
• Rib Fractures
• Lung Injuries
• Tracheobronchial Injuries
• Cardiac Injuries
• Aortic Injuries
Overview
• Rib Fractures
• Lung Injuries
• Tracheobronchial Injuries
• Cardiac Injuries
• Aortic Injuries
Rib Fractures
• Often not clinically significant in isolation
• Harbinger of other injuries
• Most commonly associated with PTX, HTX, Pulm contusion
• R sided rib fx (including 8th rib or below) 19-56% chance of assoc. liver injury
• L sided rib fx 22-28% chance of splenic injury
Rib Fractures
• Worse in the elderly– 2x mortality and thoracic
morbidity• PNA, effusion, ARDS
– Mortality increases 19% for each add’l rib fx
– Longer hospital and ICU LOS
Bulger, E; Arneson, M; Mock, C; Jurkovich, G. J Trauma. 2000.
Flail Chest
• Fracture of 4+ consecutive ribs with fx in 2 places
• Paradoxical motion of the affected chest wall segment during respiration– Flail segment collapses
during inspiration
– Expands during expiration
From Mayberry J, Trunkey D. The fractured rib in chest wall trauma. ChestSurg Clin N Am 1997;7:253.
Management
• Options– Medical
• Opioids/NSAIDS—Monotherapy if 1-2 rib fx
• Pulmonary toilet/IPPV/IS/mobilization
• Mechanical ventilation
– Anesthesia• Epidural catheter
• Paravertebral infusion (On-Q pump)
• Intercostal block
– Surgical• Rib plating
Pain Management
• Epidural
– Ideal for ≥4 rib fx
– Excellent for bilateral fx
– Inserted at mid-level of fxs
– Typically infuse narcotic and local anesthetic• Fentanyl + bupivicaine
– Low risk of local anesthetic toxicity
Thoracic Epidural Analgesia
• Risks– Hypotension
– Pruritus
– Urinary retention-not an indication to keep foley
– Muscle weakness-not an indication for bedrest
• Contraindications– Hypotension/hypovolemia
– Spinal fracture
– Coagulopathy
– Sepsis
Pain Management
• Paravertebral infusion– Excellent for unilateral fxs
– Not limited by coagulopathy or spinal fx
– Low risk of hypotension or urinary retention
– Local anesthetic toxicity more common
Pain Management
• Intercostal block– Lasts 4-8 hours,
repeatable
– Requires injection at each level plus one rib above and below fractures
– Requires palpating fractured ribs to indentify landmarks
– Difficult to identify landmarks above T7
From Karmakar MJ, Anthony MH, Acute Pain Management of Patients withMultiple Rib Fractures. J Trauma 2003; 54: 615-625
Rib Fixation
From Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications,technical issues, and future directions. World J Surg. 2009;33:14-22.
Rib fixation
• Options
– Anterior plate with wire cerclage
– Anterior plate with cortical screws
– Intramedullary fixation
– Judet strut
– U-shaped plate (RibLoc®)
– Absorbable plates
Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications,technical issues, and future directions. World J Surg. 2009;33:14-22.Lafferty P, Anavian J, Will R, Cole P. Operative Treatment of Chest Wall Injuries: Indications, Technique, and Outcome. J Bone Joint Surg Am. 2011;93:97-110.
Rib Fixation
• Advantages
– Less vent days
– Less pneumonia
– Less pulmonary dysfunction
– Less inpatient hospitalization
– Less long-term pain and disability
Overview
• Rib Fractures
• Lung Injuries
• Tracheobronchial Injuries
• Cardiac Injuries
• Aortic Injuries
Pneumothorax
• Occult PTX
– Seen on CT, but not on CXR
– Can be observed without chest tube• Even if on postive pressure ventilation
Pneumothorax
• If large or clinically significant, place chest tube
– Sterile conditions
– Periprocedural antibiotics (Ancef)
– Large bore chest tube (28F-40F)
– Posterior and apical
– Leave in place until air leak resolved and drainage down (≤2mL/kg/day or ≤200mL/day)
Hemothorax
• Often associated with PTX and/or rib fractures
• Occurs in 30-40% of thoracic trauma pts
• Operative indications
– ≥1,500 mL of blood immediately evacuated Y
– Persistent bleeding from the chest, ≥150 mL/h for 2-4 hours
– Persistent blood transfusion to maintain hemodynamic stability
HTX Management
• If retained HTX present on CXR– Consider placing 2nd chest
tube• ? Right angle chest tube
– CT chest on Day 3 to evaluate volume• >300mL requires intervention
– VATS recommended on/before Day 7
– If poor surgical candidate, intrapleural t-PA
Intrapleural t-PA
• 50mg mixed in 100mL sterile NS
• Chest tube site prepped/draped sterilely
• Injected via chest tube into pleural cavity
• Chest tube clamped at skin x 1 hour
• Patient rolled in multiple positions to distribute fluid
• Unclamp and allow to drain
• Perform once daily x 3 days
Pulmonary Contusion
• Often associated with rib fx or other chest trauma
• Best diagnosed with CT– 100% vs 38% (CXR)
– Allows for quantifying amount of lung involved
• ARDS developed in 82% of those with >20% contused lung (vs 22% in those <20%)
• May require mechanical ventilation
• No benefit to steroids or fluid restrictionMiller PR, Croce MA, Bee TK, Qaisi WG, Smith CP, Collins GL, et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high risk patients. J Trauma 2001;51(2):223– 30.
Overview
• Rib Fractures
• Lung Injuries
• Tracheobronchial Injuries
• Cardiac Injuries
• Aortic Injuries
Tracheobronchial Injuries
• Very rare in blunt trauma
• Pneumothorax, subcutaneous emphysema and hemoptysis are most common symptoms
• Persistent PTX despite chest tube should raise suspicion
Airway Management
• Avoid double-lumen tube
• Intubate with long single-lumen tube
– Go beyond injury with ETT or mainstem contralateral bronchus
• Bronchial blocker if injury more distal
Management
• Injury <1/3 circumference can be watched
• Distal 1/3 of trachea, carina and R mainstem bronchus best approached via R thoracotomy
• L mainstem bronchus approached thru left chest
• Simple interrupted absorbable sutures
• Up to 50% of trachea can be resected and reconstructed and all of mainstem bronchi
• Repair carina
Overview
• Rib Fractures
• Lung Injuries
• Tracheobronchial Injuries
• Cardiac Injuries
• Aortic Injuries
Commotio Cordis
• Sudden cardiac death due to blunt trauma
• Primarily males (95%) of adolescent or young age (78%)
• 87% mortality rate
• Survival is directly correlated with
– Quick recognition
– Rapid initiation of resuscitation,
– Availability of AED
Chamber Rupture
• Ventricular rupture is highly lethal
• Atrial rupture can be successfully repaired
• Suspect if unexplained hypotension despite fluid resuscitation (cardiac tamponade)– Rule out
• Tension PTX
• Massive HTX
• TBI
• spinal cord injury
• Negative findings from abdominal evaluation (FAST/DPL)
Blunt Cardiac Injury
• Most common cardiac injury in blunt trauma
• Wide ranging manifestations
– Sinus tach to lethal arrhythmias
• No one best test for diagnosis
– EKG and Cardiac enzymes can be misleading
– Echo probably best test
• Treatment is supportive
– May require inotropes, beta blockers, even pacing
Overview
• Rib Fractures
• Lung Injuries
• Tracheobronchial Injuries
• Cardiac Injuries
• Aortic Injuries
Aortic Injuries
• Deceleration injuries
• Most are fatal injuries
– 70-80% die at scene
– 2-5% have delayed rupture
• Injuries most commonly occur just distal to left subclavian artery
• Can be repaired via open thoracotomy or endovascular stent graft
Aortic Injuries
• Preoperative anti-impulse therapy shown to be beneficial
– Using short-acting beta-blockade to reduce wall stress by reducing blood pressure and heart rate
– Goals usually HR<100, SBP<120
• Shown to reduce in-hospital aortic rupture rates without adversely affecting other injuries
TEVAR
Advantages
• No thoracotomy
• No single-lung ventilation
• No aortic cross-clamping
• No left heart or cardiopulmonary bypass
• Requires considerably less time
• Can be done quickly in relatively unstable patients
Disadvantages• Can be logistically as well as
technically challenging
• Off-label use of these devices
• Technical limitations in younger patients with smaller aortas
• Long-term side effects and durability of the repair remain unknown
• Often requires covering L subclavian artery with stent
Aortic Injuries
• Meta-analysis demonstrated nearly 70% reduction in operative mortality by using endovascular approach
• 30-day mortality reduced by over 50%
• Post-operative paraplegia rates significantly lower with endovascular repair (OR O.32)
Questions?