Chest Trauma
19thApril 2013
Kenyatta National Hospital
Dr. Josiah Ruturi
Thoracic and Cardiovascular Surgeon .
- Approximately 150,000 people die each year in the United States as a result of trauma.
- 25% of the deaths can be directly related to thoracic injury.
- Almost all patients with thoracic trauma are treated conservatively with a successful outcome.
- urgent operative treatment was required in only:
- 0.5% of blunt thoracic injuries.
- 2.8% of penetrating thoracic injuries .
OBJECTIIVES Identify and initiate treatment of life-
threatening thoracic injuries Primary survey Secondary survey Procedures Special considerations
Immediate Life-Threatening Injuries
Airway obstruction Tension Pneumothorax Open Pneumothorax Massive Hemothorax Flail Chest Cardiac Tamponade
Potentially Life-ThreateningInjuries:
Pulmonary Contusion Myocardial Contusion Aortic Disruption Traumatic Diaphragmatic Rupture Tracheobronchial Disruption Esophageal Disruption
An unstable hemodynamic state :
1. Traumatic cardiac arrest or near arrest and
an Emergency department thoracotomy.
2. Cardiac tamponade
3. Persistent ATLS class III shock despite fluid
resuscitation (blood loss 1500–2000 mL, pulse rate > 120,
blood pressure decreased)
4. Chest Tube output > 1500 mL of blood on insertion
5. Chest Tube output > 500 mL/hour for the initial hour
6. Massive hemothorax after chest tube drainage
Primary Survey
Airway: patency, retractions, obstruction
Breathing: exposure, rate, pattern, cyanosis
Circulation: *Pulses, color, *neck veins, monitor for arrythmias
*hypovolemic patients might not exhibit
Initial Management Airway - with cervical spine control -
tracheobronchial tree disruption Breathing - tension/open pneumothorax,
flail chest, lung contusion Circulation - cardiac tamponade,
hemothorax, cardiac contusion, aortic disruption
Specific signs and symptomsPneumothorax
Tension Pneumothorax– Hypotension, tracheal deviation, distended
neck veins Pneumothorax
– No signs, tachypnea, tachycardia, decreased breath sounds, hyperresonance, SQ emphysema
Pneumomediastinum– Hamman’s sign, SQ emphysema
Subcutaneous Emphysema
Airway, Lung or Blast injury esophageal injury: Boerhaave’s Adjacent penetrating wound Progression to tension pneumothorax
Pneumothorax-Treatment
<15% -very small spontaneous can be given 100% O2 in ED and observed
<25% - simple pneumothorax can be aspirated through a small catheter
Larger pneumothoraces/ underlying lung dz –tube thoracostomy
Pneumonediastinum – conservative
Tension Pneumothorax
“one-way valve”: air enters, can’t exit
displacement of mediastinum/trachea
decreases venous return, displaces opposite lung
Causes: spontaneous pneumothorax, blunt chest trauma, penetrating trauma
Left Right
A: Air under tension in left thorax
A
B
B: Collapsed right lung
Pleural margin; partial lung
collapse
Tension Pneumothorax
Heart
LeftRight
B
B
B: pressure of tension pneumothorax pushing midline structures (heart, mediastinum) into patient’s left thoracic cavity
A
A: air, under tension, in thoracic cavity
Tension Pneumothorax
Clinical manifestations in patient with– Spontaneous breathing – Respiratory distress– Florid face– Tracheal deviation– Distended neck veins– Tachycardia– Hypotension
Needle Thoracentesis Indication: Rapidly deterioration with
tension pneumothorax. Equipment
– Povidone-iodine solution– 14-gauge catheter-over-needle device
Technique– Cleanse overlying skin– Insert needle at 2nd or 3rd intercostal space,
midclavicular line, over top of rib– Leave catheter in pleural space open to air
Sucking Chest Wound
AKA communicating pneumothorax Large defects: if opening > 2/3
trachea, air will pass preferentially. Cover immediately with cleanest
occlusive dressing 3 sides vs 4 sides
Massive Hemothorax
>1500 cc blood Mechanism:
– Penetrating injury of systemic or hilar vessels, especially wounds medial to nipples, scapulas.
– Blunt trauma Loss of Breath sounds, dullness to
percussion
Flail Chest
No bony continuity with rest of cage Multiple rib fractures, paradoxical
movement Hypoxia from injury to underlying
lung 30% missed in first 6 hours
Flail chest is a marker for significant injuries
Retrospective analysis, 92 pat, L-1 center. 46% had pulmonary contusion 70% had pneumo or hemothorax Great vessel, tracheobronchial injuries had no
associated. 27% developed ARDS 69% required mechanical ventilation 33% mortality
Ciraulo DL et al. J Am Coll Surg 1994;178(5):466. (Penn)
Traumatic Aortic Injury
Retrosternal/intrascapular pain Dyspnea, hoarseness, dysphagia,
HTN Pseudocoarctation syndrome Hypotension Harsh systolic murmur (AI) 50% without external findings
Cardiac Tamponade
Penetrating injuries most common Beck’s Triad Kussmaul’s sign (rise in CVP with
inspiration) Mimic: tension pneumo on left side EKG: electrical alternans (rare)
Management of Tamponade:
Cautious fluid management Pericardiocentesis: 15-20 cc may
immediately improve hemodynamics Open thoracotomy and inspection
Pericardiocentesis
Indications– Immediate threat to life– Severe hemodynamic impairment– Fall in systolic blood pressure >30 mm
Hg
Pericardiocentesis
Technique– Patient in supine position, upper
torso elevated– ECG limb leads attached to patient– Use echocardiography guided procedure
(rarely: ECG-guided, V lead)– Subxiphoid approach– Continuous aspiration
Pulmonary Contusion
Determinants of outcome ISS > 25 Initial GCS < 7 Transfusion > 3 U blood pO2/FiO2 < 300 Not correlated to shock or IV fluid administration Extent of contusion seen on initial chest X-ray
not predictive of mortality or intubation.
Johnson JA et al. J Trauma 1986; 26(8):695.
Diaphragmatic Rupture
Blunt trauma: large tears Penetrating: small tears, subtle More commonly diagnosed on the
left
Tracheobronchial Tree
Larynx– Hoarseness– Subcutaneous emphysema– Palpable Fracture– Crepitus
Trachea:– Noisy breathing– Penetrating injuries: esoph, carotid artery,
jugular vein trauma
Scapular and Rib Fractures
Splinting impairs ventilation Majority – optimise pain mx Scapula, often indicate major injury to the
head, neck, spinal cord, lungs and great vessels: mortality > 50%
pain, tenderness, crepitus
Penetrating Cardiac Injury
Ventricles: will self seal more commonly
RV>LV>RA>LA 56-66% overall survival 87% survival in OR thoracotomy Positive predictors: VS on admission,
short transport, SW
penetrating cardiac injury A combination of: - unstable patient: aggressive operative intervention - stable patient: ultrasound evaluation
provided an overall survival of 40% in the patients with known cardiac injury.
The diagnosis of a traumatic pericardial effusion can be made by the visualization of an echolucent region between the heart and pericardium,
right ventricular diastolic collapse will confirm tamponade.
ultrasound imaging appears to be with an accuracy, sensitivity, and specificity that exceeds 95%
Classification of Mediastinal Injuries
M1= base of the neck into mediastinum or pleura M2= one pleural cavity and mediastinal violation (central hematoma, visceral or spinal cord injury,metallic fragments in the mediastinum) M3 = parasternal injury within the nipple line or < 4 cm from the sternumM4 = two pleural cavities and mediastinal traverse.
M4 - All of the mediastinal traverse injuries were caused by gunshot wounds - this trajectory had the highest rate of instability and subsequent operative intervention. - the highest observed mortality rate (60%), M1 - Injuries from a cephalad direction were predominately stab wounds. - were responsible for the second highest incidence of instability and subsequent operative intervention.
The presence of a gunshot wound, was associated with significant risk of both instability and death.
Penetrating Chest Trauma
Low chest SW: 15% intraperitoneal, 15% require operative intervention
(diaphragm)
Pediatric Chest Trauma
Compliance = internal injury Mobility = tension pneumos, flail
chest Bronchial and diaphragmatic injuries Infrequent injuries to great vessels
Summary
Thoracic trauma is common in multiply injured patients
Life- threatening problems may be temporarily relieved by simple measures
Injury recognition important High index of suspicion for occult injuries