Thoracic Trauma
Often acutely life threatening
- Causes 25% of trauma deaths
- Contribute to additional 25% of deaths
Usually managed non-operatively
- 90% of blunt trauma
- 855 of penetrating trauma managed with observation or chest tube (increased need for operation with high velocity penetrations)
Blackbourne Study combat numbers:
n=2,048 thoracic trauma of 23,797 trauma patients pts from 2003-2011 = 8.6% incidence
Mean ISS 23, 38% with ISS > 25
6030 total injuries --> mean 3 injuries per patient
Penetrating cases: 84% chest tube alone, 16% thoracotomy
Mortality of thoracic injury = 8.3 percent
Primary Survey Thoracic Trauma
Open PTX
Tension PTX
Massive Hemothorax
Cardiac Tamponade
Open Pneumothorax (aka simple PTX or sucking chest wound)
Penetrating injury --> chest wall defect --> 2 way leak: insp pulls air in, exp pushes air out --> impaired ventilaiton (if defect >2/3 diameter of trachea) --> respiratory failure
Treatment
1. Flutter-type dressing in field
2.Chest Tube +/- coverage (large defects)
Tension PTX
Acutely life-threatening
Essential to recognize
Easy to Treat
Etiology
One-way leak from:
1. Sealing off open PTX
2. Rib Fx poking lung
3. Bronchial Injury
4. CVL complication
5. Barotrauma
Pathophysiology
One way air leak from lung or through chest wall --> air being forced into pleural space without means of escape --> complete lung collapse (HYPOXIA) --> mediastinal shift (TRACHEAL DEVIATION) --> decreased venous return to heart (OBSTRUCTIVE SHOCK) --> DEATH
Presentation
Resp. distress
Hypoxia
Absent Breath Sounds
Crepitus
Tracheal Deviation
Treatment
Immediate decompression
Chest Tube
+/- Surgery (rarely)
Needle Decompression
2nd intercostal space
Midclavicular line
Over top of rib
Use long, large bore angiocath (4.5 cm favored over 3.2cm)
Time for a Change in Approach?
- 4-65% failure rate observed with traditional approach
? Better to decompress from 5th ant axillary line?
2nd MCICS is 1.3 cm > on average depth than 5th anterior axillary line, extent of discrepancy increases with BMI
Cadaver Study:
- 100% success rate with 5th AAL approach
- 58% success rate with 2nd ICMCL approach
Easier to enter chest but what about:
? Increased kinking from AAL approach?
? Risk of Cardiac Injury from AAL approach?
? Infection Risk ?
Massive HTX
Usually secondary to penetrating trauma to great vessels &/or lung
Blunt HTX usually from rib fx & intercostal bleeding which rarely bleed massively
Presentation
Hypovolemic Shock
Respiratory Distress
Decreased BS
White Out on CXR
Treatment
Chest Tube c Reinfusion
Emergency Thoracotomy - consider for >1500 intial output or >200cc/hr for 2-4 hrs
Always confirm improvement on CXR
Vietnam Experience
1. Exploration for chest tube insertion causing loss of 1,000 to 1,500 mL of blood and continued bleeding of more than 500 mL during the first hour of observation
2. Exploration for persistence of clotted hemothorax after insertion of a chest tube
3. Exploration for chest tube insertion yielding 1,000 to 1,500 mL of blood and immediate operation for other injuries precluding a period of observation
4. Exploration for hypovolemic shock and continued hemorrhage from multiple sources, including the chest, requiring immediate operation for resuscitation
5. Other factors modifying the above including massive air leak, intratracheal bleeding, or consideration of missile trajectory
After initiation of this protocol, outcomes improved
Outcomes based on extent of resection
- progressively complex interventions associated with 1.8x (CI: 1.4 to 2.2) increase in mortality
- A study of mortality: Suture 2/22, Tractotomy 2/16, wedge 21/69, lobectomy 12/28, pneumonectomy 4/8
- A study of mortality/morbidity: wedge resection 7.5%/20%, tractotomy 14%/67%, lobectomy 17%/24%, pneumonectomy 50%/0%
After control of hemorrhage, hemodynamically stable patients with significant parenchymal damage and/or large air leaks should be considered for definitive resection in an effort to decrease thoracic complications
Retained HTX
Retained HTX or PTX complicates 20% of CT placements for Trauma
Associated with empyema, fibrothorax
Suspect c persistent abnl CXR on Day 3
Confirm suspicion c Chest CT
VATS Day 3-5 to address
- Earlier than 3 days, risk rebleeding
- After 5 days, more likely have to convert to thoracotomy, increased hospital LOS, more likely to find empyema, more often require multiple chest tube treatments
Cardiac Tamponade
Penetrating injury to heart --> noncontained bleeding --> death
or
Penetrating injury to heart --> blood contained in pericardial sac (muffled heart tones) --> pressure on heart --> decreased CO (Hypotension from obstructive shock) --> back up of venous blood (distended neck veins)
Diagnosis
Clinical Suspicion
CXR - water bottle heart
FAST - pericardial fluid - can be difficult to diagnose if hemothorax present
Pericardial Window - subxiphoid, through diaphragm, open paricardium
Treatment
Pericardiocentesis
ER Thoracotomy/emergent sternotomy
Subxiphoid window
Secondary Survey Thoracic Trauma
Moderate PTX/HTX
Flail Chest / Pulmonary Contusion
Cardiac Contusion
Diaphragmatic Hernia
Blunt Thoracic Aortic Injury
Blunt Chest Trauma
6% overall mortality rate
33% Pulmonary Complication Rate
Isolated Rib Fx - 6% mortality in elderly
Isolated Flail Chest - 16% mortality
Mechanism
Blunt trauma to chest -->bruising of underlying lung --> pulmonary contusion --> respiratory failure
Blunt trauma to chest --> multiple rib fractures along same rib
--> pain --> splinting --> atelectasis --> respiratory failure
--> loss of thoracic cage continuity --> disruption of normal chest wall movement --> respiratory failure
Pulmonary Contusion
PC seen in 30-75% of Blunt Thoracic Traumas
Can occur in isolation secondary to blast effect
Most accompanied by chest wall injuries
- most severe form of chest wall injury commonly seen = flail chest = 10-20% mortality
The major source of morbidity in FC
“Lung Bruise”
Can decrease FRC & PaO2 for years
Results in chronic fibrosis
Pulmonary Contusion: .not just a local issue
- Local effects:
Laceration to lung tissue, hemorrhage-filled alveoli, reduced compliance yielding reduced ventilation, increased shunt fraction with decrease in PO2, increase in AaDO2, increased pulmonary vascular resistance, decreased pulmonary blood flow
- Injured and uninjured lung (ipsilateral and contralateral):
Thickened alveolar septa with impaired diffusion, decreased alveolar diameter, vacuolation of pulmonary tissue, delayed capillary leak with increased BAL protein, increased neutrophils in lung tissue
- Systemic:
Increased TCC, decreased complement, increased cytokines tumor necrosis factor alpha and interleukin 6, decreased peritoneal macrophase, splenic macrophage, and splenocytes, increased mortality for a septic challenge
Flail Chest
Diagnosis
PE: tenderness, moveable/crunching ribs, paradoxical chest motion
CXR: Rib Fx at 2 or more points on 3 or more sequential ribs +/- consolidation from contusion
Treatment
1. Close observation with pulse ox.
2. Avoid Volume Overload
3. Pulmonary Toilet +/- CPAP
4. Analgesia
+/- 5.Vent support (avoid early extubation)
+/- 6. Surgical Stabilization
Analgesia in Thoracic Injuries EAST Trauma Guidelines
Level 1:
- Epidural analgesia is optimal modality of pain relief for blunt chest wall trauma and is the preferred technique after severe blunt thoracic trauma
Level 2:
- Patients with four or more rib fractures who are >=65 years of age should be provided with epidural analgesia unless contraindicated
- Younger patients with four or more rib fractures or patients aged >65 years with lesser injuries should also be considered for epidural analgesia
- High-risk patients who are not candidates for epidural analgesia should be considered for paravertebral (extrapleural) analgesia
- Combinations of narcotic and local anesthetic provide most effective epidural analgesia
Intercostal Nerve Block
Effective
Increase Peak Insp. Flow
Short Duration (~6hr)
Hard to place as a catheter
Intrapleural Anesthesia
Catheter into pleural space
Produces unilat. inter-costal nerve block by diffusion across pleura
Gravity dependent
Impaired by: chest tubes, HTX
Paravertebral Block
Unilat. Block over multiple dermatomes
Low risk of hypotension or spinal cord injury
Preserved bladder sensation
Numerous theoretic advantages
Scant data
Epidural
Effective
Nonsedating
Downsides:
- Bilateral effects can create hypotension
- Possibility of spinal cord injury
Surgical Fixation of Flail Chest
? Optimal timing (range: 1- >8 days)
? Diminished role with significant PC
? Method of Fixation
Blunt Cardiac Injury
Suspect with:
- Bent Steering Wheel
- Sternal Pain/Bruising
- Sternal FX
Diagnosis
EKG Changes
- Sinus tachycardia
- ST/T wavechanges
- RBBB
Treatment
ACLS
Observation
Cardiology Eval. with ECHO for new murmor or persistent EKG abnormalities
Diaphragmatic Injury
Low velocity penetrating injury in the box --> small hole in diaphragm --> gradual herniation of abdominal viscera into chest
High velocity or severe direct blow to abdomen --> large blow out hole in diaphragm --> acute herniation of abdominal viscera into chest
Suspect with any penetration to “Thoracoabdominal box":
Nipple to costal margin, inferior scapular angle to costal margin
In pt with other indications for celiotomy fix diaphragm concurrently.
Pt without other indication for celiotomy: semi-elective laparoscopy
R TA Box penetration & HTX: think liver first but don’t open Pandora’s box
Early dx: approach through abd
Late dx: approach through chest
Often OK to leave a-sxic right injuries
Realize any abdominal contamination communicated with chest
Diagnosis
Difficult
1. CXR - findings in 75%
2. DPL fluid out CT
3. “CT against bowel test”
4. At Laparotomy
More common on Left
Often causes SOB, Acute BO
Arterial Air Embolism
Rare Complication of Penetrating Lung Trauma
Penetrating trauma to lung --> hole in bronchi and/or bronchioles and/or pulmonary venous system -->bronchial to pulmonary venous fistula --> air in pulmonary vein, blood in airway (hemoptysis) --> air in L ventricle -->MI and cardiac arrhythmias or CVA and seizures
Prevention
Avoid High Airway Pressures
Avoid Hypotension
Consider 1 Lung ventilation
Treatment
Thoracotomy
Pulm. Hilum X-Clamp or Twist
Aspirate L Ventricle
Control Source
Pulmonary Hilar Twist
Incise Inf Pulm Lig
180 degree twist
Pack Laps to hold
Address other issues
Blunt Thoracic Aortic Injury (BAI)
Pathophysiology
Severe blunt deceleration --> shearing force --> aortic tear or transection
Epidemiology
Occurs in < 1% MVC (head-on & side impact)
16% of MVC deaths (2nd only to head injury)
3 Categories - 80% die in field, 5% unstable on presentation, 15% contained injury (30% die within 24 hrs if untreated)
Diagnosis
CXR
60-90% sensitivity
Widened mediastinum
Over-riding, indistinct aorta
1-2nd rib fractures
Apical capping
R tracheal shift
CTA
Approaches 100% sens.
Angio ~ 90% sensitive
Additional anatomic info
“Minimal Aortic Injury”
~ 10% of BAI seen on CT
? Definition
Must follow closely (< 1 cm flap --> 50% PA rate within 8 weeks)
BST Approach- Intervene for any with: significant thrombus, periaortic hematoma, lumen encroachment, pseudoaneurysm
Treatment
Medical
Beta-Blockers and Anti-hypertensives --> decrease shear stress on aortic wall
Goal SBP = 100-110 w/ HR < 100 while addressing other acutely threatening injuries
BAI Repair
AAST 1: 9% paraplegia, 31% mortality
Endovascular Stenting
Minimal physiologic stress
No bypass, no need for heparin, no paraplegia risk
No single lung ventilation
7-12% mortality, 0% paraplegia
BAI – Issues to Resolve
RPC Data?
Age Factors
Anatomy Factors
Thoracic Aortic Disruption
Diagnosis
Suspicion based on mechanism
CXR – widened mediastinum, etc…
CT, Angiography
NOT A GOOD EXPLANATION FOR ONGOING INSTABILITY
.Transmediastinal wounds.
Stable
CT +/- CTA
FAST exam
Esophagogram
Endoscopy
Unstable
Bilateral chest tubes
FAST exam
Operation
Thoracoabdominal Wounds
SSTP Experience
10 Cases (5 US, 5 Iraqi)
Mean ISS = 33 (range 17-50)
Mean Severe Injuries = 5.2 (range 2-12)
7/10 died (4/7 excluding DOAs)
- 1 potentially preventable
- 6 nonpreventable - 2 retrohepatic IVC lacerations, massive bilateral pulmonary contusions, spinal cord transection, left ventricle laceration, air embolism
FLANKS NEED PROTECTED!
Resuscitative Thoracotomy
Benefits of Resus. Thoracotomy
Relief of Tamponade
Facilitate Internal Compressions
Facilitate Aortic cross-clamping
Instruments
- Knife
- Mayo Scissors
- Rib Spreader
- Long Scissors & Toothed Pick-Up
- Large Vascular Clamp
Positioning/Prep
L arm up, Slight Roll to R
NG tube down
+/- Concurrent R CT
Approach
- Sternotomy
- ClamShell (don't forget internal mammary arteries)
- Pericardial Opening - anterior away from phrenic nerve
Cardiorrhaphy
- fix the injured heart then restart it
- Pledgets
- U stitches (avoid coronaries)
Internal Compressions
Delivers 60% of normal Aortic Pressures (adequate cerebral and coronary perfusion x 30 minutes)
Only 20% of normal pressures from external compressions (adequate perfusion for 15 minutes)
Aortic X-clamping
Initial Step = Incision Inf. Pulm. Ligament
Retract lung superior & anterior
Incise pleura ant. to Hemiazygous / Vert Body
Carefully hook around
Incise anterior pleura
Clamp
Doubles CO and MAP in severe hemorrhagic shock
Increases DBP --> increases coronary perfusion
Decreases distal flow to 10% --> renal ischemia, spinal ischemia
Only x-clamp if you have to, not helpful with tamponade
Survival Rates by Mechanism categorized by status on arrival
Isolated cardiac penetration - shock 53%, no VS 40%, no SOL 1.4%
Other penetrating injury - shock 25%, no VS 8%, no SOL 3%
Blunt trauma - 2.2%, 1.3%, 1%
(signs of life = respiratory effort, pupillary activity, BP, cardiac electrical activity)
Defining the Limits of Resuscitative Emergency Department Thoracotomy: A contemporary Western Trauma Association Perspective
Review of 56 ED Thoractomy Survivors at 18 WTA Centers ’03-09
Compared with Colorado experience 1977-2009
Goal to assess current ACS recs in light of data
Limits of resuscitative thoracotomy in the ED, don't use if:
- Prehospital CPR > 10 min after blunt trauma without response
- Prehospital CPR > 15 min after penetrating injury without response
- Asystole is presenting rhythm and there is no pericardial tamponade
Decision-influencing factors in Resuscitative Thoracotomy
Mechanism
Anatomic Site
Signs of life / Timing
Age / Comorbidities
Resources
Beck's Triad - Muffled Heart Tones, Hypotension, Distended Neck Veins