thoracic injuries - Kenyatta National Hospital

Report
Chest Trauma
19thApril 2013
Kenyatta National Hospital
Dr. Josiah Ruturi
Thoracic and Cardiovascular Surgeon .
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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 lifethreatening thoracic injuries
 Primary survey
 Secondary survey
 Procedures
 Special considerations
Immediate Life-Threatening Injuries
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Airway obstruction
Tension Pneumothorax
Open Pneumothorax
Massive Hemothorax
Flail Chest
Cardiac Tamponade
Potentially Life-Threatening
Injuries:
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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
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Airway: patency, retractions, obstruction
Breathing: exposure, rate, pattern,
cyanosis
Circulation: *Pulses, color, *neck veins,
monitor for arrythmias
*hypovolemic patients might not exhibit
Initial Management
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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 symptoms
Pneumothorax
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Tension Pneumothorax
– Hypotension, tracheal deviation, distended neck veins
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Pneumothorax
– No signs, tachypnea, tachycardia, decreased breath
sounds, hyperresonance, SQ emphysema
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Pneumomediastinum
– Hamman’s sign, SQ emphysema
Subcutaneous Emphysema
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Airway, Lung or Blast injury
esophageal injury: Boerhaave’s
Adjacent penetrating wound
Progression to tension pneumothorax
Pneumothorax
Pneumothorax
-Treatment
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<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
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“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
Tension Pneumothorax
Tension Pneumothorax
A
Pleural margin;
partial lung
collapse
A: Air under tension in
left thorax
B: Collapsed right lung
B
Left
Right
B: pressure of tension pneumothorax pushing midline
structures (heart, mediastinum) into patient’s left
thoracic cavity
A: air, under
tension, in
thoracic cavity
A
B
Heart
B
Right
Left
Tension Pneumothorax
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Clinical manifestations in patient with
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Spontaneous breathing
Respiratory distress
Florid face
Tracheal deviation
Distended neck veins
Tachycardia
Hypotension
Needle Thoracentesis
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Indication: Rapidly deterioration with tension
pneumothorax.
Equipment
– Povidone-iodine solution
– 14-gauge catheter-over-needle device
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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
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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
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>1500 cc blood
Mechanism:
– Penetrating injury of systemic or hilar vessels,
especially wounds medial to nipples, scapulas.
– Blunt trauma
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Loss of Breath sounds, dullness to
percussion
Flail Chest
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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
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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
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Retrosternal/intrascapular pain
Dyspnea, hoarseness, dysphagia, HTN
Pseudocoarctation syndrome
Hypotension
Harsh systolic murmur (AI)
50% without external findings
Cardiac Tamponade
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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:
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Cautious fluid management
Pericardiocentesis: 15-20 cc may
immediately improve hemodynamics
Open thoracotomy and inspection
Pericardiocentesis
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Indications
– Immediate threat to life
– Severe hemodynamic impairment
– Fall in systolic blood pressure >30 mm Hg
Pericardiocentesis
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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
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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
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Blunt trauma: large tears
Penetrating: small tears, subtle
More commonly diagnosed on the left
Tracheobronchial Tree
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Larynx
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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
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Sternal Fractures
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Mortality 25-45%
Underlying injuries to myocardium
Flail segment
Penetrating Cardiac Injury
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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 sternum
M4 = 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
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Compliance = internal injury
Mobility = tension pneumos, flail chest
Bronchial and diaphragmatic injuries
Infrequent injuries to great vessels
Summary
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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

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