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Thoracic Trauma

Thoracic Trauma. Korbin haycock, md, FACEP, RDMS, RDCS. Conflict of interest?. None. Epidemiology. About ¼ of trauma related death is from thoracic injuries Motor vehicle accidents are responsible for most thoracic trauma Deaths occur in tri-modal distribution:

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Thoracic Trauma

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  1. Thoracic Trauma Korbin haycock, md, FACEP, RDMS, RDCS

  2. Conflict of interest? • None

  3. Epidemiology • About ¼ of trauma related death is from thoracic injuries • Motor vehicle accidents are responsible for most thoracic trauma • Deaths occur in tri-modal distribution: • 30 minute to 3 hour time frame is a critical window for competent ED care 30 minutes to 3 hours after the injury Death at the scene Later during the hospitalization

  4. Thoracic Trauma in General • ABC’s (as appropriate) • Vital signs and pulse oximetry • Through inspection and palpation of the chest • Expansion • Ecchymosis • Crepitus • Dyspnea is an important symptom that something is wrong • Upper extremity pulse exam • Signs of brachial plexus injury

  5. Chest Wall Trauma • Rib fracture • Sternal fracture • Sternoclavicular dislocations • Flail chest • Nonpenetrating ballistic injury

  6. Chest Wall Trauma • Pathophysiology • Rigid chest wall is important for respiratory function • Compromise of the chest wall by fractures or splinting due to pain may effect respiratory function • Adequate oxygenation and ventilation is critical in the multisystem injured patient • O2 delivery • Acid/Base regulation

  7. Rib Fracture • Clinical exam • Tenderness to palpation of chest wall or tenderness at point of fracture to palpation remote to the injury site • Bony crepitus • Ecchymosis Most Rib fractures are 4-8th ribs Ribs 1-3 are protected Ribs 9-12 are more mobile

  8. Complications of rib fractures • Direct penetration by fragments • Pleura • Lung • Abdominal organs • Pulmonary contusions • Vascular injuries • Impaired gas exchange • 2 or more fractures increases risk of internal injuries • 1st and 2nd rib fractures • Treatment: • Analgesia • Pulmonary toilet • No strapping

  9. Rib Fracture • Disposition • Strongly consider admitting elderly patients or those with significant pulmonary disease • Also consider admission of multiple rib fractures • Prior to discharge, ensure adequate cough, clearing of secretions, and maintaining activity • McGillicuddy, 2007

  10. Sternal Fracture • Diagnosis based on clinical exam and lateral CXR • (Ultrasound!) • Mediastinal injuries diagnosed by CT • Can discharge home uncomplicated fractures of the sternum, after other injuries are ruled out

  11. Sternoclavicular Dislocations • Can be anterior or posterior dislocations • Anterior is more common • Posterior dislocations can have many associated injuries • Exam may reveal TTP, deformity, or pain with movement of arm • CT is best exam for evaluation

  12. Sternoclavicular Dislocations • Treatment • Anterior • Direct anterior pressure on clavicle • Posterior • May need to be done emergently • May require general anesthesia

  13. Flail Chest • 3 or more adjacent ribs fractured in 2 places • Will always have associated pulmonary contusion Orthobullets.com

  14. Flail Chest • Treatment • Treat underlying pulmonary contusion—more on this later • Monitor for signs of respiratory decompensation • Respiratory rate >35 or <8 • Hypoxia despite supplemental O2 • Hypercapnia >55 mmHg • A-a gradient > 450 • Evidence of shock • If any of above, patient requires intubation • Aggressive pulmonary physiotherapy • Analgesia • CPAP if needed • Treat pneumothorax or hemothorax • Surgical fixation if needed

  15. Pulmonary Injuries • Pulmonary Contusion • Pulmonary Laceration • Pneumothorax • Hemothorax • Tracheobroncheal Injury

  16. Pulmonary Contusion • Radiographic findings • Usually manifest by the first 6 hours, if not instantaneously • Ultrasound sees this instantaneously • CT scan may reveal significant pulmonary contusions not seen on initial CXR • Significant chest trauma had pulmonary contusion on plain CXR 16.3% vs. CT 31.2% (Traub, 2007) • Significant mechanism for injuryCT even if normal plain chest x-ray? • POCUS

  17. Pulmonary contusion causes V/Q mismatch • Intrapulmonary shunting and stiff lungs result in increase in WOBacidosis Interstitial and alveolar edema follows Fall in PVR in Healthy lung Pulmonary artery pressures exert hydrostatic pressure on the capillaries and force blood and fluid into the healthy lung tissue, turning it into contused lung

  18. Pneumothorax • Simple pneumothorax—not communicating with atmosphere and no mediastinal shift • Small < 15% • Moderate=15-60% • Large >60% • Communicating—defect in chest wall • Sucking chest wounds • May develop into tension pneumothorax (Gets a chest tube) • Tension pneumothorax—Shift in mediastinum • High pressure in pleural cavity inhibits venous return to the heart and preload of heart is decreased Small PTX can be treated with observation, moderate/large get a chest tube

  19. Tension Pneumothorax • Treatment • Decompress it STAT • Stick a long, large bore angiocath into the chest OR do a “finger thoracostomy” • Where? Avoid the heart • Chest tube follows • Failure to release air • Pericardial tamponade? • Intubated mainstem?

  20. Pneumothorax • Pneumothorax that appear small on supine CXR sometimes do require chest tubes • Therefore pneumothorax seen on plain CXR should have “CT quantification” • Anterolateral (PTX extending beyond mid-coronal line on CT) PTX is associated with an increase need for chest tube, miniscule or anterior PTX can be safely monitored • Wolfman, 1998

  21. Pneumothorax • Ultrasound for PTX • Almost as accurate as CT and more accurate then CXR for detection of PTX • U/S sensitivity=92%, specificity=99.4% • CXR sensitivity=52%, specificity=100% • Agreement in extent of PTX by U/S compared to CT • Soldati, 2008

  22. Ultrasound for PTX

  23. U/S PTX on M-mode

  24. Hemothorax • Hemorrhage in the pleural space • Associated with PTX 25% of time • Associated with extra thoracic injuries 75% of time • Bleeding may be from lungs, arteries (most commonly intercostals or internal mammary), hilar vessels, great vessels, or heart • Initial bleeding must be quantified, as well as ongoing bleeding • Indication for thoracotomy is 1 liter initial drainage from chest tube or >200mL drainage/hr for >4hours (alternative is >20ml/kg initial or >7ml/kg/hr)

  25. Hemothorax medbox.iiab.me

  26. Hemothorax • Estimate of volume: • V=(d)(d)(L) • Mandavia, 2008 • Ruskin, 1987 (CXR) • Depth <1.5cm=<260ml • “small” • Depth 1.5-4.5=260ml-1L • “moderate” • Depth >4.5=>1L • “large”

  27. Hemothorax • Treatment • Small HTX can be observed • Larger HTX or PTX with HTX needs chest tube • Resuscitation • Monitor for ongoing bleeding • Auto transfusion if blood not contaminated is safe • Risk vs. benefit depending on circumstances

  28. Hemothorax • How common is HTX absent on CXR but present on CT (occult HTX)? • 14.5%-21.4% (Ball, 2005)(Stafford, 2006) • Stafford, 2006 reported 48% underwent tube thoracostomy (injury severity scores were higher in these patients) • How big of an occult HTX needs chest tube? Do patients with occult HTX need chest tube at all? • Retrospective study showed hemothoraces with depth >1.5 cm were 4 times more likely to get chest tubes • Of all HTX <1.5cm that were managed expectantly, 92% required no intervention • Of all HTX 1.5cm-4.5cm that were managed expectantly, 57% avoided intervention

  29. Hemothorax • Management of HTX: • Unstable chest tube • Large HTX on CXR or CT chest tube • Small HTX with PTX on CXR or CT chest tube • Small HTX on CXR CT scan • <1.5cm depth observe • >1.5cm depth chest tube • (Mandavia, 2008)

  30. Cardiovascular Trauma • Blunt Cardiac Injury • Myocardial rupture • Penetrating Cardiac injuries • Pericardial Tamponade • Aortic injuries

  31. Blunt Cardiac Injury • Normal ECG plus normal 6-8 hour troponin I excludes bad outcomes • (Rajan, 2004) • (Velmahos, 2003) • If BCI suspected: • Do FAST and initial ECG and Troponin • If either positive admit • If both are negative repeat 6-8 hour troponin will exclude significant BCI

  32. Pericardial Tamponade • Blood between heart and pericardium restricts ventricular filling, resulting in hemodynamic collapse • FAST with hemopericardium • CXR not likely to help you • Intermittent decompressing tamponade

  33. Pericardial Tamponade • Treatment • IVF • Increase preload to overcome tamponade pressures • Pericardiocentesis • A little controversial • Aspiration of a little blood can make a huge difference • Blood may be clotted and won’t aspirate • Alternative option—Thoracotomy • Consider trip to OR if stable

  34. Aortic Injuries • About 80% victims die at scene, about 15% survive to hospital arrival • Most common site of injury is the aortic isthmus, just distal to the origin of the subclavian artery • Deceleration mechanism • Minor speed mechanisms have been described multiple times • McGillicuddy, 2007

  35. Aortic Injuries • ED management: • Rapid diagnosis • Note CT is method of choice for definitive diagnosis • Blood pressure control if possible • Esmolol and nicardipine • Definitely involve consulting service in these decisions • Note changing trends in time to definitive repair • Realize that: • Endovascular repair is replacing open techniques

  36. Imaging in Thoracic Trauma • Great CT controversy (not just confined to the thorax, incidentally) • CT is superior to CXR for diagnosis of intrathoracic injuries • The question is how many of these injuries that are found on CT result in new information that results in important management • Still controversial

  37. The Great CT COntroversy Arguments For Arguments Against (Winslow, 2008)(Mower, 2008) Radiation risks without definitive evidence for improved outcomes (Snyder, 2008) Rebuttal to Salim • (Trupka, 1997) • 41% had management changed based on CT • (Salim, 2006) • Change in Mx in 19.6% of chest findings

  38. ED Thoracotomy • Salvageable patient more likely if: • Stab wounds > GSW > Blunt trauma • Wounds to heart > other chest > abdominal >multiple injuries • Signs of life present > no signs of life present • Overall survival rate around 10% • Cothern, 2006 • Rhee, 2000 • Seamon, 2007

  39. ED Thoracotomy • Procedure: • BIG incision from parasternal, just below nipple line to as far back as possible in the high axilla • Deepen incision into chest, don’t injure lungs in process • Rib spreader • Pericardotomy, vertical—don’t cut the phrenic nerve • Deliver the heart and massage prn • Fix any holes in the heart, careful of the coronaries • Cross clamp the aorta, lung will need to be lifted high, don’t confuse aorta with esophagus • Clamp lung or lung hilum prn • Aspirate air embolism prn • Fix bleeding intercostals or internal mammary prn

  40. References • Ball et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. Journal of trauma 2005 • Ball et al. Occult pneumothorax in the mechanically ventilated trauma patient. Canadian journal of surgery 2003 • Bilello et al. Occult traumatic hemothorax: when can sleeping dogs lie? American journal of surgery 2005 • Cothern et al. Emergency department thoracotomy for the critically injured patient: objectives, indications and outcomes. World journal of emergency surgery 2006 • Degiannis et al. Penetrating cardiac injuries: recent experience in South Africa. World journal of surgery 2006 • Demetriades et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives Journal of Trauma 2008 • deMoya et al. Occult pneumothorax in trauma patients: development of an objective scoring system. Journal of trauma 2007 • Eren et al. Imaging of diaphragmatic hernia after trauma. Clinical radiology 2006 • Keel et al. Chest injuries—what is new? Current opinion in critical care. 2007 • Mandavia et al. Bedside echocardiography in trauma. Emergency Medicine Clinics of North America. 2004 • Mandavia. Thoracic Trauma: answers to tough questions. Lecture ACEP 2008 • Mower. Radiation does among blunt trauma patients: assessing risks and benefits of computed tomographic imaging. Annals of emergency medicine 2008 • McGillicuddy et al. Diagnostic dilemmas and current controversies in blunt chest trauma. Emergency clinics of North America 2007 • Stafford et al. Incidence and management of occult hemothoraces. American journal of surgery 2005 • Rajan et al. Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with a myocardial contusion. Journal of trauma 2004 • Rhee et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. Journal of the American collage of surgeons 2000 • Rosen’s Emergency Medicine 5th edition • Salim et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury. Archives of Surgery 2006 • Seamon et al. Emergency department thoracotomy: still useful after abdominal exsanguination? Journal of Trauma 2008 • Soldati et al. Diagnostic accuracy of lung ultrasonography in the emergency department. Chest 2008 • Snyder. Whole body imaging in blunt multisystem patients who were never examined Annals of emergency medicine 2008 • Steenburg et al. Acute traumatic aortic injury: Imaging evaluation and management. Radiology 2008 • Tintinalli’s Emergency Medicine 5th ed. • Traub et al. The use of chest computed tomography versus chest x-ray in patients with major blunt trauma. Injury 2007 • Velmahos et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. Journal of trauma 2007 • Winslow et al. Quantitative Assessment of diagnostic radiation doses in adult blunt trauma patients. Annals of emergency medicine 2008 • Wolfan et al. Validity of CT classification on management of occult pneumothorax: a prospective study. AJR 1998

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