1. Chest Trauma 19thApril 2013 Kenyatta National Hospital Dr. Josiah Ruturi Thoracic and Cardiovascular Surgeon .

2. 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 .

3. OBJECTIIVES • Identify and initiate treatment of life-threatening thoracic injuries • Primary survey • Secondary survey • Procedures • Special considerations

6. Immediate Life-Threatening Injuries • Airway obstruction • Tension Pneumothorax • Open Pneumothorax • Massive Hemothorax • Flail Chest • Cardiac Tamponade

7. Potentially Life-ThreateningInjuries: • Pulmonary Contusion • Myocardial Contusion • Aortic Disruption • Traumatic Diaphragmatic Rupture • Tracheobronchial Disruption • Esophageal Disruption

8. 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

9. Primary Survey • Airway: patency, retractions, obstruction • Breathing: exposure, rate, pattern, cyanosis • Circulation: *Pulses, color, *neck veins, monitor for arrythmias *hypovolemic patients might not exhibit

11. 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

12. 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

13. Subcutaneous Emphysema • Airway, Lung or Blast injury • esophageal injury: Boerhaave’s • Adjacent penetrating wound • Progression to tension pneumothorax

14. Pneumothorax

15. 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

16. 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

17. Tension Pneumothorax

18. A B A: Air under tension in left thorax B: Collapsed right lung Tension Pneumothorax Pleural margin; partial lung collapse Left Right

19. 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

20. Tension Pneumothorax • Clinical manifestations in patient with • Spontaneous breathing • Respiratory distress • Florid face • Tracheal deviation • Distended neck veins • Tachycardia • Hypotension

21. 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

22. 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

23. 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

24. 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

25. 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 CollSurg 1994;178(5):466. (Penn)

26. Traumatic Aortic Injury • Retrosternal/intrascapular pain • Dyspnea, hoarseness, dysphagia, HTN • Pseudocoarctation syndrome • Hypotension • Harsh systolic murmur (AI) • 50% without external findings

31. 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)

32. Management of Tamponade: • Cautious fluid management • Pericardiocentesis: 15-20 cc may immediately improve hemodynamics • Open thoracotomy and inspection

33. Pericardiocentesis • Indications • Immediate threat to life • Severe hemodynamic impairment • Fall in systolic blood pressure >30 mm Hg

34. Pericardiocentesis • Technique • Patient in supine position, uppertorso elevated • ECG limb leads attached to patient • Use echocardiography guided procedure (rarely: ECG-guided, V lead) • Subxiphoid approach • Continuous aspiration

36. 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.

37. Diaphragmatic Rupture • Blunt trauma: large tears • Penetrating: small tears, subtle • More commonly diagnosed on the left

38. Tracheobronchial Tree • Larynx • Hoarseness • Subcutaneous emphysema • Palpable Fracture • Crepitus • Trachea: • Noisy breathing • Penetrating injuries: esoph, carotid artery, jugular vein trauma

39. 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

40. Sternal Fractures • Mortality 25-45% • Underlying injuries to myocardium • Flail segment

45. 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

46. 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%

47. 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.

48. 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.

50. Penetrating Chest Trauma • Low chest SW: 15% intraperitoneal, 15% require operative intervention (diaphragm)