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CHEST TRAUMA

CHEST TRAUMA. Alyssa Reed, R1 November 2007. Thanks to : Dr Hall, Dr Patterson, Dr Oster. Objectives. FLAIL CHEST TRACHEOBRONCHIAL INJURY OCCULT PNEUMOTHORAX BLUNT CARDIAC INJURY TRAUMATIC AORTIC INJURY PENETRATING CHEST TRAUMA. Topics Not Covered. Rib Fractures

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CHEST TRAUMA

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  1. CHEST TRAUMA • Alyssa Reed, R1 • November 2007 Thanks to : Dr Hall, Dr Patterson, Dr Oster

  2. Objectives • FLAIL CHEST • TRACHEOBRONCHIAL INJURY • OCCULT PNEUMOTHORAX • BLUNT CARDIAC INJURY • TRAUMATIC AORTIC INJURY • PENETRATING CHEST TRAUMA

  3. Topics Not Covered • Rib Fractures • Isolated Sternal Fracture • Costochondral Injuries • Esophageal Injuries

  4. Life Threatening Causes??? • Airway • Obstruction • Breathing • Open pneumothorax • Flail Chest • Tension Pneumothorax • Massive Hemothorax • Circulation • Cardiac Tamponade

  5. CASE #1 42F fell down the stairs at home Dx?

  6. FLAIL CHEST • Common injury and commonly missed • Definition: THREE or more ribs fractured at TWO points, allowing a freely moving segment of the CW to move in paradoxical motion

  7. Flail Chest • PHYSIOLOGY • 1) Pulmonary contusion • 2) Paradoxical Motion • 3) Pain*

  8. Flail Chest • Mx • ABCs • Aggressive chest physio • clear c-spine, sit up • Close observation • Selective use of intubation • Pain control • Chest tubes

  9. Flail Chest and Intubation • Respiratory failure manifested by one or more of the following criteria: • 1. Clinical signs of respiratory fatigue • 2. Respiratory rate >35/min or <8/min • 3. Pao2 <60 mm Hg at Fio2 ≥0.5 • Paco2 >55 mm Hg at Fio2 ≥0.5 • Alveolar-arterial oxygen gradient >450 • Clinical evidence of severe shock • Associated severe head injury with lack of airway control or need to ventilate • Severe associated injury requiring surgery • Pao2, partial arterial oxygen tension; Fio2; fraction of inspired oxygen; Paco2, partial arterial carbon dioxide tension.

  10. Flail Chest • Ullman et al. Reg Anesth 14(1): 43-7. 1989. • Pts with flail segments comparing IV and epidural anesthesia • Group 1 (n=13) intravenous morphine • Group 2 (n= 11) epidural morphine • Results: • Vent time 18d vs 3 d • ICU time 18d vs 6d • Hosp stay 48d vs 15d • Pulm fxn best in group 2 • A lot of evidence since for the use of high block epidurals for pain relief to prevent splintingand atelectasis

  11. Flail Chest Q: Who needs a chest tube? • Hemo or Pneumothorax • Multisystem, unstable trauma • Intubated patient • Respiratory distress • Air Transport (? routine vs selective)

  12. CASE #2 • 30M MVC intubated for CHI, normal CXR • Dx?

  13. Occult Pneumo • A pneumothorax that is absent on initial CXR but seen on subsequent chest or abdominal CT • Ball et al. Am J Surg. 189(5), 2005 • n=761 • 55% were OPTHX • 84% were anterior, 0% posterior, 57% apical

  14. Occult Pneumo • Journal of Trauma. 49:281, 2000 • Retrospective, n= 230 with pneumothx • Results: 126 (54.8%) had occult pneumo identified on abdo CT • Ball et al. J of Trauma. 60(2): 294-8, 2006 • with increasing frequency of CT scans in trauma, estimate that up to 72% of all pneumos are occult

  15. Occult Pneumo WHO NEEDS A CHEST TUBE? • Ball et al. J of Trauma. Aug 2005 • n= 32, non-vented OPTHX • 10 (31%) had chest tube inserted • 22 (69%) observed • Results: • 1 needed chest tube placed later • 0 serious complications of those observed • 1 with tube had lung parenchymal injury • growing recognition that non-vented patients can be safely treated without thoracostomy

  16. Occult Pneumo • Enderson et al. J of Trauma 35(5), 1993. • Prospective RCT • n= 40 on PPV, 19 with chest tube, 21 observed • 8 with observation (38%) progressed, became symptomatic and needed chest tube • 3 of 8 developed tension pneumo • 0 with chest tube had complications • recommend that all patients with occult pneumo with PPV have tube thoracostomy

  17. Occult Pneumo • Brasel et al. • Prospective RCT • n=18 on PPV, 9 with tube, 9 observed • Results: • no difference in overall complication rate • 2 observed pts needed chest tube • Concluded that can closely monitor pts with OPTHX on PPV for signs of resp distress

  18. Occult Pneumo • Ball et al. J of Trauma 59(2), 2005. • Restrospective subset analysis • n=17 with OPHTX with PPV • 13 had chest tube and 4 were observed • 0 complications with observation • 23% had tube related complication or needed repositioning • Concluded that more research needs to be done given paucity of literature and quality of studies

  19. Occult Pneumo Summary • A Review. Emerg Med Clin North Am. 25(3), 2007 • not enough data to determine if patients with OPTHX with PPV should have tube thoracostomy • if pt is asymptomatic and no PPV it is safe to observe • if patient has to go for surgery, has other injuries, has symptoms or hard to continuously observe, it is prudent to insert a chest tube • Intubated patients generally require chest tube, more study required

  20. FLYING and PNEUMO • Cheatham et al. Am Surg 65(12), Dec 1999 • Prospective • n=12 with traumatic pneumo wanting to air travel • Results: • 10/12 waited at least 14 d after radiographic resolution • 10/10 ASx during flight • 2/12 flew within less than 14 d • 1/2 developed respiratory distress in flight *Concluded that Aerospace Medicine Association’s recommendation of waiting 2-3 post radiographic resolution is safest

  21. CASE # 3 • 30M in MVC at highway speed, restrained, no airbag deployment • Clinical Findings: hemoptysis, massive subcutaneous air, persistent pneumo despite properly done and positioned chest tube • Dx?

  22. TracheoBronchial Injury • Anatomy and Physiology • sudden deceleration pulls lungs away from the mediastinum, producing traction on the trachea at the carina which is a relatively fixed point • can also occur if glottis is closed at time of injury because large increase in intrabronchial pressure • >80% occur within 2cm of carina • wound opens into pleural space producing large pneumo, chest tube fails to re-expand lung, continuous bubbling of air in pleurovac

  23. TBI Diagnosis • CXR findings • Pneumothorax • Pneumomediastinum • Pneumopericardium • Massive subcutaneous air* • Air around mainstem bronchus

  24. TBI

  25. TBI • When to suspect? • massive air leak • persistent air leak • hemoptysis • massive subcutaneous air “Micheline Man” • CXR findings • Dx • Hara et al. Chest, 1989. • Fiberoptic bronchoscopy is most reliable means of Dx and finding exact site of injury • Best done in OR with rigid bronch if suspect

  26. TBI • MX • Endotracheal Intubation: ideally done via bronchoscope (to avoid passage into false lumen) but impractical • Selective intubation of good side can be done via scope • Definitive is thoracotomy with intraop tracheostomy and surgical repair (no role for stents routinely- depends on level of injury)

  27. CASE #4 • 35yo police officer struck by car • GCS 3, intubated by EMS • BP 80, HR 120, Sats 99% on vent, Temp N • CXR - rib fractures, small pneumo • PXR - no fracture • FAST - negative • ?Diagnosis ?Management

  28. BCI • Pathophysiology • Arrhythmias • Acute valve problems • Coronary artery injury/occlusion • Myocardial injury - microcellular injury/edema = wall motion abnormalities, decreased contractility - CHF/cardiogenic shock

  29. Myocardial Contusion • When should we consider and look for BCI? • Signs of severe chest trauma • Shock without other cause • Arrythmias noted • Signs of CHF • Controversy around how to dx and the importance of it

  30. Myocardial Contusion • Dx • GS is biopsy or autopsy • ECG • Cardiac Markers • Echo

  31. Myocardial Contusion • ECG • Normal or non-specific abnormalities • Sinus tach* • SVT • RBBB • RV damage therefore need 15 lead • Various degrees of AV block • Can develop 72 hours after injury • How does a normal or abnormal ECG impact our management?

  32. Myocardial Contusion • Nagy et al. World J Surg, 2001 • Patients at risk for BCI admitted to ICU for serial ECGs, monitoring, serial enzymes • N=171 • Results: • Pts with normal initial ECG had benign outcomes • Pts with ST change, dysrhythmias had adverse outcomes • Recommend that all patients with blunt chest trauma receive screening ECG but if normal can safely discharge but if new finding or abnormal monitor for 12 hrs

  33. Myocardial Contusion • Bertinchant et al. Journal of Trauma, 2000 • Prospective enrollment of pts with suspected BCI • n=94 • GS= significant ECG change or echo findings • TnT + in 11 (12%) of pt with BCI, no bad outcomes • TnT - in all without BCI, p>0.05 • No relationship between positive trop and clinical outcome and do not recommend using as screening

  34. Myocardial Contusion • Rajan et al. J of Trauma, 57(4) 2004 • n= 187 with blunt chest trauma • Results: • 63(34%) had + TnI levels • 47(25%) were symptomatic • 124 had - TnI levels and all stayed asymptomatic and had no adverse outcomes • severity of arrhythmia correlated directly with TnI level • Concluded that +TnI mandates further cardiologic w/u and those with -TnI are safe not to

  35. Myocardial Contusion • HOWEVER: • 1/2 of their “significant arrhythmias” were PVCs • No comment of clinically important outcomes of these arrythmias- like how many died or needed intervention • BCI outcome was defined as an elevated TnI! • In other words, they are trying to determine the value of TnI as a diagnostic test while using it as their outcome measure! • aka incorporation bias

  36. Myocardial Contusion • Ferjani et al. Chest 111(2), 1997 • Prospective study measuring TNT • Dx of cardiac contusion if • Abn echo consistent with contusion • Severe cardiac dysrhytmia (incl PVCs!) • Severe conduction abn (incl RBBB!) • Hemopericardium • n= 29 dx with contusion • Results: • Sens= 31% • Spec= 91% * Does not support the use of screening trops

  37. Myocardial Contusion • Valhamos et al. J of Trauma, Jan 2003 • Prospective study • n= 333 with significant blunt chest trauma (44/13% with clinically significant BCI) • Serial ECGs and TnI tests were performed routinely • Significant BCI defined as: • cardiogenic shock • arrhythmias requiring treatment • post-traumatic structural deficits • decreased cardiac index

  38. Myocardial Contusion • ECG more sensitive than TnI (89% vs 73%) • TnI neither sensitive or speficic • ECG and TnI combined gives 100% sens and NPV • 1 patient with initial normal ECG and TnI developed changes 8 hours post-admission • Conclude that pts with initial normal ECG and TnI and again at 8 hrs can safely r/o significant BCI

  39. Myocardial Contusion • A Review. Emerg Med Clin North Am. 25(3), 2007 • Recommend: • screening ECG for patients with suspected mechanism for BCI • if normal, asymptomatic and otherwise healthy can rule out clinically significant contusion • if abnormal or elderly with significant cardiac history should admit for further monitoring and consider other w/u (echo) • no definitive study regarding use of cardiac markers • if pt in cardiogenic shock need echo to see valves

  40. BCI Summary Suspected No evident comp Cardiac comp Arrhythmia CHF Cardiogenic shock Shock w/o cause ECG Cardiac Monitoring (12 hrs) +/- Echo New Abnormality* - cardiac monitoring 12 hrs - consider echo Normal -rules out clinically significant contusion - can d/c *Arrythmias, ST depression, T wave inversion, conduction abnormality

  41. CASE #5 • 29F unrestrained passenger in middle seat of van that was T-boned on her side at hwy speed. Ejected. Found 50 feet from vehicle. • GCS 14 • Hemodynamically stable

  42. Blunt Aortic Injury Q: Most common mechanism? • Rapid Deceleration: • Ao arch is mobile and descending arch is immobile d/t ligamentum arteriosm and tethering by intercostal arteries • 90% occur in the descending Ao just distal to the left subclavian artery

  43. BAI • DX • Clinical presentation... • Mechanism • Imaging • CXR as screening DI • CXR vs CT • CT vs Angiography • CT vs TEE

  44. BAI-SSx Q: Clinical Presentation? • RSCP/Interscapular pain • SOB • Extremity pain • Stridor • Hoarseness • Pseudocoarctation syndrome • Chest wall bruising • AI, MR murmur • 80-90% die on scene though!

  45. BAI- Mechanism • J of Trauma. April, 2003. • Cohort design using large database • Independent Positive Predictors of BAI • Age>60 • Front-seated • Frontal or near-side impact • Delta V> 40mph • Crush >40cms • Intrusion > 15cms • Negative Negative Predictors: - seatbelt use - occupant of lrg vehicle

  46. BAI Q: What are the high risk cxr findings? • mediastinal widening (>6cm PA, >8cm AP, >0.25 ratio of mediastinal to chest at knob) • Apical cap • Loss of AP window • Loss of aortic knob • Rightward deviation of NG/trachea • Rightward displacement of mainstem • Thickening of right paratracheal stripe (>5mm) • Isolated 1st/2nd rib # not predictive

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