Blunt Thoracic Injury

1. Blunt Thoracic Injury Chao-Wen Chen Attending Surgeon Trauma Service, KMUH

2. Preface • 2/3 of victims of major blunt trauma suffer from thoracic injury. • Thoracic injuries account for 20-25% of deaths due to trauma. • Major thoracic trauma is associated with multisystem injuries in 70% of cases. Trauma Conference

3. Common Injuries Develop After Blunt Chest Trauma • Thoracic cage fractures • Lung contusion and tears • Myocardium contusion • Aortic rupture Trauma Conference

4. Initial Survey • Assume the existence of C-spine injury • ABCs • Gerneral evaluation: PE, PH, ECG, or ABG… • Chest x-ray • Administer oxygen Trauma Conference

5. 處理原則 • 謹記ABC 順序與原則 • 初級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理： • 張力性氣胸 （Tension Pneumothorax） • 連枷胸 （flail chest） • 開放性胸壁傷口 （open chest wound） • 大量血胸 （massive hemothorax） • 心包填塞 （cardiac tamponade） Trauma Conference

6. 如何處理？ • 張力性氣胸 • 連枷胸 • 開放性胸壁傷口 • 大量血胸 • 心包填塞 Trauma Conference

7. 如何處理？ • 張力性氣胸 Needle decompression/ Chest Tube • 連枷胸 Pain control/ O2 / MV • 開放性胸壁傷口 Wound coverage/Chest tube • 大量血胸 Chest tube / Thoracotomy • 心包填塞 Pericardial window Trauma Conference

8. Imaging Survey • Chest x-ray : serve as a screening rather than a definite test  repeat radiography should be ordered if suspicious • Computed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest trauma • Angiogram : for suspicious great vessel injuries • Chest ultrasound : detect hemothorax, FAST Trauma Conference

9. 處理原則 • 二級檢傷時，若遇以下危及生命之狀況，需立即診斷出並加以處理： • 主動脈破裂（contained aorta rupture） • 氣管或支氣管破裂（rupture of tracheobronchial tree） • 食道破裂（perforation of esophagus） • 橫膈破裂（rupture of diaphragm） • 心肌挫傷（myocardial contusion） • 肺部挫傷（pulmonary contusion） Trauma Conference

10. Contained aortic tear Trauma Conference

11. Pneumothorax Trauma Conference

12. Hemothorax Trauma Conference

13. Troublesome Injuries • Sternal fracture • More serious injuries may accompany • If suspected, a lateral CXR may be diagnostic • Operative reduction is usually unnecessary • Hospitalization is not mandatory if the ECG is normal and the patient’s vital sign is stable Trauma Conference

14. Troublesome Injuries • Flail chest • Fracture of 2 or more consecutive ribs in at least 2 places each • About 30-40% of patients need mechanical ventilation • ARDS is increased 20-30% in the presence of flail chest Trauma Conference

15. Troublesome Injuries • Flail chest • Close monitoring of respiratory performance • Adequate analgesic therapy • Provide oxygen therapy and ventilatory support • Aggressive pulmonary toilet Trauma Conference

16. Troublesome Injuries • Lung contusion • CxR finding may range from minimal interstitial infiltrate to extensive lobar consolidation • Chest CT is accurate diagnostic tool but not always mandatory • Tx : same as flail chest, but pay attention to avoid overhydration; use of steroid and prophylactic antibiotic are still controversial Trauma Conference

17. Pulmonary contusion Trauma Conference

18. Troublesome Injuries • Blunt Cardiac Trauma - spectrum • Asymptomatic myocardiac contusion • Symptomatic myocardiac contusion • Free wall or septal wall rupture • Valvular tears • Coronary artery thrombosis Trauma Conference

19. Troublesome Injuries • Blunt Cardiac Trauma – risk factors • Chest impact > 15 mph • Marked precordial tenderness, ecchymosis or contusion • PH of cardiac disease • Fractured sternum • Thoracic spine or ribs fractures • Hemodynamic instability, or multiple injuries • Age > 50 Trauma Conference

20. Troublesome Injuries • Blunt Cardiac Trauma - assessment • Most are asymptomatic; severe cases die before arrival • Common manifestation : arrhythmia, hemo-dynamic instability • Evaluation : CxR, ECG, cardiac enzymes, echo-cardigram, MUGA Trauma Conference

21. Troublesome Injuries • Blunt cardiac trauma - management • Most cases do not require Tx; Symptomatic arrhythmia (2-5%)  antiarrthythmics • Abnormal ECG and cardiac enzymes almost return to normal within one week. • Patients with abnormal cardiac echo finding or MUGA  keep hospitalization till a repeat test show acceptable finding • Cardiac rupture  prompt surgical repair Trauma Conference

22. Troublesome Injuries • Blunt cardiac trauma - Guideline (USC+LAC) • Obtain admission ECG and CPK-MB/TnT in patient with suspect BCI • Repeat ECG 8-12 hours after admission • For unexplained hemodynamic instability, abnormal ECG, and abnormal cardiac enzyme levels  perform cardiac echogram • If no suspect symptomatolgy, lab tests or ECG finding discharge after 12 hours Trauma Conference

23. 氣胸 Needle decompression/ Chest tube 張力性氣胸 理學檢查 Needle decompression/ Chest tube 血胸 心包填塞 Subxyphoid window thoracotomy 胸部鈍傷處理流程 • PE Survey Trauma Conference

24. 氣胸 若出血>1200ml 或>200ml/hr， 考慮開胸術 Chest tube 血胸 CXR檢查 NGTrepeat X-ray UGI series U/S or CT scan 橫膈？ Pain control Oxygen supply Avoid fluid overload Resp. Distress(+)MV 連枷胸、肺挫傷 縱膈積氣 氣胸(＋)  Chest Tube 氣胸(－) 氣管支氣管鏡檢 食道鏡檢或食道造影 縱膈腔變寬 Chest CT Aortic Angiogram • X-ray Trauma Conference

25. 胸部鈍傷病患住院照護準則 • Admission Order • Day 1 • □ Consider ICU admission for elderly patients, or if other complicating factors exist. • □ NPO • □ Chest tube to suction, follow chest tube output • □ Follow-up CXR • □ Analgesia (□ oral □ epidural □ PCA) • □ Pulmonary toilet • □ OOB to chair Trauma Conference

26. 胸部鈍傷病患住院照護準則 • Day 2 • □ Advance diet • □ Chest tube to suction, follow chest tube output • □ Morning CXR • □ Analgesia (□ oral □ epidural □ PCA) • □ Pulmonary toilet • □ OOB to chair Trauma Conference

27. 胸部鈍傷病患住院照護準則 • Day 3 • □ if no air leak, chest tube to water seal, otherwise to suction. follow output • □ Morning CXR • □ Analgesia (□ oral □ epidural □ PCA) • □ Pulmonary toilet • □ Ambulate tid once chest tube is off suction Trauma Conference

28. 胸部鈍傷病患住院照護準則 • Day 4 • □ Check CXR after 6-8 hours on water seal, if lung expanded and output<150ml remove chest tube • □ Recheck CXR 6 hours post removal, discharge if expanded. • □ Change analgesia to orat • □ Keep site dressing in place × 48 hrs Trauma Conference

29. 胸部鈍傷病患住院照護準則 • 無併發症病患預計留院時間 “4” 天 • 出院時應注意下列狀況： • 病患呼吸狀況應符合生理基本需求，無窘迫情形 • 疼痛之適度處理 • 肺部擴展完全且血胸已順利引出 • 病患了解傷口後續照護原則 Trauma Conference

30. Thank you for your attention!