Transcript Blunt Thoracic Injury

Blunt Thoracic Injury
- blunt cardiac injury and othersChao-Wen Chen M.D.
Division of Surgical Emergency and Trauma,
Department of Emergency, KMUH
2003-3-31
Trauma M&M Conference
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Preface
2/3
of victims of major blunt trauma suffer from
thoracic injury.
Thoracic injury account for 20-25% of deaths due
to trauma.
Major thoracic trauma is associated with
multisystem injuries in 70% of cases.
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Common Injuries Develop After
Blunt Chest Trauma
Thoracic cage fractures
Lung
contusion and tears
Myocardium contusion
Aortic rupture
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Initial Survey
Assume the
existence of C-spine injury
ABCs
Gerneral evaluation: PE, PH, ECG,
or ABG…
Chest x-ray
Administer oxygen
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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
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Troublesome Injuries
Sternal fracture
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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
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Associated Literature
a
38-year-old female patient transferred to our hospital after
being injured in a MVA…On arrival her blood pressure (BP)
was 90/50 mmHg but it then dropped to 60/30 mmHg two
hours later….her chest x-ray and ECG did not reveal any
significant findings, the cardiac echocardiography was
performed and revealed pericardial effusion. The chest CT
revealed sternal fracture and cardiac tamponade… A
diagnosis of cardiac rupture resulting from sternal fracture
following blunt chest trauma was made. Under midline
sternotomy, her right atrial rupture was repaired.….
“Traumatic cardiac injury following sternal fracture: a case report and
literature review”
Kaohsiung Journal of Medical Sciences. 18(7):363-7, 2002 Jul.
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Troublesome Injuries
Flail chest
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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
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Trauma M&M Conference
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Troublesome Injuries
Flail chest
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Close monitoring of respiratory performance
Adequate analgesic therapy
Provide oxygen therapy and ventilatory support
Aggressive pulmonary toilet
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Trauma M&M Conference
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Troublesome Injuries
Lung
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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
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Troublesome Injuries
Blunt Cardiac Trauma
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- spectrum
Asymptomatic myocardiac contusion
Symptomatic myocardiac contusion
Free wall or septal wall rupture
Valvular tears
Coronary artery thrombosis
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Trauma M&M Conference
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Troublesome Injuries
Blunt Cardiac Trauma
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– 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
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Troublesome Injuries
Blunt Cardiac Trauma
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- assessment
Most are asymptomatic; severe cases die before
arrival
Common manifestation : arrhythmia, hemodynamic instability
Evaluation : CxR, ECG, cardiac enzymes, echocardigram, MUGA
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Associated literature
The
ratio of MBCK to total creatine kinase improved
specificity at the expense of sensitivity. Measurement
of cTnl accurately detects cardiac injury in patients
with blunt chest trauma and should facilitate the
diagnosis and management of such patients…
“Improved detection of cardiac contusion with cardiac troponin I.”
American Heart Journal. 131(2):308-12, 1996 Feb
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Associated literature
The
combination of normal ECG and TnI at
admission and 8 hours later rules out the diagnosis of
SigBCI. In the absence of other reasons for
hospitalization, such patients can be safely
discharged…
“Normal electrocardiography and serum troponin I levels preclude the
presence of clinically significant blunt cardiac injury”
Journal of Trauma-Injury Infection & Critical Care. 54(1):45-50; discussion
50-1, 2003 Jan.
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Associated Literature
Heat
shock protein (HSP) synthesis arises transiently
as a tool to protect cellular homeostasis after
exposure to heat and a wide spectrum of stressful
and potentially deleterious stimuli…
“Normal electrocardiography and serum troponin I levels preclude the
presence of clinically significant blunt cardiac injury”
Journal of trauma-injury infection & critical care. 54(1):45-50; Discussion
50-1, 2003 Jan.
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Troublesome Injuries
Blunt cardiac trauma
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- 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
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Trauma M&M Conference
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Troublesome Injuries
Blunt cardiac trauma
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- 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
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Trauma M&M Conference
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Pitfalls
Ignore the
presence of blunt cardiac injury in
patients with blunt thoracic injury
Failure to recognize the blunt cardiac injury as
the reason of hemodynamic instability in the
absence of bleeding
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Trauma M&M Conference
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Thank you for your attention!
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Trauma M&M Conference
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