Transcript Immediate Life Threatening Thoracic Injuries – Primary Survey

Learning Objectives
Understand basic statistics of thoracic
trauma
Recognize potential pitfalls in the acute
management of thoracic injuries
Recognize the types and mechanisms of
life threatening thoracic injuries
Comprehend initial assessment and
management of various thoracic injuries
Understand secondary management of
thoracic injuries and some unique
challenges they can impose
Key Questions?
What are some of the unique challenges and
pitfalls posed by thoracic injuries?
How can we identify acute life threatening
thoracic injuries early and treat them
appropriately to assure patient
survivorship?
When do thoracic injuries take precedence
over other injuries in the primary survey?
Which thoracic injuries can be treated during
the secondary survey after other issues
have been addressed?
Statistics
Thoracic trauma accounts for 20-25%
deaths due to injury in US
16,000 deaths per year due to chest injury
Rate of thoracic injuries 12 per million
population per day (~30/day in MiamiDade County)
About 50% fatalities of MVA have sustained
some chest injury
Ratio penetrating/non penetrating variable
usually about 75-85% blunt injuries
Management – Primary Survey
Always consider mechanical factors
Airway/spinal stabilization
• Trachea, bronchial disruption
Breathing
• Chest wall integrity, pneumothorax, flail
• Pulmonary contusions, 02 diffusion block
Circulation
• Tamponade, hemothorax, tension
pneumothorax
• Cardiac, great vessel injury
Immediate Life Threatening
Thoracic Injuries:
Cardiac Tamponade
Pathophysiology – intra-pericardial pressure
exceeds filling pressure of right heart
Impairs venous return and cardiac filling
leading to hypotension, narrow pulse
pressure, PEA
“Beck’s Triad” - hypotension, neck vein
distension, distant/absent heart tones
Signs and symptoms masked by hypovolemia
Treat with immediate volume replacement to
↑ CVP, pericardial decompression
Immediate Life Threatening
Thoracic Injuries:
Tension Pneumothorax
Suspect with any injury
High intra-thoracic, extrapulmonary pressure
Absent breath sounds, shift
of trachea, hypotension
Can be worsened with
intubation and + pressure
Treat symptoms → immediate
decompression
Crucial 1° Survey Differential Dx:
Cardiac Tamponade vs. Tension
Pneumothorax
Clinical Sign
Cardiac
Tamponade
Low (PEA)
Tension
Pneumothorax
Low
 Cardiac Tones
 Breath Sounds
Muffled
Normal
Normal
Absent - collapsed side
 Neck Veins
Distended
Flat
Blood Pressure
Respirations
Treatment
(flat in hypovolemia)
± Normal
Needle/drain
pericardium
Tachypnea
Needle/tube chest
Immediate Life Threatening
Thoracic Injuries:
Primary Survey
Immediate Life Threatening
Thoracic Injuries:
Primary Survey
Cardiac disruption/tamponade
Tracheal disruption
Open pneumothorax
Tension pneumothorax
Massive hemothorax (great
vessels, pulmonary vessels)
Immediate Life Threatening
Thoracic Injuries:
Cardiac Trauma
Immediate Life Threatening
Thoracic Injuries:
Cardiac Tamponade
Distribution of Penetrating
Cardiac Trauma
ED Thoracotomy (EDT)
Rationale for EDT
Resuscitate agonal patient with penetrating
cardiothoracic injuries
Evacuation of pericardial tamponade
Control intra-thoracic hemorrhage
Perform open CPR
Repair cardiac injuries
Apply x-clamp to thoracic aorta
Apply hilar x-clamp to lung
Aspirate air embolism
Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, EvidenceBased Surgery 2003: 1(1) 11-21.
Indications for ED
Thoracotomy
Indications:
1. Salvageable post-injury cardiac arrest:
 Patients sustaining witnessed penetrating trauma with < 15
minutes of pre-hospital CPR
 Patients sustaining witnessed blunt trauma with < 5 minutes of
pre-hospital CPR
2. Persistent severe post-injury hypotension (SBP<60mmHg) due to:
 Cardiac tamponade
 Hemorrhage – intra-thoracic, intra-abdominal, extremity, cervical
 Air embolism
C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and
outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA World
Journal of Emergency Surgery 2006, 1:4
Contra-indications for ED
Thoracotomy
Contraindications:
1. Penetrating trauma: CPR >15 minutes and no signs of life
(pupillary response, respiratory effort, motor activity:
2. Blunt trauma: CPR > minutes and no signs of life or asystole
C Clay Cothren and Ernest E Moore Emergency department thoracotomy for the critically injured patient: Objectives, indications, and
outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA World
Journal of Emergency Surgery 2006, 1:4
Emergency Department
Thoracotomy: Outcomes
Review of 42 published series
Survivors/
Total EDT
537/8744
(6.1%)
Survivors/ Survivors/
Penetrating
Blunt
Trauma
Trauma
500/8619
35/7945
(5.8%)
(0.44%)
Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, EvidenceBased Surgery 2003: 1(1) 11-21.
Application of Aortic Cross
Clamp
Esophagus
Aorta
Spine
Diaphragm
Vertical Pericardial Incision
LIM
A
Internal Paddles for Direct
Cardioversion
Laceration Adjacent to
Coronary Artery
Laceration Adjacent to
Coronary Artery
Coronary Artery Laceration
Ventricular Lacerations and
Repairs
Ventricular Lacerations and
Repairs
Ventricular Lacerations and
Repairs
Atrial Lacerations and Repairs
Sub-xyphoid Trans-diaphragmatic
Pericardial Window
Sub-xyphoid Trans-diaphragmatic
Pericardial Window
Blunt Cardiac Injuries
Blunt Thoracic Trauma: Cardiac
Contusions
Blunt anterior chest trauma
Acute injury pattern (anterior wall: ↑ST’s I, aVL,
V2-V4, ↓II,III, aVF), AF, BBB
W/U & Rx acute myocardial infarction, inotropes
Watch for & treat PVC’s aggressively (K+, temp)
Cardiac echo to assess wall motion, valves
Immediate Life Threatening
Thoracic Injuries:
Massive Hemothorax
Can be due to blunt
or penetrating
injuries
Immediate volume
replacement,
compression suit
and OR
Caution with CVP
lines
Application of Pulmonary Hilar
Cross Clamp
Pulmonary Tractotomy
Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy,
Partial Lobectomy, and Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades,
MD, PhD; Jeremy Goodman; James A. Murray, MD; Juan A. Asensio, MD
Arch Surg. 1999;134:186-189.
Pulmonary Tractotomy
Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy, Partial
Lobectomy, and Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades, MD, PhD;
Jeremy Goodman; James A. Murray, MD; Juan A. Asensio, MD
Arch Surg. 1999;134:186-189.
Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
Massive subcutaneous
emphysema in chest
wall – displaced trachea
Cervical, facial subcutaneous emphysema
Hemoptysis
Blunt injuries almost
always within 1” carina
Blunt Thoracic Trauma:
Tracheobronchial Injury
2° Blunt injury
Persistent
pneumothorax
Huge air leak
Rare injury 2-3% of
survivors MVA
Definitive repairs
with pleural flap
Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
Immediate Life Threatening
Thoracic Injuries:
Tracheal Disruption
 Blunt or penetrating trauma (extrinsic compression
from hematoma)
• Intra/extra thoracic location (supraglotic, glotic,
subglotic
 Presentation
• Massive, sometimes uncontrollable air leak
• Stridor, acute respiratory distress, Δ voice
• Neck, upper chest subcutaneous emphysema –
often massive and disfiguring
 Acutely manage with deep intubation (beyond
injury), scope, sometimes tracheostomy
Immediate Life Threatening
Thoracic Injuries:
Open Pneumothorax
“Sucking” chest wound
Respiratory distress
Preferential path of air
when hole ≥ ⅔
diameter of trachea
Cover 3 sides
Chest tube drainage and
auto-transfusion when
available
Immediate Life Threatening
Mediastinal Trauma :
Zone 1 Penetrating Injuries
Between mid-clavicular lines
→ sternal notch to xyphoid
and posterior infra-scapular
35% unstable → OR (½ of
unstable patients die in ED)
65% stable on arrival to ED
TEE, CT scan, endoscopy
20% stable patients have
major injury on work up
Triage and Outcome of Patients with
Mediastinal Penetrating Trauma
The Annals of Thoracic Surgery Burack JH Volume 83, Issue 2, February 2007, Pages 377-382
Stable vs. Unstable Hemodynamic State
1. Traumatic cardiac arrest or near arrest and an EDT
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
Mechanism of Initial Clinical
Presentation
Total
Stable (%)
Unstable (%)
Death (%)
SW
116
89 (77%)
27 (23%)
8 (7%)
GSW
91
46 (51%)
45 (49%)
38 (42%)
Mediastinal Injury Location and
Initial Clinical Presentation
M1= left para-sternal
M2 = right trans-mediastinal
M3 = mid-sternal (anterior and/or posterior)
M4 = lower trans-mediastinal
Total
Stable
Unstable
Death
M1
16
10 (63%)
6 (37%)
2 (13%)
M2
34
26 (76%)
8 (24%)
5 (15%)
M3
137
92 (67%)
45 (33%)
28 (20%)
M4
20
7 (35%)
13 (65%)
12 (60%)
Management Algorithm for
Penetrating Mediastinal Trauma
(72)
Occult Injury in Stable Patients
Patient
Angiographic Findings
Treatment
1
Injury (thrombosis) to 4th
Intercostal artery
Observation
2
Injury to the vertebral artery at
the thoracic inlet
Coil embolization
3
Injury to the Internal Mammary
artery
Coil embolization
4
Injury to the left Subclavian
artery
Sternotomy/thoracotomy and
interposition graft of the
subclavian artery
5
Inominate artery
pseudoaneurysm and thoracic
tracheal injury
Endovascular stent graft,
thoracotomy, and tracheal
resection
Distribution of Arterial Injuries with
Penetrating Mediastinal Trauma
Artery
Innominate
Aortic Arch
L Common Carotid
Ascending Aorta
L Subclavian
Combined/multiple
Total
Injuries Patients Deaths
23(38%) 18(35%) 1(10%)
17(28%) 13(25%) 3(30%)
11(18%)
8(15%) 2(20%)
4(7%)
4(8%) 2(20%)
5(8%)
4(7%)
0
8(15%) 2(20%)
60(100%) 52(100%) 10(19%)
K. Buchan and J.V. Robbs, Surgical management of penetrating mediastinal arterial trauma, European
Journal of Cardio-Thoracic Surgery Volume 9, Issue 2, 1995, Pages 90-94. Dept Surgery University of
Natal, South Africa
Traumatic Aortic-Innominate
Vein Fistula
Immediate Life Threatening
Thoracic Injuries:
Aortic Disruption
Most common at ligamentum
arteriosum but can be
multiple (pendulum effect)
~⅓ fatal on site due to free
rupture (uncontained)
Hypotension, exsanguination
MVA, falls from height
Contained Injuries to the Aorta
Widened mediastinum (53%
sensitivity, 59% specificity and
83% negative predictive value)
Obliteration of aortic knob
Rightward deviation of trachea
(compare NG tube to trachea)
Depression of left main stem
bronchus
Pleural/apical cap
Left hemothorax (can be bilateral)
Fractures of 1st and/or 2nd ribs
Contained Injuries to the Aorta
Contained Injuries to the Aorta
Not a source of multiple hypotensive episodes
in survivors - look for other injuries
Salvageable tear when hematoma contained
~⅓ die per 24 hours without treatment
Widened mediastinum very unreliable sign on
portable x-ray
TEE, helical contrast CT scan, MRI, aortogram
Consider percutaneous stent placement
Address after life threatening injuries stabilized
Summary
Life ending thoracic injuries are common
Survival depends on proper and
immediate diagnosis and appropriate
management
ED thoracotomy can save lives but
expected survivorship is <10%
Don’t forget ABC’s of trauma and damage
control principles