Transcript Thoracic Trauma

Thoracic Trauma
J William Finley, MD
Trauma Director
Providence Regional Medical Center
Thoracic Trauma
• Fourth Leading cause of death
– 150,000 Annual deaths
• Second only to head injury in cause of
death
– 25% of trauma related deaths
• Often associated with other injuries
• Prevention Focus
– Gun Control Legislation
– Improved motor vehicle restraint systems
• Passive Restraint Systems
• Airbags
Anatomy
• Thoracic cavity
– Thoracic inlet
– Diaphragm
• Contains a lot of important stuff
– Heart
– Lungs
– Mediastinal structures
Extensive Armor
There is no perfect protection…
It’s a Dangerous World
• Penetrating Injury
– Low Energy
• Stab wounds
– High Energy
• GSW
• Blunt Injury
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Crush
Compression
Shear
Acceleration/Deceleration
Spectrum of Disease
• Chest Wall
– Contusions
– Rib fractures
– Flail Chest
• Pulmonary
– Pulmonary contusion
– Pulmonary laceration
– Hemothorax
– Pneumothorax
Spectrum of Disease
• Cardiac
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Contusion
Laceration
Avulsion
Tamponade
• Mediastinal
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Great vessel
Tracheobronchial
Esophageal
Aortic
Keys To Diagnosis
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Index of suspicion
Injury association
Clinical signs/symptoms
Diagnostic imaging
– Xray
– CT
– Ultrasound
Basic Trauma Resuscitation
• Easy as A-B-C
– A - Airway
– B - Breathing
– C - Circulation
October 24, 2011
Thanks to Jonathan Holbrook, Tall Taurus Media, LLC
Real Heroes Breakfast 2011
Snohomish County, American Red Cross
Hemothorax
• Accumulation of blood in the pleural space
• Serious hemorrhage may accumulate 1,500
mL of blood
– Mortality rate of 75%
– Each side of thorax may hold up to 3,000 mL
• Blood loss in thorax causes a decrease in
tidal volume
– Ventilation/Perfusion Mismatch & Shock
• Typically accompanies pneumothorax
– Hemopneumothorax
Hemothorax
• Blunt or penetrating chest trauma
• Diagnosis
– Small to moderate
• Only seen on CXR or CT
– Large
• May be diagnosed clinically
– Dull to percussion over injured side
– Decreased BS on affected side
– Decreased chest expansion
Hemothorax
Hemothorax
• Management
– Placement of tube thoracostomy
• 36 French tube or greater
– Operative indications, thoracotomy
• Initial 1-1.5 L blood
• Ongoing 200-250/hr losses
ED Thoracotomy
• Most surgeons hold a
very pessimistic view
• Success rates vary
• Overall success rate 45%
• The first successful
'prehospital' thoracotomy
and cardiac repair was
carried out by Hill on a
kitchen table in
Montgomery, Alabama in
1902.
Why?
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Abysmal Success rate
Exposes medical personnel to risk
There are survivors
The main determinants for survivability
– mechanism of injury
– location of injury
– presence or absence of vital signs
Mechanism of Injury
• Penetrating thoracic injury
– Survival rate 18-33%
• stab wounds > gunshot wounds.
• Isolated thoracic stab wounds causing cardiac
tamponade approach 70% survival
• Gun shot wounds injuring more than one cardiac
chamber and causing exsanguination have a much
higher mortality.
• Blunt trauma survival rates
– Vary between 0 and 2.5%
Location of Injury
• Almost all survivors of emergency
thoracotomy suffer isolated injuries to the
thoracic cavity.
• Cardiac injuries have the highest survival
– single chamber > multiple chamber
– great vessels and pulmonary hila carry a
much higher mortality
Presence of Vital Signs
• Survival related to
– Presence of cardiac activity
– Amount of time since loss of cardiac activity
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0% for those patients arresting at scene,
4% when arrest occurred in the ambulance,
19% for emergency department arrest and
27% for those who deteriorated but did not arrest
in the emergency department1
1Tyburski
JG, J Trauma 2000.
Presence of Vital Signs
• Survival for blunt trauma patients who
never exhibited any signs of life is almost
uniformly zero.
• Survival for penetrating trauma patients
without signs of life is between 0 and 5%.
ED Thoractomy - Why?
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Release pericardial tamponade
Enable open cardiac massage
Occlude the descending aorta
Control intrathoracic hemorrhage
ED Thoracotomy - How
• Steps
– Prep chest, generally left chest
– Generous incision from sternal border to mid
axillary line
– Down to intercostal muscles
– Divide chest along upper margin of 6th rib
– Spread ribs
– Retract lung
– Identify and incise the pericardium to release
potential tamponade
ED Thoracotomy - How
• Steps
– Recognize and repair any cardiac injury
– Open cardiac massage using 2 hand
technique
– Cross clamp aorta
– Incision can be extended to right side of chest
(Clamshell)
– Ongoing resuscitation
– Closure in OR
Posterio-Lateral Thoractomy
Clamshell Thoracotomy
Thoracic Trauma
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Can create dramatic injuries
Keep to resuscitation basics A-B-C
Involve surgeons early
ED thoracotomy does have some
survivors