Transcript Document
Chest Trauma By Dr. Samir Abdallah M.D Prof. of Cardio-Thoracic Surgery Cairo University Chest Trauma Epidemiology The fact that it has become possible in recent decades for millions of people to travel at high speed had led to a phenomenal increase in blunt injury to the chest - a most lethal type of injury. All casualties, and particularly children who have been exposed to blunt chest injury may have sustained highly lethal internal lesions (rupture of the heart, the aorta or the major airway, for example, or contusion of the heart although the external stigmata of chest injury may be quite trivial or even absents altogether. For this reason any causality who has sustained blunt trauma to the chest should be considered seriously injured until proved otherwise. Frequency of Various Injuries In Motor Vehicle Accidents Extremities Head and neck Chest Abdomen 34% 32% 25% 15% Mechanism of Injury in Chest Trauma Acceleration/deceleration (motor vehicle accident) Body compression (crush injury) High-speed impact (gunshot wound) Miscellaneous Low-velocity penetration (stab wound) Airway obstruction (suffocation) Caustic injury (poisoning) Burns Electrocution Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosis Blunt or Penetration Trauma Chest wall injury Airway Obstruction Pain, Restriction, Retention of Secretions, Atelectasis Flail Chest Pneumothorax Hemorrhage Cardiac injury Tamponade Hemothorax Hypovolemia Myocardial dysfunction Pulmonary Hypoventilation Diminished Shunting Hypoxemia Cardiac Output Respiratory Acidosis Tissue Hypoxia Metabolic Acidosis TRAUMA DEATHS IMMEDIATE EARLY LATE 50% 30%-35% 15%-20% Seconds or Minutes Within Hours (Golden Hour) 2-3 Weeks Spinal Cord Injuries Thoracic Trauma Severe Brain Injuries Liver/Spleen Injuries Lesions to Great Vessels Multiple Pelvic Fractures Others Prevention Optimum Initial Care Optimum Prehospital Care Sepsis Multiple Organ Failure Optimum Initial Care (Future?) Percentage of Specific Types of Thoracic Organ Injury Chest wall 54 Flail chest Pneumothorax Hemothorax 13 20 21 Pulmonary 21 Miscellaneous 18 Assessment of patient with Thoracic injury The evaluation of thoracic injuries is only one aspect of the total assessment of severely injured patients. Both diagnosis and therapy go hand in hand. The basic principle of elective surgery - “First investigate and make the diagnosis, then treat the illness” - is a dangerous illusion. Assessment of patient with Thoracic injury The first step is to make a rough estimate of the status of the circulatory and respiratory systems. This provides the first diagnostic clues and often determines which therapeutic action is to be taken. Specific questions are then posed pertaining to individual injuries or their consequences. TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries 1. Hypovolemia? 2. Respiratory insufficiency? 3. Tension pneumothorax? 4. Cardiac tamponade Immediately lifethreatening; diagnosis and therapy before taking roentgenograms TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries 5. Multiple rib fractures? (Paradoxical respiration?) 6. Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?) 7. Hemothorax? 8. Diaphragmatic rupture? 9. Aortic rupture? 10. Cardiac contusion? Monitoring and evaluating the patient with Thoracic trauma Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles). Mediastmum (wide or normal) shifted or not. Lung parenchyma (Contusion). The heart (cardiac tamponade). Diaphragm. Pneumothorax, hemothorax. ECG CVP Arterial blood gases. Urine output. Lab. Investigations. Others. Management of patients with Thoracic Trauma The treatment of polytraumatized patient must follow a certain protocol which includes. Adequate oxygenation. Fluid replacement. Surgical intervention. Treatment of septic complications. Adequate caloric and substrate supplementation. Prevention of stress bleeding. Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis. Rib and Sternal Fracture Mechanism of Injury Indirect violence Lung injuries are more common Direct Violence Rib and Sternal fractures Diagnosis Patient complains of localized pain that is aggravated by coughing deep breathing “Localised tenderness. Subcutaneous emphysema False motion, paradoxical respiration Rib fractures must be diagnosed clinically many rib fractures are not visible on X-ray chest. Flail Chest Therapy in multiple rib fractures (not taking companion injuries into consideration) Stable thoracic wall Unstable thoracic wall Paradoxical respiration 1. Controlling pain 2. Intensive breathing exercises Analgesics (morphine derivatives) every 4h even if there are “no pains” If necessary, intercostal nerve block If necessary, epidural anesthesia Only in cases of respiratory insufficiency Mechanical ventilation; prophylactic insertion of a chest tube In exceptional cases, operative stabilization of the thoracic wall Intercostal Blocks (Sites) It is a tried and tested rule that a prophylactic chest tube should be inserted in every patient with multiple rib fractures who is to undergo an operation under general anaesthesia even when there is neither evidence of a hemothorax nor of a pneumothorax. Pneumothorax and Hemothorax Cases of pneumothorax and hemothorax can be provided with extremely effective therapy for the most part with simple methods, in more than 80% of cases. It must, however, be given early, furthermore the drainage of air and blood must be efficient. Tension Pneumothorax (Life Threatening) Every traumatic pneumothorax can develop into tension pneumothorax, however, this complication is rare with spontaneous breathing. Very frequently, in a more dangerous form by for, a tension pneumothorax occurs during mechanical ventilation. Treatment consists of immediate relief of pressure. Open Pneumothorax Diagnosis: A penetrating thoracic wound with a sucking sound of incoming and outgoing air “sucking wound” adds to the clinical and radiological evidence of pneumothorax Therapy: Immediate air tight closure of the thoracic wound. Immediate intubation and mechanical ventilation. Hemothorax Diagnosis Diminished breath sound. Muffled sound on percussion. X-ray chest: Clouding of the affected half of the thorax up to complete opacity. In the diagnosis of hemothorax formation of atelectosis and rupture of the diaphragm should be differentiated. Hemothorax Sources of blood accumulating in the chest following blunt or penetrating trauma: Pulmonary parenchymal laceration. Rupture of pleural adhesions. Mediastinal injury with or without vascular injury. Cardiac injury with pericardio-pleural communication. Decompression of abdominal hemorrhage through a traumatic diaphragmatic injury. Hemothorax Therapy The key to successful management of acute hemothorax is early aggressive care in the form of adequate pleural evacuation by thoracostomy or thoracotomy in order to minimize the morbidity. The rate and cessation of bleeding depends on the site and size of the bleeding wound. Hemothorax Thoracotomy is done if the bleeding is constant and more than 300 ml per hour during the first three to four hours. However, tube thoracotomy is all what is needed if bleeding is less and decreasing without radiological evidence of clotted blood. Insertion of Chest Tube Incision over intercostal space Development of subcutaneous tract Penetration of parietal pleura Confirmation that lung is not adherent to chest wall at puncture site Lung Parenchymal Injuries Clinical significant Lung laceration/ lung rupture Mostly harmless (exception: central lung rupture) Therapy Conservative Thoracic drainage in pneumothorax and hemothorax Operation only in exceptional cases because of bleeding or massive air loss Lung Parenchymal Injuries Intrapulmonary hematoma Clinical significant Therapy Harmless None Lung Parenchymal Injuries Traumatic lung pseudocysts Clinical significant Therapy Harmless Mostly none Lung Parenchymal Injuries Clinical significant Simple lung contusion Therapy Mostly harmless Breathing exercises Can develop into lung Careful monitoring of contusion with progress respiratory insufficiency Lung Parenchymal Injuries Clinical significant Lung contusion with respiratory insufficiency Progressive respiratory insufficiency: hypoxia, right-toleft shunt interstitial edema, considerable mortality Therapy Intubation and positive end-expiratory pressure ventilation (PEEP) Maintenance of a normal oncotic pressure (fluid infusion limited, human albumin 29%). Steroids Lung Parenchymal Injuries Clinical significant Blast injury Severest injury Progressive respiratory insufficiency Danger of arterial air embolism Hemothorax, pneumothorax, abdominal injuries (colonl) Therapy As in lung contusions with respiratory insufficiency Abnormalities following bronchial rupture and methods of management Bronchial Rupture Immediate Acute respiratory Acute Early Bronchial insufficiency Infections Obstruction Tubes Mediastinitis Empyema Atelectasis Emergency Repair or Resection Abnormalities following bronchial rupture and methods of management Delayed Pulmonary Infection Pneumonia Abscess Fibrosis Late bronchial obstruction Bronchiectasis Pneumonitis Fibrosis Elective Pulmonary Resection Atelectasi s Abscess Pathologic courses following esophageal perforation Entry into cervical or mediastinal fascial planes of: Air Bacteria and Saliva Mediastinitis Abscess Emphysema Empyema Sepsis Gastric juice Pneumothorax Burn Tension Fluid and electrolyte disturbance Pneumonia CV Collapse Essential components of and procedures used in management of esophageal perforation Therapy non-operative Fluid and Electrolytes Antibiotics High-dose IV Prevent further contamination Topical, Luminal Gast. Tube Plus Operative Prox. Tube Closure Drainage of Mediastinal and/or Or Exclusion Or Re-section fascial planes Only With reconstruction Injuries of the diaphragm Diaphragmatic Rupture: Incidence: In 3% of all sever thoracic injuries. Mechanism: Broad surface blow. Location: Left side in 85% of cases. Clinical picture. Acute: symptoms of companion injury and shock. Chronic: Intestinal obstruction or strangulation (usually) Diaphragmatic ruptures (Cont.) Radiological Ex.: Rupture of the diaphragm are frequently overlooked. Therapy: Is indicated for increasing impairment to respiration. Operative approach from chest or abdomen. Traumatic Diaphragmatic Rupture Traumatic Emphysema Subcutaneous. Mediastinal Emphysema. “Present in about 27% of patients with blunt or penetrating chest injury” Traumatic Emphysema Therapy: Despite its impressive appearance the treatment of subcutaneous emphysema it self is mostly unnecessary. Determite the site of origin. Treat underlying pneumothorax if present by tube thoracostomy. Treat tracheobronchial, or oesophageal rupture or tension pneumothorax in cases of mediastinal emphysema. Rarely, cervical mediastinotomy is needed for mediastinal enphysema. Nonpenetrating wounds of Heart Cardiac Tamponade Precordial/Epigastric Wounds Hypotension Suspect Cardiac Injury Airway Control Central Venous Lines Volume Expansion Tube Thoracostomy Hemodymanic Stability Hemodymanic Instability Operating Capability In E.R. Operating Room Transfer Subxiphoid Pericardial Window Diagnosis Confirmed No Pericardiocentesis Intrapericardial Catheter Constinous Aspiration Yes Immediate TRT Relief of Tamponade Cardiorrhaphy Operating Room Transfer Definitive Casrdiorrhaphy Control of Other Injuries Closure of Incision Algorithm for the diagnosis and management of penetrating cardiac injuries Penetrating cardiac injuries (Therapy) Penetrating cardiac injuries (Therapy) CARDIAC INJURY Repair Postoperative Period Asymptomatic Symptomatic Electrocardiogram Chest X-ray Physical examination Normal Abnormal 2-D Echocardiogram Shunts Fistulae Equivocal intracardiac Defects Foreign Bodies Cardiac Catheterization Follow-up Normal Abnormal Re-operation Other Injury Patterns in Thoracic Trauma I. Traumatic asphyxia: Due to a severe compression of thorax with sudden increase of pressure in the venous system resulting in a characteristic injury pattern where small hemorrhages in the conjunctiva, the skin and the mucous membranes of the throat and head and reddish-blue discoloration in the latter region. Therapy: Is for the companion injuries and cerebral oedema if present. Other Injury Patterns in Thoracic Trauma II. Injuries of the thoracic duct: (Chylothorax) III. Cholothorax IV. Traumatic induced hernia of the chest wall V. Arterial air embolism VI. Blast injury Indications for Thoracotomy: Decision to Operate Excluding minor surgical procedures such as tracheostomy pericardiocentesis, tube thoracostomy, and suture of chest wall lacerations, formal operations are required in only 12 to 15 percent of patients with thoracic trauma. Indications for thoracotomy: ACUTE Post-traumatic cardiovascular collapse Proved Esophageal injury Pericardial tamponade Great vessel injury Vascular injury to the thoracic outlet Continuing Hemothorax Traumatic thoracotomy Mediastinal traversing injury Massive Air leak Bullet Embolism Proved tracheobronchial injury Air Embolism Indications for thoracotomy: CHRONIC Unevaluated clotted hemothorax Chronic traumatic Diaphragmic hernia Chronic cardiac septal or valvular lesions Chronic false Aneurysms Chronic non-closing thoracic duct fistula Infected intrapulmonary hematoma Missed trachobronchial injury Traumatic Arterio-venous fistula Initial Assessment of the most important thoracic injuries Suspected if there is Additional examination required Tension pneumOthorax Inflated hemithorax with reduced mobility of thorax Initial therapeutic measures None Immediate thoracic Hypersonorous auscultation Weakened breath sounds Venous congestion in creasing elevation of central venous pressure Open pneumothorax Thoracic wounds with sound of air rushing in and out (“sucking wound”) None 1. Tight bandage +ICT or 2. Intubation mechanical ventilation Cardiac tamponade Location of wound in the precordium or corresponding tract of the bullet or knife None Pericardioeentesis Operation Initial Assessment of the most important thoracic injuries Suspected if there is Additional examination required Rib fractures Local tenderness Chest roentgenogram Compression pain Initial therapeutic measures Relief of pain Intubation and mechanical ventilation when respiratory insufficiency occurs Possibly crepitation on auscultation Inspection: possibly paradoxical respiration Pneumothorax Hyperresonance Chest roentgenogram Thoracic drainage Chest roentgenogram Thoracic drainage Diminished breath sounds Hemothorax Subcutaneous emphysema Dullness to percussion Initial Assessment of the most important thoracic injuries Suspected if there is Additional examination Initial therapeutic measures required Rupture of bronchus Mediastinal emphysema Bronchoscopy Operation Esophagography Operation Pneumothorax or tension peneumothorax No expansion of lung during thoracic drainage Total atelectasis Rupture of esophagus Mediastinal emphysema Initial Assessment of the most important thoracic injuries Suspected if there is Additional examination required Mediastinal emphysema Characteristic crunching sound above the heart, synchronous with the heart beat (Hamman’s sign) Chest roentgenogram Initial therapeutic measures Cervical mediastionotomy only when there is significant venous congestion and no rupture of bronchus or esophagus Central venous pressure Determination of possible cause by means of: Bronchoscopy Esophagography Diaphragmatic rupture Percussion: dampened or hypersonorous percussion Roentgenogram of thorax with possible use of nasogastric tube and/or contrast media Operation Initial Assessment of the most important thoracic injuries Suspected if there is Additional examination required Rupture of aorta Possibly pseudocoarctation syndrome Initial therapeutic measures Aortography Operation Cardiac enzymes ECG monitoring Possibly compression syndrome in the upper mediastinum Possibly systolic murmur Roentgenorgram: Wide mediastinum Tracheal displacement to the right Displacement of the left bronchus downward Possible left-sided hemothorax Cardiac contusion ECG: Irregularities in repolarization Disturbances in rhythm and conduction Infarct pattern Drug treatment of rhythm irregularities and of possible cardiac insufficiency