Transcript Chest Trauma Ian Maxwell

Chest Trauma
Ian Maxwell
Outline:
• Chest wall
– Rib #
– Flail chest
– Sternal #
• Lung
–
–
–
–
Contusion
Pneumothorax
Hemothorax
Tracheobronchial
injury
• Heart
– Blunt
– BTAI
• esophagus
Case:
• 24 yo male was kung fu fighting.
• Kicked in left chest by a kung fu kick.
• A/B: In pain no resp distress. Speaks
easily. O2 sat 97% RA.
• C: no concerns. P 88. BP 134/88
CXR
Rib #
• # of ribs 9,10,11:
– R side: 3X ↑ risk hepatic injury
– L side: 4X ↑ risk splenic injury
Shweiki E. J Trauma. 2001 Apr;50(4):684-8
1st Rib #
• Used to be considered harbinger of
vascular trauma
• Now only if
– Wide mediastinum on CXR
– Posterior displacement
– Sublavian groove # anteriorly
– Brachial plexus injury
– ↑ing hematoma
Gupta A Cardiovasc Surg. 1997 Feb;5(1):48-53
1st rib #
• If associated with
– Major head injury
– Long bone #
– Other rib #’s
– Abdominal trauma
Then vascular injury 24% of the time
Rib #
• Watch out for:
– Occult pneumothorax
– Atelectasis (encourage breathing)
– Pneumonia
– Occasionally neuroma or chostochondroma
Consider admission in older patients with
difficulty breathing and/or 2+ rib #’s
Sternal fracture
Brookes, Dunn. J Trauma. 1993 Jul;35(1):46-54
• More common with seatbelts less with
airbags
• >90% from MVC
• Associated injuries most important
consideration
Associated injuries:
(from Knobloch and Brookes)
•
•
•
•
•
•
•
Soft tissue injury 56%
Spine injury C>T>L 30%
Brain injury 24%
Pulmonary injury 18%
Limb # 17%
Multiple rib # 13%
Heart injury 4.5%
Association with heart damage
(more on this shortly)
• In Knobloch’s study 12/267 (4.5%) had
myocardial contusion
• In Brookes’s study only 4/272 (1.5%) had
arrhythmias that required treatment:
– ¾ had pre-existing heart disease
– ¾ fib/flutter
Knobloch. Ann Thorac Surg. 2006 Aug;82(2):444-50
Sternal fracture
• No proven association with Aortic injury
• None in Brookes or Knobloch papers
– These studies don’t include the pre-clinical
(deceased) though
Sturm JT. Ann Thorac Surg 1989;48:697– 8.
Sternal Fracture
• Sternal # per se is usually benign
Therefore management: similar to rib #
except in extreme cases
Flail chest:
• What is it?
• What about it is dangerous?
Flail Chest
• 3 or more adjacent ribs fractured at two
points:
– Allows that separated segment to move in
opposite direction
• Underlying pulmonary contusion the main
cause of problems
• Mortality of 8% - 35% (usually from
associated pathology)
Management of flail chest
• Don’t put sandbags on them
• Deal with associated injuries promptly i.e.
• PTx (especially tension)
• HemoTx
• Intubate if necessary (try to avoid)
– Respiratory failure
– Shock
– Airway control
– Surgery needed soon
Management of flail chest
• Pain control:
– Intercostal nerve blocks:
• 0.25% bupivacaine with epi (longer acting) along
inferior edge of rib, posterior to fracture site
– High thoracic epidural
Flail chest
• Key points
– Exposure is crucial to avoid miss
– Should prompt further imaging (CT)
– Deal with associated injuries promptly
– Pain control important
– Try to avoid intubation
Case:
• 18 yo male kicked out of bar by bouncers
– Was held down by 4 people
• In ER:
– Intoxicated
– Normal vital signs
– GCS 15
What is the Diagnosis?
Traumatic Asphyxia
•
•
•
•
Petechiae
Violet colour to skin
Sub-conjunctival hemorrhages
Facial edema
Traumatic asphyxia
• From compression of thorax and ↑thoracic
pressure
– Leads to retrograde flow up SVC
• Usually benign – look for other injuries
• 1/3 have LOC
• May lead to retinal hemorrhage which
could cause permanent vision loss
• CT head if neuro symptoms/signs
Case: Too much talking not enough
listening
• 27 yo male kicked repeatedly in L chest by
stampede bouncer wearing cowboy boots
• Initially:
– A/B: speaking a few words, 91% RA w/ EMS,
RR 22
– C: 145/88, P 98
– Spit up blood in ambulance, no facial trauma
– ↓AE over area of injury
CXR
Pulmonary Contusion
• Clinical features:
– Dyspnea
– Tachypnea / tachycardia
– Cyanosis
– Hypotension
– Chest wall bruising
– Hemoptysis in 50%
– ↓AE, rales over affected area
Pulmonary Contusion
• Radiographic features
– Initially may be masked by more apparent
injuries
– Patchy infiltrates / consolidation
– Rapidity of onset of x ray features correlates
with severity
– CT also useful
– Must differentiate from ARDS
Pulmonary Contusion
• Low PaO2 on ABG
• Wide AA gradient
Case: continued
• Now 30 minutes later: called back to
bedside for
– RR 36
– Using accessory muscles
– O2 sat 89% non-rebreathe mask
• What now?
Pulmonary contusion
• Management
– Same as usual intubation indications
– Sometimes double lung ventilation used
• Injured lung has less compliance
– Pulmonary toilet
– Pain control
– Restrict IV fluids
– No need for empiric ABx
Case: iatrogenic trauma
• 53 yo Male, just had unsuccessful
subclavian line insertion attempt by me
• Looks very unwell… what is your first
concern?
Case: Iatrogenic trauma
• In trauma bay
– A/B: Agitated, cyanotic, not speaking,
rightward deviated trachea, 83% HF mask,
– C: BP 88/39, P 120, distant heart sounds,
↑JVP
CXR – iatrogenic trauma
Pneumothorax
• Simple Ptx
– No communication with outside
– No shift of mediastinum
• Communicating Ptx
– Hole in chest wall
• Tension Ptx
– Shift of mediastinum – compression of
cavoatrial junction - ↓preload: shock
Ptx: clinical presentation
• May be normal, or:
• Cyanotic, dyspnea, tachypnea
• Decreased breath sounds,
hyperresonance over Ptx
• Possibly subcutaneous emphysema
Tension Pneumothorax
• An emergency!
• Signs, symptoms:
– Same as non tension Ptx +
• Agitated and possibly ↓LOC
• Deviated trachea
• Beck’s triad: ↑JVP, ↓BP, distant HS
• Should not be diagnosed on CXR
Pneumothorax - Imaging
• CXR: Upright – need 50cc air to be visible
- seen as white pleural line
with no lung vessels
Supine – need 500cc
- may see line or may just
see deep sulcus sign,
anterolateral
mediastinal air,
anterior
pleural air outline
Ultrasound dx of pneumothorax
• Gaining popularity
Soldati G.Chest. 2008 Jan;133(1):204-11. Epub 2007 Oct 9
• Looked at 109 chest trauma
patients
• ED U/S shown to be 92%
sensitive
Blaivas M, Acad Emerg Med 2005;
12:844–849
• 176 chest trauma patients, 53 with Ptx
• Ultrasound: Sensitivity 98.1% (89.9%,
99.9%)
• Supine CXR: Sensitivity 75.5% (61.7%,
86.2%)
Pneumothorax - Size
• Can estimate size by Collins method
Apical distance (mm) + midthoracic + basal
__________________________________
3
= % pneumothorax
Or: lateral width of 1cm = 10%
Or just call it big or small: chest wall → pleura > 2cm
Collins method
What do you do for management of tension
PTx?
When do you put a chest tube in someone?
Ptx - Management
• Tension Ptx:
– Immediate needle decompression
• 16G angiocath to 2nd Interspace, Mid-clavicular
line
– Followed by chest tube
• Communicating Ptx:
– Chest tube
– Cover defect in the field
Ptx - Management
• Chest tube if
•
•
•
•
•
•
•
•
•
•
•
Tension
Trauma
Large
Symptoms regardless of size
Increasing size with conservative therapy
Re-accumulation after tube removal
Bilateral Ptx
Need for positive pressure ventilation
Flying
Bilateral
Associated hemothorax
Case: ATV rollover
• 23 yo Female
• Trying to go uphill slowly on ATV: rolled
over backwards and ATV landed on her
chest
• Stable with EMS
• A/B: speaking with some distress, O2 sat
97% 5LNP,
• C: BP 144/72, P 92
Supine CXR in trauma bay
CT
Hemothorax
• Usually from
– lacerated lung
– Intercostal vessel
– Internal thoracic artery
• Heart, hilar and great vessels less
common, obviously more deadly
Hemothorax
• Clinical
– ↓AE on affected side
– Shock if lots of bleeding
• Radiographic
– Upright superior but impractical in trauma
– 200-300cc will yield blunting for upright
– Look for haziness on supine film
– Often discovered on CT
• What do we need to do for hemothorax?
Hemothorax - Management
• ABCs
• Chest tube 36 Fr (B)
– Some have advocated for conservative mgmt.
– Most feel all hemothoraces should be drained
to prevent fibrothorax and empyema
• Management of shock if present (C)
• Monitoring of chest tube output
ATV Case: continued
• No other apparent injuries on secondary
survey
• After you put in the chest tube 1100cc of
blood comes out right away.
• Hgb is 99
• You elect to watch her and she bleeds
another 250cc per hour over each of next
3 hours…
What now?
Hemothorax management
• To OR if:
– More than 1500cc of blood initially
– More than 200cc/hr for 3 hours
– Hypotension with other sources ruled out
Karmy-Jones R. Arch Surg 2001;136:513–8.
– Found mortality with 1500cc to be 3X that of 500cc
Case…
• Late twenties male CCFPEM resident who
wears glasses
• Riding motorcycle @ 100km/h down 17th
ave sw after week long crack and glue
binge
• While distracted by something in Melrose
crashes bike and hits chest on bumper of
parked Aston Martin V12 Vanquish
O/E in ER
• Conscious, but dec LOC,
• Restless, breathing Spontaneously, patent
airway
• BP 76/34
• HR 146
• Engorged Neck veins
• Faint heart sounds
• Cool extremities
CXR
ECG
Labs
• Only abnormalities:
– TnI 2 hours after injury = 0.9
– EtOH ridiculously high
Blunt Cardiac Trauma
• Usually MVC or MBA
• Also falls, sports
• Stable vitals and Normal EKG:
• Usually good outcome
Types of Injury and
Pathophysiology:
• Blunt injury:
– Coronary artery injury/thrombosis – traumatic MI
– Mural thrombus and embolization
– Interruption of action potential at vulnerable time
leading to dysrhythmia/sudden death
• commotio cordis
– Free wall / septal rupture / free wall aneurysm
• Either tamponade or exsanguination
– Valve damage and dysfunction
– Edema interfering with compliance
O/E
• Inspection: road rash, steering wheel
imprints
• Beck’s triad… possibly
– Decreased Systolic BP
– Increased JVP
– Muffled Heart Sounds
• Other signs of Shock – either cardiogenic
or hemorrhagic
Specific Labs for Cardiac Trauma
Cardiac Troponins:
Collins JN et al. Am Surg. 2001 Sep;67(9):821-5
 In blunt cardiac trauma it is most useful
when combined with EKG
 CKMB: problem is that it is not specific to
cardiac muscle – often elevated in trauma
EKG in blunt heart trauma
Salim et al. J Trauma. 2001 Feb;50(2):237-43
– Sinus Tachycardia (most sensitive least specific)
– Low voltage
– RBBB
– Prolonged PR interval
– Electrical Alternans (if tamponade)
– ST changes / T wave inversions
PPV = 28%
NPV = 95%
EKG and TnI in blunt heart trauma
• Both Abnormal: PPV = 62%
• Both Normal: NPV = approaching 100%
– Keep in mind that only 19 patients were
studied
CXR
• Will be normal in 2/3 of patients with blunt
cardiac injury
Collins JN et al. Am Surg. 2001 Sep;67(9):821-5
Management principles
Blunt cardiac trauma
• If EKG and TnI are normal and Pt. stable:
OK from cardiac perspective
• Otherwise
– EKG monitoring
– Possible radionucleotide studies (not in ER)
– Inotropic / blood pressure support
– TTE / TEE
– Repair of aneurysms / holes
– Tx of dysrhythmias
Blunt cardiac trauma: prognosis
Lindstaedt MJ Trauma. 2002 Mar;52(3):479-85
• 118 chest trauma patients
• 14/118 with myocardial contusion
• None had any cardiac complications during
admission
What about an ED thoracotomy??
Rhee PM. J Am Coll Surg. 2000 Mar;190(3):288-98
• Review of 4620 cases from 24 institutions
• Overall survival rate of 7.4%
– 8.8% for penetrating injury
– 1.4% for blunt injury
– If location of major injury was heart survival
19.4%
– Signs of life in field: 8.9% survival vs 1.2% if
none
ED thoracotomy
• Therefore current indications are:
– Penetrating:
• Cardiac arrest with signs of life seen in field
• BP <50mmHg despite fluids
• Shock with signs of tamponade
– Blunt
• Cardiac arrest in ER
What about permissive
hypotension?
• There is controversy about when to give
fluid and how much to give in trauma
Permissive hypotension
Bickell WH. N Engl J Med 1994 Oct 27;331(17):1105-9
• 2nd biggest study on the subject
• 598 gunshot or stabbing patients, odd day
randomization to either:
– Delayed administration of fluid (until OR)
– Immediate fluid
Bickell WH. N Engl J Med 1994 Oct
27;331(17):1105-9
Permissive hypotension
Turner J. Health Technol Assess. 2000;4(31):1-57
• Biggest study (N=1309): showed no
difference in delayed vs. immediate fluid
• Many problems:
– Horrible protocol compliance
– Poor randomization strategy
Permissive hypotension
• Problems:
– Odd day randomization
– Patients not stratified
– Head injured patients excluded
– Results likely not applicable to smaller centres
where OR more than 2 hours away
Permissive hypotension
• Proposed mechanism of benefit
– Avoid dilution of clotting factors
– Avoid hypothermia
– Avoid blasting off clots with ↑BP
Permissive hypotension
• Cochrane review 2008:
– No evidence for or against delayed or
reduced fluids in uncontrolled hemorrhage
– More well randomized well concealed RCTs
needed
– Definitely not desirable if head injury a
possibility
Case:
• Mr. X – 25 Y.O. driving motorcycle with Ms. Y at
130+ Km/Hr after cocaine and EtOH, found 100
ft from bike after collision with cement
embankment
– In trauma bay:
• A/B: GCS 15 but in extreme pain from road rash and long
bone injury but speaking and breathing well
• C: P 122 BP 133/77
• What are you worried about with this MOI?
CXR
CT
Case:
• CT:
– Aortic transection with pseudo-aneurysm
formation
– Tear located 2.5 cm distal to left subclavian
artery
– 7 cm pseudo-aneurysm
Case:
• Patient urgently sent to OR
• Endovascular stent graft placed
percutaneously
• Full recovery
– Still ranks riding his bike on crack among his
favourite hobbies
Case: Ms. Y
CT
Natural History
• 80% of ruptures will die at the scene of the
trauma.
• Half of those who come to hospital alive
will die in first 24 hours
J Cardiovasc Surg (Torino). 2007 Oct;48(5):557-65.
Pathophysiology
• Generally from blunt force trauma
–
–
–
–
Falls from great heights
MVCs, MBCs
Plane crashes
Crush injuries
• Location
– 90% @ isthmus
– 5% asc. Ao (25% in autopsy series)
– Others: desc (diaphram level and mid thoracic)
Pathophysiology:
• Traumatic Aortic Rupture
– Direct exsanguination
– Filling of Pericardium with blood (tamponade)
– Coverage of coronary ostia by dissection flap
– Coverage of other vessels by dissection
propagation – i.e. renal arteries, iliacs
Pathophysiology
• Shearing force theory – injury is due to
tethering at the ligamentum arteriosum
• Osseous pinch theory – due to
compression of aorta between sternum
and vertebral bodies
• Water-hammer theory – sudden increase
in intra-abdominal pressure causes
disruption
What are possible Hx Px findings?
Diagnosis
• History
– Mechanism
• Falls from as low as 5 ft and MVC at as low as 10 mph have
been reported (!)*
– +/- chest pain
• Usually huge deceleration
• Sometimes crush injuries
• O/E (not really reliable)
–
–
–
–
Bruising, presence of other injuries
BP difference between arms
Regurgitant or systolic murmur
Beck’s triad (low SBP, high CVP, quiet HS) if
tamponade
* Horton TG, et al. J Trauma 2001;51(6):1173–6
CXR Findings?
Diagnosis
• Imaging
– A normal CXR is NOT sufficient to rule out aortic injury
– However you should look for the following
• Widened mediastinum
• Deviated NG tube
• Rightward Tracheal Shift
• Apical capping
• Widened Left paraspinal line (no #)
• Widened left paratracheal line
• Loss of aortic knob contour / AP window
• Hemothorax
Mcgillicuddy et al.Emerg Med Clin N Am 25 (2007) 695–711
Mirvis SE, Radiology. 1987 May;163(2):487-93.
Wong YC. J Trauma. 2004 Jul;57(1):88-94.
• Retrospectively looked at 51 patients (21/51
aortic injury) suspected of having Ao injury
• Found they could exclude all cases with 100%
sensitivity if they met certain cutoffs:
– Mediastinal width ratio (at knob) <0.6
– Left mediastinal width <6cm
• Study underpowered to find well contained aortic
injuries which might rupture later
• Many false positives with this particular ROC
Exadaktylos et al. J Trauma. 2001 Dec;51(6):1173-6.
• Looked at 93 patients with suspicious
mechanisms
• Found that 50% of patients with normal
CXRs had injuries on CT including 2 cases
of aortic rupture.
• Therefore the mechanism must drive our
investigations
Other imaging:
• Helical CT has a NPV approaching 100%
(older studies with normal CT had
lower sensitivities)
• TEE also approaches 100% - good in
patients too unstable to go to CT
• Conventional angiogram has long been
considered the gold standard
**It is essential to understand the spectrum of traumatic
aortic injury to see why plain films are not enough to
exclude TAI
intimal hemorrhage
↓
Itimal hemorrhage with laceration
↓
Medial laceration
↓
Complete laceration of aorta
↓
Pseudoaneurysm
↓
Hemorrhage
Not all of these will give the classical XR findings
Creasy JD. Radiographics. 1997 Jan-Feb;17(1):27-45
Management
• Fast transport to hospital
• Maintain BP between 100-120 systolic
– Labetelol/Esmolol
• Operation, but life threatening intra-cranial
or intra-abdominal injuries take
precedence
Management: EVSG vs. Open
• Literature suggests major advantages of
EVSG over open repair in terms of:
– Mortality
– Morbidity including Paraplegia
Case: Stabbed
• 19 yo male stabbed once just under R
clavicle
– A/B: mild distress, speaking, 99% NRB mask,
– C: P: 95, BP 155/92
– Secondary survey: no other injuries
Chest tube: audible air and 300cc blood with
minimal bleeding after tube placement
CXR
CT
• Amazingly only injury is to lung, chest wall
and resultant pneumothorax
• But:
– Next day on unit 71 you go to see how he’s
doing
– Persistent air leak, non resolving Ptx despite
good chest tube placement
• What’s going on?
Tracheobronchial Injury
• Rare: can happen with sharp or blunt
trauma
• 80% within 2cm of carina
• Presents 2 ways:
– Immediate: pneumothorax and persistent airleak
– Delayed: contained by surrounding tissue:
may be asymptomatic until granulation
causes atelectasis or pneumonia 3 weeks
later
Tracheobronchial Injury
• Diagnosis:
– May miss on CT
– Bronchoscopy
• Management
– Intubate over bronchoscope if possible
– Surgery for definitive repair
Case: borrowed from:
Martin M. J Trauma. 2005 Jul;59(1):233-5
• Circus performer – sword swallower
– c/o vomitting blood, odono-dysphagia, pain
with neck flexion
– A/B: speaking, no major distress, vitals all
stable and appropriate
– C: no present concerns
• Labs: mild leukocytosis, no other concerns
CXR
Esophageal Perforation
• Called most fatal perforation of GI tract
• No serosal layer covering esophagus
therefore direct contact with mediastinum
• Mortality about 30%
• Usually iatrogenic
Esophageal Perforation
• Clinical:
– Pleuritic pain along esophagus
– Worse with swallowing or neck flexion
– Pain may be epigastric, substernal, back
– Gets worse over time
– Dyspnea later in time course
Esophageal Perforation
• O/E (few early signs – diagnosis largely
history and imaging driven)
– Nasal voice
– Hamman’s crunch on auscultation
– Signs of hydro/pneumothorax
– Subcutaneous air in neck
– Sepsis/SIRS (later – too late)
Labs
• Not very helpful – non-specific
• May detect amylase and low pH if
associated effusion tested
Imaging
• Plain radiograph
– Mediastinal air
– Left Pleural effusion
– Pneumothorax
– Wide mediastinum
• Lateral c-spine view may show
retropharyngeal air
Imaging
• Gastrograffin preferred over barium
because it does not obscure endoscopy
and doesn’t soil the mediastinum
• Barium more sensitive but irritating
• Endoscopy sometimes used
Esophageal Perforation
• Management
– NG suction, TPN, Abx
– Cervical: can sometimes be managed without
surgery
– Thoracic: require surgery – delayed surgery
associated with worse outcomes
Thank you! Questions?
• Other references:
– Rosen’s
– Uptodate