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Blunt and Penetrating Chest Trauma

Blunt and Penetrating Chest Trauma. Adam Oster R4 Arun Abbi, MD FRCP Core Rounds September 9, 2004. Topics. Blunt Aortic Injuries Myocardial Contusion Occult Pneumothorax ED Thoracotomy Hemothorax Pulmonary Contusion Penetrating Pneumothorax Tamponade. Case 1.

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Blunt and Penetrating Chest Trauma

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  1. Blunt and PenetratingChest Trauma Adam Oster R4 Arun Abbi, MD FRCP Core Rounds September 9, 2004.

  2. Topics • Blunt • Aortic Injuries • Myocardial Contusion • Occult Pneumothorax • ED Thoracotomy • Hemothorax • Pulmonary Contusion • Penetrating • Pneumothorax • Tamponade

  3. Case 1 • 23M unrestrained driver struck a light pole at highway speeds. Ejected. Found 20meters from his car. • GCS 9 • Hemodynamics normal • Facial trauma

  4. Case 1

  5. Blunt Aortic Injury • MC mechanism is… • Rapid deceleration • Why? • Aortic arch is mobile and descending arch is immobile d/t ligamentum arteriosum • Rapid deceleration  places aortic isthmus under tension  shearing stress can result in tearing opposite to fixation site. • 90% die on scene • Remaining 50% within 24hrs without prompt definitive treatment

  6. Blunt Aortic Injury • Clinical presentation… • Sensitivity of screening DI (CXR) • Imaging controversies; • CXR vs CT • CT vs angiography • CT vs TEE

  7. Blunt Aortic Injury • Sensitivity of the CXR • What are the high risk findings? • Mediastinal widening (>8cms?? – 1970s Marsh and Sturm) • Apical cap • Loss of AP window • Loss of aortic knob • Rightward deviation of NG (of the T3/4 SP) • Rightward deviation of the trachea • Downward displacement of lt mainstem • Thickening of right paratracheal stripe (>5mm) NB isolated # 1st/2nd ribs are not predictive of injury

  8. Blunt Aortic Injury:Sensitivity of the CXR • Sensitivity of CXR approx 90% • Loss of aortic knob (sens= 53-100%, spec 21-55%) • Mediastinal widening (sens= 81-100, spec. 10-60%) • Def’n of widening is ambiguous in the literature • >8cm at origin lt subclavian or • Ratio of mediastinal width to width of thorax at aortic knob

  9. Sensitivity of the CXR • Approx 90-98% • NPV of a normal CXR is 96% • CXR can be normal in up to 5% with TAI • Cannot completely r/o the injury • Take into account pre-test probability • PPV low 5-20%

  10. Blunt Aortic Injury and the CXR • Radiology 1987. vol. 163 (abstract only) • N=205 retrospective review with BCT • 41 with angiographically-proven BAI • Analyzed 16 distinct CXR features • most discriminating signs were • loss of the AP window, • abnormality of the aortic arch • rightward tracheal shift • widening of the left paraspinal line • No single or combination of radiographic signs demonstrated sufficient sensitivity to indicate all cases of traumatic aortic rupture on plain chest radiographs • The bedside anteroposterior upright view of the chest proved far more valuable than the supine view in detecting true-negative studies. • significant reader variability

  11. Blunt Aortic Injury • Journal of Trauma. July, 2004 • Mediastinal width (MW), left mediastinal width (LMW) and the ratio (MWR) measured on resusc CXR • GS = either surgery or angio • 51 had CT, 45 had aortogrpahy, 6 thoracotomy after CT

  12. Results • 21/51 TAI • Surgically-proved in 20 • Successful repair in 18 • 19/20 pathology at isthmus

  13. Results • Best combination predictor is LMW >6.0 and MWR >0.60 • LR = 3.0

  14. Blunt Aortic Injury

  15. Blunt Aortic Injury

  16. Blunt Aortic Injury • Journal of Trauma. December, 2001. • Prospective, n=93 • MVC >10MPH (76%) • Fall >5ft (24%) • Excluded hemodynamically unstable and severe HI • All had CXR and CT

  17. Sensitivity of CXR for Chest Injuries • Sensitivity 82% • Specificity 57% • CXR missed 2/3 BAI

  18. Blunt Aortic Injury • 7.3% with confirmed TAI had normal mediastinum on CXR.

  19. Blunt Aortic Injury: The CXR • Retrospective review of white peoples CT chest to determine normal AP width • Excluded abnormal mediastinums • Mean width 6.1cms on CT • Modern trauma rooms 7.3-7.92 cms • Historic upper limit of normal does not apply

  20. FFD and OFD

  21. The CXR in BAI • Emergency Medicine Clinics of North America. February, 1999. Meta-analysis. • Most specific findings • Lt tracheal deviation (80-95%) • NG deviation (90-94%) • Depressed lt mainstem bronchus (80-100%) • No association with sternal # or thorasic rib#

  22. Blunt Aortic Injury: Identification by Mechanism • Journal Of Trauma. June 1, 2001.

  23. Blunt Aortic Injury: Identification by Mechanism • Retrospective review of crash site data • GS was radiographic or autopsy • N=34 (12%) • Head-on crash = 5% • Side impact = 59% (20/34) • 74% in compact cars • 65% vehicle-vehicle • 35% vehicle-pole/wall ##Presence of delta V>20mph or near-side impact was present in All TAI. Either had NPV =100%

  24. Mechanics

  25. Blunt Aortic Injury: Identification by Mechanism • Journal of Trauma. April, 2003. • Cohort design. NASS database.

  26. Independent positive predictors for BAI Age > 60 Front-seated Frontal and near-side impacts Delta V>40mph Crush >40cms Intrusion >15cms Negative predictors Seat-belt use Occupant of large vehicle

  27. Blunt Aortic Injury: Identification by Mechanism • Journal of Trauma. Jan, 2001. • Retrospective autopsy review of all BAI.

  28. N=242 (12% all trauma deaths) • MC mechanism • Head-on>side-impact

  29. CXR Abnormal • How to diagnose BAI • CT • Angio • TTE • TEE • OR

  30. CT vs Angiography • Parallel CT and angiography for n=142 with suspected BAI • All had “unclearable” CXR • Blinded Radiologists

  31. CT vs Angio • CT neg = 121 (kappa 0.7) • CT pos = 7 (kappa 0.9!) • Sens = 100% • NPV = 100% • Spec = 87% • $500 cost savings/pt

  32. CT vs Angiography • Journal of Trauma. Feb, 2004.

  33. CT vs Angiography • Retrospective registry data • All pts had aortography • Most had CT • Findings confirmed surgically • NB CXR normal in 7% • Non-specifically abnormal in 53% (BAI not suspected)

  34. CT vs Angiography • CT performance • 1 miss • 5 FP • Agreed in 93 cases • Sens = 87% • Spec = 98%

  35. Chest, 1997. • Prospective review of TAI patients (n=28) confirmed by angio/surgery/MRI • All had TEE • Control group of 30 with chest trauma and wide mediastinum but no TAI • Describe the echo findings associated with TAI

  36. MC findings • Thick stripe • Intimal lesions • False aneurysms • Aortic wall hematoma

  37. TEE for Detection of Mediastinal Lesions • Journal of Trauma, 1995. • Prospective, n=70. • All intubated • TEE within 48hrs

  38. TEE for Detection of Mediastinal Lesions. Journal of Trauma, 1995. • But… • Only 1 lesion • Unclear GS • ?blinded to other investigations

  39. TEE • Smith et al. NEJM, 1995. • Prospective, n=93 • TEE followed by angio • GS = angio/surgery/autopsy • Mean time to TEE 29mins • Sens = 100% • Spec 98%

  40. TEE • Chrillo et al., Heart. 1996. • Prospective, consecutive, n=134. • Clinical evidence chest trauma or mechanism • Sens = 93% • Spec = 98% • Time to surgery shorter (30 vs 71mins)

  41. Blunt Aortic Injury • Journal of Trauma. Jan, 2004. • Retrospective registry data • Early repair = <16hrs from injury • Case controlled comparisons

  42. Delayed vs Early Repair

  43. Delayed vs Early Repair

  44. Delayed vs Early Repair • Delayed repair does not appear to be associated with increased mortality • BAI should be triaged and given appropriate priority but should not take precedent over other co-existing injuries • May lead to increased morbidity • LOS especially • …medical management of blood pressure

  45. BAI and Anti-Hypertensives • Annals of Surgery 1998. • Prospective use of labetolol or esmolol +/-nitroprusside • To SBP= 100, HR<100 • Nitroprusside added if unable to optimally control BP • Outcomes • Rupture prior to repair • Allowing delayed repair if co-existing injuries necessitated • N=71 with BAI

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