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Anesthesia for Cardiothoracic Trauma

Anesthesia for Cardiothoracic Trauma. Charles E. Smith, MD Department of Anesthesia MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio Email: csmith@metrohealth.org. Objectives. Incidence Pathophysiology Specific injuries. Trauma.

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Anesthesia for Cardiothoracic Trauma

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  1. Anesthesia for Cardiothoracic Trauma Charles E. Smith, MD Department of Anesthesia MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio Email: csmith@metrohealth.org

  2. Objectives • Incidence • Pathophysiology • Specific injuries

  3. Trauma • Leading cause of death, ages 1 - 44 yrs • 60 million injuries annually in USA • 30 million require medical care • 3.6 million require hospitalization • 9 million are disabling • 300 k = permanent; 8.7 million= temporary • Costs are staggering: > $100 billion annually, or 40% of health care $ ATLS Provider Manual

  4. Cardiothoracic Injuries • Accounts for 20% trauma deaths in US • Contributing factor in additional 25% • Immediate deaths: massive injury heart, great vessels, lungs • Early deaths: airway, hypoxia, hemorrhage, tamponade, aspiration

  5. Pathophysiology • Respiratory insufficiency + hypoxia • chest wall injury, rib fx, flail, airway • hemothorax, pneumo, contusion, aspiration • Hemodynamic collapse + shock • massive hemothorax • cardiogenic shock: tamponade or blunt cardiac • mediastinal shock: tension pneumo

  6. Siegel JH et al: Trauma: Emergency Surgery + Critical Care, 1987:201-284

  7. Blunt Chest Injuries Devitt: CJA 1991;38:506. Incidence of injuries in patients presenting to OR emergently

  8. Blunt Chest Trauma: Extra-thoracic Injuries Besson + Saegesser 1983; Switzerland, N= 1485 chest injuries

  9. Initial Evaluation • History of traumatic event: • mechanism of injury: mva, mca, assault, fall, blasts, pedestrian struck, gsw, stab • energy exchange: speed of vehicle, distance of fall, weapon caliber, entry + exit wounds • Review of systems: • allergies, meds, PMH, last meal, events before + after injury: AMPLE

  10. 1o Survey • Airway + c-spine control • Breathing, O2 sat • Circulation, pulse, stop external bleeding • Disability: Rapid neuro exam • alert, v. responds to verbal, to pain, unresponsive • Exposure/ environmental control

  11. 2o Survey • Rest of vital signs • Physical exam • Xrays: lat c-spine, chest, pelvis • FAST, DPL, CT, other studies • Done only after 1o survey completed + resuscitation begun

  12. Case: Hemopneumothorax • 26 yo female, initially stable after high speed MVA • During CT, had dyspnea, tachypnea, tachycardia, hypotension,  BS left • Transferred emergently to OR

  13. Hemothorax Which is true? • Bleeding usually continues after chest tube insertion + lung re-expansion • Respiratory failure + shock may occur • Hypoxia,  breath sounds + hyper-resonance to percussion are usual findings • Hemothorax is unlikely to occur in the setting of penetrating thoracic trauma • Emergency thoracotomy + OLV often required

  14. Blunt thoracoabdominal trauma, hemopneumo, fx ribs

  15. Grade IV splenic laceration, ruptured diaphragm, contrast in stomach

  16. Case Management • Transferred to OR: • RSI: ketamine, succinylcholine • Chest tube • Fluid + blood resuscitation (type specific uncrossmatched, Level 1 warmer) • Splenectomy, repair of ruptured diaphragm • ICU x 24 hours • Full recovery

  17. Tension Pneumothorax Which is true? • Hypoxia,  BS,  BP, dullness to percussion, +  Paw are diagnostic clues • N2O is contraindicated • ETCO2 is  with bilateral tension px • Thoracic decompression with a large-bore needle is best done in the 4rth intercostal space, mid-clavicular line

  18. Tension Pneumothorax • Pathophysiology: • accumulation of air under pressure • compression of contralateral lung, vena cava, cavo-atrial junction • Dx: • hypoxia,  BS, hyper-resonance, hypotension, tracheal deviation, JVD •  Paw (volume controlled ventilation)

  19. Management Tension Pneumo • Large bore needle • 2nd IC space, mid-clavicular line • Converts to simple px • Chest tube • 5th IC space, mid-axillary line • Avoid N2O + PEEP • High index suspicion, especially with PPV

  20. Avoid N2O

  21. Case: Undiagnosed Traumatic Diaphragmatic Hernia • 19 yo parturient, active labor, term, transferred to MHMC, non-reassuring FH trace • Anesthesia preop assessment: LUQ pain, dyspnea, tachypnea, tachycardia,  BS left, tracheal deviation to right • PMH: stab wound left chest 3 yrs prior, no rx required • Surgery delayed: trauma/thoracic consult Dietrich: Anesthesiology 2001;95:1028

  22. Traumatic Diaphragmatic Rupture Which is true? • It is self-limiting + heals spontaneously • Stomach and abdominal viscera may herniate, collapse the lung, and  risk of aspiration • It is more common after blunt than after penetrating thoraco-abdominal trauma • It is more common on the right than left side

  23. Daiphragmatic hernia in a parturient at term

  24. Saggital reconstrcution showing diaphragmatic hernia

  25. Management • C-section w spinal anesthesia • Complicated postop course b/c collapsed lung, pericardial effusion, compression of heart, strangulated + perforated bowel • Tx: Pericardial window, antibiotics, prolonged mechanical ventilation, ARDS, repair of bowel + hernia after improved pulmonary fct • Discharge to home 4 months post delivery Dietrich: Anesthesiology 2001;95:128

  26. Case: Penetrating Cardiac Trauma • 29 yo male, stab wound to heart • RSI • ED thoracotomy: 1 inch entry wound in LV • Transferred to OR, BP 80/50, HR 130-150 Lim et al: Ann Thorac Surg 2001;71:1714 + 2002;73:342

  27. Management • Art line • Scopolamine, muscle relaxant, PPV • Adenosine 12 mg IV bolus (x 3) to  HR • Transient asystole: allowed accurate placement of sutures; bypass avoided • Full recovery Lim et al: Ann Thorac Surg 2001;71:1714

  28. Cardiac Injuries Which is true? • Tamponade is best treated by pericardiocentesis in the ED • JVD is an important clue for tamponade • Echo is reliable method for detecting functional + structural cardiac abnormalities • CPB is frequently (>50%) required to repair cardiac injuries

  29. Penetrating Cardiac Injuries • GSW: usually die • Stab: usually present with tamponade • Dx: history, JVD,  BP, pulsus, echo • JVD- may be absent if hypovolemic • Tx: surgical drainage + repair, + bypass

  30. Blunt Cardiac Injury (Myocardial Contusion) • Spectrum of problems • enzyme abnormalities, ST segment  • arrhythmias: PVCs, RBBB, VT • wall motion abnormalities • cardiac failure • cardiac rupture • Dx: history, ECG, echo www.trauma.org/thoracic/index.html

  31. Echo

  32. Risk of Surgery with BCI: No Deaths, but... Flancbaum L: J Trauma 1986;26:795; Ross P: Arch Surg 1989;124:506

  33. Serious BCI @ MHMC • Specific injuries • acute myocardial rupture • valve disruption • contusion w CHF or complex arrhythmias • delayed myocardial rupture (44 d) • coronary art thrombosis • ECG suggested cardiac injuries in all • Echo useful for dx Malangoni et al: Surgery 1994;116:628

  34. Pitfalls in Cardiothoracic Trauma • Failure to appreciate severity of • pulmonary contusion • cardiac injury (blunt + penetrating) • blood loss • other injuries • Simple pneumo  tension pneumo with PPV • Endobronchial intub can mimic tension pneumo • Failure to optimize ventilation, oxygenation, organ perfusion, + circulating blood volume

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