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Thoracic injuries

Thoracic injuries. Incidence: 10%mortality (25% of traumatic deaths) <10% of blunt and 15-30% of penetrating require thoracotomy mediastinal penetrating trauma: mortality 20%, 50% are hemodynamically unstable  40%mortality additional 30% positive diagnostic evaluation

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Thoracic injuries

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  1. Thoracic injuries • Incidence: • 10%mortality (25% of traumatic deaths) • <10% of blunt and 15-30% of penetrating require thoracotomy • mediastinal penetrating trauma: mortality 20%, 50% are hemodynamically unstable  40%mortality additional 30% positive diagnostic evaluation • Patophysiology: hypoxia, hypercarbia, acidosis (hypovolemia, ventilation/perfusion mismatch, changes in intrathoracic pressures) Klinika Chirurgii Urazowej Paweł Grala

  2. Thoracic injuries • Chest wall • lacerations, l.communicating with pleural spaceopen pneumothorax, • rib frs with possible: pain, splinting, atelectasis, hypoxemiaanalgesia, pulmonary toilet, flail chest, indicative of possible internal inj. • Sternal fractures (consider myocardial contusion) • Tracheobronchial (respiratory distress, large air leak with subcutaneous emphysema) • Esophageal (penetrating trauma, delayed recognotion →↑mortality – 3fold if over 24h, esophagoscopy with contrast studies – Gastrografin, butressed repair) • Pulmonary: contusion, hemothorax, pneumothorax • Great vessel • Cardiac Klinika Chirurgii Urazowej Paweł Grala

  3. Rib fractures 25% of chest inj. • May be undetectable on CXR (excludes other intrathoracic injuries, present in 40% of symptomatic patients), US (unreliable) • Majority IV-IX • Anteroposterior compression  midshaft fr. (outward bowing), direct blow  fracture ends face inwards  potential vessel or lung parenchymal injury • X-XII  suspect hepatosplenic injury • I-III  suspect great vessel injury • Taping, rib belts – contraindicated • Relief of pain (intercostal block, intrapleural analgesia, systemic analgetics), pulmonary toilet • Flail chest – bony discontinuity of a chest fragment (>3): serious underlying lung inj., paradoxical chest wall motion, pain, splinting (muscle spasm)  hypoxia fluid restriction (if no hypovolemia), adequate ventilation with chest wall splinting  mechanical ventilation Klinika Chirurgii Urazowej Paweł Grala

  4. US in rib frs. Time 13min. Klinika Chirurgii Urazowej Paweł Grala

  5. Flail chest complication Klinika Chirurgii Urazowej Paweł Grala

  6. Stove-in chest Klinika Chirurgii Urazowej Paweł Grala

  7. Pulmonary contusion • Blunt (blast shock wawes, falls from heights) or penetrating trauma (high velocity GSW) “Spalling effect” – shearing or bursting effect occurring at the gas/liquid interface (large differences in density) “Inertial effect” – low-density alveolar tissue is stripped from heavier hilar structures as they accelerate at different rates. “Implosion effect” - rebound or overexpansion of gas bubbles after a pressure wave passes • Interstitial and/or alveolar inj. without laceration– edema, alveolar haemorrhage, parenchymal destruction • Adequate perfusion, inadequate ventilation (mismatch → hypoxemia) - ↑airway resistance, ↓compliance • Initial CXR diagnostic (irregular patchy infiltrates) – progress in density over 48h (CXR 4-6 hours /CT earlier/, resolves in 5-7 days) ABGs, pulse oximetry, • Dyspnea, hemoptysis, chest pain, cough, tachypnea, rales, decreased breath sounds, tachycardia • Respiratory support with intubation and mechanical ventilation (often unusual ventilation modes), aggressive pulmonary toilet, positioning on uninvolved side, fluid restriction, no steroids or prophylactic antibiotics. Klinika Chirurgii Urazowej Paweł Grala

  8. Pulmonary contusion – X-ray Klinika Chirurgii Urazowej Paweł Grala

  9. Pulmonary contusion – X-ray5h later: subcutaneous emphysema, pneumomediastinum Klinika Chirurgii Urazowej Paweł Grala

  10. Pulmonary contusion – CT GSW Klinika Chirurgii Urazowej Paweł Grala

  11. Pneumothorax • Blunt or penetrating inj. • Decreased breath sounds (>25% of the lung collapsed) • Sucking chest wound – communicating ptrx (over 2/3 of tracheal diameter)  preferential air flow (lung collapses on inspiration and slighly expands on expiration)  occlusive dressing + chest tube • CXR diagnostic • Tension ptrx is a clinical diagnosis • In significant chest inj. + p.p. mechanical ventilation  prophylactic tube thoracostomy (prevention of tension P.) • Chest tube into II or IIIrd intercostal space in midclavicular line • Chest tube ineffictive  tracheobronchial disruption  diagnosis + thoracotomy Klinika Chirurgii Urazowej Paweł Grala

  12. Pneumothorax Klinika Chirurgii Urazowej Paweł Grala

  13. Tension pneumothorax Klinika Chirurgii Urazowej Paweł Grala

  14. 3% autopsies in trauma victimsMVAlate diagnosis in 25-70%tachypnoea, sc. emphysema, pthxpossible no air leak (incompleate inj., possible granulation with airway obstruction 2-6w)brochoscopyposterolateral thoracotomy V ics. L main stem bronchus disruption Klinika Chirurgii Urazowej Paweł Grala

  15. Klinika Chirurgii Urazowej Paweł Grala

  16. Subcutaneous emphysema Klinika Chirurgii Urazowej Paweł Grala

  17. Tracheobronchial disruption Klinika Chirurgii Urazowej Paweł Grala

  18. Tension pneumothorax Klinika Chirurgii Urazowej Paweł Grala

  19. Tension gastrothorax Klinika Chirurgii Urazowej Paweł Grala

  20. Hemothorax • Opacification on CXR (intercostal a., internal mammary, Th spine fr., lung laceration, mediastinal vessels) • Chest tube usually sufficient (IV or Vtdh intercostal space in anterior or midaxillary line)  bleeding self-limiting • Thoracotomy guidelines individualized: severe haemodynamic instability (ERT), initial drainage exceding 1,5L, ongoing drainage of 100ml/h over 6h • Coagulation, ligation, pulmonary tractotomy, pulmonary resection (hilar injury) – significant mortality • Air embolism in significant parenchymal injury (esp. on positive pressure ventillation): sudden cardiovascular collapse – steep Trendelenburg position, aspirate air from R ventricle, cardiovascular support • Great vessel injury (profound shock, sometimes pericardiac tamponade, retrosternal chest pain, dyspnea, new systolic murmur, pseudocoarctation s., on CXR – blunt inj.: widend mediastinum, obscured aortic knob, deviation of L stem brochus, opacification of aortopulmonary window, R deviation of nasogastric tube, I or IInd rib frs.) no diagnostic investigations in unstable patient aortography, contrast enhanced CT, echocardiography fluid restriction (blunt), thoracotomy Klinika Chirurgii Urazowej Paweł Grala

  21. Hemothorax Klinika Chirurgii Urazowej Paweł Grala

  22. Hemothorax Klinika Chirurgii Urazowej Paweł Grala

  23. Hemothorax Klinika Chirurgii Urazowej Paweł Grala

  24. Hemothorax Klinika Chirurgii Urazowej Paweł Grala

  25. Hemopneumothorax Klinika Chirurgii Urazowej Paweł Grala

  26. Chest tube drainage - thoracostomy Klinika Chirurgii Urazowej Paweł Grala

  27. Widend mediastinum Klinika Chirurgii Urazowej Paweł Grala

  28. Mediastinal pseudoaneurysm Klinika Chirurgii Urazowej Paweł Grala

  29. Klinika Chirurgii Urazowej Paweł Grala

  30. Flail chest - traction Klinika Chirurgii Urazowej Paweł Grala

  31. Flail chest Klinika Chirurgii Urazowej Paweł Grala

  32. Empyema • Stages (not separated – continuum): • exsudative • fibropurulent • organizing • CXR, US, CT • Control of infection with appropriate antibiotics, drainage (ev.streptokinaze), obliteration of pleural space, thoracotomy with decortication and pleurodesis Klinika Chirurgii Urazowej Paweł Grala

  33. Cardiac injury • usually penetrating inj. between midclavicular lines • pericardiac tamponade: shock, JVD (JVD ↑ with inspiration - Kussmaul`s sign), diminished (muffled) heart sounds (Beck`s triad), electrical alterans (varying amplitude of the R wave)  warrants operation (often ERT) • blunt c.inj.: history, inappropriate cardiovascular response to injury (EKG – normal excludes, abnormal  cardiac monitoring, echocardiography) advanced cardiac life support protocols operation for myocardial or valvular rupture, ventricular aneurysm Klinika Chirurgii Urazowej Paweł Grala

  34. Commotio cordis • fatality (SCD) due to blunt thoracic injury (usually caused by a hard projectile, such as a hockey puck or baseball) without gross structural damage to the heart or other intrathoracic organs, results in ventricular fibrillation aggravated by traumatic apnea. • trauma occurs during the vulnerable period of cardiac repolarization triggering the arrhythmia (VF). Most vulnerable phase of the cardiac cycle: T – wave  heart partially depolarized and then repolarized (electrically unstable) • more common in young athletes and children because they have more compliant chest walls, thus transmitting the energy from the projectile to the heart. Klinika Chirurgii Urazowej Paweł Grala

  35. Klinika Chirurgii Urazowej Paweł Grala

  36. Thoracotomy Klinika Chirurgii Urazowej Paweł Grala

  37. Pitfalls • Simple hemothorax  retained, clotted hemothorax with lung entrapement or empyema (if infected) • Diaphragmatic inj. are often overlooked  respiratory compromise, early or late entrapement and strangulation of abd. Contents • Evaluation of widend mediastinum requires cardiothoracic surgical capabilities • Underestimation of severe pathophysiology of rib frs. esp. in the elderly (aggressive pain control with no resp. depression) • underestimation of blunt pulmonary injury severety (pulmonary contusion is not always correlated with X-ray findings) Klinika Chirurgii Urazowej Paweł Grala

  38. Klinika Chirurgii Urazowej Paweł Grala

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