TO CUT OR NOT TO CUT!

1. TO CUT OR NOT TO CUT!

2. “45 year old man, involved in road traffic accident as front seat passenger, restrained, no airbag. Trapped in his car for 40 minutes. Airlifted to hospital.

3. “In resus, no external injuries, haemodynamically stable, GCS 15 and appropriate, complaining of central chest tenderness. C-spine, pelvis normal. Chest X-Ray, slightly widened mediastinum. Abdo ultrasound – no free fluid. No pericardial fluid. “25 minutes into resus, EMD arrest, which recovered spontaneously, then VF arrest x2,…”

4. HOW WOULD YOU HANDLE THIS SITUATION?

5. THIS IS WHAT THEY DID...

6. “….responded to DC shock and adrenaline. Continued to arrest every few minutes, either EMD or VF, despite adrenaline infusion and fluid administration. CVP catheter read 25 cmH2O.”

7. Case Courtesy of: Dr. KarimBrohiBSc FRCS FRCA Trauma & Critical Unit Royal London Hospital

8. THORACIC TRAUMA Joanne (“Dr. J”) Williams, MD, FAAEM Clinical Associate Professor of Emergency Medicine Charles Drew University of Medicine & Science Keck School of Medicine of USC Los Angeles, California

9. “ESSENTIALS” OF CHEST TRAUMA • Less than 10% of blunt chest trauma patients require thoracic operations. • Radiographs do not reliably exclude rib fracture or other complications. • Multi- slice CT is a useful screening and diagnostic tool for intra-thoracic injuries in ‘stable’ high- risk patients

10. “ESSENTIALS” OF CHEST TRAUMA • Adequate analgesia is essential to prevent complications from chest-wall injury. • Needle thoracocentesis is an unreliable means of decompressing the chest of an unstable patient and should only be used as a technique of last resort.

11. “ESSENTIALS” OF CHEST TRAUMA • Blunt dissection and digital decompression of the pleura is the essential first step for pleural decompression. Drainage and insertion of a chest tube is a secondary priority • Pleural decompression and chest tube insertion during resuscitation is a procedure with a low complication rate.

12. “ESSENTIALS” OF CHEST TRAUMA • Resuscitative thoracotomy should be restricted to those patients likely to benefit. There is clearly a role for resuscitative thoracotomy in shocked patients with sonographic evidence of cardiac tamponade.

13. INTRODUCTION • The majority of chest trauma patients may be managed non-operatively. • Only 10% of blunt thoracic trauma patients will require thoracotomy, the remainder requiring supportive care including pleural decompression and drainage.

14. PREVENTABLE MORBIDITY & MORTALITY ISSUES • Delayed or inadequate ventilatory resuscitation, • Inadequate shock management, • Insufficient monitoring of arterial blood gases, and • Delay or failure to perform pleural decompression and drainage • McDermott F 1994 Severe chest injuries: problems in Victoria. Issues and controversies in the early management of major trauma. Alfred Hospital and Monash University Department of Surgery, Melbourne • Danne P, Brazenor G, Cade R, et al 1998 The Major Trauma Management Study: an analysis of the efficacy of current trauma care. Australian and New Zealand Journal of Surgery 68: 50–7

15. CONTROVERSY • Regarding the place of aggressive fluid resuscitation in chest trauma with penetrating trauma, which may exacerbate uncontrolled intra-thoracic bleeding. • It is certainly NOT a substitute for early operative intervention. • Civil I 1993 Resuscitation following injury: an end or a means? Australian and New Zealand Journal of Surgery 63: 5–10

16. LIFE THREATENING INJURIES(“5 Minute Killers”) • Flail chest • pulmonary contusion • thoracic aortic injury • Pneumothorax • Haemothorax • Pericardial tamponade, • Respiratory insufficiency secondary to rib fractures • Ruptured hemi diaphragm

17. LIFE THREATENING INJURIES(“5 Minute Killers”) • These diagnoses must to be pursued and actively excluded! • Multi- slice CT is a useful screening and diagnostic test for ‘stable’ patients at high risk of potential life- threatening injuries, in additional to the initial supine chest X-ray • Mirvis SE 2005 Imaging of acute thoracic injury: The advent of MDCT screening Seminars in Ultrasound, CT and MRI 26: 305-331.

18. LIFE THREATENING INJURIES(“5 Minute Killers”) AT-RISK PATIENTS Patients with underlying airway disease The elderly

19. CHEST WALL INJURY

20. RIB FRACTURES

21. RIB FRACTURES • Common sequelae of focal trauma. • Cause pain • May then interfere with ventilation and coughing, causing ventilatory impairment and atelectasis. • This impairment may not be manifest for hours and occasionally days post injury.

22. RIB FRACTURES • Lower left rib fractures are associated with splenic injury, • Lower right with hepatic injury • Lower posterior ribs with renal injury. • The first and second ribs are stronger and less easily injured • Usually indicative of significant force to the upper mediastinum.

23. RIB FRACTURES • Diagnosis based on the clinical findings of local rib tenderness with or without deformity and crepitus. • Up to 50% of fractured ribs are not apparent on the initial chest X-ray. • A follow-up film is recommended to improve sensitivity. • Hehir MD, Hollands MJ, Deane SA 1990 The accuracy of the first chest X-ray in the trauma patient. Australian and New Zealand Journal of Surgery 60:529–32

24. MANAGEMENT OF RIB FRACTURES • Pain relief • Minimizing pulmonary sequelae • Actively excluding associated injury. • Oral analgesics usually provide adequate pain relief for single rib fractures.

25. MANAGEMENT OF RIB FRACTURES • Multiple rib fractures often require local anaesthetic intercostal blocks, epidural analgesia and narcotic infusions to improve ventilation • Particularly in the elderly patient. • Breathing exercises, coughing and incentive spirometry minimize subsequent atelectasis.

26. FRACTURED STERNUM

27. FRACTURED STERNUM • This is a clinical diagnosis confirmed on lateral chest X-ray. • As with rib fractures, concern centres on associated intrathoracic injuries, • Specifically myocardial and other mediastinal injuries. • Isolated sternal fractures admission for analgesia is usually required • 1–2 days is usually all that is required

28. FRACTURED STERNUM

29. FLAIL CHEST

30. FLAIL CHEST • Free-floating segment of ribs that are no longer connected to the rest of the thorax • Two or more locations on the same rib • Three or more adjacent ribs anteriorly or laterally

31. FLAIL CHEST • Characterized by paradoxical movement of the associated unanchored chest wall segment. • Because of muscular spasms and splinting this segment may not be apparent initially, and may flail some time after the accident. • Clinical features of a flail segment may also be masked by positive pressure ventilation which internally splints the chest wall.

32. FLAIL CHEST • Flail chest is often associated with ventilatory insufficiency. • Ventilatory disturbance is caused by hypoventilation of the affected hemi thorax due • Mechanical disruption and • Associated pain, compounded by the underlying pulmonary contusion.

33. LITTLE FLAIL MAY BE APPARENT IMMEDIATELY AFTER INJURY!

34. Lung compliance falls More pressure is needed to inflate the lungs Increasing pressure differential between intrathoracic and atmospheric pressure May overcome the resistance of the muscles attached to the fractured ribs thereby Increasing paradox LATER…AS FLUID MOVES INTO THE AREA OF CONTUSION

35. DECREASING EFFICIENCY OF VENTILATION HYPOXEMIA INCREASING FATIGUE SUDDEN RESPIRATORY ARREST

36. THERAPY FOR FLAIL CHEST • Maintaining oxygenation, ventilation and euvolaemia. • Adequate analgesia should be supplemented with intercostal nerve blocks or epidural analgesia. • Patients with a significant flail, which impairs ventilation, will require intubation and positive-pressure ventilation or pressure support.

37. UNDER INVESTIGATION Use of malleable reabsorbable splints for the flail segment

38. If the PO2 remains less than 80 mmHg on supplemental oxygen, then… Ventilatory support is warranted!

39. EFFECT OF POSITIVE PRESSURE VENTILATION WITH FLAIL CHEST

40. FLAIL CHEST WITHPULMONARY CONTUSION

42. ASYMMETRY DUE TO FLAIL CHEST

43. RUPTURED HEMIDIAPHRAGM

44. RUPTURED HEMIDIAPHRAGM • Diaphragmatic rupture may be difficult to diagnose. • High-velocity injuries with lateral torso trauma or thoracoabdominal crush injuries should alert the clinician to the possibility of underlying diaphragmatic injury.

45. RUPTURED HEMIDIAPHRAGM INCREASED INCIDENCE ASSOCIAITED WITH... Lateral Rib Fractures Penetrating Left Upper Quadrant Wounds Fractured Pelvis

46. RUPTURED HEMIDIAPHRAGM • Placement of a radio-opaque nasogastric tube will facilitate the diagnosis of left hemi diaphragmatic disruption on chest X-ray.

47. RUPTURED HEMIDIAPHRAGM • Although gross rupture may be apparent initially, the classic radiological findings of viscera in the thoracic cavity, the nasogastric tube coiled in the thoracic cavity, or marked hemi diaphragm elevation are present only 50% of the time, with no intrathoracic pathology seen on 15% of occasions. • Brasel KJ, Borgstrom DC, Meyer P, Weigelt JA 1996 Predictors of outcome in blunt diaphragm rupture. Journal of Trauma 41: 484–7.

48. RUPTURED HEMIDIAPHRAGM • Spiral CT scan will display gross disruption but may miss small defects. Diagnostic yield may be better with multi- slice CT or MRI10. • Mirvis SE 2004 Diagnostic imaging of acute thoracic injury Seminars in Ultrasound, CT and MRI 25: 156-179.

49. RUPTURED HEMIDIAPHRAGM • Occult diaphragmatic lacerations are associated with penetrating injuries of the thoracoabdominal region • Should be actively excluded by laparoscopy, thoracoscopy or open operation. • The treatment of diaphragmatic disruption is operative repair.

50. DIAPHRAGMATIC INJURY