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Thoracic Trauma

Thoracic Trauma. Epidemiology. Significant cause of mortality; representing 20-25% of all deaths from trauma Early deaths (30 min to 3 hrs) from thoracic trauma are often preventable due to reversible causes

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Thoracic Trauma

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  1. Thoracic Trauma

  2. Epidemiology • Significant cause of mortality; representing 20-25% of all deaths from trauma • Early deaths (30 min to 3 hrs) from thoracic trauma are often preventable due to reversible causes • Most of these causes can be managed by ED physicians, with less than 10% of blunt & 15-30 % of penetrating requiring thoracotomy

  3. Pathophysiology • Hypoxia, hypercarbia, and acidosis often result from chest trauma • Hypoxia: blood loss, pulmonary ventilation/perfusion mismatch (contusion, hematoma, alveolar collapse), intrathoracic pressure relationships (tension pneumo, open pneumo) • Hypercarbia: inadequate ventilation & depressed level of consciousness • Metabolic acidosis: hypoperfusion of tissues

  4. Initial Assessment & Management • Hypoxia is the most serious feature of chest injury & early interventions need to correct it • Most life threatening injuries treated by airway control or chest tube/needle decompression • Secondary survey should be driven by the injury pattern & high index of suspicion

  5. Primary Survey: Airway • ABCs & MAJOR PROBLEMS SHOULD BE CORRECTED AS THEY ARE IDENTIFIED • Listen to air movement: nose, mouth, lung fields, inspect the oropharynx • Skeletal trauma, such as a posterior dislocation or fracture/dislocation of the SC joint – closed reduction may be achieved with extending the shoulders, grasping the clavicle with a towel clip

  6. Normal AP of a patient with a posterior dislocation of the clavicle. www.jortho.org/2007/4/3/e14/index.6.jpg

  7. Scan reveals the separation of both clavicles from their sternal attachments with posterior displacement www.jortho.org/2007/4/3/e14/index.6.jpg

  8. Primary Survey: Breathing • Chest & Neck completely exposed! • Assess respiratory movement & quality of respirations • Cyanosis is a late sign of hypoxia • Shallow respirations & respiratory rate may be the only signs of impending respiratory distress

  9. Primary Survey: Breathing • These major thoracic injuries should be recognized and addressed during the primary survey • Tension pneumo • Open pneumo • Flail chest • Massive hemothorax

  10. Tension Pneumothorax • One-way-valve/air leak occurs from the lung or chest wall without any escape causing collapse of the lung, mediastinum displacement, decreasing venous return, & compressing the opposite lung • THIS IS A CLINICAL DIAGNOSIS • Chest pain, air hunger, respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral absence breath sounds, distended neck veins, & cyanosis • Difficult to differentiate from cardiac tamponade, but hyperresonant percussion & absent breath sounds are more likely with a pneumo

  11. Tension Pneumothorax • Immediate decompression by inserting a 16-18 gauge needle through the 2nd or 3rd interspace anteriorly (mid clavicular line) or laterally 4th-5th intercostal space www.emsresponder.com www.med.yale.edu www.med.yale.edu/.../graphics/rad1.gif

  12. Open Pneumothorax • Open chest wall equilibrates intrathoracic and atmospheric pressure if the opening is approximately two-thirds the diameter of the trachea • Management: closing the defect with a sterile occlusive dressing taped on 3 sides; chest tube inserted placed on the same side at a remote location to the wound

  13. Primary Survey: Breathing • Flail Chest: segment of chest wall does not have a boney continuity with the rest of the thoracic cage; results from 2 or more ribs fractured in 2 or more places • Severe disruption of normal chest wall motion & usually underlying pulmonary contusion • Paradoxical motion of the chest wall is hallmark, but may not be dramatic due to muscle splinting • 30% of cases are not diagnosed until 6 hours after admission • CT much better at diagnosing & addressing the extent of pulmonary contusion

  14. Flail Chest Management • Oxygen, aggressive pulmonary physiotherapy, effective analgesia, selective use of intubation, & close observation in the ICU or step down unit • Indications for Intubation: clinical signs of respiratory fatigue, RR >35 or <8, PaO2 < 60 @ FiO2 >.5, PaCO2 >55 @ FiO2 >.5, AA gradient >450, sever shock, associated severe head injuries, age >65 or previous pulmonary disease

  15. Primary Survey: Circulation • Physical Exam: • Pulse – quality, rate, regularity, peripheral pulses • Blood pressure & pulse pressures • Skin color & temperature • Neck veins – may not be distended in hypotensive patients with tamponade, tension pneumo, & diaphragmatic injury • Major injuries that should be diagnosed in the Primary Survey • Massive hemothorax & Cardiac Tamponade

  16. Massive Hemothorax • Rapid accumulation of more than 1500mL of blood or 1/3 the patients blood volume or >200 mL/hour for 3 hours • Associated with pneumo 25% • Usually from penetrating chest trauma injuring lung parenchymal vessels most common source (self limiting); intercostal & internal mammary 2nd most common, and rarely hilar vessels • Shock, absent breath sounds, dullness to percussion are signs

  17. Massive Hemothorax • 200-300 mL required to blunt costophrenic angles on upright chest X-ray • Supine views can miss large collections of blood www.learningradiology.com/.../cow265lg.jpg

  18. Hemothorax Management • Blood should be removed as completely & rapidly as possible • 32-40 fr Chest tube inserted anterior axillary line & directed posteriorly and laterally • Antibiotics are controversial, however empyema rate decrease 9.4% to 0.8% in one study & intrathoracic infections decreased 17.5% to 2.9% in another

  19. Hemothorax Management • Indications for Thoracotomy • Initial drainage >20mL/kg • Persistent bleeding >7mL/kg/hr • Increasing hemothorax via x-rays • Vital signs remain unstable without any other source of bleeding and adequate resuscitation • Indications for ED Thoracotomy • Penetrating Traumatic Cardiac arrest with signs of life in the field; BP <50 after resuscitation; shock & signs of tamponade • Blunt Trauma Cardiac arrest in the ED • Suspected air embolus • *ATLS Manual 7th Ed. “Thoracotomy is not indicated unless a surgeon, qualified by training and experience, is present. • Consider auto transfusion

  20. Cardiac Tamponade • 2% incidence after penetrating trauma, rare with blunt trauma • PE: hypotension, distended neck veins, muffled heart sounds (BECK’s) • Most reliable sign is CVP >15 with associated hypotension & tachycardia • Pulsus paradoxus: decline in systolic BP >10 mmHg on inspiration • Ultrasound: sensitivity 98% Specificity 99.9% • ECG: Electrical alternans is highly specific marker, but rare in acute tamponade • Chest x-ray rarely helpful in acute tamponade, classic “water-bottle” seen in chronic pericardial effusions

  21. Cardiac Tamponade www.ecglibrary.com www.nypemergency.org www.flickr.com

  22. Cardiac Tamponade • Management: • Volume expansion with crystalloid • Pericardiocentesis if clinical deterioration; aspiration of 5-10 mL may cause improvement • Pericardiocentesis should be done under ultrasound if available and with ECG monitoring • Toracotomy indications as described earlier

  23. Secondary Survey • Requires further in-depth physical examination, with some studies already discussed in conjunction with the previous comorbidities • HEAD to Toe examination with adjuncts: upright chest, CTs, ABGs, ECGs • Eight Lethal injuries that need to be discussed that are not always obvious on PE

  24. Eight Lethal Injuries with the Secondary Survey • Simple Pneumothorax • Hemothorax • Pulmonary contusion • Tracheobronchial Tree Injury • Blunt Cardiac Injury • Traumatic Aortic Disruption • Traumatic Diaphragmatic injury • Mediastinal Traversing Wounds

  25. Simple Pneumothorax • 1st – in the setting of a minor penetrating trauma and initial negative exam & chest x-rays, the patient can be observed for 3-6 hours, have x-rays repeated & DC • Isolated simple pneumothoraces <25%, in an asymptomatic patient can be observed • However, general anesthesia or pos pressure ventilation should never be done in these patients without a chest tube (1/3 will progress)

  26. Simple Pneumothorax • Indications for tube thoracotomy • Traumatic pneumo • Mod-large pneumo • Respiratory symptoms regardless of size • Increasing size with conservative tx • Recurrence of pneumo after removal of a chest tube • Patient requires ventilator support • Patient requires general anesthesia • Associated hemothorax • Bilateral pneumo regardless of size • Tension pneumo

  27. Simple Pneumothorax • Catheter aspiration can be attempted • Simple pneumo 24-28 Fr tube thoracotomy, if significant air leak under water-seal then constant vacuum @20-30 ccH2O

  28. Tracheobronchial Tree Injury • Can occur in penetrating or blunt trauma, but rare (<3% of all trauma) • Mortality rate 10% if missed • If blunt trauma, usually occurs 2 cm from the carina • Massive air leak, hemoptysis, & subcutaneous emphysema • Hamman crunch may be audible

  29. Tracheobronchial Tree Injury • 2 Clinical Pictures • Injury opens up into pleural space & causes continuous air leak, not allowing tube thoracotomy to expand the lung & constant bubbling on water seal • Complete transaction of tracheobronchial tree without a pneumo and patient is relatively symptoms free for 1-3 weeks, but presents later with atelectasis and pneumonia

  30. Tracheobronchial Tree Injury • Pneumomediastinum, subcutaneous emphysema, fracture of the upper ribs, air surrounding the bronchus all suggest the diagnosis • >1 chest tube may be needed to overcome air leak • Bronchoscopy should be performed • Intubation over a bronchoscope can aid in opposite main step intubation or intubation distal to the injury • Surgery is needed to repair the wound

  31. Traumatic rupture, tracheobronchial tree www.medcyclopaedia.com/upload/medcyc/volumes/...

  32. Pulmonary Contusion • Most common potentially lethal chest injury • Occurs in 30-75% of significant blunt chest trauma • Bruise of the lung parenchyma with alveolar edema and hemorrhage • Dyspnea, tachypnea, cyanosis, tachycardia, hypotension are all common, with hemoptysis present in 50% • Common in children, without associated Fx • Can be overlooked due to other dramatic findings on x-ray • CT very sensitive & findings usually present in initial 6 hours and lasts 48-72 hours

  33. Pulmonary Contusion • Patients with persistent hypoxia (PaO2 <65, SaO2 <90% RA) should be considered for early intubation. • Restriction of intravenous fluids, aggressive pulmonary toilet, suctioning, and pain control improve outcomes • Pneumonia is the most common complication, but prophylactic antibiotics is not recommended

  34. Pulmonary Contusion www.learningradiology.com/.../cow167arr.jpg

  35. Traumatic Diaphragmatic Injury • More common on the left side • Blunt trauma can produce tears allowing acute herniation, while penetrating trauma produces small perforations and may take years for herniation to occur • If suspected, place an NG & this will appear in the thorax • Upper gastrointestinal contrast studies can be performed in unclear cases • Treatment is direct repair

  36. Diaphragmatic Rupture with Tension Gastrothorax bp2.blogger.com/.../s400/gastrothorax1.jpg

  37. Blunt Cardiac Injury • No gold standard for diagnosing blunt injures • Accounts for 25% of all deaths at the scene in blunt trauma • 15-25% incidence in blunt chest trauma • Wide spectrum of injuries: pericardial tears, rupture of a chamber causing tamponade, valvular injuries, contusion, laceration of cardiac arteries

  38. Blunt Cardiac Injury • Contusion • Look for external signs of trauma • Important sequelae are hypotension, conduction abnormalities, wall motion abnormality on 2-d echo • MI is very rare • Common conduction abnormalities: PVCs, sinus tach, afib, bbb, & nonspecific ST changes • Diagnosis made by appropriate clinic setting with new ECG findings, arrhythmia, HF, decreased EF, or increased CPK-MB & troponins, but new anterior wall motion abnormality is most definitive finding • If initial ECG is normal and repeat in 24 hours normal, highly unlikely any complications will occur

  39. Traumatic Aortic Disruption • Common cause of sudden death • Salvage may be possible if recognized early • 80-90% of tears in the descending aorta • Severe deceleration injury causes injury • 1/3-1/2 of these patients have no external signs of injury! • Most common symptoms are interscapular or retrosternal pain, but clinical signs are uncommon & nonspecific • Reflex HTN is common as well as HTN in the upper extremities and diminished femoral pulses

  40. Traumatic Aortic Disruption • Widen mediastinum is the most sensitive sign and is 50-92% (specificity 10%) • Other causes of widen mediastinum: spinal fx, sternum fx, bleeding clavicular fx, previous mediastinal mass • Mediastinal width > 6 cm in the erect PA film or > 8 cm in the supine AP film or > 7.5 cm at the aortic knob • Obscured aortic knob, no AP window, displaced NG tube, widened rt. Paratracheal stripe may be the most specific signs • False negative rate 7-10% • Helical CT almost 100% sensitivity & specificity • Diagnose and then get them out of your ER

  41. Widened Mediastinum www.itim.nsw.gov.au www.scienzemedicolegali.it/.../image034.jpg

  42. Mediastinal Traversing Wounds • Diagnosis is made when careful examination of the chest x-ray reveals entrance wound in one hemithorax & an exit or missile in the other • Surgical consultations is mandatory • Bilateral tube throacostomy should be performed if hemodynamically abnormal patients • Thoracostomy indications as described earlier

  43. Mediastinal Traversing Wounds • Hemodynamically normal patients, with normal chest x-rays need intensive evaluation • Helical CT & water contrast esophagography should be performed • If unstable at any time restart ABCDEs • Overall mortality rate for mediastinal penetrating wounds is 20% & this doubles if they present hemodynamically abnormal

  44. Mediastinal Traversing Wounds • Special Note: Esophageal Perforations • Mortality almost 100% if not DX in 24 hours, if before ~30% • Most Common Causes (in order) • Iatrogenic • Foreign bodies • Caustic burns • Blunt or penetrating trauma • Spontaneous rupture (Boerhaave’s Syn) • Postoperative breakdown of anastomosis

  45. Esophageal Perforations • Most reliable symptom is pleuritic pain localized along the esophagus • Mediastinal air may surround the heart to produce Hamman’s crunch • Subcutaneous emphysema may be present • Cardiopulmonary collapse and sepsis may be the initial presentation • Dx: X-ray, and gastrografin study, or urgent endoscopy • TX: broad-spectrum antibiotics, volume replacement, airway maintenance

  46. Subcutaneous Emphysema www.ispub.com/.../ijra/vol4n1/jdms-fig3.jpg

  47. Fractured Bones • Ribs • 1-3 associated with significant force • 4-8 associated with underlying pulmonary contusion • 9-12 associated with intra-abdominal pathology • Diagnosis can be made clinically with tenderness, bony creptitus, ecchymosis, and muscle spasm over the ribs

  48. Fractured Ribs • Indications for Rib X-ray studies • Suspected rib 1-2 Fx or 9-12 • Multiple rib fx • Elderly patient • Preexisting pulmonary disease • Suspected pathologic fracture • Individuals with suspicion of underlying pathology & 1st/2nd rib fx should have a helical chest CT

  49. Rib Fractures • Heal in 3-6 weeks • Analgesia usually necessary for 1-2 weeks • Binders, belts, and restrictive devices should not be used • Patients with displaced fractures or multiple fractures should be observed

  50. Sternal Fractures • Due to anterior blunt chest trauma • Isolated fractures are benign • Cardiac contusion in 1.5-6% • Spinal fractures in <10% • Rib fractures in 20% • Difficult to diagnose on X-ray, unless displaced fx • Associated injuries may be assessed with CT of the Chest, ECG, and enzymes • Management: Adequate analgesia

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