Aggressive Management of Chest Trauma. James Moore Cardiothoracic Anaesthetist & Intensive Care Specialist CCDHB

Transcription

1 Aggressive Management of Chest Trauma James Moore Cardiothoracic Anaesthetist & Intensive Care Specialist CCDHB

2 Outline Why is chest trauma important? Risk Assessment Which patients can go home? Management of blunt chest trauma Pneumothorax, Haemothorax & Penetrating chest trauma Cardiac & major vessel injury

3 Anatomy Bony & cartilaginous skeleton Protects an area containing organs of great importance! Lungs Heart Great vessels Oesophagus

4 Why is chest trauma important? Common - 10% admitted trauma patients have chest trauma Morbidity/mortality related to number of rib fractures >7 rib fractures = 30% mortality Higher ribs (1-3) indicative of higher energy mechanism association with more serious underlying injuries

5 Rib fractures 3 major problems: Pain Impaired gas exchange Altered breathing mechanics

6 Pain Chest wall highly innervated - therefore injuries are very painful Pain results in hypoventilation because of rib movement Causes low tidal volumes Predisposes to atelectasis, retention of pulmonary secretions and eventual pneumonia Providing adequate analgesia is a key goal in managing patients with chest trauma

7 Impaired gas exchange Force great enough to break ribs results in contusion to the underlying lung Contused lung becomes haemorrhagic & oedematous Cannot take part in gas exchange Image: trauma.org

8 Altered breathing mechanics Multiple rib fractures means the chest is unable to expand properly Especially important in context of a flail segment

9 Risk Assessment Severity of chest injury is related to: Number of ribs fractured Unilateral or bilateral Patient age Other injuries Other patient comorbidities

10 Do they need admission? Many patients with mild chest trauma can be managed in the community Like all decisions to discharge, take account of: Severity of injury Patient age & comorbidity Psychosocial factors, living situation, social supports

11 Discharge from ED Need to be able to mobilise and cough effectively Prescription for adequate analgesia & instructions on how to take it Clear guidance on when to seek review Inadequate analgesia to meet functional goals Signs of developing LRTI? Followup CXR with GP

12 Analgesia Key element of management of chest trauma Serial assessment of level of pain, and functional measures (cough, deep breath, get out of bed) Adjustment of analgesia based on those measures Multimodal approach - several agents, minimising adverse effects (especially sedation & delirium) APMS referral for all patients requiring admission

13 Analgesia NSAIDs have best evidence to prevent pneumonia in chest injury - Celecoxib Risk assessment to guide likely interventions If moderate-severe injury then 24/7 discussion with Acute Pain team or Anaesthesia

14 Analgesia Paracetamol Celecoxib First Line Analgesia (all patients unless contraindicated) 1g PO/IV QID, charted in regular section and First dose 400mg PO stat then 200mg PO once daily (regular) Notes: Use IV Paracetamol if not able to tolerate oral intake <50kg: Reduce doses Stat dose IV Parecoxib 40mg an option if unable to tolerate oral intake Celecoxib is also funded for outpatient management Short course of Celecoxib is well tolerated - avoid if CrCl<30ml/min, severe hepatic impairment; cautious use if high elevated cardiac risk - d/w APMS if unsure Tramadol Sevredol Persistent moderate pain on deep breathing/cough Consider PCA mg q4-6h PRN and/or 20mg q2h PRN, dose titration as required (start with 10mg in the elderly) Consider catheter-based regional analgesia Notes: Avoid using Tramadol in the elderly unless d/w APMS. If Tramadol is used, start at 50mg >75yrs or CrCl<30ml/min: Consider reducing dose and/or increasing dose interval of both tramadol (q8-12h) and sevredol (q4-6h) and monitor for adverse reactions. APMS may consider oxycodone for selected cases. Tramadol contraindicated with MAOI use; caution with SSRIs, epilepsy Sevredol: should be alert, RR>/=12. In younger patients consider titrating dose upwards or utilising PCA Use of long-acting opioids including fentanyl patches is discouraged without APMS review Moderate-severe pain despite above Urgent APMS/Anaesthetic Registrar review Notes: APMS phone: #6449 Duty anaesthetist phone: #6899 Catheter-based regional analgesia

15 Catheter-based techniques Thoracic epidural Paravertebral Erector spine plane block Serratus plane block

16 Adjuncts Antiemetics Metoclopramide + Ondansetron Bowel care Kiwicrush + Laxsol VTE prophylaxis Enoxaparin unless contraindicated

17 General Care Active mobilisation Oxygen may be required - humidified if possible PAR team referral for all moderate or severe chest injuries Monitor renal function Review medications incl. anticoagulants Followup chest X-ray

18 Pneumothorax Common following trauma Spectrum of injury from asymptomatic occult PTX through to profound cardiovascular compromise PTX visible on plain CXR following trauma usually requires placement of intercostal catheter Move towards medium sized (24-28Fr), even for those with haemothorax

19 Tension Pneumothorax Clinical diagnosis Awake patient: severe dyspnoea & air hunger + hypotension Intubated patient: Cardiovascular collapse

20 Tension Pneumothorax Signs Absent/reduced air entry on one side Distended neck veins (*maybe not if also hypovolaemic) Trachea deviated away from side of injury Hyper-resonance - unreliable in the resus bay. Percussion useful to differentiate PTX from HTX Bedside ultrasound (E-FAST)

21 Tension PTX Management Change in previous teaching Issues with 2nd ICS, MCL: poorly identified (too medial), vessel injury risk, depth to pleura New teaching: 4-5th ICS, between mid & anterior axillary line Be aware will not reach pleura in significant group of patients finger thoracostomy if needle unsuccessful (or transiently successful)

22 Small & Occult pneumothorax If small & asymptomatic may manage conservatively Occult = visible on CT but not CXR - conservative Need to clearly identify that it is there so if patient deteriorates can be managed Even if ventilated Role for small seldinger drain in these PTXs

23 Intercostal catheter insertion Sterile procedure Local anaesthesia + analgesia Stat dose cefazolin 1g if urgent insertion

24 Haemothorax Generally requires intercostal catheter placement (24-28Fr) Massive HTX = 1.5L drainage, or >200ml/hr d/w cardiothoracics Usually drainage is all that is required Ongoing significant bleeding may require surgery Retained HTX - failure to clear, or reaccumulation - lung stuck down, infected surgery

25 Penetrating Chest Trauma Beware risk of PTX, HTX and cardiac injury Discuss with cardiothoracics Consider cardiac tamponade - bedside ultrasound useful Figure 2: Box of Danger

26 Blunt aortic injury Risk factors: Older High energy (front seat, unrestrained, ejection or significant intrusion into vehicle) CXR signs - widened mediastinum, abnormal aortic knuckle, bleeding into left pleura (pleural cap, HTX), rightwards deviation of structures CT chest definitive investigation

27 Blunt cardiac injury Includes myocardial contusion, rupture (wall or valve), MI (incl coronary dissection) Consider as precipitating cause for trauma in elderly Usually associated with high energy trauma to chest (sternal fractures) Screening ECG - non-specific abnormalities most common Consider echo if unexplained shock No role for troponin monitoring unless ischaemia considered ECG monitoring x24hrs

28 Rib fracture fixation

29 SUMMARY Undertake a risk assessment on all patients Ensure adequate analgesia plan to minimise risk of hypoventilation All patients admitted to hospital with chest trauma should be referred to APMS Key functional goals: deep breath cough get out of bed

30 Questions?