Priorities in Penetrating Chest Trauma
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1 Priorities in Penetrating Chest Trauma K. Inaba, MD FRCSC FACS Division of Trauma Surgery & Critical Care LAC+USC Medical Center University of Southern California
2 ü None. DISCLOSURES
3 OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax
4 OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax
5 Penetrating Chest Injury Arresting Unstable Stable
6 Penetrating Chest Injury Arresting Unstable Stable
7 Penetrating Chest Injury Arresting Unstable Stable ED Thoracotomy Right Chest Tube
8 2001 ü 25 year review, 4,620 EDT ü Overall Survival 7.4% ü Normal Neurologic Function 92.4%
9 2001 ü 25 year review, 4,620 EDT ü Overall Survival 7.4% ü Normal Neurologic Function 92.4% ü Really Depends on: Mechanism Location
10 Survival By Mechanism 18% 16% 14% Survival 12% 10% 8% 6% 8.8% 4% 2% 0% 1.4%
11 Survival By Mechanism 18% 16% 16.8% 14% Survival 12% 10% 8% 6% 8.8% 4% 2% 0% 1.4% 4.3%
12 Injury Location 12% 10% 10.7% Survival 8% 6% 4% 2% 0% 4.5% 0.7% Thoracic Abdominal Multiple
13 Injury Location 12% 10% 10.7% Isolated Cardiac = 19.4% Survival 8% 6% 4% 2% 0% 4.5% 0.7% Thoracic Abdominal Multiple
14 2015 ü Pro, 187 trauma arrests ü Survivors 3.2%, Donors 1.6% ü FAST prior to EDT ü Ability of cardiac motion/fluid to detect survivors and donors?
15 2015 ü Cardiac Motion/Fluid Sensitivity 100% Specificity 73.7% ü FAST able to identify all survivors, avoid 59% futile EDTs ü Likelihood of survival if both motion/fluid absent is zero
16 EDT INTERVENTIONS ü Release Tamponade ü Repair Cardiac Injury ü Control Hilar Bleeding ü Cross Clamp Aorta ü Restart Heart
17 EDT INTERVENTIONS ü Release Tamponade ü Repair Cardiac Injury ü Control Hilar Bleeding ü Cross Clamp Aorta ü Restart Heart
18 Penetrating Chest Injury Arresting ER Thoracotomy Right Chest Tube Unstable Stable
19 Stable Critical Actions 1. General ü Airway/Oxygenate ü IV/BW/Monitors 2. What is at risk of injury? ü External wounds. ü Plain radiography for missile localization and trajectory mapping.
20 Stable Critical Actions 1. General ü Airway/Oxygenate ü IV/BW/Monitors 2. What is at risk of injury? ü External wounds. ü Plain radiography for missile localization and trajectory mapping.
21 Don t Forget the Back
22 For SWs CXR usually sufficient
23 RETAINED FRAGS HEMOTHORAX PNEUMOTHORAX
24 For GSWs also check back
25 For GSWs 1. External holes 2. Internal fragments Everything in between is at risk of injury CT
26 OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax
27 OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax
28 Diagnosing Cardiac Injury ü Clinical Exam Restless Shock Tachycardia Beck s triad ü CXR Enlarged heart shadow Pneumopericardium Widened mediastinum ü CVP, ECG ü Pericardiocentesis Unacceptable Sensitivity & Specificity
29 Ultrasound Advantages ü Non-invasive ü Radiation ü Repeatable ü Portable ü Rapid ü Cost effective
30 Heart Video
31 ü Prospective truncal SW or GSW ü No indication for emergent OR ü Non-radiologist performed FAST 1996
32 ü 247 consecutive pts (121 GSW, 126 SW) 100% SENSITIVITY 100% SPECIFICITY ü Pericardium not visualized in one pt Heart Injury No Heart Injury FAST FAST 0 236
33 Summary FN=0 Author Year Journal Design n TN TP FN FP Sensitivity Specificity Rozycki GS 1996 Ann Surg Prospective % 100.0% Rozycki GS 1998 Ann Surg Prospective % 99.3% Rozycki GS 1999 J Trauma Prospective % 97.0% Patel AN 2003 Ann Thorac Surg Retrospective % 99.3% Tayal VS 2004 J Ultrasound Med Prospective % 100.0% TOTAL % 99.0%
34 2009
35 Watch out for ü Large Hemothorax ü Continuous CT output Repeat FAST or do TTE
36 Penetrating Cardiac Injury ü Ultrasound has near perfect sensitivity and specificity ü Positive=sternotomy ü Equivocal=repeat, formal TTE, pericardial window ü Negative=beware the Hemothorax or ongoing CT output
37 Penetrating Cardiac Injury ü Ultrasound has near perfect sensitivity and specificity ü Positive=sternotomy ü Equivocal=repeat, formal TTE, pericardial window ü Negative=beware the Hemothorax or ongoing CT output
38 Penetrating Cardiac Injury ü Ultrasound has near perfect sensitivity and specificity ü Positive=sternotomy ü Equivocal=repeat, formal TTE, pericardial window ü Negative=beware the Hemothorax or ongoing CT output
39 Penetrating Cardiac Injury ü Ultrasound has near perfect sensitivity and specificity ü Positive=sternotomy ü Equivocal=repeat, formal TTE, pericardial window ü Negative=no injury but beware the large Hemothorax or ongoing CT output
40 OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax
41 Trans-Mediastinal Injury Traditional approach ü Unstable=OR ü Stable=Full Diagnostic Evaluation ü Pan-endoscopy ü Contrast swallow ü Angiography ü Echo
42 Trans-Mediastinal Injury Traditional approach ü Unstable=OR ü Stable=Full Diagnostic Evaluation ü Pan-endoscopy ü Contrast swallow ü Angiography ü Echo TIME CONSUMING AND EXPENSIVE
43 Retrospective, n=22. Stable TM-GSW. CT initial diagnostic test. ü 32% Positive CT, 9% required OR ü 68% Negative CT rate ü 100% NPV
44 Retrospective, n=22. Stable TM-GSW. CT initial diagnostic test. ü 32% Positive CT, 9% required OR ü 68% Negative CT rate ü 100% NPV
45 Trans-Mediastinal GSW? Unstable..OR? Stable..FAST and CTA ü Cardiac FAST ü CT Angiogram
46 Trans-Mediastinal GSW? Unstable..OR? Stable..FAST and CTA ü Cardiac FAST ü CT Angiogram
47 Trans-Mediastinal GSW? Unstable..OR? Stable..FAST and CTA ü Cardiac FAST ü CT Angiogram
48 Trans-Mediastinal GSW? Unstable..OR? Stable..FAST and CTA ü Cardiac FAST Positive=Sternotomy Negative=go to CTA ü CT Angiogram
49 Trans-Mediastinal GSW? Unstable..OR? Stable..FAST and CTA ü Cardiac FAST ü CT Angiogram Trajectory clear=done Injury=OR Equivocal=Bronch/DL, Angio, EGD, Swallow
50 OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax
51 2012 ü Pro, n=353 acute CT inserted ü 28-32Fr v Fr ü Same blood drainage ü Same duration ü Same complication rate ü Same pneumonia & empyema
52 2012 ü Same RHTx ü Same need for new tube ü Same IR rate ü Same VATS rate ü Same Thoracotomy rate Size did not matter
53 2014 ü RCT, n=40 pneumothorax ü 14Fr pigtail v 28Fr CT ü Pigtail-pain significantly less ü Duration of insertion, success and complications same
54 2012 ü Prospective, n=36 ü 14Fr Pigtail v historic 32-40Fr Chest Tubes ü Ability to drain acute HTx?
55 2012 ü Same initial output ü Same insertion complications ü Same failure rate ü Same tube duration Pigtails effective drains?
56 Chest Autotransfusion ü Cheap. ü Fast. ü Warm. ü Whole blood.
57 Autotransfusion Bacterial contamination? Red cell breakdown products? Inflammatory contents? O2 Delivery Capacity? VS. ü Cheap, fast ü Warm ü Fresh ü Factors ü Virus neutral ü ABO
58 Autotransfusion Bacterial contamination? Red cell breakdown products? Inflammatory contents? O2 Delivery Capacity? VS. Cheap, fast Warm Fresh Factors Virus neutral ABO
59 2015 ü Multicenter, retrospective ü N=272, propensity score ü +/- Autotransfusion with CPD
60 2015 ü ND mortality ü ND complications ü ND 24h INR ü Less RBC required ü Less Platelets required ü Less cost of transfusion
61 2015 ü ND mortality ü ND complications ü ND 24h INR ü Less RBC required ü Less Platelets required ü Less cost of transfusion
62 Autotransfusion ü Citrate phosphate dextrose (CPD) in all collection systems 1mL/7mL blood.
63 DISCHARGING THE STABLE PT
64 DISCHARGING THE STABLE PT ü Stable ü Examinable ü Isolated thoracic injury ü Negative U/S+CXR
65 DISCHARGING THE STABLE PT ü Stable ü Examinable ü Isolated thoracic injury ü Negative U/S+CXR When can we d/c home?
66 ü Prospective ü Penetrating chest injury ü 15 months, n=116 (93SW/23GSW) ü Normal admission CXR and no indication for CT or OR ü Repeat 3 and 6 hrs
67 ü 0.9% developed PTx on 3hr CXR requiring CT insertion ü Follow-up CXR is warranted ü No new findings on 6hr CXR
68 2008 ü Prospective, 36 months ü 100 asymptomatic, normal admission CXR ü 75% SW, 25% GSW
69 2008 ü 2% delayed PTx ü All diagnosed on 3hr CXR ü D/C by 8.8+/-2.6hrs Normal 3hr CXR = D/C home
70 2013 ü 88 prospective sw/gsw chest ü Normal initial CXR ü Repeat ordered 1 & 3hrs ü Done at 1hr 34min: 2.3% PTx ü No new information at 3 hrs Normal 1hr CXR = D/C home
71 Penetrating Chest Injury Arresting Unstable Stable ER Thoracotomy Right Chest Tube Cardiac U/S X-Rays +/- CT +/- L-scope
72 The Unstable Patient
73 Unstable-Critical Actions ü Start crystalloid resuscitation. ü Initiate cross-matching. ü Stabilize ü Arrest ü Remain Unstable
74 Unstable-Critical Actions ü Remain unstable. ü Start uncross-matched or type specific blood. ü Start thawing FFP.
75 Unstable-Critical Actions 1.Localize bleeding. Cardiac U/S Clinically directed chest tube insertion. R/O other areas of blood loss (FAST/DPA). 2. Stop bleeding.
76 Unstable-Critical Actions 1.Localize bleeding. Cardiac U/S Clinically directed chest tube insertion. R/O other areas of blood loss (FAST/DPA). 2. Stop bleeding.
77 Unstable-Critical Actions 1.Localize bleeding. Cardiac U/S - STERNOTOMY Clinically directed chest tube insertion. R/O other areas of blood loss (FAST/DPA). 2. Stop bleeding.
78 Unstable-Critical Actions 1.Localize bleeding. Cardiac U/S Clinically directed chest tube insertion - THORACOTOMY R/O other areas of blood loss (FAST/DPA). 2. Stop bleeding. ü Initial output > 1-1.5L ü Continuous > 2-250cc/hr X 2-4hrs
79 Unstable-Critical Actions 1.Localize bleeding. Cardiac U/S Clinically directed chest tube insertion. R/O other areas of blood loss (FAST/DPA) LAPAROTOMY 2. Stop bleeding.
80 OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax
81 ü Shortness of Breath ü Chest Pain ü Decreased A/E ü Low O2 Saturation ü Hyper-resonance ü Tactile fremitus
82 ü Shortness of Breath ü Chest Pain ü Decreased A/E ü Low O2 Saturation ü Hyper-resonance ü Tactile fremitus PTX
83 ü Shortness of Breath ü Chest Pain ü Decreased A/E ü Low O2 Saturation ü Hyper-resonance ü Tactile fremitus ü TACHYCARDIA ü HYPOTENSION
84 ü Shortness of Breath ü Chest Pain ü Decreased A/E ü Low O2 Saturation ü Hyper-resonance ü Tactile fremitus ü TACHYCARDIA ü HYPOTENSION TENSION PTX
85 Pleural Air
86 Pleural Air Compresses lung
87 Pleural Air Compresses lung SIMPLE PNEUMOTHORAX
88 Air Increases
89 Air Increases Compresses Lung Even More
90 Air Increases Compresses Lung Even More Shifts Mediastinum
91 Functional Deformation + Impaired Venous Return Decreased CO
92 Functional Deformation + Impaired Venous Return TENSION PNEUMOTHORAX
93 Collapsed Lung
94 Mediastinal Shift
95 ü EXTRINSIC COMPRESSION ü CARDIAC DEFORMATION ü DECREASED VENOUS RETURN
96 NEEDLE DECOMPRESSION
97 NEEDLE DECOMPRESSION ü Emergent procedure for decompression ü ATLS - 2 nd Intercostal space, Mid-clavicular line ü 5 cm catheter
98 Does it work? ü No good data on indications ü No good data on efficacy
99 THE PROBLEM ü Diagnosis is clinical ü Treatment occurs before CXR confirmation ü Never get to know if diagnosis was correct
100 DIFFERENT INSERTION SITE? 5 th Intercostal space, anterior axillary line Potential benefits P Easily accessible supine P Does not impact transport P Experience with CT insertion
101 Studies 1. CADAVERIC MODEL 2. CT BASED HUMAN EVALUATION 3. EMS EVALUATION
102 2011 ü Human cadavers ü Traditional 2 nd v. 5 th ICS ü 5cm standard catheter ü 80 needles into 20 cadavers
103 2011 ü Human cadavers ü Traditional 2 nd v. 5 th ICS ü 5cm standard catheter ü 80 needles into 20 cadavers ü Chest Wall >1cm thicker at 2 nd
104 SUCCESSFUL PENETRATION * * 60% 55%
105 SUCCESSFUL PENETRATION * 70% 15%
106 Cadaver Summary ü Chest thicker at 2 nd v. 5 th ICS ü Especially females ü 42% of 2 nd ICS did not penetrate chest ü 100% at 5 th ICS successful NO cardiac, lung, hilum, aorta, spleen or liver injury
107 2012 ü Evaluate 2 nd v 5 th using Chest CTs of real trauma patients
108 2012 ü Evaluate 2 nd v 5 th using Chest CTs of real trauma patients ü Same findings as cadaver ü Worse as the BMI increases
109 2005 ü 25 EM physicians in Ireland ü 84% ATLS certified ü Do they know where to Needle? ü Can they find it on a live model?
110 2005 ü 88% named 2 nd ICS MCL ü Only 60% able to point out where this was on patient ü 4% pointed out 5 th ICS AAL ü 8% wanted to needle abdomen below & lateral to xiphoid
111 EMS ü 20 Corpsmen, 80 needles ü 25.5+/-3.9 years, 75% male ü 4.4+/-3.3 years experience ü Half previous deployment
112 RESULTS ü Time to insertion SAME ü Ease of finding and inserting needle BETTER ü Accuracy BETTER ü Aggregate distance from correct position BETTER
113 Take Home Points ü Indications for needle decompression not well delineated ü If going to needle, know the following
114 Take Home Points ü Standard Angiocath <5cm ü Chest wall 2 nd ICS >5cm in 40-50% ü Most in upper ¾ of BMIs cannot be decompressed with standard needle
115 Take Home Points ü In controlled experiments, 60% will fail entry ü R and L ü Females > Males ü Worse as BMI increases
116 Take Home Points ü May not be in chest ü If not responding, try again with a different angle ü Especially for females or obese ü May consider alternate positions
117 Arresting Summary ü Resuscitative Thoracotomy. ü Right Sided Chest Tube.
118 Stable Summary ü What areas are at risk? External exam/roll early CXR/Plain Film Survey ü Cardiac U/S ü Negative CXR & U/S & Isolated Chest, Repeat CXR in 1 hour. ü Special Regions Trans-Mediastinal Injuries.
119 Unstable Summary ü Failed volume challenge start blood. ü Localize bleeding. Cardiac U/S. Directed Chest Tube insertion. Check other regions at risk. ü Stop bleeding.
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