THORACIC TRAUMA: THE ABCs AND BEYOND
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1 THORACIC TRAUMA: THE ABCs AND BEYOND Walter L. Biffl, M.D. Medical Director, Acute Care Surgery, The Queen s Medical Center Professor and Associate Chair for Research, Department of Surgery, JABSOM/University of Hawaii Manoa
2
3 OUTLINE Immediate Threats to Life Other Stuff
4 A - AIRWAY CONTROL Intubate for Coma (GCS <8) Consider Intubation if: Maxillofacial / Neck Trauma Laryngeal Fracture (Hoarse, SQ Emphysema, Fracture) Aspiration
5 PEARL If the Patient Says He is Having Difficulty Breathing BELIEVE HIM!!!!
6
7 AIRWAY INJURY DIAGNOSIS Neck Trauma Dyspnea Dysphonia/Aphonia Stridor/Wheezing Hemoptysis Subcutaneous Emphysema Air Leak from Wound Pneumomediastinum Air Leak from Chest Tubes
8 AIRWAY PITFALL Intubation May Obstruct Airway Intubate with Bronchoscope if Available Secure Airway = No More Emergency
9 SURGICAL AIRWAY Cricothyroidotomy Size <6.0 Percutaneous Insufflation (30-45 min) ga - 15 L/min with side-hole (1:4 sec)
10 B - IMPAIRED VENTILATION Tension Pneumothorax Open Pneumothorax Pulmonary Contusion / Flail Chest Massive Hemothorax
11 MYTHBUSTING 1. Suspected tension PTX should be decompressed in the 2 nd intercostal space, midclavicular line Fr chest tube should always be used in the trauma patient with HTX or PTX 3. A retained hemothorax should be treated first with a second chest tube 4. Occult PTX must be treated with chest tube in the mechanically ventilated patient
12 TENSION PNEUMOTHORAX One-Way Valve Venous Return, Ventilation Dx: Distended Neck Veins, Tracheal Deviation, Hyperresonance Rx: Needle Decompression / Tube Thoracostomy
13 NEEDLE DECOMPRESSION 2 nd Intercostal Space, MCL 3 rd Rib
14 NEEDLE DECOMPRESSION 2 nd Intercostal Space, MCL Breast Implant! 3 rd Rib
15 Acad Emerg Med 2004; 11:211
16 Acad Emerg Med 2004; 11:211 Acad Emerg Med 2004; 11:795
17 Am J Surg 2013; 205:329
18 BMJ 2003; 327:1459
19 J Trauma Acute Care Surg 2014; 76:1029
20 J Spec Oper Med 2013; 13:53
21 J Spec Oper Med 2013; 13:53
22 J Trauma Acute Care Surg 2013; 75:1071
23 J Trauma Acute Care Surg 2013; 75:1071
24 OPEN PNEUMOTHORAX Sucking Chest Wound Pressure Equilibration; Air Passes through Hole if >2/3 Diameter of Trachea Temporary Occlusive Dressing Taped on 3 Sides Tube Thoracostomy
25 PULMONARY CONTUSION / FLAIL CHEST Flail Segment = >2 Ribs with >2 Fxs Pain, Disruption of Mechanics NEXT LECTURE Primary Problem is Underlying Contusion Supportive Care; Intubation if Indicated Rib Blocks / Epidural Analgesia Surgical Stabilization?
26 MASSIVE HEMOTHORAX >1500 ml Blood Loss Neck Veins Flat vs Distended Shock, Absent Breath Sounds, Percussion Dullness O.R. if: >1500 ml ml/hr x 2-4 hr Continued Transfusion 200 Correct Coagulopathy, Consider Angioembolization Pitfall: High Volume Output, Abruptly Stops?Caked Hemothorax
27 C - ETIOLOGIES OF SHOCK Hemorrhagic Cardiac Compressive Cardiogenic Neurogenic Septic
28 WHERE DOES BLOOD GO? Street / Wounds Fractures Chest Pelvis Abdomen
29 CIRCULATION- BLOOD LOSS Class of Hemorrhage I II III IV Blood Loss (%) >40 HR <100 >100 >120 >140 SBP Nl Nl Dec Dec Pulse P Nl / Inc Dec Dec Dec RR >35 UO (ml/hr) > Nil Blood Vol = 7 ml/kg
30 C - ETIOLOGIES OF SHOCK Hemorrhagic Cardiac Compressive Cardiogenic Neurogenic Septic
31 CARDIAC COMPRESSIVE SHOCK Tension Pneumothorax Rx: Tube Thoracostomy
32
33 THE BOX Nagy KK et al. J Trauma 1995; 38:859
34 PHYSICAL EXAMINATION Vital Signs, Neck Veins, Auscultation Beck s Triad (Hypotension, JVD, Muffled Heart Tones) Tachycardia, Narrow Pulse Pressure Pulsus Paradoxus (SBP Drop > 10 mm Hg with Inspiration)
35 ULTRASONOGRAPHY FAST Rozycki et al. J Trauma 1995; 39:492
36 PERICARDIOCENTESIS 50% False (+): Enter Chamber. Coronary Artery Puncture; Dysrhythmia. 37% False (-): Clot
37 J Trauma Acute Care Surg 2013; 75:543
38 SUBXIPHOID PERICARDIAL WINDOW
39 Ann Surg 2015; 261:573
40
41 Ann Surg 2014; 259:438
42 MANAGEMENT OF CARDIAC WOUNDS X Wall MJ et al. J Trauma 1997; 42:905
43 RESUSCITATIVE THORACOTOMY Biffl WL et al. Op Tech Gen Surg 2000; 2:168
44 RESUSCITATIVE THORACOTOMY Objectives Release Pericardial Tamponade Repair Cardiac Wounds Perform Open Cardiac Massage Cross-Clamp Aorta to Limit Subdiaphragmatic Hemorrhage and Redistribute Blood Flow to Myocardium and Brain Control Intrathoracic Hemorrhage Control Bronchovenous Air Embolism
45 J Trauma Acute Care Surg 2012; 73:1359
46 CARDIOGENIC SHOCK Myocardial Infarction Dx: ECG, Enzymes Bronchovenous Air Embolism Dx: Shock with Positive Pressure Vent Rx: Hilar Cross-Clamp, Ventricular / Aortic Root Venting, Vigorous Cardiac Massage
47 BLUNT CARDIAC INJURY (Formerly Cardiac Contusion ) Direct Impact Injury to the Heart Right Heart (RV) Most Commonly Affected Clinical Significance: Occult and Inconsequential to Life-Threatening Dysrhythmias or Pump Failure ( Sig BCI ) No Characteristic Presentation No Diagnostic Gold Standard
48 No Patient with SIG-BCI Had Elevated CK-MB Without Abnormal ECG CK-MB Levels Were Not Predictive of SIG-BCI Am J Surg 1994; 169:523
49 CARDIAC TROPONIN Low Sensitivity and Predictive Value for SIG-BCI Fulda GJ et al. J Trauma 1997; 43:304 Bertinchant JP et al. J Trauma 2000; 48:924 Real Value: Normal Admission ECG + ctni at 4-8 Hrs Has Negative Predictive Value for SIG-BCI Approaching 100%: 0/46 Salim A et al. J Trauma 2001; 50:237 0/40 Collins JN et al. Am Surg 2001; 67:821 0/131 Velmahos GC et al. J Trauma 2003; 54:45
50 J Trauma Acute Care Surg 2012; 73:S301
51 OTHER TIDBITS
52 OCCULT PNEUMOTHORAX Seen on CT but not CXR 2% Trauma Admissions 30% PTXs DeMoya et al. J Trauma 2007; 63:13 If Asymptomatic, No Rx? Prophylactic Tube Thoracostomy for Positive-Pressure Ventilation
53 448 Pts Observed 27 (6%) Chest Tube for PTX Progression, Resp Distress, or Hemothorax 10/73 (14%) Failed on PPV- No Tension J Trauma 2011; 70:1019
54 Kirkpatrick et al. J Trauma Acute Care Surg 2013; 74:747
55 HEMOTHORAX Indications for Surgery: >1500 ml Output 200 ml/hr Output x 2-4 hr* Continued Transfusion* *Correct Coagulopathy, Consider Angioembolization
56 HTX <1.5 cm (260 ml) Can Be Watched 92% Success EAST Guideline: ALL HTXs Should be Drained Mowery NT et al. J Trauma 2011; 70:510
57 J Trauma 2012; 72:422 J Trauma Acute Care Surg 2012; 73:1423
58 J Trauma 2011; 71:1104
59 ABX FOR TUBE THORACOSTOMY Prophylactic Abx do not Reduce Empyema/Pneumonia; Associated with Resistant HAIs Maxwell et al. J Trauma 2004; 57:742 Cannot Recommend For or Against Abx J Trauma Acute Care Surg 2012; 73:S341
60 RETAINED HEMOTHORAX Residual HTX on CXR after CT Placement = 33% Risk of Empyema Karmy-Jones R et al. Can Respir J 2008; 15:255
61 J Trauma Acute Care Surg 2012; 73:752
62 RETAINED HEMOTHORAX PRCT 2 nd Chest Tube vs VATS VATS = Dec Duration of CT Drainage, LOS, Cost 10/24 with 2 nd CT (42%) Required Surgery Meyer DM et al. Ann Thoracic Surg 1997; 64:1396 EAST Guidelines 2011 Persistent retained hemothorax, seen on plain films, after placement of a thoracostomy tube should be treated with early VATS, not a second chest tube (Level 1). J Trauma 2011; 70:510
63 RIB FRACTURES Common % Trauma Admissions 12% Mortality Ziegler, J Trauma 1994; 37:975 NEXT LECTURE Mortality Elderly Young 22% 10% Bulger, J Trauma 2000; 48: % 9% Bergeron, J Trauma 2003; 54:478 20% 11% Stawicki, J Am Geriatr Soc 2004; 52:805
64 Surgery 2004; 136:426 J Trauma 2011; 71:1548
65 PNEUMOMEDIASTINUM Sign of Aerodigestive Injury 5% of Chest CTs 10% Have Injuries If Asymptomatic, Manage Expectantly Macleod et al. Am Surg 2009; 75:375 Dissanaike et al. J Trauma 2008; 65:1340
66 TRACHEOBRONCHIAL INJURY Subcu Emphysema; Pneumomediastinum; PTX w Air Leak Dx by Bronchoscopy Karmy-Jones et al. Thorac Surg Clin 2007; 17:35 J Trauma Acute Care Surg 2015; 79:1089 CTA Chest Esophagoscopy / Esophagography
67 THORACIC GSW Exam + CXR or E-FAST -Hemodynamics, Location of Wound(s); Early repeat CXR Unilateral GSW Chest tube -Drained vs Retained Htx vs Large Air Leak Transmediastinal GSW Chest tube(s), CT scan -Add l W/U based on trajectory Thoracoabdominal GSW Chest tube, Laparotomy,?Pericardial window
68 DAMAGE CONTROL RESUSCITATION
69 Damage Control: Keep a Badly Damaged Ship Afloat After Major Penetrating Injury to the Hull
70 Damage Control: Keep a Badly Damaged Ship Afloat After Major Penetrating Injury to the Hull Plug Gaping Holes Extinguish Fires Dog Down Watertight Doors Keep Ship Afloat Assess Overall Damage Establish a Plan for Definitive Repair
71 DAMAGE CONTROL IN TRAUMA Lucas and Ledgerwood Calne et al Feliciano et al Stone et al Rotondo et al
72 Kashuk J, Moore EE et al. J Trauma 1982; 22:261
73 J Trauma 2007; 62:307 Damage control resuscitation addresses the entire lethal triad immediately upon admission to a combat hospital Anticipate and Attenuate; Reverse
74 DAMAGE CONTROL RESUSCITATION Permissive Hypotension Limit Isotonic Crystalloid Aggressive Hemostatic Resuscitation Bleeding Control Rewarming Correction of Acidosis, Hypocalcemia Bogert et al. J Intensve Care Med 2016; 31:177 Giannoudi et al. Eur J Trauma Emerg Surg 2016; 42:273 Chang et al. Crit Care Clin 2017; 33:15
75 PERMISSIVE HYPOTENSION Premise: Avoid Exacerbating Hemorrhage and Dilutional Coagulopathy Caveat: Clear Evidence of Benefit and Optimal Perfusion Targets Lacking Goal: SBP 70-90; MAP >50; Radial Pulse Caution: Severe TBI; Prolonged Shock Bogert et al. J Intensve Care Med 2016; 31:177 Giannoudi et al. Eur J Trauma Emerg Surg 2016; 42:273 Chang et al. Crit Care Clin 2017; 33:15
76 LIMIT ISOTONIC CRYSTALLOID Premise: Excess Crystalloid Dilutional Coagulopathy, ARDS, Cardiac Dysfunction, Compartment Syndromes, Ileus, Anastomotic Leak, Wound Complications, MOF, Death Mechanism: Intracellular Edema Disrupt Biochemical Processes (Pancreatic Insulin, Hepatocyte Glucose Metabolism, Cardiac Myocyte Excitability); Inflammation Inflammatory Mediators; Endothelial Glycocalyx Degradation Bogert et al. J Intensve Care Med 2016; 31:177 Giannoudi et al. Eur J Trauma Emerg Surg 2016; 42:273 Chang et al. Crit Care Clin 2017; 33:15
77 J Trauma Acute Care Surg 2013; 74:1207 If Not Hypotensive, >500 ml Crystalloid Assoc w/ Higher Mortality and Coagulopathy J Trauma Acute Care Surg 2013; 74: Hr Crystalloid Correlated w/ Vent Days, ICU & Hosp LOS, ARDS, MOF, SSI, Bloodstream Infxn, Compartment Syndromes
78 OPTIMAL FLUID? Colloid- Discouraged due to Cost, Coagulopathy, Renal Dysfunction Crystalloid- NS vs LR vs Plasmalyte Am J Emerg Med 2017; 35:317
79 HEMOSTATIC RESUSCITATION Kashuk J, Moore EE et al. J Trauma 1982; 22:261
80 PRESUMPTIVE FFP Kashuk J, Moore EE et al. J Trauma 1982; 22:261
81 Biffl et al, Ann Surg 2001; 233:843
82 Post-Injury Life Threatening Coagulopathy 1:1:1 FFP:PLT:RBC
83 HEMOSTATIC RESUSCITATION 2 Lg Bore IVs Upper Ext Early MTP FFP:PLTs:PRBCs 1:1:1-2
84 MASSIVE TRANSFUSION ABC Score >2 Penetrating Mechanism SBP <90 HR >120 (+) FAST Persistent hemodynamic instability Active bleeding requiring operation or angioembolization Blood transfusion in trauma bay TQIP Best Practices
85 THROMBELASTOGRAPHY Goal-Directed Resuscitation PRBCs, FFP, PLTs Fibrinogen, Anti-Fibrinolysis
86 Ann Surg 2016; 263:1051
87 CONSISTENT TREND TOWARD REDUCED BLOOD PRODUCT UTILIZATION Kashuk et al, Transfusion 2011
88 Shock 2014; 41(Suppl 1):35
89 Prehospital Monitoring Shock/Coagulopathy Hypotensive Resuscitation; Endpoints of Resuscitation Whole Blood vs Components; Dried Products Pathogen Reduced Technology for Products Role of TBI Shock 2014; 41 Suppl 1:3
The Management of Chest Trauma. Tom Scaletta, MD FAAEM Immediate Past President, AAEM
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