Trauma Activation 7/18/17

Transcription

1 Blunt Rupture of the Thoracic Duct after Severe Thoracic Trauma Samuel Brown, MD Trauma Activation 7/18/17 53 year old male, rear end MVC, exited vehicle and was struck by a semi truck. Denies LOC, complaints of face pain, right chest pain, left lower leg pain. Primary Survey negative, GCS 15 Secondary Survey facial tenderness, bilateral chest wall tenderness, thoracic and lumbar spine tenderness, bilateral subcutaneous emphysema in chest and neck PMH DM2, hearing loss PSH none Medications none Allergies sulfa drugs CXR, Pelvis X ray Taken to CT scan for further imaging 1

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3 Left Epidural Hematoma Multiple Facial Fractures Left superior orbit, left sphenoid, left ZMC including anterior and lateral maxillary sinus, left pterygoid plate Left Scapula fracture Left Acromioclavicular fracture Bilateral Superior and Inferior pubic rami fracture Left sacral fracture Left iliac wing fracture Pneumomediastinum Severe enough to compress the left atrium Injury Summary Myocardial contusion Bilateral Pulmonary Contusions Bilateral Hemo pneumothorax Rib fractures Left 2 10 (flail chest) Posterior and anterolateral 2 7 posterior 8 10 Right 2 8 Anterolateral rib fractures of 2, 3, 5, 6, 7, 8, Posterior and antero lateral of 4th 3

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5 Hospital Course 7/18 Patient Intubated for severe respiratory distress. Bilateral chest tubes placed. Subclavian central line. Fluid resuscitation. Developed hypotension secondary to left atrial compression from the extensive mediastinal emphysema, compounded by the cardiac contusions Esophagram with contrast down OG tube was done to evaluate for esophageal injury (negative) Bronchoscopy to exclude bronchial or tracheal injury negative 7/19 OR with orthopedics for repair of pelvic fractures. ORIF of pelvis (closed reduction percutaneous pinning of left sacrum and ilium). Application of anterior pelvic INFIX (subcutaneous fixator). 7/20 Left Chest Wall Reconstruction. Open reduction and internal fixation of left sided rib fractures 3, 4, 5, 6 anteriorly 4, 5, 6, 7 posteriorly 5

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7 Hospital Course 7/22 Tube feeds started. Overnight, the patient developed milky output from chest tube. Fluid studies sent triglycerides 508 mg/dl Chylothorax defined with triglyceride level greater than 110 mg/dl Patient placed on TPN and NPO status Chest tube outputs remained high (2 3L/day) 7

8 Thoracic Duct Anatomy Discovered in 1651 by Jean Pecquet 2 3 mm in diameter, 36 to 45 cm in length posterior to the median arcuate ligament of the diaphragm between the aorta and azygos vein Crosses midline at ~T4 T6 terminates at the junction of the internal jugular and left subclavian veins Variations may include different crossover levels as well as several mediastinal trunks. 8

9 7/29 IR Lymphangiogram Lymphangiography was performed to locate chylous leak in the chest and attempt to perform Cisterna Chyli/thoracic duct scarification. Injected right groin, oil contrast coursing through lymphatics in the pelvis, coherent flow starts to stop at the level of the internal fixator rod. Injected left groin, again, contrast became irregular at the rod, and was unable to enter the iliac nodes Minimal contrast accumulation in left para aortic nodes. After 2.5 hours there was no contiguous or columnar filling of the Cisterna Chyli or thoracic duct. Spot images over the chest did show minimal lipiodol contrast that had entered the region of the upper chest, near the T3 T5 level, and into the pleural space adjacent to the chest tube tip 9

10 8/1 CT Guided Thoracic Duct Disruption/Sclerosis 18 ga x 20 cm biopsy needles were advanced to the right hepatic lobe into the retrocrural space, adjacent to oil contrast enhanced lymph nodes. Multiple needle passes made to attempt to disrupt the lymphatic system 10 cc of dehydrated alcohol was also administered to facilitate fibrosis of the selected retrocrural lymph nodes and Tornado coils were deployed in the same location. 10

11 Hospital Course 8/2 Chest tube output decreased from 3.5 to 2.5 L/day after IR procedures. Output still serous. Low triglyceride levels (58 dg/dl). Clamping trial, leakage of fluid around the tube and high output when unclamped after 6 hours (600 cc) 8/8 Continued serous output. Trial of low fat diet, chest tube output became milky once again 8/9 Started Octreotide as it has been shown to help in postsurgical chylothorax in the pediatric population 8/16 Started Midodrine 8/18 Injected Lipiodol in left supraclavicular space 8/18 CT guided injection of fibrin glue 11

12 Left Posterolateral Thoracotomy and Thoracic Duct Ligation Olive oil as well as 60 ml of cream through the nasogastric tube at start of case Left Posterolateral Thoracotomy 6 th intercostal space Obvious defect of the pleura at Poirier s point leakage and draining of milky opaque fluid 3 0 silk sutures placed in figure of eight pattern + clips Fibrin glue Mechanical pleurodesis 12

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14 Post Op Course Chest tube output decreased dramatically Patient was kept NPO and on TPN to keep him in a state of low chylous flow while the thoracic duct stump healed Advanced diet 2 weeks after the operation with no signs of recurrence 14

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