Werner Glinz. Chest Trauma. Diagnosis and Management. With 133 Figures

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2 Werner Glinz Chest Trauma Diagnosis and Management With 133 Figures Springer-Verlag Berlin Heidelberg New York 1981

3 Priv.-Doz. Dr. WERNER GLINZ Universitatsspital ZUrich Chirurgische Klinik B RamistraBe 100, CH-8091 ZUrich Translators: G. H. MUNDINGER, Sr A Monroe Drive, Boulder, Colorado 80303/USA G. H. MUNDINGER, Jr Glenkirk Road, Baltimore, Maryland 21239/USA Title of the German Edition: Werner Glinz, Thoraxverletzungen Springer-Verlag Berlin Heidelberg 1978 and 1979 ISBN-13: DOl: / e-isbn-13: Library of Congress Cataloging in Publication Data. Olinz, Werner. Chest trauma. Translation ofthoraxverletzungen. Bibliography: p. Includes index. 1. Chest-Wounds and injuries. I. Title. [DNLM: 1. Thoracic injuries-diagnosis. 2. Thoracic injuries-surgery. WF t] RD ' This work is subject to copyright. All rights are reserved, whether, the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar me~ns, and storage in data banks. Under 54 of the Oerman Copyright Law where copies are made for other than private use a fee is payable to "Verwertungsgesellschaft Wort", Munich. by Springer-Verlag Berlin' Heidelberg 1981 Softcover reprint of the hardcover 1st edition 1981 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. 2124/

4 Preface to the German Edition Expanded knowledge about the pathophysiologic effects of severe injuries, advancements in the intensive care of victims of multiple injuries, and the treatment made possible by modem cardiovascular surgery make it appear sensible to combine the assessment and therapy of thoracic injuries into a synthesis of various branches of medicine. This monograph, therefore, is intended not only for the specialist in thoracic or cardiac surgery but also primarily for the person who is the first to be confronted by thoracic injuries, namely, the general surgeon or the traumatologist. It reflects my own personal experience as chief surgeon of an emergency surgery ward of a university hospital and as head of an intensive care unit for the severely wounded, which treats well over 100 patients with severe thoracic injuries annually, and is based on an analysis of these cases. My experience as a military surgeon in Vietnam was also taken into consideration. Many wounds in the area of the thorax can be successfully treated with simple, conservative procedures, though by "conservative" I do not mean to imply "inactive." An aggressive conservatism is needed, which must pay attention to small details. In given cases, however, it requires the quick decision-making capability of the competent surgeon. For this reason, considerable space is devoted to questions of evaluation and practical procedures. In most instances, thoracic wounds are accompanied by other wounds. Among our patients, more than 75% of all patients hospitalized with blunt thoracic injuries were wounded in other parts of the body. My respected chief and teacher, Professor H. U. BUFF, frequently called attention to the fact that the severely injured patient belongs in the care of a facility that accepts responsibility for the treatment of all of his wounds and that he may not be parceled out to a multiplicity of specialists on the basis of his injured organs. This principle was put into practice in the Surgical Department B of the University Hospital in Zurich. The spirit of that approach, I hope, finds expression also in the text of this book; precisely in the chapters of the first section an attempt is made to present thoracic trauma within the framework of the patient's other wounds along with their mutual consequences. Zurich, Spring 1978 Werner GLINZ

5 Acknowledgments. I am especially indebted to Professor A. SEN NING, my teacher, in whose clinic I was able to work for many years where I had the opportunity to learn the most modern techniques of cardiac and thoracic surgery. I am grateful for his permission to use the case histories of the Surgical Clinic A at the University of Zurich. All of the roentgenograms pertain to my own patients and were prepared at the Central Institute for Radiology of the University Clinic in Zurich. The autopsy preparations were performed at the Institute for Pathology of the University of Zurich. I would like to thank Professors 1. WELLAUER and CH. HEDINGER for their consent to use these pictures. Many of the ideas and concepts for treatment of thoracic injuries that are presented in this book have been influenced by daily discussions held with my colleagues in the hospital of whom I would particularly like to mention Doctors G. HALDEMANN and K. REIST of the Institute for Anesthesiology and Dr. P. C. BAUMANN, head of the Intensive Care Unit of the Department ofinternal Medicine. The care of seriously injured patients would be impossible without the untiring devotion of the nursing personnel in the intensive care unit and the emergency ward. I wish to express my appreciation to all of them for their assistance. I am very grateful to the following for their active support in the preparation of this book: to Mrs. A. lung and her colleagues in the central photography laboratory who worked on all the figures in this book, to Mr. B. STRUCHEN who did the sketches, and to Miss B. SCHUTZ, my loyal and industrious secretary.

6 Contents Part I General Considerations for the Assessment and Treatment of Thoracic Injuries Chapter 1 Initial Considerations in the Management of 3 Severe Thoracic Injury.... I. The Ten Vital Questions in the Initial Evaluation of Severe Thoracic Injuries 4 II. Evaluation After Initial Management... 7 Chapter 2 The Patient with Additional Injuries in Other Parts of the Body I. II. III. IV. V. Craniocerebral Injuries Intra-abdominal Injuries Injuries of the Extremities Maxillofacial Injuries.. Injuries to the Vertebral Cord.... Column and Spinal Chapter 3 Interpretation of the Chest Roentgenogram 16 I. Basic Considerations. 16 II. Opacities III. Accumulation of Air 22 IV. The "Widened Mediastinum" 24 Chapter 4 Respiratory Insufficiency. 29 I. Basic Considerations II. Assessment of Respiration in Patients with Thoracic Injuries III. Respiratory Insufficiency Caused by the Thoracic Injury Itself

7 VIII Contents IV. Aspiration V. Adult Respiratory Distress Syndrome CARDS). 40 VI. Fat Embolism VII. Other Forms of Respiratory Insufficiency Among the Injured VIII. Lung Damage Caused by Therapeutic Measures 50 IX. Conclusions and Consequences for Prophylaxis and Therapy Chapter 5 Indications for Operation in Blunt Thoracic 57 Trauma.... I. Indications for Immediate or Early Operation 57 II. Indications for Subsequent Operations 59 III. Contraindications to Operative Intervention 60 Chapter 6 Operative Approaches I. Anterolateral Thoracotomy. 61 II. Posterolateral Thoracotomy 64 III. Median Sternotomy IV. Approach to the Great Vessels of the Superior Thoracic Aperture V. Thoracoabdominal Approach Chapter 7 Special Considerations in Penetrating Chest Injuries I. Causes ofinjury and Intrathoracic Injuries 70 II. Evaluation and Therapeutic Procedure 72 III. Prognosis Chapter 8 Aspects of Intensive Care of Patients with Thoracic Injuries I. Basic Considerations II. Monitoring and Evaluating the Patient with Thoracic Injuries in Intensive Care 79 III. Mechanical Ventilation IV. Principles for the Infusion of Fluids 81 V. Subsequent Pulmonary Complications 83

8 Contents Chapter 9 Physiotherapy of Patients with Thotacic Injuries I. Basic Considerations. II. General Measures. III. Forced Expiration. IV. CO 2-Induced Increase in Ventilation V. Intermittent Positive Pressure Breathing (lppb) VI. Maximal Voluntary Inspiration IX Part II Diagnosis, Clinical Significance, and Treatment of Specific Injuries Chapter 10 Rib and Sternum Fractures 101 I. General Considerations. 101 II. Specific Types of Fractures 104 III. Diagnosis IV. General Considerations for Therapy in Rib and Sternal Fractures V. Pain Control VI. Therapy of Flail Chest lis Chapter II Pneumothorax and Hemothorax I. Pneumothorax.... II. Tension Pneumothorax III. Open Pneumothorax IV. Hemothorax... V. Clotted Hemothorax, Fibrothorax VI. Thoracentesis VII. Intercostal Tube Drainage Chapter 12 Traumatic Emphysema I. Subcutaneous Emphysema II. Mediastinal Emphysema Chapter 13 Lung Injuries from Blunt Trauma I. General Considerations II. Lung Laceration, Lung Rupture 155 ISS 157

9 X Contents III. Intrapulmonary Hematoma IV. Traumatic Lung Pseudocysts (Pneumatoceles) 160 V. Lung Contusion 161 VI. Blast Injuries Chapter 14 Tracheal and Bronchial Injuries 167 I. Injuries to Trachea and Bronchi Caused by Blunt Trauma II. Old Bronchial Ruptures III. Penetrating Injuries to Trachea and Bronchi 172 Chapter 15 Injuries to the Esophagus 174 I. Rupture of the Esophagus, Penetrating and Iatro-. genic Esophageal Injuries 174 II. Traumatic Esophagotracheal Fistula Chapter 16 Injuries to the Heart by Blunt Trauma 180 I. Basic Considerations. 180 II. Pericardial Injuries, Luxation of the Heart 182 III. Hemopericardium, Cardiac Tamponade 184 IV. Posttraumatic Pericarditis 189 V. Cardiac Contusion 191 VI. Heart Wall Ruptures 204 VII. Traumatic Septal Defects 205 VIII. Heart Valve Injuries 205 IX. Injuries of the Coronary Arteries 206 X. Traumatic Cardiac Aneurysm 207 Chapter 17 Penetrating Wounds of the Heart 208 I. Penetrating Cardiac Injuries II. Late Sequelae of Penetrating Cardiac Injuries 217 III. Foreign Bodies in the Heart Chapter 18 Injuries of the Great Intrathoracic Vessels 222 I. Rupture of the Aorta II. Penetrating Injuries of the Aorta 236 III. Closed Injuries of the Supra-aortic Arteries 238

10 Contents XI IV. Injuries of the Great Veins and Pulmonary Vessels V. Penetrating Injuries of the Vessels of the Superior Thoracic Aperture VI. Posttraumatic Late Sequelae in the Great Vessels 242 Chapter 19 Injuries of the Diaphragm 246 I. Diaphragmatic Ruptures. 246 II. Penetrating Diaphragmatic Injuries 256 Chapter 20 Other Injury Patterns and Consequences of Injury in Thoracic Trauma I. Traumatic Asphyxia II. Injuries of the Thoracic Duct, Chylothorax 261 III. Cholothorax IV. Traumatically Induced Hernias of the Chest Wall 265 V. Arterial Air Embolism Bibliography. 270 Subject Index 295