Thoracic Trauma The Spectrum

Transcription

1 Thoracic Trauma The Spectrum Joseph Mathew Consultant, s & Emergency dept.

2 2 Thoracic Trauma Responsible for 20-25% of all deaths attributed to trauma. Contributing cause of death in an additional 25% of patients who die from their injuries. Incidence of 12 persons per million of population per day. Approximately 33% of these injuries require hospital admission*.

3 3 Thoracic Injuries May not be easily diagnosed Usually occur in multiples Evolve 2 nd commonest cause of death from injury Unreliably diagnosed on single examination

4 4 Thoracic Trauma Many patients survive to hospital with potentially lethal injuries that take time to become clinically apparent. Tension pneumothorax Massive haemothorax Cardiac tamponade Flail chest Pulmonary contusion Ruptured diaphragm Torn aorta

5 5 Thoracic trauma Chest injuries evolve Most serious chest injuries are adequately with ventilation and circulation support Pleural and pericardial decompression are key procedures

6 6 Alfred Surgical intervention 950 consecutive major thoracic trauma patients AIS 3 or greater 45% 7% 1% 51% nil 270 ICC 182 ET 32 RT 7

7 7 Surgical intervention Tube thoracostomy is required in 25% of patients presenting with major trauma in Australasia. Thoracotomy is indicated in 5 10% of patients sustaining major thoracic injury. Resuscitative thoracotomy is indicated in 1% of patients presenting to an Emergency/Trauma Centre with a major thoracic trauma [i]. [i] Chest Trauma, MC Fitzgerald & R Gocentas, Chapter in Emergency Medicine 2nd Edition, Cameron, Jelinek, Kelly & Rogers Eds

8 8 ICCs by chest injury

9 9 Initial Supine CXR Fails to diagnose haemothorax or pneumothorax in 32% of thoracic trauma patients with haemodynamic compromise Clinical examination is the key

10 10 CT Scanning and thoracic trauma Tam J, Fitzgerald M, Marasco S, Varma DK, Minimal injury of the descending aorta secondary to blunt trauma. Injury Jan;43(1):117-8.

11 11 A wounded British soldier in Libya lies on a cot in a desert hospital tent on June 18, 1942, shielded from the strong tropical sun. [AP Photo/Weston Haynes]

12 12 World War 2 and tension pneumothorax H. Fuld, Simple device for control of tension pneumothorax. Bri Med J 2 (1944), p. 503.

13 13 Chest decompression There is no evidence that needle thoracostomy is a reliably useful procedure for in-hospital trauma resuscitation. ~1/3 of pleural cavities not reached Sub-Q gas under tension causes false positives Anatomical landmarks poorly determined 1 1 The right place in the right space? Awareness of site for needle thoracocentesis. Ferrie E, Collum N, McGovern S. Emerg Med J 2005;22:

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15 15 Pitfalls of needle thoracocentesis Extrapleural placement of catheterover-needle thoracocentesis. The catheter length is adequate but is extra-pleural. There is no pneumothorax.

16 16 Pitfalls of needle thoracocentesis False positive as chest tube decompresses subcutaneous emphysema There is a left pneumothorax. The tube thoracostomy has been placed extrapleural in sub-cutaneous gas - creating a false positive with associated failure to decompress the pleural space.

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18 18 pneumocath

19 19 pneumocath

20 20 Pitfalls of needle thoracocentesis Incorrect identification of the midclavicular line may result in needle decompression that is too medial, with increased risk of vascular and cardiac injury. The recommended insertion point (A) in the 2nd intercostal space in the midclavicular line is more lateral to the point commonly identified - which is half-way between the midline and the lateral chest wall (B).

21 IPPV? mf yes Trauma Arrest? yes Bilateral pleural decompression no Is air entry equal? Inspiratory breath sounds can be heard clearly and equally in the mid axillary line bilaterally yes no Is SpO2 < 90? On FiO2 100% and Endotracheal Tube (ETT) correct distance from gums post ETT suction yes Binary decision matrix for chest decompression no Is Systolic BP < 100 mmhg? Despite IV filling yes Decompress pleura on affected side no yes Await supine chest X-ray yes Insert chest tube with one way valve

22 22 Positions & complications of ICCs A Trauma to the intercostal neurovascular bundle. B Extrapleural placement. C Correct position pleural space. D Intrafissural placement. E Intrapulmonary placement. F Mediastinal impingement or penetration. G Trans-diaphragmatic placement. H Infection.

23 23 ICC insertion

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25 25 Chest decompression and trauma resuscitation Tube thoracostomy is indicated for tension pneumothorax, for open pneumothorax once closed, for patients with haemodynamic or respiratory compromise with coinciding pneumothorax or haemothorax and for ventilated patients with pneumothorax. Digitally decompress the pleural space using a lateral approach then insert an ICC

26 26 What is aortic injury? Largest blood vessel in human body Directs blood flow from the heart to the peripheral circulation Thoracic aortic injuries 20 x more common than abdominal Classically at the isthmus (proximal descending aorta) Perez LR, Chan GK. Clinical decision making and management of blunt traumatic thoracic aortic injuries. Air Med J 2008;27(3):

27 27 What is aortic injury? Largest blood vessel in human body Directs blood flow from the heart to the peripheral circulation Thoracic aortic injuries 20 x more common than abdominal Classically at the isthmus (proximal descending aorta) Perez LR, Chan GK. Clinical decision making and management of blunt traumatic thoracic aortic injuries. Air Med J 2008;27(3):

28 28 How is it injured? Traditionally thought to involve shearing forces that stress the aorta at the isthmus High speed sudden-deceleration is the classic mechanism Brinkman WT, et al. Overview of great vessel trauma. Thorac Surg Clin 2007;17(1):

29 29 Epidemiology >95% of major trauma in Australia is due to blunt mechanisms BTAI responsible for 1/3 of blunt trauma fatalities Average age of patients: ~40 years old (>70% men) Alfred Health (2014). Caring for the Severely Injured in Australia: Inaugural Report of the Australian 2010 to Alfred Health, Melbourne, Victoria. Teixeira PG, et al. Blunt thoracic aortic injuries: An autopsy study. J Vasc Surg 2011;54(2):581. Fabian TC, et al. Prospective study of blunt aortic injury: Multicenter trial of the American Association for the Surgery of Trauma. Journal of Trauma - Injury, Infection and Critical Care 1997;42(3):

30 30 What happens when it is injured? Blunt Trauma Patients surviving to hospital Parmley LF, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17:

31 31 What happens when it is injured? Blunt Trauma Incomplete Rupture Haemorrhage contained by adventitia or surrounding tissue Patients surviving to hospital Parmley LF, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17:

32 32 What happens when it is injured? Blunt Trauma Incomplete Rupture Haemorrhage contained by adventitia or surrounding tissue Interval of unpredictable duration Patients surviving to hospital Parmley LF, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17:

33 33 What happens when it is injured? Blunt Trauma Incomplete Rupture Haemorrhage contained by adventitia or surrounding tissue Interval of unpredictable duration Patients surviving to hospital Total Rupture Parmley LF, et al. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17:

34 34 What can be done in hospital? Resuscitation and stabilization of associated injuries CT diagnosis of BTAI BTAI never suspected Anti-hypertensive therapy Total rupture Endovascular Repair (TEVAR) 96% in-hospital survival Open Repair 83% in-hospital survival Cook CC, Gleason TG. Great vessel and cardiac trauma. Surg Clin North Am 2009;89(4): , viii. Symbas PN. Cardiothoracic trauma. Curr Probl Surg 1991;28(11):

35 35 What can be done in hospital? Critical Step: Decision to CT Resuscitation and stabilization of associated injuries CT diagnosis of BTAI BTAI never suspected Endovascular Repair (TEVAR) 96% in-hospital survival Anti-hypertensive therapy Open Repair 83% in-hospital survival Total rupture ½ of all patients die within 24h if untreated prior to rupture Cook CC, Gleason TG. Great vessel and cardiac trauma. Surg Clin North Am 2009;89(4): , viii. Symbas PN. Cardiothoracic trauma. Curr Probl Surg 1991;28(11):

36 36 Pitfalls Left-sided ICC RSI

37 37 Systematic Review (focused clinical question) Clinical signs of BTAI have been reported to be uncommon Diagnosis is based on Clinical suspicion (given mechanism of injury) Imaging studies Signs and symptoms not reliable Mechanism of Injury Signs and Symptoms Chest X-Ray (widened mediastinum) Sastry P, et al. Low-impact scenarios may account for two-thirds of blunt traumatic aortic rupture. Emerg Med J 2010;27(5): Decision to CT

38 Systematic Review (focused clinical question) 38 Clinical signs of BTAI have been reported to be uncommon Diagnosis is based on Clinical suspicion (given mechanism of injury) Imaging studies Mechanism of Injury Chest X-Ray (widened mediastinum) Signs and Symptoms Sastry P, et al. Low-impact scenarios may account for two-thirds of blunt traumatic aortic rupture. Emerg Med J 2010;27(5): Cook AD, et al. Chest radiographs of limited utility in the diagnosis of blunt traumatic aortic laceration. Journal of Trauma-Injury Infection & Critical Care 2001;50(5): Decision to CT

39 39 Conclusions Many patients present in a stable condition Clinical signs and CXR are insensitive to exclude TAI TAI can result from low energy mechanisms

40 40 Conclusions Two distinct modes of presentation Unstable patients: often more severe TAI, abnormal Ix, increased immediate risk of death Stable patients (majority): may have minor or severe TAI

41 Tracheobronchial Tree Injury 41 Often missed Blunt or penetrating Persistent pneumothorax-bubbling Bronchoscopy Treatment -Airway and ventilation -Tube thoracostomy -Operation

42 42 Simple Pneumothorax Penetrating / blunt trauma Ventilation / perfusion defect Hyperresonance Decreased breath sounds Tube thoracostomy Do not apply spontaneous pneumothorax rules

43 43 Pulmonary Contusion Common Oxygenate and ventilate Selective intubation Delayed X-ray changes ICU Review

44 44 Hemothorax Chest wall injury Lung / vessel laceration Tube thoracostomy - Size of ICC - Position of ICC

45 45 Fractures and Associated Injuries Sternum, Scapular, and Rib Ribs 1-3 Severe force Associated injuries have high mortality risk Ribs 4-9 Pulmonary contusion and pneumothorax Ribs Suspect abdominal injury

46 46 Subcutaneous Emphysema Airway injury Pneumothorax Blast injury Iatrogenic

47 47 Blunt Cardiac Injury Injury spectrum Abnormal ECG / monitor changes Echocardiography Treat -Dysrhythmias -Perfusion -Complications

48 48 Blunt Esophageal Rupture Blunt vs. penetrating injury Severe epigastric blow Pain / shock out of proportion to injury Left pneumothorax or hemothorax without rib fracture

49 49 Esophageal Injury Chest tube: Particulate matter Mediastinal air Contrast swallow, esophagoscopy Operation

50 50 Diaphragmatic Injury Most diagnosed on left Blunt: Large tears Penetrating: Small perforations Misinterpreted x-ray Contrast radiography Operation

51 51 Traumatic Asphyxia Petechiae Swelling Plethora Cerebral edema

52 52 Resuscitative Thoracotomy When should I consider resuscitative thoracotomy? Patients with penetrating or blunt thoracic injury with SBP <70mmHg may be a candidate Signs of life within the last 10 minutes Evidence of tamponade on FAST When a surgeon with appropriate skills is present or you have appropriate critical care staff credentialled

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