Priorities in Penetrating Chest Trauma

Priorities in Penetrating Chest Trauma K. Inaba, MD FRCSC FACS Division of Trauma Surgery & Critical Care LAC+USC Medical Center University of Southern California

ü None. DISCLOSURES

OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax

Penetrating Chest Injury Arresting Unstable Stable

Penetrating Chest Injury Arresting Unstable Stable ED Thoracotomy Right Chest Tube

2001 ü 25 year review, 4,620 EDT ü Overall Survival 7.4% ü Normal Neurologic Function 92.4%

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

Survival By Mechanism 18% 16% 14% Survival 12% 10% 8% 6% 8.8% 4% 2% 0% 1.4%

Survival By Mechanism 18% 16% 16.8% 14% Survival 12% 10% 8% 6% 8.8% 4% 2% 0% 1.4% 4.3%

Injury Location 12% 10% 10.7% Survival 8% 6% 4% 2% 0% 4.5% 0.7% Thoracic Abdominal Multiple

Injury Location 12% 10% 10.7% Isolated Cardiac = 19.4% Survival 8% 6% 4% 2% 0% 4.5% 0.7% Thoracic Abdominal Multiple

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?

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

EDT INTERVENTIONS ü Release Tamponade ü Repair Cardiac Injury ü Control Hilar Bleeding ü Cross Clamp Aorta ü Restart Heart

Penetrating Chest Injury Arresting ER Thoracotomy Right Chest Tube Unstable Stable

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.

Don t Forget the Back

For SWs CXR usually sufficient

RETAINED FRAGS HEMOTHORAX PNEUMOTHORAX

For GSWs also check back

For GSWs 1. External holes 2. Internal fragments Everything in between is at risk of injury CT

OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax

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

Ultrasound Advantages ü Non-invasive ü Radiation ü Repeatable ü Portable ü Rapid ü Cost effective

Heart Video

ü Prospective truncal SW or GSW ü No indication for emergent OR ü Non-radiologist performed FAST 1996

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 + 10 0 FAST 0 236

Summary FN=0 Author Year Journal Design n TN TP FN FP Sensitivity Specificity Rozycki GS 1996 Ann Surg Prospective 247 236 10 0 0 100.0% 100.0% Rozycki GS 1998 Ann Surg Prospective 313 289 22 0 2 100.0% 99.3% Rozycki GS 1999 J Trauma Prospective 261 225 29 0 7 100.0% 97.0% Patel AN 2003 Ann Thorac Surg Retrospective 478 455 20 0 3 100.0% 99.3% Tayal VS 2004 J Ultrasound Med Prospective 32 24 8 0 0 100.0% 100.0% TOTAL 1331 1229 89 0 12 100.0% 99.0%

2009

Watch out for ü Large Hemothorax ü Continuous CT output Repeat FAST or do TTE

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

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

OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax

Trans-Mediastinal Injury Traditional approach ü Unstable=OR ü Stable=Full Diagnostic Evaluation ü Pan-endoscopy ü Contrast swallow ü Angiography ü Echo

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

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

Trans-Mediastinal GSW? Unstable..OR? Stable..FAST and CTA ü Cardiac FAST ü CT Angiogram

Trans-Mediastinal GSW? Unstable..OR? Stable..FAST and CTA ü Cardiac FAST Positive=Sternotomy Negative=go to CTA ü CT Angiogram

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

OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax

2012 ü Pro, n=353 acute CT inserted ü 28-32Fr v. 36-40Fr ü Same blood drainage ü Same duration ü Same complication rate ü Same pneumonia & empyema

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

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

2012 ü Prospective, n=36 ü 14Fr Pigtail v historic 32-40Fr Chest Tubes ü Ability to drain acute HTx?

2012 ü Same initial output ü Same insertion complications ü Same failure rate ü Same tube duration Pigtails effective drains?

Chest Autotransfusion ü Cheap. ü Fast. ü Warm. ü Whole blood.

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

Autotransfusion Bacterial contamination? Red cell breakdown products? Inflammatory contents? O2 Delivery Capacity? VS. Cheap, fast Warm Fresh Factors Virus neutral ABO

2015 ü Multicenter, retrospective ü N=272, propensity score ü +/- Autotransfusion with CPD

2015 ü ND mortality ü ND complications ü ND 24h INR ü Less RBC required ü Less Platelets required ü Less cost of transfusion

Autotransfusion ü Citrate phosphate dextrose (CPD) in all collection systems 1mL/7mL blood.

DISCHARGING THE STABLE PT

DISCHARGING THE STABLE PT ü Stable ü Examinable ü Isolated thoracic injury ü Negative U/S+CXR

DISCHARGING THE STABLE PT ü Stable ü Examinable ü Isolated thoracic injury ü Negative U/S+CXR When can we d/c home?

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 CXR @ 3 and 6 hrs

ü 0.9% developed PTx on 3hr CXR requiring CT insertion ü Follow-up CXR is warranted ü No new findings on 6hr CXR

2008 ü Prospective, 36 months ü 100 asymptomatic, normal admission CXR ü 75% SW, 25% GSW

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

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

Penetrating Chest Injury Arresting Unstable Stable ER Thoracotomy Right Chest Tube Cardiac U/S X-Rays +/- CT +/- L-scope

The Unstable Patient

Unstable-Critical Actions ü Start crystalloid resuscitation. ü Initiate cross-matching. ü Stabilize ü Arrest ü Remain Unstable

Unstable-Critical Actions ü Remain unstable. ü Start uncross-matched or type specific blood. ü Start thawing FFP.

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.

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.

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

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.

OBJECTIVES ü Practical approach ü Heart ü Trans-mediastinal wounds ü Autotransfusion ü Tension Pneumothorax

ü Shortness of Breath ü Chest Pain ü Decreased A/E ü Low O2 Saturation ü Hyper-resonance ü Tactile fremitus

ü Shortness of Breath ü Chest Pain ü Decreased A/E ü Low O2 Saturation ü Hyper-resonance ü Tactile fremitus PTX

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

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

Pleural Air

Pleural Air Compresses lung

Pleural Air Compresses lung SIMPLE PNEUMOTHORAX

Air Increases

Air Increases Compresses Lung Even More

Air Increases Compresses Lung Even More Shifts Mediastinum

Functional Deformation + Impaired Venous Return Decreased CO

Functional Deformation + Impaired Venous Return TENSION PNEUMOTHORAX

Collapsed Lung

Mediastinal Shift

ü EXTRINSIC COMPRESSION ü CARDIAC DEFORMATION ü DECREASED VENOUS RETURN

NEEDLE DECOMPRESSION

NEEDLE DECOMPRESSION ü Emergent procedure for decompression ü ATLS - 2 nd Intercostal space, Mid-clavicular line ü 5 cm catheter

Does it work? ü No good data on indications ü No good data on efficacy

THE PROBLEM ü Diagnosis is clinical ü Treatment occurs before CXR confirmation ü Never get to know if diagnosis was correct

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

Studies 1. CADAVERIC MODEL 2. CT BASED HUMAN EVALUATION 3. EMS EVALUATION

2011 ü Human cadavers ü Traditional 2 nd v. 5 th ICS ü 5cm standard catheter ü 80 needles into 20 cadavers

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

SUCCESSFUL PENETRATION * * 60% 55%

SUCCESSFUL PENETRATION * 70% 15%

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

2012 ü Evaluate 2 nd v 5 th using Chest CTs of real trauma patients

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

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?

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

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

RESULTS ü Time to insertion SAME ü Ease of finding and inserting needle BETTER ü Accuracy BETTER ü Aggregate distance from correct position BETTER

Take Home Points ü Indications for needle decompression not well delineated ü If going to needle, know the following

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

Take Home Points ü In controlled experiments, 60% will fail entry ü R and L ü Females > Males ü Worse as BMI increases

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

Arresting Summary ü Resuscitative Thoracotomy. ü Right Sided Chest Tube.

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.

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.