Case capsule

• 35/Male• No co-morbid illnesses.• Alleged stab injury over the chest.• No other injuries.

• 9.30am- • HR- 80/minute. RR- 24/minute

BP:100/70mmHg• CVS- S1 S2 normal.• RS- B/L equal air entry. • One episode of hypotension responded to

fluids.• FAST- minimal fluid in abdomen.

• What would you do next?

4 pm • Hypotension not responding to fluids.• BP 70 systolic. HR- 80 minute.• Abdomen – distended. No peritoneal

signs.• Drop in Hb by 5g% on ABG• Posted for operation

2pm CT abdomen -moderate hemopericardium , mild ascites

ECHO by CTVS – pericardial fluid+, nil intervention

Intraoperative findings

• 2x2 cm rent in the left dome of diaphragm, cardiac movements were seen.

• 1L hemoperitoneum.• 2cm laceration in the right lobe of liver.• No ongoing bleeding

• How would you proceed?

• Post operatively shifted to SICU• ECHO- pericardial effusion and occasional RV

collapse.• Serial cardiac enzymes and ECG was normal.• Repeat CXR- no evidence of

hemo/pneumothorax.• Post operative day 6 – discharged.

Penetrating thoracoabdominal trauma

Anatomy• Thoracoabdominal region(intrthoracic

abdomen)• 4th ICS/level of nipple anteriorly• 6th ICS laterally• 8th ICS posteriorly

Thoracoabdominal region

Organs commonly injured in thoracoabdominal trauma

Thoracic AbdominalLung parenchyma Major vasculaturePulmonary hilum  Aorta and branchesHeart IVCMajor vasculature Esophagus Aorta, great vessels Stomach IVC SpleenEsophagus LiverDiaphragm Duodenum

PancreasSmall and large bowelGenitourinary structures

History

• Earliest literature on thoraco abdominal trauma form WW-II

• Overall mortality of 8-40% during WW-II• In recent studies mortality 2-18%.• Incidence of thoracoabdominal trauma in

penetrating thoracic injury – 10-30%

Why is thoracoabdominal region is distinct?

1. 70 percent of pericardial injuries are occult.2. Likely to miss diaphragmatic injuries.3. Decision making. – Which cavity to open

first? 4. The organs and vessels in the region.5. High mortality

Abdominal organs commonly involved in penetrating thoracoabdominal trauma

Site of Injury Mechanism of Injury

Oparah(%) Moore(%) Seimens(%) NS Borja(%) GSW

GSW SW

Liver 40 29 3 24 20

Diaphragm 35 28 12 32 30

Spleen 16 8 5 10 7

Stomach 15 15 1 12 8

Colon 15 14 3 13 6

Small bowel 8 9 2 ND 7

Operative intervention in thoracoabdominal penetrating trauma

• intraperitoneal injury in close to 45% cases needing laparotomy.

• Peritoneal penetration more common with GSW . Multiorgan involvement more common in GSW.

• Most thoracic trauma can be managed with chest tube alone.

• 10-15% need thoracotomy ( higher mortality 13% compared to 3%)

• Incorrect preoperative sequencing reported in around 30 % cases.

Evaluation of thoracoabdominal injuries

• Follow ATLS guidelines.• All thoracoabdominal injuries are potentially

fatal.• Physical examination• Chest - often unreliable , needs imaging,

atleast Chest Xray.• Abdomen – reliable if no neurological deficits.

FAST

• 100% sensitivity and 99% specificity for pericardial fluid.

• 86-99% sensitivity for intraperitoneal fluid.

• Also highly sensitive and specific for pleural effusion and hemothorax.

• Indications for immediate laparotomy• - peritonitis.• - hypotension• - on going hemorrhage• - evisceration• - Others need serial abdominal examinations

and close observation.

Indications for thoracotomy

• 85% cases managed by Chest drains, respiratory support and analgesia .

• Hemodynamic instability• Suspicion on cardiac tamponade.• Significant air leak from chest tube• On going bleeding from chest tube(>200 ml/hour).• Injury to great vessels or esophagus/• Tracheobronchial injury.

Cardiac tamponade• Becks triad (Seen in 10% cases) – hypotension,

elevated JVP,muffled heart sounds. • ECHO should be done for all hemodynamically

stable patients with precordial chest trauma.• Sensitivity and specificity ~100%• Sensitivity of ECHO reduces from 100% to 56%

in presence of hemothorax.

In the presence of cardiac tamponade – • median sternotomy is the procedure of choice

vs. anterolateral thoracotomy. In case of high suspicion of pericardial injury• pericardiocetesis (poor sensitivity/specificity)• subxiphoid pericardial window (reliable)• Serial ECHO

Diaphragmatic injuries

• Incidence 10-80%• Physical and radiographic changes- non specific.• High likelihood for missing asymptomatic

injuries can lead to diaphragmatic hernias later.

• Late presentation of diaphragmatic injury – 25% mortality

• Complications much higher on the left side.

• In penetrating left thoracoabdominal injuries incidence of diaphragmatic injury– 42%

• Laparoscopy –mandatory for left thoracoabdominal injuries if no other indication for open procedure.

Laparoscopy in penetrating thoracoabdominal injuries.

• Currently recommended for left sided injuries in asymptomatic patients in the absence of indication for laparotomy.

• 27% of occult diaphragmatic injuries detected

• VIDEO ASSISTED THORACOSCOPY• To assess diaphragmatic injuries/hemothorax.• Laparoscopy vs. thoracospoy- surgeon

preference.

References

• World Journal of Emergency Surgery 2014, 9:33• Clinical decision making in unstable patients with,

thoraco-abdominal stab wounds and, potential injuries in multiple body cavities, Injury, Volume 42, Issue 5, May 2011, Pages 478-481

• Emergency Medicine Clinics of North America Volume 16, Issue 1, 1 February 1998, Pages 107–128