CHEST TRAUMA Sept 4/2003 Todd Ring Gord McNeil. Overview Approach to patient with chest trauma...

CHEST TRAUMACHEST TRAUMA

Sept 4/2003Sept 4/2003

Todd Ring Todd Ring

Gord McNeilGord McNeil

OverviewOverview

Approach to patient with chest traumaApproach to patient with chest trauma Pulmonary injuries:Pulmonary injuries:

– Management of occult pneumothoraxManagement of occult pneumothorax– OR intervention for hemothoraxOR intervention for hemothorax– Imaging of pulmonary contusionImaging of pulmonary contusion

Traumatic aortic injury: imaging modalitiesTraumatic aortic injury: imaging modalities Blunt and penetrating cardiac injuryBlunt and penetrating cardiac injury

– Role of ED ThoracotomyRole of ED Thoracotomy Chest wall and other injuriesChest wall and other injuries Gord’s chest trauma casesGord’s chest trauma cases

EpidemiologyEpidemiology

22ndnd commonest cause of traumatic death after head commonest cause of traumatic death after head injuries (USA = 16,000 deaths per year)injuries (USA = 16,000 deaths per year)

25% of all trauma related deaths25% of all trauma related deaths 10 % mortality10 % mortality

5 – 10 % of pediatric trauma admissions but 5 – 10 % of pediatric trauma admissions but higher mortaliltyhigher mortalilty– 5% mortality when isolated5% mortality when isolated

– 25 % mortality with head or abdominal trauma25 % mortality with head or abdominal trauma

– 40 % mortality when head, abdominal and chest injury40 % mortality when head, abdominal and chest injury

Initial Management and Initial Management and AssessmentAssessment

ABC’sABC’s Six Immediately Life Threatening Injuries:Six Immediately Life Threatening Injuries:

– airway obstructionairway obstruction– flail chestflail chest– tension pneumothoraxtension pneumothorax– open peumothoraxopen peumothorax– massive hemothoraxmassive hemothorax– cardiac tamponadecardiac tamponade

All can be identified in the primary surveyAll can be identified in the primary survey CXR not necessary to make the diagnosisCXR not necessary to make the diagnosis

Secondary SurveySecondary Survey

More detailed examination including reassessment More detailed examination including reassessment of items covered in primary surveyof items covered in primary survey

Appropriate investigations: CXR, pulse oximeter, Appropriate investigations: CXR, pulse oximeter, EKG, ABGEKG, ABG

Identify “potentially” lethal chest injuriesIdentify “potentially” lethal chest injuries– simple pneumothorax, hemothorax, pulmonnary simple pneumothorax, hemothorax, pulmonnary

contusion, tracheobronchial tree injury, blunt cardiac contusion, tracheobronchial tree injury, blunt cardiac injury, traumatic aortic injury, diaphragmatic injury, injury, traumatic aortic injury, diaphragmatic injury, wounds transversing the mediastinumwounds transversing the mediastinum

ClassificationClassification

1) Chest wall injuries 50% 1) Chest wall injuries 50% – rib fractures, flail chest, sternal fracturesrib fractures, flail chest, sternal fractures

2) Pulmonary injuries 25%2) Pulmonary injuries 25%– pulmonary contusion, hemothorax, pneumothorax, pulmonary contusion, hemothorax, pneumothorax,

tracheo-bronchial disruptiontracheo-bronchial disruption

3) Cardiovascular injuries 20%3) Cardiovascular injuries 20%– myocardial contusion, aortic disruption, cardiac myocardial contusion, aortic disruption, cardiac

rupture/tamponaderupture/tamponade

4) Other 5% 4) Other 5% – esophageal/diaphragmatic injuriesesophageal/diaphragmatic injuries

Mr. C. TubeMr. C. Tube

22 yo male driver MVC. Unrestrained found 10 22 yo male driver MVC. Unrestrained found 10 feet from vehicle. GCS 8 at scene. Intubated for feet from vehicle. GCS 8 at scene. Intubated for airway protection. Hemodynamically stable. CXR airway protection. Hemodynamically stable. CXR normal. CT head and spine normal. CT abdomen normal. CT head and spine normal. CT abdomen demonstrates small pneumothoracies, no demonstrates small pneumothoracies, no abdominal pathology.abdominal pathology.– What features on supine CXR useful in identifying What features on supine CXR useful in identifying

pneumothoracies?pneumothoracies?– Does this patient require a chest tube?Does this patient require a chest tube?– Does he require antibiotic prophylaxis if he gets a chest Does he require antibiotic prophylaxis if he gets a chest

tube?tube?

Simple PneumothoraxSimple Pneumothorax

• No communication with No communication with atmosphereatmosphere

• No shift of mediastinum No shift of mediastinum or hemidiaphragmor hemidiaphragm

• MechanismMechanism- Fractured ribFractured rib- Increased Increased

intrathoracic pressure intrathoracic pressure with closed glottiswith closed glottis

Open PneumothoraxOpen Pneumothorax

• Open defect in chest wall; if > Open defect in chest wall; if > 2/3 diameter of trachea then 2/3 diameter of trachea then path of least resistance for airpath of least resistance for air

• Paradoxical motion of Paradoxical motion of affected lungaffected lung

• Large dead space = severe Large dead space = severe ventilatory disturbanceventilatory disturbance

• Cover with occlusive dressingCover with occlusive dressing• High risk of conversion to High risk of conversion to

tension pneumothorax tension pneumothorax especially if PPVespecially if PPV

Tension PneumothoraxTension Pneumothorax

Trapping of air created Trapping of air created by one way valveby one way valve

Cardinal signsCardinal signs– decreased BS and decreased BS and

hyper-resonance on hyper-resonance on one sideone side

– distended neck veinsdistended neck veins– hypotensionhypotension– tachycardiatachycardia

Needle decompression Needle decompression 22ndnd ICS MCL then CT ICS MCL then CT

Pneumothorax on CXRPneumothorax on CXR

Frequently missed (20-30%) on initial Frequently missed (20-30%) on initial trauma CXR (small size or supine position)trauma CXR (small size or supine position)

If pneumothorax suspected:If pneumothorax suspected:– sit patient upsit patient up– expiration filmexpiration film– repeat in 3 hoursrepeat in 3 hours– +/- indication for CT chest+/- indication for CT chest

Pneumothorax on Supine FilmPneumothorax on Supine Film

Deep sulcus signDeep sulcus sign– deep lucent costophrenic sulcusdeep lucent costophrenic sulcus

Depression of involved hemidiaphragmDepression of involved hemidiaphragm Hyperlucency in lower chestHyperlucency in lower chest Double diaphragm signDouble diaphragm sign

– Seen at interface of dorsal and ventral Seen at interface of dorsal and ventral pneumothorax with anterior and posterior pneumothorax with anterior and posterior aspects of hemidiaphragmaspects of hemidiaphragm

Pneumothoarx on CXRPneumothoarx on CXR

Estimation of size of pneumothoraxEstimation of size of pneumothorax Generally inaccurate – varies with Generally inaccurate – varies with

inspiratory effort and shift of mediastinuminspiratory effort and shift of mediastinum– From lateral chest wall (~4From lateral chest wall (~4thth rib) 1cm = 10%, rib) 1cm = 10%,

2cm = 20%2cm = 20%– Generally intervention is indicated if >20%Generally intervention is indicated if >20%

Treatment of Occult Treatment of Occult PneumothoraciesPneumothoracies

• Occult pneumothoracies are often missed on CXR and Occult pneumothoracies are often missed on CXR and found on abdominal CT scans—do these patients need found on abdominal CT scans—do these patients need chest tubes?chest tubes?

• Brasel et al. conducted a prospective, randomized trial Brasel et al. conducted a prospective, randomized trial comparing CT to observation in 39 patients with comparing CT to observation in 39 patients with pneumothoracies from blunt chest trauma (including 9 pneumothoracies from blunt chest trauma (including 9 patients in each group with PPV)patients in each group with PPV)- there was no difference in overall complication rate (progression there was no difference in overall complication rate (progression

of pneumo or resp. distress) of pneumo or resp. distress) - no patient had respiratory distress related to the OPTX or required no patient had respiratory distress related to the OPTX or required

emergent CTemergent CTBrasel et al. Treatment of occult pneumothoraces from blunt trauma. Journal of Brasel et al. Treatment of occult pneumothoraces from blunt trauma. Journal of Trauma-Injury Infection & Critical Care. 46(6):987-90Trauma-Injury Infection & Critical Care. 46(6):987-90

Occult Pneumothorax in MV PatientsOccult Pneumothorax in MV Patients

Enderson et al. studied forty trauma patients with occult Enderson et al. studied forty trauma patients with occult pneumothoraxpneumothorax who were prospectively randomized to who were prospectively randomized to management with CT (n = 19) or observation (n = 21) in management with CT (n = 19) or observation (n = 21) in MV patientsMV patients– 8 of 21 patients observed had progression of their 8 of 21 patients observed had progression of their

pneumothoraces on PPV with 3 developing tension pneumothoraxpneumothoraces on PPV with 3 developing tension pneumothorax– no patients with CT suffered major complicationsno patients with CT suffered major complications– hospital and ICU stays were not increased by CThospital and ICU stays were not increased by CT– they concluded that patients with occult pneumothorax on PPV they concluded that patients with occult pneumothorax on PPV

should undergo tube thoracostomyshould undergo tube thoracostomyEnderson et al. Tube thoracostomy for occult pneumothorax: a prospective randomized Enderson et al. Tube thoracostomy for occult pneumothorax: a prospective randomized

study of its use. Journal of Trauma-Injury Infection & Critical Care. 35(5):726-9study of its use. Journal of Trauma-Injury Infection & Critical Care. 35(5):726-9

Chest Tube IndicationsChest Tube Indications

• Traumatic cause of pneumothoraxTraumatic cause of pneumothorax• Moderate-to-large pneumothoraxModerate-to-large pneumothorax• Respiratory distressRespiratory distress• Increasing size with conservative therapyIncreasing size with conservative therapy• Recurrence after removal of chest tubeRecurrence after removal of chest tube• Patient requires ventilationPatient requires ventilation• HemothoraxHemothorax• Bilateral pneumothorax (regardless of size)Bilateral pneumothorax (regardless of size)• Tension pneumothoraxTension pneumothorax

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.© 2002 Mosby, Inc.

Chest Tube ComplicationsChest Tube Complications

• Complications:Complications:- neurovascular bundle damage, intrapulmonary insertion, neurovascular bundle damage, intrapulmonary insertion,

subcutaneous emphysema, bronchopleural fistulasubcutaneous emphysema, bronchopleural fistula• Bailey et al. performed a retrospective case series of all Bailey et al. performed a retrospective case series of all

trauma patients who underwent chest tube over a one trauma patients who underwent chest tube over a one year period to determine rates of complications in year period to determine rates of complications in trauma patientstrauma patients- 57 CT’s placed in 47 patients with no insertional 57 CT’s placed in 47 patients with no insertional

complications and only one major complicationcomplications and only one major complication- they concluded no need to decrease rates of CTthey concluded no need to decrease rates of CT

Bailey et al. Complications of tube thoracostomy in trauma.Bailey et al. Complications of tube thoracostomy in trauma.Journal of Accident & Emergency Medicine. 17(2):111-4, 2000 Mar.Journal of Accident & Emergency Medicine. 17(2):111-4, 2000 Mar.

Antibiotic Prophylaxis in Antibiotic Prophylaxis in Patients with Chest TubesPatients with Chest Tubes

Reported incidence of empyema 1.6 – 26 % after Reported incidence of empyema 1.6 – 26 % after chest tubechest tube

Mandal et al. recommend antibiotics for emergent Mandal et al. recommend antibiotics for emergent or urgent thoracotomy, shotgun blast to chest wall, or urgent thoracotomy, shotgun blast to chest wall, lung contusion with hemoptysis, exploratory lap, lung contusion with hemoptysis, exploratory lap, or open long bone fractureor open long bone fracture– 5474 patients followed protocol with only 1.6% 5474 patients followed protocol with only 1.6%

developed empyemadeveloped empyema

Mandal et al. Post traumatic empyema. Risk factor analysis. Arch Surg Mandal et al. Post traumatic empyema. Risk factor analysis. Arch Surg 1997; 132: 647-651.1997; 132: 647-651.

Antibiotics con’t…Antibiotics con’t…

Richardson’s review article from 7 RTC’s Richardson’s review article from 7 RTC’s comparing antibiotics vs. nonecomparing antibiotics vs. none– Infection rate in placebo 20.9% vs. 4.5 % in treatmentInfection rate in placebo 20.9% vs. 4.5 % in treatment

Richardson. Thoracic infection after trauma. Chest Surg. Clin NA. Richardson. Thoracic infection after trauma. Chest Surg. Clin NA. 1997; 7: 401-4261997; 7: 401-426

No infectious complications in hemothoracies > No infectious complications in hemothoracies > 500 cc (often thought to be nidus for infection)500 cc (often thought to be nidus for infection)

Staph aureus most common pathogen; gram Staph aureus most common pathogen; gram negative, anaerobes also pathogensnegative, anaerobes also pathogens

Air Travel Following Air Travel Following PneumothoraxPneumothorax

Aerospace Medicine Association recommends Aerospace Medicine Association recommends waiting 2-3 weeks after radiographic resolution of waiting 2-3 weeks after radiographic resolution of pneumothorax prior to air travelpneumothorax prior to air travel

Cheatham et al. conducted a prospective study of Cheatham et al. conducted a prospective study of air travel following pneumothoraxair travel following pneumothorax– 12 patients who flew 14 days after pneumothorax 12 patients who flew 14 days after pneumothorax

resolved had no symptomsresolved had no symptoms– 2 patients who flew within 14 days; one patient 2 patients who flew within 14 days; one patient

developed symptomsdeveloped symptomsCheatham et al. Air travel following traumatic pneumothorax. When is it Cheatham et al. Air travel following traumatic pneumothorax. When is it

safe? Am Surg. 1999; 65:1, 160-4.safe? Am Surg. 1999; 65:1, 160-4.

““Stick-em up!”Stick-em up!”

41 year old male, “minding his own 41 year old male, “minding his own business,” single GSW to R chest by small business,” single GSW to R chest by small caliber handgun. Tachycardic. BP 90/50. caliber handgun. Tachycardic. BP 90/50. Decreased BS to R chest. CXR Decreased BS to R chest. CXR opacification of R lung. CT on R initial opacification of R lung. CT on R initial drainage 1000cc.drainage 1000cc.– Does this patient require immediate OR?Does this patient require immediate OR?

HemothoraxHemothorax

• Accumulation of blood in pleural spaceAccumulation of blood in pleural space• Can cause severe hypovolemia, shock, and Can cause severe hypovolemia, shock, and

decrease vital capacitydecrease vital capacity• Generally due to injured lung parenchyma – Generally due to injured lung parenchyma –

usually self-limitingusually self-limiting• More severe bleeding from intercostal and More severe bleeding from intercostal and

internal mammary arteriesinternal mammary arteries• Uncommonly from great vesselsUncommonly from great vessels

Xray in HemothoraxXray in Hemothorax

Poor ability to predicit amount of blood in chest Poor ability to predicit amount of blood in chest cavity using CXRcavity using CXR

250 ml required to cause blunting of costophrenic 250 ml required to cause blunting of costophrenic angle on uprightangle on upright

On supine film fluid layers posteriorlyOn supine film fluid layers posteriorly– increased density over hemithoraxincreased density over hemithorax

25 % of cases associated with pneumothorax25 % of cases associated with pneumothorax– may see air fluid level on upright CXRmay see air fluid level on upright CXR

CT more sensitive than CXR but generally CT more sensitive than CXR but generally clinically insignificant if not visible on CXRclinically insignificant if not visible on CXR

TreatmentTreatment

#38 chest tube at midaxillary line#38 chest tube at midaxillary line BIG PROBLEM = BIG CUT = BIG TUBEBIG PROBLEM = BIG CUT = BIG TUBE

Who needs the OR?Who needs the OR?

initial drainage > 20 ml/kg of blood (1500ml)initial drainage > 20 ml/kg of blood (1500ml) persistent bleeding at > 7 ml/kg/hr (500ml/h)persistent bleeding at > 7 ml/kg/hr (500ml/h) increasing hemothorax on CXRincreasing hemothorax on CXR persistent hypotension despite adequate blood persistent hypotension despite adequate blood

replacement and other sites ruled out as sourcereplacement and other sites ruled out as source patient decompensates after initial resuscitationpatient decompensates after initial resuscitation

15mg/kg of blood initially or 3-4mg/kg/h15mg/kg of blood initially or 3-4mg/kg/h

Tracheo-bronchial InjuryTracheo-bronchial Injury

Occur with either blunt or penetrating Occur with either blunt or penetrating injuriesinjuries

Relatively rare injury (<3 % of chest Relatively rare injury (<3 % of chest injuries)injuries)

Mortality rate of 30 % (50 % die within first Mortality rate of 30 % (50 % die within first hour)hour)

Rare in children but high mortalityRare in children but high mortality– 33% die in 133% die in 1stst hour hour

Clinical PresentationClinical Presentation

TypicallyTypically– Hoarseness, dyspnea, hemoptysis, blood in larynx, Hoarseness, dyspnea, hemoptysis, blood in larynx,

subcutaneous emphysema, pneumothorax not subcutaneous emphysema, pneumothorax not improving with chest tube and large air leak despite 2 improving with chest tube and large air leak despite 2 chest tubeschest tubes

Two clinical patterns depending on location of Two clinical patterns depending on location of injuryinjury

1.1. wound opens in to pleural cavitywound opens in to pleural cavity2.2. no communication with pleural cavity therefore no no communication with pleural cavity therefore no

pneumothorax (occult presentation); identified at later pneumothorax (occult presentation); identified at later date due to atelectasis/pneumonia from granulation date due to atelectasis/pneumonia from granulation tissue obstructing airwaytissue obstructing airway

Diagnosis and ManagementDiagnosis and Management

• X-rayX-ray- Lateral neck view – pretracheal or Lateral neck view – pretracheal or

subcutaneous airsubcutaneous air- CXR – mediastinal air, pneumothoraxCXR – mediastinal air, pneumothorax

• Fiberoptic bronchoscopyFiberoptic bronchoscopy• Intubation over bronchoscopy to prevent Intubation over bronchoscopy to prevent

extratracheal intubation into mediastinum extratracheal intubation into mediastinum (case reports of this occurring)(case reports of this occurring)

Pulmonary ContusionPulmonary Contusion

Most common injury following chest traumaMost common injury following chest trauma Often in combination with other injuries such as Often in combination with other injuries such as

rib fracture or flail chestrib fracture or flail chest Bleeding from laceration of lung parenchyma Bleeding from laceration of lung parenchyma

Most common thoracic injury in pediatric traumaMost common thoracic injury in pediatric trauma

Often isolated injury due to pliable chest wallOften isolated injury due to pliable chest wall

Imaging in Pulmonary Imaging in Pulmonary ContusionContusion

Contusion usually present on initial CXR and always Contusion usually present on initial CXR and always appears within 6 hoursappears within 6 hours

Appear as patchy or diffuse airspace diseaseAppear as patchy or diffuse airspace disease Can identify occult contusions on chest CT but clinically Can identify occult contusions on chest CT but clinically

utility unclearutility unclear– Guerro-Lopez et al. conducted a cohort study of 375 patients. Guerro-Lopez et al. conducted a cohort study of 375 patients.

One group received admission CT the other CXR.One group received admission CT the other CXR.– Induced therapy changes in 30 % of patients but no effect on Induced therapy changes in 30 % of patients but no effect on

MV, ICU stay or mortality MV, ICU stay or mortality Guerrero-Lopez F, Vazquez-Mata G, Alcazar-Romero PP, et al. Evaluation of the Guerrero-Lopez F, Vazquez-Mata G, Alcazar-Romero PP, et al. Evaluation of the utility of computed tomography in the initial assessment of the critical care patient utility of computed tomography in the initial assessment of the critical care patient with chest trauma. Crit Care Medwith chest trauma. Crit Care Med2000;28:1370-5 2000;28:1370-5

Pulmonary Contusion vs. Pulmonary Contusion vs. ARDSARDS

ContusionContusion Manifest within minutes

(up to 6 hours) Usually confined to one

lobe Apparent on initial CXR

– Resolve on CXR by 48 –72 hours

ARDSARDS Development delayed Diffuse Onset between 24-72

hours

ManagementManagement

Hospitalize for observationHospitalize for observation Chest physio/incentive spirometry/ Chest physio/incentive spirometry/

analgesia/supplemental O2analgesia/supplemental O2 In patients who remain hospitalized greater In patients who remain hospitalized greater

than 48 h and have progression of CXR than 48 h and have progression of CXR finding should prompt suspicion of other finding should prompt suspicion of other diagnosises including ARDS or aspiration diagnosises including ARDS or aspiration

Mrs. Dee SellarationMrs. Dee Sellaration

55 yo female. Driver of single vehicle MVC 55 yo female. Driver of single vehicle MVC into telephone pole (approx 70 kph). into telephone pole (approx 70 kph). Restrained. Airbag deployed. LOC at scene Restrained. Airbag deployed. LOC at scene GCS 3. Intubated. Tachycardic but BP GCS 3. Intubated. Tachycardic but BP 90/50.90/50.– Findings on CXR to suggest TAI?Findings on CXR to suggest TAI?– What is the next imaging study of choice?What is the next imaging study of choice?– How aggressive do you fluid resuscitate this How aggressive do you fluid resuscitate this

patient?patient?

Great Vessel InjuryGreat Vessel Injury

Injury of high speed MVCInjury of high speed MVC– mortality 1947 < 1%mortality 1947 < 1%– mortality now 15 %mortality now 15 %

More frequent with penetrating trauma More frequent with penetrating trauma (90%)(90%)

Aorta most commonly injured; high Aorta most commonly injured; high mortality associated with this injury mortality associated with this injury Rare in pediatrics—almost all secondary to Rare in pediatrics—almost all secondary to MVCMVC

Aortic AnatomyAortic Anatomy

Pathologic TerminologyPathologic Terminology

Traumatic aortic injury:Traumatic aortic injury: generic term that generic term that covers all of the below; should be used to covers all of the below; should be used to describe the lesion until injury fully defineddescribe the lesion until injury fully defined

Aortic traumatic rupture:Aortic traumatic rupture: full thickness full thickness disruption of the walldisruption of the wall

Aortic traumatic tear:Aortic traumatic tear: partial thickness tear partial thickness tear limited to intima and muscularislimited to intima and muscularis

Aortic traumatic intimal tear:Aortic traumatic intimal tear: disruption of disruption of the intimathe intima

Who cares about terminology?Who cares about terminology?

Most patients presenting to the ED with Most patients presenting to the ED with TAI have a TAI have a partial thicknesspartial thickness injury injury

Of those patients suffering a Of those patients suffering a complete TAIcomplete TAI– 80 – 85 % exsanguinate at the scene, 15-20% 80 – 85 % exsanguinate at the scene, 15-20%

arrive in the ED alivearrive in the ED alive– of these 50% exsanguinate in the first 24 hours; of these 50% exsanguinate in the first 24 hours;

80% by one week and 95% by four months80% by one week and 95% by four months– 2 – 5 % long term survivors2 – 5 % long term survivors

Risk factors for Aortic InjuryRisk factors for Aortic Injury

Dyer et al. conducted a prospective study of 1561 Dyer et al. conducted a prospective study of 1561 patients with suspected aortic injury over 5 year patients with suspected aortic injury over 5 year periodperiod– Only significant RF was high speed MVC (>60kph)Only significant RF was high speed MVC (>60kph)– No association for front vs. side impact, ejection, fatality, No association for front vs. side impact, ejection, fatality,

sudden deceleration, damagesudden deceleration, damage– No blunt TAI from fall < 10 feetNo blunt TAI from fall < 10 feet– Concluded by recommended the liberal use of chest CT Concluded by recommended the liberal use of chest CT

in blunt chest traumain blunt chest traumaDryer et al. Dryer et al. Thoracic Aortic Injury: How Predictive Is Mechanism and Is Chest Thoracic Aortic Injury: How Predictive Is Mechanism and Is Chest

Computed Tomography a Reliable Screening Tool? Journal of Trauma Computed Tomography a Reliable Screening Tool? Journal of Trauma 2000;48:673-6832000;48:673-683

Location, location, location...Location, location, location...

55 - 65% involve proximal descending aorta55 - 65% involve proximal descending aorta 10-15% ascending aorta or arch10-15% ascending aorta or arch 12% distal12% distal 13-18% multiple sites13-18% multiple sites Patients with ascending aorta tears have a 70-Patients with ascending aorta tears have a 70-

80% incidence of associated lethal injuries80% incidence of associated lethal injuries– pericarditis, tamponade, aortic valve tear, pericarditis, tamponade, aortic valve tear,

coronary artery injurycoronary artery injury

Prehospital ManagementPrehospital Management

Good evidence to avoid military anti-shock Good evidence to avoid military anti-shock trousers trousers elevates BP elevates BP

No effective in field therapy for injuries to No effective in field therapy for injuries to the great vessels therefore “scoop and run” the great vessels therefore “scoop and run” best pre-hospital managementbest pre-hospital management

ATLS recommends 1-2 L fluid bolous for ATLS recommends 1-2 L fluid bolous for patients in shock to return BP to “normal” patients in shock to return BP to “normal” HOWEVER...HOWEVER...

Fluid Restriction in TAIFluid Restriction in TAI

Bickell et al. conducted a prospective trial of Bickell et al. conducted a prospective trial of penetrating torso trauma in patients with SBP < 90penetrating torso trauma in patients with SBP < 90

Fluid restricted group received no fluid Fluid restricted group received no fluid rescusitation until arrival at ORrescusitation until arrival at OR

Control group received standard resuscitationControl group received standard resuscitation– 203/289 (70 %) patients in restricted group survived to 203/289 (70 %) patients in restricted group survived to

hospital d/c compared to 193/309 (62 %) of control hospital d/c compared to 193/309 (62 %) of control groupgroup

Bickell et al. Immediate versus Delayed Fluid Resuscitation for Bickell et al. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. NEJM Hypotensive Patients with Penetrating Torso Injuries. NEJM 331:1105-1109331:1105-1109


HistoryHistory MVC: impact, MVC: impact,

duration of extraction, duration of extraction, intrsuion, blood lossintrsuion, blood loss

Penetrating trauma: Penetrating trauma: length of knife, length of knife, firearm type, number firearm type, number of rounds fired and of rounds fired and distancedistance

Physical ExaminationPhysical Examination Do not disregard the Do not disregard the

possibility of aortic possibility of aortic injury based on injury based on patients clinical patients clinical apperanceapperance

Physical Findings that Increase Physical Findings that Increase Suspicion of Blunt Aortic InjurySuspicion of Blunt Aortic Injury

• Hypotension: Up to 50% of patients with proven aortic rupture present with hypotension.

• Hypertension: Up to 72% of patients may be hypertensive before fluid or vasoactive drug administration. The hypertension may result from a stretching stimulus of the sympathetic afferent nerve fibers, located in the area of the aortic isthmus.

• Pseudocoarctation syndrome: Acute onset of upper extremity hypertension, along with absent or diminished femoral pulses. Reported to occur in up to one third of the patients due to compression of the aortic lumen by the periaortic hematoma.

• Expanding hematoma: At the thoracic outlet.

• Interscapular murmur: Reported in up to 31% of the patients.

• Palpable fracture:Of the sternum.

• Palpable fracture:Of the thoracic spine.

• Hemothorax:Chest tube with an initial “rush” of more than 1500 mL or more 200-300 mL/h is suggestive of a major vessel injury and an indication for urgent thoracotomy.

Radiography in TAIRadiography in TAI

Specific findings:Specific findings:– mediastinal wideningmediastinal widening– depression of left mainstem depression of left mainstem

bronchusbronchus– loss of paravertebral stripeloss of paravertebral stripe– NG deviationNG deviation– lateral displacement of trachealateral displacement of trachea– left apical capleft apical cap– obscured aortic knobobscured aortic knob– widened paratracheal stripwidened paratracheal strip

Difficult to assess Difficult to assess mediastinal widening in mediastinal widening in pediatrics because of thymuspediatrics because of thymus

Radiographic FindingsRadiographic Findings

Table 3. Radiographic Findings of Mediastinal Hematoma

Finding Sensitivity Specificity

Mediastinal widening 50-90% 10%

Depression of the left mainstem bronchus

70-80% 80-100%

Deviation of nasogastric tube 23-71% 90-94%

Lateral displacement of trachea 12-100% 80-95%

Left apical pleural cap 20-63% 75-76%

Loss of paravertebral pleural stripe

Obscured aortic knob

Widened paratracheal stripe

CXR in TAICXR in TAI

Despite multiple suggestive findings on Despite multiple suggestive findings on CXR not completely reliableCXR not completely reliable

The CXR visualises the mediastinum not The CXR visualises the mediastinum not the aortathe aorta

Sensitivity of widened mediastinum only Sensitivity of widened mediastinum only 89% and of any abnormality 92-98%89% and of any abnormality 92-98%

Take home message CXR will miss 2-11% Take home message CXR will miss 2-11% of injuriesof injuries

AortographyAortography

The “gold standard” with sensitivity of 100% The “gold standard” with sensitivity of 100% Also localizes the area of injury and can identify lesions Also localizes the area of injury and can identify lesions

in other vesselsin other vessels BUTBUT

– time consumingtime consuming– in location away from EDin location away from ED– not readily availablenot readily available– high contrast loadhigh contrast load

Complication rate of 2.6 % in series of trauma patientsComplication rate of 2.6 % in series of trauma patientsReid et al. The assessment of proximity of a wound to major vascular Reid et al. The assessment of proximity of a wound to major vascular structures as an indication for arteriography. Arch Surgery 1988; 123: 942-structures as an indication for arteriography. Arch Surgery 1988; 123: 942-946.946.

Chest CTChest CT

Many advantages over aortographyMany advantages over aortography– readily accessible in most most urban ED’sreadily accessible in most most urban ED’s– low complication ratelow complication rate– less contrastless contrast– fastfast– gives information about structures other than gives information about structures other than

the aortathe aorta

Evidence for CT in Blunt Evidence for CT in Blunt Trauma?Trauma?

Early scanners (non-helical) were disappointing but Early scanners (non-helical) were disappointing but new helical CT’s have sensitivities of 100% and new helical CT’s have sensitivities of 100% and specificity of 96 %specificity of 96 %Mirvis et al. Traumatic aortic injury. Diagnosis with contrast enhanced Mirvis et al. Traumatic aortic injury. Diagnosis with contrast enhanced

thoracic CT—five year experience at a major trauma center. Radiology thoracic CT—five year experience at a major trauma center. Radiology 1990; 176: 181-1831990; 176: 181-183

Garrant et al. Blunt traumatic aortic rupture. Detection with helical CT of the Garrant et al. Blunt traumatic aortic rupture. Detection with helical CT of the chest. Radiology 1995; 197: 125-133.chest. Radiology 1995; 197: 125-133.

Demetriades et al. concluded that “all trauma patients Demetriades et al. concluded that “all trauma patients with high risk deceleration injuries undergo routine with high risk deceleration injuries undergo routine helical CT irrespective of CXR findings”helical CT irrespective of CXR findings”Demetriades et al. Routine helical CT evaluation of the mediastinum in the Demetriades et al. Routine helical CT evaluation of the mediastinum in the

high risk trauma patient. Arch Surg 1998; 133: 1084-1088.high risk trauma patient. Arch Surg 1998; 133: 1084-1088.

Helical CT in Penetrating Helical CT in Penetrating TraumaTrauma

In stable patients with a GSW to the torso, In stable patients with a GSW to the torso, CT can be used to follow the trajectory of CT can be used to follow the trajectory of the bullet thereby decreasing the need for the bullet thereby decreasing the need for exploratory surgeryexploratory surgeryGrossman et al. Determining anatomical injury in selected torso Grossman et al. Determining anatomical injury in selected torso

gunshot wounds. J Trauma 1998; 446-456gunshot wounds. J Trauma 1998; 446-456

TEE in TAITEE in TAI Sturn et al. conducted a prospective, nonrandomized study Sturn et al. conducted a prospective, nonrandomized study

of 160 patients with TAI and found a sensitivity and of 160 patients with TAI and found a sensitivity and specificity of 100 % (3 studies unequivocal requiring specificity of 100 % (3 studies unequivocal requiring aortography)aortography)Sturn et al. Thoracic aortography following blunt chest trauma. A J of Emerg Med 1990; Sturn et al. Thoracic aortography following blunt chest trauma. A J of Emerg Med 1990;

8:1928:192

Buckmaster et al. also found similar results with sensitivity Buckmaster et al. also found similar results with sensitivity of 100 % and specificity of 98 %of 100 % and specificity of 98 %Buckmaster et al. Further experience with TEE in evaluation of thoracic aortic injury. J Buckmaster et al. Further experience with TEE in evaluation of thoracic aortic injury. J

Trauma. 1994; 37:989Trauma. 1994; 37:989

Patients who only had TEE as the diagnostic test had Patients who only had TEE as the diagnostic test had significantly shorter (30 vs. 71 min.) times to ORsignificantly shorter (30 vs. 71 min.) times to ORSmith et al. TEE in the diagnosis of traumatic rupture of the aorta. NEJM 1995; 332: 356-Smith et al. TEE in the diagnosis of traumatic rupture of the aorta. NEJM 1995; 332: 356-

362362

TEE in TAITEE in TAI

Advantages:Advantages: Bedside applicationBedside application No contrastNo contrast Quick to performQuick to perform Gives additional Gives additional

information about information about heart functionheart function

Disadvantages:Disadvantages: Limited by experience Limited by experience

and access to operatorand access to operator Limited in evaluation Limited in evaluation

of aortic branch of aortic branch arteriesarteries

Contraindicated in Contraindicated in esophageal perforation esophageal perforation and cervical traumaand cervical trauma

The Bottom Line in Imagaing The Bottom Line in Imagaing TAITAI

No clear algorithm to followNo clear algorithm to follow Variation from center to centerVariation from center to center Some centers use a widened mediastinum to Some centers use a widened mediastinum to

prompt further investigation while others use prompt further investigation while others use mechanism of high velocity deceleration to mechanism of high velocity deceleration to advocate for aortography or helical CT advocate for aortography or helical CT

In pediatrics making the diagnosis crucial as high In pediatrics making the diagnosis crucial as high survival rate (70 – 90 % once diagnosis made)survival rate (70 – 90 % once diagnosis made)


Pharmacologic management similar to Pharmacologic management similar to aortic dissectionaortic dissection

Maintain systolic blood pressure between Maintain systolic blood pressure between 100 – 120 100 – 120

Beta-blockers decrease pulse pressure and Beta-blockers decrease pulse pressure and shear forces on the wall of the adventiashear forces on the wall of the adventia– esmolol preferred because short acting and esmolol preferred because short acting and

titrateabletitrateable Addition of nitroprusside as neededAddition of nitroprusside as needed

Non-operative ManagementNon-operative Management

Approach for patients with high intra-Approach for patients with high intra-operative risk of death or injuries that are operative risk of death or injuries that are uniformly fataluniformly fatal

Giles et al.reported a case series of 42 Giles et al.reported a case series of 42 patients with TAIpatients with TAI– 21 with immediate repair had a mortality rate of 21 with immediate repair had a mortality rate of

19% vs. no deaths in 21 patients treated non-19% vs. no deaths in 21 patients treated non-operativelyoperatively

Indications for Conservative Indications for Conservative Management of TAIManagement of TAI

Severe injury to the CNSSevere injury to the CNS Major burns with high infection riskMajor burns with high infection risk SepsisSepsis Contaminated open wounds with high risk of Contaminated open wounds with high risk of

infectioninfection Severe respiratory insufficiencySevere respiratory insufficiency Hemodynamic instabilityHemodynamic instability Presence of a non-threatening lesion (an intimal Presence of a non-threatening lesion (an intimal

defect only)defect only) False aneurymsFalse aneuryms

Mr. Al KoholMr. Al Kohol

43 yo male. EtOH earlier in evening. Driving 43 yo male. EtOH earlier in evening. Driving home, loses control of vehicle hits parked car head home, loses control of vehicle hits parked car head on (estimated speed 70 kph). Not wearing seat belt on (estimated speed 70 kph). Not wearing seat belt and no air bag. Hits steering wheel with chest. No and no air bag. Hits steering wheel with chest. No LOC. Brought in by EMS complaining of chest LOC. Brought in by EMS complaining of chest pain. CXR and ECG normal.pain. CXR and ECG normal.– What is the role of troponin in cardiac contusion?What is the role of troponin in cardiac contusion?

– Does this patient need admission?Does this patient need admission?

Blunt Cardiac TraumaBlunt Cardiac Trauma

Result of high speed MVC with chest wall Result of high speed MVC with chest wall striking the steering columnstriking the steering column

Less commonly from falls, crush injury, Less commonly from falls, crush injury, blast and direct blowsblast and direct blows

Importance of diagnosis lies in recognition Importance of diagnosis lies in recognition of associated fatal conditionsof associated fatal conditions– dysrhythmias, CHF, cardiogenic shock, dysrhythmias, CHF, cardiogenic shock,

tamponade, cardiac rupture, intraventricular tamponade, cardiac rupture, intraventricular thrombi, coronary artery occlusionthrombi, coronary artery occlusion

Myocardial ConcussionMyocardial Concussion

““Commotio cordis”Commotio cordis” An acute form of blunt cardiac trauma that An acute form of blunt cardiac trauma that

stuns the myocardium and results in a brief stuns the myocardium and results in a brief dysrrhythmia, hypotension and LOCdysrrhythmia, hypotension and LOC

No long lasting histopathological changesNo long lasting histopathological changes Death can result from an initial non-Death can result from an initial non-

perfusing rhythm such as VF that results in perfusing rhythm such as VF that results in cardiac arrest cardiac arrest

Myocardial ContusionMyocardial Contusion

Continuum from: Continuum from: concussionsconcussionscontusioncontusioninfarctinfarct

Clinical picture varied and non-specificClinical picture varied and non-specific– 73% have external signs of thoracic trauma73% have external signs of thoracic trauma– other associated injuries: pulmonary contusion, other associated injuries: pulmonary contusion,

pneumothorax, hemothorax, external fracture, pneumothorax, hemothorax, external fracture, great vessel injurygreat vessel injury

– sinus tachycardia most sensitive but least sinus tachycardia most sensitive but least specificspecific

DiagnosisDiagnosis

Obvious at autopsy!Obvious at autopsy! No true “gold standard” for making No true “gold standard” for making

diagnosisdiagnosis Normal ECG reassuring if no obvious Normal ECG reassuring if no obvious

clinical symptomsclinical symptoms Non-specific ECG findings include sinus Non-specific ECG findings include sinus

tachy, PVC’s and PAC’s but also other tachy, PVC’s and PAC’s but also other conduction and rhythym disordersconduction and rhythym disorders

Troponin in Blunt Cardiac Troponin in Blunt Cardiac TraumaTrauma

Collins et al. conducted a prospective evaluation of Collins et al. conducted a prospective evaluation of all blunt trauma patients admitted with the possible all blunt trauma patients admitted with the possible diagnosis of blunt cardiac injury to exclude diagnosis diagnosis of blunt cardiac injury to exclude diagnosis of cardiac contusionof cardiac contusion– 72 patients enrolled, 40 normal ECG and Tnt, 16 abnormal 72 patients enrolled, 40 normal ECG and Tnt, 16 abnormal

ECG and normal troponin, 10 patients elevated TntECG and normal troponin, 10 patients elevated Tnt2 2 died, 1 poor LV function on echo, 8 d/c’d homedied, 1 poor LV function on echo, 8 d/c’d home

– Concluded that normal Tnt exclude contusion and elevated Concluded that normal Tnt exclude contusion and elevated Tnt should require ongoing monitoring…BUT…Tnt should require ongoing monitoring…BUT…

Collins et al. The usefulness of serum troponin levels in evaluating cardiac injury. Collins et al. The usefulness of serum troponin levels in evaluating cardiac injury. American Surgeon. 67(9):821-5; discussion 825-6, 2001 Sep.American Surgeon. 67(9):821-5; discussion 825-6, 2001 Sep.

Troponin in Blunt Cardiac Troponin in Blunt Cardiac InjuryInjury

Berchinant studied Tnt in 96 chest trauma Berchinant studied Tnt in 96 chest trauma patients of which 26 were diagnosed with patients of which 26 were diagnosed with myocardial contusion (echo and/or ECG) myocardial contusion (echo and/or ECG) over 18 months over 18 months – 23 % of patients with myocardial contusion had 23 % of patients with myocardial contusion had

positive Tnt vs. 3 % of placebopositive Tnt vs. 3 % of placebo– Sensitivity 23 %, specificity 97 %Sensitivity 23 %, specificity 97 %

Berchinant et al. Evaluation of incidence, clinical significance, and Berchinant et al. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin. Journal of prognostic value of circulating cardiac troponin. Journal of Trauma-Injury Infection & Critical Care. 48(5):924-31, 2000 MayTrauma-Injury Infection & Critical Care. 48(5):924-31, 2000 May

Myocardial RuptureMyocardial Rupture

An acute perforation of the atria or ventriclesAn acute perforation of the atria or ventricles Also includes pericardial rupture or rupture or Also includes pericardial rupture or rupture or

laceration of the interventricualr or atrial septum, laceration of the interventricualr or atrial septum, papillary muscle, chrodae, or valvespapillary muscle, chrodae, or valves

MVC’s most common causeMVC’s most common cause 0.5 – 2 % of cases of chest trauma accounting for 0.5 – 2 % of cases of chest trauma accounting for

5% mortality of all chest traumas5% mortality of all chest traumas


Usually that of cardiac tamponadeUsually that of cardiac tamponade Less common hemothorax, hypotension, Less common hemothorax, hypotension,

hypovolumeia suggesting pericardial rupturehypovolumeia suggesting pericardial rupture Diagnosis of shock and elevated JVP in blunt Diagnosis of shock and elevated JVP in blunt

chest trauma patient = pericardial tamponade (also chest trauma patient = pericardial tamponade (also consider tension pneumothorax, RV contusion, consider tension pneumothorax, RV contusion, SVC obstruction, ruptures tricuspid valve, chronic SVC obstruction, ruptures tricuspid valve, chronic pulmnonary disease)pulmnonary disease)


EMSEMS– scoop and runscoop and run

EDED– immediate decompression of tamponade and immediate decompression of tamponade and

control of hemorrhagecontrol of hemorrhage– emergency thoracotomy and percardiotomy emergency thoracotomy and percardiotomy

then OR for definitive repairthen OR for definitive repair

Penetrating Cardiac InjuryPenetrating Cardiac Injury

Interpersonal violence vast majority of causesInterpersonal violence vast majority of causes– GSW or SWGSW or SW

Two conditions may occurTwo conditions may occur– exsanguinating hemorrhage: free communication with exsanguinating hemorrhage: free communication with

pleural spacepleural space– cardiac tamponade: contained within the pericardiumcardiac tamponade: contained within the pericardium

Those with exsanguination often die or will meet Those with exsanguination often die or will meet criteria for ED thoracotomycriteria for ED thoracotomy

Those with tamponade provides some protection Those with tamponade provides some protection but require immediate attentionbut require immediate attention

FAST ExamFAST Exam

Focused Abdominal Sonography for Focused Abdominal Sonography for TraumaTrauma

4 windows:4 windows:– Pericaridial, perisplenic, perihepatic, pelvicPericaridial, perisplenic, perihepatic, pelvic

Purpose is for identification of Purpose is for identification of hemopericardium and hemoperitoneumhemopericardium and hemoperitoneum

FAST Exam in Penetrating FAST Exam in Penetrating Cardiac InjuryCardiac Injury

Rozycki et al. conducted a prospective multi-Rozycki et al. conducted a prospective multi-center trial of 261 patients to assess US center trial of 261 patients to assess US identification of pericardial fluididentification of pericardial fluid– 100 % sensitive, 96.9 % specific for identification of 100 % sensitive, 96.9 % specific for identification of

hemopericardiumhemopericardium

– Based on there findings recommend immediate OR for Based on there findings recommend immediate OR for positive findingspositive findings

Rozycki et al. The role of US in patients with possible penetrating Rozycki et al. The role of US in patients with possible penetrating cardiac wounds. J Trauma 1999; 46:543-552cardiac wounds. J Trauma 1999; 46:543-552

FAST Exam in Penetrating FAST Exam in Penetrating Cardiac InjuryCardiac Injury

Thourani et al conducted a retrospective chart review of 22 Thourani et al conducted a retrospective chart review of 22 years for penetrating cardiac trauma at their institution; years for penetrating cardiac trauma at their institution; divided into two 11 year subgroups based on introduction divided into two 11 year subgroups based on introduction of FAST examof FAST exam– Current approaches impacting mortality are: shorter field time, Current approaches impacting mortality are: shorter field time,

more FAST exams in normotensive or moderately hypotensive more FAST exams in normotensive or moderately hypotensive patients and earlier ORpatients and earlier OR

– Mortality rate similar in both groups (25 %) but trend to better Mortality rate similar in both groups (25 %) but trend to better survivial in FAST group of normotensive and moderately survivial in FAST group of normotensive and moderately hypotensive patientshypotensive patients

Thourani et al. Penetrating cardiac trauma at an uran trauma center. Am Thourani et al. Penetrating cardiac trauma at an uran trauma center. Am Surgeon 1999; 65:811-818Surgeon 1999; 65:811-818

Indications for ED Indications for ED ThoracotomyThoracotomy

Penetrating traumaPenetrating trauma– cardiac arrest at any point with initial vitals at the scene (< 10 cardiac arrest at any point with initial vitals at the scene (< 10

min transport time)min transport time)– systolic blood pressure < 50 after fluid resuscitationsystolic blood pressure < 50 after fluid resuscitation– severe shock with signs of tamponadesevere shock with signs of tamponade

Blunt traumaBlunt trauma– cardiac arrest in EDcardiac arrest in ED

MiscellaneousMiscellaneous– suspect air embolism suspect air embolism

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.© 2002 Mosby, Inc.

Evidence for ED ThoracotomyEvidence for ED Thoracotomy Rhee et al. completed a large review of 24 studies including 4,620 Rhee et al. completed a large review of 24 studies including 4,620

cases of EDT for blunt and penetrating trauma over past 25 yearscases of EDT for blunt and penetrating trauma over past 25 years Primary outcome was in hospital survivalPrimary outcome was in hospital survival EDT overall survival rate of 7.4 %EDT overall survival rate of 7.4 % Normal neurological outcome 92.4 %Normal neurological outcome 92.4 % 3 main factors affecting outcome:3 main factors affecting outcome:

– MOI: penetrating 8.8 % vs. 1.4 % for blunt; of penetrating injuries GSW MOI: penetrating 8.8 % vs. 1.4 % for blunt; of penetrating injuries GSW 4.3 % vs. SW 16.8 %4.3 % vs. SW 16.8 %

– LOMI: 10.7 % thoracic, 4.5 % abdominal, 0.7 % multiple; if heart then LOMI: 10.7 % thoracic, 4.5 % abdominal, 0.7 % multiple; if heart then 19.4 %19.4 %

– SOL: present on arrival to hospital 11.5 % vs. 2.6 % if absent; during SOL: present on arrival to hospital 11.5 % vs. 2.6 % if absent; during transport 8.9 %; absent in field 1.2 %transport 8.9 %; absent in field 1.2 %

Rhee et al. Survival after ED thoracotomy. J of Amer Col of Surgeons 2000; 190(3): Rhee et al. Survival after ED thoracotomy. J of Amer Col of Surgeons 2000; 190(3): 288-298288-298

Poor Outcome in Blunt Chest Poor Outcome in Blunt Chest TraumaTrauma

Martin et al. conducted a retrospective review of blunt trauma victims Martin et al. conducted a retrospective review of blunt trauma victims with prehospital PEA from 1997 to 2001 with prehospital PEA from 1997 to 2001

110 patients 79 with PEA at the scene, and 31 experienced PEA en route110 patients 79 with PEA at the scene, and 31 experienced PEA en route CPR initiated when PEA was detectedCPR initiated when PEA was detected Vital signs were regained en route or at the trauma center by 25 patients Vital signs were regained en route or at the trauma center by 25 patients

(23%)(23%) Only one patient, who has significant residual neurologic impairment, Only one patient, who has significant residual neurologic impairment,

survivedsurvived Conclusions in keeping with other studies– consideration should be Conclusions in keeping with other studies– consideration should be

given to allowing paramedics to declare blunt trauma victims with PEA given to allowing paramedics to declare blunt trauma victims with PEA dead at the scenedead at the sceneMartin et al. Blunt Trauma Patients with Prehospital Pulseless Electrical Activity (PEA): Poor Martin et al. Blunt Trauma Patients with Prehospital Pulseless Electrical Activity (PEA): Poor Ending Assured. The Journal of Trauma: Injury, Infection, and Critical Care 2002; 53(5):876-Ending Assured. The Journal of Trauma: Injury, Infection, and Critical Care 2002; 53(5):876-

881881

Favorable Prognostic SignsFavorable Prognostic Signs

• Penetrating thoracic traumaPenetrating thoracic trauma• Isolated stab woundIsolated stab wound• Pericardial tamponadePericardial tamponade• Vital signs in ERVital signs in ER• Mild shockMild shock• Short EMS transit timeShort EMS transit time• Intubation in the fieldIntubation in the field

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.Copyright © 2002 Mosby, Inc.

Adverse Prognostic FactorsAdverse Prognostic Factors

• Blunt thoracic traumaBlunt thoracic trauma• Gunshot woundGunshot wound• Exsanguinating hemorrhage through pericardiumExsanguinating hemorrhage through pericardium• No signs of lifeNo signs of life• Extreme shockExtreme shock• Prolonged EMS transit timeProlonged EMS transit time• Unsuccessful field intubationUnsuccessful field intubation• Asystole as initial cardiac rhythmAsystole as initial cardiac rhythm

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.2002 Mosby, Inc.

Overall SurvivalOverall Survival

Overall survival from EDT 4 - 16 %Overall survival from EDT 4 - 16 % Of patients with SW who reach the OR Of patients with SW who reach the OR

survival 70 - 80 %survival 70 - 80 % Of patients with GSW who reach the OR Of patients with GSW who reach the OR

survival 20 - 40%survival 20 - 40%

ED ThoracotomyED Thoracotomy

•Scalpel incision in left 5th intercostal space

•Divide muscle and soft tissue with scissors above rib margin

•Insert rib spreaders and spread

Relief of TamponadeRelief of Tamponade

•Make small incision in pericardium with scissors

•Longitudinal blunt dissection to avoid phrenic nerve

•Manually evacuate blood clot from pericardial cavity

Control of HemorrhageControl of Hemorrhage

•3-0 non-adsorbable suture – use mattress technique•Skin stapler•Finger•Foley catheter

Internal Cardiac MassageInternal Cardiac Massage

• Commence Commence immediately following immediately following control of hemorrhage control of hemorrhage or relief of tamponadeor relief of tamponade

• Two handed technique Two handed technique produces better produces better cardiac output (55% of cardiac output (55% of baseline)baseline)

Cardiac TamponadeCardiac Tamponade

2% of patients with penetrating thoracic 2% of patients with penetrating thoracic trauma develop cardiac tamponadetrauma develop cardiac tamponade

Rarely seen in blunt traumaRarely seen in blunt trauma 60 - 80% of stab wounds to heart develop 60 - 80% of stab wounds to heart develop

tamponadetamponade 20% of GSW to heart20% of GSW to heart

Cardiac TamponadeCardiac Tamponade

• Collection of blood in indispensable Collection of blood in indispensable pericardiumpericardium

• 60 - 100cc blood tolerated before 60 - 100cc blood tolerated before decompensation begins (normal = 5 – 60 cc decompensation begins (normal = 5 – 60 cc pericardial fluid)pericardial fluid)


• Beck’s triadBeck’s triad: : • hypotensionhypotension• distended neck veins (>15mm H20 with distended neck veins (>15mm H20 with

hypotension is diagnostic)hypotension is diagnostic)• muffled heart sounds (unlikely to be heard in muffled heart sounds (unlikely to be heard in

trauma room)trauma room)• Pulsus paradoxus – difficult to measure Pulsus paradoxus – difficult to measure

during resuscitationduring resuscitation• No response to vigorous fluid resuscitationNo response to vigorous fluid resuscitation

Electrical AlternansElectrical Alternans

PericardiocentesisPericardiocentesis

• Diagnostic and therapeuticDiagnostic and therapeutic• Many false positives / false negatives (clotted blood)Many false positives / false negatives (clotted blood)• Improvement possible with small volume of blood Improvement possible with small volume of blood

removedremoved• ComplicationsComplications

• Pericardial tamponadePericardial tamponade• Laceration of coronary artery / lungLaceration of coronary artery / lung• Induction of dysrhythmiaInduction of dysrhythmia

• Continued deterioration may necessitate thoracotomyContinued deterioration may necessitate thoracotomy

Pericardiocentesis TechniquePericardiocentesis Technique 18 gauge, 10 cm spinal needle, 20 cc syringe18 gauge, 10 cm spinal needle, 20 cc syringe Continuous ECG monitoringContinuous ECG monitoring Needle enters subxyphoid areaNeedle enters subxyphoid area Aim for left scapulaAim for left scapula Aspirate every 1-2 mmAspirate every 1-2 mm Stop if blood aspirated, cardiac pulsations felt, Stop if blood aspirated, cardiac pulsations felt,

ECG changesECG changes If more than 20 cc blood is removed easily you are If more than 20 cc blood is removed easily you are

probably in the RVprobably in the RV

““He was trying to break up the He was trying to break up the fight…”fight…”

21 year old male, “brought fists to a knife fight.” 21 year old male, “brought fists to a knife fight.” Stabbed once in the abdomen with “long” knife. Stabbed once in the abdomen with “long” knife. Hemodynamically stable. Mild SOB but O2 sat, Hemodynamically stable. Mild SOB but O2 sat, vitals stable. CXR normal. To OR for laparotomy. vitals stable. CXR normal. To OR for laparotomy. Multiple abdominal lacerations including Multiple abdominal lacerations including laceration of L diaphragm.laceration of L diaphragm.– CXR findings suggestive of diaphragmatic injury?CXR findings suggestive of diaphragmatic injury?

– Is there a role for DPL or CT scan?Is there a role for DPL or CT scan?

Diaphragmatic InjuriesDiaphragmatic Injuries

1-6% of people sustaining multiple trauma1-6% of people sustaining multiple trauma 55% from penetrating trauma and 45% from blunt 55% from penetrating trauma and 45% from blunt

traumatrauma High speed blunt trauma to the diaphragm or High speed blunt trauma to the diaphragm or

direct injury to diaphragm from penetrating direct injury to diaphragm from penetrating traumatrauma

Transmission of abdominal pressure through Transmission of abdominal pressure through diaphragmdiaphragm

Left sided traumatic hernias 3-4x’s more commonLeft sided traumatic hernias 3-4x’s more common– liver acts as bufferliver acts as buffer

Diaphragmatic InjuriesDiaphragmatic Injuries

Symptoms and signs variable and often Symptoms and signs variable and often over shadowed by associated injuriesover shadowed by associated injuries

30 % missed in acute phase30 % missed in acute phase Often not accompanied by herniation of Often not accompanied by herniation of

abdominal visceraabdominal viscera

Radiography of Diaphragmatic Radiography of Diaphragmatic InjuryInjury

Nonspecific but Nonspecific but generally abnormalgenerally abnormal

Indistinct left Indistinct left hemidiaphragm, focal hemidiaphragm, focal atelectasis in LLL, atelectasis in LLL, visualisation of viscera visualisation of viscera or NG tube above the or NG tube above the left hemidiaphragmleft hemidiaphragm

15% of patients have 15% of patients have normal CXRnormal CXR

Investigation of Diaphragmatic Investigation of Diaphragmatic InjuryInjury

DPL found unreliableDPL found unreliable– False negative rate of 34 %False negative rate of 34 %

CT variable sensitivity 14 - 61% if no herniation CT variable sensitivity 14 - 61% if no herniation of abdominal viscera and specificity of 76 – 99 %of abdominal viscera and specificity of 76 – 99 %

Most common finding is defect in hemi-Most common finding is defect in hemi-diaphragm diaphragm – Seen in approx. 70 % of rupturesSeen in approx. 70 % of ruptures

– CT collar sign 100 % specific but only 30 % sensitiveCT collar sign 100 % specific but only 30 % sensitive

Latent PhaseLatent Phase

Herniation can be intermittent making the Herniation can be intermittent making the diagnosis difficultdiagnosis difficult

Requires serial examination if persistent Requires serial examination if persistent symptomssymptoms

Contrast studies usefulContrast studies useful

Esophageal InjuryEsophageal Injury

Result of blunt or penetrating trauma, Result of blunt or penetrating trauma, barotrauma (blast), or ingestion of caustic barotrauma (blast), or ingestion of caustic materialmaterial

Symptoms: chest, throat or neck pain, Symptoms: chest, throat or neck pain, dysphagia or odynophagiadysphagia or odynophagia

Signs: fever choking, subcutaneous Signs: fever choking, subcutaneous emphysema, redness, swelling, shockemphysema, redness, swelling, shock

DiagnosisDiagnosis

Clinical: subcutaneous crepitusClinical: subcutaneous crepitus Neck and CXR: air in cervical tissue or Neck and CXR: air in cervical tissue or

mediastinum or pleural effusionsmediastinum or pleural effusions Diagnosis made by esophogram using Diagnosis made by esophogram using

gastrografin initially then barium if no gastrografin initially then barium if no lesion identifiedlesion identified

Endoscopy identifies 50 - 100% of injuries Endoscopy identifies 50 - 100% of injuries but can enlarge the perforationbut can enlarge the perforation


Surgical management is definitive treatment Surgical management is definitive treatment if patient is stableif patient is stable

If patient is not a suitable surgical candidate If patient is not a suitable surgical candidate and continuing to have ongoing leak then and continuing to have ongoing leak then treat with IV antibiotics, NG suction, treat with IV antibiotics, NG suction, parenteral nutrionparenteral nutrion

High mortality with medical management High mortality with medical management with mortality rate 50 % or greater if with mortality rate 50 % or greater if surgery delayed > 24 hourssurgery delayed > 24 hours

Rib FracturesRib Fractures

Ribs 4-9 most commonly brokenRibs 4-9 most commonly broken Ribs 1-3 well protectedRibs 1-3 well protected

– marker for severe intrathoracic injurymarker for severe intrathoracic injury Ribs 9-12 mobile anteriorlyRibs 9-12 mobile anteriorly

– marker for intra-abdominal injury (liver, spleen, marker for intra-abdominal injury (liver, spleen, kidney)kidney)

Rib Fractures less common in pediatric population Rib Fractures less common in pediatric population because of chest wall compliancebecause of chest wall complianceRib fractures in children less than 3 yo need to Rib fractures in children less than 3 yo need to rule out NATrule out NAT


Single rib fractureSingle rib fracture– May limit ventilation and cough reflex secondary to May limit ventilation and cough reflex secondary to

painpain

– Conservative managementConservative management

Multiple rib fracturesMultiple rib fractures– More force = more injuriesMore force = more injuries

– Look for flail chest, pneumothorax, hemothorax, and Look for flail chest, pneumothorax, hemothorax, and extrathoracic injuries (liver, spleen, kidney – 30% of extrathoracic injuries (liver, spleen, kidney – 30% of patients with 9-12patients with 9-12thth rib fractures) rib fractures)


ClinicalClinical– Tenderness, bony crepitus, ecchymosis, muscle Tenderness, bony crepitus, ecchymosis, muscle

spasmspasm RadiologicalRadiological

– best diagnosed using CXR but still miss 50%best diagnosed using CXR but still miss 50%– CXR inadequate for evaluation of rib fractures, CXR inadequate for evaluation of rib fractures,

but valuable for seeing intrathoracic/ but valuable for seeing intrathoracic/ mediastinal injuriesmediastinal injuries

Rib Views: IndicationsRib Views: Indications

Fractures suspected, ribs 1-2Fractures suspected, ribs 1-2 Fractures suspected, ribs 9-12Fractures suspected, ribs 9-12 Multiple rib fracturesMultiple rib fractures Elderly patientElderly patient Preexisting pulmonary diseasePreexisting pulmonary disease Suspected pathologic fracturesSuspected pathologic fractures

Rib Fractures: TreatmentRib Fractures: Treatment

Pain reliefPain relief Medication/intercostal nerve block/epiduralMedication/intercostal nerve block/epidural Deep breathing exercisesDeep breathing exercises Do not useDo not use

– binders, belts, other restrictive devices as they binders, belts, other restrictive devices as they promote atelectasis, pneumoniapromote atelectasis, pneumonia

Mr. FlailMr. Flail

65 yo male passenger in MVC. T-Bone collision 65 yo male passenger in MVC. T-Bone collision at high speed. Restrained. No LOC. Complaining at high speed. Restrained. No LOC. Complaining of L chest wall pain. Mild respiratory difficulty. of L chest wall pain. Mild respiratory difficulty. RR 30. O2 sat 95 % on 5L. Tender on L chest RR 30. O2 sat 95 % on 5L. Tender on L chest wall. ? Palpable flail segment. CXR flail segment wall. ? Palpable flail segment. CXR flail segment on L chest wall.on L chest wall.– What are the indications for MV in flail chest?What are the indications for MV in flail chest?

– Does this patient require prophylactic intubation?Does this patient require prophylactic intubation?

Flail ChestFlail Chest

> 2 adjacent ribs fractured at two points> 2 adjacent ribs fractured at two points Mortality 8 - 35%Mortality 8 - 35% Respiration adversely affectedRespiration adversely affected

– Free segment moves paradoxicallyFree segment moves paradoxically– Frequently associated with underlying Frequently associated with underlying

pulmonary contusionpulmonary contusion Intubation and ventilation can splint and Intubation and ventilation can splint and

mask flail chestmask flail chest

Flail Chest: ManagementFlail Chest: Management

• Observe for signs of underlying pulmonary Observe for signs of underlying pulmonary injury/pathologyinjury/pathology

• Conserstone of Rx: physiotherapy, Conserstone of Rx: physiotherapy, analgesia, selective use of endotracheal analgesia, selective use of endotracheal intubation/MV, and observation for intubation/MV, and observation for respiratory compromiserespiratory compromise

Who needs MV in Flail Chest?Who needs MV in Flail Chest?

Freedland et al. conducted a retrospective study to Freedland et al. conducted a retrospective study to identify factors affecting outcome in 57 patients identify factors affecting outcome in 57 patients with flail chestwith flail chest

Factors correlating with need for MVFactors correlating with need for MV– ISS > 22, blood transfusion in 1ISS > 22, blood transfusion in 1stst 24 h, moderate to 24 h, moderate to

severe associated injuriessevere associated injuries Factors correlating with adverse outcome (MV Factors correlating with adverse outcome (MV

>2/52), death from sepsis or pneumonia>2/52), death from sepsis or pneumonia– ISS >30, moderate or severe associated injuries or need ISS >30, moderate or severe associated injuries or need

for transfsuionfor transfsuionFreeland M, et al. The management of flail chest injury: Factors affecting Freeland M, et al. The management of flail chest injury: Factors affecting outcome. J Trauma. 1990; 30: 1460-1468outcome. J Trauma. 1990; 30: 1460-1468

Sternal FractureSternal Fracture

Mechanism generally anterior blunt chest traumaMechanism generally anterior blunt chest trauma Usually MVCUsually MVC

– More likely with restrained passengersMore likely with restrained passengers Associated withAssociated with

– myocardial contusion (1.5-6%)myocardial contusion (1.5-6%)– rib fractures (21%)rib fractures (21%)– spinal fractures (<10%)spinal fractures (<10%)– mediastinal hematomamediastinal hematoma– no association with aortic ruptureno association with aortic rupture

Isolated sternal fractures – low mortality (0.7%)Isolated sternal fractures – low mortality (0.7%)

Indications for MV in Flail Indications for MV in Flail ChestChest

Signs of respiratory fatigueSigns of respiratory fatigue RR >35 or < 8 bths/minRR >35 or < 8 bths/min PaO2 <60 (FiO2 > .5)PaO2 <60 (FiO2 > .5) PaCO2 >55 (FiO2 > .5)PaCO2 >55 (FiO2 > .5) Evidence of shockEvidence of shock Associated severe head injuryAssociated severe head injury Associated severe injury needing surgeryAssociated severe injury needing surgery

Sternal FractureSternal Fracture

ClinicalClinical– Point tenderness on sternum, palpable deformityPoint tenderness on sternum, palpable deformity

RadiologicalRadiological– Lateral CXR; CT poor at picking up horizontal Lateral CXR; CT poor at picking up horizontal

fracturesfractures

TreatmentTreatment– Treat associated injuriesTreat associated injuries

– Isolated sternal injury can be discharged with Isolated sternal injury can be discharged with analgesiaanalgesia

Sternoclavicular DislocationSternoclavicular Dislocation

SC dislocation best studied with CT scanSC dislocation best studied with CT scan Anterior (more common)Anterior (more common) Lateral compressive force applied to Lateral compressive force applied to

shouldershoulder Medial end of clavicle prominent and Medial end of clavicle prominent and

palpable, may be visible on lateral CXRpalpable, may be visible on lateral CXR Treat with closed reduction–apply pressure Treat with closed reduction–apply pressure

on medial end of clavicleon medial end of clavicle

Posterior DislocationPosterior Dislocation

RareRare Direct blow to medial end of clavicleDirect blow to medial end of clavicle

– Possible compression of airways or major Possible compression of airways or major blood vesselsblood vessels

CXR visible deformity along lateral CXR visible deformity along lateral sternumsternum

If obstructing airway requires immediate If obstructing airway requires immediate intervention otherwise closed reduction intervention otherwise closed reduction under general anaesthesiaunder general anaesthesia

CHEST TRAUMA Sept 4/2003 Todd Ring Gord McNeil. Overview Approach to patient with chest trauma...

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Transcript of CHEST TRAUMA Sept 4/2003 Todd Ring Gord McNeil. Overview Approach to patient with chest trauma...