Korbin haycock, md, FACEP, RDMS, RDCS - PowerPoint Presentation

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Korbin haycock, md, FACEP, RDMS, RDCS

Thoracic Trauma

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Conflict of interest?

None

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Epidemiology

About ¼ of trauma related death is from thoracic injuries

Motor vehicle accidents are responsible for most thoracic trauma

Deaths occur in tri-modal distribution:

30 minute to 3 hour time frame is a critical window for competent ED care

Death at the scene

30 minutes to 3 hours after the injury

Later during the hospitalization

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Thoracic Trauma in General

ABC’s (as appropriate)

Vital signs and pulse oximetry

Through inspection and

palpation

of the chestExpansionEcchymosisCrepitusDyspnea is an important symptom that something is wrongUpper extremity pulse exam

Signs of brachial plexus injury

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Chest Wall Trauma

Rib fracture

Sternal fracture

Sternoclavicular dislocations

Flail chest

Nonpenetrating ballistic injury

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Chest Wall Trauma

Pathophysiology

Rigid chest wall is important for respiratory function

Compromise of the chest wall by fractures or splinting due to pain may effect respiratory function

Adequate oxygenation and ventilation is critical in the multisystem injured patient

O2 deliveryAcid/Base regulation

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Rib Fracture

Clinical exam

Tenderness to palpation of chest wall or tenderness at point of fracture to palpation remote to the injury site

Bony crepitus

Ecchymosis

Most Rib fractures are 4-8th ribs

Ribs 1-3 are protected

Ribs 9-12 are more mobile

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Complications of rib fractures

Direct penetration by fragments

Pleura

Lung

Abdominal organs

Pulmonary contusionsVascular injuriesImpaired gas exchange2 or more fractures increases risk of internal injuries1st and 2

nd rib fracturesTreatment:AnalgesiaPulmonary toiletNo strapping

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Rib Fracture

Disposition

Strongly consider admitting elderly patients or those with significant pulmonary disease

Also consider admission of multiple rib fractures

Prior to discharge, ensure adequate cough, clearing of secretions, and maintaining activity

McGillicuddy, 2007

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Sternal Fracture

Diagnosis based on clinical exam and lateral CXR

(Ultrasound!)

Mediastinal injuries diagnosed by CT

Can discharge home uncomplicated fractures of the sternum, after other injuries are ruled out

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Sternoclavicular Dislocations

Can be anterior or posterior dislocations

Anterior is more common

Posterior dislocations can have many associated injuries

Exam may reveal TTP, deformity, or pain with movement of arm

CT is best exam for evaluation

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Sternoclavicular Dislocations

Treatment

Anterior

Direct anterior pressure on clavicle

Posterior

May need to be done emergentlyMay require general anesthesia

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Flail Chest

3 or more adjacent ribs fractured in 2 places

Will always have associated pulmonary contusion

Orthobullets.com

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Flail Chest

Treatment

Treat underlying pulmonary contusion—more on this later

Monitor for signs of respiratory decompensation

Respiratory rate >35 or <8

Hypoxia despite supplemental O2Hypercapnia >55 mmHgA-a gradient > 450Evidence of shockIf any of above, patient requires intubation

Aggressive pulmonary physiotherapyAnalgesiaCPAP if needed

Treat pneumothorax or hemothoraxSurgical fixation if needed

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Pulmonary Injuries

Pulmonary Contusion

Pulmonary Laceration

Pneumothorax

Hemothorax

Tracheobroncheal Injury

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Pulmonary Contusion

Radiographic findings

Usually manifest by the first 6 hours, if not instantaneously

Ultrasound sees this instantaneously

CT scan may reveal significant pulmonary contusions not seen on initial CXR

Significant chest trauma had pulmonary contusion on plain CXR 16.3% vs. CT 31.2% (Traub, 2007)Significant mechanism for injuryCT even if normal plain chest x-ray?POCUS

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Pulmonary contusion causes V/Q mismatch

Fall in PVR in Healthy lung

Pulmonary artery pressures exert hydrostatic pressure on the capillaries and force blood and fluid into the healthy lung tissue, turning it into contused lung

Interstitial and alveolar edema follows

Intrapulmonary shunting and stiff lungs result in increase in WOB

acidosis

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Pneumothorax

Simple pneumothorax—not communicating with atmosphere and no mediastinal shift

Small < 15%

Moderate=15-60%

Large >60%

Communicating—defect in chest wallSucking chest woundsMay develop into tension pneumothorax (Gets a chest tube)

Tension pneumothorax—Shift in mediastinum High pressure in pleural cavity inhibits venous return to the heart and preload of heart is decreased

Small PTX can be treated with observation

,

moderate/large get a chest tube

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Tension Pneumothorax

Treatment

Decompress it STAT

Stick a long, large bore angiocath into the chest OR do a “finger thoracostomy”

Where? Avoid the heart

Chest tube followsFailure to release airPericardial tamponade?Intubated mainstem?

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Pneumothorax

Pneumothorax that appear small on supine CXR sometimes do require chest tubes

Therefore pneumothorax seen on plain CXR should have “CT quantification”

Anterolateral (PTX extending beyond mid-coronal line on CT) PTX is associated with an increase need for chest tube, miniscule or anterior PTX can be safely monitored

Wolfman, 1998

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Pneumothorax

Ultrasound for PTX

Almost as accurate as CT and more accurate then CXR for detection of PTX

U/S sensitivity=92%, specificity=99.4%

CXR sensitivity=52%, specificity=100%

Agreement in extent of PTX by U/S compared to CTSoldati, 2008

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Ultrasound for PTX

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U/S PTX on M-mode

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Hemothorax

Hemorrhage in the pleural space

Associated with PTX 25% of time

Associated with extra thoracic injuries 75% of time

Bleeding may be from lungs, arteries (most commonly intercostals or internal mammary), hilar vessels, great vessels, or heart

Initial bleeding must be quantified, as well as ongoing bleedingIndication for thoracotomy is 1 liter initial drainage from chest tube or >200mL drainage/hr for >4hours (alternative is >20ml/kg initial or >7ml/kg/hr)

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Hemothorax

medbox.iiab.me

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Hemothorax

Estimate of volume:

V=(d)(d)(L)

Mandavia, 2008

Ruskin, 1987 (CXR)

Depth <1.5cm=<260ml“small”Depth 1.5-4.5=260ml-1L“moderate”Depth >4.5=>1L“large”

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Hemothorax

Treatment

Small HTX can be observed

Larger HTX or PTX with HTX needs chest tube

Resuscitation

Monitor for ongoing bleedingAuto transfusion if blood not contaminated is safeRisk vs. benefit depending on circumstances

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Hemothorax

How common is HTX absent on CXR but present on CT (occult HTX)?

14.5%-21.4% (Ball, 2005)(Stafford, 2006)

Stafford, 2006 reported 48% underwent tube thoracostomy (injury severity scores were higher in these patients)

How big of an occult HTX needs chest tube? Do patients with occult HTX need chest tube at all?

Retrospective study showed hemothoraces with depth >1.5 cm were 4 times more likely to get chest tubesOf all HTX <1.5cm that were managed expectantly, 92% required no interventionOf all HTX 1.5cm-4.5cm that were managed expectantly, 57% avoided intervention

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Hemothorax

Management of HTX:

Unstable

 chest tube

Large HTX on CXR or CT chest tube

Small HTX with PTX on CXR or CT chest tubeSmall HTX on CXR CT scan<1.5cm depth observe

>1.5cm depth chest tube(Mandavia, 2008)

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Cardiovascular Trauma

Blunt Cardiac Injury

Myocardial rupture

Penetrating Cardiac injuries

Pericardial Tamponade

Aortic injuries

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Blunt Cardiac Injury

Normal ECG plus normal 6-8 hour troponin I excludes bad outcomes

(Rajan, 2004)

(Velmahos, 2003)

If BCI suspected:

Do FAST and initial ECG and TroponinIf either positive admitIf both are negative repeat 6-8 hour troponin will exclude significant BCI

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Pericardial Tamponade

Blood between heart and pericardium restricts ventricular filling, resulting in hemodynamic collapse

FAST with hemopericardium

CXR not likely to help you

Intermittent decompressing tamponade

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Pericardial Tamponade

Treatment

IVF

Increase preload to overcome tamponade pressures

Pericardiocentesis

A little controversialAspiration of a little blood can make a huge difference Blood may be clotted and won’t aspirateAlternative option—ThoracotomyConsider trip to OR if stable

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Aortic Injuries

About 80% victims die at scene, about 15% survive to hospital arrival

Most common site of injury is the aortic isthmus, just distal to the origin of the subclavian artery

Deceleration mechanism

Minor speed mechanisms have been described multiple times

McGillicuddy, 2007

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Aortic Injuries

ED management:

Rapid diagnosis

Note CT is method of choice for definitive diagnosis

Blood pressure control if possible

Esmolol and nicardipineDefinitely involve consulting service in these decisionsNote changing trends in time to definitive repairRealize that:Endovascular repair is replacing open techniques

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Imaging in Thoracic Trauma

Great CT controversy (not just confined to the thorax, incidentally)

CT is superior to CXR for diagnosis of intrathoracic injuries

The question is how many of these injuries that are found on CT result in new information that results in important management

Still controversial

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The Great CT COntroversy

Arguments For

(Trupka, 1997)

41% had management changed based on CT

(Salim, 2006)

Change in Mx in 19.6% of chest findings

Arguments Against(Winslow, 2008)(Mower, 2008)

Radiation risks without definitive evidence for improved outcomes(Snyder, 2008)Rebuttal to Salim

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ED Thoracotomy

Salvageable patient more likely if:

Stab wounds > GSW > Blunt trauma

Wounds to heart > other chest > abdominal >multiple injuries

Signs of life present > no signs of life present

Overall survival rate around 10%Cothern, 2006 Rhee, 2000Seamon, 2007

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ED Thoracotomy

Procedure:

BIG incision from parasternal, just below nipple line to as far back as possible in the high axilla

Deepen incision into chest, don’t injure lungs in process

Rib spreader

Pericardotomy, vertical—don’t cut the phrenic nerve Deliver the heart and massage prnFix any holes in the heart, careful of the coronaries Cross clamp the aorta, lung will need to be lifted high, don’t confuse aorta with esophagus

Clamp lung or lung hilum prnAspirate air embolism prnFix bleeding intercostals or internal mammary prn

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References

Ball et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. Journal of trauma 2005

Ball et al. Occult pneumothorax in the mechanically ventilated trauma patient. Canadian journal of surgery 2003

Bilello et al. Occult traumatic hemothorax: when can sleeping dogs lie? American journal of surgery 2005

Cothern et al. Emergency department thoracotomy for the critically injured patient: objectives, indications and outcomes. World journal of emergency surgery 2006

Degiannis et al. Penetrating cardiac injuries: recent experience in South Africa. World journal of surgery 2006Demetriades et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives Journal of Trauma 2008

deMoya et al. Occult pneumothorax in trauma patients: development of an objective scoring system. Journal of trauma 2007Eren et al. Imaging of diaphragmatic hernia after trauma. Clinical radiology 2006Keel et al. Chest injuries—what is new? Current opinion in critical care. 2007

Mandavia et al. Bedside echocardiography in trauma. Emergency Medicine Clinics of North America. 2004Mandavia. Thoracic Trauma: answers to tough questions. Lecture ACEP 2008

Mower. Radiation does among blunt trauma patients: assessing risks and benefits of computed tomographic imaging. Annals of emergency medicine 2008McGillicuddy et al. Diagnostic dilemmas and current controversies in blunt chest trauma. Emergency clinics of North America 2007Stafford et al. Incidence and management of occult hemothoraces. American journal of surgery 2005

Rajan et al. Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with a myocardial contusion. Journal of trauma 2004

Rhee et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. Journal of the American collage of surgeons 2000

Rosen’s Emergency Medicine 5

th

edition

Salim et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury. Archives of Surgery 2006

Seamon et al. Emergency department thoracotomy: still useful after abdominal exsanguination? Journal of Trauma 2008

Soldati et al. Diagnostic accuracy of lung ultrasonography in the emergency department. Chest 2008

Snyder. Whole body imaging in blunt multisystem patients who were never examined Annals of emergency medicine 2008

Steenburg et al. Acute traumatic aortic injury: Imaging evaluation and management. Radiology 2008

Tintinalli’s Emergency Medicine 5

th

ed.

Traub et al. The use of chest computed tomography versus chest x-ray in patients with major blunt trauma. Injury 2007

Velmahos et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. Journal of trauma 2007

Winslow et al. Quantitative Assessment of diagnostic radiation doses in adult blunt trauma patients. Annals of emergency medicine 2008

Wolfan et al. Validity of CT classification on management of occult pneumothorax: a prospective study. AJR 1998