Surgery 6th year, Tutorial (Dr. Aram Baram)


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Oct. 29th & Nov. 19th, 2011

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Surgery 6th year, Tutorial (Dr. Aram Baram)

  1. 1. ThoracicTrauma By Doctor Aram Baram
  2. 2. Thoracic Trauma• Thoracic trauma is responsible for more than 25% of trauma deaths.• Blunt trauma accounts for 70% of chest injuries and more than 70% of these injuries result from Motor Vehicle Accidents.•• Penetrating injuries: 60 to 70% are due to stab wounds.• Chest wall and soft tissue are the most common locations for both blunt and penetrating trauma.• Less than 10% of blunt injuries and only 15 to 30% of penetrating injuries require thoracotomy• One in four cases with cardiothoracic trauma, regardless of etiology, requires hospital admission. 2
  3. 3. Types•Blunt 70% of chest injuries• Penetrating 60 to 70% are due to stab wounds. 3
  4. 4. Penetrating Trauma• Injuries are uncommon in either elderly or pediatric patients, but they remain one of the most common causes of death from trauma in persons up to 40 years of age.• Low-velocity handguns, seen primarily in the civilian population, transmit very little damage to surrounding tissues.• Conversely, much more damage and energy is conducted along the path of high-velocity missiles, usually associated with the military, but now often seen in violent assaults as well. 4
  5. 5. Blunt TraumaAccounts for 70% of chest injuries and more than 70% of these injuries result from Motor Vehicle Accidents.Less than 10% of blunt injuries and only 15 to 30% of penetrating injuries require thoracotomy 5
  6. 6. Initial Assessment and ManagementPrimary surveyResuscitation of vital functionsDetailed secondary surveyDefinitive care 6
  7. 7. Pathophysiology of Chest TraumaIs the derrangement in normal flow of air and blood hypovolemia ventilation- perfusion Inadequate oxygen mismatch delivery to tissues changes in intrathoracic pressure TISSUE relationships HYPOXIA 7
  8. 8. THE PRIMARY SURVEYRapid and thorough performance of the “ABCs” is the standard.This begins with traditional resuscitation as outlined by the American College of Surgeons in the Advanced Trauma Life Support guidelines.The airway must be controlled and breathing assessed and established immediately if necessary.Circulation must be supported through rapid establishment of reliable, large- bore venous access and the initiation of fluid resuscitation.The primary survey is performed to search for immediate life-threatening injuries that could account for ventilation or hemodynamic instabilities, which, if left uncorrected, could cause the acute demise of the patient.These life-threatening injuries are listed in the table below: 8
  9. 9. Injuries ManagementTension pneumothorax Tube thoracostomyMassive haemothorax Tube thoracostomy operative repairCardiac tamponade Pericardiocentesis operative repairDeceleration aortic injury Operative repairMassive flail chest with pulmonary Intubation, pain control, fluid restrictioncontusionUpper and lower airway obstruction Intubation, airway, bronchoscopyTracheobronchial rupture Bronchoscopy, operative repairDiaphragmatic rupture with visceral Operative repairherniationEsophageal perforation Operative repair 9
  10. 10. The presentation depends on the mechanism of injury and the organ systems injured. • Thoraco-abdominal injury • Any wound below nipples in front and • Inferior scapula angles dorsally•Any penetrating wound such as this should be consideredto have an abdominal component until proven otherwise. 10
  11. 11. Diagnosing Thoracic Injuries• The time of injury, mechanism of injury, estimates of MVA velocity and deceleration, and evidence of associated injury to other systems (eg, loss of consciousness) are all salient features of an adequate clinical history.• Information should be obtained directly from the patient whenever possible and from other witnesses to the accident if available. 11
  12. 12. Inspection• Chest Wall: look for signs of injury such as wounds (sucking), contusions, abnormal movement (flail chest), swellings, cyanosis, pallor, types of respiration…• Neck: distended neck veins, subcutaneous emphysema, swelling and cyanosis.• Abdomen: scaphoid abdomen(diaphragmatic rupture) or rocking horse ventilation(high cord injury). Never forget the back 12
  13. 13. Physical Exam• General examination: PR, RR, BP• Palpation: tracheal position, tenderness, or crepitus (surgical emphysema).• Percussion: dullness for hemothorax and hyperresonance for pneumothorax• Auscultation: Equal breath sounds & air entry, heart sounds, bowel sounds high in chest. 13
  14. 14. Imaging studies• The chest radiograph (CXR) (PA& Lateral):• ECG• Focused Assessment for the Sonographic Examination of the Trauma Patient (FAST).• Chest CT scan• Transthoracic echocardiography (TTE) 14
  15. 15. AngiographyAngiography remains the gold standard in the diagnosis of aortic transection or injuries to the great vessels. Indications for Angiographic Studies for Potential Thoracic Injuries are:1) High-speed deceleration injuries2) Chest X-ray findings: Widened mediastinum Loss of aortic knob shadow Tracheal or esophageal deviation to the right Widening of paraspinal stripe and/or apical capping Downward displacement of left mainstem bronchus Obliteration of the aortopulmonary window3) Fractured first rib, sternum, or scapula4) Multiple rib fractures or flail chest5) Massive hemothorax6) Upper extremity hypertension7) Unexplained hypotension8) Pulse deficits or asymmetry9) Systolic murmur 15
  16. 16. Pericadiocentesis:Performed in the resuscitative phase as a diagnostic or at best a temporising modality in cardiac tamponade.Pericardiocentesis cannot be relied on to diagnose cardiac injuries in a trauma setting because of high false positive and false negative (10 to 20%) rates. 16
  17. 17. Lab studies• Blood type and cross match• Arterial blood gas: Arterial blood gas (ABG) analysis, though not as important in the initial assessme of trauma victims, is important in their subsequent management.• Serum chemistry profile: Urea , createnin, K,Na, Ca,…etc.• Coagulation profile The coagulation profile, including prothrombin time/activated partial thromboplastin time, fibrinogen, fibrin degradation product, and D-dimer analyses, can be helpful in the management of patients who receive massive transfusions (eg, >10 U packed RBCs).• Serum troponin levels• Serum myocardial muscle creatine kinase isoenzyme levels.• Serum lactate levels 17
  18. 18. Primary Survey• Airway• Breathing• Circulation 18
  19. 19. Management• Initial management As always in trauma, management begins with establishing ABCs.• Indications for emergency endotracheal intubation include apnea, profound shock, and inadequate ventilation.• Chest radiography is not indicated in patients with clinical signs of a tension pneumothorax, and immediate chest decompression is accomplished with either a large-bore needle at the second intercostal space or, more definitively, with a tube thoracostomy.• A sucking chest wound must be appropriately covered to permit adequate ventilation and to prevent the iatrogenic development of a tension pneumothorax. 19
  20. 20. Initial assessment and management• Hypoxia is most serious problem - early interventions aimed at reversing• Immediate life-threatening injuries treated quickly and simply - usually with a tube or a needle• Secondary survey guided by high suspicion for specific injuries 20
  21. 21. SPECIFIC INJUERIES: A. Chest wall Injuries• 1. Fracture Ribs• Fracture of the ribs is the most common blunt thoracic injury, occurring in an estimated 39% of patients.• Rib fractures represent an important indicator of trauma severity. In general, the greater the number of ribs fractured, the higher the patient’s morbidity and mortality.• The number of ribs fractured has been significantly correlated with the presence of hemothorax or pneumothorax, with 81% of patients having either condition if two or more ribs were fractured.• Fractures of the fourth through the ninth rib are associated with injuries to the lung, bronchus, pleura, and heart, whereas fractures below the ninth rib are indicative of spleen, hepatic, or renal injuries. 21
  22. 22. Symptoms• The main symptoms include pain, tenderness, and possibly crepitus.• An upright chest X-ray is the standard way to diagnose fractures.• After adjusting for severity of injury, comorbidity, and presence of multiple rib fractures, elderly patients (>65 years old) with simple rib fractures still were five times more likely to die compared with patients under age 65.• First rib fracture has particular significance because of the great force required for it to occur and the likelihood that intrathoracic visceral injury also has taken place 22
  23. 23. Treatment• Once a haemopneumothorax and major skeletal injuries are excluded, the management is mainly for control of chest pain by• Nalgesics mostly NSAIDS,• intercostals blocks by local anesthesia, T.E.N.S may be useful.• Chest strapping or bed rest is no longer advised and early ambulation with vigorous physiotherapy (and oral antibiotics if necessary) is encouraged 23
  24. 24. Flail Chest• Free floating segment of ribs. – 3 or more rib fractures broken in 2 places.• Look for paradoxical chest wall motion – Inhaleinward – Exhaleoutward• Decreased air entry. 24
  25. 25. Types of flail chest• Anterior: Bilateral anterior fractures with bilateral costochondral separation (15%) or fractures of sternum with associated costochondral separation (7%).• Lateral: Multiple fractures on the same side with or without costochondral separation (73%) or fractures of several ribs with two or more fracture points on the same side (5%). 25
  26. 26. Treatment:• Approximately 50% of patients with flail chest can be managed without mechanical ventilation with the use of epidural analgesia, chest physiotherapy, bronchoscopy for mucus plugs, bronchodilators and mucolytic agents and supplemental oxygen.• Mechanical ventilation is used when signs of progressive hypoxia not responding to simple oxygen therapy.• In the more severe case, endotracheal intubation is required with positive-pressure ventilation for up to 3 weeks, until the frac-tures become less mobile.• Thoracotomy with fracture fixation is occasionally appropriate if there is an underlying lung injury to be treated at the same time.• An anterior flail segment with the sternum moving paradoxically with respiration can be stabilised by internal fixation but operative management is not usual for either. 26
  27. 27. Sternal Fractures• Most often in MVA.• Incidence 3%.• Normal vitals and normal EKG. Repeat EKG in 6 hrs and D/C if unchanged.• Practice varies between institutions. 27
  28. 28. Subcutaneous Emphysema• Air leak from lung parenchyma, or tracheobronchial tree.• Interstitial lung injury through hilum and mediastinum.• If extensive then suspect injury to pharynx, larynx, or esophagus.• Should be assumed that pt has pneumothorax even if not visible on chest x-ray. 28
  29. 29. Thanks for your Attention 29
  30. 30. Traumatic Pneumothorax• Traumatic injury causes laceration of the lung parenchyma &/or tracheobronchial tree and air enters the pleural space.• Negative pressure in pleural space facilitates air escape 30
  31. 31. Traumatic Pneumothorax Trauma Simple Open or sucking Tensionpneumothorax. pneumothorax. pneumothorax.
  32. 32. Simple Pneumothorax • Clinically the breath sounds are decreased on the affected side with a hyper resonant percussion note. • An erect CXR aids the diagnosis. • Pneumothoraces <2cm from the inner rib surface could observed • If these patients decompensate, or if pneumothorax enlarges or if the patient needs ventilation, tube thoracostomy should be performed.
  33. 33. Tension Pneumothorax• Develops when a "one way valve" air leak occurs either from the lung or through the chest wall (Sucking wound).• The mediastinum is displaced to the opposite side leading to decrease venous return and compression of the opposite lung and impaired ventilation and end with circulatory collaps.• This is a clinical diagnosis and treatment should not be delayed by waiting for radiologic confirmation.
  34. 34. Inferior vena cava 34
  35. 35. Tension PneumothoraxTension pneumothorax is characterised by† air hunger,† respiratory distress,† tachycardia,† hypotension,† tracheal deviation to the opposite side of injury,† unilateral absence of breath Tension pneumothorax requires immediate sounds, decompression and is managed initially by† neck vein distention and rapid insertion of a large bore needle into the 2nd intercoastal space in the mid-clavicular† cyanosis as a late line. manifestation. Definitive treatment is tube thoracostomy via a chest tube inserted in the safety triangle.
  36. 36. Chest TubeInsertion:should be in the “safetriangle” is the trianglebordered by the anteriorborder of the latissimusdorsi, the lateral border ofthe pectoralis major muscle,a line superior to thehorizontal level of thenipple, and an apex belowthe axilla. 36
  37. 37. Open Pneumothorax A: InspirationSeen in patients with large chest wall defects (Sucking wound), where the area of the defect is 2/3 that of tracheal diameter or is larger than the area of glottic opening.Air passes preferentially through the chest defect with each respiratory effort because air tends to follow the path of least resistance through the large chest wall defect. B:Experation
  38. 38. Open Pneumothorax 38
  39. 39. Haemothorax Haemothorax is a collection of blood in the pleural space and may be caused by blunt or penetrating trauma. Most haemothoraces are the result of rib fractures, lung parenchymal and minor venous injuries, and as such are self- limiting. Less commonly there is an arterial injury (intercostal or internal mammary vessels) which is more likely to require surgical repair. 39
  40. 40. Haemothorax• Diagnosis is made on clinical examination by the decreased breath sounds and dullness to percussion on affected side.• Confirmation is by CXR which shows complete or partial opacification of the affected side.• Chest tube thoracostomy is performed in the safety triangle for haemothorax by wide-bore tube (> 28French).• Bleeding is classified as minimal (<350 ml), moderate (350 to 500ml) massive (>1500 ml).
  41. 41. Massive Hemothorax• Each hemithorax can hold 40-50% of blood volume.• Defined: 1500 mL or more intial drainge.• Cause: Injury to lung parenchyma, intercostal artery or internal mammary artery 41
  42. 42. Which exam to request? Hematological: To detecte blood loss Chest x-ray:• Upright film (PA & Lat): 200-300 mL of blood.• Supine film: >1000mL of blood 42
  43. 43. ManagementChet tube : In 85% of the patients, > 32FAbout 5-15% of pts admitted with chest trauma require thorocotomy.Indications of Thoracotomy: 1) The initial blood drainage is >1500ml. 2) When bleeding persists at a rate of 200 to 300ml per hour over 3 to 4 hours. 3) When there is haemodynamic instability. 43
  44. 44. Pulmonary Contusion• Occurs in 50 to 60% of patients with blunt trauma.• Intrusion of ribs after frontal or lateral impact can cause direct damage injury to alveolar lining, capillaries and lung parenchyma cause hemorrhage and cellular disruption.• Grossly involved lung becomes hemorrhagic consolidated and oedematous irregular patches.• The resulting hypoxemia occurs 24 to 36 hours after injury.• Localised contusion usually resolves without major sequelae. This process usually takes 10 to 14 days.• Alternatively this may progress to varying degrees of ARDS in some patients.Treatment:• Supplement oxygen.• Chest physiotherapy.• Bronchodilators and mucolytics.• Limit fluid administration.• Steroids - use controversial.• Antibiotics also controversial.• Mechanical ventilation if indicated.• Analgesics are strongly indicated
  45. 45. Diaphragmatic rupture• The mechanism for diaphragmatic rupture is high- speed blunt abdominal trauma with a closed glottis.• The incidence is 1-3% of all chest trauma cases.• The sudden rise in intra-abdominal pressure breaches the weakest part of the abdominal wall, namely the diaphragm.• The injury to left diaphragm is 4 times commoner than the right due to protection afforded by the liver on the right.
  46. 46. Diaphragmatic rupture• Bowel sounds may be heard in the chest and the chest radiograph may reveal bowel gas in the lung fields.• A plain chest x-ray with a NG tube in the stomach can confirm the diagnosis or a contrast study.• But if the patient has signs of acute abdomen the repair to be by a laperatomy to deal with any intra- abdominal injuries.• Whilst chronic injuries (more than one month) should be approached through the chest due to adhesions.
  47. 47. Oesophageal injury• It should be noted whether the presentation after injury is delayed >24hours as this affects management.• The majority of cases occur in the cervical region.• The clinical suspicion is heightened by the association of fever, pain in the neck and tachycardia (Makler’s triad), crepitus and a “mediastinal crunch” may be heard on auscultation.• Contrast radiography could be performed by Gastrografine.
  48. 48. ManagementEarly diagnosis : An NG tube should be passed and IV prophylactic antibiotics started. A right sided thoracotomy is used for the middle 1/3 oesophageal injury. The lower 1/3 is better approached via the left side of the chest.Delayed presentation: Primary closure is often not possible due to florid sepsis. Options open to a surgeon are:• Tube drainage and oesophageal suction• T-tube insertion in perforation• Cervical oesophagostomy and distal ligation• Oesophageal resectionThe mortality for delayed presentation is +/-25%
  49. 49. Cardiac Tamponade• Is impairment of ventricular filling due to increased intrapericardial pressure due an increase in the intrapericardial content such as blood and/or effusions.• Unless recognized and treated promptly cardiac tamponade can be fatal.• The pericardial space normally contains 20-50 mL of fluid.
  50. 50. Cardiac Tamponade• Rapid accumulation of as little as 150 mL of fluid can result in a marked increase in pericardial pressure and can severely impede cardiac output.• Approximately 2% of penetrating injuries are reported to result in cardiac tamponade
  51. 51. Diagnosis• Beck’s Triad: (hypotension, jugular venous distention, and muffled heart sounds) occurs in only 10% to 40% of patients.• Pulsus paradoxus also paradoxic pulse This is an exaggeration (>12 mm Hg or 9%) of the normal inspiratory decrease in systemic blood pressure..• Kussmaul’s sign, or paradoxical inspiratory distention of neck veins upon expiration, is another classic sign attributed to pericardial tamponade.• FAST is rapid and accurate method of diagnosis
  52. 52. Cardiac Tamponade• A clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise.• The overall risk of death depends on the speed of diagnosis, the treatment provided, and the underlying cause of the tamponade. 52
  53. 53. Cardiac Tamponade• Caused by blunt and penetrating trauma.• Stab wounds to midchest most common cause.• Pericardial sack has poor compliance.• Normally it contains 20-50 mL of fluid. Only 150-200 mL can result in tamponade. 53
  54. 54. Cardiac Tamponade• History:• Symptoms vary with the underlying cause and the acuteness of the tamponade.• Patients with acute tamponade may present with dyspnea, tachycardia, and tachypnea.• Cold and clammy extremities from hypoperfusion are also observed in some patients. 54
  55. 55. Treatment• Pericardiocentesis or• Subxiphoid pericardiotomy or• Left anterior thoracotomy
  56. 56. Pericardiocentesis• Paraxiphoid approach• Can direct needle toward left scapula or right scapula (less likely to damage ventricle).• Up and back at 45 degrees for 4-5 cm.• Aspirate every 1-2mm.• Removal of 5-10 mL can increase stroke volume by 25-50%. 56
  57. 57. COMPLICATIONS OF THORACIC TRAUMA Pulmonary Pleural Space VascularAtelectasis Empyema ThromboembolismAcute respiratory Bronchopleural Air embolismdistress fistulasyndrome/acute lunginjuryPneumonia Organized Pseudoaneurysm hemothoraxInfarction Chylothorax Great vessel fistulaLung abscess Fibrothorax VascularArteriovenous fistula Diaphragmatic Thromboembolism herniasBronchial stenosis Pleural Space Air embolism