3. . Cardiac – which includes
1. Tamponade.
2. Coronary arteries.
3. Cardiac chambers.
4. Great vessels.
4.
5.
6. 1.Chest wall: Chest wall injury -- a single rib
fracture to multiple rib fractures ---flail chest.
Fractured ribs---severe pain-- limiting the
respiratory movements leading to
hypoventilation--deleterious in pre-existing
COPD.
X-ray chest is required to rule out atelectasis or
pneumothorax.
7. Treatment: Surgical fixation or even strapping is
rarely required-- lead to atelectasis.
Ventilation can be improved by pain relief with
Analgesics
Intercostal nerve blocks, interpleural catheters,
epidural narcotics and PCA.
In case of persistent hypoxemia 5 cm CPAP via
mask may be required.
8. Surgical repair may necessitate intubation ,G.A.
and mechanical ventilation.
Sternal fracture with “Steering Wheel Syndrome”
now has been replaced by “Seat Belt Syndrome” in
motor vehicle accidents.
Steering wheel impact on sternum causes rapid
deceleration leading to deeper thoracic structure
injuries
9. A blunt chest injury may cause acute myocardial infar
ction-like signs and symptoms
contusion of the
anterior epicardium
myocardium, compression of the heart between
sternum and vertebral column
An abrupt increased in intrathoracic pressure
potentially rupturing cardiac structures—
e.g., ventricular septum, chordae tendinieae
10. 2.Pleural space: Athoracic injury can give rise
to
Pneumothorax (PNT )
Tension PNT (TNT)
Simple open PNT
Haemothorax
11. PNT:An opening in the chest wall allows
atmospheric air to enter the pleural space
permitting the interpleural pressure to equalize
atmosphere pressure producing PNT and
pressure collapse of the lung.
A sort of ‘sucking wound’ i.e. air entering pleural
space during inspiration and exiting during
expiration
12. The air may also enter pleural space from inside from
tracheobronchial or lung parenchymal injury.
TNT occurs--air enters the pleural space during
inspiration -- cannot escape during expiration.
TNT compresses ipsilateral lung directly and opposite
lung by mediastinal shift.
Increase in pleural pressure decreases venous return
and COP.
13. Cardinal signs of TNT are
Rapid deterioration of vital signs
Decreased pulmonary compliance
Decreased or no breath sounds on affected sides
Tracheal deviation towards normal side
Occasionally, the air leak may also cause
pneumomediastinum and pneumopericardium.
14. Diagnosis: PNT less than 20% is not detectable
Clinically; PNT more than 20% causes chest pain
that increases on breathing.
PNT more than 40% may cause cyanosis and
tracheal deviation.
Clinical findings with rib fracture are suggestive
and CXR in expiration confirms it.
15. Treatment:
A simple open PNT--- chest tube drainage (ICD)
Small wounds --sealed by dressing
TNT suspected ---- immediate decompression by insertion of a
14G needle in the second intercostal space (ICS) in midclavicular
line (MCL) followed by ICD.
If patient --transported by air even a minor PNT should be
drained . i.e. air volume increases with decreasing pressure at
heights.
16. GA is indicated --debridement and primary closure.
ICD tube is inserted under local anaesthesia.
Anaesthesiologist must be very cautious considering
the possibilities of converting a small, untreated
simple PNT into a large TNT during induction and
IPPV.
Avoid nitrous oxide.
Monitor chest tube for continued function.
17. Only about 400ml or more blood in pleural space can be
detected in upright CXR.
One side pleural space can easily accommodate 30-40% (>1.5L)
of victims’ blood.
The consequences are-
Hypotension
Compression of ipsilateral lung
Mediastinal shift followed by
Compression of contralateral lung
Ventilatory impairment
18. Tube thoracostomy in 6th intercostal space in midaxillary
line.
If the source of bleeding is pulmonary vessel (low
perfusion pressure) only tube drainage is enough
bleeding from systemic vessel if 300 ml.hr-1 or more after
initial drainage will require emergency thoracotomy.
Sometimes a chest tube may release a tamponade --
massive haemorrhage.
19. A fast transfusion with the help of pump may be required.
Acute respiratory failure prior to surgery ---intubation
and PPV.
Double lumen tube (DLT) may be considered if
there is : Large air leak from chest tube (tracheobronchial
injury)
Hemoptysis or a significant amount of blood in airways
20. Pulmonary contusion--both penetrating--rapid
deceleration conditions.
Rib fractures--50% of such cases.
Initial CXR is not helpful and CT Scan is required to know
the extent.
Progressive decrease of pulmonary compliance and PaO2
and increase in alveolar edema.
PaO2/FiO2 < 250 is the best indicator of poor outcome.
21. edema phase-- treated with application of PEEP,
diuretics and controlled fluid administration.
Colloid versus crystalloid infusion is not an important
issue as the area has to become edematous due to
deranged pulmonary characteristics.
Pulmonary laceration is infrequent with blunt chest
trauma but blunt shearing or the ends of the broken
ribs can cause it.
22. TBD should be suspected with penetrating or
blunt injury to the neck or chest.
Subcutaneous or mediastinal emphysema
Hemoptysis, PNT, bronchopleural fistulas
(BPF)
Persistent air leak after tube insertion are the
definite signs of TBD.
23. A knife laceration to lung may transect many
bronchioles behaving like BPFs.
Flexible bronchoscopy should be performed
to assess the level of disruption
24. distal tears with minimal air leak or major bronchus
tear involving less than one third of circumference
_______ treated nonsurgically.
Small to moderate high tracheal tear --ETT with cuff
reaching distal to tear.
Tracheostomy is indicated in high tracheolaryngeal
disruptions.
Majority of TBD require surgery.
25. Intubation is done depending upon
in awake or anaesthetized, relaxed or spontaneously ventilated
patient
using a single lumen tube (SLT) or double lumen tube (DLT) over
a fiberscope to reach distal to tear and avoiding further tear by
blind advancement of ETT.
DLT should be used when separation of lung is life saving and
PPV of the affected lung may convert a simple mucosal tear to a
major BPF , injuries at or below carina.
26. In case of SLT:
Maintain spontaneous ventilation during induction, intubation and
maintenance of anaesthesia.
If required, a gentle PPV can be given when chest is opened.
As an alternative to ETT, a small catheter can be passed beyond the
injury for High Frequency Ventilation and High Flow Apnoeic Ventilation.
Sterile ETTs of different sizes should be kept ready for intraoperative
bronchial placement from within during airway repair.
27. Blunt forces--a sudden rise in intraluminal pressure or
esophagus may be crushed between trachea and vertebral bodies
but more common cause is penetrating trauma.
Injury to esophagus from outside or within is not immediately
life threatening
Untreated and unrecognized esophageal injury has an extremely
high mortality due to mediastinitis, empyema and sepsis.
Repair within 24 hrs remarkably reduces mortality.
28. Diagnosis:
Clinically chest pain, dysphagia, hematemesis, emphysema
and fever.
Oesophagography ; Oesophagoscopy is not always necessary.
Treatment:
Surgery--a minor primary repair to resection of oesophagus .
Tears of upper and middle thirds are repaired from right and
lower one third from left thoracotomies.
29. Respiratory hemodynamic and GI
considerations.
Use of DLT and one lung ventilation facilitate
surgery.
No esophageal instrumentation -- gently
guiding a nasogastric tube beyond repair at
the end of operation by surgeon.
30. Blunt forces or gunshots from chest or
abdomen can disrupt diaphragm.
Abdominal viscera may be pushed up to the
chest causing respiratory embarrassment.
If the injury is to be approached by
thoracotomy, the surgical exposure -- DLT
31. Blunt trauma may cause cardiac contusion or aortic
disruption at isthmus with fractured sternum.
Cardiac arrhythmias and ST changes on ECG may
indicate cardiac contusions but rise in troponin I is
more specific.
Penetrating cardiac injuries –gunshots or stab
wounds to neck, precordium or upper left abdomen.
32. Gunshot wounds are more devastating, can injure
one or more cardiac chambers .
Right ventricle with its anterior placement is
more prone to injury.
Several serious effects may result from
penetrating cardiac injury but the commonest
one is cardiac tamponade
33. Pericardial space normally contains 60 ml of serous Fluid
A relatively non-stretchable structure if filled with 100 –
200ml of blood may limit diastolic expansion of the heart.
Gradually if allowed it can accommodate up to 2 L of blood
severely affecting the cardiac output.
Diagnosis: It can be diagnosed by
Site of wound
Beck’s triad of – distended neck veins, hypotension
Muffled heart sounds
34. Kussmaul’s sign (paradoxic filling of neck veins on
inspiration).
Pulses paradoxus.
ECG – Pulsus alternans.
Shock and raised CVP.
Treatment: The definitive treatment is surgery but
pericardiocentesis may be done first to relieve rapidly
increasing tapenade.
35. In a moribund and unconscious patient
pericardiocentesis is done only under local
anaesthesia
Oxygen and/or PPV.
Administration of GA with a significant
tamponade is potentially lethal.
36. In a conscious, restless, non-cooperative patient
GA is required even for pericardiocentesis
followed by surgical correction.
Maintain CVP > 15cm H2O, avoid peripheral
vasodilatation, myocardial depression and
arrhythmias.
37. Ketamine, vecuronium, high FiO2 are the choices.
If patient deteriorates before tamponade is
relieved, isoproterenol infusion is started
Conservative anaesthetic management must be
followed even after tamponade is relieved but
narcotics e.g. fentanyl can be added.
38. Coronary artery injury: Being anterior usually left coronary artery
is involved. It may lead to hemorrhage, infarction or tamponade.
From an-aesthetic view point these patients should be managed
similarly to the patients with acute MI.
Cardiac chamber injury: Immediate surgery for
repair of hole is required.
General anesthetic considerations as discussed earlier with
special management of hemorrhagic shock --Great vessels’
injury:
39. Aort ic injury – It leads to devastating haemorrhage and only 15%
reaches hospital alive.
The signs are:-
Mediastinal widening
Haemothorax
Tracheal deviation
Caval injuries -
Most difficult to deal surgically
Extremely high mortality
40. Depending upon the condition , the general
anaesthetic management plan is employed.
Goal is to maintain a rapid fluid replacement.
Cardiopulmonary bypass is rarely required
but always better to keep the facility
available.
41. Extensive chest trauma is always life threatening
due to respiratory and hemorrhage problems.
The anesthesiologist must be able to initiate
primary resuscitation, diagnose life threatening
chest injuries and plan the anesthetic
management of any surgical intervention if
required.
42. Non-penetrating usually caused by blunt
trauma, deceleration or blast forces.
Penetrating injuries caused by gunshots,
stabs, arrows
Most of the deaths in these cases are due to
asphyxia and hemorrhage and are avoidable.
43. Extensive thoracic injuries are always life
threatening and they should be managed
aggressively
The amount of destruction of the organ is
proportional to the shearing forces
Tissue destruction following a gun shot depends
upon the kinetic energy (KE) transmitted to the
tissues
44. Assessment and resuscitation: patient should
be scaled on injury severity score (ISS). Any
ISS more than 25 is severe .
physical examination (involving one side of
chest or transmediastinal gun shot wound)
Diagnostic studies
Life-saving surgery
45.
46. A. Establish airway and ventilation.
B. Maintain circulation in terms of cardiac
function and intravascular volume.
C. Check neurological status (GCS)
D. Determine the mechanism of injury.
47. Airway: Intubate an unconscious, shocked
and hypoxic patient immediately.
If there is neck injury or bleeding, do
cricothyroidotomy or tracheotomy.
Patient with collapsed neck veins is assumed
to be in hypovolemic shock.
48. C. Neurologic status: Glasgow Coma Scale is
only important when there are associated
head and neck injuries or air in cerebral
circulation.
D. Mechanism: It may be penetrating, blunt
with high velocity, low velocity or crushing
factor.
49. Patient with distended neck veins but
hypotensive may
have the possibilities of:
Myocardial contusion or MI
Tension pneumothorax (TNT)
Air embolism
Pericardial tamponade
50. penetrating thoracic injury (PTI) who has no
obvious head injury but has focal neurological
signs may have air bubbles occluding the
cerebral circulation.
Fundoscopy showing air bubbles in retinal
vessels may confirm it.
Intubated patient on IPPV who develops sudden
51. cardiovascular collapse ----- either TNT or
coronary air embolism.
The definitive treatment is emergency
thoracotomy in ‘steep head down ’position.
Pericardial tamponade is a frequent---
pericardiocentesis can be done as life saving
measure but immediate thoracotomy is the
definitive treatment.
52. If patient becomes haemodynamically stable
after initial resuscitation then a secondary
survey for diagnostic studies and surgical
priorities should be followed
53. Pre-operative assessment:
Monitoring
Induction:
Unconscious moribund patient should be intubated
and surgery is performed without anesthesia.
When vital signs and consciousness improve,
anesthetics can be added to start with lower doses.
Ketamine is the drug of choice.
54. Avoid thiopentone and like drugs including
inhalational agents in shocked patients. They
should be used only after correction of BP
with adequate fluid replacement.
Excessive crystalloids may lead to
hypoproteinemia and further pharmacokinetic
disturbances
55. after adequate hydration colloids should be added as
plasma expanders.
Consider full stomach and delayed gastric emptying.
Pre-curarization and rapid sequence induction and
intubation is a must with succinylcholine
Apply cricoid pressure from intubation to cuff
inflation
56. In a stable patient it is left to the discretion of the
anaesthesiologist.
O2/air mixtures, muscle relaxants, narcotics,
amnestics and minimal inhalational agents can
be used.
Avoid N2O .
Intraoperatively watch for the development of any
other unwanted new sign e.g. TNT or tamponade.
57. Non-responding fluid replacement therapy
from upper veins may indicate towards
possibility of tear in SVC
58. Muscle relaxant :
Avoid succinylcholine in massive trauma
____hyperkalemia
Vecuronium or rocuronium are cardiovascularly
stable and relaxants of choice.
Avoid atracurium due to rapidly changing
acidbase status and due to its hypotensive effect.
59. Observe for drug interactions e.g. antibiotic
vs relaxants.
Hypothermia is hazardous.
Awareness is a major but almost unavoidable
hazard .
