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Thoracic trauma and pain management
- 1. Thoracic trauma Dr Neisevilie Nisa Dept. Anaesthesia AIIMS Hospital New Delhi
- 2. Overview ๏ถ Anatomy ๏ถ Pathophysiology of thoracic trauma ๏ถ Assessment and management ๏ถ Flail chest ๏ถ Pain management in thoracic trauma
- 3. Epidemiology ๏ถ 10-20% of polytrauma ๏ถ 2nd most common cause of death after head trauma ๏ถ 25% of death in polytrauma
- 4. India ๏ถMost common cause is Motor vehicle injury ๏ถ 6% of global vehicular accidents ๏ถ Male , mean age 21-40 years ๏ถ Violence ,industrial accidents, falls, assaults, gunshot
- 5. AIIMS Trauma HEAD & NECK 91 6% FACE/MF 149 10% THORAX 358 24% ABDOMEN&PELVIS 400 26% ISOLATED PELVIS 54 4% EXTREMITY +PELVIC &SHOULDER GIRDLE 250 16% EXTERNAL 220 14% (N=1522)
- 6. Thoracic Trauma (n=358) Non-operative โ 345 (95.3%) Operative n=13(4.7%) With ICDT 280 INDICATION for THORACOTOMY Pneumonectomy 01 With out ICDT 65 Lobectomy 01 Bronchial repair 03 Massive Hemothorax 06 VATS 01 Epidural 82 Descending thoracic aorta stenting 01 Diaphragmatic repair 09 (6-Open abdominal approach; 3-Lap)
- 7. Etiology 624, 57% 189, 17% 122, 11% 32, 3% 27, 3% 97, 9% RTI Assault FFH Railway Suicidal Unintentional
- 8. Anatomy
- 10. Blunt Thoracic Trauma ๏ถ Globally = Road traffic accident represent the most common cause ๏ถ Eastern mediterranean countries = Assault ๏ถ Other causes - Assault - Fall - Industrial - Sports - Animal attacks
- 11. Blunt trauma contdโฆโฆ ๏ถ Results from kinetic energy forces - Blast - Crush - Decelaration ๏ถ Blast - Pressure wave - Tear blood vessels & disrupt alveolar tissue - Disruption of tracheobronchial tree - Traumatic diaphragm rupture
- 12. ๏ถ Crush (Compression) โ Body compressed between an object and a hard surface โ Direct injury of chest wall and internal structures ๏ถ Deceleration โ Body in motion strikes a fixed object โ Internal structures continue in motion โ Force exceeds tissue tensile strength โ Ligamentum Arteriosum shears aorta
- 13. Penetrating Trauma ๏ถPenetrating Trauma โ Low Energy ๏ถ Arrows, knives โ High Energy ๏ถ Military, hunting rifles & high powered hand guns ๏ถ Extensive injury due to high pressure cavitation
- 15. Injuries Associated with Thoracic Trauma Airway Tension pneumothorax Open pneumothorax Circulation Massive hemothorax Cardiac temponade Secondary Simple pneumothorax Hemothorax Pulmonary contusion Tracheabronchial tree Blunt cardiac injury Aortic disruption Diaphragmatic injury Mediastinal transversing wound Flail chest
- 16. ATLS Primary survey Resuscitaion of vital functions Secondary survey Definitive care
- 17. Primary survey ๏ถ Airway ๏ถ Laryngeal trauma ๏ถ Sternoclavicular joint Listen Observe Palpate
- 18. Breathing Open pneumothorax Tension pneumothoraxListen Observe Palpate
- 19. Circulation Pulse Blood pressure Skin Neck veins SPo2, ECG Cardiac temponade Massive hemothorax
- 20. Resuscitative Thoracotomy ๏ถ Release pericardial tamponade ๏ถ Control cardiac/great vessel bleeding ๏ถ Perform open cardiac massage ๏ถ Aortic cross clamping
- 21. Tracheobronchial injury ๏ถ Hemoptysis ๏ถ Air escaping from neck wound ๏ถ Dyspnoea, resp distress ๏ถ Hoarseness, dysphonia ๏ถ Emphysema ๏ถ Pneumothorax
- 22. Management ๏ถ Bronchoscopy : confirms diagnosis ๏ถ Secure airway ๏ถ Unstable patients : surgical intervention ๏ถ Stable patients : After acute inflamation and oedema resolve
- 23. Diaphragmatic Rupture ๏ถ More common on left side ๏ถ Commonly diagnosed during laparatomy ๏ถ Chest X-ray with gastric tube, contrast study ๏ถ Treatmant is direct repair
- 24. Esophageal Injury ๏ถ Penetrating Injury most frequent cause ๏ถ Forceful expansion of gastric contents
- 25. Esophageal Injury ๏ถAssessment Findings - Pain/shock out of proportion to the apparent injury - Dysphagia, Respiratory distress - Particulate matter in the chest tube - Mediastinitis, pneumomediastinum, emphysema - Contrast study - Direct repair
- 26. Traumatic Aortic Rupture ๏ถ Common cause of sudden death ๏ถ Slim chances of survival ๏ถ Ligamentum arteriosum ๏ถImmediate survivors, early diagnosis and treatment
- 27. Signs and symptoms ๏ถ Non specific : High index of suspicion ๏ถ Burning or Tearing Sensation in chest or shoulder ๏ถ Rapidly dropping Blood Pressure and increasing pulse ๏ถ Decreased or loss of pulse or BP on left side compared to right side ๏ถ Rapid Loss of Consciousness
- 28. Management ๏ถ ABCโs and RAPID TRANSPORT to higher center ๏ถ Angiography is gold standard ๏ถ Other investigation non specific ๏ถ Primary repair or resection and grafting
- 29. Flail chest ๏ถ Flail chest has mortality of 10 โ 20 % and typically associated with pulmonary contusion ๏ถTraditional = Paradoxical movement and โPendelluftโ โ Pulmonary contusion causes major respiratory compromise and flail chest secondary problem of pain and splinting โ
- 30. Definition Fracture of 2 or more ribs in 2 or more places
- 34. Clinical features Symptoms ๏ถ Breathlessness ๏ถ Pain Signs ๏ถ Hypoxia ๏ถ Bruising/Swelling ๏ถ Crepitus ๏ถ Increased pulmonary vascular resistance
- 35. Investigations
- 36. Management ๏ถ Principles of fluid management ? ๏ถ Invasive or non- invasive ventilation ? ๏ถ Optimal mode of ventilation ? ๏ถ Role of surgical fixation ? ๏ถ Role of steroids ? Rule of thumb = Adequate analgesia and chest physiotherapy
- 37. Management contdโฆ ๏ถ Humidified oxygen ๏ถ Analgesia ๏ถ Ventilation and re-expansion of lung ๏ถ Sandbag and extensive strapping contraindicated ๏ถ No role of steroids
- 38. Fluid management ๏ถโCongestive atelectasisโ - Aggressive fluid resuscitation increase the size of lesion Trinkle et al 1973 ๏ถ Colloids better than crystalloids ๏ถ Pulmonary dysfunction unrelated to hemodilution ๏ถ Mortality related to pulmonary function on admission โ Fluid resuscitation should not be restricted to maintain adequate tissue perfussionโ
- 39. Ventilatory support ๏ถ Initially = โ obligatory mechanical ventilation โ ๏ถ Longer hospital stay, increase mortality and morbidity โ Correct abnormalities of gas exchange rather to overcome instability of chest wall โ
- 40. Indication for intubation ๏ถ Severe head injury ๏ถ Several associated injury ๏ถ Shock ๏ถ Fracture of eight or more ribs ๏ถ Age > 65 years ๏ถ Previous pulmonary disease ๏ถ RR > 35/mt ๏ถ Pao2 < 60mmHg ๏ถ PaCO2 > 55mmhg ๏ถ SPo2 < 90%
- 41. Which mode ? ๏ถ No difference between CMV and IMV ๏ถ CPAP or PEEP of 10-15 cm H2O ๏ถ Alveolar recruitment and increase FRC ๏ถ Independent lung ventilation in severe unilateral chest trauma ๏ถ HFOV : Failure of conventional methods
- 42. Indication of surgical repair ๏ถ Thoracotomy ๏ถ FC with respiratory insufficiency without pulmonary contusion ๏ถ Severe flail chest requiring prolonged ventilatory support ๏ถ Progressive dislocation of ribs
- 43. Summary โ Flail chest component causes short term respiratory dysfunction, Pulmonary contusion responsible for long term dyspnoea, low FRC , PaO2 โ โ Adequate analgesia and chest physiotherapy is mainstay of treatment โ
- 44. Pain management in thoracic trauma
- 45. History Optimal pain control and chest physiotherapy
- 49. Intravenous analgesics Advantages Disadvantages ๏ถEasy to administer and monitor ๏ถ Avoids invasive procedure ๏ถ Specialised personnel not required ๏ถ Sedation ๏ถ Cough suppression ๏ถ Respiratory depression ๏ถ Hypoxemia
- 50. Epidural analgesia Advantages Disadvantages ๏ถ Avoids sedation ๏ถ Improve PFT ๏ถ Decrease airway resistance ๏ถ Effective chest physiotherapy ๏ถ Technically demanding ๏ถ Hypotension ๏ถ Infection ๏ถ Spinal chord trauma ๏ถ Mask symptoms of associated abdominal injury ๏ถ Monitoring required
- 51. Epidural superior to intravenous narcotics Less ventilator days Less tracheostomy rate Less ICU stay Shorter hospital length of stay
- 52. Epidural contdโฆ. ๏ถ Lumbar โORโ thoracic ๏ถ Opiods โORโ LA ๏ถ Infusion โORโ intermittent boluses
- 53. Epidural contdโฆ. ๏ถ Equally effective pain scores but superior PFT Cicala et al 1990 ๏ถ Combination therapy ๏ถ Lower pain scores ๏ถ IV narcotic sparing Logas et al 1997 ๏ถ Lower doses of both ๏ถ Boluses has higher rate of complication kurek et al 1997
- 54. Complications ๏ถ Unsuccessful catheter placement ๏ถ Dural puncture ๏ถ Neurological injury ๏ถ Hypotension ๏ถ Radicular pain ๏ถ Pruritus ๏ถ Respiratory depression ๏ถ Urinary retention ๏ถ Nausea ๏ถ Vomitting
- 55. Paravertebral block Advantages Disadvantages ๏ถ Ribs palpation not required ๏ถ Upper ribs fracture ๏ถ Avoids EDA side effects ๏ถ Unilateral block ๏ถ Less spinal chord trauma ๏ถ Pleural puncture ๏ถ Pneumothorax ๏ถ Vascular puncture ๏ถ Higher failure rate
- 57. Intercostal nerve block Advantages Disadvantages ๏ถ Increase PEFR ,lung volumes ๏ถ Less hypotension ๏ถ Bladder function preserved ๏ถ Palpation of fractured ribs ๏ถ LA Toxicity ๏ถ Difficult for upper ribs ๏ถ Multiple infections ๏ถ Pneumothorax
- 58. Intrapleural anesthesia Advantages Disadvantages ๏ถ Unilateral block ๏ถ Similar to intercostal ๏ถ LA lost via chest tube ๏ถ Gravity dependent ๏ถ Pneumothorax ๏ถ Impair diffusion of LA ๏ถ Diaphragmatic function
- 59. Newer modalities ๏ถ 5 % lignocaine patch ( LIDODERM ) ๏ถ No opiod sparing versus placebo group Ingalls et al 2010
- 60. Summary ๏ถEpidural analgesia: Optimal modality of pain control and preferred technique after severe blunt thoracic trauma ๏ถ Safe with negligible complications ๏ถ PVB when ED is contraindicated ๏ถ Combination of narcotic and LA superior