Thoracoabdominal trauma

1. Case capsule

2. • 35/Male
• No co-morbid illnesses.
• Alleged stab injury over the chest.
• No other injuries.

3. • 9.30am-
• HR- 80/minute. RR- 24/minute
BP:100/70mmHg
• CVS- S1 S2 normal.
• RS- B/L equal air entry.
• One episode of hypotension responded to
fluids.
• FAST- minimal fluid in abdomen.

4. • What would you do next?

10. 4 pm
• Hypotension not responding to fluids.
• BP 70 systolic. HR- 80 minute.
• Abdomen – distended. No peritoneal
signs.
• Drop in Hb by 5g% on ABG
• Posted for operation
2pm
CT abdomen -moderate hemopericardium , mild ascites
ECHO by CTVS – pericardial fluid+, nil
intervention

11. Intraoperative findings
• 2x2 cm rent in the left dome of diaphragm,
cardiac movements were seen.
• 1L hemoperitoneum.
• 2cm laceration in the right lobe of liver.
• No ongoing bleeding

12. • How would you proceed?

13. • Post operatively shifted to SICU
• ECHO- pericardial effusion and occasional RV
collapse.
• Serial cardiac enzymes and ECG was normal.
• Repeat CXR- no evidence of
hemo/pneumothorax.
• Post operative day 6 – discharged.

14. Penetrating thoracoabdominal
trauma

15. Anatomy
• Thoracoabdominal region(intrthoracic
abdomen)
• 4th ICS/level of nipple anteriorly
• 6th ICS laterally
• 8th ICS posteriorly
Thoracoabdominal region

16. Organs commonly injured in
thoracoabdominal trauma
Thoracic Abdominal
Lung parenchyma Major vasculature
Pulmonary hilum Aorta and branches
Heart IVC
Major vasculature Esophagus
Aorta, great vessels Stomach
IVC Spleen
Esophagus Liver
Diaphragm Duodenum
Pancreas
Small and large bowel
Genitourinary structures

17. History
• Earliest literature on thoraco abdominal
trauma form WW-II
• Overall mortality of 8-40% during WW-II
• In recent studies mortality 2-18%.
• Incidence of thoracoabdominal trauma in
penetrating thoracic injury – 10-30%

18. Why is thoracoabdominal region is
distinct?
1. 70 percent of pericardial injuries are occult.
2. Likely to miss diaphragmatic injuries.
3. Decision making. – Which cavity to open
first?
4. The organs and vessels in the region.
5. High mortality

19. Abdominal organs commonly involved in penetrating
thoracoabdominal trauma
Site of
Injury
Mechanism
of Injury
Oparah(%) Moore(%) Seimens(%) NS Borja(%)
GSWGSW SW
Liver 40 29 3 24 20
Diaphragm 35 28 12 32 30
Spleen 16 8 5 10 7
Stomach 15 15 1 12 8
Colon 15 14 3 13 6
Small bowel 8 9 2 ND 7

20. Operative intervention in
thoracoabdominal penetrating trauma
• intraperitoneal injury in close to 45% cases
needing laparotomy.
• Peritoneal penetration more common with GSW .
Multiorgan involvement more common in GSW.
• Most thoracic trauma can be managed with chest
tube alone.
• 10-15% need thoracotomy ( higher mortality 13%
compared to 3%)
• Incorrect preoperative sequencing reported in
around 30 % cases.

21. Evaluation of thoracoabdominal
injuries
• Follow ATLS guidelines.
• All thoracoabdominal injuries are potentially
fatal.
• Physical examination
• Chest - often unreliable , needs imaging,
atleast Chest Xray.
• Abdomen – reliable if no neurological deficits.

22. FAST
• 100% sensitivity and
99% specificity for
pericardial fluid.
• 86-99% sensitivity for
intraperitoneal fluid.
• Also highly sensitive
and specific for pleural
effusion and
hemothorax.

23. • Indications for immediate laparotomy
• - peritonitis.
• - hypotension
• - on going hemorrhage
• - evisceration
• - Others need serial abdominal examinations
and close observation.

24. Indications for thoracotomy
• 85% cases managed by Chest drains, respiratory
support and analgesia .
• Hemodynamic instability
• Suspicion on cardiac tamponade.
• Significant air leak from chest tube
• On going bleeding from chest tube(>200
ml/hour).
• Injury to great vessels or esophagus/
• Tracheobronchial injury.

25. Cardiac tamponade
• Becks triad (Seen in 10% cases) – hypotension,
elevated JVP,muffled heart sounds.
• ECHO should be done for all hemodynamically
stable patients with precordial chest trauma.
• Sensitivity and specificity ~100%
• Sensitivity of ECHO reduces from 100% to 56%
in presence of hemothorax.

26. In the presence of cardiac tamponade –
• median sternotomy is the procedure of choice
vs. anterolateral thoracotomy.
In case of high suspicion of pericardial injury
• pericardiocetesis (poor sensitivity/specificity)
• subxiphoid pericardial window (reliable)
• Serial ECHO

27. Diaphragmatic injuries
• Incidence 10-80%
• Physical and radiographic changes- non
specific.
• High likelihood for missing asymptomatic
injuries can lead to diaphragmatic hernias
later.
• Late presentation of diaphragmatic injury –
25% mortality
• Complications much higher on the left side.

28. • In penetrating left thoracoabdominal injuries
incidence of diaphragmatic injury– 42%
• Laparoscopy –mandatory for left
thoracoabdominal injuries if no other
indication for open procedure.

29. Laparoscopy in penetrating
thoracoabdominal injuries.
• Currently recommended for left sided injuries
in asymptomatic patients in the absence of
indication for laparotomy.
• 27% of occult diaphragmatic injuries detected

30. • VIDEO ASSISTED THORACOSCOPY
• To assess diaphragmatic injuries/hemothorax.
• Laparoscopy vs. thoracospoy- surgeon
preference.

32. References
• World Journal of Emergency Surgery 2014, 9:33
• Clinical decision making in unstable patients with,
thoraco-abdominal stab wounds and, potential
injuries in multiple body cavities, Injury, Volume
42, Issue 5, May 2011, Pages 478-481
• Emergency Medicine Clinics of North America
Volume 16, Issue 1, 1 February 1998, Pages 107–
128