Thoracic Trauma-.pptx

Thoracic Trauma R.Madansein Department of Cardiothoracic Surgery UKZN  Syllabus Blunt and Penetrating Trauma Chest wall – muscle &bone Pleura lung parenchyma Tracheobronchial (& foreign body) Oesophagus (& foreign body) Diap...

Thoracic Trauma R.Madansein Department of Cardiothoracic Surgery UKZN  Syllabus Blunt and Penetrating Trauma Chest wall – muscle &bone Pleura lung parenchyma Tracheobronchial (& foreign body) Oesophagus (& foreign body) Diaphragm Cardiovascular  Thoracic trauma Thoracic injury account for 20-25% of thoracic death worldwide Male vs female Age Blunt , penetrating ,transfixing  Mechanism of Injury 1.Penetrating High velocity - Gunshots Low velocity - Stab wounds 2.Blunt Direct Assault and blast Indirect Falls, MVA (acceleration-deceleration injuries, crush injuries and shearing forces) 3.Transfixing Special factors Pediatric Thorax: More cartilage = Absorbs forces Geriatric Thorax: Calcification & osteoporosis = More fractures  ACCELERATION - DECELERATION Shearing, Tearing, Traction Forces in relation to some structure being more FIXED than others Aorta Heart Oesophagus  Initial evaluation GOAL: Prompt identification of life threatening injuries Pathology Airway Obstruction Loss of Oxygenation or Ventilation Hypovolaemia Obstructive shock Ventilation -perfusion mismatch  Initial evaluation Physiological causes of death Tissue hypoxia Hypercarbia Metabolic acidosis  Initial evaluation Determines the outcome of patient ATLS Primary survey (Airway-breathing-circulation) Airway obstruction Tension pneumothorax Open pneumo/ sucking chest wound Flail chest Massive haemothorax Cardiac tamponade Paediatrics vs elderly vs pregnant patients  Initial evaluation Secondary survey (with the aid of imaging, record every injury from head to toes systemically) Simple pneumothorax Haemothorax (2 rib fractures in 2 segments creating a flail - paradoxical motion Associated with lung contusion Management: Supportive Surgical: help wean off of MV  Traumatic rib fractures Other bony fractures of the chest wall Sternal fractures: Up to 4% Transverse, in the upper or midportions Associated injuries- myocardium Cf: point of tenderness, swelling & deformity. CXR sternal fracture on lateral view. CT- delineating fracture. Scapular & clavicle Results from severe force, uncommon, 80-90% accompanying injuries eg brachial plexus Mortality 10%  PLEURA Traumatic pneumothorax May be missed initially, erect CXR must exclude during 2nd survery  PLEURA Haemothorax Associated with penetrating or blunt chest trauma with bony injury Mx with ICD for complete evacuation, failure = retained clotted haem – trapped lung - decortication Massive haemorrhage (> 1500ml) or ( 200ml/hr for 2-4hrs) = need for exploration  Lung Injury Clinical Haemoptysis ,pneumothorax ,haemothorax Management Severity of injury (laceration) ICD and chest physiotherapy Surgery: suture/wedge resection/pulmonary tractotomy/ lobectomy and pneumonectomy  LUNG INJURY Pulmonary contusion Blunt trauma, usual MOI High energy impact– potentially lethal CF: Subsequent resp failure, slow progressing Resp compromise with dullness to percussion Dx on CXR / CT chest MX : supportive, O2 , analgesia, pulmonary toilet Intubation – significant hypoxia, pre existing condition eg COPD, Renal F, also in patients requiring transfer  LUNG INJURY Pulmonary hematoma Difficult to differentiate from pul contusion 24 – 48 hours after injury develops into a discrete mass with discrete margins CT chest helps diagnose (from pul contusion) Cab be 2nd infected – abscess, requiring drainage (rare)  Tracheobronchial tree injuries Central airways Common after blunt injury, high energy impact Mechanism: Forceful AP compression High airway pressure Rapid deceleration injury 80% :TBI rupture within 2.5cm of the carina Approximately 2-3% of all trauma, about 1% reach hospital setting 0.4% blunt vs 4.5% penetrating  Tracheobronchial tree injuries Penetrating injury is rare Site: Cervical trachea most common  Tracheobronchial tree injuries CF: NB: can be missed for years in >30% of patients, high suspicion in : Mediastinal emphysema/subcutaneous emphysema>pneumothorax(including tension) not resolving with icd>haemoptysis,> & not resolving atelectasis with conserve mx Early : respiratory insufficiency persistent pneumothorax haemoptysis and massive air leak Late : asymptomatic recurrent pneumonia bronchial stenosis bronchiectasis  Tracheobronchial tree injuries Investigations: CXR pneumothorax , Fallen lung sign of Kumpe CT scan Associated injuries, underlying lung disease Oesophogram exclude oesophageal injury Bronchoscopy diagnostic, site of injury, bronchial stenosis. (Can also help intubation)  Tracheobronchial tree injuries Conservative Surgical: - Unstable airway, assoc oropharyngeal injury, mediastinal distortion that make intubation difficult Approach: (based on the location + extension) Cervical collar incision: proximal trachea Right postero-lateral thoracotomy: lower trachea, Carina, RMB and proximal LMB Left postero-lateral thoracotomy: distal LMB Options: Primary repair Sleeve resection Lung resection  Foreign Body in the Airway Management Acute: Urgent bronchoscopy +/- Bronchotomy Chronic : Bronchoscopy with precaution +/- lung resection  Esophagus injuries Blunt trauma, rare Penetrating d/t stab or trans-mediastinal gunshot injury Cervical esophageal injuries –most common  Esophageal injuries CF Pneumothorax (left) Haemothorax without rib fractures Lower sternum or epigastric pain (severe blunt trauma) Particulate matter in the ICD Penetrating injury that has crossed mediastinum Odynophagia Dysphagia Surgical emphysema Mediastinitis Investigations Combination of clinical suspicion, CXR, Water soluble contrast swallow and oesophogram, Oesophogoscopy Esophagus injuries  Esophagus injuries Mx : Timing 24 hrs: debride and drainage surgical repair or resection with delayed reconstruction Via : RPLT 4TH ICS for upper esophagus LPLT 6TH ICS for lower esophagus  Esophagus injuries Complications Mediastinal contamination Abscess formation Empyema thoracis  Foreign Body in the Esophagus Types Bone, meat, battery, coin Clinical presentation Acute: Dysphagia, choking, hematemesis Chronic: Haemoptysis, coughing when feeding Management Oesophagoscopy +/- mediastinal drainage +/- repair  Diaphragmatic injuries Often occult, easily missed – L diaphragm commonly detected Marker of severe thoracoabdominal trauma Blunt vs penetrating (stab/iatrogenic-ICD) Cf: With or without signs of bowel obstruction, drainage of peritoneal content via chest drain NGT in the chest (CXR) Herniation of GIT Acute, delayed, common left Invest: CXR- elevated hemidiaphragm, haemo-pneumo Swallow and follow through Contrast enhanced CT scan Mx: surgical repair = thoracotomy vs thoraco-abdominal incision vs laparotomy, laparoscopy  Cardiac Injuries Penetrating Blunt Myocardial contusion - transient arrhythmias Valve injuries IVS rupture Frequency of Injury Myocardium/ventricle et al., J Trauma 42:905,1997 rupture  Blunt Cardiac Injuries (BCI) Pathology: Patchy areas of muscle necrosis hemorrhagic infiltrate Rupture of small vessels Hemorrhage into the interstitium and around the muscle fibers. Myocardial contusion has been reported in 60-100% autopsy series of patients with BCI Inv & Mx Admit HCU/ICU for monitoring ECG / cardiac enzymes Treat dysarrhythmias and heart failure Formal ECHO/TEE  Surgery Elective or Urgent Myocardial rupture- simple cardiorrhaphy, pledgetted sutured Mitral valve - repair/replacement Tricuspid - repair IVS - traumatic VSD-closure for the bigger ones. Bypass/not Penetrating Cardiac Injury Laceration Coronaries  Great Vessel Injuries Aorta most commonly injured in severe blunt or penetrating trauma 85-95% mortality Typically patients will survive the initial injury insult 30% mortality in 6 hrs 50% mortality in 24 hrs 70% mortality in 1 week  Blunt Aortic Injuries Mechanisms acceleration - deceleration production of shearing forces direct luminal compression - fixation points Site: isthmus, near ligamentum arteriosum Clinical: Death on the scene - rapid exsanguination Expanding thoracic inlet haematoma, bruit, hypotension, pulse deficit Blunt Aortic Injuries  Aortic Disruption Radiographic features associated with thoracic aortic injury Loss of aortic knuckle contour Widened mediastinum Obliteration of aorto-pulmonary window 1st/2nd rib fracture Depression of RMB Deviated NGT and tracheal displacement to the right Widened para-tracheal stripe Left massive haemothorax Left pleural cap  Management Medical Endovascular stents Open surgical procedures  References Shields T.W,LoCicero J,Ponn R.B,Rusch V.W.General Thoracic Surgery ,Volume 1,6’th Edition ,Philadelphia,2005,Lippincott Williams & Wilkins South African journal of surgery 2010;48(3):90-93 Advanced trauma life support ,10th Edition; (4): 95-101 British thoracic Society