Cardiothoracic Trauma.pdf

CARDIOTHORACIC TRAUMA Walid Abu Arab Professor of Cardiothoracic Surgery University of Alexandria Learning Objectives 1. How to resuscitate a patient with cardiothoracic trauma. 2. Des...

CARDIOTHORACIC TRAUMA Walid Abu Arab Professor of Cardiothoracic Surgery University of Alexandria Learning Objectives 1. How to resuscitate a patient with cardiothoracic trauma. 2. Describe a systematic method for evaluating patients with cardiothoracic trauma. 3. How to reach a diagnosis in cardiothoracic surgery patient. 4. Discuss differential diagnosis in a patient with cardiothoracic trauma. 5. Describe the outlines of surgical treatment in cardiothoracic trauma patient. 1|Page Walid Abu Arab Cardiothoracic Trauma  Chest Trauma ❑ Types of Thoracic Trauma ▪ Accidental Trauma. 1. Blunt trauma: Road traffic accidents (RTA) Fig.46, fall from a height and trauma by blunt objects. 2. Penetrating trauma: Stab wounds by knife, sword, or sharp objects. N.B. Perforating injury has inlet and exit ▪ Iatrogenic Trauma. ▪ Chemical Trauma. ▪ Thermal Trauma. ▪ Barotrauma and blast injuries. Association: a. Isolated thoracic trauma. b. Thoraco-abdominal. c. Associated with others e.g. Neurological or orthopedic. Blunt trauma (RTA) Penetrating trauma, bullet Penetrating trauma, bullet injury (PA) injury (Lat) Penetrating trauma, air-gun injury Penetrating trauma, shot-gun injury ▪ 2|Page Walid Abu Arab Cardiothoracic Trauma  ▪ Effects or squeals: 1- Immediate or direct effects - Chest wall: a- Fracture rib. b- Flail chest or stove-in chest. c- Fracture sternum. - Pleura: a- Pneumothorax. b- Hemothorax. c- Chylothorax. - Lung: a- Contusion. b- Laceration. c- Hematoma. - Mediastinum: a-Traumatic asphyxia. b-Pneumomediastinum. - Tracheobronchial injury. - Oesophageal trauma. - Diaphragmatic trauma. - Heart and great vessels: a. Pericardial injury. b. Haemopericardium. c. Myocardial contusion. d. Cardiac rupture. e. Coronary injury. f. Injury of great vessels. - Thoracic duct injury. 2- Delayed effects or complications A) Pulmonary: Atelectasis, Acute respiratory distress syndrome, pneumonia, infarction, lung abscess, AV- fistulae, bronchial stenosis, organized hematoma. B) Pleural: Empyema, clotted hemothorax, fibrothorax, bronchopleural fistula, chylothorax, diaphragmatic hernias. C) Mediastinum: Mediastinitis, Pericarditis. D) Vascular: Thromboembolism, Pseudoaneurysm, air embolism. 3|Page Walid Abu Arab Cardiothoracic Trauma  ▪ Pathophysiology of thoracic trauma: Primary Survey Resuscitation phase: ABCDE (Airway, Breathing, Circulation, Disability, and Exposure). Rapid clinical assessment of: 1. Life-threatening thoracic injuries. 2. Associated injuries. A-Airway Airway obstruction cleared by: 4|Page Walid Abu Arab Cardiothoracic Trauma  - Suction (oral, nasopharyngeal, nasotracheal). - Oral or nasal Airway. - Endotracheal or endobronchial tube. - Cricothyroidotomy. - Tracheostomy. - Bronchoscopy. Cricothyroidotomy Tracheotomy B-Breathing - Oxygen inhalation. - Close chest wall defects (open pneumothorax). - Expand lung by intercostal tube drainage (ICTD). - Stabilize chest wall. - Blood gas analysis. - Mechanical Ventilation. C-Circulation - Large-bore venous access. - CVP line. - Volume resuscitation. - Stop bleeding (ICTD, Thoracotomy). - Exclude cardiac tamponade. D-Disability/Neurologic assessment - Neurological assessment: known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). - Glasgow Coma Scale. E-Exposure and environmental control - The patient is undressed & Covered with warm blankets to prevent hypothermia. 5|Page Walid Abu Arab Cardiothoracic Trauma  ▪ Immediate Life-threatening Injuries 1. Airway obstruction. 2. Tension pneumothorax. 3. Open pneumothorax. 4. Massive hemothorax. 5. Cardiac Tamponade. 6. Massive flail chest. Secondary Survey More thorough examination + investigations are done. Chest X-ray. CT scan. MRI. U/S: FAST & eFAST ECHO Angiography Upper GIT Studies: Focused assessment with sonography for trauma (FAST) Rapid bedside ultrasound examination performed as a screening test for blood around the heart (pericardial effusion) or abdominal organs (hemoperitoneum) after trauma. Extended FAST (eFAST) Examination of both lungs by adding bilateral anterior thoracic sonography to the FAST exam. ❑ Potential life-threatening injuries a) Cardiac contusion b) Deceleration aortic injury c) Tracheo-bronchial rupture d) Diaphragmatic rupture e) Oesophageal perforation f) Pulmonary contusion Tertiary survey - A careful and complete examination followed by serial assessments help recognize missed injuries and related problems, allowing a definitive care management. - The rate of delayed diagnosis may be as high as 10%. 6|Page Walid Abu Arab Cardiothoracic Trauma  - I- Thoracic Cage Injuries A-Surgical emphysema - Presence of air in subcutaneous tissue from surgical causes. Infection with gas forming organisms may cause subcutaneous emphysema. ▪ Aetiology: 1. Fractured rib injuring underlying lung resulting in closed or tension pneumothorax. 2. Tracheobronchial tears. 3. Penetrating chest injury and open pneumothorax. 4. Mediastinal emphysema due to ruptured bronchioles or alveoli without disrupting the visceral pleura following blunt trauma or barotrauma of ventilators or even spontaneously especially in asthmatics. 5. Ruptured oesophagus. 6. After intercostal tube insertion for pneumothorax when the tube is blocked. ▪ Presentation: - Presence of air under the skin with characteristic crackling sensation (subcutaneous crepitation). - Localised or rapidly progressive; up to neck and face closing eyelids (Fig.52), or down to abdominal wall and scrotum. - It causes patient’s discomfort and worry. - It is benign but may signify serious underlying problem. - It is evident in X-ray and CT chest. Surgical emphysema face 7|Page Walid Abu Arab Cardiothoracic Trauma  ▪ Treatment: - It will be absorbed spontaneously. - Find and manage its cause. - If extensive, evacuated with needles, skin incisions or subcutaneous catheters. B-Fracture Ribs ▪ Etiology: 1. Direct violence. 2. Indirect violence. 3. Muscular violence. ▪ Effects: - Fracture ribs → severe pain → cause decreased respiratory movements & ineffective coughing → Atelectasis & pneumonia. - Injury of underlying pleura and lung. - Injury of intercostal bundle. ▪ Clinical Picture: - Severe pain. - Localized tenderness. - Crepitus. - Surgical emphysema. - Look for associated Hemopneumothorax. ▪ Diagnosis: - Plain chest X-ray (Rib view). - Multi-slice CT scan (Skeleton view). ▪ Treatment: - Systemic analgesics. - Intercostal nerve block (fracture of less than 4 ribs). - Epidural analgesia (in fracture of more than 4 ribs). - Avoid binders, tape or strapping. First Rib Fracture is dangerous, may be associated with brachial plexus or subclavian vessels injury. - Lower ribs fracture may be associated with trauma to the spleen or liver. Multiple fracture ribs on the left side 8|Page Walid Abu Arab Cardiothoracic Trauma C- Flail Chest ▪ Definition: Paradoxial movement of a segment of chest wall caused by fractures of three or more ribs broken in two or more places. ▪ Etiology: Severe blunt trauma. ▪ Types of flail Chest: - Anterior - Lateral. - Posterior (least dangerous). - Flail sternum. Types of flail chest ▪ Pathophysiology: Pathophysiology of flail chest 9|Page Walid Abu Arab Cardiothoracic Trauma  o Hypoxaemia due to: 1. Underlying pulmonary contusion with ventilation perfusion mismatch. 2. Pain of rib fractures → ↓ tidal volume; accumulate secretions →Atelectasis →↑ pulmonary shunting & ↓functional reserve capacity. 3. Associated hemopneumothorax or cardiac trauma. 4. Hypoventilation of the underlying lung from paradoxical respiration. 5. Mediastinal flutter with kink of great vessels. 6. Pendulum-like movement of dead space air. ▪ Presentation: - Severe blunt trauma. - Severe chest pain of rib fractures. - Dyspnea, tachypnea and cyanosis. - Hypotension and tachycardia. - Paradoxical movement of the flail segment. - Chest wall contusions ± surgical emphysema. ▪ Investigations: - Chest -ray: Flail chest is a clinical and not a radiological sign based on finding of a paradoxical movement of a segment of chest wall. Right side flail chest - CT scan chest. - Multislice CT (MSCT) scan chest wall. - Blood gas analysis. ▪ Prevention: - Safer Automobiles, seat belt, air bag design. 10 | P a g e W a l i d A b u A r a b Cardiothoracic Trauma  ▪ Prognosis: - 5-10% mortality depending on severity of injury, age, bilaterality and number of ribs fractured. ▪ Treatment: A. Oxygen inhalation. B. Pain relief: - Systemic analgesics (avoid opiate), patient-controlled analgesia (PCA) machines. - Intercostal nerve block C. Epidural catheter. D. Pulmonary toilet: to clear secretions from the airways and prevents atelectasis. By suctioning of airways, nasotracheal suction, bronchoscopy, tracheostomy, chest physiotherapy, blow bottles, incentive spirometry, coughing, percussion and positioning in prone position. E. Stabilization: a) External chest wall stabilization by compressive dressing strapping (this should be done as emergency to stop paradoxical movement). b) CPAP (Continuous Positive Airway Pressure) by mask. c) IPPV (Intermittent Positive Pressure Ventilation) when blood gases deteriorate (PaO2 < 60mmHg, PaCO2 > 60mmHg) with tachypnea > 30/min. by tracheal intubation and mechanical ventilation. d) Internal chest wall stabilization by orthopedic devices (Judet struts or Kirschner [K-] wires). 11 | P a g e W a l i d A b u A r a b Cardiothoracic Trauma  Internal chest wall stabilization D-Fracture Sternum Transverse fractures generally in the body of the sternum near the manibriosternal junction. ▪ Diagnosed by: - Lateral X-ray chest. - CT scan to exclude associated injuries. - In most cases, analgesia & follow up. - In severe cases, IPPV &/or operative reduction. Fracture sternum, lateral CXR II-Pleural space injuries A- Pneumothorax ▪ Definition: Presence of air in the pleural cavity. ▪ Etiology: 1. Spontaneous: a) Primary: Ruptured apical bleb (subpleural collection of air contained within the visceral pleura due to localized form of interstitial emphysema). b) Secondary to preexisting lung disease: Associated with: - Chronic obstructive lung disease (rupture of air-filled bulla within lung parenchyma). - Cystic fibrosis. 12 | P a g e W a l i d A b u A r a b Cardiothoracic Trauma  - Infection: Cavitating nonspecific bacterial, tuberculous, mycotic and parasitic infections. - Tumors: Rupture of ischemic primary or metastatic lung carcinoma, lymphoma, and sarcoma. - Catamenial: Associated with menstruation (focal pleural endometriosis). - Miscellaneous: Associated with many connective tissue and autoimmune diseases. 2. Traumatic: a) Iatrogenic: Lung biopsy, central line insertion, barotrauma (mechanical ventilation), postoperativeand after thoracocentesis. b) Penetrating or blunt chest trauma: Disruption of tracheobronchial tree, pulmonary parenchyma, esophageal perforation, open pneumothorax. ▪ Types of pneumothoraxes: A. Communication: a. Closed pneumothorax: without communication to the exterior. b. Open pneumothorax: with communication through the chest wall to the exterior (sucking wound). B. Tension: a. Simple pneumothorax without tension (mild, moderate, massive). b. Tension pneumothorax (presence of one-way valvular mechanism or on positive pressure ventilation). ▪ Recurrence: o Primary o Recurrent closed pneumothorax and B, open pneumothorax. ▪ Pathogenesis of pneumothorax: - Penetration of chest wall. - Laceration of the lung. - Perforation of bronchus , trachea or oesophagus. - Tear of the lung by driven-in rib fragment. 13 | P a g e W a l i d A b u A r a b Cardiothoracic Trauma  - Rupture of alveoli secondary to blunt trauma or straining → pulmonary interstitial emphysema → Mediastinal emphysema → Pneumothorax or surgical emphysema. Pathogenesis of pneumothorax ▪ Clinical Picture: - Symptoms are related to the degree of lung collapse and underlying pulmonary function. - The patient may be asymptomatic or symptomatic (dyspnea, chest pain, dry cough, severe respiratory distress with hypoxia, hypercarbia and acidosis). - Signs: Decreased movement on the same side. Tympanetic percussion note. - Diminished air entry on auscultation. ▪ Investigations: o CXR: Expiratory film accentuates small pneumothorax. - -mild → one finger breadth. - moderate → two fingers breadth. - massive → total lung collapse. - tension → mediastinal shift to the other side. Left sided traumatic pneumothorax (blunt trauma) 14 | P a g e W a l i d A b u A r a b Cardiothoracic Trauma  o CT scan: Can diagnose the smallest amount of pneumothorax. Differentiates lung cysts and bullae in the presence of subcutaneous emphysema, and quantitates the degree of pneumothorax. ▪ Complications: 1. Persistent air leak: More common with secondary pneumothorax and denotes bronchopleural fistula. 2. Recurrence: Up to 20% within 2 years. 3. Tension pneumothorax: Alveolar air enters the pleural space but is not resorbed because of one-way valve mechanism. Intrapleural pressure exceeds atmospheric pressure resulting in respiratory failure (altered lung mechanics, mediastinal shift, reduced ventilation, increased intrapulmonary shunt, decreased tissue oxygenation) and cardiovascular collapse (tachycardia, reduced cardiac output). 4. Hemothorax: Results from tearing of vascular adhesion between the lung and chest wall. 5. Pneumomediastinum: Due to dissection of air along bronchovascular structures. ▪ Treatment: 1. Observation: If the patient is asymptomatic and the pneumothorax is small (