CHEST TRAUMA

Joe Lex, MD, FAAEM Temple University Hospital Philadelphia, PA July 20 th, 2006

Incidence of Chest Trauma

1/4 American trauma deaths Contributes to another 1 of 4 Many die after reaching hospital preventable if recognized <10% blunt needs surgery ~1/3 penetrating needs surgery Most life-saving procedures do NOT require thoracic surgeon

Pathophysiology of Chest Trauma

hypovolemia ventilationperfusion mismatch changes in intrathoracic pressure relationships Inadequate oxygen delivery to tissues

TISSUE HYPOXIA

Pathophysiology of Chest Trauma

Tissue hypoxia Hypercarbia Respiratory acidosis: inadequate ventilation Metabolic acidosis: tissue hypoperfusion (e.g., shock)

Blunt trauma

Blunt trauma

Blunt trauma

Blunt trauma

Blunt trauma

Blunt trauma

Blunt trauma

Blunt trauma

Blunt trauma

Blunt trauma

Penetrating trauma

Penetrating trauma

Penetrating trauma

Splinter

Penetrating trauma

Penetrating trauma

Penetrating trauma

Penetrating trauma

Penetrating trauma

Penetrating trauma

Penetrating trauma

6 Immediate Life Threats

Airway obstruction Tension pneumothorax Open pneumothorax sucking chest wound Massive hemothorax Flail chest Cardiac tamponade

6 Potential Life Threats

Lung contusion Heart contusion Aorta rupture Diaphragm rupture Tracheobronchial tree injury larynx, trachea, bronchus Esophagus trauma

6 Other Frequent Injuries

Subcutaneous emphysema Traumatic asphyxia Simple pneumothorax Hemothorax Scapula fracture Rib fractures

Primary Survey

Airway Breathing Circulation

A = Airway
Assess for airway patency and air exchange - listen at nose & mouth Assess for intercostal and supraclavicular muscle retractions Assess oropharynx for foreign body obstruction

B = Breathing
Assess respiratory movements and quality of respirations look, listen, feel Shallow respirations are early indicator of distress cyanosis is late

C = Circulation
Assess pulses for quality, rate, regularity Assess blood pressure and pulse pressure Skin - look and feel for color, temperature, capillary refill Look at neck veins - flat vs. distended Cardiac monitor

Where can adults hide blood and go into shock?

Chest: listen, do chest x-ray Abdomen: do DPL or CT or US Retroperitoneum: do CT Thigh: physical examination Street: ask paramedic ...and in children, add Head

Initial assessment and management Primary survey Resuscitation of vital functions Detailed secondary survey Definitive care

Initial assessment and management

Hypoxia most serious problem: early interventions aimed at reversing Immediate life-threatening injuries treated quickly and simply, usually with tube or a needle Secondary survey guided by high suspicion for specific injuries

Thoracotomy
Closed heart massage is ineffective in a hypovolemic patient Left anterior thoracotomy with crossclamping of descending thoracic aorta and open-chest massage may be useful in pulseless victim of penetrating trauma

Thoracotomy

Emergency department thoracotomy for patients without cardiac activity who are victims of blunt thoracic injuries is ineffective

Thoracotomy

Thoracotomy

Thoracotomy

Thoracotomy

6 Immediate Life Threats

Airway obstruction Tension pneumothorax Open pneumothorax sucking chest wound Massive hemothorax Flail chest Cardiac tamponade

Airway Obstruction
Airway obstruction at alveolar level: assessed and managed during 2o survey Upper airway obstruction immediate life threat which must be dealt with in primary survey Most common cause: patients tongue

Airway Obstruction
Chin-lift: fingers under mandible, lift forward so chin is anterior

Airway Obstruction

Airway Obstruction
Jaw thrust: grasp angles of mandible and bring jaw forward

Airway Obstruction
Oropharyngeal airway: insert into mouth behind tongue DO NOT push tongue further back

Airway Obstruction
Nasopharyngeal airway: gently insert welllubricated trumpet through nostril

Airway Obstruction
Definitive Airway Management: tube in trachea through vocal cords with balloon inflated

Airway Obstruction
Orotracheal intubation Nasotracheal intubation: in breathing patient without major facial trauma Surgical airways
jet insufflation retrograde cricothyrotomy tracheostomy

Airway Obstruction

Jet insufflation adapters

How to perform cricothyroidotomy

Tension pneumothorax
Air leak through lung or chest wall One-way valve lung collapse Mediastinum shifts to opposite side Inferior vena cava kinks on diaphragm decreased venous return cardiovascular collapse

Inferior vena cava

Tension pneumothorax
Tension pneumothorax is not an x-ray diagnosis it MUST be recognized clinically Treatment is decompression needle into 2nd intercostal space of mid-clavicular line - followed by thoracotomy tube

Insert needle here

Open pneumothorax
Sucking Chest Wound Normal ventilation requires negative intrathoracic pressure Large open chest-wall defect immediate equilibration of intra-thoracic and atmospheric pressures If hole >2/3 tracheal diameter, air prefers chest defect

Open pneumothorax

Open pneumothorax
Initial treatment: seal defect and secure on three sides (total occlusion may lead to tension pneumothorax Definitive repair of defect in O.R.

Massive hemothorax
Rapid accumulation of >1500 cc blood in chest cavity Hypovolemia & hypoxemia Neck veins may be:
Flat: from hypovolemia Distended: intrathoracic blood

Absent breath sounds, DULL to percussion

Massive hemothorax: treatment

Large-bore (32 to 36 F) tube to drain blood If moderate sized (500 to 1500 ml) and stops bleeding, closed drainage usually sufficient If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated

Chest tube

How to place a chest tube

Pleural space

Flail chest
Free-floating chest segment, usually from multiple ribs fractures Pain and restricted movement paradoxical movement of chest wall with respiration

Flail chest

Flail treatment (old)

Flail treatment (old)

Flail treatment
Ventilate well Humidify oxygen Resuscitate with fluids Manage pain (!!) Stabilize chest
Internal ventilator External sand bags (rare)

Cardiac tamponade
Usually from penetrating injuries Classic Becks triad
elevated venous pressure - neck veins decreased arterial pressure - BP muffled heart sounds

Blood in sac prevents cardiac activity

Cardiac tamponade
May find pulsus paradoxus - a decrease of 10 mm Hg or greater in systolic BP during inspiration Systolic to diastolic gradient of less than 30 mm Hg also suggestive

Cardiac tamponade
Treatment is removal of small amount of blood 15 to 20 ml may be sufficient from pericardial sac

Pericardiocentesis

Stab wound to right ventricle

pericardium epicardial fat

Ten-m inute b reak

The Flock of Birds behind the heart Vagoose n. Azygoose v. Esophagoose Thoracic duck

6 Potential Life Threats

Pulmonary contusion Myocardial contusion Traumatic aortic rupture (TAR) Traumatic diaphragmatic rupture Tracheobronchial tree injury: larynx, trachea, bronchus Esophageal trauma

Pulmonary contusion
Potentially life-threatening condition with insidious onset Parenchymal injury without laceration More than 50% will develop pneumonia, even with treatment Up to 50% have only hemoptysis as presenting symptom

Pulmonary contusion
Patients with pre-existing conditions (emphysema, renal failure) need early intubation Treatment needs to occur over time as symptoms develop

Myocardial contusion
Blunt precordial chest trauma Difficult to diagnose Risk for dysrhythmia, sudden death, tamponade, pericarditis, ventricular aneurysm

Myocardial contusion

Myocardial contusion
Also may see: myocardial concussion stunned myocardium with no cell death coronary artery laceration Diagnosis by: trans-esophageal echocardiogram (TEE) serial cardiac enzymes / markers

Myocardial contusion
Question: Does it matter? New nomenclature: Anterior Chest Wall Syndrome

Traumatic aortic rupture

90% or more dead at scene 90% mortality each undiagnosed day Must have high index of suspicion Disruption occurs at ligamentum arteriosum (ductus arteriosus) Contained hematoma of 500 to 1000 ml of blood

Traumatic aortic rupture

Radiographic signs Wide mediastinum (>8cm) Fractured 1st & 2nd rib Obliterated aortic knob Trachea deviated to right Pleural cap Elevated mainstem bronchus with shift to right Obliterated aortic window Esophagus shifted to right (NG at T4) Depressed left mainstem bronchus

dye leakage

Traumatic aortic rupture

CT becoming imaging of choice Must know site! NPV of normal chest x-ray (good quality, upright): 98% (CT will find mediastinal hemorrhage in 3%, TAR in 0.4%) 78% of patients with post-traumatic wide mediastinum on chest film have normal CT

Traumatic aortic rupture

Treatment SURGICAL REPAIR

Traumatic diaphragmatic rupture

Blunt trauma: tears leading to immediate herniation Penetrating trauma: small tears which may take years to develop herniation Usually on left side

Traumatic diaphragmatic rupture

Treatment: surgical repair

Tracheobronchial tree injury

Larynx - rare Hoarseness Subcutaneous emphysema Palpable crepitus Intubation may be difficult: tracheostomy (not cricothyroidotomy) is treatment of choice

Tracheobronchial tree injury

Trachea Blunt or penetrating Esophagus, carotid artery and jugular vein may be involved Noisy breathing partial airway obstruction

Tracheobronchial tree injury

Bronchus 1.5% blunt chest trauma 80% due to BLUNT trauma within one inch of carina (tethered)

Esophageal trauma
Penetrating > blunt Lethal if not recognized High suspicion if left pneumothorax and hemothorax without rib fracture shock out of proportion to apparent blunt chest trauma particulate matter in chest tube

Esophageal trauma

Esophageal trauma
Blunt trauma, most tears superior If low esophagus leakage of stomach contents into mediastinum

6 Other Frequent Injuries

Subcutaneous emphysema Traumatic asphyxia Simple pneumothorax Hemothorax Scapula fracture Rib fractures

Subcutaneous emphysema
Rice Krispies May result from
airway injury lung injury blast injury

No treatment required address underlying problem

Traumatic asphyxia
Purple face from extravasation of blood (Masque ecchymotique) Major damage is to underlying structures Purple face fades over time in survivors

Simple pneumothorax
Air enters potential space between visceral and parietal pleura Breath sounds down on affected side Percussion hyper-resonance Treatment: chest tube in 4th or 5th intercostal space anterior to mid-axillary line

Medial pneumothorax

Pocket shooter

Hemothorax
Lacerated lung OR disrupted intercostal artery or internal mammary artery Most are self-limiting Surgical consultation if initial drainage of >20 cc/kg (~1500 cc) continued flow of >200 cc/hr

Scapula fractures
Fractured scapula or 1st & 2nd ribs indicates major mechanism of injury; consider underlying damage

Rib fractures
Most frequent thoracic cage injury Most commonly injured: 4th 9th If 10th / 11th / 12th suspect liver or spleen injury If 1st / 2nd / 3rd worry about injury to head, neck, spinal cords, lungs, great vessels

Rib fractures treatment

Intercostal blocks Epidural anesthesia Systemic analgesics Do not use taping rib belts external splints

Rib fractures
Ribs x-rays are expensive are inaccurate for diagnosis (~50% sensitivity) add nothing to treatment require painful positioning of the patient are, in general, not useful

In conclusion...
Chest trauma is common in the multiply-injured patient Most conditions can be treated by the evaluating physician and do not require emergent thoracotomy Airway management and a judiciously placed needle can save many lives

Next time
February 27th, 2004 Respiratory Emergencies Joe Lex joe@joelex.net