Thoracic Trauma

Hesham Ahmed, MD
Assistant Professor of Surgery

Introduction

Trauma 3rd leading cause of death in the U.S. Trauma is the leading cause of death in those under 40 yr There are 100,000 accidental deaths/yr and 9,000,000 disabling injuries yearly in the U.S. 25% of deaths from blunt trauma are due solely to chest injuries

Introduction to Thoracic Injury

Vital Structures Heart, Great Vessels, Esophagus, Tracheobronchial Tree & Lungs 25% of MVC deaths are due to thoracic trauma 12,000 annually in US Abdominal injuries are common with chest trauma. Prevention Focus Improved motor vehicle restraint systems

-Gun Control Legislation

Passive Restraint Systems Airbags

Anatomy

Injuries of chest

Simple/Closed Pneumothorax Open Pneumothorax Tension Pneumothorax Flail Chest Hemothorax Esophageal injury

Cardiac Tamponade Traumatic Aortic Rupture Traumatic Asphyxia Diaphragmatic Rupture Tracheal/ bronchial injury

Blunt Chest Trauma

Higher mortality than penetrating trauma More frequent simultaneous injuries of multiple organs MVA: leading cause of chest trauma with 50,000 deaths and 2 million disabling injuries/year

Blunt Trauma
Results from kinetic energy forces Subdivision Mechanisms

Blast

Crush (Compression) Deceleration

Pressure wave causes tissue disruption Tear blood vessels & disrupt alveolar tissue Disruption of tracheobronchial tree Traumatic diaphragm rupture

Body is compressed between an object and a hard surface Direct injury of chest wall and internal structures Body in motion strikes a fixed object Blunt trauma to chest wall Internal structures continue in motion

Age Factors

Ligamentum Arteriosum shears aorta

Pediatric Thorax: More cartilage = Absorbs forces Geriatric Thorax: Calcification & osteoporosis = More fractures

Penetrating Chest Injuries

Majority are stab wounds or gunshot wounds (GSW). Lower mortality rates. 85% of penetrating chest wounds can be treated with tube thoracostomy .

Pathophysiology of Thoracic Trauma

Penetrating Trauma
Low Energy

Arrows, knives, handguns Injury caused by direct contact and cavitation Military, hunting rifles & high powered hand guns Extensive injury due to high pressure cavitation
Trauma.org

High Energy

High Velocity Missile Injuries

Cavitation phenomenon: causes damage to structures distal to the path of the missile. Striking and shattering bone and other tissue may add to the damage Associated injuries to the large vessels and bronchi is common Severe pulmonary contusion Vietnam experience

Pathophysiology of Thoracic Trauma

Penetrating Injuries (cont.)

Shotgun

Injury severity based upon the distance between the victim and shotgun & caliber of shot Type I: >7 meters from the weapon Soft tissue injury Type II: 3-7 meters from weapon Penetration into deep fascia and some internal organs Type III: <3 meters from weapon Massive tissue destruction

Chest Trauma

History & PE ATLS protocol

A,B,C,D,Es
Contusions, diminished or absent breath sounds, SQ emphysema

PE..

PE

AMPLE
A Allergies M Medications (Anticoagulants, insulin and cardiovascular medications especially) P Previous medical/surgical history L Last meal (Time) E Events /Environment surrounding the injury; ie. Exactly what happened

Radiological studies

CXR- fast, easy, least expensive for initial evaluation Ultrasound-may soon replace CXR as initial radiographic study in chest trauma CT Scan VS Angiography ECO VS Transesophogeal Echocardiography

FAST

Normal CXR

Pneumothorax

Iatrogenic PTX from NG

Simple Pneumothorax
Closed Pneumothorax

Progresses into Tension Pneumothorax

Occurs when lung tissue is disrupted and air leaks into the pleural space

Progressive Pathology

Air accumulates in pleural space Lung collapses Alveoli collapse (atelectasis) Reduced oxygen and carbon dioxide exchange

Ventilation/Perfusion Mismatch

Open Pneumothorax
Free passage of air between atmosphere and pleural space Air replaces lung tissue Mediastinum shifts to uninjured side Air will be drawn through wound if wound is 2/3 diameter of the trachea or larger Signs & Symptoms

Penetrating chest trauma Sucking chest wound Frothy blood at wound site Severe Dyspnea

Management of the Chest Injury Patient

Open Pneumothorax
High flow O2 Cover site with sterile occlusive dressing taped on three sides Progressive airway management if indicated

Tension Pneumothorax
Buildup of air under pressure in the thorax. Air is unable to escape from inside the pleural space Progression of Simple or Open Pneumothorax

Tension Pneumothorax

Tension Pneumothorax
Inhale

Tension Pneumothorax Exhale

Tension Pneumothorax Inhale

Tension Pneumothorax
Exhale

Tension Pneumothorax
Inhale

Tension Pneumothorax
Inhale

Tension Pneumothorax
The trachea is pushed to the good side

Heart is being compressed

S/S of Tension Pneumothorax

Anxiety/Restlessness Severe Dyspnea Absent Breath sounds on affected side Tachypnea Tachycardia

Accessory Muscle Use JVD Narrowing Pulse Pressures Hypotension Tracheal Deviation (late if seen at all)

Management of the Chest Injury Patient

Tension Pneumothorax Confirmation

Auscultaton & Percussion 2nd intercostal space in mid-clavicular line

TOP OF RIB

Pleural Decompression

Consider multiple decompression sites if patient remains symptomatic Large over the needle catheter: 14ga

Chest Tube

Operative intervention

Massive or persistent bleeding

Massive air leak Tracheobronchial injuries Esophageal perforation Cardiac or great vessel injuries Post-traumatic empyema

Subcutaneous Emphysema

Subcutaneous Emphysema

Trauma.org

Hemothorax

Hemothorax
Accumulation of blood in the pleural space Serious hemorrhage may accumulate 1,500 mL of blood

Mortality rate of 75% Each side of thorax may hold up to 3,000 mL

Blood loss in thorax causes a decrease in tidal volume

Ventilation/Perfusion Mismatch & Shock Hemopneumothorax

Typically accompanies pneumothorax

Hemothorax Signs & Symptoms

Blunt or penetrating chest trauma Shock

Dyspnea Tachycardia Tachypnea Diaphoresis Hypotension

Dull to percussion over injured side

Operative Intervention for Hemothorax

Hemothorax: massive = initial drainage more than 1,000 cc or Continuous bleeding of 200 cc/hr for 2 hrs

Fractured Ribs: Chest Wall Trauma

Rib fxs are found in 52% of patients with documented cardiac contusion Mortality doubles with there are 3 or more ribs ( age related) Blunt trauma with chest injury increases mortality rate by 27% than without chest injuries.

Associated risk for death increases:

1-Pneumo by 38% 2-Hemothorax by 42% 3-Pulmonary contusion by 56% 4-Flail chest by 69%

Flail Chest
Segment of the chest that becomes free to move with the pressure changes of respiration Three or more adjacent rib fracture in two or more places Serious chest wall injury with underlying pulmonary injury

Reduces volume of respiration Adds to increased mortality

Paradoxical flail segment movement Positive pressure ventilation can restore tidal volume

Flail Chest

Flail chest
Combination of pulmonary contusion and flail chest has a mortality of 42% Pulmonary contusion with flail chest: 75% require ventilation Flail chest ALONE: 48% require ventilation tx Aggressive chest PT and pain control

Pulmonary Contusion
30-75% of patients with significant blunt chest trauma Frequently associated with rib fracture Typical MOI

Deceleration
Chest impact on steering wheel

Bullet Cavitation
High velocity ammunition

Microhemorrhage may account for 1- 1 L of blood loss in alveolar tissue

Progressive deterioration of ventilatory status

Hemoptysis typically present

Pulmonary Contusion
Inspiratory rales, decreased air entry Patchy alveolar infiltrates due to intra-alveolar hemorrhage Intrapulmonary bleeding reaches maximal extent within 6 hrs Progression of a pulmonary contusion on X-ray after 48 hrs should raise suspicion that aspiration, bacterial pneumonitis or ARDS has developed

Management of lung contusion

ABCs High flow O2 via NRB Intubate if indicated Consider RSI Mechanical ventilation Hypoxia If VC less than 500 mL Anticipate Myocardial Compromise Shock Management

Chest Wall Injuries

Sternal Fracture & Dislocation

Associated with severe blunt anterior trauma Typical MOI Incidence: 5-8% Mortality: 25-45%

Direct Blow (i.e. Steering wheel)

Dislocation uncommon but same MOI as fracture

Myocardial contusion Pericardial tamponade Cardiac rupture Pulmonary contusion

Tracheal depression if posterior

Chest wall injuries

Scapular fractures
3% of blunt trauma cases 54% have pulmonary contusions 11% have associated ipsilateral subclavian, axillary or brachial artery injury Over 1/3 are missed on initial evaluation

Blunt Cardiac Injury

Myocardial Contusion
Occurs in 76% of patients with severe blunt chest trauma Right Atrium and Ventricle is commonly injured Injury may reduce strength of cardiac contractions

Reduced cardiac output

Electrical Disturbances due to irritability of damaged myocardial cells Progressive Problems

Hematoma Hemoperitoneum Myocardial necrosis Dysrhythmias CHF & or Cardiogenic shock

Myocardial Contusion Signs & Symptoms

Bruising of chest wall Tachycardia and/or irregular rhythm Retrosternal pain similar to MI Associated injuries Rib/ Sternal fractures Chest pain unrelieved by oxygen May be relieved with rest THIS IS TRAUMA-RELATED PAIN

Similar signs and symptoms of medical chest pain

Blunt Cardiac Injury

EKG (for any blunt chest injury, persistent tachycardia, ST-T changes or ectopy) Cardiac enzymes (CPK, CK-MB and Troponin I) [see EAST guideline] Echocardiography (TEE)

Pericardial Tamponade
Restriction to cardiac filling caused by blood or other fluid within the pericardium Occurs in <2% of all serious chest trauma

However, very high mortality

Results from tear in the coronary artery or penetration of myocardium

Blood seeps into pericardium and is unable to escape 200 ml of blood can restrict effectiveness of cardiac contractions

Pericardial Tamponade Signs & Symptoms

Dyspnea Possible cyanosis Becks Triad JVD Distant heart tones Hypotension or narrowing pulse pressure Weak, thready pulse Shock

Kussmauls sign Decrease or absence of JVD during inspiration Pulsus Paradoxus Drop in SBP >10 during inspiration Electrical Alterans P, QRS, & T amplitude changes in every other cardiac cycle PEA

Myocardial Aneurysm or Rupture

Occurs almost exclusively with extreme blunt thoracic trauma Secondary due to necrosis resulting from MI Signs & Symptoms

Severe rib or sternal fracture Possible signs and symptoms of cardiac tamponade If affects valves only
Signs & symptoms of right or left heart failure

Absence of vital signs

Traumatic Aortic injury

Aorta most commonly injured in severe blunt

85-95% mortality

Injury may be confined to areas of aorta attachment Signs & Symptoms

Rapid and deterioration of vitals Pulse deficit between right and left upper or lower extremities

Traumatic Esophageal Rupture

Rare complication of blunt thoracic trauma 30% mortality Contents in esophagus/stomach may move into mediastinum

Serious infection occurs Chemical irritation Damage to mediastinal structures Air enters mediastinum

Subcutaneous emphysema and penetrating trauma present

Tracheo-bronchial Injury

50% of patients with injury die within 1 hr of injury Disruption can occur anywhere in tracheobronchial tree Signs & Symptoms

Blunt trauma Penetrating trauma

Dyspnea Cyanosis Hemoptysis Massive subcutaneous emphysema Suspect/ evaluate for other closed chest trauma

Traumatic Asphyxia
Results from severe compressive forces applied to the thorax Causes backwards flow of blood from right side of heart into superior vena cava and the upper extremities Signs & Symptoms

Head & Neck become engorged with blood

JVD Hypotension, Hypoxemia, Shock Face and tongue swollen Bulging eyes with conjunctival hemorrhage

Skin becomes deep red, purple, or blue NOT RESPIRATORY RELATED

Management of Traumatic Asphyxia

Support airway 2 large bore IVs Evaluate and treat for concomitant injuries If entrapment > 20 min with chest compression
Consider Provide

O2

1mEq/kg of Sodium Bicarbonate

Treatment summary

ATLS protocol: A,B,C,D,Es Emergency management

Needle thoracentesis Tube thoracostomy Subxiphoid pericardotomy Video assisted thoracic surgery (VATS)

ER Thoracotomy

Questions?