THORACIC TRAUMA

OBJECTIVES

• Identify and treat life-threatening thoracic injuries

• Recognize and treat potentially life-threatening thoracic injuries

EPIDEMIOLOGY

• Mortality– Many die pre-hospital or on arrival– In-Hospital

• Isolated Thoracic: 4-8%• Multiple Trauma: 35%

• Civilian (30% of injuries)– Blunt: 70%– Penetrating: 30%

• Military (15% of injuries)– Blunt: 10%– Penetrating: 90%

EPIDEMIOLOGY

• Surgical Intervention– Blunt: Less than 10%– Penetrating: 15-30%

• Early survival depends on:– Initial resuscitation– Timeliness & correct sequence of

diagnostic investigations

• Late survival depends on:– Post-traumatic complications

INITIAL EVALUATION

• Primary Survey– ABCs– Airway Control!!!!!– Cardiac monitor and pulse oximeter– FAST– Concurrent resuscitation– Emergent procedures as needed (e.g. chest

tubes, etc.)

• Secondary survey

PHYSICAL EXAM

• External Signs (e.g. contusions, seat belt, wounds, etc.)

• Breath sounds (e.g. symmetrical, etc.)

• Palpation (e.g. crepitus, etc.)

• Roll the patient – check the posterior thorax!

LIFE-THREATENING INJURIES

• Tension Pneumothorax

• Massive Hemothorax

• Cardiac Tamponade

• Open Pneumothorax

• Flail Chest

TENSION PNEUMOTHORAX

• Characteristics– Clinical diagnosis– “One-way” valve traps air,

collapses lung, shifts mediastinum to opposite side

• Signs & Symptoms– Respiratory distress– Unilateral breath sounds– Distended neck veins– Hypotension

TENSION PNEUMOTHORAX

• Diagnosis: Clinical

• Treatment: Immediate Decompression– Needle– Tube Thoracostomy

MASSIVE HEMOTHORAX

• Characteristics– Rapid accumulation of

greater than 1500 cc or 1/3 blood volume in chest cavity

• Signs & Symptoms– Hypotension– Unilateral breath sounds– Dullness to percussion

MASSIVE HEMOTHORAX

• Diagnosis– CXR– Tube thoracostomy reveals blood

• Treatment– Tube Thoracostomy– Autotransfusion– Thoracotomy: Greater than 1500 cc or

200 cc/hr over 4 hrs

CARDIAC TAMPONADE

• Characteristics– Penetrating or blunt

trauma– High index of suspicion

• Signs & Symptoms– Respiratory distress– Distended neck veins– Hypotension– Bilateral breath sounds

CARDIAC TAMPONADE

• Diagnosis– FAST– Pericardial Window

• Treatment– Stable patient:

Median Sternotomy or Thoracotomy

– Unstable patient: Emergent Thoracotomy

OPEN PNEUMOTHORAX

• Characteristics– “Sucking” chest

wound

• Signs & Symptoms– Respiratory distress– Unilateral breath

sounds– Open thoracic

wound

OPEN PNEUMOTHORAX

• Diagnosis: Clinical

• Treatment– 3-sided dressing– Tube Thoracostomy– Operative Intervention– 4-sided dressing =

Tension pneumothorax

FLAIL CHEST

• Characteristics– Pulmonary contusion

always– Floating chest wall

segment; 2 or more fractures per rib

• Signs & Symptoms– Respiratory distress– Crepitus– Paridoxical chest wall

motion

FLAIL CHEST

• Diagnosis– Clinical signs– CXR: Multiple rib

fractures

• Treatment– Adequate

oxygenation & ventilation

– Resuscitation– Analgesia

POTENTIALLYLIFE-THREATENING

INJURIES

• Simple Pneumothorax

• Hemothorax

• Tracheobronchial Tree Injury

• Blunt Cardiac Injury

• Traumatic Aortic Disruption

• Diaphragmatic Rupture

• Esophageal Injury

SIMPLE PNEUMOTHORAX

• Signs & Symptoms– Unilateral breath sounds– Respiratory distress

• Diagnosis– Clinical suspicion– CXR confirmation

• Treatment: Tube Thoracostomy

HEMOTHORAX

• Signs & Symptoms– Unilateral breath sounds– Respiratory distress– Dullness to percussion

• Diagnosis– Clinical suspicion– CXR confirmation

• Treatment: Tube Thoracostomy

TRACHEOBRONCHIAL TREE INJURY

• Distribution– Penetrating– Blunt

• Signs & Symptoms– Subcutaneous emphysema– Hemoptysis– After tube thoracostomy:

• Persistent air leak• Lung does not properly

inflate

TRACHEOBRONCHIAL TREE INJURY

• Diagnosis– May see on CT scan (e.g.

pneumomediastiunum, etc.)– Confirm with Bronchoscopy

• Treatment– Operative Intervention– Observation

BLUNT CARDIAC INJURY

• Signs & Symptoms– Abnormal EKG in first 24 hours– Arrythmias– Hypotension

• Diagnosis– Cardiac Enzymes?– Echocardiogram

• Treatment– Supportive care– Symptomatic therapy

TRAUMATIC AORTIC DISRUPTION

• Characteristics– Blunt Mortality

• Scene: 85%• Unstable transport: > 96%• Stable transport: 5-30%

– Blunt Mechanism: Acceleration/Deceleration injury

• Signs & Symptoms– Mechanism– Thoracic trauma– Impending doom– High index of suspicion

TRAUMATIC AORTIC DISRUPTION

• Diagnosis– Chest X-ray

• Wide Mediastinum (>8 cm) 85%• Indistinct aortic knob 24%• Left pleural effusion 19%• 1st or 2nd rib fracture 13%• Tracheal deviation 12%• NG Tube deviation 11%• Negative findings 7%• Depressed left bronchus 5%

– Transesophageal Echocardiography

TRAUMATIC AORTIC DISRUPTION

• Diagnosis– Helical CT Angiogram

• Sensitivity: 90-100%• Specificity: 83-100%• NPV: 99-100%

– Catheter Angiography: Gold Standard• Sensitivity: 92-100%• Specificity: 95-99%• NPV: 97-100%

TRAUMATIC AORTIC DISRUPTION

• Management– Preoperative

• Systolic BP < 100 mm Hg• HR < 100• Begin with -blocker; add nitroprusside

– Operative Intervention• Immediate repair is best approach• Direct repair vs endoluminal stent

– Non-operative Intervention• Selected populations with more severe/life-threatening

injures (e.g. CHI, unstable, pulmonary, etc.)• Anti-hypertensive therapy is mandatory

DIAPHRAGMATIC RUPTURE

• Characteristics– Most occur on Left– Blunt = Large tears– Penetrating = Small perforations

• Signs & Symptoms– Respiratory distress– High index of suspicion– Mechanism

DIAPHRAGMATIC RUPTURE

• Diagnosis– CXR

• Elevated hemidiaphragm• Effusion• Intrathoracic contents

– GI Contrast Study– CT Scan, Laparoscopy, Thoracoscopy,

Laparotomy

• Treatment– Operative Repair

ESOPHAGEAL INJURIES

• Characteristics– Penetrating more common– Severe blow to epigastrium– High index of suspicion based on mechanism– Diagnostic delay = significant morbidity/mortality

• Signs & Symptoms– Shock– Pain out of proportion– Cervical emphysema

ESOPHAGEAL INJURIES

• Diagnosis– CXR

• Effusion or pneumo/hemothorax• Mediastinal air• Particulate matter in chest tube

– GI Contrast Study: • Gastrograffin, then Barium

• Treatment– Operative Repair– Upper esophagus: Right thoracotomy– Lower esophagus: Left thoracotomy

SUMMARY

• Life-Threatening Thoracic Injuries– Prompt Diagnosis– Emergent Therapy

• Potentially Life-Threatening Injuries– Identified in Primary or Secondary survey– High index of suspicion– Appropriate management

QUESTIONS

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