CHEST TRAUMAAlyssa Reed, R1November 2007

Thanks to : Dr Hall,Dr Patterson, Dr Oster

Objectives

•FLAIL CHEST

•TRACHEOBRONCHIAL INJURY

•OCCULT PNEUMOTHORAX

•BLUNT CARDIAC INJURY

•TRAUMATIC AORTIC INJURY

•PENETRATING CHEST TRAUMA

Topics Not Covered

•Rib Fractures

•Isolated Sternal Fracture

•Costochondral Injuries

•Esophageal Injuries

Life Threatening

Airway• Obstruction

Breathing • Open pneumothorax

• Flail Chest

• Tension Pneumothorax

• Massive Hemothorax

Circulation • Cardiac Tamponade

Causes???

CASE #1

42F fell down the stairs at home

Dx?

FLAIL CHEST

•Common injury and commonly missed

•Definition: THREE or more ribs fractured at TWO points, allowing a freely moving segment of the CW to move in paradoxical motion

•PHYSIOLOGY

•1) Pulmonary contusion

•2) Paradoxical Motion

•3) Pain*

Flail Chest

Flail ChestMx

• ABCs

• Aggressive chest physio

- clear c-spine, sit up

• Close observation

• Selective use of intubation

• Pain control

• Chest tubes

Flail Chest and Intubation   

Respiratory failure manifested by one or more of the following criteria:  

1. Clinical signs of respiratory fatigue

2. Respiratory rate >35/min or <8/min

3. Pao2 <60 mm Hg at Fio2 ≥0.5

4.Paco2 >55 mm Hg at Fio2 ≥0.5

•Alveolar-arterial oxygen gradient >450

•Clinical evidence of severe shock  

Associated severe head injury with lack of airway control or need to ventilate  Severe associated injury requiring surgeryPao2, partial arterial oxygen tension; Fio2; fraction of inspired oxygen; Paco2, partial arterial carbon dioxide tension.

Flail Chest Ullman et al. Reg Anesth 14(1): 43-7. 1989.

•Pts with flail segments comparing IV and epidural anesthesia

•Group 1 (n=13) intravenous morphine

•Group 2 (n= 11) epidural morphine

•Results:

- Vent time 18d vs 3 d

- ICU time 18d vs 6d

- Hosp stay 48d vs 15d

- Pulm fxn best in group 2

★ A lot of evidence since for the use of high block epidurals for pain relief to prevent splinting and atelectasis

Flail Chest

•Hemo or Pneumothorax

•Multisystem, unstable trauma

•Intubated patient

•Respiratory distress

•Air Transport (? routine vs selective)

Q: Who needs a chest tube?

• 30M MVC intubated for CHI, normal CXR

• Dx?

CASE #2

Occult Pneumo

•A pneumothorax that is absent on initial CXR but seen on subsequent chest or abdominal CT

•Ball et al. Am J Surg. 189(5), 2005

- n=761

- 55% were OPTHX

- 84% were anterior, 0% posterior, 57% apical

Occult PneumoJournal of Trauma. 49:281, 2000

•Retrospective, n= 230 with pneumothx

•Results: 126 (54.8%) had occult pneumo identified on abdo CT

Ball et al. J of Trauma. 60(2): 294-8, 2006

•with increasing frequency of CT scans in trauma, estimate that up to 72% of all pneumos are occult

Occult Pneumo

•Ball et al. J of Trauma. Aug 2005- n= 32, non-vented OPTHX- 10 (31%) had chest tube inserted- 22 (69%) observed- Results: ✓ 1 needed chest tube placed later✓ 0 serious complications of those observed✓ 1 with tube had lung parenchymal injury★ growing recognition that non-vented patients can

be safely treated without thoracostomy

WHO NEEDS A CHEST TUBE?

Occult PneumoEnderson et al. J of Trauma 35(5), 1993.

- Prospective RCT

- n= 40 on PPV, 19 with chest tube, 21 observed

- 8 with observation (38%) progressed, became symptomatic and needed chest tube

- 3 of 8 developed tension pneumo

- 0 with chest tube had complications

★ recommend that all patients with occult pneumo with PPV have tube thoracostomy

Occult PneumoBrasel et al.

- Prospective RCT

- n=18 on PPV, 9 with tube, 9 observed

- Results:‣ no difference in overall complication

rate‣ 2 observed pts needed chest tube

★ Concluded that can closely monitor pts with OPTHX on PPV for signs of resp distress

Occult PneumoBall et al. J of Trauma 59(2), 2005.

- Restrospective subset analysis

- n=17 with OPHTX with PPV

- 13 had chest tube and 4 were observed

- 0 complications with observation

- 23% had tube related complication or needed repositioning

★ Concluded that more research needs to be done given paucity of literature and quality of studies

Occult Pneumo Summary

A Review. Emerg Med Clin North Am. 25(3), 2007

- not enough data to determine if patients with OPTHX with PPV should have tube thoracostomy

- if pt is asymptomatic and no PPV it is safe to observe

- if patient has to go for surgery, has other injuries, has symptoms or hard to continuously observe, it is prudent to insert a chest tube

-Intubated patients generally require chest tube, more study required

FLYING and PNEUMO

Cheatham et al. Am Surg 65(12), Dec 1999

-Prospective

-n=12 with traumatic pneumo wanting to air travel

-Results:

‣ 10/12 waited at least 14 d after radiographic resolution

• 10/10 ASx during flight

‣ 2/12 flew within less than 14 d

• 1/2 developed respiratory distress in flight*Concluded that Aerospace Medicine Association’s recommendation of waiting 2-3 post radiographic resolution is safest

•30M in MVC at highway speed, restrained, no airbag deployment

•Clinical Findings: hemoptysis, massive subcutaneous air, persistent pneumo despite properly done and positioned chest tube

•Dx?

CASE # 3

TracheoBronchial Injury

Anatomy and Physiology• sudden deceleration pulls lungs away

from the mediastinum, producing traction on the trachea at the carina which is a relatively fixed point

• can also occur if glottis is closed at time of injury because large increase in intrabronchial pressure

• >80% occur within 2cm of carina

• wound opens into pleural space producing large pneumo, chest tube fails to re-expand lung, continuous bubbling of air in pleurovac

TBI DiagnosisCXR findings

- Pneumothorax

- Pneumomediastinum

- Pneumopericardium

- Massive subcutaneous air*

- Air around mainstem bronchus

TBI

TBI•When to suspect?

- massive air leak

- persistent air leak

- hemoptysis

- massive subcutaneous air “Micheline Man”

- CXR findings

•Dx- Hara et al. Chest, 1989.

- Fiberoptic bronchoscopy is most reliable means of Dx and finding exact site of injury

- Best done in OR with rigid bronch if suspect

MX

• Endotracheal Intubation: ideally done via bronchoscope (to avoid passage into false lumen) but impractical

• Selective intubation of good side can be done via scope

• Definitive is thoracotomy with intraop tracheostomy and surgical repair (no role for stents routinely- depends on level of injury)

TBI

•35yo police officer struck by car

•GCS 3, intubated by EMS

•BP 80, HR 120, Sats 99% on vent, Temp N

- CXR - rib fractures, small pneumo

- PXR - no fracture

- FAST - negative

- ?Diagnosis ?Management

CASE #4

BCI

Pathophysiology

- Arrhythmias

- Acute valve problems

- Coronary artery injury/occlusion

- Myocardial injury - microcellular injury/edema = wall motion abnormalities, decreased contractility - CHF/cardiogenic shock

Myocardial Contusion

•When should we consider and look for BCI?

- Signs of severe chest trauma

- Shock without other cause

- Arrythmias noted

- Signs of CHF

•Controversy around how to dx and the importance of it

Myocardial Contusion

Dx- GS is biopsy or autopsy

- ECG

- Cardiac Markers

- Echo

ECG- Normal or non-specific abnormalities- Sinus tach*- SVT - RBBB- RV damage therefore need 15 lead- Various degrees of AV block- Can develop 72 hours after injury✴How does a normal or abnormal ECG

impact our management?

Myocardial Contusion

Myocardial Contusion

• Nagy et al. World J Surg, 2001

- Patients at risk for BCI admitted to ICU for serial ECGs, monitoring, serial enzymes

- N=171

- Results:✓ Pts with normal initial ECG had benign

outcomes

✓ Pts with ST change, dysrhythmias had adverse outcomes

✴ Recommend that all patients with blunt chest trauma receive screening ECG but if normal can safely discharge but if new finding or abnormal monitor for 12 hrs

Myocardial Contusion

• Bertinchant et al. Journal of Trauma, 2000

- Prospective enrollment of pts with suspected BCI

- n=94

- GS= significant ECG change or echo findings

- TnT + in 11 (12%) of pt with BCI, no bad outcomes

- TnT - in all without BCI, p>0.05

✴ No relationship between positive trop and clinical outcome and do not recommend using as screening

Myocardial Contusion

Rajan et al. J of Trauma, 57(4) 2004

• n= 187 with blunt chest trauma

• Results:

- 63(34%) had + TnI levels

- 47(25%) were symptomatic

- 124 had - TnI levels and all stayed asymptomatic and had no adverse outcomes

- severity of arrhythmia correlated directly with TnI level

✴ Concluded that +TnI mandates further cardiologic w/u and those with -TnI are safe not to

Myocardial Contusion

• HOWEVER:

- 1/2 of their “significant arrhythmias” were PVCs

- No comment of clinically important outcomes of these arrythmias- like how many died or needed intervention

- BCI outcome was defined as an elevated TnI!➡ In other words, they are trying to determine

the value of TnI as a diagnostic test while using it as their outcome measure!

➡ aka incorporation bias

Myocardial Contusion

Ferjani et al. Chest 111(2), 1997

•Prospective study measuring TNT

•Dx of cardiac contusion if 1. Abn echo consistent with contusion

2.Severe cardiac dysrhytmia (incl PVCs!)

3.Severe conduction abn (incl RBBB!)

4.Hemopericardium

•n= 29 dx with contusion

•Results:

• Sens= 31%

• Spec= 91%

* Does not support the use of screening trops

Myocardial Contusion

Valhamos et al. J of Trauma, Jan 2003

-Prospective study

-n= 333 with significant blunt chest trauma (44/13% with clinically significant BCI)

-Serial ECGs and TnI tests were performed routinely

-Significant BCI defined as:1.cardiogenic shock

2.arrhythmias requiring treatment

3.post-traumatic structural deficits

• decreased cardiac index

Myocardial Contusion

• ECG more sensitive than TnI (89% vs 73%)

• TnI neither sensitive or speficic

• ECG and TnI combined gives 100% sens and NPV

• 1 patient with initial normal ECG and TnI developed changes 8 hours post-admission

✴ Conclude that pts with initial normal ECG and TnI and again at 8 hrs can safely r/o significant BCI

Myocardial Contusion

A Review. Emerg Med Clin North Am. 25(3), 2007

Recommend:1.screening ECG for patients with

suspected mechanism for BCI

2.if normal, asymptomatic and otherwise healthy can rule out clinically significant contusion

3.if abnormal or elderly with significant cardiac history should admit for further monitoring and consider other w/u (echo)

4.no definitive study regarding use of cardiac markers

5.if pt in cardiogenic shock need echo to see valves

BCI Summary

No evident comp Cardiac comp

Suspected

ArrhythmiaCHF

Cardiogenic shock

Shock w/o cause

Cardiac Monitoring (12 hrs) +/- Echo

ECG

Normal-rules out clinically significant contusion- can d/c

New Abnormality*

- cardiac monitoring 12 hrs- consider echo

*Arrythmias, ST depression, T wave inversion,

conduction abnormality

•29F unrestrained passenger in middle seat of van that was T-boned on her side at hwy speed. Ejected. Found 50 feet from vehicle.

- GCS 14

- Hemodynamically stable

CASE #5

Blunt Aortic Injury

‣ Rapid Deceleration:

- Ao arch is mobile and descending arch is immobile d/t ligamentum arteriosm and tethering by intercostal arteries

‣ 90% occur in the descending Ao just distal to the left subclavian artery

Q: Most common mechanism?

DX• Clinical presentation...

• Mechanism

• Imaging

• CXR as screening DI

• CXR vs CT

• CT vs Angiography

• CT vs TEE

BAI

BAI-SSx

- RSCP/Interscapular pain

- SOB

- Extremity pain

- Stridor

- Hoarseness

- Pseudocoarctation syndrome

- Chest wall bruising

- AI, MR murmur ★ 80-90% die on scene though!

Q: Clinical Presentation?

•J of Trauma. April, 2003.

•Cohort design using large database➡ Independent Positive Predictors of BAI

• Age>60

• Front-seated

• Frontal or near-side impact

• Delta V> 40mph

• Crush >40cms

• Intrusion > 15cms

•Negative

BAI- Mechanism

Negative Predictors:- seatbelt use- occupant of lrg vehicle

BAI

• mediastinal widening (>6cm PA, >8cm AP, >0.25 ratio of mediastinal to chest at knob)

• Apical cap

• Loss of AP window

• Loss of aortic knob

• Rightward deviation of NG/trachea

• Rightward displacement of mainstem

• Thickening of right paratracheal stripe (>5mm)

✴ Isolated 1st/2nd rib # not predictive

Q: What are the high risk cxr findings?

BAI and the CXR

• Reviewed multiple articles

- Sensitivity of CXR approx 90%

- CXR can be normal in up to 5% with TAI

- Loss of Ao knob (sens= 53-100%, spec 21-55%)

- Mediastinal widening (sens- 81-100%, spec 10-60%)

★ Cannot completely r/o the injury

BAI and the CXR

•7.3% with confirmed TAI had normal mediastinum on CXR

★ Bottom line in many studies is that CXR is not that good at diagnosing TAI and the classic widened mediastinum is controversial and not that sensitive

BAI

• Journal of Trauma. Dec, 2001.

• Prospective, n=93

- Included pts with MVC>10mph, Fall> 5ft

- Excluded unstable and severe HI

- All had CXR and CT

BAI- CXR and CT•Results:

- 68 (73%) showed at least 1 pathological sign on CXR

- 25 (27%) N CXR

- CXR sens 82%

- CXR spec 57%

- CXR missed 2/3 BAIs!!

Q: Do you want a CT in pts with major chest trauma?

BAI and CT

Dyer at al. J of Trauma. April, 2000

- Prospective study over 5.5 years

- N= 1561, n= 30 (TAI)

- Results of CTs ability to dx:

• 100% sensitive

• 100% NPV

BAI and CT

• Aortography long considered the gold standard, but new CTs are proving they have high sensitivity

• CT Direct signs of BAI

• Intimal flap

• Aortic wall disruption

• Extravasation of iv contrast

• Advantages: rapid, other injuries, less contrast than angio, lower stroke risk*Use aortography if CT is equivocal -

pseudocoarctation or mediastinal hematoma

BAI and Echo

•Smith et al. NEJM, 1995• Prospective, n= 93

• TEE followed by angio

• Sens= 100%

• Spec= 98%

•Chrillo et al. Heart, 1996• Prospective, n= 134

• Sens= 93%

• Spec= 98%

• Time to surgical correction shorter by 40min

BAI Tx

Current Therapeutic Approaches:

1.Surgical

2.Nonoperative or delay of surgery with pharmacologic BP control

3.Endovascular stenting

BAI Tx- Stent vs Open

Ott et al. J of Trauma 56(3), 2004

•Review of prospective registry over 11.5 yrs

•n= 18 with TAI repair (6 by EVS, 12 by open)

•Results:

- Open: 2 early mortality, 2 paraplegia, 2 recurrent laryngeal nerve injury outcomes

- EVS: 0 of all above *EVS is emerging as preferred method of repair

BAI Tx

Dunham et al. J of Trauma 56(6), June 2004

•Retrospective review

•n= 16 (TAI treated with EVSG)

•Results:- 100% technical success

- 0% graft related complications during follow-up (mean 10.7 m)

- 0% paraplegia

- 1 post-op mortality due to secondary injury

*Concluded that repair of BAI with EVSG can be performed safely

BAI Tx- early vs late

Hemmila et al. Journal of Trauma. Jan, 2004.

• Retrospective using registry data

• Early repair defined as <16 hrs from injury

BAI Tx- early vs late

•delayed repair is not associated with increased mortality

•shows that other injuries must be given appropriate consideration- often have to anticoagulate after EVS

★ small sample and still large % difference in mortality

BAI Tx

✓ Consult Trauma/Vascular/Intervential rad✓ BP Control

- Pain control first, be VERY cautious!- Discuss BP control with vascular

• Fabian et al. Ann Surg, 1998. ‣ antihypertensive therapy maintaining

SBP between 100-120mmHg shown to reduce continued dissection and rupture

‣ Esmolol > labetolol

Q: What do we do?

BAI Summary• Suspect in deceleration injuries

• CXR can miss a significant proportion

• “Wide mediastinum” not that good at predicting

• CT if CXR abnormal or big mechanism

• Angio still gold standard but CT has similar sensitivity and 1st line now

• Stenting becoming favored treatment- but turf war

• Control BP only if you have to