Chest Trauma and Indications for Thoracotomy Dr.Sami Alnassar.

Chest Trauma and Chest Trauma and Indications for ThoracotomyIndications for Thoracotomy

Dr.Sami AlnassarDr.Sami Alnassar

Primary surveyPrimary survey

Aim to identify life threatening chest injuryAim to identify life threatening chest injury– Tension pnemothoraxTension pnemothorax– Massive hemothoraxMassive hemothorax– Cardiac temponadeCardiac temponade– Flail chestFlail chest– Open pneumothrax Open pneumothrax

EXAMINATIONEXAMINATION

LOOKLOOK

FEELFEEL

LIESTENLIESTEN

PERCUSSPERCUSS

EXAMINATIONEXAMINATION

LOOKLOOK

FEELFEEL

LISTENLISTEN

PERCUSSPERCUSS

ExaminationExamination

Don’t forget to examine the back??Don’t forget to examine the back??

DIAGNOSTIC IMIGINGDIAGNOSTIC IMIGING

CXRCXR

FASTFAST

secondary surveysecondary survey

Is more detailed and completed Is more detailed and completed examination to Identified :examination to Identified :

– Ribs fractures , flial chestRibs fractures , flial chest– Lung contusionLung contusion– Simple pneumothoraxSimple pneumothorax– Simple haemothoraxSimple haemothorax

Sucondrey survaySucondrey survay

Further diagnostic study :Further diagnostic study :Chest CTChest CT

BroncoscopyBroncoscopy

AngiogramAngiogram

Oesophagoscopy / oesophagram Oesophagoscopy / oesophagram

Tension PneumothraxTension Pneumothrax

is the progressive build-up of air within the is the progressive build-up of air within the pleural space pleural space

Usually due to a lung laceration Usually due to a lung laceration

Classical signs : Classical signs : deviation of the trachea deviation of the trachea

increased percussion note increased percussion note

hyper-expanded chest hyper-expanded chest

Increase CVP ( may be normal ? )Increase CVP ( may be normal ? )

Tension pneumothraxTension pneumothrax

These classical signs may be absentThese classical signs may be absent

tachycardia and tachypnea, and may be tachycardia and tachypnea, and may be hypoxia. hypoxia.

These signs are followed by circulatory These signs are followed by circulatory collapse with hypotension and PEAcollapse with hypotension and PEA

Tension PneumothoraxTension Pneumothorax

The presence of The presence of chest tubes does not chest tubes does not mean a patient mean a patient cannot develop a cannot develop a tension tension pneumothorax pneumothorax

Tension PneumothraxTension Pneumothrax

Tension pneumothorax may also persist if Tension pneumothorax may also persist if there is an injury to a major airway there is an injury to a major airway

2 or more CT may be needed2 or more CT may be needed

in these cases thoracotomy is usually in these cases thoracotomy is usually indicatedindicated

Bilateral tension PneumothoraxBilateral tension Pneumothorax

Beware also the Beware also the patient with bilateral patient with bilateral tension tension pneumothoraces pneumothoraces

treatmenttreatment

Needle Thoracostomy Needle Thoracostomy

Chest tube placementChest tube placement

Possible thoracotomy Possible thoracotomy or thoracoscopyor thoracoscopy

Tracheo-broncheal injuryTracheo-broncheal injury

Its rare ,from 0.2 to 4%Its rare ,from 0.2 to 4%

Most victims die prior to ERMost victims die prior to ER

80% within 2.5 from carina80% within 2.5 from carina

Main stem 86% Main stem 86%

More common in right sideMore common in right side


Signs and symptoms :Signs and symptoms :StriderStrider

HoarsenessHoarseness

HemptysisHemptysis

Pnemothorax with major air leakPnemothorax with major air leak

Up to 10% will not produce any clinical or Up to 10% will not produce any clinical or radiological signs ( recognized months radiological signs ( recognized months after stricture occurafter stricture occur

Bronchoscopy is the most reliable testBronchoscopy is the most reliable test


Intraoperative airway management :Intraoperative airway management :Coordinate with anesthesiologistCoordinate with anesthesiologist

Sterile anesthesia circuitSterile anesthesia circuit

Double lumen tubeDouble lumen tube

Tracheostomy if needed 2-3 rings above the Tracheostomy if needed 2-3 rings above the injured segmentinjured segment

Postoperative airway management :Postoperative airway management :Maintained low airway pressureMaintained low airway pressure

Allows immediate extubationAllows immediate extubation


Surgical approach :Surgical approach :Extrathoracic consider collar incisionExtrathoracic consider collar incision

RT thoracotomy for RT bronchial and proximal leftRT thoracotomy for RT bronchial and proximal left

LT thoracotomy for distal LT bronchial injuryLT thoracotomy for distal LT bronchial injury

Debriment , mucosa to mucosa, absorbable sutureDebriment , mucosa to mucosa, absorbable suture

Reinforce suture line with pericardium, pleura,..Reinforce suture line with pericardium, pleura,..

Outcome:Outcome:>90 of patient reach hospital alive, have good >90 of patient reach hospital alive, have good outcomeoutcome


Tension gastrothoraxTension gastrothorax

may be confused with may be confused with a tension a tension pneumothorax. pneumothorax. There is There is haemodynamic haemodynamic compromise, tracheal compromise, tracheal & mediastinal & mediastinal deviation, and deviation, and decreased air entry in decreased air entry in the affected the affected hemithorax hemithorax

Open PneumothoraxOpen Pneumothorax

occurs when there is a pneumothorax occurs when there is a pneumothorax associated with a chest wall defectassociated with a chest wall defect

air is entrained into the chest cavity not through air is entrained into the chest cavity not through the trachea but through the hole in the chest the trachea but through the hole in the chest wall. wall.

Once the size of the hole is more than 0.75 Once the size of the hole is more than 0.75 times the size of the trachea, air preferentially times the size of the trachea, air preferentially enters through the thoracic cavity. enters through the thoracic cavity.

Open PneumothoraxOpen Pneumothorax

Diagnosis should be Diagnosis should be made clinically made clinically

Sucking chest wall Sucking chest wall woundwound

managementsmanagements

Oxygenation and possible intubations if in Oxygenation and possible intubations if in distressdistress

Occlusive dressing to the woundOcclusive dressing to the wound

Immediate CT insertionImmediate CT insertion

If no CT available , If no CT available , bandage may be bandage may be applied over the wound and taped on 3 applied over the wound and taped on 3 sides sides

OR for closure of the defectOR for closure of the defect

hemothoraxhemothorax

Most hemothoraces are the result of rib Most hemothoraces are the result of rib fractures, lung parenchymal and minor fractures, lung parenchymal and minor venous injuries venous injuries Less commonly there is an arterial injury, Less commonly there is an arterial injury, which is more likely to require surgical which is more likely to require surgical repair. repair. The classic signs of a haemothorax are The classic signs of a haemothorax are decreased chest expansion, dullness to decreased chest expansion, dullness to percussion and reduced breath sounds percussion and reduced breath sounds


CXR is the standard CXR is the standard testtest

Erect film more Erect film more sensitive but it take sensitive but it take 400 t0 500 to 400 t0 500 to obliterate the costo-obliterate the costo-phrenic angle phrenic angle


FAST is useful in FAST is useful in unstable patient , it unstable patient , it detect small detect small hemothoraxhemothorax

CT is more sensitive CT is more sensitive testtest

It detect other It detect other associated injury associated injury


CT insertion firstCT insertion first

Thoracotomy indicated if Thoracotomy indicated if immediate immediate drainage of 1000-1500mls of blood drainage of 1000-1500mls of blood

Or 200ml for 4 hoursOr 200ml for 4 hours

However the initial volume of blood However the initial volume of blood drained is not as important as the amount drained is not as important as the amount of on-going bleeding of on-going bleeding

Tension hemothoraxTension hemothorax

Tension hemothoraxTension hemothorax

Flail chestFlail chest

occurs when a segment of the thoracic occurs when a segment of the thoracic cage is separated from the rest of the cage is separated from the rest of the chest wall. chest wall.

it defined as at least two fractures per rib , it defined as at least two fractures per rib , in at least two ribs. in at least two ribs.

Usually associated lung contusionUsually associated lung contusion

It result in impaired ventilation It result in impaired ventilation

DiagnosisDiagnosis

paradoxical paradoxical movement of a movement of a segment of the chest segment of the chest wall wall

CXR and CT CXR and CT established the established the diagnosisdiagnosis

Clip

Flail ChestFlail Chest

it directed toweredit directed toweredProtected underling lungProtected underling lung

Maintain ventilationMaintain ventilation

Prevent pneumoniaPrevent pneumonia

Analgesia is the main treatmentAnalgesia is the main treatmentPCA and NSAIDPCA and NSAID

Epidural is the best option ( elderly )Epidural is the best option ( elderly )

Intubations and mechanical ventilation is Intubations and mechanical ventilation is rarely indicated rarely indicated


Operative Fixation by Operative Fixation by wires or plates wires or plates indicated inindicated in– Patient going for Patient going for

thoracotomythoracotomy– Fixed thoracic Fixed thoracic

impactionimpaction– Failure to wean from Failure to wean from

ventilatorventilator

Operative fixationOperative fixation

Operative fixation(Judet plates )Operative fixation(Judet plates )

Operative fixation(Sanchez plates )Operative fixation(Sanchez plates )

Thoracoscopy for trauma patients Thoracoscopy for trauma patients (carllio AJS 2005)(carllio AJS 2005)

DIAGNOSTIC APPLICATIONS :DIAGNOSTIC APPLICATIONS :DIAGNOSIS OF DIAPHRAGMATIC INJURIESDIAGNOSIS OF DIAPHRAGMATIC INJURIES

DIAGNOSIS OF PERSISTENT HEMORRHAGEDIAGNOSIS OF PERSISTENT HEMORRHAGE

DIAGNOSIS OF BRONCHOPLEURAL FISTULASDIAGNOSIS OF BRONCHOPLEURAL FISTULAS

ASSESSMENT OF CARDIAC AND MEDIASTINAL ASSESSMENT OF CARDIAC AND MEDIASTINAL STRUCTURESSTRUCTURES

THERAPEUTIC APPLICATIONS THERAPEUTIC APPLICATIONS MANAGEMENT OF RETAINED THORACIC MANAGEMENT OF RETAINED THORACIC COLLECTIONSCOLLECTIONS

REPAIR OF DIAPHRAGMATIC INJURIESREPAIR OF DIAPHRAGMATIC INJURIES

Emergency Department Emergency Department ThoracotomyThoracotomy

Accepted IndicationsAccepted Indications : :– Penetrating thoracic injury :Penetrating thoracic injury :

Traumatic arrest with previously witnessed cardiac Traumatic arrest with previously witnessed cardiac activity activity

Unresponsive hypotension (BP < 70mmHg) Unresponsive hypotension (BP < 70mmHg)

– Blunt thoracic injury Blunt thoracic injury Unresponsive hypotension (BP < 70mmHg)Unresponsive hypotension (BP < 70mmHg)

Rapid exsanguination from chest tube (>1500ml) Rapid exsanguination from chest tube (>1500ml)


Relative IndicationsRelative Indications : :– Penetrating thoracic injury Penetrating thoracic injury

Traumatic arrest without previously witnessed Traumatic arrest without previously witnessed cardiac activity cardiac activity

– Penetrating non-thoracic injury :Penetrating non-thoracic injury :Traumatic arrest with previously witnessed cardiac Traumatic arrest with previously witnessed cardiac activity activity

– Blunt thoracic injuries:Blunt thoracic injuries:Traumatic arrest with previously witnessed cardiac Traumatic arrest with previously witnessed cardiac activity activity


ContraindicationsContraindications : :– Blunt injuries:Blunt injuries:

Blunt thoracic injuries with no witnessed cardiac Blunt thoracic injuries with no witnessed cardiac activityactivity

Multiple blunt trauma Multiple blunt trauma

Severe head injury Severe head injury


RationaleRationale

Overall survival of patients undergoing Overall survival of patients undergoing emergency thoracotomy is between 4 and emergency thoracotomy is between 4 and 33% 33%

The main determinants for survivability The main determinants for survivability are the mechanism of injury are the mechanism of injury

For penetrating thoracic injury the survival For penetrating thoracic injury the survival rate is fairly uniform at 18-33% rate is fairly uniform at 18-33%


RationaleRationale Blunt trauma survival rates vary between 0 and 2.5% Blunt trauma survival rates vary between 0 and 2.5% The presence of cardiac activity, consistently related to The presence of cardiac activity, consistently related to the outcome following emergency thoracotomy the outcome following emergency thoracotomy In one study of 152 patients (Tyburski) survival rates In one study of 152 patients (Tyburski) survival rates were 0% for those patients arresting at scene, 4% when were 0% for those patients arresting at scene, 4% when arrest occurred in the ambulance, 19% for emergency arrest occurred in the ambulance, 19% for emergency department arrest department arrest Survival for blunt trauma patients who never exhibited Survival for blunt trauma patients who never exhibited any signs of life is almost uniformly zero. Survival for any signs of life is almost uniformly zero. Survival for penetrating trauma patients without signs of life is penetrating trauma patients without signs of life is between 0 and 5%. between 0 and 5%.


Operative TechniqueOperative Technique

The primary aims of emergency The primary aims of emergency thoractomy are:thoractomy are:

Release of cardiac tamponade Release of cardiac tamponade

Control of haemorrhage Control of haemorrhage

Allow access for internal cardiac massage Allow access for internal cardiac massage

Secondary manoeuvers Secondary manoeuvers cross-clamping of the descending thoracic aorta. cross-clamping of the descending thoracic aorta.



Approach :Approach :– A supine anterolateral thoracotomy A supine anterolateral thoracotomy – left sided approach is used in all patients and left sided approach is used in all patients and

with injuries to the left chest with injuries to the left chest – Patients who are not arrested but with Patients who are not arrested but with

profound hypotension and right sided injuries profound hypotension and right sided injuries have their right chest opened first. have their right chest opened first.





Approach :Approach :– In both cases it may become necessary to In both cases it may become necessary to

extend the incision across the sternum extend the incision across the sternum – skin incision is made in the 5th intercostal skin incision is made in the 5th intercostal

space space

Relief of tamponade :Relief of tamponade :– The pericardium is opened longitudinally to The pericardium is opened longitudinally to

avoid damage to the phrenic nerve, avoid damage to the phrenic nerve,



Control of haemorrhage :Control of haemorrhage :– Cardiac wounds :Cardiac wounds :

controlled initially with direct finger pressure. controlled initially with direct finger pressure. sutured using non-absorbable 3/0 sutures sutured using non-absorbable 3/0 sutures mattress sutures are used to avoid obstructing mattress sutures are used to avoid obstructing coronary flow coronary flow

– Pulmonary & Hilar injuries. Pulmonary & Hilar injuries. temporarily controlled with finger pressure at the temporarily controlled with finger pressure at the pulmonary hilum. pulmonary hilum.



Control of haemorrhage:Control of haemorrhage:– Pulmonary & Hilar injuries :Pulmonary & Hilar injuries :

This may be augmented by placement of a This may be augmented by placement of a Satinsky clamp across the hilum Satinsky clamp across the hilum

Lesser haemorrhage from the lung parenchymas Lesser haemorrhage from the lung parenchymas can be controlled with a temporary clamp can be controlled with a temporary clamp

– Great vessel injuries :Great vessel injuries :Small aortic injuries can be sutured directly using Small aortic injuries can be sutured directly using the 3/0 the 3/0



Larger injuries, especially to the arch may require Larger injuries, especially to the arch may require temporary digital occlusion and insitution of cardiac temporary digital occlusion and insitution of cardiac bypass. bypass.

Internal cardiac massage Internal cardiac massage – internal cardiac massage should be started as internal cardiac massage should be started as

soon as possible soon as possible – A two-handed technique produces a better A two-handed technique produces a better

cardiac outputcardiac output



Aortic cross-clamping :Aortic cross-clamping :The rationale for clamping the aorta is to The rationale for clamping the aorta is to redistribute blood flow to the coronary vessels, redistribute blood flow to the coronary vessels, lungs and brain, lungs and brain,

Clamp time should ideally be 30 minutes or less. Clamp time should ideally be 30 minutes or less.

Cross-clamping is done ideally at the level of the Cross-clamping is done ideally at the level of the diaphragm, to maximise spinal cord perfusion diaphragm, to maximise spinal cord perfusion





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Chest Trauma and Indications for Thoracotomy Dr.Sami Alnassar.

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