Thoracic and Thoracic and Abdominal TraumaAbdominal Trauma

Bartholomew J TortellaBartholomew J TortellaMTS, MD, MBA, FACS, FCCMMTS, MD, MBA, FACS, FCCM

through the kindness ofthrough the kindness of

James Eakins, MDJames Eakins, MD

Hahnemann Wolforth Trauma CenterHahnemann Wolforth Trauma Center

Thoracic TraumaThoracic Trauma

• AnatomyAnatomy• MechanismMechanism• ABC’sABC’s• Specific InjuriesSpecific Injuries

PhysiologyPhysiology Signs and symptomsSigns and symptoms DiagnosisDiagnosis TherapyTherapy

• Special TopicsSpecial Topics

AnatomyAnatomy

• LungsLungs• Visceral and Parietal pleuraVisceral and Parietal pleura• MediastinumMediastinum

HeartHeart Great vesselsGreat vessels EsophagusEsophagus Trachea / BronchiTrachea / Bronchi

MechanismMechanism

• BluntBlunt• PenetratingPenetrating

ThoracicThoracicLungsLungsMediastinumMediastinum

Thoraco-abdominalThoraco-abdominal

• Most injuries can occur with either Most injuries can occur with either mechanismmechanism

ABC’sABC’s

• Same as for any other traumaSame as for any other trauma• Don’t necessarily need to know diagnosis Don’t necessarily need to know diagnosis

to initiate therapyto initiate therapy

Specific InjuriesSpecific Injuries

• Simple pneumothoraxSimple pneumothorax• Tension pneumothoraxTension pneumothorax• Open pneumothoraxOpen pneumothorax• Massive hemothoraxMassive hemothorax• Cardiac tamponadeCardiac tamponade• Flail chestFlail chest

Simple PneumothoraxSimple Pneumothorax

• Air between lung and chest wallAir between lung and chest wall• Causes lung to collapse, interfering with Causes lung to collapse, interfering with

ventilation and oxygenationventilation and oxygenation

Diagnosis – Simple PneumothoraxDiagnosis – Simple Pneumothorax

• Decreased breath soundsDecreased breath sounds• Decreased pulse-oxDecreased pulse-ox• Shortness of breathShortness of breath• CrepitusCrepitus• Subcutaneous airSubcutaneous air• High index of suspicion based on High index of suspicion based on

mechanismmechanism

Treatment – Simple PneumothoraxTreatment – Simple Pneumothorax

• By definition, there is no hemodynamic By definition, there is no hemodynamic compromise with a simple pneumothoraxcompromise with a simple pneumothorax

• Treat respiratory distress symptomaticallyTreat respiratory distress symptomatically• Chest tube to definitively treat Chest tube to definitively treat

pneumothoraxpneumothorax

Tension PneumothoraxTension Pneumothorax

• Air under tension in Air under tension in pleural space between pleural space between lung and chest walllung and chest wall

• Increased thoracic Increased thoracic pressure interferes with pressure interferes with venous return to the venous return to the heart, therefore heart, therefore decreasing cardiac decreasing cardiac outputoutput

Diagnosis – Tension pneumothoraxDiagnosis – Tension pneumothorax

• HypotensionHypotension• Jugular venous distensionJugular venous distension• Absent breath soundsAbsent breath sounds• Tympanic chestTympanic chest• Tracheal deviation – usually a pre-morbid Tracheal deviation – usually a pre-morbid

signsign

Treatment – Tension PneumothoraxTreatment – Tension Pneumothorax

• Needle decompression – converts tension Needle decompression – converts tension pneumothorax to simple pneumothoraxpneumothorax to simple pneumothorax

• Chest tube to definitively treat Chest tube to definitively treat pneumothoraxpneumothorax

• Treat respiratory distress symptomaticallyTreat respiratory distress symptomatically

Open PneumothoraxOpen Pneumothorax

• aka “sucking chest wound”aka “sucking chest wound”• Defect in chest wallDefect in chest wall• Air follows path of least resistance and Air follows path of least resistance and

goes through hole in chest wall rather than goes through hole in chest wall rather than through airway into lungsthrough airway into lungs

• Patient unable to ventilatePatient unable to ventilate• Requires a defect of about 2/3 diameter of Requires a defect of about 2/3 diameter of

tracheatrachea

Diagnosis – Open PneumothoraxDiagnosis – Open Pneumothorax

• Visible defect in chest wallVisible defect in chest wall• Air audibly moves in and outAir audibly moves in and out

Massive hemothoraxMassive hemothorax

• Massive bleeding into pleural spaceMassive bleeding into pleural space• Sources include lung, heart, great vesselsSources include lung, heart, great vessels

Diagnosis – Massive hemothoraxDiagnosis – Massive hemothorax

• Signs and symptoms of massive Signs and symptoms of massive hemorrhagehemorrhage TachycardiaTachycardia HypotensionHypotension ShockShock

• Decreased breath soundsDecreased breath sounds• Dullness to percussionDullness to percussion• Can be obvious with penetrating but hard Can be obvious with penetrating but hard

to diagnose in blunt traumato diagnose in blunt trauma

Treatment – Massive hemothoraxTreatment – Massive hemothorax

• Volume resuscitationVolume resuscitation• Mechanical ventilation Mechanical ventilation

for shock or for shock or respiratory distressrespiratory distress

• Chest tubeChest tube• AutotransfusionAutotransfusion• Operative intervention Operative intervention

– need to stop the – need to stop the bleedingbleeding

Cardiac TamponadeCardiac Tamponade

• Buildup of blood in pericardial sacBuildup of blood in pericardial sac• Compresses heart and impairs venous Compresses heart and impairs venous

return to the heartreturn to the heart• Decreased cardiac outputDecreased cardiac output• Therefore – hypotension and deathTherefore – hypotension and death

Cardiac TamponadeCardiac Tamponade

Diagnosis - TamponadeDiagnosis - Tamponade

• Beck’s TriadBeck’s Triad Jugular venous distensionJugular venous distension HypotensionHypotension Muffled heart soundsMuffled heart sounds

• Not always present and conditions / Not always present and conditions / environment frequently difficultenvironment frequently difficult

• Index of suspicion must be highIndex of suspicion must be high

Treatment - TamponadeTreatment - Tamponade

• VolumeVolume• Operative Operative

interventionintervention Decompress Decompress

pericardiumpericardium Control bleedingControl bleeding

• Pericardiocentesis Pericardiocentesis can be a bridge to can be a bridge to definitive therapydefinitive therapy

Flail ChestFlail Chest• Definition – 3 or more ribs broken in 2 placesDefinition – 3 or more ribs broken in 2 places

Flail ChestFlail Chest

• Paradoxical chest wall Paradoxical chest wall movement – not always movement – not always present and breathing present and breathing mechanics are usually mechanics are usually not the main problemnot the main problem

• PainPain• Underlying pulmonary Underlying pulmonary

contusioncontusion• CXR important in CXR important in

diagnosisdiagnosis

Treatment – Flail chestTreatment – Flail chest

• Pain ControlPain Control• Treat respiratory distress symptomaticallyTreat respiratory distress symptomatically• Intubation because of the pulmonary Intubation because of the pulmonary

problems, not the rib fracturesproblems, not the rib fractures• Taping: NEVER!!!!Taping: NEVER!!!!

ConclusionConclusion

• Many life-threatening injuries possible with Many life-threatening injuries possible with thoracic traumathoracic trauma

• ABC’s remain the sameABC’s remain the same• Prompt diagnosis and treatment is the keyPrompt diagnosis and treatment is the key

Abdominal TraumaAbdominal Trauma

IntroductionIntroduction

• MechanismMechanism BluntBlunt PenetratingPenetrating

• The injuries are the same but the workup The injuries are the same but the workup depends on mechanism and depends on mechanism and hemodynamicshemodynamics

IntroductionIntroduction

• ABC’sABC’s• AnatomyAnatomy• EvaluationEvaluation• Indications for surgeryIndications for surgery

Initial EvaluationInitial Evaluation

• AirwayAirway• BreathingBreathing• CirculationCirculation• Evaluation of the abdomen can become Evaluation of the abdomen can become

important as early as “C”important as early as “C”

AnatomyAnatomy

• ExternalExternal AbdomenAbdomen FlankFlank BackBack

• InternalInternal IntraperitonealIntraperitoneal RetroperitonealRetroperitoneal PelvisPelvis

IntraperitonealIntraperitoneal

• LiverLiver• SpleenSpleen• MesenteryMesentery• Small IntestineSmall Intestine• ColonColon• StomachStomach• BladderBladder

RetroperitonealRetroperitoneal

• DuodenumDuodenum• ColonColon• PancreasPancreas• KidneysKidneys• Large VesselsLarge Vessels

PelvisPelvis

• Large VesselsLarge Vessels• BladderBladder• Reproductive organsReproductive organs• Bony PelvisBony Pelvis

• The most important factor in the The most important factor in the evaluation of patients with evaluation of patients with abdominal trauma is to determine abdominal trauma is to determine

who needs an operationwho needs an operation..

• There are two general indications for There are two general indications for abdominal surgeryabdominal surgery BleedingBleeding Hollow viscus injuryHollow viscus injury

• It is only necessary to determine that one It is only necessary to determine that one of the two exists, not the specific organ of the two exists, not the specific organ involved.involved.

Blunt Trauma EvaluationBlunt Trauma Evaluation

• Peritoneal LavagePeritoneal Lavage• UltrasoundUltrasound• CAT ScanCAT Scan

Peritoneal LavagePeritoneal Lavage

• AdvantagesAdvantages FastFast Very sensitiveVery sensitive No need to travelNo need to travel

• DisadvantagesDisadvantages Unable to evaluate the Unable to evaluate the

retroperitoneumretroperitoneum Not specificNot specific InvasiveInvasive

Ultrasound (FAST)Ultrasound (FAST)• AdvantagesAdvantages

Non-invasiveNon-invasive FastFast No need for travelNo need for travel

• DisadvantagesDisadvantages Non-specificNon-specific Poor visualization Poor visualization

of the of the retroperitoneumretroperitoneum

User dependentUser dependent

Ultrasound (FAST)Ultrasound (FAST)

1 2 3 4

CAT ScanCAT Scan

• AdvantagesAdvantages Very specificVery specific Very sensitiveVery sensitive Good visualization of Good visualization of

retroperitoneumretroperitoneum

• DisadvantagesDisadvantages TimeTime Need for travelNeed for travel

Algorithm for Blunt TraumaAlgorithm for Blunt Trauma

• If unstable, need to evaluate quickly for If unstable, need to evaluate quickly for intra-abdominal bleeding using U/S or DPLintra-abdominal bleeding using U/S or DPL If positive, then surgeryIf positive, then surgery If negative, then evaluate for other bleeding If negative, then evaluate for other bleeding

sources and obtain CT Scan when more sources and obtain CT Scan when more stablestable

• If stable, CT Scan is the test of choiceIf stable, CT Scan is the test of choice

Penetrating TraumaPenetrating Trauma

• Any GSW from nipple line to top of Any GSW from nipple line to top of groin crease requires exploratory groin crease requires exploratory laparotomylaparotomy

• Stab wounds are differentStab wounds are different Unstable requires surgeryUnstable requires surgery Stable: depends on locationStable: depends on location

Anterior abdomen – local wound Anterior abdomen – local wound explorationexploration

• Home if it doesn’t penetrate Home if it doesn’t penetrate fasciafascia

• Multiple possibilities if it Multiple possibilities if it doesdoes

Flank and back – CT Scan with Flank and back – CT Scan with operation for any evidence of operation for any evidence of intra-abdominal penetrationintra-abdominal penetration

Indications for surgeryIndications for surgery

• Any GSWAny GSW• Unstable SWUnstable SW• SW that penetrates anterior fascia or evidence SW that penetrates anterior fascia or evidence

of abdominal penetration on CT Scanof abdominal penetration on CT Scan• Unstable blunt trauma with intra-abdominal fluid Unstable blunt trauma with intra-abdominal fluid

by U/S or DPLby U/S or DPL• Stable blunt trauma with positive CT ScanStable blunt trauma with positive CT Scan

Free airFree air Free fluid without solid organ injuryFree fluid without solid organ injury Suspicion for significant retroperitoneal injurySuspicion for significant retroperitoneal injury

ConclusionConclusion

• ABC’s always come firstABC’s always come first• Not necessary to determine specific injury, Not necessary to determine specific injury,

only whether an operation is neededonly whether an operation is needed• Specific evaluation depends on patient Specific evaluation depends on patient

mechanism and stabilitymechanism and stability