Nov 14, 2011 - thoracic aortic injuries: An analysis of the National Trauma Databank. J Vasc Surg 2009; 49:988. .... Ullman EA, Donley LP, Brady WJ. Pulmonary trauma .... Blunt aortic injury is the most lethal injury of the thorax if untreated.
Chest Trauma Dr. Rajab Ghoubashy Dr. Abdullrhman Hammad Dr. Ahmad Alassal Dr. Husain Jabbad 14 November 2011
Anatomy and physiology • The rib cage, intercostal muscles, and costal cartilage form the basic structure of the chest wall. • The neurovascular bundles comprised of an intercostal nerve, artery, and vein run along each rib. • The inner lining of the chest wall is the parietal pleura. Visceral pleura covers the major thoracic organs, between the two is a potential space with a small amount of lubricating fluid.
Anatomy of The Chest Wall
Anatomy and physiology • The anterior chest wall also contains the sternum , pectoralis major and minor muscles as well as the clavicle at its superior border. • Posteriorly the scapula provides added protection to the superior thorax. • The scapula is a dense bone encased in muscle and significant force is necessary to fracture it.
Movements of The Chest Wall
Anatomy of The Upper Chest Wall and the Thoracic Inlet
Chest Trauma • Blunt Trauma – Motor vehicle accidents – Fall from heights
• Penetrating Trauma – Sharp objects – Bullets ( low velocity, high velocity)
• Blast trauma – Explosions – Industrial accidents
Motor vehicle collisions (MVC) Motor vehicle collisions (MVC) represent the most common cause of major thoracic injury among emergency department patients
•Liman ST, Kuzucu A, Tastepe AI, et al. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003; 23:374.
Stab Wound – Penetrating Trauma
Thoracic Trauma • Motor vehicle collisions (MVC) represent the most common cause of major thoracic injuries • Several factors are associated with a higher risk of thoracic injury: – High speed – Not wearing a seatbelt – Extensive vehicular damage – Steering wheel deformity • Increased mortality and morbidity is associated with multiple rib fractures, increased age, and higher injury severity scores (ISS)
Blunt aortic injury • The majority of blunt trauma patients who sustain a major aortic injury die immediately. • Of those who reach the hospital alive, the majority either die during initial management or are unable to undergo aortic repair due to their injuries, both intra and extra thoracic. • Up to 20 % of deaths from motor vehicle collisions are attributable to blunt cardiac injuries.
Arthurs ZM, Starnes BW, Sohn VY, et al. Functional and survival outcomes in traumatic blunt thoracic aortic injuries: An analysis of the National Trauma Databank. J Vasc Surg 2009; 49:988.
Motor vehicle collisions Factors are associated with a higher risk of thoracic injury: • High speed • Not wearing a seatbelt • Extensive vehicular damage • Steering wheel deformity Increased mortality and morbidity is associated with: • Multiple rib fractures • Increased age • Higher injury severity scores (ISS) •Rodriguez RM, Hendey GW, Marek G, et al. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med 2006; 47:415. •Nirula R, Talmor D, Brasel K. Predicting significant torso trauma. J Trauma 2005; 59:132
• High-risk occupant characteristics include: – Age ≥60 (RR 3.6; 95% CI 2.5-5.2) – Front-seat occupancy (RR 3.1; 95% CI 1.5-6.3) – Not wearing a seatbelt (RR 3.0; 95% CI 2.2-4.3)
• High-risk collision characteristics include: – Front or near-side motor vehicle crash (RR 3.1; 95% CI 1.9-5.1; and RR 4.3; 95% CI 2.6-7.2, respectively) – Abrupt deceleration ≥40 km/hour (RR 3.8; 95% CI 2.6-5.6) – Crushing of the vehicle (ie, ≥40 cm) (RR 4.1; 95% CI 2.7-6.3) – Intrusion ≥15 cm (RR, 5.0; 95% CI 3.5-7.3)
Blunt Chest Trauma • The incidence of occult pneumothorax among victims of blunt trauma is not clear, ranging from 2 to 55 % in patients who undergo computed tomography (CT) of the chest or abdomen.
Ball CG, Kirkpatrick AW, Laupland KB, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma 2005; 59:917.
Pneumothorax Pneumothorax is a common complication of thoracic trauma
Tension Pneumothorax
Haemothorax
Blunt Chest Trauma Sternal fractures • Sternal fractures are found in up to 8 % of blunt chest trauma. • A direct high-energy blow to the sternum is the usual cause. • The incidence is greater among passengers in older cars where occupants wear seat belts but air bags are not available. • over-the-shoulder seat belts contribute to these fractures and their incidence has risen with the increased prevalence of seat belt use. •Budd JS. Effect of seat belt legislation on the incidence of sternal fractures seen in the accident department. Br Med J (Clin Res Ed) 1985; 291:785.
•Arajärvi E, Santavirta S. Chest injuries sustained in severe traffic accidents by seatbelt wearers. J Trauma 1989; 29:37.
Blunt Chest Trauma Scapular fractures • Occur in 3.7 % of blunt trauma patients. 1 % of all fractures and < 5 % of fractures to the shoulder. • Scapular fractures generally require significant force, they are highly associated with other significant injuries, including rib fracture, pneumothorax, and pulmonary contusion . • Scapular fractures rarely cause blunt aortic injury .
•McLennan JG, Ungersma J. Pneumothorax complicating fracture of the scapula. J Bone Joint Surg Am 1982; 64:598 •Baldwin KD, Ohman-Strickland P, Mehta S, Hume E. Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database. J Trauma 2008; 65:430.
•Brown CV, Velmahos G, Wang D, et al. Association of scapular fractures and blunt thoracic aortic injury: fact or fiction? Am Surg 2005; 71:54.
Blunt Chest Trauma Rib Fractures • Present in 10 % of all trauma patients and in 30 % of patients with significant chest trauma. • The presence of intrathoracic injury correlates directly with the number of fractured ribs. • Fracture of multiple ribs in more than one location can lead to flail chest (or open chest wound) significantly compromising respiratory function.
- Sirmali M, Türüt H, Topçu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003; 24:133. - Liman ST, Kuzucu A, Tastepe AI, et al. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003; 23:374.
Flail Chest (“stoved-in” chest, crushed chest)
Blunt Chest Trauma Rib fractures • multiple rib fractures (>2) is the most common serious thoracic injury, it occurred in approximately 5 % of trauma patients. • The presence of multiple rib fractures, particularly ribs one two & three increases the risk of intrathoracic injury, especially in the elderly.
•Rodriguez RM, Hendey GW, Marek G, et al. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med 2006; 47:415.
Treatment of Rib Fractures • The main goals in the treatment of multiple rib fractures are – Control of pain. – Support of respiratory function and stabilization of the chest wall either through mechanical ventilation or surgical fracture fixation.
Ullman EA, Donley LP, Brady WJ. Pulmonary trauma emergency department evaluation and management. Emerg Med Clin North Am 2003; 21:291.
Multiple Rib Fractures • Choice of analgesia – Epidural analgesia (in patients with no contraindications to placement of a thoracic epidural catheter). – Parenteral opioid agents administered intravenously or via patient-controlled analgesia (PCA) – Non-steroidal anti-inflammatory drugs (if not contraindicated). – local anesthetic blocks are a useful option.
Management of Multiple Rib Fractures • Analgesia • Pulmonary care and support – Thoracostomy drainage – Volume expansion – Mechanical ventilation • Surgical management In randomized trials the operative group demonstrated – significantly fewer patients requiring mechanical ventilation – Fewer days in the intensive care unit, shorter hospital stay – lower incidence of pneumonia compared with the conservatively managed group. - Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005; 4:583. - Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest pts. J Trauma 2002; 52:727.
Indications for Operative Rib Fixation • A flail segment in a patient with failure to wean from mechanical ventilation. • Painful, movable ribs refractory to pain management strategies. • Significant chest wall deformity or presence of a tissue defect • Chest wall instability due to nonunion of rib fractures. • Significantly displaced ribs found at thoracotomy being performed for other reasons. - Thomas AN, Blaisdell FW, Lewis FR Jr, Schlobohm RM. Operative stabilization for flail chest after blunt trauma. J Thorac Cardiovasc Surg 1978; 75:793. - Tanaka H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002; 52:727. - Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg 2009; 33:14.
External Stabilization
Management of Multiple Rib Fractures • Thoracostomy drainage: (insertion of 32 - 36 French CHEST TUBE) – Patients with hemothorax or significant pneumothorax following blunt chest trauma. – Any signs of significant respiratory compromise or need for positive pressure ventilation due to respiratory fatigue or general anesthesia should prompt placement of a chest tube.
- Karmy-Jones R, Jurkovich GJ, Nathens AB, et al. Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study. Arch Surg 2001; 136:513
- Stewart RM, Corneille MG. Common complications following thoracic trauma: their prevention and treatment. Semin Thorac Cardiovasc Surg 2008; 20:69
Management of Multiple Rib Fractures • Indications to proceed with thoracotomy to control hemorrhage – Initial drainage of >1500 mL of blood or – ongoing bleeding at a rate >200 mL/hr are considered. – initial drainage of >10 mL/kg/hr is an indication to consider a second thoracostomy tube .
- Karmy-Jones R, Jurkovich GJ, Nathens AB, et al. Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study. Arch Surg 2001; 136:513 - Stewart RM, Corneille MG. Common complications following thoracic trauma: their prevention and treatment. Semin Thorac Cardiovasc Surg 2008; 20:69
Management of Multiple Rib Fractures • GENERAL MANAGEMENT ISSUES : – Monitoring (with continuous pulse oximetry) – Fluid management – DVT prophylaxis – Antibiotics (prophylactic antibiotics ) – Pain Management (Options for analgesia) • Intravenous narcotics • Regional anesthesia – continuous epidural infusion *** – paravertebral block – intercostal nerve block. – intrapleural infusion - Govindarajan R, Bakalova T, Michael R, Abadir AR. Epidural buprenorphine in management of pain in multiple rib fractures. Acta Anaesthesiol Scand 2002; 46:660.
Pneumothorax
Pneumomediastinum Ct scan & Chest X Ray
Acute cardiac tamponade during coronary angioplasty (Blood Pressure & Central Venous Pressure)
Pericardial effusion and Pericardial Tamponade Echocardiography
Aortic Dissection Diagnosis Echocardiography
Classifications of Aortic Dissection •
DeBakey Classification I. II. III.
•
•
Involve ascending & descending aorta Involve ascending aorta Involve descending aorta
Stanford (Daily) Classification
Regardless of the site of primary intimal tear A. Involve ascending aorta &/or aortic arch B. Other
Varient classification
36
Classifications of Aortic Dissection
37
Diagnosis of Aortic Dissection I. II. III. IV. V. VI. VII. VIII.
Clinical manifestations Chest X rays 12 lead ECG Echocardiogram (TTE,TEE) MRI Electron beam CT scan Spiral CT scan Angiogram
38
Diagnosis of Aortic Dissection Clinical manifestations 1.
Pain (typical 80% type A, 65% type B)
i. ii. iii. iv. i.
ii.
acute/ abrupt onset sever decrease with time sharp/ tearing anterior retrosternal posterior inter-scapular may radiate to the back to the abdomen associated symptoms
type A type B A 47 / B 65% , A 22 / B 43%
39
Diagnosis of Aortic Dissection Clinical manifestations 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Hypertension 70% type A, 36% type B Syncope 15% type A (CVA, cardiac tamponade) Aortic regurge Myocardial ischemia Pulse deficit 30% type A, 9% type B Hemothorax Arm blood pressure variation > 30 mmHg Neurologic deficit Horner syndrome Vocal cord paralysis & hoarseness of voice 40
Diagnosis of Aortic Dissection • 96% of acute aortic dissections can be identified based upon 3 clinical features
• Immediate onset pain with tearing character • Mediastinal widening on chest X rays • Variation of arm pulse / blood pressure Other imaging studies to establish diagnosis are not performed until the patient is stabilized
41
Aortic Dissection Chest X Ray
42
Radiological Diagnosis of Aortic Dissection Type B MRI
Type B Sagital MRI (spinEcho)
43
Diagnosis of Blunt Aortic Injury (BAI) CT Scan with Contrast
44
Diagnosis of Blunt Aortic Injury (BAI) CT Scan
type A - with pleural effusion
type A - with calcification of the true wall 45
Blunt Chest Trauma • Multiple structures are at risk of injury. • In addition to direct trauma, rapid deceleration and other mechanisms can cause injury to thoracic structures. • Major concerns include chest wall injury, such as – Rib fractures or flail chest – Cardiovascular injury, such as blunt aortic injury or cardiac contusion – Pulmonary injury, such as contusions or lacerations. • Blunt aortic injury is the most lethal injury of the thorax if untreated.
Diagnosis of Diagnosis of Blunt Aortic Injury
Electron Beam CT Scan
Spiral CT scanSagittal reconstruction
47
Diagnosis of Diagnosis of Blunt Aortic Injury (BAI) Ct Scan with contrast pericardial effusion
Spiral CT scan
48
Diagnosis of Aortic Dissection Contrast MRI
49
Endovascular Stenting for Management of Type B Aortic Dissection
50
ESOC Guidelines of Therapy of Acute Type A of Blunt Aortic Injury (BAI) 1. 2. 3. 4. 5.
Emergency surgery to avoid rupture Valve preserving tube graft surgery Replacement of aorta and aortic valve (I) Valve sparing operations and aortic root remodeling for abnormal valves Valve preservation and aortic root remolding in marfan patients (IIa)
51
ESOC Guidelines of Therapy of Acute Type B - Blunt Aortic Injury 1. 2.
Medical Therapy (I) Surgical aortic replacement (I) a. If signs of persistent or recurrent pain b. Peripheral ischemic complications c. Rupture 3. Surgical or endovascular fenestration and stenting if (IIa) a. Persistent mesenteric, limb, renal ischemia b. Neurological deficit
52
ESOC Guidelines Initial Management of Patients with Suspected Aortic Dissection 1. 2.
Detailed medical history & physical exam. IV line, blood sample (CK, troponin I, myoglobin, WBC, D-dimer, Hct, LDH) 3. ECG : documentation of ischemia 4. Heart rate & blood pressure monitoring 5. Pain relief (morphine sulphate) 6. Reduction of systolic BP using Beta blockers IV 7. Transfer the patient to the ICU 8. IV Nipride if required (BP = 100-120 mmHg) 9. Calcium channel blockers in COPD patients 10. Chest X -ray 53
CXR Findings Suggesting Blunt Aortic Injury • • • • • •
Wide mediastinum (supine CXR >8 cm; upright CXR >6 cm) Obscured aortic knob; abnormal aortic contour Left "apical cap" (pleural blood above apex of left lung) Large left hemothorax Deviation of nasogastric tube rightward Deviation of trachea rightward and/or right main stem bronchus downward • Wide left paravertebral stripe
Diagnosis of Aortic Dissection -Aortogram
55
Diagnosis of Aortic Dissection Tran-Esophageal Echocardiogram
56
Chest X Ray Findings of Aortic Dissection • • • • • • •
Widened superior mediastinum Displacement of intimal calcifications Localized lump in the aortic arch Pleural cap Left pleural effusion Displacement of the trachea, right or left main stem bronchus Displacement of NG tube
57
Diagnostic tests for aortic rupture Plain radiograph
Upright preferable; sensitivity of supine unclear Normal PA radiograph has high negative predictive value; good test for patients with low to moderate suspicion If high clinical suspicion, or abnormal radiograph, further testing required
Chest CT scan
Test of choice Highly sensitive and specific Requires IV contrast Can usually proceed directly to OR with a positive CT Equivocal study necessitates angiography
Angiography
Highly sensitive and specific Mainly used for equivocal CT scans Rarely adds value in the setting of a diagnostic CT and delays potentially life-saving operative intervention
Transesphosageal echocardiography
Highly accurate Can be performed at bedside, in OR, or in patients who cannot tolerate contrast Limited in proximal ruptures, but overall an excellent test when CT is unavailable or contraindicated
Blunt cardiac injury • A spectrum of pathology ranging from clinically silent, transient dysrhythmia to deadly free wall rupture. • The most common and controversial form is "cardiac contusion" or injury to the cardiac myocardium. • The absence of a clear definition and accepted gold standard for testing makes the diagnosis of cardiac contusion difficult. • Important considerations in blunt cardiac trauma include – Dysrhythmia – Cardiac wall motion abnormalities – Possibly progressing to cardiogenic shock, and rupture of valves, inter-ventricular septum, or a ventricular wall
Blunt cardiac injury • Echocardiography and cardiology consultation are necessary for any patient with blunt thoracic trauma and evidence of – Complex cardiac dysrhythmia – Cardiac dysfunction – Diastolic murmur (not known to be old) – or signs of heart failure
Chest wall injuries in children • Chest wall injuries in children are significant primarily because they often occur as the result forceful mechanisms that also cause serious associated injuries. • The thoracic cage of a child is more elastic and flexible than that of an adult, that is why less of the force of impact is absorbed by the chest wall and proportionally more force is transmitted to intrathoracic organs. • Intrathoracic injury (e.g. pulmonary contusion) often occurs without visible damage to the chest wall.
Chest wall injuries in children • Mortality for children with chest wall injuries is usually the result of associated injuries, particularly head injury. • In several retrospective series describing children with thoracic trauma, only 4 to 14 %t of deaths occurred because of thoracic injuries alone. • Mortality rates for children with chest and head injuries ranged from 28 to 37 %
- Peclet MH, Newman KD, Eichelberger MR, et al. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg 1990; 25:961. - Black TL, Snyder CL, Miller JP, et al. Significance of chest trauma in children. South Med J 1996; 89:494 - Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg 1994; 29:33
General approach to penetrating thoracic trauma in adults • Penetrating chest traumas are generally less common but more deadly than blunt chest trauma. • The presentation can vary widely from stable patients with few complaints to hemodynamically unstable patients requiring immediate life-saving interventions. • Even apparently stable patients with penetrating chest injuries can deteriorate precipitously. • A focused evaluation must be rapidly performed to assess for life-threatening conditions.
penetrating thoracic trauma in adults Causes • Gunshots • Stabbings • Industrial accidents • Falls • Collisions • Blast injuries • Fragmenting military devices.
•Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma 1990; 30:1356.
penetrating thoracic trauma in adults Incidence • In the United States – 10 % of all major traumas involve gunshots to the chest & 9.5 % involve stabbings to the chest. – 9 % of all trauma related deaths occur from injuries to the thorax, of which 1/3 involve a penetrating mechanism.
• In Europe, the incidence of penetrating trauma is reported to be as low as 4 %.
•LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989; 69:15.
•Miniño AM, Anderson RN, Fingerhut LA, et al. Deaths: injuries, 2002. Natl Vital Stat Rep 2006; 54:1. •Yates DW, Woodford M, Hollis S. Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study. BMJ 1992; 305:737
General concepts about mechanism of penetrating thoracic trauma in adults • The direction and extent of penetration from a stab wound is difficult to assess from the physical examination alone. • The extent of internal injury from a seemingly small external wound can easily be underestimated. • Of particular importance are penetrating wounds to “the box” because of the high risk of injury to the heart and other mediastinal structures
•Nagy KK, Lohmann C, Kim DO, Barrett J. Role of echocardiography in the diagnosis of occult penetrating cardiac injury. J Trauma 1995; 38:859.
penetrating thoracic trauma in adults • The thoracic structures at risk from penetrating chest trauma 1. Chest wall 2. Lungs 3. Tracheobronchial tree 4. Heart 5. Aorta and thoracic great vessels 6. Esophagus 7. Diaphragm 8. Spinal cord 9. Thoracic vertebrae 10. The thoracic duct.
penetrating thoracic trauma in adults 1.
The chest wall
– Low-energy mechanisms & stab wounds rarely cause important injuries to the chest wall, except for intercostal artery lacerations or single rib fractures. – High-energy shotgun wounds can cause significant bony & soft tissue damage.
penetrating thoracic trauma in adults 2. Lungs – – – – –
Pneumothorax Hemothorax pulmonary contusion (high energy) pulmonary laceration bronchopleural fistula (uncommon) Hemorrhage within the lung parenchyma occurs at the time of trauma followed by interstitial edema, which usually begins within one to two hours and peaks at 24 hours following injury.
penetrating thoracic trauma in adults • 15 to 30 %of penetrating thoracic injuries require surgery, < 10% of injuries from blunt chest trauma. • 4 % of patients with penetrating chest injuries have major vascular injuries. • Penetrating tracheobronchial wounds – associated with concurrent esophageal and major vascular injures in approximately 30 % of cases. – 3 % sustains Cardiac injuries & are associated with high mortality. (the acute accumulation of 50 mL of blood can cause tamponade. )
•Chen JD, Shanmuganathan K, Mirvis SE, et al. Using CT to diagnose tracheal rupture. Am J Roentgenol 2001; 176:1273.
penetrating thoracic trauma in adults 5. Aorta and thoracic great vessels –
most patients with such wounds expire in the field. – vascular injury can present as massive hemothorax, necessitating immediate decompression and emergency operative intervention.
•Demetriades D. Penetrating injuries to the thoracic great vessels. J Card Surg 1997; 12:173.
penetrating thoracic trauma in adults 3. Tracheobronchial tree – less common in penetrating trauma than in blunt trauma and generally involve the cervical trachea. – often go unrecognized because early symptoms and signs of the injury are nonspecific. – partial tears of the trachea and complete or partial tears of the bronchi may not be detected until the development of sequelae • tracheoesophageal fistula • mediastinitis • empyema. •Chen JD, Shanmuganathan K, Mirvis SE, et al. Using CT to diagnose tracheal rupture. Am J Roentgenol 2001; 176:1273.
penetrating thoracic trauma in adults Diaphragm • Stab or gunshot wounds to the lower chest often entail injury of the diaphragm. • The diaphragm can rise up to the level of the 4th intercostal space during exhalation and thus penetrating wounds of the thorax can involve intraabdominal organs as well. • The diaphragmatic injury severity scale is as follows: – – – – –
Grade I: Contusion Grade II: Laceration ≤2 cm Grade III: Laceration 2 to 10 cm Grade IV: Laceration >10 cm; tissue loss ≤25 cm2 Grade V: Laceration and tissue loss >25 cm2
penetrating thoracic trauma in adults Diaphragm • Penetrating mechanisms to the thoracoabdominal region, account for about 65 % of all diaphragmatic injuries • Blunt mechanisms account for the remaining 35 % of diaphragmatic injuries occur in 0.8 to 1.6% of patients sustaining blunt trauma. • Motor vehicle collisions are responsible for up to 90 % of blunt diaphragm rupture with the remainder due to falls or crush injury.
•National Trauma Data Base. American College of Surgeons 2000-2004.
•Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients. J Trauma 1986; 26:438.
penetrating thoracic trauma in adults • For blunt trauma, the percent of patients with a given injury who also have a traumatic diaphragmatic rupture are: – – – – – – – – – –
liver Hemothorax /pneumothorax Spleen Rib fracture Bowel Kidney Pelvic fracture Closed head injury Thoracic aorta Spinal cord injury
48 % 47 % 35 % 28 % 23 % 16 % 14 % 11 % 4% 4%
penetrating thoracic trauma in adults • Findings on CT scan suggestive of diaphragm injury include: – – – – –
Discontinuity of the diaphragm Herniation of the abdominal contents into the chest Abnormal positioning of a nasogastric tube Waist-like constriction of bowel Dependence of the viscera meaning that the viscera (liver, stomach) are in direct contact with the posterior ribs – Contiguous injury from one side of the diaphragm to the other (ie, left pulmonary laceration and splenic laceration) Murray JA, Demetriades D, Asensio JA, et al. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 1998; 187:626 Murray JA, Demetriades D, Cornwell EE 3rd, et al. Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. J Trauma 1997; 43:624 •Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 2002;.
penetrating thoracic trauma in adults Management of Diaphragm injury • 31%of the patients found to have diaphragmatic injury on laparoscopy had no abdominal tenderness and normal chest radiograph was seen in 40 %. • CT scanners (16 slice) have a sensitivity of 87 % and specificity of 99 %
• Laparoscopy has a sensitivity of 88 % and a specificity approaching 100 % in the diagnosis of diaphragmatic injury • All injuries of the diaphragm are detected by thoracoscopy • Direct transabdominal repair of acute diaphragmatic injuries
•Gangahar R, Doshi D. FAST scan in the diagnosis of acute diaphragmatic rupture. Am J Emerg Med 2010; 28:387.e1. •Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 2005; 58:789.
penetrating thoracic trauma in adults Important signs during patient Evaluation • • • • •
Hemodynamic instability Persistent shortness of breath A foreign body sensation in the throat or change in voice Diminished breath sounds Jugular venous distension Subcutaneous air (crepitus)
Initial Evaluation and Management The primary survey : * Airway assessment and protection (while maintaining cervical spine stabilization) * Breathing and ventilation assessment * Circulation assessment * Disability assessment * Exposure, with environmental control
Radiological Evaluation and Management of penetrating thoracic trauma in adults Supine AP chest radiographs may not detect the presence of a small or medium sized pneumothorax so ultrasound examination of the chest is recommended looking for pneumothorax, to be performed in all patients with penetrating chest trauma.
Rowan KR, Kirkpatrick AW, Liu D, et al. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT--initial experience. Radiology 2002; 225:210. Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005; 12:844.
Evaluation of Patients with penetrating thoracic trauma in adults The Secondary Survey • In hemodynamically unstable patient with penetrating thoracic trauma Definitive management must not be delayed to perform a more detailed secondary evaluation. • Such patients are taken directly to the operating room or angiography suite, or transferred to a major trauma center.
Evaluation and Management of penetrating thoracic trauma in adults • Injuries may not manifest initially. • Early studies showed that 2 to 12 % of initially asymptomatic patients with a normal AP chest X-ray at presentation are at risk for subsequently developing a pneumothorax or hemothorax. • The negative predictive value of plain radiographs to diagnose these injuries increases to nearly 100 % if repeated six hours after presentation Ordog GJ, Wasserberger J, Balasubramanium S, Shoemaker W. Asymptomatic stab wounds of the chest. J Trauma 1994; 36:680. Shatz DV, de la Pedraja J, Erbella J, et al. Efficacy of follow-up evaluation in penetrating thoracic injuries: 3- vs. 6-hour radiographs of the chest. J Emerg Med 2001; 20:281. Seamon MJ, Medina CR, Pieri PG, et al. Follow-up after asymptomatic penetrating thoracic injury: 3 hours is enough. J Trauma 2008; 65:549.
Evaluation and Management of penetrating thoracic trauma in adults Indications for obtaining a chest CT in a hemodynamically stable patient: * Trajectory of a penetrating object crosses the mediastinum or middle of the chest. * Symptoms or signs concerning for esophageal or tracheobronchial or vascular injury are present. * Chest pain, shortness of breath, or other symptoms consistent with injury are present that are not explained adequately by a plain chest radiograph. Burack JH, Kandil E, Sawas A, et al. Triage and outcome of patients with mediastinal penetrating trauma. Ann Thorac Surg 2007; 83:377.
EMERGENCY DEPARTMENT THORACOTOMY (EDT) • performed in the emergency department to resuscitate trauma patients who have just sustained or are on the verge of cardiac arrest. • A left anterolateral thoracotomy enables knowledgeable clinicians to perform several potentially life-saving maneuvers including – Pericardotomy to decompress pericardial tamponade – Temporary repair of penetrating myocardial wounds – Cross-clamping of the descending thoracic aorta (thereby preventing exsanguinating hemorrhage in the abdomen and increasing perfusion of the brain and heart) – Open cardiac massage. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons. Committee on Trauma. Practice management guidelines for emergency department thoracotomy. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. J Am Coll Surg 2001; 193:303.
EMERGENCY DEPARTMENT THORACOTOMY (EDT) Only Justified in the following conditions: # Patient manifests signs of life in the field or the hospital AND # Patient has penetrating thoracic trauma and is hemodynamically unstable despite appropriate fluid resuscitation OR has not been pulse less for longer than 15 minutes AND # A thoracic or trauma surgeon is available within approximately 45 minute Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons. Committee on Trauma. Practice management guidelines for emergency department thoracotomy. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. J Am Coll Surg 2001; 193:303.
Anatomy of The Chest Wall
Anatomy of The Arterial Wall
92
93
94
Zones of The Neck
Anatomy of The Chest Wall
Anatomy and physiology • The rib cage, intercostal muscles, and costal cartilage form the basic structure of the chest wall. • In addition, neurovascular bundles comprised of an intercostal nerve, artery and vein run along each rib. • The inner lining of the chest wall is the parietal pleura. • The visceral pleura covers the major thoracic organs between the two is a potential space with a small amount of lubricating fluid.
Blunt chest trauma ED management
Diagnosis of blunt aortic injury
Varient Classifications of Aortic Dissection
101
CT Scan – calcification of the true wall
103
Pneumo-mediastinum
Sagital (spinEcho) MRI Aortic Dissection Type B 105
Diagnosis of Aortic Dissection Electron Beam CT Scan
106
Diagnosis of Aortic Dissection -TEE
107
Aortic Dissection
Pathology
108
Aortic Dissection Pathology
109
Diagnosis of Aortic Dissection Type B
Angiogram 110
TEE Displacement of aortic atheroma
111
TEE aortic flap Aortic Dissection type A 112
Type A Dissection (Echocardiogram)
113
Anatomy of the thoracic outlet
Tension Pneumothorax
penetrating thoracic trauma in adults 2. Lungs – – – – –
Pneumothorax Hemothorax pulmonary contusion (high energy) pulmonary laceration bronchopleural fistula (uncommon) Hemorrhage within the lung parenchyma occurs at the time of trauma followed by interstitial edema, which usually begins within one to two hours and peaks at 24 hours following injury.
