Blunt and Penetrating Chest Trauma Heather Patterson PGY-1 Core Rounds Oct 13. 2005 Rob Hall MD FRCPC

Blunt and PenetratingBlunt and PenetratingChest TraumaChest Trauma

Heather PattersonHeather PattersonPGY-1PGY-1

Core Rounds Oct 13. 2005Core Rounds Oct 13. 2005Rob Hall MD FRCPCRob Hall MD FRCPC

ObjectivesObjectives

Blunt TraumaBlunt Trauma::- Flail Chest and Pulmonary Contusion- Flail Chest and Pulmonary Contusion- Tracheobronchial injury - Tracheobronchial injury - Myocardial Contusion- Myocardial Contusion- TAI- TAI- Indications for CT chest in blunt trauma- Indications for CT chest in blunt trauma

Penetrating TraumaPenetrating Trauma::- Preparation- Preparation- Management of stable and unstable patients- Management of stable and unstable patients- ED Thoracotomy- ED Thoracotomy- Pericardial Tamponade- Pericardial Tamponade

Case 1Case 1

85yo male85yo male PMHx: COPD, CAD, CHF, AfibPMHx: COPD, CAD, CHF, Afib Passenger of small car vs pick up truck; Passenger of small car vs pick up truck;

impact at his doorimpact at his door Unconscious on EMS arrival, GCS now 12Unconscious on EMS arrival, GCS now 12 Hemodynamically stableHemodynamically stable SATS 91% on NRB 10 L/minSATS 91% on NRB 10 L/min Right sided subcutaneous air, tendernessRight sided subcutaneous air, tenderness RUQ tendernessRUQ tenderness

Case 1Case 1

DIAGNOSIS?

PROGNOSIS?

MANAGEMENT OF THISPATIENT?

“PROPHYLACTIC CHEST TUBE”

Flail Chest:Flail Chest:DefinitionDefinition

Occurs when 3 or more adjacent ribs are Occurs when 3 or more adjacent ribs are fractured at 2 locations creating a freely fractured at 2 locations creating a freely moving segment of the chest wall.moving segment of the chest wall.

Disturbs normal respiratory physiology:Disturbs normal respiratory physiology:– Paradoxical mov’t of flail segment disrupts Paradoxical mov’t of flail segment disrupts

ventilation.ventilation.– Splinting may cause atelectasis, decreased Splinting may cause atelectasis, decreased

cardiac output, and hypoxemiacardiac output, and hypoxemia– Underlying injuries may also contribute to Underlying injuries may also contribute to

disrupted respiratory physiologydisrupted respiratory physiology

Flail Chest:Flail Chest:PathophysiologyPathophysiology

Why is a Flail Chest a bad injury? Why is a Flail Chest a bad injury?

(List FIVE mechanisms of respiratory (List FIVE mechanisms of respiratory failure with a Flail Chest).failure with a Flail Chest).– Splinting/hypoventilationSplinting/hypoventilation– Atelectasis and V/Q mismatchingAtelectasis and V/Q mismatching– Underlying pulmonary contusion Underlying pulmonary contusion – Underlying hemo or pneumothoraxUnderlying hemo or pneumothorax– Paradoxical chest wall movement (MINOR)Paradoxical chest wall movement (MINOR)

Flail Chest:Flail Chest:Does this look normal to you?Does this look normal to you?

Flail Chest Management:Flail Chest Management:Which do you prefer?Which do you prefer?

Flail Chest:Flail Chest:ManagementManagement

Good Supportive Care:Good Supportive Care:– O2O2– Careful fluid managementCareful fluid management– Clear spines ASAP so patient can be sittingClear spines ASAP so patient can be sitting– Manage tracheal-bronchial toiletManage tracheal-bronchial toilet– Chest physioChest physio

AVOID chest restriction (devices or bad side down)AVOID chest restriction (devices or bad side down)

Analgesia:Analgesia:– May include intercostal nerve blocks and epidural anesthesiaMay include intercostal nerve blocks and epidural anesthesia

BiPAP has been tried (CAUTION with elderly or multitrauma BiPAP has been tried (CAUTION with elderly or multitrauma patients)patients)

Intubation for respiratory failureIntubation for respiratory failure– Increased risk for pneumoniaIncreased risk for pneumonia

Pulmonary Contusion:Pulmonary Contusion:EpidemiologyEpidemiology

Epidemiology:Epidemiology:– Present in 30-75% of patients with Present in 30-75% of patients with

significant blunt chest traumasignificant blunt chest trauma– Association with flail chestAssociation with flail chest– Mortality:Mortality:

Adults 5-35%Adults 5-35% Children 24-43%Children 24-43%

Pulmonary Contusion:Pulmonary Contusion:CXRCXR

Pulmonary Contusion:Pulmonary Contusion:CXRCXR

Pulmonary Contusion:Pulmonary Contusion:CTCT

Pulmonary Contusion:Pulmonary Contusion:ThoracotomyThoracotomy

Pulmonary Contusion:Pulmonary Contusion:ImagingImaging

CXR findings:CXR findings: Patchy alveolar infiltrate to frank consolidation Patchy alveolar infiltrate to frank consolidation Limited to affected segments or lobes Limited to affected segments or lobes Usually present on initial exam, always Usually present on initial exam, always

present in 4-6 hours present in 4-6 hours

CTCT Not necessary for diagnosis but allows early Not necessary for diagnosis but allows early

detection of contusion.detection of contusion. Contusion vs atelectasis can be difficultContusion vs atelectasis can be difficult

Pulmonary ContusionPulmonary Contusion

PulmonaryPulmonary

ContusionContusionARDSARDS

TimingTiming Immediate – Immediate – 4 hours4 hours

Delayed ~ Delayed ~ 24-48 hours24-48 hours

LocationLocation Segmental or Segmental or lobarlobar

AsymmetricAsymmetric

DiffuseDiffuse

SymmetricSymmetric

DurationDuration 24-48 hours24-48 hours VariableVariable

Can you see the difference?Can you see the difference?

Pulmonary Contusion: Pulmonary Contusion: ManagementManagement

Supportive: Supportive: – IV fluid restrictionIV fluid restriction– Tracheobronchial toiletTracheobronchial toilet– SuctioningSuctioning– Pain reliefPain relief– +/- steroids+/- steroids

BiPAP has been usedBiPAP has been used IntubationIntubation

– Differential intubation when indicatedDifferential intubation when indicated

Pulmonary Contusion: Pulmonary Contusion: ManagementManagement

Cohn 1997. J Trauma. Pulmonary Contusion: Review Cohn 1997. J Trauma. Pulmonary Contusion: Review of the clinical entity.of the clinical entity.

Fluid resuscitation:Fluid resuscitation:– Conflicting evidence. ? Increased capillary Conflicting evidence. ? Increased capillary

permeability leading to increased alveolar permeability leading to increased alveolar edema with high volumes of fluid resuscitationedema with high volumes of fluid resuscitation

Prophylactic ABx and steriodsProphylactic ABx and steriods– No studies supporting use of prophylactic ABx in No studies supporting use of prophylactic ABx in

this clinical settingthis clinical setting– No human studies demonstrating clinical benefit No human studies demonstrating clinical benefit

for corticosteriod use in this clinical settingfor corticosteriod use in this clinical setting

Pulmonary Contusion:Pulmonary Contusion:ManagementManagement

Cohn 1997. J Trauma. Pulmonary Contusion: Review Cohn 1997. J Trauma. Pulmonary Contusion: Review of the clinical entityof the clinical entity..

Ventilation:Ventilation:– Only for respiratory distressOnly for respiratory distress– CT is able to classify extent of injury CT is able to classify extent of injury

more accurately than CXR. more accurately than CXR. Wagner et al 1989 predicated the need for Wagner et al 1989 predicated the need for

ventilation based on airspace consolidationventilation based on airspace consolidation All patients with > 28% consolidation All patients with > 28% consolidation

required ventilation. required ventilation. CLINICIANS TRUMP RADIOLOGISTS

Case 2Case 2

19yo male riding a motorbike19yo male riding a motorbike Car hit him from the side then took offCar hit him from the side then took off GCS 3, intubated on sceneGCS 3, intubated on scene BP 70, HR 120, Sats 85%, NRB 15 BP 70, HR 120, Sats 85%, NRB 15

L/minL/min MASSIVE subcutaneous emphysema MASSIVE subcutaneous emphysema

on anterior chest, left side of chest, on anterior chest, left side of chest, neckneck

Case 2Case 2

As you cut As you cut skin for a skin for a chest tube, chest tube, you get a you get a gush of air gush of air from the from the subcutaneousubcutaneous space s space

Tracheobronchial Injury:Tracheobronchial Injury:EpidemiologyEpidemiology

Occurs in less than 3% of patients Occurs in less than 3% of patients with significant chest injurywith significant chest injury

Why do we worry about this?Why do we worry about this? Overall mortality of 30%Overall mortality of 30% 50% of those who die will do so in the first 50% of those who die will do so in the first

hourhour

Tracheobronchial Injury:Tracheobronchial Injury:MechanismMechanism

– Results from penetrating and blunt Results from penetrating and blunt trauma. trauma.

– Blunt: Blunt: direct blows direct blows crush injury crush injury shearing forces shearing forces produces injuries at fixed produces injuries at fixed

pointspoints sudden increase in intrabronchial pressure sudden increase in intrabronchial pressure

burst injuryburst injury

* Classically, all injuries will occur within * Classically, all injuries will occur within 2.5 cm of the carina2.5 cm of the carina

Tracheobronchial Injury:Tracheobronchial Injury:Diagnosis Diagnosis

When to be suspicious of a TB injury?When to be suspicious of a TB injury?– Massive subcutaneous air in chestMassive subcutaneous air in chest– Subcutaneous air in the neckSubcutaneous air in the neck– Persistent pneumothorax despite functioning chest Persistent pneumothorax despite functioning chest

tubetube– Persistent air leak from chest tubePersistent air leak from chest tube– HemoptysisHemoptysis– Hamman’s crunchHamman’s crunch– CXR findings CXR findings

pneumopericardium or pneumomediastinum pneumopericardium or pneumomediastinum Persistent medial pleural pneumothorax despite chest tubePersistent medial pleural pneumothorax despite chest tube Subcutaneous air Subcutaneous air Localized air around bronchusLocalized air around bronchus

Tracheobronchial Injury:Tracheobronchial Injury:Management Management

ManagementManagement– Multiple chest tubesMultiple chest tubes– Intubation over a bronchoscope ideal but often not Intubation over a bronchoscope ideal but often not

practical. Blind intubation may result in placement practical. Blind intubation may result in placement into soft tissues or false passageinto soft tissues or false passage

– Selective intubation of GOOD lungSelective intubation of GOOD lung Should be done under Bronchoscopic guidance; could be Should be done under Bronchoscopic guidance; could be

done blind in periphery if last resortdone blind in periphery if last resort Anesthesia can place double lumen tubesAnesthesia can place double lumen tubes Right: blind advancement (not too far)Right: blind advancement (not too far) Left: bouigee turned to the leftLeft: bouigee turned to the left

– Requires thoracotomy with tracheostomy and Requires thoracotomy with tracheostomy and surgical repair of transected airway in most cases. surgical repair of transected airway in most cases.

Case 3Case 3

Blunt chest traumaBlunt chest trauma No pneumothorax on CXRNo pneumothorax on CXR CT chest shows small apical pneumo; CT chest shows small apical pneumo;

patient stablepatient stable Management:Management:

– Non-intubated patient?Non-intubated patient?– Intubated patient?Intubated patient?

Occult Pneumothorax: Occult Pneumothorax: the the evidenceevidence

Enderson BL, j Enderson BL, j Truama 1999; Truama 1999; 46:987-91.46:987-91.– N = 40N = 40– Randomized to chest Randomized to chest

tube or observationtube or observation– Ventilation in 15/21 Ventilation in 15/21

observed and 12/19 observed and 12/19 with chest tubewith chest tube

– ObservationObservation 53% had progression 53% had progression

(40% were tension)(40% were tension)

Brasel KJ. J Trauma Brasel KJ. J Trauma 1999; 46; 987-91999; 46; 987-9– N= 39N= 39– Randomized Randomized – 9 in each group 9 in each group

ventilatedventilated– 2/9 (22%) 2/9 (22%)

progressed to need progressed to need chest tube in chest tube in observation group, observation group, neither were tensionneither were tension

Occult Pneumothorax: Occult Pneumothorax: the the evidenceevidence

Local publishingLocal publishing– Chad Ball. Can J Surg. Vol 46 (5). Oct Chad Ball. Can J Surg. Vol 46 (5). Oct

2003. P. 3737-379.2003. P. 3737-379. This is a good review of occult This is a good review of occult

pneumothoraxpneumothorax

– Chad Ball. J Trauma. Aug 2005. Vol Chad Ball. J Trauma. Aug 2005. Vol 59(2). 1-8.59(2). 1-8. This is a retrospective review of incidence, This is a retrospective review of incidence,

risk factors, and outcomes of occult pneumo risk factors, and outcomes of occult pneumo from our regional trauma databasefrom our regional trauma database

Occult PneumothoraxOccult Pneumothorax

O b se rva tionR e p e at C X R s

S tab leN o t m u lt i-tra u m a

N o t in tu b a ted

C h e st T u be

S tab leM u lti-tra u m aN o t in tu b a ted

C ra p py u n de rlyin g lu n gs

C h es t tu be

U n sta b leIn tub a ted /V e ntila ted

O ccu lt P n e u m o tho rax

Case 4Case 4

9 yo boy9 yo boy Run over by TractorRun over by Tractor Blunt trauma to chest and upper abdBlunt trauma to chest and upper abd Splenic lac being conservatively Splenic lac being conservatively

managedmanaged Chest tube placed for left pthrxChest tube placed for left pthrx Admitted to PICU for observationAdmitted to PICU for observation Peds Intensivist asks you to order a Peds Intensivist asks you to order a

Troponin to “rule out” a blunt cardiac Troponin to “rule out” a blunt cardiac injuryinjury

Blunt Myocardial Injury:Blunt Myocardial Injury:EpidemiologyEpidemiology

EpidemiologyEpidemiology– Due to the diagnostic challenge, in Due to the diagnostic challenge, in

severe closed chest trauma the severe closed chest trauma the incidence ranges between 3-75% incidence ranges between 3-75%

– The gold standard for diagnosis is the The gold standard for diagnosis is the presence of necrotic myocardial cells at presence of necrotic myocardial cells at autopsyautopsy

BCI: BCI: Clinical PresentationClinical Presentation

Due to the variability of sequelae after Due to the variability of sequelae after BMI, presentation is variable.BMI, presentation is variable.

The most common non specific finding The most common non specific finding is sinus tachycardiais sinus tachycardia

Pain is often unrelieved by analgesia Pain is often unrelieved by analgesia and may mimic ACSand may mimic ACS

73% of BMI have associated injuries 73% of BMI have associated injuries and external evidence of chest traumaand external evidence of chest trauma

BCI:BCI:DiagnosisDiagnosis

Study Weaknesses:Study Weaknesses:– No GOOD gold standard for the diagnosis of No GOOD gold standard for the diagnosis of

blunt cardiac injury thus all studies looking at blunt cardiac injury thus all studies looking at tests for BCI are flawedtests for BCI are flawed

– Different range for abN troponin valuesDifferent range for abN troponin values– Timing of measurement variedTiming of measurement varied– Variable severity of trauma patients included in Variable severity of trauma patients included in

studiesstudies– Most excluded those with pre-existing cardiac Most excluded those with pre-existing cardiac

diseasedisease– Small numbers in most studiesSmall numbers in most studies– Variable outcome measuresVariable outcome measures


Bansal et al 2005 EMJ; Myocardial contusion Bansal et al 2005 EMJ; Myocardial contusion injury: redefining the diagnostic injury: redefining the diagnostic algorhythmalgorhythm..

noted 40-83% of patients with BCI have noted 40-83% of patients with BCI have ECG changesECG changesMay see:May see:

ArhythmiasArhythmias Conduction disturbancesConduction disturbances ST changesST changes

AbN ECG may reflect:AbN ECG may reflect: IschemiaIschemia Enhanced purkinje automaticityEnhanced purkinje automaticity abN electrical conduction in poorly perfused regionsabN electrical conduction in poorly perfused regions


Jackson 2005 Best Evidence Topic Report: Use of Jackson 2005 Best Evidence Topic Report: Use of troponin for the diagnosis of myocardial contusion troponin for the diagnosis of myocardial contusion after blunt chest trauma. Emergency Medicine Journalafter blunt chest trauma. Emergency Medicine Journal

– Review of 75 papers with 6 having “best Review of 75 papers with 6 having “best evidence to answer clinical question”evidence to answer clinical question”

– TnT TnT Sensitivity 0.31 - 0.63 Sensitivity 0.31 - 0.63 Specificity 0.71-0.91Specificity 0.71-0.91

– TnITnI Sensitivity 1Sensitivity 1 Specificity 0.68 -0.87Specificity 0.68 -0.87Concluded that “troponins” are a sensitive indicator for Concluded that “troponins” are a sensitive indicator for

myocardial damage.myocardial damage.

BCI: BCI: DiagnosisDiagnosis

Edouard et al 2004 Anesthsiology;Edouard et al 2004 Anesthsiology; Incidence and Incidence and Significance of Cardiac Troponin I Resease in Severe Significance of Cardiac Troponin I Resease in Severe Trauma Patients. Trauma Patients. – 728 trauma ICU patients all received TnI and ECG. 728 trauma ICU patients all received TnI and ECG. – Significant BCI found in 5% (95% CI)Significant BCI found in 5% (95% CI)– TnI:TnI:

Sensitivity = 63%Sensitivity = 63% Specificity = 98%Specificity = 98% PPV = 40%PPV = 40% NPV = 98%NPV = 98%

– TnI levels to not have prognostic valueTnI levels to not have prognostic value No significant different in mortality between those with or No significant different in mortality between those with or

without TnI release. without TnI release. – TnI is released in many severe trauma patients during TnI is released in many severe trauma patients during

hyperadrenergic states inducing myocardial contraction hyperadrenergic states inducing myocardial contraction bands in absence of a significant direct myocardial injurybands in absence of a significant direct myocardial injury


Velmahos et al 2003. J Trauma. Normal Velmahos et al 2003. J Trauma. Normal Electrocardiography and Serum Troponin l Levels Electrocardiography and Serum Troponin l Levels Preclude the Presence of Clinically Significant Blunt Preclude the Presence of Clinically Significant Blunt Cardiac InjuryCardiac Injury

333 significant blunt thoracic trauma patients 333 significant blunt thoracic trauma patients followed prospectivelyfollowed prospectively

Serial ECG and TnI Serial ECG and TnI ECG:ECG:

– Sensitivity: 89%Sensitivity: 89%– Specificity: 67%Specificity: 67%– PPV: 29%PPV: 29%– NPV: 98%NPV: 98%


TnI:TnI:– Sensitivity: 73%Sensitivity: 73%– Specificity: 60%Specificity: 60%– PPV: 21%PPV: 21%– NPV: 94%NPV: 94%

Normal ECG and TnI at 8 hours rules out Normal ECG and TnI at 8 hours rules out significant BCIsignificant BCI– Sensitivity 100%Sensitivity 100%– Specificity 71%Specificity 71%– PPV 34%PPV 34%– NPV 100%NPV 100%

BCI:BCI:Imaging - ECHO Imaging - ECHO

Symbrandy et al 2003 Heart: Diagnosing Cardiac Symbrandy et al 2003 Heart: Diagnosing Cardiac Contusion: Old wisdom and new insights.Contusion: Old wisdom and new insights.

ECHO:ECHO:– May demonstrate wall motion abnormalities, May demonstrate wall motion abnormalities,

valvular dysfunction, thrombosis, and valvular dysfunction, thrombosis, and effusions.effusions.

– Can use both TTE and TEE for trauma patientsCan use both TTE and TEE for trauma patients TEE has been established as a safe procedure for TEE has been established as a safe procedure for

blunt trauma patientsblunt trauma patients Bansal et al concluded that TEE is an effective BCI Bansal et al concluded that TEE is an effective BCI

screening tool screening tool


Bansal et al 2005 EMJ; Myocardial contusion injury: Bansal et al 2005 EMJ; Myocardial contusion injury:

redefining the diagnostic algorhythmredefining the diagnostic algorhythm.. Based on a review of current Based on a review of current

literature, suggested:literature, suggested:

Copyright ©2005 BMJ Publishing Group Ltd.

Bansal, M K et al. Emerg Med J 2005;22:465-469

Approach to Myocardial Approach to Myocardial Contusion/Blunt Cardiac Contusion/Blunt Cardiac

InjuryInjury

M in o r Tra u m aN o t g o in g fo r C T c h e st

D o n 't lo ok

S T O P

N o rm a l E C GN o ne w ch an g es

C a rd iac M o n ito r X 1 2 h rsE ch oca rd io g ra p hy

S t d ep ress ion , p ro fo un d T w ave inv e rs io n ,co n du c tion a bn o rm a lity

M o n ito r fe w ho u rs , co rre ctlyte s e tc , re p e a t E C G

N o n sp ec if ic S Tch a ng es

E C G u sed asa s sc re en in g te st

N o A p p are n tC a rd ia c C o m plica tio ns

C a rd ia c M o n ito rE ch oca rd io g ra p hy

A rryth m ia s , C H F,C a rd iog e n ic S h o ck

A p p are n t C a rd iac C om p lica tio ns

M a jo r C h e s t Tra u m aG o in g fo r C T ch e st

W he n to go loo kin g?

Case 5Case 5

MVC 100km/hr, hit MVC 100km/hr, hit wall, shoulder belt wall, shoulder belt didn’t lock, chest didn’t lock, chest hit steering wheelhit steering wheel

Investigations?

Case 5Case 5

MVC 100km/hr, hit MVC 100km/hr, hit wall, shoulder belt wall, shoulder belt didn’t lock, chest didn’t lock, chest hit steering wheelhit steering wheel

Investigations?

Traumatic Aortic InjuryTraumatic Aortic InjuryPathophysiologyPathophysiology

– Ascending aorta: Ascending aorta: shearing forces just above the aortic valve shearing forces just above the aortic valve

are created by rapid displacement of the are created by rapid displacement of the heart in rapid deceleration and chest heart in rapid deceleration and chest compression.compression.

– Thoracic aorta: Thoracic aorta: arch is relatively mobile when compared to arch is relatively mobile when compared to

the thoracic aorta which is tethered by the thoracic aorta which is tethered by intercostal arteries and lig. Arteriosum. intercostal arteries and lig. Arteriosum.

Rapid deceleration causes shearing forces at Rapid deceleration causes shearing forces at the isthmus.the isthmus.

TAI:TAI:Clinical PresentationClinical Presentation

Any patient with a deceleration injury pattern should be Any patient with a deceleration injury pattern should be evaluated for TAI. Can be masked by symptoms of other evaluated for TAI. Can be masked by symptoms of other injuries.injuries.

Symptoms:Symptoms:– Interscapular or retrosternal pain is only present in 25% of Interscapular or retrosternal pain is only present in 25% of

patients with TAIpatients with TAI– Other uncommon symptoms include: stridor, hoarseness, Other uncommon symptoms include: stridor, hoarseness,

dyspnea, dysphagia, extremity paindyspnea, dysphagia, extremity pain Signs:Signs:

– Generalized hypertension is possible.Generalized hypertension is possible.– Harsh systolic murmur (1/3 of patients)Harsh systolic murmur (1/3 of patients)– Upper extremity hypertension +/- lower extremity pulse deficit Upper extremity hypertension +/- lower extremity pulse deficit

and paralysisand paralysis– Anterior chest contusionAnterior chest contusion– Initial chest tube output of >750 mlInitial chest tube output of >750 ml

None reliable enough to rule out!

TAI: Diagnostic StrategiesTAI: Diagnostic StrategiesCXRCXR


Sinclair 2002 Emergency Radiology; Traumatic aortic Sinclair 2002 Emergency Radiology; Traumatic aortic injury: an imaging reviewinjury: an imaging review

CXR changes depend on the CXR changes depend on the detecting a mediastinal hematoma – detecting a mediastinal hematoma – an indirect sign of aortic injuryan indirect sign of aortic injury

Normal CXR are seen in 2-5% of Normal CXR are seen in 2-5% of patients with TAI patients with TAI

Recent Studies suggest the sensitivity may be asLow as 90% in patients with high MOI

TAI:TAI:CXRCXR

– Findings include:Findings include: Mediastinal widening (? > 8cm)Mediastinal widening (? > 8cm)

– Sensitivity = 81-100%Sensitivity = 81-100%– Specificity = 10-60%Specificity = 10-60%

Obscuration of the aortic knob Obscuration of the aortic knob – Sensitivity = 53-100%Sensitivity = 53-100%– Specificity = 21-55%Specificity = 21-55%

Displacement of NG or trachea to the rightDisplacement of NG or trachea to the right Left apical pleural capLeft apical pleural cap Widened paraspinal lineWidened paraspinal line Widened right paratacheal stripe >5mmWidened right paratacheal stripe >5mm Loss of descending aortic lineLoss of descending aortic line Depression of L mainstem bronchus or elevation of Depression of L mainstem bronchus or elevation of

right mainstem bronchus right mainstem bronchus

–Sensitivity of CXR for detecting mediastinal Sensitivity of CXR for detecting mediastinal hemorrage >90%hemorrage >90%

TAI:TAI:CXRCXR

Gleeson et al 2001 EMJ; The mediastinum Is it wide?Gleeson et al 2001 EMJ; The mediastinum Is it wide?

– Demonstrated that xray technique in Demonstrated that xray technique in trauma bays can magnify the normal trauma bays can magnify the normal mediastinum up to 10-12.5 cm. mediastinum up to 10-12.5 cm.

Gleeson et al 2001

Supine vs Upright CXRSupine vs Upright CXR


O’Conor 2004 EMJ; Diagnosing Traumatic Rupture of O’Conor 2004 EMJ; Diagnosing Traumatic Rupture of the thoracic aorta in the emergency department the thoracic aorta in the emergency department (review)(review)

Ratio of mediastinal width to thorax Ratio of mediastinal width to thorax width at the level of the aortic knob.width at the level of the aortic knob.– Controversial evidenceControversial evidence

Several authors of papers reviewed Several authors of papers reviewed commented that it is the overall commented that it is the overall contour of the mediastinum that leads contour of the mediastinum that leads to further investigation.to further investigation.

TAI: Diagnostic StrategiesTAI: Diagnostic StrategiesCTCT

Sinclair 2002 Emergency Radiology; Traumatic aortic Sinclair 2002 Emergency Radiology; Traumatic aortic injury: an imaging review.injury: an imaging review.

Helical CT:Helical CT:– Sensitivity: 90 - 100Sensitivity: 90 - 100– Specificity: 81 – 89Specificity: 81 – 89

Recommended further imaging in all Recommended further imaging in all inconclusive scansinconclusive scans

TAI:TAI:CTCT

O’Conor 2004 EMJ; Diagnosing traumatic rupture of the thoracic O’Conor 2004 EMJ; Diagnosing traumatic rupture of the thoracic aorta in the emergency department.aorta in the emergency department.

Hemodynamically unstable patients with clinical Hemodynamically unstable patients with clinical features or findings suggestive for TAI on CXR should features or findings suggestive for TAI on CXR should procede to OR thoracotomyprocede to OR thoracotomy– They may go directly to OR for management of They may go directly to OR for management of

head/belly/pelvis but CT chest is NEEDED prior to aorta repair head/belly/pelvis but CT chest is NEEDED prior to aorta repair Stent vs open repairStent vs open repair Thoracotomy vs sternotomyThoracotomy vs sternotomy Extent of branch vessel involvementExtent of branch vessel involvement

Hemodynamically stable patients with clinical features Hemodynamically stable patients with clinical features or CXR findings suggestive for TAI are appropriate or CXR findings suggestive for TAI are appropriate candidates for contrast enhanced helical CT.candidates for contrast enhanced helical CT.

Diagnostic scans are sufficient for OR thoracotomy, Diagnostic scans are sufficient for OR thoracotomy, equivocal scans should precede to angiography.equivocal scans should precede to angiography.

Traumatic Aortic Injury Traumatic Aortic Injury PearlsPearls

CT chest is the diagnostic study of choice and CT chest is the diagnostic study of choice and has replaced angiogramshas replaced angiograms– Accurate, quantifies amount of bleeding, good view of mid arch level, gives Accurate, quantifies amount of bleeding, good view of mid arch level, gives

measurements for size of stent, gives info for involvement of branch vesselsmeasurements for size of stent, gives info for involvement of branch vessels

Vascular surgery will operate based on CT Vascular surgery will operate based on CT chest chest

Endovascular STENTS are the method of choice Endovascular STENTS are the method of choice for surgical repairfor surgical repair– Endovascular Stent Grafts for Acute Blunt Aortic Injury. Dunham, Moore et. al. Endovascular Stent Grafts for Acute Blunt Aortic Injury. Dunham, Moore et. al.

J Trauma June 2004. Vol 56(6) p 1173-1178.J Trauma June 2004. Vol 56(6) p 1173-1178.– Place in OR with echo guidance, heparin X 1 dosePlace in OR with echo guidance, heparin X 1 dose

Timing of endovascular stentsTiming of endovascular stents– Multisystem trauma with CHI: delayed stent placement has been shown to Multisystem trauma with CHI: delayed stent placement has been shown to

decrease mortality from 20% to 10%; CT chest q24hrs fro monitoringdecrease mortality from 20% to 10%; CT chest q24hrs fro monitoring– Stable isolated arch injuries: OR ASAP for stentStable isolated arch injuries: OR ASAP for stent

Traumatic Aortic Injury Traumatic Aortic Injury PearlsPearls

Our patient has a BP of 160/100 and HR 120Our patient has a BP of 160/100 and HR 120 Management of hypertension?Management of hypertension?

– Risk: hemodynamic instabilityRisk: hemodynamic instability– Benefit: decreased bleeding, decreased ruptureBenefit: decreased bleeding, decreased rupture– Pain control firstPain control first– Labetolol 10 – 20 mg iv until double product Labetolol 10 – 20 mg iv until double product

downdown– Esmolol if borderlineEsmolol if borderline– No nitroglycerin in isolationNo nitroglycerin in isolation

Indications for CT chest with Indications for CT chest with blunt traumablunt trauma

Abnormal CXRAbnormal CXR Multisystem trauma patientMultisystem trauma patient High Mechanism of Injury (even with High Mechanism of Injury (even with

normal looking CXR)normal looking CXR)– High speed MVCHigh speed MVC– MVC with ejectionMVC with ejection– Fall from great heightFall from great height– Hard to be more specific (NOT studied)Hard to be more specific (NOT studied)

ObjectivesObjectives

Blunt TraumaBlunt Trauma::- Flail Chest and Pulmonary Contusion- Flail Chest and Pulmonary Contusion- Tracheobronchial injury - Tracheobronchial injury - Myocardial Contusion- Myocardial Contusion- TAI- TAI- Indications for CT chest in blunt trauma- Indications for CT chest in blunt trauma

Penetrating TraumaPenetrating Trauma::- Preparation- Preparation- Management of stable and unstable patients- Management of stable and unstable patients- Fluids and Hypotension- Fluids and Hypotension- ED Thoracotomy- ED Thoracotomy- Pericardial Tamponade- Pericardial Tamponade

Case 6Case 6

Middle aged maleMiddle aged male Shot while driving car on deerfootShot while driving car on deerfoot Paramedics patch: Multiple GSWs to Paramedics patch: Multiple GSWs to

chest, abdomen, and neck, BP 60, HR chest, abdomen, and neck, BP 60, HR 140, one 18guage iv, see you in 5 140, one 18guage iv, see you in 5 minmin

Penetrating Trauma:Penetrating Trauma:EMSEMS

Scoop and RunScoop and Run IV fluids will not save a lifeIV fluids will not save a life Intubation will not save a lifeIntubation will not save a life

Penetrating TraumaPenetrating Trauma

Penetrating chest trauma ETA 5 min. Penetrating chest trauma ETA 5 min. What are you doing?What are you doing?

A) Finishing your A) Finishing your weak and dizzy weak and dizzy history in bed 75. history in bed 75.

B) Heading for the B) Heading for the nearest exit.nearest exit.

C) Hanging out with the monkeys in C) Hanging out with the monkeys in Nicaragua!Nicaragua!

D) You are already prepared and D) You are already prepared and waiting in the trauma bay! (You waiting in the trauma bay! (You even practiced on nursing staff last even practiced on nursing staff last week!)week!)

Preparation for unstable Preparation for unstable penetrating traumapenetrating trauma

Gowns, double gloves, masksGowns, double gloves, masks Airway equipmentAirway equipment Two 14 guage iv.s for chest decompressionTwo 14 guage iv.s for chest decompression Two chest tube trays open and readyTwo chest tube trays open and ready Central line kit openCentral line kit open TWO Bertha’s primed with bloodTWO Bertha’s primed with blood Call Trauma surgeon: Level I call out so OR awareCall Trauma surgeon: Level I call out so OR aware ED U/S machine at bedside, on, lubedED U/S machine at bedside, on, lubed Have RN draw Ketamine/SuccHave RN draw Ketamine/Succ ED thoracotomy kit out; GET BIG FOLEY, stapler, silk ED thoracotomy kit out; GET BIG FOLEY, stapler, silk

sutures ready if it sounds like an EDT casesutures ready if it sounds like an EDT case Identify who is going to do what: IMPORTANTIdentify who is going to do what: IMPORTANT!!

Case 6 continuedCase 6 continued

Paramedics arriveParamedics arrive Has had 1L bolus NSHas had 1L bolus NS Not intubatedNot intubated Agonal resps, being baggedAgonal resps, being bagged BP 80 HR 140 Sats 92% NRB BP 80 HR 140 Sats 92% NRB

UnconsciousUnconscious This guy needs a lot of things and FAST, This guy needs a lot of things and FAST,

what order are you going to do things?what order are you going to do things?

The FIRST 10 min of The FIRST 10 min of unstable unstable

penetrating chest traumapenetrating chest trauma 1. 1. Needle decompress both sides of chestNeedle decompress both sides of chest 2. Intubate (nothing or ketamine/succ)2. Intubate (nothing or ketamine/succ) 3. Establish good iv access and give blood 3. Establish good iv access and give blood

– Does NOT have to be centralDoes NOT have to be central– Think of where to go: above and below injuryThink of where to go: above and below injury

4. Place bilateral chest tubes4. Place bilateral chest tubes 5. Perform a FAST starting at cardiac 5. Perform a FAST starting at cardiac

windowwindowWHAT IS THE EVIDENCE FOR CONTROLLED FLUID RESUSCITATION?

Penetrating Trauma:Penetrating Trauma:Fluid ResuscitationFluid Resuscitation

Bickell et al 1994 NEMJ; Immediate vs delayed fluid Bickell et al 1994 NEMJ; Immediate vs delayed fluid resuscitation for hypotensive patients with resuscitation for hypotensive patients with penetrating torso injuries.penetrating torso injuries.

Prospective trial of 598 adults with Prospective trial of 598 adults with penetrating torso injuries presenting penetrating torso injuries presenting with SBP<90mmHg.with SBP<90mmHg.

Immediate fluid group – standard fluid Immediate fluid group – standard fluid resuscitationresuscitation

Delayed group – IV but no fluids until Delayed group – IV but no fluids until OROR

Penetrating Trauma:Penetrating Trauma:Fluid ResuscitationFluid Resuscitation

Treatment Treatment GroupGroup

Survival and Survival and d/c homed/c home

(p = 0.04)(p = 0.04)

ComplicatioComplications ns

(p = 0.08)(p = 0.08)

ImmediateImmediate

(n = 309)(n = 309)193 193

62%62%69/22769/227

(30%)(30%)

DelayedDelayed

(n = 289)(n = 289)203203

70%70%55/23855/238

(23%)(23%)

Penetrating Trauma:Penetrating Trauma:Target BP?Target BP?

Dutton et al 2002 Journal of Trauma; Hypotensive resuscitation during Dutton et al 2002 Journal of Trauma; Hypotensive resuscitation during active hemorrhage: Impact on in-hospital mortalityactive hemorrhage: Impact on in-hospital mortality

110 patients in hemorrhagic shock were randomized 110 patients in hemorrhagic shock were randomized to 2 fluid protocols:to 2 fluid protocols:

Target SBP>100Target SBP>100 Target SBP>70 Target SBP>70

51% were penetrating trauma victims51% were penetrating trauma victims 24% in each group were chest trauma24% in each group were chest trauma

Avg SBP was 114 =+/-12 vs 100 +/- 17Avg SBP was 114 =+/-12 vs 100 +/- 17 Duration of hemorrhage was not significantly Duration of hemorrhage was not significantly

differentdifferent Survival 92.7% in both groups with 4 deaths per Survival 92.7% in both groups with 4 deaths per

groupgroup Concluded that may be due to imprecision of SBP as Concluded that may be due to imprecision of SBP as

a marker for tissue 02 delivery.a marker for tissue 02 delivery.

Case 6 continued:Case 6 continued:

This guy lost his pulseThis guy lost his pulse Monitor shows slow and wide PEAMonitor shows slow and wide PEA Management?Management?

ED Thoracotomy:ED Thoracotomy:Why?Why?

Karmy-Jones et al 2004 J of Trauma; Urgent and Karmy-Jones et al 2004 J of Trauma; Urgent and Emergent Thoracotomy for Penetrating Chest Emergent Thoracotomy for Penetrating Chest Trauma.Trauma.

Suggested 6 possible therapeutic goals:Suggested 6 possible therapeutic goals:– Control of bleeding – identification and Control of bleeding – identification and

management of vascular hilum injuriesmanagement of vascular hilum injuries– Release of pericardial tamponade and repair of Release of pericardial tamponade and repair of

cardiac injuries.cardiac injuries.– Effective cardiac compressions Effective cardiac compressions – Cross clamping the pulmonary hilum in Cross clamping the pulmonary hilum in

suspected air embolussuspected air embolus– Cross claming the descending aorta for lower Cross claming the descending aorta for lower

torso hemorrhage (controversial)torso hemorrhage (controversial)– Confirming proper ETT placementConfirming proper ETT placement

ED Thoracotomy:ED Thoracotomy:Who?Who?

Rhee et al 2000 J of American College of Surgeons. Rhee et al 2000 J of American College of Surgeons. Survival after emergency department thoracotomy: Survival after emergency department thoracotomy: review of published data form the past 25 yearsreview of published data form the past 25 years.. (abstract only)(abstract only)

Reviewed 24 studies for a total of 4620 patients Reviewed 24 studies for a total of 4620 patients with blunt or penetrating traumawith blunt or penetrating trauma– 14 studies exclusively thoracic trauma patients14 studies exclusively thoracic trauma patients

SOL in hospital = 11.5%SOL in hospital = 11.5% SOL in transport = 8.9%SOL in transport = 8.9% No SOL in field = 1.2%No SOL in field = 1.2% Blunt trauma = 1.4% Blunt trauma = 1.4% Penetrating = 8.8%Penetrating = 8.8%

– GSW = 4.3%GSW = 4.3%– SW = 16.8%SW = 16.8%


Ladd et al. 2002 American Surgeon. Ladd et al. 2002 American Surgeon. Emergency Room Thoracotomy: Updated Emergency Room Thoracotomy: Updated Guidelines for a Level 1 Trauma CentreGuidelines for a Level 1 Trauma Centre

Evaluated the survival rates in Evaluated the survival rates in patients undergoing EDT following patients undergoing EDT following the 1995 EDT guidelines:the 1995 EDT guidelines:– Penetrating chest injuriesPenetrating chest injuries– SOL in ED or loss of SOL in EDSOL in ED or loss of SOL in ED– No EDT for those who lose SOL in No EDT for those who lose SOL in

transport or without SOL at scenetransport or without SOL at scene


79 patients79 patients– GSW = 65, SW = 14GSW = 65, SW = 14

2.6% overall survival. 2.6% overall survival. Cannot explain lack of improvement Cannot explain lack of improvement

in survival with current data.in survival with current data.

ED Thoracotomy:ED Thoracotomy:Do we follow these guidelines?Do we follow these guidelines?

Miglietta et al. 2001 Journal of Trauma. Current Opinion Miglietta et al. 2001 Journal of Trauma. Current Opinion Regarding Indications for Emergency Department Regarding Indications for Emergency Department Thoracotomy.Thoracotomy.

304 surveys completed by trauma surgeons. 304 surveys completed by trauma surgeons. Lack of agreement on what qualifies as SOLLack of agreement on what qualifies as SOL

EDT:EDT:Do we follow the guidelines? Do we follow the guidelines?

Lack of agreement on Lack of agreement on indications for EDT indications for EDT based on specific based on specific clinical scenariosclinical scenarios– 2/3 responded they 2/3 responded they

would perform EDT for would perform EDT for blunt trauma in specific blunt trauma in specific clinical situations, clinical situations, although they although they recognized that EDT recognized that EDT was indicated “more was indicated “more often” for penetrating often” for penetrating trauma.trauma.

EDT:EDT:At what risk?At what risk?

Sikka et al. 2004 J Trauma. Analysis of Sikka et al. 2004 J Trauma. Analysis of Occupational Exposures Associated with Occupational Exposures Associated with Emergency Department Thoracotomy.Emergency Department Thoracotomy.

Hep C prevalence in ED patients:Hep C prevalence in ED patients:– 7.7-18.8%7.7-18.8%

HIV prevalence in ED patients:HIV prevalence in ED patients:– 7.1-14.6%7.1-14.6%

No current data for exposure rates No current data for exposure rates during EDT but hypothesized to be during EDT but hypothesized to be significant. significant.

Indications for ED Indications for ED ThoracotomyThoracotomy

1.1. Loss of vital signs in EDLoss of vital signs in ED

2.2. Loss of vital signs in transport to ED Loss of vital signs in transport to ED and short down time (? < 10 min)and short down time (? < 10 min)

3.3. Peri-mortem condition in ED and OR Peri-mortem condition in ED and OR not immediately available (< 5-10 not immediately available (< 5-10 min)min)

Indications for OR Indications for OR ThoracotomyThoracotomy

1.1. Initial tube drainage >20ml/kg of Initial tube drainage >20ml/kg of bloodblood

2.2. Persistent bleeding at >4-7ml/kg/hrPersistent bleeding at >4-7ml/kg/hr

3.3. Increasing hemothorax seen on CXRIncreasing hemothorax seen on CXR

4.4. Persistent hypotension despite Persistent hypotension despite adequate flood replacement AND adequate flood replacement AND other sites of blood loss ruled outother sites of blood loss ruled out

5.5. Patient decompensates after initial Patient decompensates after initial response to resuscitation.response to resuscitation.

Case 7:Case 7: 35 yo male35 yo male Involved in knife fightInvolved in knife fight Right anterior chest wound from a small knifeRight anterior chest wound from a small knife HR 110 BP 150/90 Sats normal on RA, AlertHR 110 BP 150/90 Sats normal on RA, Alert Exam normal except woundExam normal except wound CXR normal (SITTING); FAST -veCXR normal (SITTING); FAST -ve Management?Management?

– A: CT chestA: CT chest– B: Observation, repeat CXR 6hrs, home if normalB: Observation, repeat CXR 6hrs, home if normal– C: Local wound exploration, CT if positiveC: Local wound exploration, CT if positive– D: Consult trauma and let them decide D: Consult trauma and let them decide

Investigation of Stable Investigation of Stable Patients Patients

with penetrating chest with penetrating chest traumatrauma

Evolving standard of care seems to be CT Evolving standard of care seems to be CT chest for all but obviously minor injurieschest for all but obviously minor injuries

There is no definitive literature on this issueThere is no definitive literature on this issue Ask the trauma surgeonsAsk the trauma surgeons

– Kirkpatrick: all should get CT chestKirkpatrick: all should get CT chest– Kortbeek: most should get CT chest; penetrating Kortbeek: most should get CT chest; penetrating

injuries with trajectories definitely outside the injuries with trajectories definitely outside the mediastinum, above the abdomen, and not in mediastinum, above the abdomen, and not in the thoracic outlet can be managed with CXR the thoracic outlet can be managed with CXR alonealone

Stable Penetrating chest Stable Penetrating chest traumatrauma

-ve FAST-ve FAST No major injuries on CT chestNo major injuries on CT chest Does the CT chest replace the Does the CT chest replace the

angiogram, bronchoscopy, angiogram, bronchoscopy, esophagoscopy?esophagoscopy?– Basically yes although controversial and Basically yes although controversial and

we don’t have to make that decisionwe don’t have to make that decision

““Disposition” of Penetrating Disposition” of Penetrating Chest TraumaChest Trauma

E D T h o ra co to m y

L o ss o f v ita ls en rou te ,in E D , o r p e ri-m o rtem

in E D

T o O R fo rS te rno to m y

H e m od yn a m ic In sta b ility

T o O R fo rS te rno to m y(o r to C T fo r

fu rthe r de fin it io n )

F A S T + ve fo rP e rica rd ia l E ffu s ion

T o C T scan

F A S T -ve fo rP e rica rd ia l E ffu s ion

H e m od yn a m ica lly S ta b le

P e n e tra tin g C h e stT ra u m a

What about chest vs What about chest vs abdomenalabdomenal

penetration?penetration? Remember the black Remember the black boxbox

NO FAST availableNO FAST available– Laparatomy + Laparatomy +

pericardial window pericardial window (open chest if +Ve)(open chest if +Ve)

FAST –veFAST –ve– Laparotomy +/- Laparotomy +/-

pericardial windowpericardial window FAST +VEFAST +VE

– Laparotomy + Laparotomy + sternotomysternotomy

BOX

Acute Pericardial Tamponade:Acute Pericardial Tamponade:EpidemiologyEpidemiology

2% of patients with penetrating 2% of patients with penetrating trauma to the chest or upper trauma to the chest or upper abdomenabdomen

More common in SW than GSWMore common in SW than GSW– 60-80% of patients with SW to the heart 60-80% of patients with SW to the heart

develop tamponadedevelop tamponade

Acute Pericardial Tamponade:Acute Pericardial Tamponade:FASTFAST

Diku et al 2004. Emergency Medicine Clinics. Diku et al 2004. Emergency Medicine Clinics.

Bedside echocardiography in chest traumaBedside echocardiography in chest trauma.. Plummer et al 1992. Plummer et al 1992.

– 10 year retrospective review of 10 year retrospective review of penetrating cardiac trauma patientspenetrating cardiac trauma patients

– Demonstrated echo group had a shorter Demonstrated echo group had a shorter time to dx (15.5 vs 42.4 min) and better time to dx (15.5 vs 42.4 min) and better survival (100% vs 57.1%)survival (100% vs 57.1%)

Acute Pericardial Tamponade:Acute Pericardial Tamponade:FASTFAST

Ma et al 1995. J Trauma. Prospective Analysis Ma et al 1995. J Trauma. Prospective Analysis of a Rapid Trauma Ultrasound Examination of a Rapid Trauma Ultrasound Examination Performed by Emergency Physicians.Performed by Emergency Physicians.

– 245 ED ultrasounds looking for free fluid 245 ED ultrasounds looking for free fluid in the pericardial sacin the pericardial sac 6 positive findings (confirmed by formal 6 positive findings (confirmed by formal

echo)echo) 238 true-negative results, 1 false-positive, 238 true-negative results, 1 false-positive,

and no false-negativesand no false-negatives Sensitivity =100% Specificity = 99% specificSensitivity =100% Specificity = 99% specific

Acute Pericardial Tamponade:Acute Pericardial Tamponade:ManagementManagement

Asensio et al 2001 Surgery Today; Penetrating Asensio et al 2001 Surgery Today; Penetrating

Cardiac Injuries: A complex challengeCardiac Injuries: A complex challenge. . Subxiphoid pericardial window – gold Subxiphoid pericardial window – gold

standard for diagnosis of cardiac standard for diagnosis of cardiac injuryinjury

Should be performed in the OR Should be performed in the OR unless EDT indicated. unless EDT indicated.

Take Home PointsTake Home Points

Flail chest and pulmonary contusionFlail chest and pulmonary contusion– Intubate for respiratory failureIntubate for respiratory failure

Tracheobronchial injuryTracheobronchial injury– Multiple chest tubes.Multiple chest tubes.– Intubate good lung with bronchoscope if Intubate good lung with bronchoscope if

possible. possible. – To OR.To OR.

BCIBCI– Role of TnI and ECG still under debateRole of TnI and ECG still under debate

Take Home PointsTake Home Points

TAITAI– CT chest is the diagnostic study of CT chest is the diagnostic study of

choice.choice.

Penetrating TraumaPenetrating Trauma– Be prepared! Be prepared! – EDT in specific situationsEDT in specific situations– CT chest for all but obviously minor CT chest for all but obviously minor

injuriesinjuries

Documents

Blunt and Penetrating Chest Trauma Heather Patterson PGY-1 Core Rounds Oct 13. 2005 Rob Hall MD FRCPC