Chest Trauma and Indication for Thoracotomy

Chest Trauma and Indications for ThoracotomyDr.Sami Alnassar

Primary surveyAim to identify life threatening chest injuryTension pnemothoraxMassive hemothoraxCardiac temponadeFlail chestOpen pneumothrax

EXAMINATIONLOOK

FEEL

LIESTEN

PERCUSS

EXAMINATIONLOOK

FEEL

LISTEN

PERCUSS

Examination

Dont forget to examine the back??

DIAGNOSTIC IMIGINGCXR

FAST

secondary surveyIs more detailed and completed examination to Identified :

Ribs fractures , flial chestLung contusionSimple pneumothoraxSimple haemothorax

Secondary surveyFurther diagnostic study :Chest CTBroncoscopyAngiogramOesophagoscopy / oesophagram

Tension Pneumothraxis the progressive build-up of air within the pleural space Usually due to a lung laceration Classical signs : deviation of the trachea increased percussion note hyper-expanded chest Increase CVP ( may be normal ? )

Tension pneumothraxThese classical signs may be absenttachycardia and tachypnea, and may be hypoxia. These signs are followed by circulatory collapse with hypotension and PEA

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

Tension PneumothraxTension pneumothorax may also persist if there is an injury to a major airway 2 or more CT may be needed

in these cases thoracotomy is usually indicated

Bilateral tension PneumothoraxBeware also the patient with bilateral tension pneumothoraces

treatmentNeedle Thoracostomy

Chest tube placement

Possible thoracotomy or thoracoscopy

Tracheo-broncheal injuryIts rare ,from 0.2 to 4%

Most victims die prior to ER

80% within 2.5 from carina

Main stem 86%

More common in right side

Tracheo-broncheal injurySigns and symptoms :StriderHoarsenessHemptysisPnemothorax with major air leakUp to 10% will not produce any clinical or radiological signs ( recognized months after stricture occurBronchoscopy is the most reliable test

Tracheo-broncheal injuryIntraoperative airway management :Coordinate with anesthesiologistSterile anesthesia circuitDouble lumen tubeTracheostomy if needed 2-3 rings above the injured segmentPostoperative airway management :Maintained low airway pressureAllows immediate extubation

Tracheo-broncheal injurySurgical approach :Extrathoracic consider collar incisionRT thoracotomy for RT bronchial and proximal leftLT thoracotomy for distal LT bronchial injuryDebriment , mucosa to mucosa, absorbable sutureReinforce suture line with pericardium, pleura,..Outcome:>90 of patient reach hospital alive, have good outcome

Tracheo-broncheal injury

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

Open Pneumothoraxoccurs when there is a pneumothorax associated with a chest wall defectair is entrained into the chest cavity not through the trachea but through the hole in the chest wall.

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

Open PneumothoraxDiagnosis should be made clinically Sucking chest wall wound

managementsOxygenation and possible intubations if in distressOcclusive dressing to the woundImmediate CT insertionIf no CT available , bandage may be applied over the wound and taped on 3 sides OR for closure of the defect

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

hemothoraxCXR is the standard test

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

hemothoraxFAST is useful in unstable patient , it detect small hemothoraxCT is more sensitive testIt detect other associated injury

managementsCT insertion first

Thoracotomy indicated if immediate drainage of 1000-1500mls of blood Or 200ml for 4 hoursHowever the initial volume of blood drained is not as important as the amount of on-going bleeding

Tension hemothorax

Flail chestoccurs when a segment of the thoracic cage is separated from the rest of the chest wall. it defined as at least two fractures per rib , in at least two ribs. Usually associated lung contusionIt result in impaired ventilation

Diagnosisparadoxical movement of a segment of the chest wall CXR and CT established the diagnosis

Flail Chestit directed toweredProtected underling lungMaintain ventilationPrevent pneumoniaAnalgesia is the main treatmentPCA and NSAIDEpidural is the best option ( elderly )Intubations and mechanical ventilation is rarely indicated

managementsOperative Fixation by wires or plates indicated inPatient going for thoracotomyFixed thoracic impactionFailure to wean from ventilator

Operative fixation

Operative fixation(Judet plates )

Operative fixation(Sanchez plates )

Thoracoscopy for trauma patients (carllio AJS 2005)DIAGNOSTIC APPLICATIONS :DIAGNOSIS OF DIAPHRAGMATIC INJURIES DIAGNOSIS OF PERSISTENT HEMORRHAGE DIAGNOSIS OF BRONCHOPLEURAL FISTULAS ASSESSMENT OF CARDIAC AND MEDIASTINAL STRUCTURES THERAPEUTIC APPLICATIONS MANAGEMENT OF RETAINED THORACIC COLLECTIONS REPAIR OF DIAPHRAGMATIC INJURIES

Emergency Department Thoracotomy

Accepted Indications :Penetrating thoracic injury :Traumatic arrest with previously witnessed cardiac activity Unresponsive hypotension (BP < 70mmHg) Blunt thoracic injury Unresponsive hypotension (BP < 70mmHg)Rapid exsanguination from chest tube (>1500ml)


Relative Indications :Penetrating thoracic injury Traumatic arrest without previously witnessed cardiac activity Penetrating non-thoracic injury :Traumatic arrest with previously witnessed cardiac activity Blunt thoracic injuries:Traumatic arrest with previously witnessed cardiac activity


Contraindications :Blunt injuries:Blunt thoracic injuries with no witnessed cardiac activityMultiple blunt trauma Severe head injury

Emergency Department ThoracotomyRationale

Overall survival of patients undergoing emergency thoracotomy is between 4 and 33% The main determinants for survivability are the mechanism of injury For penetrating thoracic injury the survival rate is fairly uniform at 18-33%

Emergency Department ThoracotomyRationale

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

Emergency Department ThoracotomyOperative Technique

The primary aims of emergency thoractomy are:Release of cardiac tamponade Control of haemorrhage Allow access for internal cardiac massage Secondary manoeuvers cross-clamping of the descending thoracic aorta.


Approach :A supine anterolateral thoracotomy left sided approach is used in all patients and with injuries to the left chest Patients who are not arrested but with profound hypotension and right sided injuries have their right chest opened first.


Approach :In both cases it may become necessary to extend the incision across the sternum skin incision is made in the 5th intercostal space Relief of tamponade :The pericardium is opened longitudinally to avoid damage to the phrenic nerve,


Control of haemorrhage :Cardiac wounds :controlled initially with direct finger pressure. sutured using non-absorbable 3/0 sutures mattress sutures are used to avoid obstructing coronary flow Pulmonary & Hilar injuries. temporarily controlled with finger pressure at the pulmonary hilum.

Emergency Department ThoracotomyOperative TechniqueControl of haemorrhage:Pulmonary & Hilar injuries :This may be augmented by placement of a Satinsky clamp across the hilum Lesser haemorrhage from the lung parenchymas can be controlled with a temporary clamp Great vessel injuries :Small aortic injuries can be sutured directly using the 3/0


Larger injuries, especially to the arch may require temporary digital occlusion and insitution of cardiac bypass. Internal cardiac massage internal cardiac massage should be started as soon as possible A two-handed technique produces a better cardiac output


Aortic cross-clamping :The rationale for clamping the aorta is to redistribute blood flow to the coronary vessels, lungs and brain, Clamp time should ideally be 30 minutes or less. Cross-clamping is done ideally at the level of the diaphragm, to maximise spinal cord perfusion


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Chest Trauma and Indication for Thoracotomy