THORACIC TRAUMA

Nolan Ortega Aludino, M.D.Department of Surgery

Ospital ng Maynila Medical Center

General Data: N.A.

35 years oldMale

Pandacan Manila

Chief Complaint: Stab wound

History of Present Illness

� Few minutes PTC ! patient was allegedlyattacked with a knife byan unknown assailant for no apparent reason

Consult

Physical Examination

� General Survey:� Conscious, coherent, in distress

� Vital SignsBP = 90/60 CR = 110 RR = 27

Physical Examination

� HEENT:� pink palpebral conjunctivae, anicteric sclerae,

PERLA, supple neck� Chest:

� Symmetrical chest expansion, no retractions, decreased breath sounds on the Left lung field, (+) crepitations on Left lateral thoracic wall

Physical Examination

� Stab wound level of the 4th

intercostal Left MAL

Physical Examination

� Cardiac:� tachycardic, regular rhythm, no murmur

Physical Examination

� Abdomen: � Flat, soft, nontender, no mass

� Extremities:� Full and equal pulses, no deformities

Salient Features

� 35 y/o� Male� Cardiorespiratory distress� Stabwound, LMAL� Decreased Breath Sounds� Crepitations

Initial Impression

CertaintyDiagnosis

15%Non

Penetrating Chest Injury

Secondary Diagnosis

85%Penetrating Chest Injury

Primary Diagnosis

Paraclinical Diagnostic Procedure

� Do I need to perform a paraclinicaldiagnostic procedure?

�YES�

Options

Not readily available(++++)Exposure to

radiation

Sensitivity: Pneumothorax: (+++)Hemothorax: (+++)

CT-Scan

available(++)No radiation exposure

Sensitivity: Pneumothorax: (++)Hemothorax:(+)

Ultrasound

available(+)Exposure to radiation

Sensitivity: Pneumothorax: (+)Hemothorax:(+)

X-Ray

AvailabilityCostRiskBenefit

Chest X-ray

Pre Treatment Diagnosis

Pneumohemothorax, Left

secondary to penetrating chest injury

GOALS OF TREATMENT

� Resolution of hemothorax� Resolution of pneumothorax� Monitor for ongoing bleeding

Treatment Options

available(+)-Injury to adjacent structure

-Useful in small hemothorax-incomplete evacuation

Thoracentesis

available(++)- Injury to adjacent structure

-Complete evacuation of fluid-can monitor ongoing bleeding-hemostatic

Tube Thoracostomy

AvailabilityCostRiskBenefit

Management

CLOSED TUBE THORACOSTOMY, LEFT

Preoperative Preparation

� Informed consent� Provide psychosocial support� Optimize patient condition

� Hydration� Antibiotics

Operative technique

� Patient semi-sitting with the ipsilateral arm placed above the head to expose the lateral aspect of the chest

� chest prepared with antiseptic solution� draped to create a sterile field� large bore chest tube (F36) chosen to

facilitate adequate drainage

Operative technique

� 5th ICS midaxillary line identified and skin, periosteum, and pleura anesthesized with 1% lidocaine

� transverse incision made over the underlying space

� blunt dissection continued with Kelly clamp� clamp passed adjacent to the superior

surface of the rib to prevent injury to the intercostals neurovascular bundle

Operative technique

� entry into the pleural space confirmed with rush of blood-filled fluid

� finger inserted into the pleural space to identify any pleural adhesions

� Fr 36 chest tube inserted into the pleural space on a Kelly clamp and directed posteriorly

� tube secured with a silk 0 suture

Operative technique

� attached to a water sealed thora-bottle� insertion site dressed gauze and covered

with air-tight dressing� initial and subsequent drainage recorded� post-procedure chest film obtained

Operative Findings

� 400cc of fresh non clotted blood evacuated

Postoperative Management

� Adequate analgesia� Monitoring of CT output

Protocol on CTT

� May proceed to thoracotomy if:� initial output is ≥ 1000 cc of blood� There is continuous CTT output of more than

150cc/hour

TUBE THORACOSTOMY

HEMOTHORAX

Complete evacuationNo ongoing bleeding<1/3 lung volume

RetainedCollection>1/3 lung volume

MAINTAIN CTT AND OBSERVE

SUCTION

Protocol on CTT

Post CTT CXR

� Marked resolution of Pneumohemothorax

Final Diagnosis

Pneumohemothorax, LeftSecondary to Penetrating Stab Wound

COURSE IN THE WARD

� 1st Hospital Day� DAT� Adequate Antibiotic� Adequate Analgesia� Blow bottle exercises

COURSE IN THE WARD

� 2nd-3rd Hospital Day� DAT� Adequate Antibiotic� Adequate Analgesia� Blow bottle exercises� Change of thora bottle

COURSE IN THE WARD

� 4th Hospital Day� Repeat CXR done� Chest tube removed

COURSE IN THE WARD

� 5th Hospital Day� Patient discharged

PREVENTION AND HEALTH PROMOTION

� Advise given to patient regarding� Possible complications� Proper wound care� OPD follow up

DISCUSSION

THORACIC TRAUMA

� blunt trauma� penetrating trauma� both

THORACIC TRAUMA

� motor vehicle crashes� blast injuries� falls from heights� blows to the chest� chest compression� Gunshot� stab wounds

THORACIC TRAUMA

� Thoracic injuries include:� Skeletal� Pulmonary� Heart� great vessels� diaphragm

THORACIC TRAUMA

Potentially lethal injuries:� flail chest� Hemothorax� Pneumothorax� tension pneumothorax� myocardial contusion� sucking chest wound� cardiac tamponade� aortic rupture� diaphragmatic rupture

Hemothorax

� collection of blood in the pleural space� may be caused by blunt or penetrating

trauma

Hemothorax

� Most are the result of:� rib fractures� lung parenchymal� minor venous injuriesand as such are self-limiting

� Less commonly there is an arterial injury, more likely to require surgical repair.

Pneumothorax

� the collection of air in the pleural space� air may come from:

� injury to the lung tissue� bronchial tear� chest wall injury allowing air to be sucked in

from the outside.

Pneumothorax

� Simple pneumothorax� A simple

pneumothorax is a non-expanding collection of air around the lung.

Pneumothorax

� Tension pneumothorax� the progressive build-

up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return.

Complications

� Retained Haemothorax� Empyema

Complications

� Failure to adequately drain a haemothorax:� initially results in residual, clotted

haemothorax which will not drain via a chest tube

� left untreated, these retained haemothoracesmay become infected and lead to empyemaformation

Complications

� If uninfected:� clot will organise and fibrose� resulting in a loss of lung volume ! impaired

pulmonary function

Complications

� Surgery:� indicated if there is evidence of empyema

(fever, raised white cell count, air-fluid levels on CT)

� haemothorax is large enough to cause lung volume loss

� should be performed early, within the first 3-7 days following injury

References� Fallon W, Barnosci A, Mancuso C, Injury to the Chest,

Complications and Management: Experience at a Level I Trauma Center, Top Emerg Med 1990.

� Etoch SW, Bar-Natan MF, Miller FB, Richardson JD, Tube thoracostomy. Factors related to complications. Arch Surg. 1995.

� Eggerstedt JM: Hemothorax. eMedicine Journal [serial online]. 2002. Available at: http://www.emedicine.com/med/topic2915.htm

� Shahani R, Penetrating Chest Trauma, eMedicine eMedicineJournal [serial online]. 2004. Available at: http://www.emedicine.com/med/topic2916.htm.

� Thoracic trauma, htto://www.trauma.org 9:2, 2004.� Handheld ultrasound better at detecting trauma induced occult

pneumothoraces, http://www.diagnosticimaging.com.

Questions

#1 (MCQ)On CXR, one intercostal space of

hemothorax approximates how many cc of blood?

a. 100b. 150c. 200d. 250

Questions

#1 (MCQ)On CXR, one intercostal space of

hemothorax approximates how many cc of blood?

a. 100b. 150c. 200d. 250

Questions

#2 (MCQ)The progressive build-up of air within the

pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return is also known as:

a. Simple pneumothoraxb. Open pneumothoraxc. Tension pneumothoraxd. All of the above

Questions

#2 (MCQ)The progressive build-up of air within the

pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return is also known as:

a. Simple pneumothoraxb. Open pneumothoraxc. Tension pneumothoraxd. All of the above

Questions

#3 (MCR)According to OMMC Department of Surgery

Protocol, thoracotomy is indicated in the following conditions:

(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Initial output of 1,000 cc2. Initial output of 1,500 cc3. Output of ≥150 cc/hour4. Output of ≥ 200 cc/hour

Questions

#3 (MCR)According to OMMC Department of Surgery

Protocol, thoracotomy is indicated in the following conditions:

(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Initial output of 1,000 cc2. Initial output of 1,500 cc3. Output of ≥150 cc/hour4. Output of ≥ 200 cc/hour

Questions

#4 (MCR)The following are possible complications of tube

thoracostomy(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Empyema2. Retained hemothorax3. Volume loss4. Subcutaneous emphysema

Questions

#4 (MCR)The following are possible complications of tube

thoracostomy(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Empyema2. Retained hemothorax3. Volume loss4. Subcutaneous emphysema

Questions

#4 (MCR)The following are possible complications of tube

thoracostomy(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Empyema2. Retained hemothorax3. Volume loss4. Subcutaneous emphysema

Questions#5 (MCR)Indications for Chest tube suctioning includes the

following:(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Non fluctuating chest tube2. Retained hemothorax occupying more than 1/4

of the lung field3. Output greater than 150 cc/hour4. Retained hemothorax occupying more than 1/3

of the lung field

Questions#5 (MCR)Indications for Chest tube suctioning includes the

following:(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Non fluctuating chest tube2. Retained hemothorax occupying more than 1/4

of the lung field3. Output greater than 150 cc/hour4. Retained hemothorax occupying more than 1/3

of the lung field