chest trauma - w1.med.cmu.ac.th · •great vessel injury •cardiac tamponade •loss of chest...
TRANSCRIPT
CHEST TRAUMA
OBJECTIVES
• สามารถบอกความส าคญั และ อนัตรายทีเ่กดิจากการบาดเจ็บ
ของทรวงอกได ้
• สามารถใหก้ารวนิิจฉัย และ รกัษาเบือ้งตน้เพือ่ชว่ยชวีติในผูป่้วย
ทีม่ี immediate life-threatening chest trauma
• สามารถใหก้ารวนิิจฉัย สบืคน้เพิม่เตมิ และบอกแนวทางการ
รกัษาในผูป่้วยทีม่ี potential life-threatening chest
trauma
INTRODUCTION
• High morbidity and mortality
• Need for surgery (Thoracotomy)
Blunt ~ 10%
Penetrating ~ 25%
• Most : Treat successfully with ICD only
APPROACH
TO
CHEST TRAUMA
Immediate Life-threatening
• Acute airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest
• Massive hemothorax
• Cardiac tamponade
• Air embolism
Impair ventilation
Impair Circulation
Potential Life-threatening condition
• Ribs fracture
• Simple pneumothorax
• Simple hemothorax
• Great vessel injury
• Tracheobronchial tree injury
Potential Life-threatening condition
• Esophageal injury
• Blunt myocardial injury
• Lung contusion
Tension Pneumothorax
• Collection of large amount of air in pleural
cavity result in mediastinal shift and lung
collapse
• Air leakage from lung laceration / airway injury
• Most treatable life-threatening condition
Tension Pneumothorax
Symptoms and Signs (clinical diagnosis)
• Respiratory distress
• Hypotension
• Tracheal deviation, neck vein distension
• Hyperresonance on percussion
• Absent or decrease breath sound
Tension Pneumothorax
Management
• Immediate decompression without CXR
• Needle thoracocentesis with large bore
needle at 5th ICS, anterior to midaxillary line
• Finger decompression
• ICD at 5th ICS just anterior to midaxillary line
Open Pneumothorax
• Sucking chest wound
• Diagnosis : Open wound at chest wall with air
entrance and / or exit through wound
• If large defect (> 2/3 trachea diameter) : Air pass
preferentially through defect
• One way valve : develop tension pneumothorax
Open Pneumothorax
Management
• Temporary closure defect with 3-sided sterile
occlusive dressing
• ICD remote to defect
• Closure of defect : suture or close all side
Flail Chest
• Multiple segmental ribs fracture ( > 2 adjacent
ribs)
• Anterior or lateral part of chest wall
• Diagnosis : Paradoxical chest movement
• Respiratory failure
Flail Chest
Respiratory failure due to
• Pain : restricted chest movement
• Lung contusion
• Pneumothorax & Hemothorax
• Loss of normal lung mechanics
Flail Chest
Management
• High flow Oxygen supplement
• ICD
• Consider need for Endotracheal intubation with mechanical ventilator
• Pain control
• Prevent crystalloid fluid overload
Flail Chest
Definitive treatment
• Surgery : SRF (Surgical ribs fixation)
Lung Contusion
• Direct injury to parenchyma
• V/Q mismatch result in acute hypoxia
• S/S : normal to respiratory failure
• Respiratory failure may be subtle and develop
later (require monitoring and reevaluation)
Lung Contusion
Management
• Observe and monitor respiration, O2 saturation,
ABG
• Selective intubation with mechanical ventilation
• Avoid crystalloid fluid over load : can worsening
lung contusion and may result in ARDS
Massive Hemothorax
• Massive bleeding in pleural cavity
• Blood drain immediately from ICD > 1500 cc
• Hemodynamic instability
• Diagnosis by clinical : Respiratory distress,
decrease BS, dullness on percussion and S/S of
shock
Decrease BS,
dullness
Shock
Flat neck vein
Respiratory distress
Massive Hemothorax
• Sources of bleeding : Chest wall vessels, lungs,
Hilar vessels, heart and great vessels
• Intra-abdominal bleeding with diaphragmatic
injury
Massive Hemothorax
Management
• IV fluid resuscitation
• ICD : consider amount of bleeding from ICD
• Emergency thoracotomy, ER thoracotomy
Cardiac tamponade
• Blood accumulate in pericardial
sac -- increase pressure
• Impair RA filling / decrease RV
preload -- decrease cardiac
output & increase CVP
• Penetrating > Blunt
Cardiac tamponade
• Beck's triads (Hypotension, Distended neck
vein and distance heart sound) - Not reliable
in trauma
• High index of suspicious : mechanism of injury,
shock
• CVP may aid for diagnosis
Cardiac box
Cardiac tamponade
Further investigations
• FAST
• Pericardiocentesis
• Subxiphoid window
Suspected cardiac tamponade
Extremis Patients
ER Thoracotomy
FAST
Pericardiocentesis
Median sternotomy
Subxiphoid window / CT
Positive Equivocal Negative
Transfer Re-evaluation
Cardiac tamponade
Management
• Pericardiocentesis in patient with FAST positive
before transfer
• Immediate transfer to OR : thoracotomy or median
sternotomy
• ER thoracotomy in extremis patients
• Equivocal : subxiphoid window or CT
Air Embolism
• Infrequent
• Mostly from penetrating injury
• Fistula between pulmonary vein and bronchus
cause systemic air embolism
• Especially after positive pressure ventilation
• Difficult in diagnosis
Air Embolism
• Sudden neurodeficit or circulatory collapse
after positive pressure ventilation
• Management : ER thoracotomy in extremist
patient
• Immediate transfer to OR after successful
resuscitation
Indications
For
Thoracotomy
Acute Indications
• Drainage > 1500 cc
immediately from
ICD
• Continuous
bleeding > 200 cc
for 3 hours
• Great vessel injury
• Cardiac tamponade
• Loss of chest wall
substance
• Large air leakage
• Esophageal injury
• Impalement
Non-acute Indications
• Caked or clotted hemothorax
• Continuous air leakage
• Chronic diaphragmatic herniation
• Missed or delay bronchial injury
• Septal or valvular injury of heart
ER Thoracotomy
• Resuscitative thoracotomy in resuscitation
area in extremis patient (cardiac arrest or
severe hypotension)
• Select patients : mechanism of injury, sign of
life, outcome, risk of personnel contamination
ER Thoracotomy
Indications
• Best perform in penetrating cardiac injury
• Should perform in penetrating chest injury (non-cardiac
injury)
• Should perform in penetrating exsanguinated abdominal
vascular injury
• Especially with signs of life
• Very low benefit in blunt trauma
ER Thoracotomy
Objectives of ER thoracotomy
• Release cardiac tamponade
• Temporary control of bleeding
• Control air embolism
• Internal or open cardiac massage
• Temporary occlusion of descending thoracic aorta
ER Thoracotomy
• Immediate transfer to OR after successful
resuscitation
Results
• Cardiac injury > non-cardiac injury
• Sign of life > no sign of life
• Very few survival in blunt trauma
Potential Life-threatening
Chest Trauma
Secondary Survey
• Complete history taking and physical exam
• Complete Chest examination : Inspection,
Palpation (include chest compression test),
percussion and auscultation
• Adjunct : Pluse oximetry, CXR, ABG, eFAST
Secondary Survey
• Most of injury diagnosis or suggestive
diagnosis by CXR
• Blunt : rarely for esophageal injury
• Penetrating : addition by CXR AP & lateral (for
GSW), CVP
CXR Interpretation
• D : Detail
• R : Rotation, Inspiration, Picture, Exposure
• S : Soft tissue & Bone
• A : Airway
• B : Breathing
• C : Circulation
• D : Diaphragm
• E : Extra (tube & line)
“DRS ABCDE”
Extended-FAST (E-FAST)
• Pneumothorax & Hemothorax
Ribs Fracture
• Most common chest trauma
• S/S : localized pain, tenderness, crepitus, limit
chest movement
• CXR : Identify fracture and other associated
injury
Ribs Fracture
• Pain !!
• Limit chest movement
• Impair ventilation, oxygenation and effective
cough
• Consider associated injury
Ribs Fracture
• Upper (Rib 1-3) : risk of head, neck, great
vessel injury
• Middle (Rib 4-9) : intrathoracic injury
• Lower (Rib 10-12) : Suspicious of liver or
splenic injury
• Children : Flexible chest wall
Ribs Fracture
Management
• Adequate pain control : NSAIDs, IV narcotic (with
titration dose), intercostal nerve block, epidural
anesthesia
• Oxygen supplement, Observe respiration
• Follow up CXR in 12-24 hrs
• SRF - controversy
Sternal Fracture
• Uncommon
• Direct impact to sternum
• Most common site : upper or mid portion
• Associated injury : thoracic and non-thoracic
injury
• Blunt myocardial injury (arrhythmias)
Sternal Fracture
• S/S : anterior chest pain and tenderness,
ecchymosis and palpable fracture
• Film : lateral sternal view, CT
• Management : EKG, pain control, bed rest,
treat associated injury
• Surgery ??
Simple Pneumothorax
• Air In pleural cavity : from lung laceration or
bronchus
• No mediastinal shift (No tracheal deviation, no
hypotension
• S/S : decrease breath sound, Hyperresonance
on percussion, subcutaneous emphysema
Simple Pneumothorax
• May be absent or minimal clinical findings
• CXR : confirm diagnosis in patient with blunt
injury and no respiratory distress
• Incidental finding from CT : occult
pneumothorax
Simple Pneumothorax
Management
• ICD at 5th ICS just anterior to midaxillary line
• Oxygen supplement, CXR after ICD insertion
• Aspiration : not recommend
• Occult pneumothorax : observe & CXR follow
up
Simple Hemothorax
• Bleeding in pleural cavity : not massive
• S/S : decrease breath sound, dullness on
percussion, no S/S of shock
• CXR : confirm diagnosis as in simple
pneumothorax
Simple Hemothorax
Management
• ICD at 5th ICS just anterior to midaxillary line
• Consider amount of blood and observe for
continuation of bleeding
• Follow up CXR
Simple Hemothorax
• Complication : clotted or caked hemothorax
(undrained hemothorax)
• CXR still haziness after ICD insertion, and
minimal drainage from ICD
• Management : VATS, Thoracotomy
Tube Thoracostomy
• For hemothorax or pneumothorax
• Position : 5th ICS just anterior to Midaxillary
line
• No. 28 or 32 , Point supero-posteriorly
• Connect to underwater with or without suction
• CXR after insertion
Tube Thoracostomy
• Avoid malfunction of ICD : Kinking, clamping,
leakage
• Left in place until : Lung is fully expand, no air
leakage, straw color fluid drainage < 100 cc in
24 hr.
Blunt Myocardial Injury
• Direct injury to myocardium (Cardiac
contusion)
• S/S : sternal fracture, abnormal EKG,
hypotension, elevated CVP
• cardiac enzyme : not reliable in diagnosis
Blunt Myocardial Injury
• DDX : true MI
Management
• EKG monitoring
• Treatment of cardiac arrhythmia
• Supportive treatment : Inotropic drugs
Esophageal Injury
• Mostly from penetrating injury
• S/S : chest pain, hematemesis, fever, dyspnea,
sepsis (from mediastinitis)
• CXR : pneumomediastinum, pleural effusion
• suggest diagnosis by clinical and CXR
Esophageal injury
• Further studies : Esophagoscopy and/or
Esophagography
• Treatment : Operative repair
• IV antibiotics
• Nutritional support
Tracheobronchial Injury
• Uncommon
• S/S : hemoptysis, air leakage, persistent
pneumothorax, pneumomediastinum
• Further diagnosis : Bronchoscopy
• Treatment : Thoracotomy to repair bronchus,
segmentectomy or lobectomy
Great vessel injury
• Most common cause of death in MVAs
• Free rupture (massive hemothorax)
• Concealed rupture contain in mediastinum
• Mechanism injury : direct impact VS
Acceleration-deceleration injury (important)
• Most common site : ischmus
Great vessel injury
• S/S : Massive hemothorax or no specific
symptoms, asymptomatic
• Diagnosis by suspicious from mechanism
of injury suggestive sign from CXR
Suggestive signs from CXR
• Widening mediastinum
• Obliteration of aortic knob
• Deviation of trachea to the right
• Obliteration of AP window
• Depression of left main bronchus
• Deviation of NG tube to the right
Suggestive signs from CXR
• Widening of paravertebral interface
• Presence of apical cap
• Left hemothorax
• First, second rib or scapular fracture
• Funny looking mediastinum
Great vessel injury
• Further investigation to confirm diagnosis
• CT Angiography : standard investigation now
• Perform in stable patient only
Great vessel injury
Treatment
• Control pain, control BP (MAP
60-70) HR (< 80)
• Open repair VS Endovascular
repair
จบ