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SpC Surgery > Interactive Tutorial: Chest Trauma And Lung Transplant > Flashcards

Interactive Tutorial: Chest Trauma And Lung Transplant Flashcards

1
Q

Classification of Chest trauma

A
  • Common
  • Account for ~25% of trauma deaths
  • Overall chest trauma mortality is 10%
  • <15% of patients with chest trauma require surgical intervention
  • Inadequate / Delayed treatment —> Death
  • Mortality
    —> Immediate deaths
    —> Deaths within a few hours
    —> Late deaths (days - weeks)

Classification based on ***Mechanism:

  1. Blunt trauma
    - High velocity impact (e.g. RTA)
    - Low velocity impact (e.g. falling on level ground)
    - Crush injury (e.g. industrial accident)
  2. Penetrating trauma
    - Sharps (e.g. knife)
    - Gun shot

Classification based on ***Anatomy:

  1. Chest wall injury
    - Rib fracture
    - Sternal fracture
    - Clavicular fracture
    - Vertebral fracture
    - Scapular fracture
    - Soft tissue injury
  2. Pleural cavity injury
    - Haemothorax
    - Pneumothorax
  3. Parenchymal lung injury
    - Contusion
    - Laceration
    - Haematoma
  4. Airway injury
  5. Heat and Great vessel injury
    - Cardiac tamponade
  6. Others
    - Diaphragmatic injury
    - Esophageal injury
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2
Q

Investigations of Chest trauma

A
  1. CXR
  2. CT thorax
  3. Angiography
  4. Echocardiography
  5. Bronchoscopy
  6. MRI
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3
Q

Management of Chest trauma

A

Initial management:

  1. ABC
  2. Early detection of life-threatening injuries
  3. Assess as a whole
  4. Identify indications for immediate operation

Treatment:

  1. Simple therapeutic procedures (Non-operative)
    - majority of patients
    - Analgesia, Pulmonary hygiene, ETT intubation, Chest drain insertion, Physiotherapy
  2. Thoracotomy / Sternotomy
    - <10% of blunt chest injuries
    - 15-30% of penetrating chest injuries
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4
Q

***Indications for Immediate operation

A
  1. Massive haemothorax
  2. Ongoing bleeding from chest
  3. Cardiac tamponade
  4. Penetrating transmediastinal chest wounds
  5. Chest wall disruption / Impalement wounds to chest
  6. Massive air leak from chest tube
  7. Major tracheobronchial injury
  8. Great vessel injury with unstable haemodynamics
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5
Q

Major thoracic injuries

A
  1. Tension pneumothorax
  2. Massive haemothorax
  3. Flail chest
  4. Pulmonary contusion
  5. Tracheobronchial injuries
  6. Cardiac tamponade
  7. Traumatic aortic disruption
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6
Q
  1. Tension pneumothorax
A
  • Air enters pleural space without a means of exit —> “one-way-valve” air leak
  • Gradual increase in volume of air in pleural cavity
    —> Ipsilateral collapse of lung
    —> Pressure continue to develop
    —> Mediastinum displaced to opposite lung
    —> Impairing venous return (∵ kinking of SVC / IVC) + relaxation of heart
    —> Decreasing cardiac output

Causes:

  1. Penetrating injury to chest
  2. Blunt trauma with parenchymal lung injury
  3. Mechanical ventilation with high airway pressure (Barotrauma)
  4. Spontaneous pneumothorax

Diagnosis:

  1. **Clinical (NOT wait for CXR)
    - Severe respiratory distress
    - **    Unilateral absence of breath sounds
    - **Tracheal deviation
    - **    Tachycardia / Hypotension
    - ***Neck vein distension
    - Cyanosis (late manifestation)
  2. CXR
    - Large pneumothorax (from radiopaedia: visible visceral pleural edge seen as white thin line, no lung markings seen peripheral to this lung, radiolucent peripheral space)
    - Mediastinal shift

Treatment:
1. Immediate decompression
- Insertion of ***large bore needle into 2nd ICS along MCL
—> Convert Tension pneumothorax into Simple open pneumothorax

  1. Chest drain insertion (Definitive)
    - After stabilisation by decompression

Algorithm:
Traumatic pneumothorax
—> Simple pneumothorax —> **Observation / **Chest drain insertion (depend on size)
—> Tension pneumothorax —> ***Urgent needle decompression followed by Chest drain insertion

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7
Q
  1. Massive haemothorax
A
  • Common in penetrating trauma
  • Each hemithorax can hold up to 3L of blood
  • Intercostal / Internal mammary vessels most commonly injured
  • Neck veins can be flat (hypovolaemia) / distended (mediastinal compression)
  • Hilar / Great vessel disruption —> Severe shock

Diagnosis:

  1. Clinical
    - Haemorrhagic shock
    - Flat neck veins
    - Unilateral absence / diminution of breath sounds
    - Unilateral dullness
  2. CXR
    - Unilateral “white out” on CXR

Treatment:

  1. Rapid fluid resuscitation
  2. Decompression of chest cavity
  3. Intubate a patient in shock / respiratory difficulty
  4. Thoracotomy (Operative intervention)
    - if 1.5L blood evacuated initially
    - ongoing bleeding from chest drain of >200ml/hr for 2-4 hours
    - failure to achieve complete drainage / clotted haemothorax
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8
Q
  1. Flail chest
A
  • Results from direct high energy impact (blunt force)
  • Multiple rib fracture
    —> >=2 ribs fractured in >=2 places
    —> A segment of chest wall separated from rest of bony chest wall
    —> Paradoxical motion of chest wall segment with inspiration and expiration
    —> Segment of lung not moving as intended (Inspiration —> alveoli collapse, Expiration —> alveoli expansion)
    —> Inefficient respiratory movement
    —> Effective lung volume reduced (patient has to take deeper / more rapid breaths —> more work for breathing)

Complications:

  1. High risk for pneumothorax / haemothorax
  2. Respiratory failure ∵
    - Paradoxical motion of chest wall
    - Underlying lung injury
    - Severe pain with restricted chest wall movement

Treatment:

  1. Analgesia
  2. Mechanical ventilation (usually necessary)
    - Immediately intubate for respiratory distress
    - Consider intubation for haemodynamic instability
  3. Early surgery to restore integrity of ribcage
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9
Q
  1. Pulmonary contusion
A
  • Most common potentially lethal chest injury
  • Caused by haemorrhage into lung parenchyma
  • Commonly associated with fractured ribs

Natural progression:
- Worsening hypoxaemia for first 24-48 hours

Diagnosis:

  1. Clinical (can be difficult)
    - Few respiratory symptoms —> Main problem in diagnosis
    - Mainly Chest pain, SOB
    - Haemoptysis (rare)
  2. CXR
    - Haziness in lung / Infiltration of lung segments + Rib fractures
    - Can be ***delayed (within 24-48 hours)
  3. ***CT thorax
    - More accurate

Treatment (mainly ***supportive):

  1. Supportive with supplemental O2
  2. Physiotherapy
  3. Mild analgesic
  4. Broad spectrum antibiotics
  5. Mechanical ventilation when necessary
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10
Q
  1. Tracheobronchial injuries
A
  • Unusual (1%) but potentially fatal
  • Frequently missed injury
  • Result from Penetrating / Blunt trauma
  • Most patients die at scene
  • High mortality from associated injuries (in posterior mediastinum)

Classification:

  1. Cervical tracheal injuries
    - ***Upper airway obstruction, Cyanosis
    - Dysphagia, Cough, Haemoptysis
    - Subcutaneous emphysema
  2. Thoracic tracheal / bronchial injuries
    - **Intrapleural laceration
    —> Persistent SOB
    —> Massive air leak
    —> Massive pneumothorax
    - **    Pneumomediastinum / Subcutaneous emphysema

CXR signs:

  1. ***Peri-bronchial air
  2. Deep cervical emphysema
  3. Subcutaneous emphysema
  4. Lung collapsed ***laterally with pneumomediastinum
  5. Pneumothorax
  6. Pleural effusion
  7. Fallen lung sign

CT signs:

  1. Fallen lung sign
    - bronchial fracture —> causing lung to collapse (∵ air leak) + fall to dependent part of chest
    - hanging onto hilum by vascular connections only

Treatment:

  1. Secure airway
    - Intubation
    - Cricothyroidotomy / Tracheostomy
  2. Immediate operation to primary repair
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11
Q
  1. Cardiac tamponade
A
  • Penetrating (more common) / Blunt injury
  • 75 to 100ml of blood can produce tamponade physiology in adult

Clinical features:

  1. Beck’s triad
    - Hypotension
    - Distended neck vein
    - Muffled heart sound
  2. Shock / Ongoing hypotension without obvious blood loss (more common) (i.e. Obstructive shock)

Diagnosis:
1. Transthoracic echocardiography

Treatment:

  1. Emergency pericardiocentesis
    - catheter inserted subxiphoid area —> 45o from midline —> aiming left shoulder
  2. Surgical pericardial drainage
    - through median sternotomy / subxiphoid incision
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12
Q
  1. Traumatic aortic disruption
A
  • Tear in wall of aorta
  • Mechanism: ***Rapid deceleration
  • Usually located near ***ligamentum arteriosum
  • Most die before reaching the hospital

Clinical signs:

  1. Asymmetry in upper extremity BP
  2. Widened pulse pressure
  3. Chest wall contusion
  4. Posterior scapular pain, intrascapular murmur

CXR:

  1. Widened mediastinum (>8cm)
  2. ***Loss of aortopulmonary window (notch between aortic arch and pulmonary artery)
  3. ***Blurring of aortic knob
  4. Deviation of trachea to right
  5. Depression of left main stem bronchus
  6. Fracture of first 3 ribs / scapula / sternum
  7. Left pleural effusion

Diagnosis:

  1. CT thorax with contrast
    - Valuable diagnostic tool for aortic injury
  2. Aortography
    - Good standard for diagnosis
    - Useful for indeterminate cases / more detailed planning required

Treatment:

  1. Urgent surgical repair
  2. Endovascular aortic stent grafts (definitive treatment / buy time until definitive surgical repair)
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13
Q

Pitfalls in Chest trauma

A
  1. Simple pneumothorax can progress to Tension pneumothorax
  2. Simple haemothorax can progress to a Clotted haemothroax —> ***Empyema
  3. Undiagnosed diaphragmatic injury can result in Pulmonary compromise + Strangulation of peritoneal contents
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14
Q

Lung transplantation

A
  • Removal of one / both diseased lungs from patient —> Replacement with healthy lungs from a donor
  • Accepted modality of treatment for ***End stage lung disease that is refractory to maximal medical treatment
  • Poorest 5 year survival among all organ transplants: ~50%

Types:

  1. Double transplant
  2. Single transplant
  3. Lobar transplant
  4. Part of Heart-Lung transplant
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15
Q

Indications of Lung transplant

A
  1. Obstructive lung disease
    - ***COPD
    - Alpha 1 antitrypsin deficiency
  2. Restrictive lung disease
    - ***Idiopathic pulmonary fibrosis
    - ILD
  3. Septic lung disease
    - ***Cystic fibrosis
    - Bronchiectasis
  4. Pulmonary vascular disease
    - Pulmonary hypertension
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16
Q

Morbidity of Lung transplant

A
  1. Use of Immunosuppressant / Steroid
    - Hypertension
    - DM
    - Hyperlipidaemia
  2. Renal dysfunction
  3. Bronchiolitis obliterans syndrome (after 5 years)
    - ∵ chronic rejection
17
Q

Candidacy considerations

A
  1. High risk of death (>50%) due to lung disease within 2 years if lung transplantation not performed
  2. High likelihood (>80%) of surviving >=90 days after lung transplantation
  3. High likelihood (>80%) of 5-year post-transplant survival from a general medical perspective provided there is adequate graft function
18
Q

CI of Lung transplantation

A

Absolute CI:

  1. Recent history of malignancy
    - 5-year disease free interval is prudent
  2. Untreatable significant dysfunction of another major organ system (unless combined organ transplantation)
  3. Uncorrected atherosclerotic disease with end-organ ischaemia / dysfunction / CAD not amenable to revascularisation
  4. Acute medical instability
  5. Uncorrectable bleeding diathesis
  6. Chronic infection with highly virulent / resistant microbes that are poorly controlled pre-transplant
  7. Active TB infection
  8. Significant chest wall / spinal deformity expected to cause severe restriction
  9. Class 2/3 obesity (BMI >35)
  10. Current non-adherence to medical therapy / history of repeated / prolonged episodes of non-adherence
  11. Psychiatric / Psychological conditions associated with inability to cooperate
  12. Absence of an adequate / reliable social support system
  13. Severely limited functional status with poor rehabilitation potential
  14. Substance abuse / dependence (e.g. alcohol, tobacco, marijuana, other illicit substances) within last 6 months

Relative CI:

  1. Age >65
  2. Class 1 obesity (BMI 30-34.9)
  3. Progressive / Severe malnutrition
  4. Severe, symptomatic osteoporosis
  5. Extensive prior chest surgery with lung resection
  6. Mechanical ventilation / ECLS
    - however, carefully selected candidates without other acute / chronic organ dysfunction may be successfully transplanted
19
Q

Mechanical bridges to Lung transplantation

A

ECLS (Extracorporeal life support) recommended:

  • Young age
  • Absence of multiple-organ dysfunction
  • Good potential for rehabilitation

ECLS not recommended:

  • Septic shock
  • Multi-organ dysfunction
  • Severe arterial occlusive disease
  • Heparin-induced thrombocytopenia
  • Prior prolonged mechanical ventilation
  • Advanced age
  • Obesity
20
Q

Currently accepted “Ideal” donor

A
  1. Age <55
  2. ABO compatibility
  3. Clear chest radiograph
  4. PaO2 >300 on FiO2=100%, PEEP 5 cmH2O (P:F ratio —> reflect ability of oxygenation by lung)
  5. Tobacco history <20 pack years
  6. Absence of chest trauma
  7. No evidence of aspiration / sepsis
  8. No prior cardiopulmonary surgery
  9. Sputum gram stain - absence of organisms
  10. Absence of purulent secretions at bronchoscopy

Only 49% of donor lung satisfy above criteria, 51% are ***extended criteria donor lungs

21
Q

Absolute CI for donor lungs

A
  1. Age >65
  2. History of lung disease
  3. History of prior cardiopulmonary surgery
  4. History of severs chest trauma
  5. Evidence of pulmonary edema
  6. Long smoking history >20 pack years
  7. Abnormal CXR
  8. Fulminant pneumonia
  9. HbsAg +ve, HCV Ab +ve
  10. P/F radio <300 on FiO2=100%, PEEP 5 cmH2O
  11. Evidence of aspiration clinically, on CXR / bronchoscopy
22
Q

Potential donor lungs are prone to injury

A 
Inside in donor:
1. Cold ischaemia
2. Brain death
3. Hypotension
4. Trauama
5. Mechanical ventilation
6. Pneumonia
7. Aspiration
—> Activation of inflammation + coagulation in donor
—> ***Ischaemia-reperfusion induced lung injury after transplantation

Method to resolve:

  1. Normothermic Ex Vivo lung perfusion (EVLP)
    - opportunity to salvage borderline lungs
    - increase donor lung supply
    - reduce transplant waiting list morbidity and mortality
  2. Living donor lobar lung transplant (LDLLT)
    - possible serious complications in donor lobectomy —> LDLLT indicated only for critically ill patients who are unlikely to survive the long wait for cadaveric lungs

Monitor:
- CXR of explanted lung

SpC Surgery (11 decks)

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