Thoracic Trauma Flashcards
Overview
- Sig source of morbidity and mortality: Blunt chest trauma → 7-17% mortality and 33% morbidity (pneumonia, empyema, atelectasis)
- Occurs in up to 20% trauma admissions
- Blunt: <10% require sx intervention
- Penetrating: 15-30% require intervention
Rib Fx
- overview
- Extremely painful: Splinting secondary to pain might prevent adequate ventilation
- Affects lung and chest wall mechanics
- May damage underlying lung: hemorrhage, lung laceration, contusions
- May produce prolonged morbidity: chronic pain, respiratory insufficiency
Rib Fx
- mortality related to what
- Intrathoracic injury
- Extrathoracic injury
- Advanced age
- 5+ rib fractures, mortality increases 1.8-3.2% per rib
Flail chest
- Three sequential ribs fx in two or more places
• Difficult to break this way, indicates significant amount of trauma
• Harder to break ribs 1-4 - Hypoventilation dt pain and paradoxical chest wall movement → inefficient mechanical ventilation
- Associated with contusion of underlying lung which can lead to hypoxia and increased shunt fraction
- PE: can feel crepitus, subcutaneous emphysema on CXR
Rib Fx
- Tx
- Respiratory support: basic or advanced ventilation
- Resuscitation as needed
- Pain management: spinal blocks and epidurals vs. opiates
- Early mobilization: fixate ribs to reduce movement reduces pain
- Treat underlying conditions/injuries
- Operative fixation if needed
Rib Fx
- Operative fixation
- Decreased incidence of pneumonia and mortality
- Not for every pt, select operative pts carefully
- Avoid in polytrauma patients: TBI and multi-orthopedic injuries
Rib Fx
- Non-ventilator guidelines
- Optimize analgesia (ideally epidural, also paravertebral analgesia if epidural CI)
- Chest physiotherapy? Not common in real world
- Diuretics if hydrostatic fluid overload, crystalloid to keep pressure up
Rib Fx
- Ventilator guidelines
- CPAP/BIPAP if awake, helps prevent intubation
- PEEP
- High-frequency oscillatory ventilation (HFOV) via pulmonologist
- Independent lung ventilation: if severe unilateral issue, ventilation mis-match situation
Pulmonary Contusion
- Overview
- MC source of pulm dysfunction in chest trauma
- Ventilation: perfusion mismatch → hypoxia
- Immunologic response can lead to SIRS, may directly involve the alveolar-capillary membrane
- Can lead to ARDS
Pulmonary Contusion
- tx
- Pulmonary PT and hygiene to prevent infection/pneumonia
- PEEP/CPAP to maintain alveolar expansion
- IVF: hydration and pressure support
Pneumothorax
- overview
- Collection of air in pleural space
- One of the MC injuries sustained in major trauma (>20%)
Pneumothorax
- Three types
- Simple
- Tension
- Open
Simple Pneumothorax
- Air in pleural space
- Not associated with hemodynamic instability
- Usually dt lung injury
- Might not need tx, does not require emergent intervention (absence of breath sounds IS NOT indication for emergent chest decompression)
- Can progress to tension pneumo
Occult Pneumothorax
- Not seen on CXR
- Was it really occult or just missed…
- Concern for occult in setting of severe trauma IS valid indication for thoracic CT
- If pt is stable, may be observed
Tension pneumothorax
- Air collecting in pleural space is under more pressure than atmospheric pressure – transmitted onto mediastinum which causes a shift in the heart and great vessels away from the pneumothorax
- Leads to decreased venous return and possibly total circulatory collapse
Tension pneumothorax
- dx
Clinical: • Respiratory distress • Shock • Unilateral decreased breath sounds • Distended neck veins • Hyperresonance
Tension pneumothorax
- tx
- Needle decompression
- Tube thoracostomy
- Between 2nd and 3rd at mid-clavicular line (above 3rd rib)
Open pneumothorax
- Chest wall allows air to enter pleural space from outside the chest
- Always need chest tube, commonly associated with hemothorax
- 3-sided occlusive dressing over wound + chest tube, possible sx
Pneumothorax management
- small
- Often no intervention needed
• Pulmonary PT
• Repeat films to show stability/resolution
• O2?
Pneumothorax management
- Chest tube required
- Suction and water seal
- Chest tube removal once PTX resolved (no more bubbles in water seal)
- Persistent leak: 3 days post injury → VATS evaluation. VATS is video assisted thoracotomy
Pneumothorax management
- pt education
Ok to fly >14 days after resolution of PTX
Hemothorax
- define
Blood in pleural space, can be from any source
Massive hemothorax
- > 1.5 L, associated signs of shock and hypoperfusion
- Can cause tension physiology
- Decreased breath sounds
- Dullness to percussion (vs. hyperresonant like tension pneumo)
- Neck veins NOT a good indicator
Hemothorax
- tx
- Restoration of volume, rapid
- Chest decompression + chest tube
- Possible operative intervention
- All should be considered for drainage, initial attempt via tube thoracostomy: if pull out a lot of blood, need to find source!!
Hemothorax
- problem with blood
causes lots of long term problems including inflammation and fibrosis. Can also delay healing and cause infection and empyema
Hemothorax
- indications for operative intervention
- Based on patient physiology
- 1500 mL of output / 24 hr regardless of mechanism
- 200 mL / hour output for several hours after tube placement
Risks associated with retained hemothorax
- Empyema
- Pneumonia
- Fibrothorax (can’t re-expand the lungs)
Retained hemothorax tx
- VATS has high rates of success for tx but ¼ require thoracotomy
- If retained HTX occurs after chest tube, don’t’ place another tube, do VATS
- VATS should be done between hospital days 3-7
- Intrapleural thombolytics may also be used to remove clots
Penetrating trauma of the precordium
- aka the box, where the important stuff is :)
- Sternum and spine protect this area well, requires sig trauma to get injury here
Penetrating trauma of the precordium
- Dx tests for diaphragm injury
- CXR, DPL, CT, FAST US
* Laparotomy is risky
Complications of missed diaphragm injury
strangulated abd viscera (bowel MC), 36% mortality
Thoracotomy
- Indications
Not clear
Thoractomy
- Questions to ask prior to performing
- Are there signs of life? Respiratory or motor effort, cardiac electrical activity, pupillary activity??
- How long was arrest vs. presentation to ER
- Blunt trauma? No indication if blunt
Thoractomy
- Indications
- Witnessed penetrating trauma and < 15 min pre-hospital CPR
- Witnessed penetrating non-thoracic trauma with <5 min pre-hospital CPR
- Witnessed blunt trauma with <5 min pre-hospital CPR
- Persistent severe post injury hypotension (SBP <60) dt cardiac tamponade, hemorrhage, air embolism
Thoracotomy
- Primary objectives
- Release pericardial tamponade
- Control cardiac hemorrhage
- Control intrathoracic bleeding
- Evacuate massive air embolism
- Perform open cardiac massage
- Temp. occlude descending thoracic aorta
