1. Anesthesia Considerations in Thoracic Trauma Patients
張婉玲 醫師
嘉義長庚醫院 麻醉科

2. Introduction Mortality from chest injuries is around 10%
The majority of patients with thoracic trauma can be managed conservatively
Require thoracotomy：
Blunt trauma：10 %
Penetrating trauma：15 %～30 %

3. Initial Management Plan
Airway maintenance with cervical spine protection
Breathing: ventilation and oxygenation
Circulation with hemorrhage control

4. Initial Assessment Primary Survey: –AIRWAY
•Always assume a cervical spine injury exists until proven
Jaw-thrust maneuver

5. Initial Assessment
ALWAYS ASSUME FULL STOMACH PRECAUTIONS---RAPID SEQUENCE INTUBATION

6. Indications for intubation:
–Airway obstruction
–PaO2 < 80 mmHg or SpO2 < 90% with O2
–Shock with SBP < 90 mmHg
–Severe head injury or unconscious (GCS <9)
–Anticipated surgery with multisystem injury

7. Initial Assessment
Awake intubation: local, topical superior laryngeal nerve blocks
Awake fiberoptic: may be too bloody
Awake cricothyrotomy/tracheostomy
Know your difficult airway algorithm!

8. Initial Assessment BREATHING –100 % O2
–Always verify correct position of ETT.

9. Initial Assessment Circulation –Control hemorrhage first!
–Crystalloids vs. colloids vs. blood products?

10. Secondary survey
After primary survey complete, attempt to complete a head-to-toe assessment

11. Preop assessment Cardiac: S/S shock, EKG changes
Respiratory: Breath sounds, crepitus, respiratory patterns/distress, CXR
Neurologic: GCS, LOC; assume C-spine injury until ruled outLateral C-spine Xray, palpate neck
Renal: monitor urine output, amount and color

12. Preop assessment Gastrointestional: FULL STOMACH!!!!
Endocrine: release of stress hormones (catecholaminesand glucose)
Hematologic: hypovolemicshock; coagulopathies

13. Laboratory/diagnostic tests
CBC, electrolytes, urinalysis, PT/PTT, lactate, baseline ABG (as condition permits)
CXR, lateral C-spine, CT/MRI
12 lead EKG
FAST: focused abdominal sonography for trauma

14. INJURIES TO IDENTIFY DURING PRE-OPERATIVE ASSESSMENT

15. AIRWAY INJURY/OBSTRUCTION
Intrathoracic tracheobronchial injuries are less common than upper airway injuries.
High mortality.
A definitive airway can usually be secured using a fiber-optic bronchoscope

16. Pneumothorax Accumulation of air between parietal and visceral pleura
Results in severe V/Q mismatch and hypoxia
S/S:
–chest wall hyperresonant to percussion
–Breath sounds decreased or absent unilaterally
–Subcutaneous emphysema
–CXR confirms

17. Tension pneumothorax
Diagnosis of tension pneumothorax is clinical rather than radiological
- Absent breath sounds
- Hyper-resonant percussion
- No chest movement
- Tracheal deviation to the injured side
- Distended neck veins (may not be seen if the patient is hypovolaemic).
- Severe dyspnoea, tachycardia and hypotension

18. Tension pneumothorax Immediate chest decompression is required.
During anaesthesia
In pressure controlled modes:
↓ tidal volume
In volume controlled modes:
↑ peak airway pressure

20. OPEN PNEUMOTHORAX
>2/3rd the diameter of the trachea.
This results in paradoxical breathing with collapse of the lung on the affected side during inspiration.
This results in increased intra-pulmonary shunt, decreased venous return and progressive hypoxaemia and hypercapnia.
Administration of oxygen, covering the wound and chest drain insertion.

22. Hemothorax
Can be caused from bleeding of intercostal vessels, pulmonary arteries or veins, avulsion of mediastinal vessels or penetrating cardiac injury.
Differentiated from pneumothorax by dullness to percussion with absent breath sounds

25. Hemothorax
The choice and dose of anaesthetic induction agent is determined by the severity of the shock and any preexisting medical co-morbidity
Fluid load before chest tube placement
Thoracotomy may be needed if drainage is more than 250 mls per hour, or the patient’s physiological status continues to deteriorate despite fluid replacement.

26. Flail chest
Results from two or more ribs fracture in two or more places
Accompanied by hemothorax or pulmonary contusion
Patients with 3 or more rib fractures have greater likelihood of hepatic or splenicinjury

27. Flail chest S/S –Paradoxical chest wall movement Treatment –O2
–Pain control

28. Cardiac tamponade Life-threatening emergency
Bleeding into pericardial space, which restricts cardiac filling during diastole and creates a low cardiac output state
Initial symptoms
- Dyspnea
– Orthopnea
– tachycardia

29. Cardiac tamponade Classic symptoms
–Beck’s triad neck vein distention, hypotension, muffled heart sounds
–Pulsus paradoxus: > 10 mmHg decrease in blood pressure during spontaneous inspiration
May not be evident in hypovolemia

30. Cardiac tamponade
Echocardiography provides the definitive diagnosis.

31. ANAESTHESIA FOR RESUSCITATIVE THORACOTOMY
Penetrating cardiac injury may rapidly lead to cardiac arrest.
Induction of anaesthesia may lead to
a dramatic loss of blood pressure and care should be taken with the choice of induction agent.

32. AORTIC DISRUPTION
A wide mediastinum on chest X-ray may be the only indication that the injury has occurred
Spiral contrast CT is now performed more frequently than angiography

33. TRACHEOBRONCHIAL INJURY
high mortality
In blunt trauma the majority of injuries occur within a 2 – 3 cm of the carina
Signs include haemoptysis, subcutaneous emphysema and persisting pneumothorax
or broncho-pleural fistula following chest drain insertion.

34. TRACHEOBRONCHIAL INJURY
Low tidal volume, permissive hypercapnia ventilatory strategies are required until surgical intervention has occurred.
Once intubated fibre optic bronchoscopy is needed to identify the site of the leak.

35. OESOPHAGEAL DISRUPTION
very rare
most frequently occurring in the lower oesophagus

36. DIAPHRAGMATIC RUPTURE
most commonly after blunt abdominal trauma.
Usually on the left side.
Classically the stomach, nasogastric tube or colon is noted to be in the left side of the chest on chest X-ray.

37. Pulmonary contusion
Intra-alveolar hemorrhage and edema resulting from sudden increase in intra-alveolar pressure and rupture of alveolar-capillary interface
Difficult to diagnosis

38. ARDS Later pulmonary complication
Attributed to direct thoracic injury, sepsis, aspiration, head injury, massive transfusion, oxygen toxicity, and fat embolism
Mortality rate reaching 50%

39. INTRA-OPERATIVE LUNG PROTECTIVE STRATEGIES
LUNG PROTECTIVE VENTILATION
tidal volume mls/kg
trans alveolar pressure is kept below 35 cm of water (plateau airway pressure of cm of water).

40. INTRA-OPERATIVE LUNG PROTECTIVE STRATEGIES
INTRA-OPERATIVE LUNG RECRUITMENT
Extrinsic PEEP
a single large tidal breath and holding end inspiration for 20 seconds

41. Myocardial contusion Associated with blunt trauma
Contusion most often right ventricle since lies directly posterior to sternum
S/S
–Dysrhythmias: heart block to Vfib; ST segment elevation
–Elevated CPK-MB; ? Troponin elevation
–CHF
–Anginal pain which may or may not respond to nitrates

42. Anesthetic management
The general principles of trauma anesthesia such as oxygenation, restoration of circulating volume, correction of hypothermia and coagulopathy.

43. Anesthetic management
Induction
Standard monitors
Preoxygenation
direct laryngoscopy + RSI
Invasive monitors as indicated

44. Induction agents
Thiopental 3-4 mg/kg; reduce doses in unstable patients
Ketamine mg/kg; useful for burn and hypovolemic patients; avoid with head injuried
Etomidate mg/kg; reduce doses with hypovolemia
Propofol 1-2 mg/kg in stable patients; reduce doses in hypovolemia

45. Muscle relaxants Succinylcholine: 1-2 mg/kg; useful for RSI
Rocuronium: 1 mg/kg

46. ONE LUNG ANAESTHESIA
Double-lumen tubes are often difficult to insert during rapid sequence intubation and are commonlyassociated with malposition.

47. Maintenance
Low-dose volatile agent with fentanyl and nondepolarizing muscle relaxant is usually suitable.
Avoid Nitrous oxide.
Bispectral index monitor

48. Conclusion
Blunt or penetrating thoracic injuries present a particular challenge as a result of complex, dynamic and lifethreatening
injuries
The roles of the anesthesiologist and anesthetist are critical.