1. Klinika Chirurgii Urazowej Paweł Grala Thoracic injuries  Incidence: 1. 10%mortality (25% of traumatic deaths) 2. <10% of blunt and 15-30% of penetrating require thoracotomy 3. mediastinal penetrating trauma: mortality 20%, 50% are hemodynamically unstable  40%mortality additional 30% positive diagnostic evaluation  Patophysiology: hypoxia, hypercarbia, acidosis (hypovolemia, ventilation/perfusion mismatch, changes in intrathoracic pressures)

2. Klinika Chirurgii Urazowej Paweł Grala Thoracic injuries  Chest wall 1. lacerations, l.communicating with pleural space  open pneumothorax, 2. rib frs with possible: pain, splinting, atelectasis, hypoxemia  analgesia, pulmonary toilet, flail chest, indicative of possible internal inj. 3. Sternal fractures (consider myocardial contusion)  Tracheobronchial (respiratory distress, large air leak with subcutaneous emphysema)  Esophageal (penetrating trauma, delayed recognotion →↑ mortality – 3fold if over 24h, esophagoscopy with contrast studies – Gastrografin, butressed repair)  Pulmonary: contusion, hemothorax, pneumothorax  Great vessel  Cardiac

3. Klinika Chirurgii Urazowej Paweł Grala Rib fractures  May be undetectable on chest X-ray (excludes other intrathoracic injuries)  Majority IV-IX  Anteroposterior compression  midshaft fr. (outward bowing), direct blow  fracture ends face inwards  potential vessel or lung parenchymal injury  X-XII  suspect hepatosplenic injury  I-III  suspect great vessel injury  Taping, rib belts – contraindicated  Relief of pain (intercostal block, intrapleural analgesia, systemic analgetics), pulmonary toilet  Flail chest – bony discontinuity of a chest fragment (>3): serious underlying lung inj., paradoxical chest wall motion, pain, splinting (muscle spasm)  hypoxia fluid restriction (if no hypovolemia), adequate ventilation with chest wall splinting  mechanical ventilation

4. Klinika Chirurgii Urazowej Paweł Grala Flail chest complication

5. Klinika Chirurgii Urazowej Paweł Grala Flail chest complication

6. Klinika Chirurgii Urazowej Paweł Grala Pulmonary contusion  Blunt (blast shock wawes, falls from heights) or penetrating trauma (high velocity GSW) “Spalling effect” – shearing or bursting effect occurring at the gas/liquid interface (large differences in density) “Inertial effect” – low-density alveolar tissue is stripped from heavier hilar structures as they accelerate at different rates. “Implosion effect” - rebound or overexpansion of gas bubbles after a pressure wave passes  Interstitial or alveolar inj. – edema, alveolar haemorrhage, parenchymal destruction  Adequate perfusion, inadequate ventilation (mismatch → hypoxemia) - ↑ airway resistance, ↓ compliance  Initial chest X-ray diagnostic – progress in density over 48h ( Chest x-ray 4-6 hours /CT earlier/, resolves in 5-7 days) ABGs, pulse oximetry,  Dyspnea, hemoptysis, chest pain, cough, tachypnea, rales, decreased breath sounds, tachycardia  Respiratory support with intubation and mechanical ventilation (often unusual ventilation modes), aggressive pulmonary toilet, positioning on uninvolved side, fluid restriction, no steroids or prophylactic antibiotics.

7. Klinika Chirurgii Urazowej Paweł Grala Pulmonary contusion – X-ray

8. Klinika Chirurgii Urazowej Paweł Grala Pulmonary contusion – X-ray 5h later: subcutaneous emphysema, pneumomediastinum

9. Klinika Chirurgii Urazowej Paweł Grala Pulmonary contusion – CT GSW

10. Klinika Chirurgii Urazowej Paweł Grala Pneumothorax  Blunt or penetrating inj.  Decreased breath sounds (>25% of the lung collapsed)  Sucking chest wound (over 2/3 of tracheal diameter)  preferential air flow  occlusive dressing + chest tube  Chest X-ray diagnostic  In significant chest inj. + p.p. mechanical ventilation  prophylactic tube thoracostomy (prevention of tension P.)  Chest tube into II or IIIrd intercostal space in midclavicular line  Chest tube ineffictive  tracheobronchial disruption  diagnosis + thoracotomy

11. Klinika Chirurgii Urazowej Paweł GralaPneumothorax

12. Tension pneumothorax

13. Klinika Chirurgii Urazowej Paweł Grala Tension pneumothorax

14. Klinika Chirurgii Urazowej Paweł Grala Tension gastrothorax

15. Klinika Chirurgii Urazowej Paweł GralaHemothorax  Opacification on chest X-ray (intercostal a., internal mammary, Th spine fr., lung laceration, mediastinal vessels)  Chest tube usually sufficient (IV or Vtdh intercostal space in anterior or midaxillary line)  bleeding self-limiting  Thoracotomy guidelines individualized: severe haemodynamic instability (ERT), initial drainage exceding 1,5L, ongoing drainage of 100ml/h over 6h  Coagulation, ligation, pulmonary tractotomy, pulmonary resection (hilar injury) – significant mortality  Air embolism in significant parenchymal injury (esp. on positive pressure ventillation): sudden cardiovascular collapse – steep Trendelenburg position, aspirate air from R ventricle, cardiovascular support  Great vessel injury (profound shock, sometimes pericardiac tamponade, on chest X-ray – blunt inj.: widend mediastinum, obscured aortic knob, deviation of L stem brochus, opacification of aortopulmonary window, R deviation of nasogastric tube, I or IInd rib frs.) no diagnostic investigations in unstable patient aortography, contrast enhanced CT, echocardiography fluid restriction (blunt), thoracotomy

16. Klinika Chirurgii Urazowej Paweł GralaHemothorax

17. Hemothorax

18. Hemothorax

19. Hemothorax

20. Hemopneumothorax

21. Widend mediastinum

22. Klinika Chirurgii Urazowej Paweł Grala Flail chest - traction

23. Klinika Chirurgii Urazowej Paweł Grala Flail chest

24. Klinika Chirurgii Urazowej Paweł Grala Empyema  Stages (not separated – continuum): exsudative exsudative fibropurulent fibropurulent organizing organizing  Chest X-ray, US, CT  Control of infection with appropriate antibiotics, drainage (ev.streptokinaze), obliteration of pleural space, thoracotomy with decortication and pleurodesis

25. Klinika Chirurgii Urazowej Paweł Grala Cardiac injury  usually penetrating inj. between midclavicular lines  pericardiac tamponade: shock, distended neck veins, diminished heart sounds (Beck`s triad), j.v.distension ↑ with inspiration (Kussmaul`s sign)  warrants operation (often ERT)  blunt c.inj.: history, inappropriate cardiovascular response to injury (EKG – normal excludes, abnormal  cardiac monitoring, echocardiography) advanced cardiac life support protocols operation for myocardial or valvular rupture, ventricular aneurysm

26. Klinika Chirurgii Urazowej Paweł Grala  Commotio cordis – fatality due to blunt thoracic injury, without gross structural damage to the heart or other intrathoracic organs. Death attributed to cardiac arrhythmia aggravated by traumatic apnea. Most vulnerable phase of the cardiac cycle: T – wave  heart partially depolarized and then repolarized (electrically unstable)

27. Klinika Chirurgii Urazowej Paweł Grala

28. Thoracotomy

29. Pitfalls  Simple hemothorax  retained, clotted hemothorax with lung entrapement or empyema (if infected)  Diaphragmatic inj. are often overlooked  respiratory compromise, early or late entrapement and strangulation of abd. Contents  Evaluation of widend mediastinum requires cardiothoracic surgical capabilities  Underestimation of severe pathophysiology of rib frs. esp. in the elderly (aggressive pain control with no resp. depression)  underestimation of blunt pulmonary injury severety (pulmonary contusion is not always correlated with X-ray findings)