1. THORACIC TRAUMA

2. OBJECTIVES Identify and treat life-threatening thoracic injuries Recognize and treat potentially life- threatening thoracic injuries

3. EPIDEMIOLOGY Mortality –Many die pre-hospital or on arrival –In-Hospital Isolated Thoracic: 4-8% Multiple Trauma: 35% Civilian (30% of injuries) –Blunt: 70% –Penetrating: 30% Military (15% of injuries) –Blunt: 10% –Penetrating: 90%

4. EPIDEMIOLOGY Surgical Intervention –Blunt: Less than 10% –Penetrating: 15-30% Early survival depends on: –Initial resuscitation –Timeliness & correct sequence of diagnostic investigations Late survival depends on: –Post-traumatic complications

5. INITIAL EVALUATION Primary Survey –ABCs –Airway Control!!!!! –Cardiac monitor and pulse oximeter –FAST –Concurrent resuscitation –Emergent procedures as needed (e.g. chest tubes, etc.) Secondary survey

6. PHYSICAL EXAM External Signs (e.g. contusions, seat belt, wounds, etc.) Breath sounds (e.g. symmetrical, etc.) Palpation (e.g. crepitus, etc.) Roll the patient – check the posterior thorax!

7. LIFE-THREATENING INJURIES Tension Pneumothorax Massive Hemothorax Cardiac Tamponade Open Pneumothorax Flail Chest

8. TENSION PNEUMOTHORAX Characteristics –Clinical diagnosis –“One-way” valve traps air, collapses lung, shifts mediastinum to opposite side Signs & Symptoms –Respiratory distress –Unilateral breath sounds –Distended neck veins –Hypotension

9. TENSION PNEUMOTHORAX Diagnosis: Clinical Treatment: Immediate Decompression –Needle –Tube Thoracostomy

10. MASSIVE HEMOTHORAX Characteristics –Rapid accumulation of greater than 1500 cc or 1/3 blood volume in chest cavity Signs & Symptoms –Hypotension –Unilateral breath sounds –Dullness to percussion

11. MASSIVE HEMOTHORAX Diagnosis –CXR –Tube thoracostomy reveals blood Treatment –Tube Thoracostomy –Autotransfusion –Thoracotomy: Greater than 1500 cc or 200 cc/hr over 4 hrs

12. CARDIAC TAMPONADE Characteristics –Penetrating or blunt trauma –High index of suspicion Signs & Symptoms –Respiratory distress –Distended neck veins –Hypotension –Bilateral breath sounds

13. CARDIAC TAMPONADE Diagnosis –FAST –Pericardial Window Treatment –Stable patient: Median Sternotomy or Thoracotomy –Unstable patient: Emergent Thoracotomy

14. OPEN PNEUMOTHORAX Characteristics –“Sucking” chest wound Signs & Symptoms –Respiratory distress –Unilateral breath sounds –Open thoracic wound

15. OPEN PNEUMOTHORAX Diagnosis: Clinical Treatment –3-sided dressing –Tube Thoracostomy –Operative Intervention –4-sided dressing = Tension pneumothorax

16. FLAIL CHEST Characteristics –Pulmonary contusion always –Floating chest wall segment; 2 or more fractures per rib Signs & Symptoms –Respiratory distress –Crepitus –Paridoxical chest wall motion

17. FLAIL CHEST Diagnosis –Clinical signs –CXR: Multiple rib fractures Treatment –Adequate oxygenation & ventilation –Resuscitation –Analgesia

18. POTENTIALLY LIFE-THREATENING INJURIES Simple Pneumothorax Hemothorax Tracheobronchial Tree Injury Blunt Cardiac Injury Traumatic Aortic Disruption Diaphragmatic Rupture Esophageal Injury

19. SIMPLE PNEUMOTHORAX Signs & Symptoms –Unilateral breath sounds –Respiratory distress Diagnosis –Clinical suspicion –CXR confirmation Treatment: Tube Thoracostomy

20. HEMOTHORAX Signs & Symptoms –Unilateral breath sounds –Respiratory distress –Dullness to percussion Diagnosis –Clinical suspicion –CXR confirmation Treatment: Tube Thoracostomy

21. TRACHEOBRONCHIAL TREE INJURY Distribution –Penetrating –Blunt Signs & Symptoms –Subcutaneous emphysema –Hemoptysis –After tube thoracostomy: Persistent air leak Lung does not properly inflate

22. TRACHEOBRONCHIAL TREE INJURY Diagnosis –May see on CT scan (e.g. pneumomediastiunum, etc.) –Confirm with Bronchoscopy Treatment –Operative Intervention –Observation

23. BLUNT CARDIAC INJURY Signs & Symptoms –Abnormal EKG in first 24 hours –Arrythmias –Hypotension Diagnosis –Cardiac Enzymes? –Echocardiogram Treatment –Supportive care –Symptomatic therapy

24. TRAUMATIC AORTIC DISRUPTION Characteristics –Blunt Mortality Scene: 85% Unstable transport: > 96% Stable transport: 5-30% –Blunt Mechanism: Acceleration/Deceleration injury Signs & Symptoms –Mechanism –Thoracic trauma –Impending doom –High index of suspicion

25. TRAUMATIC AORTIC DISRUPTION Diagnosis –Chest X-ray Wide Mediastinum (>8 cm)85% Indistinct aortic knob24% Left pleural effusion19% 1 st or 2 nd rib fracture13% Tracheal deviation12% NG Tube deviation11% Negative findings 7% Depressed left bronchus 5% –Transesophageal Echocardiography

26. TRAUMATIC AORTIC DISRUPTION Diagnosis –Helical CT Angiogram Sensitivity: 90-100% Specificity: 83-100% NPV: 99-100% –Catheter Angiography: Gold Standard Sensitivity: 92-100% Specificity: 95-99% NPV: 97-100%

27. TRAUMATIC AORTIC DISRUPTION Management –Preoperative Systolic BP < 100 mm Hg HR < 100 Begin with  -blocker; add nitroprusside –Operative Intervention Immediate repair is best approach Direct repair vs endoluminal stent –Non-operative Intervention Selected populations with more severe/life-threatening injures (e.g. CHI, unstable, pulmonary, etc.) Anti-hypertensive therapy is mandatory

28. DIAPHRAGMATIC RUPTURE Characteristics –Most occur on Left –Blunt = Large tears –Penetrating = Small perforations Signs & Symptoms –Respiratory distress –High index of suspicion –Mechanism

29. DIAPHRAGMATIC RUPTURE Diagnosis –CXR Elevated hemidiaphragm Effusion Intrathoracic contents –GI Contrast Study –CT Scan, Laparoscopy, Thoracoscopy, Laparotomy Treatment –Operative Repair

30. ESOPHAGEAL INJURIES Characteristics –Penetrating more common –Severe blow to epigastrium –High index of suspicion based on mechanism –Diagnostic delay = significant morbidity/mortality Signs & Symptoms –Shock –Pain out of proportion –Cervical emphysema

31. ESOPHAGEAL INJURIES Diagnosis –CXR Effusion or pneumo/hemothorax Mediastinal air Particulate matter in chest tube –GI Contrast Study: Gastrograffin, then Barium Treatment –Operative Repair –Upper esophagus: Right thoracotomy –Lower esophagus: Left thoracotomy

32. SUMMARY Life-Threatening Thoracic Injuries –Prompt Diagnosis –Emergent Therapy Potentially Life-Threatening Injuries –Identified in Primary or Secondary survey –High index of suspicion –Appropriate management

33. QUESTIONS ?