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CHEST TRAUMA
CHEST TRAUMA
Objectives
Objectives
Topics Not Covered
Topics Not Covered
Life Threatening
Life Threatening
CASE #1
CASE #1
CHEST TRAUMA
CHEST TRAUMA
FLAIL CHEST
FLAIL CHEST
Flail Chest
Flail Chest
Flail Chest
Flail Chest
Flail Chest and Intubation
Flail Chest and Intubation
Flail Chest
Flail Chest
Flail Chest
Flail Chest
CASE #2
CASE #2
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo
Occult Pneumo Summary
Occult Pneumo Summary
FLYING and PNEUMO
FLYING and PNEUMO
CASE # 3
CASE # 3
TracheoBronchial Injury
TracheoBronchial Injury
TBI Diagnosis
TBI Diagnosis
TBI
TBI
TBI
TBI
TBI
TBI
CASE #4
CASE #4
BCI
BCI
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
Myocardial Contusion
BCI Summary
BCI Summary
CASE #5
CASE #5
CHEST TRAUMA
CHEST TRAUMA
CHEST TRAUMA
CHEST TRAUMA
Blunt Aortic Injury
Blunt Aortic Injury
CHEST TRAUMA
CHEST TRAUMA
BAI
BAI
BAI-SSx
BAI-SSx
BAI- Mechanism
BAI- Mechanism
BAI
BAI
CHEST TRAUMA
CHEST TRAUMA
BAI and the CXR
BAI and the CXR
BAI and the CXR
BAI and the CXR
BAI
BAI
BAI- CXR and CT
BAI- CXR and CT
BAI and CT
BAI and CT
BAI and CT
BAI and CT
BAI and Echo
BAI and Echo
BAI Tx
BAI Tx
BAI Tx- Stent vs Open
BAI Tx- Stent vs Open
BAI Tx
BAI Tx
BAI Tx- early vs late
BAI Tx- early vs late
BAI Tx- early vs late
BAI Tx- early vs late
BAI Tx
BAI Tx
BAI Summary
BAI Summary

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1 CHEST TRAUMA

CHEST TRAUMA

Alyssa Reed, R1 November 2007

Thanks to : Dr Hall, Dr Patterson, Dr Oster

2 Objectives

Objectives

FLAIL CHEST TRACHEOBRONCHIAL INJURY OCCULT PNEUMOTHORAX BLUNT CARDIAC INJURY TRAUMATIC AORTIC INJURY PENETRATING CHEST TRAUMA

3 Topics Not Covered

Topics Not Covered

Rib Fractures Isolated Sternal Fracture Costochondral Injuries Esophageal Injuries

4 Life Threatening

Life Threatening

Causes???

Airway Obstruction Breathing Open pneumothorax Flail Chest Tension Pneumothorax Massive Hemothorax Circulation Cardiac Tamponade

5 CASE #1

CASE #1

42F fell down the stairs at home Dx?

6 CHEST TRAUMA
7 FLAIL CHEST

FLAIL CHEST

Common injury and commonly missed Definition: THREE or more ribs fractured at TWO points, allowing a freely moving segment of the CW to move in paradoxical motion

8 Flail Chest

Flail Chest

PHYSIOLOGY 1) Pulmonary contusion 2) Paradoxical Motion 3) Pain*

9 Flail Chest

Flail Chest

Mx ABCs Aggressive chest physio clear c-spine, sit up Close observation Selective use of intubation Pain control Chest tubes

10 Flail Chest and Intubation

Flail Chest and Intubation

Respiratory failure manifested by one or more of the following criteria: 1. Clinical signs of respiratory fatigue 2. Respiratory rate >35/min or <8/min 3. Pao2 <60 mm Hg at Fio2 ?0.5 Paco2 >55 mm Hg at Fio2 ?0.5 Alveolar-arterial oxygen gradient >450 Clinical evidence of severe shock Associated severe head injury with lack of airway control or need to ventilate Severe associated injury requiring surgery Pao2, partial arterial oxygen tension; Fio2; fraction of inspired oxygen; Paco2, partial arterial carbon dioxide tension.

11 Flail Chest

Flail Chest

Ullman et al. Reg Anesth 14(1): 43-7. 1989. Pts with flail segments comparing IV and epidural anesthesia Group 1 (n=13) intravenous morphine Group 2 (n= 11) epidural morphine Results: Vent time 18d vs 3 d ICU time 18d vs 6d Hosp stay 48d vs 15d Pulm fxn best in group 2 A lot of evidence since for the use of high block epidurals for pain relief to prevent splinting and atelectasis

12 Flail Chest

Flail Chest

Q: Who needs a chest tube?

Hemo or Pneumothorax Multisystem, unstable trauma Intubated patient Respiratory distress Air Transport (? routine vs selective)

13 CASE #2

CASE #2

30M MVC intubated for CHI, normal CXR Dx?

14 Occult Pneumo

Occult Pneumo

A pneumothorax that is absent on initial CXR but seen on subsequent chest or abdominal CT Ball et al. Am J Surg. 189(5), 2005 n=761 55% were OPTHX 84% were anterior, 0% posterior, 57% apical

15 Occult Pneumo

Occult Pneumo

Journal of Trauma. 49:281, 2000 Retrospective, n= 230 with pneumothx Results: 126 (54.8%) had occult pneumo identified on abdo CT Ball et al. J of Trauma. 60(2): 294-8, 2006 with increasing frequency of CT scans in trauma, estimate that up to 72% of all pneumos are occult

16 Occult Pneumo

Occult Pneumo

WHO NEEDS A CHEST TUBE?

Ball et al. J of Trauma. Aug 2005 n= 32, non-vented OPTHX 10 (31%) had chest tube inserted 22 (69%) observed Results: 1 needed chest tube placed later 0 serious complications of those observed 1 with tube had lung parenchymal injury growing recognition that non-vented patients can be safely treated without thoracostomy

17 Occult Pneumo

Occult Pneumo

Enderson et al. J of Trauma 35(5), 1993. Prospective RCT n= 40 on PPV, 19 with chest tube, 21 observed 8 with observation (38%) progressed, became symptomatic and needed chest tube 3 of 8 developed tension pneumo 0 with chest tube had complications recommend that all patients with occult pneumo with PPV have tube thoracostomy

18 Occult Pneumo

Occult Pneumo

Brasel et al. Prospective RCT n=18 on PPV, 9 with tube, 9 observed Results: no difference in overall complication rate 2 observed pts needed chest tube Concluded that can closely monitor pts with OPTHX on PPV for signs of resp distress

19 Occult Pneumo

Occult Pneumo

Ball et al. J of Trauma 59(2), 2005. Restrospective subset analysis n=17 with OPHTX with PPV 13 had chest tube and 4 were observed 0 complications with observation 23% had tube related complication or needed repositioning Concluded that more research needs to be done given paucity of literature and quality of studies

20 Occult Pneumo Summary

Occult Pneumo Summary

A Review. Emerg Med Clin North Am. 25(3), 2007 not enough data to determine if patients with OPTHX with PPV should have tube thoracostomy if pt is asymptomatic and no PPV it is safe to observe if patient has to go for surgery, has other injuries, has symptoms or hard to continuously observe, it is prudent to insert a chest tube Intubated patients generally require chest tube, more study required

21 FLYING and PNEUMO

FLYING and PNEUMO

Cheatham et al. Am Surg 65(12), Dec 1999 Prospective n=12 with traumatic pneumo wanting to air travel Results: 10/12 waited at least 14 d after radiographic resolution 10/10 ASx during flight 2/12 flew within less than 14 d 1/2 developed respiratory distress in flight

*Concluded that Aerospace Medicine Association’s recommendation of waiting 2-3 post radiographic resolution is safest

22 CASE # 3

CASE # 3

30M in MVC at highway speed, restrained, no airbag deployment Clinical Findings: hemoptysis, massive subcutaneous air, persistent pneumo despite properly done and positioned chest tube Dx?

23 TracheoBronchial Injury

TracheoBronchial Injury

Anatomy and Physiology sudden deceleration pulls lungs away from the mediastinum, producing traction on the trachea at the carina which is a relatively fixed point can also occur if glottis is closed at time of injury because large increase in intrabronchial pressure >80% occur within 2cm of carina wound opens into pleural space producing large pneumo, chest tube fails to re-expand lung, continuous bubbling of air in pleurovac

24 TBI Diagnosis

TBI Diagnosis

CXR findings Pneumothorax Pneumomediastinum Pneumopericardium Massive subcutaneous air* Air around mainstem bronchus

25 TBI

TBI

26 TBI

TBI

When to suspect? massive air leak persistent air leak hemoptysis massive subcutaneous air “Micheline Man” CXR findings Dx Hara et al. Chest, 1989. Fiberoptic bronchoscopy is most reliable means of Dx and finding exact site of injury Best done in OR with rigid bronch if suspect

27 TBI

TBI

MX Endotracheal Intubation: ideally done via bronchoscope (to avoid passage into false lumen) but impractical Selective intubation of good side can be done via scope Definitive is thoracotomy with intraop tracheostomy and surgical repair (no role for stents routinely- depends on level of injury)

28 CASE #4

CASE #4

35yo police officer struck by car GCS 3, intubated by EMS BP 80, HR 120, Sats 99% on vent, Temp N CXR - rib fractures, small pneumo PXR - no fracture FAST - negative ?Diagnosis ?Management

29 BCI

BCI

Pathophysiology Arrhythmias Acute valve problems Coronary artery injury/occlusion Myocardial injury - microcellular injury/edema = wall motion abnormalities, decreased contractility - CHF/cardiogenic shock

30 Myocardial Contusion

Myocardial Contusion

When should we consider and look for BCI? Signs of severe chest trauma Shock without other cause Arrythmias noted Signs of CHF Controversy around how to dx and the importance of it

31 Myocardial Contusion

Myocardial Contusion

Dx GS is biopsy or autopsy ECG Cardiac Markers Echo

32 Myocardial Contusion

Myocardial Contusion

ECG Normal or non-specific abnormalities Sinus tach* SVT RBBB RV damage therefore need 15 lead Various degrees of AV block Can develop 72 hours after injury How does a normal or abnormal ECG impact our management?

33 Myocardial Contusion

Myocardial Contusion

Nagy et al. World J Surg, 2001 Patients at risk for BCI admitted to ICU for serial ECGs, monitoring, serial enzymes N=171 Results: Pts with normal initial ECG had benign outcomes Pts with ST change, dysrhythmias had adverse outcomes Recommend that all patients with blunt chest trauma receive screening ECG but if normal can safely discharge but if new finding or abnormal monitor for 12 hrs

34 Myocardial Contusion

Myocardial Contusion

Bertinchant et al. Journal of Trauma, 2000 Prospective enrollment of pts with suspected BCI n=94 GS= significant ECG change or echo findings TnT + in 11 (12%) of pt with BCI, no bad outcomes TnT - in all without BCI, p>0.05 No relationship between positive trop and clinical outcome and do not recommend using as screening

35 Myocardial Contusion

Myocardial Contusion

Rajan et al. J of Trauma, 57(4) 2004 n= 187 with blunt chest trauma Results: 63(34%) had + TnI levels 47(25%) were symptomatic 124 had - TnI levels and all stayed asymptomatic and had no adverse outcomes severity of arrhythmia correlated directly with TnI level Concluded that +TnI mandates further cardiologic w/u and those with -TnI are safe not to

36 Myocardial Contusion

Myocardial Contusion

HOWEVER: 1/2 of their “significant arrhythmias” were PVCs No comment of clinically important outcomes of these arrythmias- like how many died or needed intervention BCI outcome was defined as an elevated TnI! In other words, they are trying to determine the value of TnI as a diagnostic test while using it as their outcome measure! aka incorporation bias

37 Myocardial Contusion

Myocardial Contusion

Ferjani et al. Chest 111(2), 1997 Prospective study measuring TNT Dx of cardiac contusion if Abn echo consistent with contusion Severe cardiac dysrhytmia (incl PVCs!) Severe conduction abn (incl RBBB!) Hemopericardium n= 29 dx with contusion Results: Sens= 31% Spec= 91%

* Does not support the use of screening trops

38 Myocardial Contusion

Myocardial Contusion

Valhamos et al. J of Trauma, Jan 2003 Prospective study n= 333 with significant blunt chest trauma (44/13% with clinically significant BCI) Serial ECGs and TnI tests were performed routinely Significant BCI defined as: cardiogenic shock arrhythmias requiring treatment post-traumatic structural deficits decreased cardiac index

39 Myocardial Contusion

Myocardial Contusion

ECG more sensitive than TnI (89% vs 73%) TnI neither sensitive or speficic ECG and TnI combined gives 100% sens and NPV 1 patient with initial normal ECG and TnI developed changes 8 hours post-admission Conclude that pts with initial normal ECG and TnI and again at 8 hrs can safely r/o significant BCI

40 Myocardial Contusion

Myocardial Contusion

A Review. Emerg Med Clin North Am. 25(3), 2007 Recommend: screening ECG for patients with suspected mechanism for BCI if normal, asymptomatic and otherwise healthy can rule out clinically significant contusion if abnormal or elderly with significant cardiac history should admit for further monitoring and consider other w/u (echo) no definitive study regarding use of cardiac markers if pt in cardiogenic shock need echo to see valves

41 BCI Summary

BCI Summary

Suspected

No evident comp

Cardiac comp

ECG

Cardiac Monitoring (12 hrs) +/- Echo

New Abnormality* - cardiac monitoring 12 hrs - consider echo

Normal -rules out clinically significant contusion - can d/c

*Arrythmias, ST depression, T wave inversion, conduction abnormality

Arrhythmia CHF Cardiogenic shock Shock w/o cause

42 CASE #5

CASE #5

29F unrestrained passenger in middle seat of van that was T-boned on her side at hwy speed. Ejected. Found 50 feet from vehicle. GCS 14 Hemodynamically stable

43 CHEST TRAUMA
44 CHEST TRAUMA
45 Blunt Aortic Injury

Blunt Aortic Injury

Q: Most common mechanism?

Rapid Deceleration: Ao arch is mobile and descending arch is immobile d/t ligamentum arteriosm and tethering by intercostal arteries 90% occur in the descending Ao just distal to the left subclavian artery

46 CHEST TRAUMA
47 BAI

BAI

DX Clinical presentation... Mechanism Imaging CXR as screening DI CXR vs CT CT vs Angiography CT vs TEE

48 BAI-SSx

BAI-SSx

Q: Clinical Presentation?

RSCP/Interscapular pain SOB Extremity pain Stridor Hoarseness Pseudocoarctation syndrome Chest wall bruising AI, MR murmur 80-90% die on scene though!

49 BAI- Mechanism

BAI- Mechanism

J of Trauma. April, 2003. Cohort design using large database Independent Positive Predictors of BAI Age>60 Front-seated Frontal or near-side impact Delta V> 40mph Crush >40cms Intrusion > 15cms Negative

Negative Predictors: - seatbelt use - occupant of lrg vehicle

50 BAI

BAI

Q: What are the high risk cxr findings?

mediastinal widening (>6cm PA, >8cm AP, >0.25 ratio of mediastinal to chest at knob) Apical cap Loss of AP window Loss of aortic knob Rightward deviation of NG/trachea Rightward displacement of mainstem Thickening of right paratracheal stripe (>5mm) Isolated 1st/2nd rib # not predictive

51 CHEST TRAUMA
52 BAI and the CXR

BAI and the CXR

Reviewed multiple articles Sensitivity of CXR approx 90% CXR can be normal in up to 5% with TAI Loss of Ao knob (sens= 53-100%, spec 21-55%) Mediastinal widening (sens- 81-100%, spec 10-60%) Cannot completely r/o the injury

53 BAI and the CXR

BAI and the CXR

7.3% with confirmed TAI had normal mediastinum on CXR Bottom line in many studies is that CXR is not that good at diagnosing TAI and the classic widened mediastinum is controversial and not that sensitive

54 BAI

BAI

Journal of Trauma. Dec, 2001. Prospective, n=93 Included pts with MVC>10mph, Fall> 5ft Excluded unstable and severe HI All had CXR and CT

55 BAI- CXR and CT

BAI- CXR and CT

Results: 68 (73%) showed at least 1 pathological sign on CXR 25 (27%) N CXR CXR sens 82% CXR spec 57% CXR missed 2/3 BAIs!!

Q: Do you want a CT in pts with major chest trauma?

56 BAI and CT

BAI and CT

Dyer at al. J of Trauma. April, 2000 Prospective study over 5.5 years N= 1561, n= 30 (TAI) Results of CTs ability to dx: 100% sensitive 100% NPV

57 BAI and CT

BAI and CT

Aortography long considered the gold standard, but new CTs are proving they have high sensitivity CT Direct signs of BAI Intimal flap Aortic wall disruption Extravasation of iv contrast Advantages: rapid, other injuries, less contrast than angio, lower stroke risk

*Use aortography if CT is equivocal - pseudocoarctation or mediastinal hematoma

58 BAI and Echo

BAI and Echo

Smith et al. NEJM, 1995 Prospective, n= 93 TEE followed by angio Sens= 100% Spec= 98% Chrillo et al. Heart, 1996 Prospective, n= 134 Sens= 93% Spec= 98% Time to surgical correction shorter by 40min

59 BAI Tx

BAI Tx

Current Therapeutic Approaches: Surgical Nonoperative or delay of surgery with pharmacologic BP control Endovascular stenting

60 BAI Tx- Stent vs Open

BAI Tx- Stent vs Open

Ott et al. J of Trauma 56(3), 2004 Review of prospective registry over 11.5 yrs n= 18 with TAI repair (6 by EVS, 12 by open) Results: Open: 2 early mortality, 2 paraplegia, 2 recurrent laryngeal nerve injury outcomes EVS: 0 of all above

*EVS is emerging as preferred method of repair

61 BAI Tx

BAI Tx

Dunham et al. J of Trauma 56(6), June 2004 Retrospective review n= 16 (TAI treated with EVSG) Results: 100% technical success 0% graft related complications during follow-up (mean 10.7 m) 0% paraplegia 1 post-op mortality due to secondary injury

*Concluded that repair of BAI with EVSG can be performed safely

62 BAI Tx- early vs late

BAI Tx- early vs late

Hemmila et al. Journal of Trauma. Jan, 2004. Retrospective using registry data Early repair defined as <16 hrs from injury

63 BAI Tx- early vs late

BAI Tx- early vs late

delayed repair is not associated with increased mortality shows that other injuries must be given appropriate consideration- often have to anticoagulate after EVS small sample and still large % difference in mortality

64 BAI Tx

BAI Tx

Q: What do we do?

Consult Trauma/Vascular/Intervential rad BP Control Pain control first, be VERY cautious! Discuss BP control with vascular Fabian et al. Ann Surg, 1998. antihypertensive therapy maintaining SBP between 100-120mmHg shown to reduce continued dissection and rupture Esmolol > labetolol

65 BAI Summary

BAI Summary

Suspect in deceleration injuries CXR can miss a significant proportion “Wide mediastinum” not that good at predicting CT if CXR abnormal or big mechanism Angio still gold standard but CT has similar sensitivity and 1st line now Stenting becoming favored treatment- but turf war Control BP only if you have to

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