Chest trauma

1
Chest trauma

• When and how to intervene
• Chimei medical center
• Thoracic surgery
• Chief ??

2
Introduction

• Trauma death 140000/annually
• Leading cause of death in younger than 40y/0
• 75 has thoracic trauma
• Most injury of chest can managed with simple
  maneuver
• 10-15 need definitive operative repair

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Thoracotomy

• Immediate (ER Thoracotomy)
• Urgent In OR1-4 hrs of arrival
• Delayed (24hrs after admission)

4
EDT

• Primary use in severe penetrating injury
• Lesser extent after blunt injury

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Therapeutic goals of EDT

• Effective cardiac compression
• cross clamping of hilum for air embolism and
  massive bronchopleural fistula
• Release of cardiac tamponade
• Cross clamping of descending aorta for lower
  torso hemorrhage control

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• After condition stabilization, the patient has to
  transport to OR for further management

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Three factor need consideration

• Mechanism of injury
• Location of major injury
• Sign of life
• Better outcome in penetrating injury 8-10
• Bad outcome in blunt injury (1)
• Stab wound better than gunshot wound

8

• Chest penetrating injury is better than
  multi-cavity injury.
• Sign of life also need consideration
• Penetrating trauma with sign of life in OR or who
  loss sign of life within 10 min is better than
  blunt trauma without sign of life ( poor outcome)
  EDT should not perform in this condition.

9
Current guideline in ATLS for EDT

• With penetrating chest trauma and cardiac
  electrical activity but not with pulseless blunt
  trauma or penetrating trauma without cardiac
  electrical activity

10

• No role for pericardiocentesis in these patient
• Often is not effective in removing clotted blood
  from pericardial space
• It is not a risk-free procedure
• It potentially delay the surgical procedure
• Use FAST (Focused assessment with sonography for
  trauma)

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• The standard incision of EDT is a left
  anterolateral thoracotomy
• Could modified the procedure depend on the
  condition
• ????? ? damage control

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Urgent thoracotomy

• Compensated cardiac injuries
• Non-exsanguinating injuries to the great vessels
  of the aorta
• Tracheobronchial injuries
• Esophageal injuries
• Traumatic rupture of the aorta

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Indications for UT

• Presence of cardiac tamponade (Becks
  triadsmuffled heart tones,distended neck vein
  and hypotension)
• High chest tube output or ongoing bleeding
• Massive persistent air leak
• Air embolism (usually in bronchus and pul vein
  fistula initial stable but condition change after
  intubation and ventilator support)

14
Select incision is important in UT

• Right chest
• Left chest
• Mediastinum
• Concomitant abdominal injuries
• Peritoneal cavity

15

• Massive hemothorax suggest the presence of major
  vascular injuries that is unlikely to stop
  without surgical intervention

16
Chest exploration

• Initial More than 1000ml blood loss as an
  indication to consider chest exploration
• Ongoing bleeding after chest tube placement at a
  rate of 200-300ml/hr also indication

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Wait and see in some patient

• 1. Pulmonary parenchymal bleeding
• 2.Blunt trauma with delay presentation
• 3. coagulopathy ( Medication in elderly patient
  or close head injuries)

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Delayed thoracotomy

• Retained hemothorax
• Post traumatic empyema
• Delay tracheobronchial injuries
• Intracardiac injuries

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Favorable patient outcomes

• Right time
• Right place
• Right surgeon
• Right care