Chest Trauma and Indications for Thoracotomy

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Chest Trauma and Indications for Thoracotomy

• Dr.Sami Alnassar

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Primary survey

• Aim to identify life threatening chest injury
• Tension pnemothorax
• Massive hemothorax
• Cardiac temponade
• Flail chest
• Open pneumothrax

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EXAMINATION

• LOOK
• FEEL
• LIESTEN
• PERCUSS

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EXAMINATION

• LOOK
• FEEL
• LISTEN
• PERCUSS

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Examination
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Dont forget to examine the back??
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DIAGNOSTIC IMIGING

• CXR
• FAST

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secondary survey

• Is more detailed and completed examination to
  Identified
• Ribs fractures , flial chest
• Lung contusion
• Simple pneumothorax
• Simple haemothorax

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Sucondrey survay

• Further diagnostic study
• Chest CT
• Broncoscopy
• Angiogram
• Oesophagoscopy / oesophagram

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Tension Pneumothrax

• is the progressive build-up of air within the
  pleural space
• Usually due to a lung laceration
• Classical signs
• deviation of the trachea
• increased percussion note
• hyper-expanded chest
• Increase CVP ( may be normal ? )

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Tension pneumothrax

• These classical signs may be absent
• tachycardia and tachypnea, and may be hypoxia.
• These signs are followed by circulatory collapse
  with hypotension and PEA

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Tension Pneumothorax

• The presence of chest tubes does not mean a
  patient cannot develop a tension pneumothorax

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Tension Pneumothrax

• Tension pneumothorax may also persist if there is
  an injury to a major airway
• 2 or more CT may be needed
• in these cases thoracotomy is usually indicated

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Bilateral tension Pneumothorax

• Beware also the patient with bilateral tension
  pneumothoraces

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treatment

• Needle Thoracostomy
• Chest tube placement
• Possible thoracotomy or thoracoscopy

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Tracheo-broncheal injury

• Its rare ,from 0.2 to 4
• Most victims die prior to ER
• 80 within 2.5 from carina
• Main stem 86
• More common in right side

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Tracheo-broncheal injury

• Signs and symptoms
• Strider
• Hoarseness
• Hemptysis
• Pnemothorax with major air leak
• Up to 10 will not produce any clinical or
  radiological signs ( recognized months after
  stricture occur
• Bronchoscopy is the most reliable test

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Tracheo-broncheal injury

• Intraoperative airway management
• Coordinate with anesthesiologist
• Sterile anesthesia circuit
• Double lumen tube
• Tracheostomy if needed 2-3 rings above the
  injured segment
• Postoperative airway management
• Maintained low airway pressure
• Allows immediate extubation

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Tracheo-broncheal injury

• Surgical approach
• Extrathoracic consider collar incision
• RT thoracotomy for RT bronchial and proximal left
• LT thoracotomy for distal LT bronchial injury
• Debriment , mucosa to mucosa, absorbable suture
• Reinforce suture line with pericardium,
  pleura,..
• Outcome
• gt90 of patient reach hospital alive, have good
  outcome

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Tracheo-broncheal injury
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Tension gastrothorax

• may be confused with a tension pneumothorax.
• There is haemodynamic compromise, tracheal
  mediastinal deviation, and decreased air entry in
  the affected hemithorax

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Open Pneumothorax

• occurs when there is a pneumothorax associated
  with a chest wall defect
• air is entrained into the chest cavity not
  through the trachea but through the hole in the
  chest wall.
• Once the size of the hole is more than 0.75 times
  the size of the trachea, air preferentially
  enters through the thoracic cavity.

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Open Pneumothorax

• Diagnosis should be made clinically
• Sucking chest wall wound

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managements

• Oxygenation and possible intubations if in
  distress
• Occlusive dressing to the wound
• Immediate CT insertion
• If no CT available , bandage may be applied over
  the wound and taped on 3 sides
• OR for closure of the defect

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hemothorax

• Most hemothoraces are the result of rib
  fractures, lung parenchymal and minor venous
  injuries
• Less commonly there is an arterial injury, which
  is more likely to require surgical repair.
• The classic signs of a haemothorax are decreased
  chest expansion, dullness to percussion and
  reduced breath sounds

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hemothorax

• CXR is the standard test
• Erect film more sensitive but it take 400 t0 500
  to obliterate the costo-phrenic angle

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hemothorax

• FAST is useful in unstable patient , it detect
  small hemothorax
• CT is more sensitive test
• It detect other associated injury

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managements

• CT insertion first
• Thoracotomy indicated if immediate drainage of
  1000-1500mls of blood
• Or 200ml for 4 hours
• However the initial volume of blood drained is
  not as important as the amount of on-going
  bleeding

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Tension hemothorax
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Tension hemothorax
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Flail chest

• occurs when a segment of the thoracic cage is
  separated from the rest of the chest wall.
• it defined as at least two fractures per rib , in
  at least two ribs.
• Usually associated lung contusion
• It result in impaired ventilation

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Diagnosis

• paradoxical movement of a segment of the chest
  wall
• CXR and CT established the diagnosis

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Clip
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Flail Chest

• it directed towered
• Protected underling lung
• Maintain ventilation
• Prevent pneumonia
• Analgesia is the main treatment
• PCA and NSAID
• Epidural is the best option ( elderly )
• Intubations and mechanical ventilation is rarely
  indicated

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managements

• Operative Fixation by wires or plates indicated
  in
• Patient going for thoracotomy
• Fixed thoracic impaction
• Failure to wean from ventilator

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Operative fixation
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Operative fixation(Judet plates )
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Operative fixation(Sanchez plates )
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Thoracoscopy for trauma patients (carllio AJS
2005)

• DIAGNOSTIC APPLICATIONS
• DIAGNOSIS OF DIAPHRAGMATIC INJURIES
• DIAGNOSIS OF PERSISTENT HEMORRHAGE
• DIAGNOSIS OF BRONCHOPLEURAL FISTULAS
• ASSESSMENT OF CARDIAC AND MEDIASTINAL STRUCTURES
• THERAPEUTIC APPLICATIONS
• MANAGEMENT OF RETAINED THORACIC COLLECTIONS
• REPAIR OF DIAPHRAGMATIC INJURIES

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Emergency Department Thoracotomy

• Accepted Indications
• Penetrating thoracic injury
• Traumatic arrest with previously witnessed
  cardiac activity
• Unresponsive hypotension (BP lt 70mmHg)
• Blunt thoracic injury
• Unresponsive hypotension (BP lt 70mmHg)
• Rapid exsanguination from chest tube (gt1500ml)

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Emergency Department Thoracotomy

• Relative Indications
• Penetrating thoracic injury
• Traumatic arrest without previously witnessed
  cardiac activity
• Penetrating non-thoracic injury
• Traumatic arrest with previously witnessed
  cardiac activity
• Blunt thoracic injuries
• Traumatic arrest with previously witnessed
  cardiac activity

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Emergency Department Thoracotomy

• Contraindications
• Blunt injuries
• Blunt thoracic injuries with no witnessed cardiac
  activity
• Multiple blunt trauma
• Severe head injury

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Emergency Department ThoracotomyRationale

• Overall survival of patients undergoing emergency
  thoracotomy is between 4 and 33
• The main determinants for survivability are the
  mechanism of injury
• For penetrating thoracic injury the survival rate
  is fairly uniform at 18-33

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Emergency Department ThoracotomyRationale

• Blunt trauma survival rates vary between 0 and
  2.5
• The presence of cardiac activity, consistently
  related to the outcome following emergency
  thoracotomy
• In one study of 152 patients (Tyburski) survival
  rates were 0 for those patients arresting at
  scene, 4 when arrest occurred in the ambulance,
  19 for emergency department arrest
• Survival for blunt trauma patients who never
  exhibited any signs of life is almost uniformly
  zero. Survival for penetrating trauma patients
  without signs of life is between 0 and 5.

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Emergency Department ThoracotomyOperative
Technique

• The primary aims of emergency thoractomy are
• Release of cardiac tamponade
• Control of haemorrhage
• Allow access for internal cardiac massage
• Secondary manoeuvers
• cross-clamping of the descending thoracic aorta.

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Emergency Department ThoracotomyOperative
Technique

• Approach
• A supine anterolateral thoracotomy
• left sided approach is used in all patients and
  with injuries to the left chest
• Patients who are not arrested but with profound
  hypotension and right sided injuries have their
  right chest opened first.

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Emergency Department ThoracotomyOperative
Technique
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Emergency Department ThoracotomyOperative
Technique

• Approach
• In both cases it may become necessary to extend
  the incision across the sternum
• skin incision is made in the 5th intercostal
  space
• Relief of tamponade
• The pericardium is opened longitudinally to avoid
  damage to the phrenic nerve,

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Emergency Department ThoracotomyOperative
Technique

• Control of haemorrhage
• Cardiac wounds
• controlled initially with direct finger pressure.
  
• sutured using non-absorbable 3/0 sutures
• mattress sutures are used to avoid obstructing
  coronary flow
• Pulmonary Hilar injuries.
• temporarily controlled with finger pressure at
  the pulmonary hilum.

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Emergency Department ThoracotomyOperative
Technique

• Control of haemorrhage
• Pulmonary Hilar injuries
• This may be augmented by placement of a Satinsky
  clamp across the hilum
• Lesser haemorrhage from the lung parenchymas can
  be controlled with a temporary clamp
• Great vessel injuries
• Small aortic injuries can be sutured directly
  using the 3/0

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Emergency Department ThoracotomyOperative
Technique

• Larger injuries, especially to the arch may
  require temporary digital occlusion and
  insitution of cardiac bypass.
• Internal cardiac massage
• internal cardiac massage should be started as
  soon as possible
• A two-handed technique produces a better cardiac
  output

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Emergency Department ThoracotomyOperative
Technique

• Aortic cross-clamping
• The rationale for clamping the aorta is to
  redistribute blood flow to the coronary vessels,
  lungs and brain,
• Clamp time should ideally be 30 minutes or less.
• Cross-clamping is done ideally at the level of
  the diaphragm, to maximise spinal cord perfusion

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Emergency Department ThoracotomyOperative
Technique
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Emergency Department ThoracotomyOperative
Technique