Thoracic Trauma

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Thoracic Trauma

• J William Finley, MD
• Trauma Director
• Providence Regional Medical Center

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Thoracic Trauma

• Fourth Leading cause of death
• 150,000 Annual deaths
• Second only to head injury in cause of death
• 25 of trauma related deaths
• Often associated with other injuries
• Prevention Focus
• Gun Control Legislation
• Improved motor vehicle restraint systems
• Passive Restraint Systems
• Airbags

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Anatomy

• Thoracic cavity
• Thoracic inlet
• Diaphragm
• Contains a lot of important stuff
• Heart
• Lungs
• Mediastinal structures

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Extensive Armor
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There is no perfect protection
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Its a Dangerous World

• Penetrating Injury
• Low Energy
• Stab wounds
• High Energy
• GSW
• Blunt Injury
• Crush
• Compression
• Shear
• Acceleration/Deceleration

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Spectrum of Disease

• Chest Wall
• Contusions
• Rib fractures
• Flail Chest
• Pulmonary
• Pulmonary contusion
• Pulmonary laceration
• Hemothorax
• Pneumothorax

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Spectrum of Disease

• Cardiac
• Contusion
• Laceration
• Avulsion
• Tamponade
• Mediastinal
• Great vessel
• Tracheobronchial
• Esophageal
• Aortic

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Keys To Diagnosis

• Index of suspicion
• Injury association
• Clinical signs/symptoms
• Diagnostic imaging
• Xray
• CT
• Ultrasound

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Basic Trauma Resuscitation

• Easy as A-B-C
• A - Airway
• B - Breathing
• C - Circulation

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October 24, 2011
Thanks to Jonathan Holbrook, Tall Taurus Media,
LLC Real Heroes Breakfast 2011 Snohomish County,
American Red Cross
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Hemothorax

• Accumulation of blood in the pleural space
• Serious hemorrhage may accumulate 1,500 mL of
  blood
• Mortality rate of 75
• Each side of thorax may hold up to 3,000 mL
• Blood loss in thorax causes a decrease in tidal
  volume
• Ventilation/Perfusion Mismatch Shock
• Typically accompanies pneumothorax
• Hemopneumothorax

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Hemothorax

• Blunt or penetrating chest trauma
• Diagnosis
• Small to moderate
• Only seen on CXR or CT
• Large
• May be diagnosed clinically
• Dull to percussion over injured side
• Decreased BS on affected side
• Decreased chest expansion

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Hemothorax
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Hemothorax

• Management
• Placement of tube thoracostomy
• 36 French tube or greater
• Operative indications, thoracotomy
• Initial 1-1.5 L blood
• Ongoing 200-250/hr losses

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ED Thoracotomy

• Most surgeons hold a very pessimistic view
• Success rates vary
• Overall success rate 4-5
• The first successful 'prehospital' thoracotomy
  and cardiac repair was carried out by Hill on a
  kitchen table in Montgomery, Alabama in 1902.

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Why?

• Abysmal Success rate
• Exposes medical personnel to risk
• There are survivors
• The main determinants for survivability
• mechanism of injury
• location of injury
• presence or absence of vital signs

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Mechanism of Injury

• Penetrating thoracic injury
• Survival rate 18-33
• stab wounds gt gunshot wounds.
• Isolated thoracic stab wounds causing cardiac
  tamponade approach 70 survival
• Gun shot wounds injuring more than one cardiac
  chamber and causing exsanguination have a much
  higher mortality.
• Blunt trauma survival rates
• Vary between 0 and 2.5

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Location of Injury

• Almost all survivors of emergency thoracotomy
  suffer isolated injuries to the thoracic cavity.
• Cardiac injuries have the highest survival
• single chamber gt multiple chamber
• great vessels and pulmonary hila carry a much
  higher mortality

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Presence of Vital Signs

• Survival related to
• Presence of cardiac activity
• Amount of time since loss of cardiac activity
• 0 for those patients arresting at scene,
• 4 when arrest occurred in the ambulance,
• 19 for emergency department arrest and
• 27 for those who deteriorated but did not arrest
  in the emergency department1

1Tyburski JG, J Trauma 2000.
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Presence of Vital Signs

• 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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ED Thoractomy - Why?

• Release pericardial tamponade
• Enable open cardiac massage
• Occlude the descending aorta
• Control intrathoracic hemorrhage

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ED Thoracotomy - How

• Steps
• Prep chest, generally left chest
• Generous incision from sternal border to mid
  axillary line
• Down to intercostal muscles
• Divide chest along upper margin of 6th rib
• Spread ribs
• Retract lung
• Identify and incise the pericardium to release
  potential tamponade

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ED Thoracotomy - How

• Steps
• Recognize and repair any cardiac injury
• Open cardiac massage using 2 hand technique
• Cross clamp aorta
• Incision can be extended to right side of chest
  (Clamshell)
• Ongoing resuscitation
• Closure in OR

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Posterio-Lateral Thoractomy
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Clamshell Thoracotomy
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Thoracic Trauma

• Can create dramatic injuries
• Keep to resuscitation basics A-B-C
• Involve surgeons early
• ED thoracotomy does have some survivors