Trauma and Critical Care—Thoracic Trauma
Concept
Major cause of trauma mortality. Life threatening prob- lems should be treated as they are identified. Multiple, pos- sibly lethal, injuries that must be identified and treated promptly:
Tension Pneumothorax Massive hemothorax
Tracheobronchial tree injuries Cardiac tamponade
Traumatic aortic injury
Examiners will also be interested in determining if you know when and when not to get additional tests versus move directly to pericardial window, thoracotomy, or median sternotomy. Don’t forget to rule out other non- thoraic injuries.
Way Question May be Asked?
“Called to ED to see a 24 y/o male who suffered a GSW to the chest. His HR is 130 and his SBP is 90/palp. What do you want to do?” Will usually be a question testing your management priorities and if you know how to take care of the unstable patient.
How to Answer?
Brief H +P while resuscitating the patient:
ABCs then:
PMHx Meds Allergies
Physical Exam
VS (if unstable, you will be doing procedures during your evaluation)
Distended neck veins and hypotension (tamponade, tension pneumothorax)
Head to toe physical exam
Chest auscultation (to determine pneumothorax) Do not remove any foreign bodies (knives are removed
in OR!) SQ emphysema
“Sucking chest wound”
Flail segment
Algorithm
ABCs (airway first!)
Resuscitation (IVF, full labs including PT/PTT, T +C, NGT, Foley)
Lateral C-spine
CXR (r/o widened mediastinum, hemothorax, apical cap, depressed left mainstem bronchus, deviated NGT)
Pelvis x-ray
Diagnostic Tests
CT scan (not in unstable pt)
Angiogram (any pt with suspicion of traumatic rupture of aorta but not in unstable pt—traumatic rupture doesn’t explain hypotension in trauma pt)
Surgical Treatment
(1) When to place chest tube?
Absent breath sounds, even prior to CXR Penetrating injury to one side of chest
Initial output > 1000 cc, or > 200cc/h for four consecutive h →OR!
(2) When to do ED thoracotomy?
Penetrating trauma with actual or impending car- diac arrest or “Signs of life” in the field and lost en route to ED
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Done through sixth intercostal space, left antero- lateral incision
Rib spreader, hold lung superiorly with sponge stick or assistant’s hand
Open pericardium anterior to phrenic nerve Clamp descending aorta jut above diaphragm
(feel for NGT)
Not for blunt trauma or when lost “signs of life”
and > 10 minutes resuscitation en route (3) When to take to OR for thoracotomy?
CT output > 1000 cc initially
CT output > 200 cc for 4 consecutive hours Large air leak with hypoxemia (on side of injury) Esophageal injury (right thoracotomy unless distal
third esophagus)
Left subclavian and descending aortic injury (4) When to do median sternotomy?
Left supraclavicular stab wound
Suspicion of great vessel injury (pulmonary hilum) Suspicion of injury to right inominant artery (can’t
reach this through anterolateral thoracotomy) Tracheal injury
Allows access to ascending aorta, inominant, prox- imal right subclavian, right carotid
(5) When to do pericardial window?
Stable pt with transmediastinal GSW Dilated neck veins/high CVP and pt in shock (6) Diaphragmatic injuries
High index of suspicion (CT, MRI, U/S, fluo- roscopy, laparoscopy)
Look for displaced NGT into left chest
Repair in two layers with non-absorbable sutures and place G-tube if on left side
Repair transabdominally if diagnose early, through thoracotomy if diagnose late secondary to intra-thoracic adhesions
May need a mesh if very large defect (Gortex) (7) Mediastinal injuries
Make sure to do bronchoscopy, esophagoscopy, gastrografin swallow to rule out tracheo- bronchial/esophageal injuries in penetrating trauma
(8) Cardiac contusion
Rarely the cause of shock in trauma pts
Check EKG, enzyme levels, observation on telemetry
If any ischemic changes, treat as MI pt in ICU Echo will diagnose contusion, dyskinesia, tamponade,
valvular injury (9) Flail chest
Aggressive pulmonary toilet Careful fluid management
Pain control ( +/− epidural, intercostal blocks) Will be underlying lung contusion
Follow ABGs/CXR
Selective intubation based on associated injuries/respiratory status
Common Curveballs
When to do thoracotomy When to place chest tube When to take to OR
When to do angiogram to r/o aortic injury Pt will be unstable
Pt will have tracheo/esophageal injury Pt will need lung resection
Pt will have visceral herniation through diaphragmatic hernia
Pt will need median sternotomy
Pt will have coincident closed head injury (which do you approach first)
Pt will have obvious intraabdominal injury (which do you approach first)
To describe where aortic injury typically occurs and how to repair
There will be contralateral injury There will be post-op thoracic duct leak There will be post-op empyema
Strikeouts
Not knowing when to do ED thoracotomy (never in blunt trauma)
Not knowing when to place CT tube (before Cxe) Not knowing how to diagnose aortic injury Performing CT scan in unstable pt
Not knowing how to repair diaphragmatic injury Not going through ABCs
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