42 a.hill ThoracicTraumaJune2008Modified

7/28/2019 42 a.hill ThoracicTraumaJune2008Modified

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THORACIC TRAUMA

Arthur Hill, M.D.Department of Surgery

Division of Cardiothoracic SurgeryUniversity of California, San Francisco


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EPIDEMIOLOGIC ISSUES

BLUNT

MVC Falls Airplane Crashes

PENETRATING

Stab wounds Bullet wounds


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BLUNT THORACIC TRAUMA

45 50% of unrestrained drivers havethoracic injuries

25% of drivers who die have thoracicinjuries


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Blunt Thoracic Trauma

Distribution of Organ Injury: Chest Wall 70%

Lung 21%

Heart 7%

Diaphragm 7%

Esophagus 7%

Aorta 4.8%

Tracheobronchial Injuries 0.8%

Jones KW. Thoracic Trauma. SurgClinNorth Am 1980; 60: 957-81.Hill AB, Fleiszer DM, Brown RA. Chest trauma in a Canadian urban setting - implications for trauma research in Canada. J Trauma 1991; 31: 971-73.Devitt JH, McLean RF, Koch J-P. Anaesthetic management of blunt thoracic trauma. Can J Anaesth1991; 38: 506-10.ShorrRM, Crittenden M, Indeck M, HartunianSL, Rodriguez A. Blunt thoracic trauma; analysis of 515 patients. Ann Surg1987; 206: 200-5.


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DISTRIBUTION OF THORACIC INJURIES

SECONARY TO BLUNT TRAUMA Consequences of Chest Wall Injury:

Rib Fractures (most common chest wall injury in blunt trauma)

Hemothorax (70-80% of penetrating and major blunt injuries) Flail Chest (Incidence 1.2% -- 20-40% mortality)

Sternal Fracture(5-8% in blunt trauma; 25-30% mortality)

Consequences of Chest Wall Injury and Lung Injury

Pulmonary Contusion (30-75% of blunt trauma; mortality 14-20%) Pneumothorax (10-30% in blunt injury; 95% in penetrating injury)

Simple

Open

Tension

Consequences of Cardiac Injury

Pericardial Tamponade (usually associate with penetrating trauma)

Myocardial Contusion (most common blunt injury to heart)


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PENETRATING THORACICINJURIES

Low velocity missile

High velocity missile


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PENETRATING THORACICTRAUMA

40% Penetrating Injury Involves the Thorax

15-28% of Penetrating Thoracic Injuries

Require Thoracotomy


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PENETRATING THORACICTRAUMA

Distribution of Organ Injury Chest Wall 100% Lung 65-90% Heart 49%

Diaphragm 30% Intra-Abdominal Injury

Liver 20% Stomach 8%

Small intestine 7% Colon 6% Kidney 5%


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Mechanisms of Early Death afterThoracic Injury

Airway Obstruction Loss of Oxygenation or Ventilation

Exsanguination Cardiac Failure

Cardiac Tamponade

Air Embolism


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ATLS Algorithm

A Airway (with c-spine protection)

B Breathing (pleural drainage)

C Circulation (stop the bleeding) D Disability (neurostatus, fractures)

E Exposure (temperature, pain)


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RECOGNITION OF TREATABLELIFE-THREATING INJURY

Tension Pneumothorax

Cardiac Tamponade


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TENSION PNEUMOTHORAX

Physical Exam

CXR

Unilateral absence

of breath soundsJVDHypotensionTracheal deviation


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TENSION PNEUMOTHORAX

Treatment: Needle thoracostomy

(buy time)

Chest-tube (definitive)


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CARDICAC TAMPONADE

Physical Exam

FAST/ECHO

Hypotension

Muffled HeartSounds

JVD

PulsusParadoxus


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PulsusParadoxus


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CARDICAC TAMPONADE

Treatment Drainage

Surgical

L thoracotomy Laparotomy

(with pericardial window)

Median Sternotomy

Pericardiocentesis


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THORACIC TRAUMA

All major thoracic trauma requirestreatment by a surgeon.


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Thoracic Incisions Used in Trauma

AnterolateralThoracotomy

Supraclavicular/trap-doorincision

Thoracocervical incision

Thoracoabdominalincision

Median Sternotomy Combinations of the

above


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Incision Choice for Tracheal Injury


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RESUSCITATIVE (ER)THORACOTOMY

INDICATIONS

TECHNIQUE


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RESUSCITATIVE (ER)THORACOTOMY

10-15% of Thoracic Traumapatients will requireResuscitative Thoracotomy


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Indication for ERT

Penetrating thoracic trauma with Recent loss of signs of life followed by acute hemodynamic deterioration

Penetrating abdominal trauma with

signs of life on admissionfollowed by acute hemodynamic deterioration

Selected Blunt thoracic trauma with signs of life on admissionfollowed by observed acute hemodynamic deterioration


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Contraindication to ERT withPresentation to ER

Blunt trauma without signs of life Penetrating torso trauma without signs of

life at the scene

No cardiac activity in the absence oftamponadeby FAST Exam


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Purpose of ERT

Terminate exsanguination Cardiac

Non-cardiac

Relieve cardiac tamponade

Open chest CPR

Treatment of Massive air embolism Thoracic aortic cross-clamping


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Resuscitative (ER) Thoracotomy


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Rapid, versatile incision

Can expose left subclavian veins if made

higher than usualCan be extended into clam shell or trap door

Anterio-lateral Thoracotomy


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Resuscitative ThoracotomyOVERALL SURVIVAL

Overall 0-70%

Penetrating 9-70%

Stab wounds 70%GSW 9-33%

Blunt 0-2.5 %Asensio J A, Berne JD, DemetriadesD et al. 'One hundred five penetrating cardiac injuries: A 2-year prospective evaluation'. J Trauma 1998;44:1073-108Karmy-J ones R, J urkovich GJ , NathensAB et al. 'Timing of Urgent Thoracotomyfor Hemorrhage After Trauma: A Multicenter Study.' Arch Surg 2001;136:513-518

Tyburski J G, Astra L , Wilson RF et al. 'Factors affecting prognosis with penetrating wounds of the heart'. J Trauma 2000;48:587-590Rhee PM , Acosta J , Bridgeman A et al. 'Survival after emergency department thoracotomy: review of published data from the past 25 years.' J Am Coll Surg2000;190:288-298BranneySW, Moore EE, FeldhausKM et al. ' Critical analysis of two decades of experience with postinjuryemergency department thoracotomyin a regional trauma center'. J

Trauma 1998;45:87-95Campbell NC, Thomson SR, Muckart DJ J .' Review of 1198 cases of penetrating cardiac trauma'. Br J Surg 1997;84:1737-1740


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Wielenberg , A. J. et al. Am. J. Roentgenol. 2006;187:W239-W240

--25-year-old man with cardiac herniation after motorcycle accident


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Specific Challenges in ThoracicTrauma

Thoracic Aortic Injury

Cardiac Injury


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THORACIC AORTIC INJURY

Mechanism:rapiddeceleration

producesshearing injurybetween fixedand mobileportions of theaorta.


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DISTRIBUTION OF AORTICINJURIES


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TraumaticAortic


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Traumatic Aortic

Dissection/Rupture 15% of fatal MVC victims have aortic rupture

85% die instantaneously

10-15% survive to hospital

21% die within six hours 31% die within 24 hours

84% die within 4 months

Musthave high index of suspicion

Parmlyet al (Circulation 1958)


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DIAGNOSIS OF BAI

Chest X-ray Aortography

Thoracic CT SCAN

Thoracic MRI

Cardiac Echo (TEE)


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MEDIASTINAL WIDENING


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CXR FINDINGS


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CXR FINDINGS

in 259 patients with blunt aortic injury.


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Thoracic Aortic Injury

BAI: DEFINITIVE DIAGNOSIS


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Thoracic CT

Angiography

TEE (operatordependent)



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Helical CT vs. Angiography

Prospective Non-randomized Trial (1998) 494 patients 71 diagnosed with BAI

Conclusion: CT comparable to Aortography



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TEE vs. Angiography

Prospective Non-randomized Trial (1998) 34 patients

TEE unsuccessful in 15% of patients

Conclusion: TEE is an inferior imagingModality compared to aortography (and CT).


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TREATMENT OPTIONS IN BAI

Surgical therapy Clamp-and-sew

Bypass

Endovascular Stent Therapy


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PARTIAL BYPASS

Decrease upper bodyhypertension

Perfusion to lower body(gut/kidney/liver)

Prevent spinal cordischemia/infarction

DATA SUPPORTING THE USE OF


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DATA SUPPORTING THE USE OF

BYPASS FOR SURGICAL TREATMENTOF BAI

Prospective Non-randomized Trial (1997) Multicenter

274 patients

Endpoints:

Mortality

Paraplegia

USE OF CENTRIFUGAL


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PUMP FOR BAI

Conclusion: Bypass is associated with adecreased paraplegia rate when used inBAI Standard of Care.

Multicenter Trial: 207 patients; 1997


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SURGICAL REPAIR OF BAI


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ENDOVASCULAR THERAPIES


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ENDOVASCULAR STENT GRAFTS FORACUTE BLUNT AORTIC INJURY

ENDOVASCULAR STENT GRAFTS FOR


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ACUTE BLUNT AORTIC INJURY

Where do we stand?


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Available Devices

GORE TAG FDA approved

Medtronic TalentTM

FDA approved

VALOR Study (non-traumaticthoracic aortic aneurysms)

99.5 successful deployment

All cause death rate: 16.1 vs.

29.8 (p


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Retrospective

1999-200316 patientsReview ofLiterature


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Retrospective ReviewUniversity of

Western Ontario200418 patients

6 Stent

12 Open

RetrospectiveStudy2006


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2006

27 patients14 Non-operative8 Endovascular

0% prm25% mortality37% complication rate

5 Thoracotomy20% prm60% mortality

Grafts used:AneuRx 8Talent 1Gore 1

Retrospective Comparison


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Retrospective Comparison

200830 patients

14 Stented

12 Open

Conclusion: Endovascular therapyis safer and as effective and openrepair for BAI

META-ANALYSIS


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TxLOSParaplegiaMortality


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Evolving Technology

No Level I data

No Clinical Equipoise

The Gold Standardwithin the next 2-5years

Standard of Care


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OPERATIVE REPAIR OF THEINJURED HEART

Technique

LOCATION OF CARDIACINJURY FROM


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INJURY FROMPENETRATING TRAUMA

Frequency of injury dependents on thelocation of penetration.

20 year study with 711 cardiac injuries

Right Ventricle- 40%

Left Ventricle- 40% Right Atrium 24% Left Atrium- 3% Coronary arteries- 5%

Wall et al., J Trauma 42:905,1997


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Maneuvers to

control bleeding:

MANUAL

COMPRESSION


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CARDIAC INJURY


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JEXHAUSTIVE EVALUATION

Cardiac Echo

Cardiac Catheterization

Definitive Repair

PREDICTORS OF SURVIVAL IN


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CARDIAC TRAUMA

Prospective Study60 patients (USC 1998)Parameters predictive ofSurvival:

Mechanism of injuryCVRSNeed for Aox-clampingInability to restore

original rhythm


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Thoracic Trauma

Recognition

Diagnosis

Severity/Lethality

Early Treatment


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THORACIC TRAUMA EPIDEMIOLOGY

Blunt Injury Penetrating Injury

SPECTRUM OF THORACICTRAUMA

APPROACHES TO THETREATMENT RESUSCITATIVE

THORACOTOMY SPECIFIC CHALLENGES IN

THORACIC TRAUMA Aortic Trauma Cardiac Trauma

42 a.hill ThoracicTraumaJune2008Modified

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