THORACIC TRAUMA
Nolan Ortega Aludino, M.D.Department of Surgery
Ospital ng Maynila Medical Center
General Data: N.A.
35 years oldMale
Pandacan Manila
Chief Complaint: Stab wound
History of Present Illness
� Few minutes PTC ! patient was allegedlyattacked with a knife byan unknown assailant for no apparent reason
Consult
Physical Examination
� General Survey:� Conscious, coherent, in distress
� Vital SignsBP = 90/60 CR = 110 RR = 27
Physical Examination
� HEENT:� pink palpebral conjunctivae, anicteric sclerae,
PERLA, supple neck� Chest:
� Symmetrical chest expansion, no retractions, decreased breath sounds on the Left lung field, (+) crepitations on Left lateral thoracic wall
Physical Examination
� Stab wound level of the 4th
intercostal Left MAL
Physical Examination
� Cardiac:� tachycardic, regular rhythm, no murmur
Physical Examination
� Abdomen: � Flat, soft, nontender, no mass
� Extremities:� Full and equal pulses, no deformities
Salient Features
� 35 y/o� Male� Cardiorespiratory distress� Stabwound, LMAL� Decreased Breath Sounds� Crepitations
Initial Impression
CertaintyDiagnosis
15%Non
Penetrating Chest Injury
Secondary Diagnosis
85%Penetrating Chest Injury
Primary Diagnosis
Paraclinical Diagnostic Procedure
� Do I need to perform a paraclinicaldiagnostic procedure?
�YES�
Options
Not readily available(++++)Exposure to
radiation
Sensitivity: Pneumothorax: (+++)Hemothorax: (+++)
CT-Scan
available(++)No radiation exposure
Sensitivity: Pneumothorax: (++)Hemothorax:(+)
Ultrasound
available(+)Exposure to radiation
Sensitivity: Pneumothorax: (+)Hemothorax:(+)
X-Ray
AvailabilityCostRiskBenefit
Chest X-ray
Pre Treatment Diagnosis
Pneumohemothorax, Left
secondary to penetrating chest injury
GOALS OF TREATMENT
� Resolution of hemothorax� Resolution of pneumothorax� Monitor for ongoing bleeding
Treatment Options
available(+)-Injury to adjacent structure
-Useful in small hemothorax-incomplete evacuation
Thoracentesis
available(++)- Injury to adjacent structure
-Complete evacuation of fluid-can monitor ongoing bleeding-hemostatic
Tube Thoracostomy
AvailabilityCostRiskBenefit
Management
CLOSED TUBE THORACOSTOMY, LEFT
Preoperative Preparation
� Informed consent� Provide psychosocial support� Optimize patient condition
� Hydration� Antibiotics
Operative technique
� Patient semi-sitting with the ipsilateral arm placed above the head to expose the lateral aspect of the chest
� chest prepared with antiseptic solution� draped to create a sterile field� large bore chest tube (F36) chosen to
facilitate adequate drainage
Operative technique
� 5th ICS midaxillary line identified and skin, periosteum, and pleura anesthesized with 1% lidocaine
� transverse incision made over the underlying space
� blunt dissection continued with Kelly clamp� clamp passed adjacent to the superior
surface of the rib to prevent injury to the intercostals neurovascular bundle
Operative technique
� entry into the pleural space confirmed with rush of blood-filled fluid
� finger inserted into the pleural space to identify any pleural adhesions
� Fr 36 chest tube inserted into the pleural space on a Kelly clamp and directed posteriorly
� tube secured with a silk 0 suture
Operative technique
� attached to a water sealed thora-bottle� insertion site dressed gauze and covered
with air-tight dressing� initial and subsequent drainage recorded� post-procedure chest film obtained
Operative Findings
� 400cc of fresh non clotted blood evacuated
Postoperative Management
� Adequate analgesia� Monitoring of CT output
Protocol on CTT
� May proceed to thoracotomy if:� initial output is ≥ 1000 cc of blood� There is continuous CTT output of more than
150cc/hour
TUBE THORACOSTOMY
HEMOTHORAX
Complete evacuationNo ongoing bleeding<1/3 lung volume
RetainedCollection>1/3 lung volume
MAINTAIN CTT AND OBSERVE
SUCTION
Protocol on CTT
Post CTT CXR
� Marked resolution of Pneumohemothorax
Final Diagnosis
Pneumohemothorax, LeftSecondary to Penetrating Stab Wound
COURSE IN THE WARD
� 1st Hospital Day� DAT� Adequate Antibiotic� Adequate Analgesia� Blow bottle exercises
COURSE IN THE WARD
� 2nd-3rd Hospital Day� DAT� Adequate Antibiotic� Adequate Analgesia� Blow bottle exercises� Change of thora bottle
COURSE IN THE WARD
� 4th Hospital Day� Repeat CXR done� Chest tube removed
COURSE IN THE WARD
� 5th Hospital Day� Patient discharged
PREVENTION AND HEALTH PROMOTION
� Advise given to patient regarding� Possible complications� Proper wound care� OPD follow up
DISCUSSION
THORACIC TRAUMA
� blunt trauma� penetrating trauma� both
THORACIC TRAUMA
� motor vehicle crashes� blast injuries� falls from heights� blows to the chest� chest compression� Gunshot� stab wounds
THORACIC TRAUMA
� Thoracic injuries include:� Skeletal� Pulmonary� Heart� great vessels� diaphragm
THORACIC TRAUMA
Potentially lethal injuries:� flail chest� Hemothorax� Pneumothorax� tension pneumothorax� myocardial contusion� sucking chest wound� cardiac tamponade� aortic rupture� diaphragmatic rupture
Hemothorax
� collection of blood in the pleural space� may be caused by blunt or penetrating
trauma
Hemothorax
� Most are the result of:� rib fractures� lung parenchymal� minor venous injuriesand as such are self-limiting
� Less commonly there is an arterial injury, more likely to require surgical repair.
Pneumothorax
� the collection of air in the pleural space� air may come from:
� injury to the lung tissue� bronchial tear� chest wall injury allowing air to be sucked in
from the outside.
Pneumothorax
� Simple pneumothorax� A simple
pneumothorax is a non-expanding collection of air around the lung.
Pneumothorax
� Tension pneumothorax� the progressive build-
up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return.
Complications
� Retained Haemothorax� Empyema
Complications
� Failure to adequately drain a haemothorax:� initially results in residual, clotted
haemothorax which will not drain via a chest tube
� left untreated, these retained haemothoracesmay become infected and lead to empyemaformation
Complications
� If uninfected:� clot will organise and fibrose� resulting in a loss of lung volume ! impaired
pulmonary function
Complications
� Surgery:� indicated if there is evidence of empyema
(fever, raised white cell count, air-fluid levels on CT)
� haemothorax is large enough to cause lung volume loss
� should be performed early, within the first 3-7 days following injury
References� Fallon W, Barnosci A, Mancuso C, Injury to the Chest,
Complications and Management: Experience at a Level I Trauma Center, Top Emerg Med 1990.
� Etoch SW, Bar-Natan MF, Miller FB, Richardson JD, Tube thoracostomy. Factors related to complications. Arch Surg. 1995.
� Eggerstedt JM: Hemothorax. eMedicine Journal [serial online]. 2002. Available at: http://www.emedicine.com/med/topic2915.htm
� Shahani R, Penetrating Chest Trauma, eMedicine eMedicineJournal [serial online]. 2004. Available at: http://www.emedicine.com/med/topic2916.htm.
� Thoracic trauma, htto://www.trauma.org 9:2, 2004.� Handheld ultrasound better at detecting trauma induced occult
pneumothoraces, http://www.diagnosticimaging.com.
Questions
#1 (MCQ)On CXR, one intercostal space of
hemothorax approximates how many cc of blood?
a. 100b. 150c. 200d. 250
Questions
#1 (MCQ)On CXR, one intercostal space of
hemothorax approximates how many cc of blood?
a. 100b. 150c. 200d. 250
Questions
#2 (MCQ)The progressive build-up of air within the
pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return is also known as:
a. Simple pneumothoraxb. Open pneumothoraxc. Tension pneumothoraxd. All of the above
Questions
#2 (MCQ)The progressive build-up of air within the
pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return is also known as:
a. Simple pneumothoraxb. Open pneumothoraxc. Tension pneumothoraxd. All of the above
Questions
#3 (MCR)According to OMMC Department of Surgery
Protocol, thoracotomy is indicated in the following conditions:
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Initial output of 1,000 cc2. Initial output of 1,500 cc3. Output of ≥150 cc/hour4. Output of ≥ 200 cc/hour
Questions
#3 (MCR)According to OMMC Department of Surgery
Protocol, thoracotomy is indicated in the following conditions:
(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Initial output of 1,000 cc2. Initial output of 1,500 cc3. Output of ≥150 cc/hour4. Output of ≥ 200 cc/hour
Questions
#4 (MCR)The following are possible complications of tube
thoracostomy(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Empyema2. Retained hemothorax3. Volume loss4. Subcutaneous emphysema
Questions
#4 (MCR)The following are possible complications of tube
thoracostomy(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Empyema2. Retained hemothorax3. Volume loss4. Subcutaneous emphysema
Questions
#4 (MCR)The following are possible complications of tube
thoracostomy(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Empyema2. Retained hemothorax3. Volume loss4. Subcutaneous emphysema
Questions#5 (MCR)Indications for Chest tube suctioning includes the
following:(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Non fluctuating chest tube2. Retained hemothorax occupying more than 1/4
of the lung field3. Output greater than 150 cc/hour4. Retained hemothorax occupying more than 1/3
of the lung field
Questions#5 (MCR)Indications for Chest tube suctioning includes the
following:(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)1. Non fluctuating chest tube2. Retained hemothorax occupying more than 1/4
of the lung field3. Output greater than 150 cc/hour4. Retained hemothorax occupying more than 1/3
of the lung field
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