klinika chirurgii urazowej paweł grala thoracic injuries incidence: 1. 10%mortality (25% of...

Klinika Chirurgii Urazowej Klinika Chirurgii Urazowej Paweł Grala Paweł Grala

Thoracic injuriesThoracic injuries

Incidence:Incidence:1.1. 10%mortality (25% of traumatic deaths)10%mortality (25% of traumatic deaths)2.2. <10% of blunt and 15-30% of penetrating require <10% of blunt and 15-30% of penetrating require

thoracotomythoracotomy3.3. mediastinal penetrating trauma: mediastinal penetrating trauma:

mortality 20%, mortality 20%, 50% are hemodynamically unstable 50% are hemodynamically unstable 40%mortality 40%mortalityadditional 30% positive diagnostic evaluationadditional 30% positive diagnostic evaluation

Patophysiology: Patophysiology: hypoxia, hypercarbia, acidosis (hypovolemia, hypoxia, hypercarbia, acidosis (hypovolemia, ventilation/perfusion mismatch, changes in intrathoracic ventilation/perfusion mismatch, changes in intrathoracic pressures) pressures)


Thoracic injuriesThoracic injuries Chest wallChest wall1.1. lacerations, l.communicating with pleural spacelacerations, l.communicating with pleural spaceopen open

pneumothorax, pneumothorax, 2.2. rib frs with possible: pain, splinting, atelectasis, rib frs with possible: pain, splinting, atelectasis,

hypoxemiahypoxemiaanalgesia, pulmonary toilet, flail chest, analgesia, pulmonary toilet, flail chest, indicative of possible internal inj.indicative of possible internal inj.

3.3. Sternal fractures (consider myocardial contusion)Sternal fractures (consider myocardial contusion) Tracheobronchial (respiratory distress, large air leak Tracheobronchial (respiratory distress, large air leak

with subcutaneous emphysema)with subcutaneous emphysema) Esophageal (penetrating trauma, delayed recognotion Esophageal (penetrating trauma, delayed recognotion

→↑→↑mortality – 3fold if over 24h, esophagoscopy mortality – 3fold if over 24h, esophagoscopy with contrast studies – Gastrografin, butressed with contrast studies – Gastrografin, butressed repair)repair)

Pulmonary: contusion, hemothorax, pneumothorax Pulmonary: contusion, hemothorax, pneumothorax Great vesselGreat vessel CardiacCardiac


Rib fracturesRib fractures May be undetectable on chest X-ray (excludes other May be undetectable on chest X-ray (excludes other

intrathoracic injuries)intrathoracic injuries) Majority IV-IXMajority IV-IX Anteroposterior compression Anteroposterior compression midshaft fr. (outward midshaft fr. (outward

bowing), direct blow bowing), direct blow fracture ends face inwards fracture ends face inwards potential vessel or lung parenchymal injury potential vessel or lung parenchymal injury

X-XII X-XII suspect hepatosplenic injury suspect hepatosplenic injury I-III I-III suspect great vessel injury suspect great vessel injury Taping, rib belts – contraindicatedTaping, rib belts – contraindicated Relief of pain (intercostal block, intrapleural analgesia, Relief of pain (intercostal block, intrapleural analgesia,

systemic analgetics), pulmonary toiletsystemic analgetics), pulmonary toilet Flail chest – bony discontinuity of a chest fragment (>3): Flail chest – bony discontinuity of a chest fragment (>3):

serious underlying lung inj., paradoxical chest wall serious underlying lung inj., paradoxical chest wall motion, pain, splinting (muscle spasm) motion, pain, splinting (muscle spasm) hypoxia hypoxiafluid restriction (if no hypovolemia), adequate ventilation fluid restriction (if no hypovolemia), adequate ventilation with chest wall splinting with chest wall splinting mechanical ventilation mechanical ventilation


Flail chest complicationFlail chest complication


Pulmonary contusionPulmonary contusion Blunt (blast shock wawes, falls from heights) or penetrating Blunt (blast shock wawes, falls from heights) or penetrating

trauma (high velocity GSW) trauma (high velocity GSW) ““Spalling effect” – shearing or bursting effect occurring at the gas/liquid Spalling effect” – shearing or bursting effect occurring at the gas/liquid

interface (large differences in density)interface (large differences in density)““Inertial effect” – low-density alveolar tissue is stripped from heavier Inertial effect” – low-density alveolar tissue is stripped from heavier

hilar structures as they accelerate at different rates.hilar structures as they accelerate at different rates.““Implosion effect” - rebound or overexpansion of gas bubbles after a Implosion effect” - rebound or overexpansion of gas bubbles after a

pressure wave passespressure wave passes Interstitial or alveolar inj. – edema, Interstitial or alveolar inj. – edema, alveolar haemorrhage, alveolar haemorrhage,

parenchymal destructionparenchymal destruction Adequate perfusion, inadequate ventilation (mismatch Adequate perfusion, inadequate ventilation (mismatch → →

hypoxemia) - ↑airway resistance, ↓compliancehypoxemia) - ↑airway resistance, ↓compliance Initial chest X-ray diagnostic – progress in density over 48h Initial chest X-ray diagnostic – progress in density over 48h

((Chest x-ray 4-6 hours Chest x-ray 4-6 hours //CT earlierCT earlier//, resolves in 5-7 days, resolves in 5-7 days)) ABGs, pulse oximetry, ABGs, pulse oximetry,

Dyspnea, hemoptysis, chest pain, cough, tachypnea, rales, Dyspnea, hemoptysis, chest pain, cough, tachypnea, rales, decreased breath sounds, tachycardiadecreased breath sounds, tachycardia

Respiratory support with intubation and mechanical Respiratory support with intubation and mechanical ventilation (often unusual ventilation modes), aggressive ventilation (often unusual ventilation modes), aggressive pulmonary toilet, positioning on uninvolved side, fluid pulmonary toilet, positioning on uninvolved side, fluid restriction, no steroids or prophylactic antibiotics.restriction, no steroids or prophylactic antibiotics.


Pulmonary contusion – X-rayPulmonary contusion – X-ray


Pulmonary contusion – X-rayPulmonary contusion – X-ray

5h later: subcutaneous emphysema, pneumomediastinum5h later: subcutaneous emphysema, pneumomediastinum


Pulmonary contusion – CT GSWPulmonary contusion – CT GSW


PneumothoraxPneumothorax Blunt or penetrating inj.Blunt or penetrating inj. Decreased breath sounds (>25% of the lung collapsed)Decreased breath sounds (>25% of the lung collapsed) Sucking chest wound (over 2/3 of tracheal diameter) Sucking chest wound (over 2/3 of tracheal diameter)

preferential air flow preferential air flow occlusive dressing + chest tube occlusive dressing + chest tube Chest X-ray diagnosticChest X-ray diagnostic In significant chest inj. + p.p. mechanical ventilation In significant chest inj. + p.p. mechanical ventilation

prophylactic tube thoracostomy (prevention of tension prophylactic tube thoracostomy (prevention of tension P.)P.)

Chest tube into II or IIIrd intercostal space in Chest tube into II or IIIrd intercostal space in midclavicular linemidclavicular line

Chest tube ineffictive Chest tube ineffictive tracheobronchial disruption tracheobronchial disruption diagnosis + thoracotomydiagnosis + thoracotomy


PneumothoraxPneumothorax


Tension pneumothoraxTension pneumothorax


Tension gastrothoraxTension gastrothorax


HemothoraxHemothorax Opacification on chest X-ray (intercostal a., internal mammary, Th Opacification on chest X-ray (intercostal a., internal mammary, Th

spine fr., lung laceration, mediastinal vessels)spine fr., lung laceration, mediastinal vessels) Chest tube usually sufficient (IV or Vtdh intercostal space in anterior Chest tube usually sufficient (IV or Vtdh intercostal space in anterior

or midaxillary line) or midaxillary line) bleeding self-limiting bleeding self-limiting Thoracotomy guidelines individualized: severe haemodynamic Thoracotomy guidelines individualized: severe haemodynamic

instability (ERT), initial drainage exceding 1,5L, ongoing drainage of instability (ERT), initial drainage exceding 1,5L, ongoing drainage of 100ml/h over 6h100ml/h over 6h

Coagulation, ligation, pulmonary tractotomy, pulmonary resection Coagulation, ligation, pulmonary tractotomy, pulmonary resection (hilar injury) – significant mortality(hilar injury) – significant mortality

Air embolism in significant parenchymal injury (esp. on positive Air embolism in significant parenchymal injury (esp. on positive pressure ventillation): sudden cardiovascular collapse – steep pressure ventillation): sudden cardiovascular collapse – steep Trendelenburg position, aspirate air from R ventricle, cardiovascular Trendelenburg position, aspirate air from R ventricle, cardiovascular supportsupport

Great vessel injury (profound shock, sometimes pericardiac Great vessel injury (profound shock, sometimes pericardiac tamponade, on chest X-ray – blunt inj.: widend mediastinum, tamponade, on chest X-ray – blunt inj.: widend mediastinum, obscured aortic knob, deviation of L stem brochus, opacification of obscured aortic knob, deviation of L stem brochus, opacification of aortopulmonary window, R deviation of nasogastric tube, I or IInd rib aortopulmonary window, R deviation of nasogastric tube, I or IInd rib frs.)frs.)no diagnostic investigations in unstable patientno diagnostic investigations in unstable patientaortography, contrast enhanced CT, echocardiographyaortography, contrast enhanced CT, echocardiographyfluid restriction (blunt), thoracotomyfluid restriction (blunt), thoracotomy


HemothoraxHemothorax


HemopneumothoraxHemopneumothorax


Widend mediastinumWidend mediastinum


Flail chest - tractionFlail chest - traction


Flail chestFlail chest


EmpyemaEmpyema

Stages (not separated – continuum):Stages (not separated – continuum): exsudative exsudative fibropurulentfibropurulent organizingorganizing

Chest X-ray, US, CTChest X-ray, US, CT Control of infection with appropriate Control of infection with appropriate

antibiotics, drainage (ev.streptokinaze), antibiotics, drainage (ev.streptokinaze), obliteration of pleural space, thoracotomy obliteration of pleural space, thoracotomy with decortication and pleurodesiswith decortication and pleurodesis


Cardiac injuryCardiac injury usually penetrating inj. between midclavicular usually penetrating inj. between midclavicular

lineslines pericardiac tamponade: shock, distended neck pericardiac tamponade: shock, distended neck

veins, diminished heart sounds (Beck`s triad), veins, diminished heart sounds (Beck`s triad), j.v.distension j.v.distension ↑ with inspiration (Kussmaul`s ↑ with inspiration (Kussmaul`s sign) sign) warrants operation (often ERT) warrants operation (often ERT)

blunt c.inj.: history, inappropriate cardiovascular blunt c.inj.: history, inappropriate cardiovascular response to injury (EKG – normal excludes, response to injury (EKG – normal excludes, abnormal abnormal cardiac monitoring, cardiac monitoring, echocardiography)echocardiography)advanced cardiac life support protocolsadvanced cardiac life support protocolsoperation for myocardial or valvular rupture, operation for myocardial or valvular rupture, ventricular aneurysm ventricular aneurysm


Commotio cordisCommotio cordis – fatality due to blunt – fatality due to blunt thoracic injury, without gross structural thoracic injury, without gross structural damage to the heart or other intrathoracic damage to the heart or other intrathoracic organs. Death attributed to cardiac organs. Death attributed to cardiac arrhythmia aggravated by traumatic arrhythmia aggravated by traumatic apnea. Most vulnerable phase of the apnea. Most vulnerable phase of the cardiac cycle: T – wave cardiac cycle: T – wave heart partially heart partially depolarized and then repolarized depolarized and then repolarized (electrically unstable)(electrically unstable)


ThoracotomyThoracotomy


PitfallsPitfalls

Simple hemothorax Simple hemothorax retained, clotted hemothorax with retained, clotted hemothorax with lung entrapement or empyema (if infected)lung entrapement or empyema (if infected)

Diaphragmatic inj. are often overlooked Diaphragmatic inj. are often overlooked respiratory respiratory compromise, early or late entrapement and strangulation compromise, early or late entrapement and strangulation of abd. Contentsof abd. Contents

Evaluation of widend mediastinum requires Evaluation of widend mediastinum requires cardiothoracic surgical capabilitiescardiothoracic surgical capabilities

Underestimation of severe pathophysiology of rib frs. Underestimation of severe pathophysiology of rib frs. esp. in the elderly (aggressive pain control with no resp. esp. in the elderly (aggressive pain control with no resp. depression)depression)

underestimation of blunt pulmonary injury severety underestimation of blunt pulmonary injury severety (pulmonary contusion is not always correlated with X-ray (pulmonary contusion is not always correlated with X-ray findings)findings)

klinika chirurgii urazowej paweł grala thoracic injuries incidence: 1. 10%mortality (25% of...

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