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Thoracic Trauma

Thoracic Trauma. J William Finley, MD Trauma Director Providence Regional Medical Center. 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

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Thoracic Trauma

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  1. Thoracic Trauma J William Finley, MD Trauma Director Providence Regional Medical Center

  2. 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

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

  4. Extensive Armor

  5. There is no perfect protection…

  6. It’s a Dangerous World • Penetrating Injury • Low Energy • Stab wounds • High Energy • GSW • Blunt Injury • Crush • Compression • Shear • Acceleration/Deceleration

  7. Spectrum of Disease • Chest Wall • Contusions • Rib fractures • Flail Chest • Pulmonary • Pulmonary contusion • Pulmonary laceration • Hemothorax • Pneumothorax

  8. Spectrum of Disease • Cardiac • Contusion • Laceration • Avulsion • Tamponade • Mediastinal • Great vessel • Tracheobronchial • Esophageal • Aortic

  9. Keys To Diagnosis • Index of suspicion • Injury association • Clinical signs/symptoms • Diagnostic imaging • Xray • CT • Ultrasound

  10. Basic Trauma Resuscitation • Easy as A-B-C • A - Airway • B - Breathing • C - Circulation

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

  12. 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

  13. 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

  14. Hemothorax

  15. 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

  16. 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.

  17. 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

  18. Mechanism of Injury • Penetrating thoracic injury • Survival rate 18-33% • stab wounds > 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%

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

  20. 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.

  21. 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%.

  22. ED Thoractomy - Why? • Release pericardial tamponade • Enable open cardiac massage • Occlude the descending aorta • Control intrathoracic hemorrhage

  23. 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

  24. 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

  25. Posterio-Lateral Thoractomy

  26. Clamshell Thoracotomy

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

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