Health-Process Evidence-Based Clinical Practice Guidelines for Trauma on Thoracic Area Jonathan...

Health-ProcessEvidence-Based

Clinical Practice Guidelinesfor

Trauma on Thoracic Area

Jonathan Malabanan MD

OMMC

October 11, 2007

Thoracic Trauma

A. Overview of the Problem• Concept• Common Types• Common CausesB. General Management Guidelines• Clinical Diagnosis• Paraclinical Diagnosis• Treatment

Clinical Questions1. What is a operational concept of

trauma on the thoracic area?

Trauma - body injury produced by

sudden force

Thorax- region

Clinical Questions2. What is a operational concept of

“Non- Penetrating Thoracic Injury”?

- Blunt trauma to the thoracic area

Clinical Questions3. What is a operational concept of

“Penetrating Thoracic Injury”?

-Potential surgical patient

4. How is head trauma classified in terms of mechanism of injury?

- Blunt/ non- penetrating trauma

- Penetrating trauma

Clinical Questions

Clinical Questions

5. What are the most common causes of penetrating thoracic injury?

- Assault with sharp object

- Gunshot Injury

Clinical Questions

7. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury?

- difficulty of breathing

- decreased breath sounds on the affected lung field

Clinical Questions

7. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury?

- tachycardia

- increased respiratory rate

Clinical Questions

7. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient had penetrating thoracic injury?

- presence of paradoxical pulse

8. If a paraclinical diagnostic procedure is needed for trauma to the thoracic area, the most

cost effective would be:

Benefit Risk Cost Availability

X-RayPneumothorax: (+)

Hemothorax:(+)

Exposure to radiation

P200 available

UltrasoundPneumothorax: (++)

Hemothorax:(+)

No radiation exposure

P600 available

CT-ScanPneumothorax: (+++)

Hemothorax: (+++)

Exposure to radiation P6000

Not readily available

http://www.diagnosticimaging .com

9. What are the goals of treatment for the following?

A. Non- Penetrating Thoracic Injury

B. Penetrating Thoracic Injury

GOALS OF TREATMENT

• Resolution of hemothorax or pneumothorax

• Full re- expansion of left lung• Monitor for ongoing bleeding

11. What is the most cost-effective operative treatment for the following?

A. Non- Penetrating Thoracic Injury

B. Penetrating Thoracic Injury

Treatment Options

Benefit Risk Cost Availability

Tube Thoracostomy

-Complete evacuation of fluid

-can monitor ongoing bleeding

-hemostatic

- Injury to adjacent structure

P10000 available

Thoracentesis -Useful in small hemothorax-incomplete evacuation

-Injury to adjacent structure

P5000 available

Practice Level of Evidence

• Standards (I) need to be followed

• Guidelines (II) suggested

• Options (III) considered

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

Protocol on Prevention of Posttraumatic Retained Hemothorax

Department of Surgery, OMMC

Hemothorax

CTT

Thoracotomy>1 Liter>150cc/hr x 4 hrs

Suctioning>1/3 retained

Hemothorax by CXR

Active ObservationGomco

< 1/3 retained hemothorax

•Turiñgan H, Hernandez D, Joson O. Posttraumatic Retained Hemothorax – Incidence, Prevention and Management with Suctioning. Published PJSS,2004

What is the role of fluid resuscitation prior to surgery in the treatment of significant

thoracic injury?

• Fluid resuscitation should be given to avoid hypotension (II)