Arthur Hill, M.D.; Professor, Department of SurgeryDivision of Cardiothoracic Surgery; University of California, San FranciscoApril 2, 2016

� Structural/Anatomic� Epidemiologic� Clinical presentation/Physiologic phenomena� Resuscitative thoracotomy

Polytrauma 40% Head injuries 30% Thoracic trauma 20% Abdominal trauma 10% Extremity 2%

1.Marx, J (2010). Rosen's emergency medicine: concepts and clinical practice 7th edition. Philadelphia: Mosby/Elsevier. pp. 243–842. ISBN 978-0-323-05472-0.2. "The Barell Injury Diagnosis Matrix, Classification by Body Region and Nature of the Injury". Center for Disease Control. Retrieved 19 June 2013.3. Bonatti, H; Calland, JF (2008). "Trauma". Emergency Medicine Clinics of North America 26 (3): 625–48. doi:10.1016/j.emc.2008.05.001. PMID 18655938

� BLUNT• MVC• Falls• Airplane Crashes

� PENETRATING• Stab wounds• Bullet wounds

� Thoracic injuries are present in 45 – 50% of unrestrained drivers involved in high speed MVC’s

� Thoracic injuries are the cause of death in 25% of MVC fatalities.

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. Surg Clin North 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 Anaesth 1991; 38: 506-10. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma; analysis of 515 patients. Ann Surg 1987; 206: 200-5.

�Low velocity missile

�High velocity missile

�40% Penetrating Injury Involves the Thorax

�15-28% of Penetrating Thoracic Injuries Require Thoracotomy

� Distribution of Organ Injury• Chest Wall 100%• Lung 65-90%• Heart 49%• Diaphragm 30%• Intra-Abdominal Injuryx Liver 20%x Stomach 8%x Small intestine 7%x Colon 6%x Kidney 5%

Clinical PresentationPhysiological Consequences

�Airway Obstruction�Hemothorax�Tension Pneumothorax�Cardiac Tamponade�Major Vascular Injury�Air Embolization

�A – Airway (with c-spine protection)

�B – Breathing (pleural drainage)

�C – Circulation (stop the bleeding)

�D – Disability (neuro status, fractures)

�E – Exposure (temperature, pain)

�Airway Obstruction/Injury�Hemothorax

�Tension Pneumothorax

�Cardiac Tamponade

�Vascular Injury

�Esophageal Injury

�Air Embolization

�Causes:• Blunt• Penetrating

� If the patient makes wet bubbling

sounds

• fluid in respiratory tract

• removal – manual/suction

� If the patient has respiratory stridor

• larynx is probably obstructed

• Airway intubation: ETT/tracheostomy

� If the patient has to–and–fro stridor

• the trachea is probably obstructed

• Airway intubation: ETT/tracheostomy/OR

� Anatomic localization of site of obstruction (neck vs. thorax)

� Method of airway control• Standard ET intbation

• Tracheostomy

� Imaging• CXR

• CT

� Endoscopy• Simultaneous with airway control

� Teamwork• Anesthesiology

• ENT

� Simple maneuvers:• Upper airway• Manual removal of

obstructive objects• Suctioning

� Complex airway maneuvers• Operating Room• Oro-tracheal Intubation

vs. Tracheostomy• Bronchoscopy• Thoracotomy vs. Stenting

AIRWAY INJURY

INCISION CHOICE FOR TRACHEAL INJURY

�Stent placement

�Airway Obstruction

�Hemothorax�Tension Pneumothorax

�Cardiac Tamponade

�Vascular Injury

�Esophageal Injury

�Air Embolism

HEMOTHORAX

Two forms of physiologic insult occurring simultaneously:

1. Circulatoryi. Blood lossii. Tension hemothorax

with inflow occlusion

2. Respiratory

HEMOTHORAX

• Blunt or Penetrating Trauma• Requires chest tube

placement• Volume resuscitation• Thoracotomy required if:

• Hemodynamic Instability• Chest tube output > 1200cc• > 250 cc/hr• Ineffective chest tube drainage

with large hemothorax • (VATS may be an option in a stable

patient)

�Thoracotomy is done on the side with the hemothorax.

�Extension across midline if needed.�Median sternotomy is contraindicated.

�Airway Obstruction

�Hemothorax

�Tension Pneumothorax�Cardiac Tamponade

�Vascular Injury

�Esophageal Injury

�Air embolism

� Progressive build-up of air within the pleural space• usually due to a lung laceration which

� Air to escape into the pleural space but cannot to return

� Positive pressure ventilation aggravates the 'one-way-valve' effect

� Mediastinal shift to the opposite hemithorax

� Obstruction of venous return to the heart

� Circulatory instability/traumatic arrest

�Physical Exam

�CXR

•Unilateral absenceof breath sounds

•JVD•Hypotension•Tracheal deviation

�Treatment:• Needle

thoracostomy

x (buy time)

• Chest-tube

x (definitive)

�Airway Obstruction�Hemothorax�Tension Pneumothorax�Cardiac Tamponade

• Cardiac Injury�Vascular Injury�Esophageal Injury�Air Embolism

Definition:

Fluid collection within the pericardium with: 9 compression of the heart9 hemodynamic compromise9 elevation and equalization of

atrial pressures9 physical exam findings

�Physical Exam

� Imaging:

FAST/ECHO

CT scan

•Hypotension•Muffled Heart Sounds

•JVD•Pulsus Paradoxus

PULSUS PARADOXUS

ECHOCARDIOGRAPHIC DIAGNOSIS OF CARDIAC TAMPONADE

CT SCAN DIAGNOSIS OF CARDIAC TAMPONADE

CARDIAC TAMPONADE

Treatment• Drainage

• Pericardiocentesis• Percutaneous pericardial

window

• Surgical• L thoracotomy• Median Sternotomy• Laparotomy

(with pericardial window)

�Cardiac injury with tamponade:Requires emergency surgery

x Left anterolateral thoracotomy

(Extension to clam-shell)

x Median Sternotomy

LOCATION OF CARDIAC INJURY FROM PENETRATING TRAUMA

x Frequency of injury dependents on the location of penetration.

x 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

�Airway Obstruction

�Hemothorax

�Tension Pneumothorax

�Cardiac Tamponade

�Thoracic Vascular Injury�Esophageal Injury

�Air Embolism

�Exsanguinating vascular injuries• Hemothorax

• Mediastinal hemorrhage

�Major vascular injury without

exsanguination• Aorta

• Major branches of thoracic aorta

Priorities:

• Identification of patients with possible vascular injury –mechanism of injury

• Identification of anatomic location of injury/site of exsanguination• Thoracic CT angiography• Formal angiography

• Rapid choice of therapy:• Surgical• Percutaneous/Interventional• Stent-graft placement

THORACIC AORTIC INJURY

Mechanism: rapid deceleration produces shearing injury between fixed and mobile portions of the aorta.

DISTRIBUTION OF AORTIC INJURIES

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• Must have high index of suspicion

Parmly et al (Circulation 1958)

TREATMENT OPTIONS IN BAI

• Pre-surgical pharmacologic treatment:– β Blocker (dP/dT reduction)– HR < 100; MAP < 100

• Surgical therapy– Clamp-and-sew– Bypass

• Endovascular Stent Therapy

INCISIONS USED FOR THORACIC VASCULAR INJURIES

ENDOVASCULAR STENT GRAFTS FOR ACUTE BLUNT AORTIC INJURY

ENDOVASCULAR STENT GRAFTS FOR ACUTE BLUNT AORTIC INJURY

�Airway Obstruction

�Hemothorax

�Tension Pneumothorax

�Cardiac Tamponade

�Vascular Injury

�Air Embolism

� Identification• Presentation:x Mechanism (Pulmonary/Hilar

injury)

x Murmur/Ventricular arrhythmia

x Severe unexplained hemodynamic deterioration

• Visible air in coronary arteries• Air seen in LA and LV by

echocardiography *� Treatment

• Hilar occlusion• Pulmonary resection• Cardiac chamber de-airing

maneuvers• Cardiopulmonary bypass• Hyperbaric O2 therapy

� Identification• Presentation:x Mechanism (Pulmonary/Hilar injury)

x Murmur

x Severe unexplained hemodynamic deterioration

x ventricular arrhythmia

• Diagnosis by exclusion

• Visible air in coronary arteries

• Air seen in LA and LV by echocardiography *

� Treatment• Hilar occlusion

• Pulmonary resection

• Cardiac chamber de-airing maneuvers

• Cardiopulmonary bypass

• Hyperbaric O2 therapy

�Airway Obstruction

�Hemothorax

�Tension Pneumothorax

�Cardiac Tamponade

�Vascular Injury

�Esophageal injury

�Air Embolism

• Esophageal Injuries• Cardiac Herniation• Flail Chest

�Mechanism of injury• Blunt

• Penetrating

�Diagnosis:• High index of suspicion

• Contrast imaging studies

• Endoscopic studies

�Cervical injury• Cervical incision

�Upper thoracic injury• Right thoracotomy

�Lower thoracic/

GE junction injury• Left thoracoabdominal

incision

�Esophagus• Repair (<24 hours)

• Debridement and resection

x Staged repair

• Extensive drainage

Cardiac Herniation

Flail Chest

INDICATIONS

TECHNIQUE

10-15% of Thoracic Trauma patients

will require Resuscitative Thoracotomy

• Overall 0-70%

• Penetrating 9-70%x Stab wounds 70%

x GSW 9-33%

• Blunt 0-2.5 %

Asensio JA, Berne JD, Demetriades D et al. 'One hundred five penetrating cardiac injuries: A 2-year prospective evaluation'. J Trauma 1998;44:1073-108 Karmy-Jones R, Jurkovich GJ, Nathens AB et al. 'Timing of Urgent Thoracotomy for Hemorrhage After Trauma: A Multicenter Study.' Arch Surg 2001;136:513-518 Tyburski JG, Astra L, Wilson RF et al. 'Factors affecting prognosis with penetrating wounds of the heart'. J Trauma 2000;48:587-590 Rhee PM, Acosta J, Bridgeman A et al. 'Survival after emergency department thoracotomy: review of published data from the past 25 years.' J Am Coll Surg 2000;190:288-298 Branney SW, Moore EE, Feldhaus KM et al. ' Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center'. J Trauma 1998;45:87-95 Campbell NC, Thomson SR, Muckart DJJ.' Review of 1198 cases of penetrating cardiac trauma'. Br J Surg 1997;84:1737-1740

RESUSCITATIVE (ER) THORACOTOMY

� Pulmonary• Pulmonary resectionx Wedge resection

x Lobectomy

x Pneumonectomy

• Hilar repairx Hilar occlusion

x Vascular repair

x Airway repair

• Tractotomy for penetrating trauma• Chest wall reconstructionx Ribs

x Sternum

x spine

x diaphragm

�Airway Obstruction

�Hemothorax

�Tension Pneumothorax

�Cardiac Tamponade

�Major Vascular Injury

�Air Embolization

Arthur.Hill@ucsf.edu

�20 year old female driver of an

automobile which crashed head-on into

another vehicle at 80 mph

�Admitted to ER with HR 110; BP 121/60

�Head trauma: GCS 4

�What procedure should be done first?

• Thoracic Examination: • Crepitus at right chest wall• Absent right-sided breath sounds• Hypoxemia

�What procedure should be performed next?�A right-sided chest-tube is placed.�The patient became profoundly

hemodynamically unstable.

�What procedure should be performed next?

Time: 22:11Post-intubation

Time: 22:22Post-chest-tube placement

�What procedure should be performed next?

CARDIAC HERNIATION

Cardiac Herniation

• Overall 0-70%

• Penetrating 9-70%x Stab wounds 70%x GSW 9-33%

• Blunt 0-2.5 %

Asensio JA, Berne JD, Demetriades D et al. 'One hundred five penetrating cardiac injuries: A 2-year prospective evaluation'. J Trauma 1998;44:1073-108 Karmy-Jones R, Jurkovich GJ, Nathens AB et al. 'Timing of Urgent Thoracotomy for Hemorrhage After Trauma: A Multicenter Study.' Arch Surg 2001;136:513-518 Tyburski JG, Astra L, Wilson RF et al. 'Factors affecting prognosis with penetrating wounds of the heart'. J Trauma 2000;48:587-590 Rhee PM, Acosta J, Bridgeman A et al. 'Survival after emergency department thoracotomy: review of published data from the past 25 years.' J Am Coll Surg 2000;190:288-298 Branney SW, Moore EE, Feldhaus KM et al. ' Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center'. J Trauma 1998;45:87-95 Campbell NC, Thomson SR, Muckart DJJ.' Review of 1198 cases of penetrating cardiac trauma'. Br J Surg 1997;84:1737-1740

�Blunt thoracic trauma – another example

of blunt trauma which requires

thoracotomy…

� Incisions:• Thoracotomy

• Median sternotomy

• (Laparotomy)

�Left thoracotomy

�Median Sternotmy

Flail Chest

Flail Chest

• Overall 0-70%

• Penetrating 9-70%x Stab wounds 70%x GSW 9-33%

• Blunt 0-2.5 %

Asensio JA, Berne JD, Demetriades D et al. 'One hundred five penetrating cardiac injuries: A 2-year prospective evaluation'. J Trauma 1998;44:1073-108 Karmy-Jones R, Jurkovich GJ, Nathens AB et al. 'Timing of Urgent Thoracotomy for Hemorrhage After Trauma: A Multicenter Study.' Arch Surg 2001;136:513-518 Tyburski JG, Astra L, Wilson RF et al. 'Factors affecting prognosis with penetrating wounds of the heart'. J Trauma 2000;48:587-590 Rhee PM, Acosta J, Bridgeman A et al. 'Survival after emergency department thoracotomy: review of published data from the past 25 years.' J Am Coll Surg 2000;190:288-298 Branney SW, Moore EE, Feldhaus KM et al. ' Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center'. J Trauma 1998;45:87-95 Campbell NC, Thomson SR, Muckart DJJ.' Review of 1198 cases of penetrating cardiac trauma'. Br J Surg 1997;84:1737-1740