Shapiro - Blunt Chest and Abdominal Trauma

							        Blunt Chest and
       Abdominal Trauma

Marc J. Shapiro, M.D., F.A.C.S., F.C.C.M.
          Department of Surgery


            SUNY-Stony Brook
          Stony Brook, New York
A 20 year old male is an unrestrained passenger involved
in a high speed front end motor vehicle collision. He
arrives 20 minutes after the crash in the ED with a pulse
of 130, BP 90/60 and a bruise over his sternum. Both
femoral pulses are weaker than the radial pulses. A chest
x-ray shows a 12 cm mediastinum. What should be done
next of those listed ?


A.   KUB
B.   Angiography
C.   Helical CT scan
D.   Sternal films
E.   Repeat chest x-ray
What is most likely injured?


A.
A    Di h
     Diaphragm
B.   Esophagus
C.   Aorta
D.   Heart
E.   Vagus nerve
A 30 year old female driver runs at 60 mph into a concrete median
when the sun gets in her eyes. She is belted and air-bag
deployment occurs. She arrives in the Emergency Department with
a pulse of 130, a BP of 80/60 and a seat belt sign. She complains
of diffuse abdominal pain which is confirmed by examination.
Chest, c-spine and pelvic radigraphs show no acute changes. What
           p        p          g p                       g
is the next step of those listed?


A.        f h h d
     CT of the head
B.   FAST exam
C.   KUB
D
D.   Dilated ophthalmologic exam
E.   Vaginal ultrasound
What is most likely injured?


A.
A    Li
     Liver
B.   Spleen
C.   Stomach
D.   Heart
E.   Colon
   THORACIC INJURIES

• 85% Require intervention to:
    Correct hypoxia
    Improve circulation
    Alleviate ventilatory obstruction
• 15% Require definitive operation
    ETIOLOGY OF HYPOXIA

•   Hypovolemia → tissue hypoxia
•   Perfusion of unventilated lung
•   Ventilation of unperfused lung
•              p
    Abnormal pleural and airway  y
    relationships
    PULMONARY CONTUSION

•   Common
•   Loss of alveolar–capillary membrane
•   S & SX: hypoxia
•   X-ray: i t titi l infiltrate
    X      interstitial i filt t
PULMONARY CONTUSION


          Treatment

          +/-
 • Oxygen +/ intubation
 • Judicious fluids
 • Analgesia
       RIB FRACTURES

•   Common
•   #1-3: high kinetic energy
•   #4-8: pulmonary injury
•   #9-12: splenic/hepatic injury
•   S & Sx:     pain
                splinting
                chest wall deformity
    RIB FRACTURES

•           p      g
    Pain / splinting
•   Impaired ventilation
•   Increased secretions
•   Atelectasis / pneumonia
     PNEUMOTHORAX

• Common: Usually has rib fractures
      SX: Pain in h t h t        f
• S & SX P i i chest, shortness of
     breath, dyspnea, splinting
• DX: Chest x-ray
         Q
       V/Q mismatch
       Hyper-resonant
       ↓ Breath sounds
PNEUMOTHORAX


           Treatment

• Needle
• Chest tube – suction
• Oxygen
DIGITAL THORACOTOMY
TENSION PNEUMOTHORAX

•              p        p
    Air enters pleural space – no exit
•   Collapse of affected lung
•   I    i d            t
    Impaired venous return
•   Impaired ventilation of unaffected
       p
    lung
TENSION PNEUMOTHORAX

 • Tracheal deviation
 • Respiratory distress
 • Unilateral absence of breath
   sounds
 • Distended neck veins
 • Cyanosis - late
 MASSIVE HEMOTHORAX

• ≥ 2000 ml blood loss
• Systemic / pulmonary vessel
           p
     disruption
• Flat vs distended neck veins
• Shock with no breath sounds and/or
     percussion dullness
MASSIVE HEMOTHORAX

           Treatment
 • Rapid volume restoration
   Chest decompression and
 • Ch t d            i    d
     roentgenogram
 • Auto – transfusion
 • Operative intervention
MYOCARDIAL CONTUSION

•   Focal region of myocardial “ecchymosis”
•   Right     t i l     ll ff t d
    Ri ht ventricle usually affected
•   S & SX: arrythmias (atrial)
•   DX:     EKG – not specefic
            enzymes – 5% rule
            troponin – little help
            echo/TEE – nonspecific
                               p
MYOCARDIAL CONTUSION

           Treatment

   23
 • 23° admit and monitor
 • Only if symptomatic consider
   treatment
CARDIAC CONTUSION
             Treatment
    Do t     t
  • D not postpone surgery
  •   Monitor
  •   Fluids
      Fl id
  •   O2
  •   Lid i
      Lidocaine
  •   Inotropes
  •   IABP
MYOCARDIAL CONTUSION

   • Still undefined
   • Too much Press
   • Almost all don t need ICU
                don’t
      ? Admission
        Telemetry
      ?T l      t
      ? CPK
       ? Troponin
    TRAUMATIC AORTIC
        RUPTURE

• Most common cause of death
     Auto crash
     F ll from a great height
     Fall f           t h i ht
       g p                           y
• Salvage possible if identified early
• Common site: Ligamentum arteriosum
WIDENED MEDIASTINUM
     ON CHEST
  ROENTGENOGRAM
  TRAUMATIC AORTIC
      RUPTURE

          Treatment
• Direct repair
• Resection and grafting
  Stent
• St t
              yq            g
• Treatment by qualified surgeon
         TRAUMATIC
    DIAPHRAGMATIC HERNIA

•      g
    Diagnosed on left side more commonly y
•   Blunt → large tears
•   P t ti → small perforations
    Penetrating         ll   f ti
•           p              g  g
    Misinterpreted roentgenogram
•   Radiography for diagnosis ± ventilator
•   Treatment: O
    T t                ti
             t Operation
       TRAUMATIC
 DIAPHRAGMATIC RUPTURE
                Conclusion
•(L) sided tear easier to diagnose on initial CXR
 Intubation
•Intubation hinders diagnosis
    especially right sided tear
•Post extubation film helpful

                                                      51:27,1996
                                  Shapiro MJ Clin Rad 51:27 1996
TRACHEOBRONCHIAL

• Signs and Symptoms
    Hemoptysis
    Subcutaneous emphysema
    Pneumomediastinum
    Dyspnea
    Chest pain
TRACHEOBRONCHIAL

      g
 • Diagnosis

              py
    Bronchoscopy
    Operation
TRACHEOBRONCHIAL

  • Operation
           y p
     Primary repair
     Resection
    ESOPHAGUS

• Diagnosis
    Barium swallow
    Esophagoscopy
    Operation
        Methylene blue
        Air
        Ai
  ESOPHAGUS

• Symptoms and signs
     Chest pain
     Dyspnea
     Subcutaneous emphysema
     Hamman’s crunch
     Mediastinal widening
     Hemothroax
     Pneumothorax
     Hematemesis
         ESOPHAGUS
• Operation
    Primary repair/patch
    Resection
    Colon interposition
• Mortality 30-65% with 24 hour delay
SUBCUTANEOUS
 EMPHYSEMA

• Airway injury
• Pneumothorax
• Blast injury
• GI tract injury
ABDOMINAL TRAUMA
ABDOMINAL REGIONS

  • Peritoneum
      Intrathoracic
      Abdominal
    Retroperitoneum
  • R t     it
  • Pelvis
  ASSESSMENT

     p
• Inspection
     Lower chest
    Abdomen
    Flank / back
    Perineum
  ASSESSMENT

• Auscultation
    Bowel sounds
    Bruit
      ASSESSMENT

• Percussion
    Dull or tympanitic
    Subtle b    d tenderness
    S btl rebound t d
    Peritoneal irritation
        ASSESSMENT

• Palpation
    Pain
    Involuntary muscle g arding
    In ol ntar m scle guarding
       q
    Unequivocal rebound tenderness
     Rigidity
         MANAGEMENT

• Nasogastric Tube
    Decompression / analysis
    Bleeding
    Bl di
    Contraindicated: Cribiform plate fx
                     Maxillofacial fx
   ASSESSMENT

         Perineum
• Blood at urethral meatus
• Scrotal hematoma
• High riding prostate
            MANAGEMENT

• Urethrogram
    i     C
• Urinary Catheter placement
     Perform cystogram
      Decompress bladder
      Monitor urinary output
                     y    p
      Evaluate and follow hematuria
     Contraindicated: Suspected urethral injury
   ASSESSMENT

• Rectal
     Blood
     Bl d
     Sphincter tone
     F t db            l  t
     Fractured bony elements
     Prostate position
• Vaginal
     Blood
     Fractured bony elements
ABSOLUTE INDICATIONS FOR
       SURGERY

• Persistent hypotension – no source
• Peritoneal signs
 Free air
•F     i
• ± hemoperitoneum
 OPTIONS


• Observation
• Splenorrhaphy
• Splenectomy
HEPATIC TRAUMA
   HEPATIC TRAUMA

• Operative Approach
    Drainage
           d for j injuries
        need f major i j i
        self – suction
        penrose
      HEPATIC TRAUMA

• Operative Approach
    Finger – fracture technique
      Incise Glisson’s capsule
      Individually ligate vessels and ducts
  PELVIC FRACTURES


• 2% trauma deaths
• 3% skeletal injuries
• 50% have significant hemorrhage
 LAWS OF THE HOUSE OF
       TRAUMA
• The closeness in relationship of a doctor
  to a lawyer is directly proportional to
  the chances of having a major
  complication

• The number of unsurvivable injuries a
          s   i es app o imatel eq al
  patient survives is approximately equal
  to the number of felonies committed
  while incurring the trauma
  LAWS OF THE HOUSE OF
        TRAUMA
• Survivability is inversely proportional to
  societal worth

               h t     t bb d
• If you were shot or stabbed you
  probably deserved it

• Never give an emergency room doctor
  anything sharper than a tongue blade
 LAWS OF THE HOUSE OF
       TRAUMA

      number     drug convictions equals
• The n mbe of d g con ictions eq als
  the number of central lines necessary to
  resuscitate your patient

• Remember: The life you save may take
  your own
 LAWS OF THE HOUSE OF
       TRAUMA
  The h          fd i f          i   i j
• Th chance of dying from a given injury
  is inversely proportional to the number
    f tattoos
  of t tt

• 12 or more tattoos confers immortality