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Blunt Thoracic Trauma

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					Blunt Thoracic Trauma 848th FST

Blunt Cardiac Injury (BCI)
• Cardiac injury may be the most common unsuspected fatal visceral injury • Majority of BCI associated with motor vehicle crashes or other deceleration injuries • Incidence in thoracic trauma:
– 46% per autopsy have a BCI – 15% life threatening – Right side of heart injured more often.

Clinical Presentation of BCI
• Chest pain • SOB • Chest bruising, crepitance, open chest wound • Hemodynamic instability • Auscultation may reveal a friction rub, gallop, murmur or lack of breath sounds

BCI Diagnosis
• EKG- 35 to 80% show ST segment changes. • SVT, PVC’s, AFIB, VT/VFIB, 2nd or 3rd AV Block or Complete Heart Block are all possible • Alteration of R-wave amplitude is usually a key sign of cardiac tamponade • A normal EKG is reassuring, b/c small risk of any cardiac trauma
– No EKG changes in 12 hours then contusion is ruled out

Anesthetic Risk with BCI
• Ross stated that GENA is safe and no greater risk with BCI • Flancbaum stated BCI pt’s with proper monitoring, aggressive fluid resuscitation and inotropic treatment to maintain CO had an 80% survival rate, if they entered surgery

Anesthetic Recommendations for BCI
• Invasive monitoring should be dictated by injury and type of surgery • Avoid PEEP if cardiac tamponade is suspected (keep intrathoracic pressure low) • Delay surgery, if possible, 24 to 48 hours to allow cardiac dysfunction to resolve (cardiac contusion) • Maintain CO with fluids and/or pharmacological intervention • Maintain tachycardia intra-op to maintain CO

Flail Chest and Pulmonary Contusion
• Rib Fx at least 2 locations on same rib • Rib and sternum move independently of remaining thorax • Hypoxia and respiratory failure usually due to pulmonary contusion (pulmonary edema), rather than flail chest

Treatment of Flail Chest and Pulmonary Contusion
• • • • • • Ventilator if signs of pulmonary failure CPAP per mask Epidural narcotics for pain relief Intercostal nerve blocks for pain relief Methylprednisone 30mg/kg If severe pulm contusion:
– Inhaled anesthesia may increase pulmonary shunting b/c lungs loose ability to autoregulate blood flow effectively

Traumatic Pneumothorax
• Usually associated with blunt and penetrating thoracic injuries • Most common cause is penetrating displacement of a rib fracture • 40% of patients with rib fractures have a pneumothorax

Signs and Symptoms of Pneumothorax
• Subcutaneous emphysema is the most sensitive clinical sign, but may not be present • Tracheal shift from midline • SOB, hypoxia, increased airway inflation pressures, hypotension, tachycardia • Tension pneumothorax: does not lower CO or preload, instead massive intrapulmonary shunting causes hypoxia, tachycardia, low bp and SOB

Treatment of Pneumothorax
• Needle thoracostomy placement (4th intercostal space) will reinflate lung • Pre-hospital needle thoracostomy placement per EMS had 45% of needles not placed in pleural space • Chest tube is gold standard treatment

Anesthesia Implications of Pneumothorax
• Unrecognized in OR with (+) pressure ventilation tension pneumo:
– Cardiovascular collapse – N2O may exacerbate problem
– Precipitous hypoxia, absent breath sounds, tracheal deviation and increased airway pressures are classic presentation

Traumatic Hemothorax
• Can occur with both penetrating and nonpenetrating thoracic trauma • 40% of blood volume can be contained in thoracic cavity • Initially, same signs and symptoms as pneumothorax

Treatment of Hemothorax
• Chest tube placement allows continual blood loss measurement • Continued hypotension after aggressive fluid resuscitation may require emergent thoracotomy
• 1500cc immediate blood loss per chest tube indicates thoracotomy

• Anesthesia: intubate, ventilate with 100% oxygen, muscle relaxant and fluid resuscitate

Diaphragmatic Rupture
• Relatively uncommon: 2 to 3% of thoracic trauma patients • Mortality approximately 20% • 75% occur on LEFT side secondary to shielding effect of the liver

Anesthesia for Diaphragmatic Rupture
• Change in pulmonary compliance and increased inspiratory pressures may be noted • Increased gastric suction per NGT • Difficulty weaning pt off ventilator post-op should arouse suspicion of a missed diaphragmatic hernia/rupture

• Laparotomy/laparoscopy is best way to inspect integrity of diaphragm

Penetrating Trauma of Lung
• Usually only require thoracostomy tube for lung re-expansion • Patient at risk for systemic air embolus with positive pressure ventilation
– Animal studies indicate air emboli embed in coronary arteries frequently

• Inspiratory pressures upto 100 cm H2O may be required during resuscitative thoracotomy

Tracheobronchial Injuries
• Usually due to shrapnel penetrating thorax, and usually within 2.5cm of carina • Other mechanisms of injury include:
– Rapid deceleration: shearing of airway tree – Increased interthoracic pressure b/c closed glottis at time of blunt thoracic trauma
• Causes traction on the pericardial portion of the trachea

Signs and Symptoms of Tracheobronchial Injuries
• Dyspnea • Cough • Painful hemoptysis • Subcutaneous emphysema • 10% of patients are unsymptomatic initially

Anesthesia for Tracheobroncheal Injuries
• Intubating the traditional way is not recommended b/c posterior displacement of trachea is possible and will not be visualized • Utilize fiberoptic scope and visualize right and lift bronchi for displacment or disruption • Some recommend a long ETT or Double lumen to intubate the non-injured lung only • May be able to use fiberoptic scope as a “stent” between disruption of the trachea, and pass ETT beyond the distal tracheal tear

Questions

David Reed, CPT


				
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