CARDIOTHORACIC

TRAUMA
DR. ASHENAFI BERHANU
GENERAL AND CTS
UOG
INTRODUCTION

• Account for 25% of all trauma deaths

• 2/3 of deaths  after reaching the hospital
• Appropriate and timely intervention saves lives  PROTOCOLIZED CARE
PHYSIOLOGIC CAUSES OF DEATH FOLLOWING
THORACIC TRAUMA
• Tissue hypoxia  hypovolemia /shock ,V/Q mismatch , loss of intrathoracic negative
pressure , tension pnx , open pnx

• Hypercarbia  inadequate ventilation , depressed level of consciousness,

• Metabolic acidosis  shock ( cardiogenic, hypovolemic , neurogenic )

EACH COULD AND SHOOLD BE ADRESSED FROM THE TIME OF TRAUMA

TRAUMA CARE PHYLOSOPHIES

THREE PHASES
• Pre event
• Event
• Post event
PRE EVENT ( PREVENTION)

Tools :
• Public education
• Work place safety
• Following speed limits
• Non violent means of conflict resolution
• Helmets
• Drinking and driving
• Child safety seats
Event
• Paramedical education and safe driving
• Stabilize patient
• Cervical collar
• Spinal board (correct use )
• ABCDE
• Emergency Bilateral thoracotomy
Post event
• Immediate death : fetal injuries (great vessel ,heart and brain)
• Early death (GOLDEN HOUR )  mins to hrs.  can be avoided
• Causes : insufficient ventilation ,impaired oxygenation , CV collapse , failed end organ
perfusion , massive brain injury
PREHOSPITAL TRAUMA LIFE SUPPORT (PHTLS)

3 impt philosophies
• Immediately recognize life threatening injuries (TRIAGE)
• Start sufficient supportive treatment
• Transfer to appropriate facility

TWO IMPT CONCEPTS  GOLDEN HOUR AND TRIAGE

GOLDEN HOUR
• Mins to the first hour after trauma
• Each minute directly proportional to mortality

 SO , PERFORM 4 STEPS APPROPRATLY IN THEIR ORDER

 Scene assessment  SAFETY and SITUATION
 Patient assessment and triage
 Initial evaluation and management
 Informing the appropriate facility
TRIAGE
• DONE  At the scene and airing (transport) of the patient
At the scene
patients are labeled in to one of the categories
 Immediate life threatening : best outcomes (tension pnx)
 Delayed long bone#
 Minor walking wounded
 Expectant LEAST CHANCE OF SURVIVAL raptured aorta
 Dead

• Redo triage
LIFE TREATENING CONDITIONS FOLLOWING
TRAUMA

 Compromised airway
 Interrupted ventilation ( open /tension pnx, flial chest , hypoxia )
 Hemorrhage
 Abn. Neurological status
 Penetrating trauma
 Amputation or near amputation
 Comorbidities
 Age >55
 Hypothermia
 Facial burns
 Pregnancy
SKILLS FOR PHTLS

• Airway manual clearing , jaw trust ,chin lift , head tilt , LMA , transtracheal jet ventilation
, intubation
• Collar application and spinal board use
• Controlling hemorrhage
• PASG
INHOSPITAL TRAUMA MANAGEMNT

Begins with
• Good information transfer (MIST ) and triage (T-system)
• Triage  Canadian triage T- system
 MIST
 M= mechanism
 I= injuries suspected
 S= vital Signs
 T= treatment enroute
T-system
 T1 immediate
 T2 emergency  with in 30mins
 T3 urgent --. 30mins to 1hour
 T4 delayed  1 to 4 hours
 T5 expectant  walking non urgent

• COLOUR CODED
PRIMARY SURVEY

ATLS guidelines
• Airway and C-spine stabilization
• Breathing
• Circulation
• Disability
• Exposure
AIR WAY AND C- SPINE IMMOBILIZATION

Signs of compromise
 Nonresponse
 Stridor
 Hoarse reply
 Confusion
Causes
 Tongue fall
 Blood
 Vomitus
 FB
 Facial/ laryngeal injury
 Depressed level of consciousness
 Inhalational injuries
Intubation indications
GCS < 8
Need for FiO2 >95%
Decreased RR
Expanding hematoma of the neck
Airway/ pul. Burns
Protection of the air way from aspiration
multisystem injury
Uncooperative bhr
Child
CIRCULATION

• Two large bore IV cannula

• Controlling hemorrhage
• Crystalloids , colloids ?????
• Blood and blood products
DISABILITY AND EXPOSURE

• Ongoing neurological assessment

• Exposure of the patient
• Warm blankets
• Heated air and warm IV fluids
Monitoring and tubes
 V/S
 ETCo2
 Urinary catheter
 NG tube for decompression
Blood tests
 CBC, RFT, LFT, COAGULATION , X-MATCH , SERIAL ABG
RADIOLOGIC STUDIES

• CXR hemothorax, pneumothorax, fractures, contusion , mediastinal injuries

• e FAST  4windows
• Angiography
EMERGENCY THORACOTOMY

Absolute indications
 Unresponsive hypotension (SBP <60 mm hg)
 Exsanguination from thoracic cavity (>1500ml)
 After penetrating trauma traumatic cardiac arrest that was witnessed pre or during
hospital admission
 Persistent hypotension (SBP <60mmhg ) with diagnosed cardiac tamponade or air
embolism
Relative indication
 Traumatic cardiac arrest following blunt or penetrating thoracic injury with previously
witnessed cardiac activity
 Pre hospital CPR  <10mins for intubated patient and <5mins for nonintubated patient
 Contraindications
 Blunt trauma with no previously witnessed cardiac activity
 Multiple blunt injuries
 Sever head injury
THORACIC TRAUMA

• BLUNT / PENETRATING
BLUNT THORACIC INJURY

Mechanism
 Direct blow
 Acceleration and deceleration compression
 High speed deceleration injuries

Etiology
 Falls, sports, mva , stick, kick Blast kinetic energy
Injuries can be ;
Chest wall
 Rib #, flial chest , sternal #, clavicular # , scapular #
Lung injuries
 Pul contusion
 Hemothorax
 Pneumothorax

Mediastinum
 Pneumomediastinum
TENSION PNEUMOTHORAX

• Increasing pnx  with each breathing cycle

Pathophysiology
 Visceral pleural tear  one way valve
 Collapsed lung  mediastinal shift  kinking of the SVC  dec. in VR  dec. CO 
hypotension  Cardiac arrest
Diagnosis
 Clinical
 Deviated trachea
 Dec. expansion
 Absent or decreased breath sounds
 Inc. percussion note
 Distended neck veins
 Hypotension
Treatment
 Large bore cannula at 2nd ICS mid clavicular line
 Chest tube insertion
 Emergency thoracotomy
HEMOTHORAX

• Blood in the pleural cavity

Sources : chest wall , lungs and mediastinum ( arterial or venous)
 can cause profound hypovolemia and shock
C/F
 Hypovolemia
 Absence of breath sounds
 Dullness to percussion
Inv .
 CXR : may be confused with collapse or contusion

Treatment
 Rapid decompression with chest tube and IV fluids
 May require thoracotomy
 Hemodynamic instability
 Blood loss >200ml/hr for 2 -4 hrs
 Penetrating injury bn the two midclavicular lines
 Penetrating injury medial to the scapulae
OPEN SUCKING CHEST WOUND

• Full thickness chest wall injury with diameter >than tracheal diameter

PATHOPHYSIOLOGY
 High resistance low flow  low resistance high flow
 Associated injuries
Treatment
Closure of the wound
 High flow O2 sterile occlusive dressing on three side
 Progressive air way management
 Chest tube insertion
PULMONARY CONTIUSION

• Lung injury from bleeding in to the alveli and interstitial spaces

• Injury could be to the lungs tracheobronchial tree
• Tendency to evolve  over next two –three days
• Cf
• Dyspnea, hemoptysis , inc.RR , cyanosis, hypoxia
• Dx
• CXR and CT scan
• Treatment
• Intubation and PPV
• Restrict IV fluids
• Abcs ???
• Steroids?????
• Surgery rearlly indicated
RIB FRACTURES

Can be :
 Single multiple
 Displaced undisplace
 Anterior posterior
 Flial
• Gives clue to the underlying injuries
• 4-9 ribs lung bronchus pleura heart
• 9-12 ribs spleen liver kidney
• 1st rib aortic
Treatment
• Pain relief *****
• Optimize pulmonary toilet
• Fixation
FLIAL CHEST

• 3 or more ribs at two sites

• Paradoxical chest wall motion
• Unilateral or bilateral
• Commonly associated with other injuries
• Impairs respiratory mechanics  hypoventilation and atelectasis
Treatment
 ETT
 Chest wall stabilization
 Pain reliefe
 Chest PT
 Yoga
 Abcs
 Bronchoscopy and lavage
TRACHEOBRONCHIAL INJURIES

• 76% with in 2cm of the carina

• 46% RMB

C/f
• hemoptysis ,SC emphysema , pnx
• Bronchoscopy
Rx
• Stenting
• Surgical repair ,pneumonectomy , lobectomy
GREAT VESSEL INJURY

• Descending aorta injury 50% mortality

• Arch injuries deceleration injuries
Dx angiogram or aotogram TEE
Treatment
 Control pulse rate
 Endovascular
 Surgical reapir
CARDIAC TAMPONADE

• Blood in pericardial cavity

• Penetrating >blunt

Dx
• clinical
• Raised JVP, muffled heart sounds , hypotension , pusus paradoxus
• FAST
Rx
• Pericardiocentesis , surgical exploration
PENETRATING THORACIC TRAUMA

Specific considerations
Stab wounds
• Mechanism and location
• Puncture wound may be missed  inspect axilla
• Injury limited to the tract off the knife
Gunshot injury
• Kinetic energy is impt consideration
• Entry and exit
• Direct and indirect injuries
Blast
• Both penetrating and blunt injury
• Primary ,secondary , tertiary

Impaled objects  never pull out

READING ASSIGNMENT

• cardiac ,Diaphramatic and esophageal

VASCULAR EMERGENCIES

Acute limb ischemia

• Sudden deterioration of blood supply to part of the limbs
Etiology
 EMBOLIC
 THROMBOTIC
 TRAUMA
 IATROGENIC
EMOLIC

• From embolos meaning to plug

• The artery is HEALTHY
Class.
• Cardio-arterial embolic
• Aterio- arterial
THROMBOTIC

• Diseased artery
Etiology
 Progressive atherosclerosis
 Hyper coagulability
 Aortic or arterial dissection
C/F

• Sudden sever pain in the extremity

• Sensory Nerves are first motor nerves skin muscle
• Muscle tenderness is a late sign
6 P’s
 Pulselessness , pallor , perishingly cold , paralysis, pain , paresthesia
• Duration is most important
• 6-8 hrs irreversible injury occurs
Inv
• Doppler studies
• Arteriography
Treatment
Supportive measures
Revascularization ( embolectomy , thrombectomy ,endarterectomy , stenting )
Fasciotomy
Amputation
VASCULAR TRAUMA

• Involve : vein or artery

Etiology
• Blunt , penetrating , iatrogenic
• May involve every region of the body
• 90% occur in extremity
Key points
 Suspicion or diagnosis of vascular injury
 Possibility of limb salvage
 How long we have to manage the injury
 Preexisting vascular conditions
C/F
HARD SIGNS
 Shock ,pulsatile bleeding , abscent pulse with stable or progressive neurological deficit ,
expanding hematoma  97% have injury
SOFT SIGNS
 Hx of massive bleeding, neurologic injury , tract of the injury ,unequal arm pressures
Treatment
 Individualized
 Anticoagulation
 Immediate exploration main stay of treatment
LUNG SURGERIES

• Open
• Minimally invasive (VATS or ENDOBRONCHIAL )

COMMON INDICATIONS
 Infectious
 Congenital
 Neoplastic
 Vascular
 Anatomic
LUNG CANCER

Introduction and epidemiology

• Leading cause of cancer death
• 5 years survival is 15%
• > colorectal, breast, prostate ,pancreases together in 2007
• Trend is also rising
• Females are reaching male ratios Ove the past 20 years
RISK FACTORS

 Gender
 SPN
 Smoking
 Elder age
 Prescence of air flow obstruction
 Genetic predisposition
 Occupational exposure
SMOKING AND LUNG CA

• From all ca patient 85-87% active ,3-5% passive

• However only 20% of smokers develop lung cancer in their life time
• Risk dec. if you stop smoking
Occupational exposure
 Arsenic, asbestoses , chromium , mustard gas , nickel , ionizing radiation  proven
 Silicon, wood dust , iron ore suspected
C/F

Symptom at presentation

Due to primary tumor

 Cough, hemoptysis, chest pain, wheezing , dyspnea, fever
Due to intrathoracic extension
 Chest pain, dysphagia, hoarseness, SVC syndrome

Due to metastasis
 LN enlargement , bone pain , neurological deficit , skin and sc lesions

Systemic
 Fatigue , wt loss, anorexia ,paraneoplastic
Patients present with advanced symptoms bc early
stages are asymptomatic

Histologic variants
• NSCLC (80%)
• SCLC (20%)
NSCLC

Adenocarcinoma
 Commonest
 Peripheral
 Ixc : glandular formation and mucin production
 No smoking association
Bronchoalveolar
 Variant of adenocarcinoma
 Airway spread
 Aggressive
Squamous
 Cavitation
 Central
 Ixc intercellular invasion , keratinization , intravascular invasion

Large cell carcinoma

 Poorly differentiated
 Dx of exclusion
 Ixc large cells with abundant cytoplasm
INVESTIGATION

CXR
 Nodule vs mass  3cm
 Central vs peripheral
 Single vs multiple
 Obstruction ; atelectasis or pneumonia
 Hilar enlargement
 Pleural effusion
 Elevated hemidiaphragm
CT scan
• Ixc a nodule
• Evaluate mass and extension to adjucent tissue
• Mediastinal LAP
• Upper abdominal metastasis
PET Scan
Mediastinoscopy /VATS
Pathologic diagnosis
 CT/ US guided FNAC / BIOPSY
 MEDIASTINOSCOPY
 BRONCHOSCOPIC
 OPEN
STAGING  TNM
AVAILABLE TREATMENT OPTIONS

 Surgical
 Chemo radiation
 Targeted therapy
 Hormonal therapy
 Immunotherapy
Important considerations
 Is the patient operable
 Stage of the tumor and respectability  stage IIa , stage IIIa
 Age
 Histology
Surgery is main stay of treatment
 Lobectomy to pneumonectomy

Reading assignment : approach to hemoptysis