EMCrit.org

Thoracic Trauma

Tube Drainage Indications for Thoracotomy

20 cc per kilo initially or 5 cc/kg/hr or 25 cc/kg total to OR

1.5 liters initially or 350  (200) cc/hr or 2 1/2 liters total.

The presence of more than 1500 mL of blood in the initial chest tube drainage, drainage of more than 200 mL an hour for 2-4 hours, or ongoing transfusion requirements mandate surgical exploration with open thoracotomy

CT Chest is useful (J Am Surgeon 2001;67:660-664)

"The Box"

Notch and Clavicles (roof), Nipple line are lateral (sides), Costal Margins (bottom)

Echo initially and repeat in 6 hours.  C-XR initially and in 6 hours.  Can use helical CT to evaluate for pericardial fluid, just as good.

“The box:” definition of proximity to the heart for penetrating injuries. X = wounds that
produced cardiac injuries (Nagy KK, J Trauma 1995)

Thoracoabdominal

Nipple Line to costal margins/below the scapula

Both cavities and worry about the diaphragm

DPL is good here, use low cut-off 5000 RBCs per cc

7% risk of occult diaphragmatic injury (J Trauma 2003;55(4):646)

Rib Fx

X-Ray if ribs 1-2, 9-12, pathological fx, or elderly

1^st or 2^nd rib is fx along with another rib-get angio

Flail-3 ribs in two places

Traumatic Asphyxia

Pulmonary Contusion

Epidural analgesia probably reduces vent days and nosocomial pneumonia (J Surg 2004;136(2):426)

A Prospective Randomized Trial of Nebulized Morphine Compared with Patient-Controlled Analgesia Morphine in the Management of Acute Thoracic Pain
[Original Articles]
Fulda, Gerard J. MD, FACS, FCCM; Giberson, Frederick MD, FACS; Fagraeus, Lennart MD, PhD

From the Departments of Surgical Intensive Care (F.G. and G.J.F.) and Anesthesia (L.F.), Christiana Care Health Services, Newark, Delaware.
Submitted for publication October 26, 2004.
Accepted for publication May 10, 2005.
Presented at the 63rd Annual Meeting of the American Association of the Surgery of Trauma, September 29–October 2, 2004, Maui, Hawaii.
Address for reprints: Gerard J. Fulda, MD, FACS, FCCM, Director, Surgical Intensive Care, Associate Director of Trauma, Christiana Care Health Services, Room 2325, 4755 Ogletown-Stanton Road, Newark, DE 19718; email: gfulda@christianacare.org.
Abstract
Background: Successfully managing pain for the trauma patient decreases morbidity, improves patient satisfaction, and is an essential component of critical care. Using patient-controlled analgesia (PCA) morphine to control pain may be complicated by concerns of respiratory depression, hemodynamic instability, addiction, urinary retention, and drug-induced ileus. Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract, achieving systemic concentrations equal to 20% of equivalent intravenous doses. The purpose of this study was to evaluate the safety, efficacy, and utility of nebulized morphine in patients with posttraumatic thoracic pain.

Methods: This double-blinded, prospective study randomized patients with severe posttraumatic thoracic pain into two groups. The experimental group (NMS) received nebulized morphine every 4 hours and normal saline by PCA. The control group (PCA) received nebulized saline every 4 hours and morphine by PCA. Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale (VAS) for pain. Pulmonary function, pain relief (VAS), level of sedation (0–3), total drug administration, and systematic side effects were recorded.

Results: Forty-four patients were randomized (22 per group). Seven hundred seventy observations were made. The mean 4-hour dose of morphine was 11.96 ± 3.4 mg for NMS and 6.22 ± 4.7 mg for PCA (p < 0.001). Patients with NMS had lower heart rates compared with PCA (79 ± 11 bpm versus 92 ± 12 bpm; p < 0.001) and were less sedated ( 0.33 ± 0.7 versus 0.56 ± 0.9; p = 0.03). The mean pain level (VAS) was 3.38 ± 1.8 for NMS and 3.84 ± 2.7 for PCA (p = 0.2). There was no difference between pain levels before and after dosing. There were no differences between groups with respect to arterial blood pressure, respiratory rate, vital capacity, mean forced expiratory volume in 1 second, spirometric volumes, or Sao 2.

Conclusion: Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain. Pain can be successfully managed while vital capacity, mean forced expiratory volume in one second, and spirometric volumes are maintained. Compared with PCA morphine, nebulized morphine provides equivalent pain relief with less sedative effects.

Treatment and Dosing


All patients had, at baseline, pulmonary function assessments before study initiation. Pulmonary function assessments consisted of forced expiratory volume in 1 second (FEV 1), maximum spirometric capacity, vital capacity, pulse oximetry, arterial blood pressure, and heart rate. Each patient then received an intravenous loading dose of morphine sulfate 0.07 mg/kg (approximately 5 mg). This was to provide all patients with a baseline level of pain control. Patients then received a continuous intravenous infusion of study medication, either morphine 1 mg/h (PCA group) with no on-demand morphine or an equivalent amount of 0.9% saline solution via PCA (NMS group). Both groups also received a nebulized study drug of either 0.9% saline solution (PCA group) or morphine sulfate 8 mg/mL Normal Saline (NSS) (NMS group) every 4 hours around the clock (ATC). In summary, the PCA group received nebulized saline every 4 hours with PCA morphine, and the NMS Group received nebulized morphine every 4 hours with PCA saline. The rational for the initial doses and interval was based on published pharmacokinetic data. 4,5 This data suggest that inhaled morphine administered every 4 hours follows similar kinetics and elimination as a single intravenous injection. However, the dose of nebulized morphine needs to exceed twice the intravenous dose to provide similar bioavailability and half-life.



Nebulized morphine was prepared and administered as follows. Morphine and placebo vials were prepared and blinded by the pharmacist. Standard injectable morphine sulfate with preservative was used (Abbott Labs, Chicago, IL). The patient's nurse provided the correct dosage of study medication to the respiratory therapist. The nurse and therapist were responsible for ensuring that normal saline was added to the study medication to equal a 3 ml total volume. The solution was nebulized using a Respirguard II nebulizer system with the Acorn II nebulizer (Vital Signs, Inc., Totowa, NJ). This system produces an aerosol with a mass median aerodynamic diameter of 1.67 µm with an output of 0.34 mL/min at 8 L/min. The patient received the nebulizer treatment for 10 to 12 minutes.
(J Trauma 2005;59(2)

OLD Folks do poorly with Rib Fractures

Bergeron E et al: Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 54:478,
2003;

Pneumothorax

32-40 French

Thoracotomy-20 cc/kg of initial blood, >7cc/kg/hr, decompensation, increased hemothorax

If you get supine AP x-ray, look for deep sulcus sign

1.25% of percent of Pneumo spontaneously absorbed each day, more c 100% O2

Can get a delayed Pneumo up to 4 days post line placement

Normally film 6 hours after initial chest x-ray in trauma, but article suggests 3 hours sufficient (JEM 20:3)

Spontaneous Pneumothoraces

One shot of manual aspiration is supported and efficacious.  If it fails, don’t try again, move on to chest tube or Heimlich valve (Am J Resp Crit Care Med 165:1240, 2002)

J Trauma. 1993 Nov;35(5):726-9; discussion 729-30.Links
Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use.
Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI.
Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville.
Occult pneumothorax is defined as a pneumothorax that is detected by abdominal computed tomographic (CT) scanning, but not routine supine screening chest roentgenograms. Forty trauma patients with occult pneumothorax were prospectively randomized to management with tube thoracostomy (n = 19) or observation (n = 21) without regard to the possible need for positive pressure ventilation, to test the hypothesis that tube thoracostomy is unnecessary in this entity. Eight of the 21 patients observed had progression of their pneumothoraces on positive pressure ventilation, with three developing tension pneumothorax. None of the patients with tube thoracostomy suffered major complications as a result of the procedure. Hospital and ICU lengths of stay were not increased by tube thoracostomy. Patients with occult pneumothorax who require positive pressure ventilation should undergo tube thoracostomy.

Cardiovascular Trauma

Myocardial Concussion

Brief dysrhythmia, hypotension or LOC c no lasting effects, no autopsy evidence

Myocardial Contusion

Most commonly from mva

Autopsy evidence

Can cause vasospasm or thromboembolism

Pericardial effusion +- friction rub, S3 gallop, rales, elevated CVP

2 mechanisms of injury:  transient reduction in bloodflow and transient dysrhythmias

70% of pts have tachycardia

EKG is the screening exam, if negative, do not have to admit

Common ekg abnormalities are PVCs, 1st degree av block, RBBB (Right ventricle is closest to anterior chest wall)

It is possible to have problems 12-72 hours after injury

If available, gated radionucleotide angiography is excellent test

Thalium also good

Monitor for 12 hours then can send home, b/c no life threatening problems seen after this time

If decreased cardiac output, can use dobutamine or IABP

Send 1 Troponin and get EKG:  both normal, young patient, send home (Journal of Trauma 50:237 2001) 100% sensitivity

Another study used 0 and 8 hour trops (J Trauma 2003;54:45-51.)

Abnormal Admit to Tele Bed

If the patient is unstable, get an echo

troponin specific but insensitive for myo injury in trauma (Anesthesiology 2004;101:1262)

Acute Pericardial Tamponade

2% of penetrating chest trauma

CVP increases to greater than 15

Becks triad-distant heart sounds, JVD, hypotension.  Also see pulsus paradoxus

EKG-electric alternans-alternates amplitude every other beat from decreased oscillation of heart, much more common in chronic effusion.

Chronic=water bottle heart on X-ray

Myocardial Rupture

Possible complication of CPR

KK Nagy, SH Gilkey, RR Roberts, JJ Fildes and J Barrett
Department of Trauma, Cook County Hospital, Chicago, IL, USA. kknagy@aol.com

OBJECTIVE: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable patients with penetrating chest injuries. METHODS: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center. RESULTS: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18-100%), 96.6% (95% CI 88-100%), and 96.7% (95% CI 89- 100%), respectively. CONCLUSION: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.

Esophageal and Diaphragmatic Trauma

Esophageal Perforation (Boerhaave's)

Esophagus has no serosa, so perf = direct access to mediastinum

DX by pain, possibly pleuritic

Hamman’s crunch from air surrounding heart

Pleural effusion

C-XR:  mediastinal air, L pleural effusion, pneumothorax, increased mediastinum

Get Esophogram 1^st gastro then barium

Rx:  Broad spectrum ABX, NGT

In a message dated 7/19/2006 3:20:07 P.M. Central Standard Time,
docrickfry@aol.com writes:

And I  have just as valid anecdotes--at least two of our tubed patients---NOT
trickled but given full esophageal contrast swallows with barium--injuries
found, and in our institution in 21 years one never yet missed with
it--so--what does that prove--as ......

The issue here might be with the medium used.  BARIUM is the only  acceptable
medium to use in esophagograms to look for leaks.  I have never  understood,
nor can I find any scientific reason or support for, the urban  legend that
one should use gastrographin for an esophagogram.    Gastrographin is DANGEROUS,
in that if aspirated, can cause chemical  pneumonitis.   It also has a
significant false negative  rate.    Virtually every trauma and thoracic surgery
textbook  chapter that I can find recommends BARIUM.   Thoracic and trauma
surgeons who present at national meetings recommend BARIUM, and ridicule
gastrographin.      SO.................................     the contrarian views  on
this link server might be due to the fact that those reporting false negative
results with esophagograms were using the wrong media.

k mattox

andre
consider yourself fortunate to have never had a significant aspiration of gastrografin

i have practiced radiology for 35 years and have never had a fatal complication of intravascular contrast administration.

i have had, very early in my career before I knew better, two deaths caused by aspiration of gastrografin.

The use of barium is reliable and barium is inert in the neck and mediastinum.

Could not the inflammation that you describe have been caused by the leakage from the perforation rather than the barium?

HOWEVER, barium comes in all sizes and flavors. Barium paste would be unlikely to be reliable. Too thich to exit many of the perforation sites. Same goes for thick barium suspension. A moderately dilute "full strength" barium (30-40%) is likely to be the best option for finding holes.

a CAVEAT i have mentioned here before bears repeating. If there are penetrations near the EG junction or if you are doing a esophagogram in a patient who might have a concomitant intraperitoneal perforation, start with gastrografin since barium does sometimes cause a severe peritonitis.

sal

Penetrating Esophageal Injuries

From: McSwain, Norman E Jr. <nmcswai@tulane.edu>
Date: May 29, 2008 3:33 PM
Subject: RE: Delayed oesophageal injury
To: "Trauma &amp; Critical Care mailing list" <trauma-list@trauma.org>

I would have closed the injury, pulled muscle over the areas of repair
and WOULD NOT have place any drains. Drains create fistulae. Muscle
provides sealing coverage.  NPO x 48 hours of antibiotics. IV fluids.
Esophageal swallow to access the repair in 48-72 hours.

This is assuming a standard sized stab wound < 2 cm on each side and no
vascular injury

I would not have created a spit fistula nor a jejunostomy

I would have treated a GSW the same way unless massive tissue
destruction

Diaphragmatic Injuries

L much weaker than right in blunt trauma b/c liver protects right.  Most likely sight of injury posterio-lateral portion of L diaphragm

Diaphragm can extend to L2/L3 posteriorly

15 year review of all patients with blunt diaphragm injury [n=13]:
Results:  77% left, 23% right  30% missed during the initial evaluation
Delay 1 one – 10 years
(Patselas TN. Am Surg 2002; 68:633-9.)

Penetrating

Laparoscopy study in 110 patients with left-chest penetrating trauma and no indications for laparotomy:
Diaphragm injury in 24%
21% of these had a normal CXR
31% of these had hemo/pneumothorax
(Murray JA. J Am Coll Surg 1998; 187:626-30.) (Gibb's Lecture)

Miscellaneous

Valve Rupture

Most commonly aortic

Cervicothoracic Seatbelt Sign

Not necessarily indicative of underlying injury.  Most of those with injury will have some other physical sign (J Trauma 52:618 2002) (Am Surg 68:441, 2002)

Pulmonary Contusion

may have no signs on initial x-ray

opacities appear at 6 hours and usually resolve by 72 hours.

Emergent Pneumonectomy

Am Surg. 1996 Nov;62(11):967-72.


Survival after trauma pneumonectomy: the pathophysiologic balance of shock resuscitation with right heart failure.

Baumgartner F, Omari B, Lee J, Bleiweis M, Snyder R, Robertson J, Sheppard B, Milliken J.

Division of Cardiothoracic Surgery, Harbor-UCLA Medical Center, Torrance, California, USA.

Emergency pneumonectomy for trauma has a high mortality. Although exsanguination is a major factor leading to death, mortality remains high even after adequate resuscitation and is thought to be related to pulmonary edema and right heart failure. We present a series of nine patients who underwent pneumonectomy at Harbor-UCLA from penetrating (7) and blunt (2) trauma. Two patients survived; three initially survived the surgery but died postoperatively of hypoxemia and right heart failure; four died intraoperatively (2 from right heart failure and 2 from exsanguination). One survivor required open cardiac massage for asystole. Careful attention to prevent volume overloading before and during trauma pneumonectomy and maintaining a negative fluid balance postoperatively may contribute to survival in these patients.

 

Always Consider Bronchial Injuries if Mediastinal Damage (Ann Thorac Surg 2004;78:2157)

Penetrating Esophageal Injuries

Rare. Article on factors affecting outcome (Br J Surg 2004;91:1513)

Lung Wounds

can do tractotomy for gunshot wound to the lung use a GIA 80 stapler across the tract to open it up nicely

Bronchopleural Fistula

Can use endobronchial blockers to isolate (J Trauma 2006;61:755)

Endobronchial Bleeding

it's a big deal. Albumin in the blood destroys surfactant

Lung Sequestration Syndrome

oversew area of dead lung

CT Scan for Chest Trauma

Results: Sixty-eight patients (73.1%)
showed at least one pathologic sign on
chest radiograph, and 25 patients (26.9%)
had normal chest radiograph. In 13
(52.0%) of these 25 patients, the CT scan
showed multiple injuries; among these
were two aortic lacerations, three pleural
effusions, and one pericardial effusion.
Conclusion: Over 50% of patients
with normal initial chest radiograph
showed multiple injuries on the CT scan,
among which were also two (8%) potentially
fatal aortic lesions. We therefore
recommend primary routine chest CT
scan in all patients with major chest
trauma.
Key Words: Blunt chest trauma, Deceleration
trauma, Motor vehicle crash
(MVC), Fall from height, Undetected injuries,
Aortic lesion, Computed tomographic
(CT) scan, Chest radiograph.
J Trauma. 2001;51:1173–1176.

Penetrating Cardiac Trauma

Injury 2005;36(6):745-750
Haemopericardium in stable patients after penetrating injury: Is subxiphoid pericardial window and drainage enough?--Small study (14 patients) of conservative management of pericardial blood

Study of blind subxiphoid pericardiotomy (J Trauma 2006;61:582)

Do we need a chest xray

absence of palpation tenderness and hypoxia identified most of pathology (Ann Emerg Med 2006;47(5):415)

Macklin effect: a peripheral alveolus ruptures and the air tracks centrally along the interstitium into the mediastinum and soft tissues (NEJM, May 17, 2007, pg. 2083).