GenSurg.nz

Chest trauma

Section: Trauma Curriculum: Curriculum, page 78

Immediately Life-Threatening Injuries

  • Airway
    • Laryngeal/tracheal disruption/obstruction
    • Extensive facial bony/soft tissue injuries
  • Breathing
    • Tracheobronchial tree disruption
    • Tension and open PTX
    • Flail chest
  • Circulation
    • Cardiac tamponade
    • Massive HTX
    • Air embolism

Potentially Life-Threatening Injuries (CRAVD)

  • Cardiac
    • Blunt cardiac trauma - Myocardial Contusion
  • Respiratory
    • Pneumothorax
    • Haemothorax
    • Flail Chest
    • Pulmonary Contusion
  • Aerodigestive
    • Oesophageal Disruption
    • Tracheobronchial Tree disruption
  • Vascular
    • Traumatic Aortic rupture
  • Diaphragmatic
    • Traumatic diaphragmatic hernia

Pathophysiology of Thoracic Trauma

  • Broad Concepts
    • Impaired ventilation
    • Impaired gas exchange
    • Impaired circulation
    • Impaired cardiac function
  • Paediatric Considerations
    • Flexible CW/ribs - if broken = High energy injury and likely associated injuries
    • Large thymus
    • Sternum soft - can be divided with heavy scissors

Applied Surgical Anatomy of the Chest

  • Triangle of Safety
    • Musculature is thin and no important structures
    • For chest drain placement
    • Bordered by Pectoralis Major, Anterior Axillary Line and Nipple Line
  • Chest floor = Diaphragm
    • In deep expiration it can rise to as high as the 5th IC Space
    • So any penetrating injury below 5th IC space could be intra-abdominal
  • Chest Contents
  • Divisions
    • Superior Mediastinum
    • Anterior | Middle | Posterior
  • Tracheobronchial tree
    • Trachea
      • Cricoid cartilage (C5) → Carina (T6) - Point of bifurcation
    • Right Main Bronchus
      • Shorter, straighter and less angulated
      • Below the junction of Azygos Vein to SVC
      • Behind Right Pulmonary Artery
  • Lungs/Pleurae
    • Right lung
      • Oblique and transverse fissures → 3 lobes
    • Left lung
      • Transverse fissure → 2 lobes
    • Bronchopulmonary segments
      • Branches of lesser bronchi
      • Branches of Pulmonary Artery (from RV → lungs)
      • R+L Pulmonary Arteries pass anterior to each bronchus
      • Sup and Inf R+L Pul V’s (Middle Lobe via Superior)
    • Pleura
      • Parietal on chest cage
      • Visceral on lung
      • Meet at hilum
  • Heart/Pericardium
    • Middle mediastinum
    • Level of 3rd Costal Cartilage to Xiphisternal joint
    • Anterior heart
      • Sup - RA and appendage
      • Inf - RV
  • Aorta
    • Emerges cranially and goes left as arch
  • Pulmonary Artery
    • Emerges cranially and bifurcates within arch concavity
    • Left Pulmonary Artery - Ligamentum Arteriosum to arch just distal to origin of Left Subclavian Artery
  • Pericardium
    • Attached to diaphragm (Septum Transversum)
  • Oesophagus C6 to T11
    • 25cm
    • Pharynx (level of C6) to stomach
    • Through diaphragm 2.5cm left of midline at T10 level
  • Thoracic Duct
    • Commences at cisterna chyli on L1/L2
    • Posterior and right of Aorta
    • Through oesophageal hiatus between Aorta and Azygos Vein (anterior to right intercostal branches of aorta)
    • Ascends posterior to oesophagus and crosses at T5
    • Drains into junction of Left IJV and Left Subclavian Vein

Initial investigations

  • CXR - Mark wounds/tracts with paperclips
  • FAST
  • CT with oral and IV contrast

Surgical Approaches to the Thorax

Left Anterolateral Thoracotomy

  • 4th or 5th ICS incision from Costochondral Junction to Mid-Axillary Line
  • Extension
    • To right chest for clamshell
    • To abdo for laparotomy
  • Access
    • To all of left chest and above nipple line right chest stuff
    • If need access to below nipple line on right → laparotomy (usually liver)
  • Considerations
    • Anterior wound - risk of injury to Internal Mammary Artery (sternal border)
    • Don’t cut Pectoralis Major or Trapezius
    • Finochietto Rib Retractor - Handles lateral
    • Autotransfusion device! CELLSAVER
    • Avoid Phrenic Nerve on lateral aspect of Pericardium
      • If incision needed → 1cm anterior

Median Sternotomy

  • Use oscillating saw from sternal notch to xiphisternum (or Lebsche knife)
    • Finger sweep retrosternal to create planes
  • Suprasternal Space of Burns - Transverse Communicating Vein - Beware
  • Close pericardium
  • Leave and sternal wire closure

Clamshell Thoracotomy

  • Bilateral trans-sternal thoracotomy through 4th or 5th space
  • High morbidity
  • Gives wide exposure EXCEPT to superior mediastinal structures
  • Only useful if bilateral access is needed emergently
  • Transmediastinal injury, lung injury, right side injury needing aortic control

Posterolateral Thoracotomy

  • NOT ACUTELY

Resuscitative Thoracotomy

  • Objectives
    • Cardiac tamponade decompression
    • Control intra-thoracic bleeding
    • Control air embolism or bronchopleural fistula
    • Permit open cardiac massage
    • Allow temporary descending aorta occlusion to limit abdominal haemorrhage
  • WEST guideline
    • Indication
      • Penetrating trauma <15 CPR
      • Blunt trauma <10 minutes of CPR
      • Penetrating neck or extremities with <5 minutes CPR
      • Profound refractory shock - CPR with SBP <60 or signs of life
    • Against
      • Inverse of above
  • EAST guideline
    • Signs of life defined as any of the following
      • Pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, or cardiac electrical activity.
    • Recommendations
      • Strong
        • Pulseless with SOL after penetrating thoracic injury
      • Conditional
        • Pulseless with SOL after blunt injury
        • Pulseless with SOL after penetrating extra-thoracic injury
        • Pulseless without SOL after penetrating extra-thoracic injury
        • Pulseless without SOL after penetrating thoracic injury
      • Against
        • Pulseless without SOL after blunt injury
  • End Points of Emergency Department Thoracotomy
    • Unrepairable cardiac or great vessel damage occurred
    • Massive head injuries identified (probably shouldn’t start if identified prior)
    • No ROSC after 15 minutes

Surgical Procedures

  • Steps
    • Incision in 5th intercostal space
      • Lateral border of the sternum to the table
      • #10 blade
    • Divide the pleura
    • Damage control
      • Stop massive bleeding with pressure
      • Hilar twist/clamp
    • Open pericardium
    • Cross clamp aorta
    • Open CPR
  • Pericardial Tamponade
    • Pericardial incision 1cm anterior to phrenic nerve, cranial to caudal
    • Assess whole heart and source control
    • Close pericardium over a drain
  • Cardiac Injury
    • Digital pressure or large balloon foley on gentle traction
    • 3.0 or 4.0 prolene
    • Mattress sutures under coronaries
    • Can use a foley catheter and gentle traction
  • Pulmonary Haemorrhage
    • Clamp hilum for proximal control
    • Oversew, segmental or lobar resection
    • In air embolism → Clamp hilum, needle aspirate LV apex
    • Pulmonary Tractotomy
      • Stapler fired down tract
      • Non anatomical lung preservation
      • For injuries crossing multiple segments
      • Damage control
    • To perform hilar clamping or the “pulmonary hilar twist”
      • Mobilize the injured lung hilum by first dividing the inferior pulmonary ligament to the level of the inferior pulmonary vein
      • Control the hilum of the lung with a large vascular clamp (eg, Crawford or Satinsky) or by using a Rommel tourniquet and snares
      • For the pulmonary twist maneuver, rotate the lower lobe anteriorly up over the upper lobe twisting the lung clockwise 180°, which compresses the main pulmonary artery and vein against the bronchus
      • Place lараrotοmу packs at the base and apex of the lung to prevent the lung from untwisting.
  • Thoracic Aortic Cross Clamping
    • Left anterolateral thoracotomy with cross-clamping of the descending thoracic aorta and open cardiac massage to control massive intra-abdominal bleeding, page 1
    • Steps
      • Retract the left lung superiorly.
      • Divide the inferior pulmonary ligament.
      • Palpate the orogastric or nasogastric tube (if present) to differentiate the esophagus from the empty descending aorta.
      • Perform the periaortic dissection at the level of an intervertebral space in a plane perpendicular to the aorta to avoid injսrу to intercostal vessels, which branch from the aorta at the level of the mid-vertebral body
      • Incise the parietal pleura overlying the aorta and separate the tissues between the aorta and esophagus, as well as the prevertebral fascia to create sufficient space to place the aortic clamp without avulsing the intercostal arteries from the posterior surface of the aorta.
      • The aorta should be cross-clamped at the most distal location that is practical to preserve spinal cord blood supply.
    • Benefits
      • Vital organ perfusion → Heart, Brain
      • Limit infra-diaphragmatic haemorrhage
      • How simplified
        • Left lung retracted anterosuperiorly
        • Dissect descending thoracic aorta off oesophagus and prevertebral fascia
        • Cross clamp
        • Note time - should be < 30 mins

Oesophageal Injury

  • Presentation
    • Dysphagia/odynophagia
    • Delayed with mediastinitis
    • Pain/ fever/ pneumomediastinum/ persistent Ptx despite chest drain
    • Can get pleural effusions and contrast leak
  • Cervical Oesophageal injuries
    • Debridement and closure with drainage
    • Access cervical oesophagus via the anterior SCM incision
  • Thoracic Oesophageal injuries timeline of injury important
    • Below is old school teaching - these time cut offs are no longer used and not supported by evidence but are somewhat useful to be aware of
      • If < 6 hrs old
        • As above
        • 2-layered closure
        • TPN and Antibiotics
      • If 6 - 24 hrs
        • Gray zone
        • Attempt at closure vs drainage and TPN

      • 24 hrs old

        • Drainage and TPN and Antibiotics
  • Complications
    • Mediastinitis
    • Wound infection
    • Empyema
  • Grading
    • 1 - Contusion/Haematoma (no devascularization), Partial thickness laceration
    • 2 - Full thickness laceration, < 50% circumference
    • 3 - Full thickness laceration, > 50% circumference
    • 4 - Segmental loss/ devascularisation < 2cm
    • 5 - Segmental loss/ devascularisation > 2cm
  • Management Options- Repair of traumatic oesophageal injury
    • Endoscopic covered stent
    • Surgery → Wide drainage, repair
      • Principles of surgical management
        • Source control - Debridement, defect closure 2 layers, drainage
        • Feeding - PEG or feeding jejunostomy
      • If less severe (1-3)
        • Primary closure or over T-tube
      • If severe (4-5)
        • Oesophagectomy
        • End oesophagostomy and distal oesophagectomy
        • Delayed oesophageal reconstruction
          • OG
          • Colonic conduit

Thoracic Duct Injury

Light’s Criteria - ? Transudate or Exudate

Chest Drain

  • Insertion
    • Via triangle of safety - pec major | mid axillary line | 5th ICS (above) | axilla
  • Indications
    • Haemothorax
    • Pneumothorax
      • Tension, > 3cm, Any resp distress
      • Any size undergoing transfer, GA or positive pressure ventilation (say this for the exam but in reality not all patient receving PPV need a chest drain but instead close monitoring)
  • Mechanism of effect of an Under Water Seal Chest Drain
    • Inhalation and lung expansion pushes pleural air and space out via drain
    • Chest drain creates a siphon effect for fluid and air
    • Fluid drained via gravity (keep canister below level of insertion)
    • Air drained through water seal valve reservoir which prevents back flow into the pleural space
  • Equipment
    • 3 chambers - fluid, air and suction
    • 1 - Fluid collecting chamber
    • 2 - UWSD for air
    • 3 - Suction chamber to apply wall suction at low pressure
      • Also has a pressure release valve
  • Complications
    • Bleeding - Intercostal vessels → HTX
    • Pain - Intercostal nerve
    • Traumatic organ injury - lung, great vessels, oesophagus, colon, spleen, liver
    • Infection
    • Malposition/kinking/blocking
    • Recurrence or tension
  • Pathophysiology
    • HTX and fluid drained by gravity dependence - chest drain below patient
    • PTX drained via UWSD
    • Normally intrapleural pressure is negative
      • Chest injury causes loss of negative intrapleural pressure - lung collapse
    • UWSD drains air but creating a subatmospheric intra-pleural space and a one way valve
      • Air bubbles and can’t return due to UWSD
      • Vented out as well to maintain pressure gradient

Cardiac Box

  • Bounded by clavicles, mid clavicular line and costal margin
    • Clavicles, nipples, costal margin
  • Indicates high risk of cardiac injury if penetrating mechanism

Cardiac Injuries

  • Tamponade
    • Presentation
      • SOB/Shocked - BP/HR
      • JVP up and distended neck veins
      • Beck’s Triad - High JVP, low BP, muffled HS
      • Pulsus paradoxus
      • Kussmaul’s sign - distended neck veins, paradoxically elevated JVP in inspiration
    • Treatment
    • Complications
      • Recurrence (prevent by leaving a drain)
      • Mediastinitis
        • Treat by debriding and temporary closure then relook
      • Post Cardiotomy syndrome - Autoimmune re-accumulation of effusion (pericardial or pleural)
      • Cardiac herniation (prevent by loosely re-opposing the pericardium)

Tracheobronchial Tree Injury

  • General
    • Right main stem bronchus more common
    • Left = Longer and protected (aorta)
  • Presentation
    • Haemoptysis | AW obs | Increasing mediastinal air | Subcut emphysema
    • Tension PTX | Persistent air leak with chest drain in
    • Distal bronchus disruption usually settle with time and chest drain
    • Respiratory deterioration (acute or chronic)
    • Subcutaneous emphysema
    • Hamman’s Sign - crackling with pulse - pericardial emphysema
  • Investigations
    • Gold std - Bronchoscopy
  • Mx Principles
    • Resuscitation with targeted ventilation and gas exchange optimisation
      • ETT / tracheostomy / DIFFICULT
    • If persistent or impaired ventilation
      • If they don’t settle with multiple chest drains (e.g. persistent air leak) - need bronchoscopy to confirm proximal injury then surgery
      • Bronchoscopy ?proximal
      • Posterolateral thoracotomy
        • Options
          • Repair with monofilament suture
          • Segmental or lobar resection
    • Restore tracheobronchial continuity or resect
      • Stent
      • Suture repair
      • Lobectomy
  • Complications
    • Airway - obstruction, continued air leak, respiratory failure
    • Infection - mediastinitis
    • Shock - inadequate oxygenation capacity

Pneumothorax and Hemothorax

  • Pathophysiology of Pneumothorax
    • Normally intrapleural pressure is negative (lung tends to recoil, CW pulls outwards)
    • Disruption of visceral pleura or tracheobronchial tree = loss of pressure gradient between lung and atmosphere and progressive rise in intrapleural pressure
    • Inspiration air entering the pleural space which can’t all be exhaled
    • Lung collapses further - impaired ability to receive inhaled air for gas exchange
  • Hypoxaemia
    • Tension occurs due to a one way valve system
    • The rising intrapleural pressure causes mediastinal/tracheal deviation to contralateral side
    • Lung collapsed – hypoxaemia
      • Pulmonary vasoconstriction and increased Pulmonary Vascular Resistance
    • Can compress contralateral lung and vasculature - HD instability
      • Impaired diastole and reduced VR
    • Hypoaxaemia | Acidosis | Decreased CO → death

Pulmonary Contusion

  • Parenchymal lung injury with oedema and haemorrhage
  • Not confined to one segment or lobe
  • Cause → Blunt trauma | deceleration | blast
  • CXR – Ill-defined consolidation
  • CT - Parenchymal opacification with subpleural sparing
  • Usually respiratory supportive mx

Pulmonary Lacerations

  • Always associated with contusion
  • Affected areas of parenchyma recoils causing spheres of lung - pneumatocoeles or haematocoeles
  • Can bleed and need chest drains
  • If surgery is required - can do tractotomy with stapling

Flail Chest

  • 3 or more contiguous ribs are fracture with 2 or more fractures on each rib creating a floating segment which loses mechanical continuity with and thus moves paradoxically compared to the remainder of the chest wall
  • Pathophysiology
    • Ineffective ventilation
      • Increased dead space
      • Decreased intrathoracic pressure
      • Increased oxygen demand from injured tissue
    • Pulmonary contusion
      • Oedema and haemorrhage
      • Impaired gas exchange
      • Decreased compliance
    • Hypoventilation and Atelectasis from pain
      • Splinting - reduced tidal volume
      • Causes atelectasis
  • Rib Plating
    • Indication for Rib Plating
      • Respiratory failure
        • Impending or true
        • Pain from #’s
        • Flail chest
        • Deformity of CW (significant)
        • Failure to wean off ventilation
        • Significant displacement detected during thoracotomy for another reason
        • Pain/deformity from mal- or non-union
    • Contraindications
      • Significant pulmonary contusion
      • Other injuries that preclude separation from ventilation (e.g. HI)
    • Benefits
      • Reduced need for intubation
      • Less respiratory complications incl. pneumonia
      • Easier to wean ventilation
      • More likely to wean ventilation
      • Reduce mortality | Ventilation period | LOS | Pneumonia | Tracheostomy
    • Earlier plating within 72 hrs is better
    • Usually only needed for ribs 4-9 as upper ribs don’t contribute much to ventilation and posteriorly are difficult to access (scapula) and lower ribs don’t add much value
    • How
      • Open plating on external surface or rib
      • Exposure, dissection away from lower border (NV bundle)
      • 2-3 fixation screws to hold contoured plate
  • Internal pneumatic stabilization
    • Achieved with positive pressure ventilation
    • Treats the flail with splinting and the contusion

Diaphragm Injury

  • General
    • Common to injure left side penetrating
    • Right handed assailant
    • Blunt - Increased intra-abdo pressure
    • Associated injuries to heart | lung | colon | liver | spleen
    • With abdominal viscera in chest - impaired ventilation, reduced CO, reduced VR
  • Grading
    • 1 - Contusion
    • 2 - Laceration < 2cm
    • 3 - Laceration 2-10cm
    • 4 - Laceration > 10cm with < 25cm2 tissue loss
    • 5 - Laceration > 10cm with > 25cm2 tissue loss
  • Diaphragm repair
    • Principles
      • Reduction of abdominal contents
      • Closure of defect
      • Minimised contamination
    • Method
      • Grasp defect edges with allis clamps
      • Lavage of chest and abdomen
      • Debride edges to healthy tissue
      • Suture from deepest extent, towards myself with 0 Prolene or Nylon (permanent monofilament) in continuous fashion
    • Mesh
      • Usually not need
      • If can’t close defect
        • Clean - nonabsorbable prosthetic mesh (eg, polytetrafluoroethylene, polyethylene)
        • Contaminated - Permacol
  • Complications
    • Hernia
    • Pulmonary
      • Diaphragm paralysis
      • Impaired ventilation

Pneumothorax

Open

  • 3 side occlusive dressing

  • Chest drain

  • Debridement and temporary dressings

  • Recon - flaps

  • Tension

  • Needle decompression/ finger thoracostomy

  • Chest drain

Massive Haemothorax

  • Potential sites of bleeding (may need thoracotomy)
  • CW vessel - Intercostal, Internal mammary
  • Cardiac or lung hilum
  • Pulmonary Laceration - Suture | tractotomy | segmental or lobar resection

Pulmonary Contusion

  • Causes - Direct chest trauma | High velocity missiles | Blast injuries
  • Pathophysiology
    • VQ mismatch
    • Shunts
  • Mx
    • CV and ventilatory support
    • Gram stain and CXR
      • If bug isolated and increasing WBC - abx

Air Embolism

  • Pathophysiology
    • Fistula from bronchus to pulmonary vein
    • Pressure differential
      • Bronchus to vein - embolism
        • E.g. positive pressure ventilation
      • Vein to bronchus - haemoptysis
  • Presentation
    • Focal/lateralizing neurology - air embolism distal
    • Sudden CV collapse - air embolism to coronaries
    • Frothy blood sample
    • Be suspicious if has no HI, chest injury obvious and neurology
    • Fundoscopy - air in retinal vessels
  • Mx
    • Thoracotomy
      • Can clamp offending hilum initially
      • Repair pulmonary lacerations or staple off
      • Lobectomy
    • Other considerations
      • Cardiac massage and hold ascending aorta for 1-2 beats
      • Dissipates coronary air
      • Adrenaline - down ETT or IV - drives air out of systemic microcirculation
      • Vent LA and LV and asc aorta once lung has been clamped

Great Vessel Injury

  • High mortality
  • Complications
    • Rebleeding
    • False aneurysm
    • Thrombosis
    • Paraplegia
      • Associated spinal cord injury
      • Ligation of intercostal arteries that may provide collateral to spinal cord

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