Chest Trauma
John Kortbeek
Outline
Emergency & ResuscitativeThoracotomy
• To evaluate the survival of Adult Trauma Patients in the Calgary Health Region who have undergone Emergency Thoracotomy.
• To evaluate further outcomes of the survivors.
• To document variation in technique used for emergency thoracotomies in the region.
Emergency & ResuscitativeThoracotomy
• 5 year retrospective study.
• Prehospital and hospital records were reviewed for all trauma patients requiring emergency thoracotomies who were brought to Foothills Hospital, a Level I Trauma Center, during a 5-year period (Apr 1998 - Mar 2003).
• Patients were identified through the Alberta Trauma Registry.
Emergency & ResuscitativeThoracotomy
• Thoracotomies were classified as "emergent" when the procedure was performed for a patient in the Emergency Department (ED) or in the first 24 h after admission in the Operating Room (OR).
• Exclusion criteria: thoracotomies were not performed control of acute hemorrhage.
Emergency & ResuscitativeThoracotomy
• Outcomes
• Survival rate.
• Comparison Mechanism of Injury and ER vs OR thoracotomy.
Neurological status at discharge.
Emergency & ResuscitativeThoracotomy
• D/C Status: Of 15 survivors:
• 11 to home w/o support GCS of 15
• 2 D/C home with some support, 2 to another care facility (one with GCS 9 died 3 Mo. Later)
Emergency & ResuscitativeThoracotomy
• In Blunt Trauma:
All survivors had + BP in ER & All successful thoracotomies were performed in OR.
• In Penetrating Trauma:
Survivors from all groups.
36% of survivor thoracotomies were performed in ER
• 1/3 of ED thoracotomies performed for penetrating trauma survived.
• Our findings support the recommendations of the American College of Surgeons Committee on Trauma
Tyburski et al, J Trauma 2000
• Detroit receiving, Penetrating heart wounds. 17 years 152 ED thoracotomies & 150 OR thoracotomies.
• OR Thoracotomies 74% survival
• Of The 152 ED thoracotomies
• 93 GSW no survivors
• 59 stab wounds - 20% survivors.
Emergency & ResuscitativeThoracotomy
• OR Thoracotomies 74% survival
Approach to juxtacardiac wounds
Juxta-cardiac wounds
• 1. Pericardial window
• 2. Echo TTE, TEE
• 3. FAST
• 4. CT
• 5. Local exploration
FAST
• Acad Emerg Med 2000, Wisconsin
• Residents and faculty - Emergency Med Training program exposed to standard subxiphoid FAST exams and questionnaires
• Sensitivity 73%, specificity 44%
• Epicardial fat pads confused with effusions.
FAST
• Annals Thor Surg 2003, Baylor
• 478 patients underwent sonography for penetrating thoracic trauma
• 23 positive, 20 had a cardiac injury at surgery. Spec 99% PPV 87% NPV 100%
• CT: Louisville, Kentucky, 22 stable transmediastinal GSW, CXR, U/S negative
• 7 positive - further investigation led to thoracotomy in 2.
• 15 negative, no further investigations, therapy required.
• CT safe and effective for evaluation of stable transmediastinal GSW
Juxtacardiac wounds
• Stab Unstable with vitals, GSW below nipples.( Stable or unstable with vitals) - CXR then to OR.
• Nipples and below - Lap first. Above nipples thoracotomy first.
• Stable stab or GSW above nipples - CXR - FAST - If negative then to CT, if positive then to OR for window or thoracotomy.
• Ant. Stab - sternotomy, GSW - Ant Lat thoracotomy.
Challenging Pradigms Blunt Aortic Injury.
• Endovascular repair
• Timing
BTAI Open repair.
• Death 20 -30%
• Paralysis 5% ( rates up to 20% reported with clamp and sew)
• Open thoracotomy - acute and chronic pain syndromes.
• RLN injury 10%
• Retrospective review, Jan 99 - Feb 03
• 28 patients with BTAI treated with EVSG
• 12 were delayed > 30 days
• 16 were acute F/U mean 11 months ( 3-30)
• 1 death, no graft complications, no paraplegia, 1 stroke due to co-existant carotid dissection.
BTAI
• Parmley
• Non operative management
• Delayed operative management
BTAI
Delayed operation
• Significant CHI
• Severe ALI
• Multiple complex abdominal injuries with coagulopathy.
• Risk of death in this group > 20%
• Risk of delayed rupture before repair approx 5%
BTAI
No operation
• Minimal aortic injuries with intimal flap < 1cm and minimal periaortic hematoma.
• Small injury extending proximally into arch
• Severe cardiac / age related co-morbidity and/or severe atherosclerotic disease of the aorta.
• > 33% mortality/ 0% attributable to rupture.
Case of the wandering bullet
Pulmonary Bullet emboli
• 32 cases - 3 (9% - Rx ?)
• 12 ( 30%) Thoracotomy for extraction.
• 3 (9%) percutaneous extraction
• 14 ( 44%) observation. F/U 9months - 5 years - No deaths or complications.
Bullet emboli
• Pitfalls
• Removal
• L sided cardiac
• Large arterial
• Right sided larger irregular projectiles
• Mobile R intracardiac
Bullet emboli
• Leave
• Asymptomatic Pulmonary emboli
• Immobile cardiac ( embedded, blurred)
• Multiple small pellets.
Bullet emboli
• Consider:
• Bullets which have traversed GI tract
• retained explosives
• Devastator bullets
• RPGs
Conclusions
• 1. Indications for resus thoracotomy.
• 2. Stable juxtacardiac wounds non-op
• 3. Endovascular repair here to stay.
• 4. Missile emboli, look for it and beware the pitfalls
Chest Trauma Summary
1.ERThoracotomy for Stab wounds with signs of life.
2. EVSG For BTAI, Select non-op
3. Juxtacardiac wounds, Always check the heart.
4. Beware the wandering bullet.
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