Neck Chest Trauma

8/18/2019 Neck Chest Trauma

http://slidepdf.com/reader/full/neck-chest-trauma 1/124

Management of Penetrating Neck

Trauma

Ottawa Civic



MVA, aphasia, R hemiplegia



Types of eapons

!ow velocity " knives, ice picks, glass #igh velocity " han$guns, shotguns, shrapnel



%uns



&allistics



Anatomy



Anatomy



'nci$ence an$ Mortality





(igns of 'n)ury*



(igns of 'n)ury*



'nitial Management



Management of the (ta+le Patient*

The Standard:



The (tan$ar$*

&ase$ on wartime eperiences -ogelman et al ./0123 * imme$iate neck eploration45 +etter outcomes in

vascular in)uries6 negative neck eplorations in 5 178

Arteriogram9 screening tool +efore eploration :one / an$ ; in)uries

har$ to $etect on physical

(afe answer on +oar$ eam<



Arteriogram

-lintet al

./0=;3* negative P6>6 in ;?8 of pts6 with ma)or :one /

vascular in)ury6

Arteriogram can +e accompanie$ +y

treatment .e6g6 em+oli:ation36



A Newer Algorithm

Mansour et al 1991 retrospective study



Newer Algorithm .Mansour3

2;8 of the stu$y population was in theo+servation group6

Overall mortality /618 similar to those in more rigorous treatment

protocols6 (imilar results o+taine$ in other large

stu$ies with similar protocols .e6g6 &i@ et

al /00=36 NOT>* Arteriogram in asymptomatic patients

with :one / in)ury6



Points of Controversy*

Most trauma surgeons accept o+servation ofselect patients similar to the Mansouralgorithm6

(tu$y +y >$$y et al uestions the necessity for arteriogram B

esophagoscopy in asymptomatic :one / in)ury.use of P6>6 an$ CR resulte$ in no falsenegatives36

Other noninvasive mo$alities than

arteriogram eist for screening patients forvascular in)ury6



CT scan

Can i$ weapon tra)ectory an$ structures

only in sta+le patients6

%racias et al .?77/3 CT scan in sta+le patients*

a+le to save patients from arteriogram in$icate$ +y otherprotocols 178 of the time

avoi$ esophagoscopy in 078 of teste$ patients who mightotherwise have un$ergone it6



Duple Eltrasonography

Reuires the presence of relia+le technicianan$ ra$iologist6

A $ou+le +lin$e$ stu$y +y %ins+urg et al ./0023 showe$ /778 true negative, /778

sensitivity in $etecting arterial in)ury, usingarteriography as the gol$ stan$ar$6







's this really wise99



'ncision for Neck >ploration*



'ncisions for Neck >ploration*



Management of Vascular 'n)uries*

Common caroti$* repair preferre$ over ligation in almost all cases6 (aphenous vein graft may +e use$6 (hunting is rarely necessary6 Throm+ectomy may +e necessary6

'nternal caroti$* (hunting is usually necessary

Verte+ral* Angiographic em+oli:ation proimal ligation can +e use$ if the contralateral verte+ral

artery is intact6

'nternal Fugular* Repair vs6 ligation6



>sophageal 'n)ury*

Diagnosis* esophagoscopy an$ esophagram insymptomatic patients6

'n)ection of air or methylene +lue in the mouthmay ai$ in locali:ing in)uries6

Controlle$ Gstula with T4tu+e eteriori:ation of low non4repaira+le woun$s

(mall pharyngeal lesions a+ove arytenoi$s

can +e treate$ with NPO an$ o+servation14= $ays All patients shoul$ +e NPO for 14= $ays6



!aryngealBTracheal 'n)ury

Thorough Direct !aryngoscopy for suspicious woun$s

Tracheotomy for suspecte$ laryngeal in)ury



Thoracic Trauma



Thoracic Trauma

?n$

lea$ing cause of trauma $eaths after hea$ in)ury

/74?78 of all trauma $eaths

Many $eaths are preventa+le



Thoracic Trauma

Mechanisms of 'n)ury &lunt 'n)ury

Deceleration

Compression Penetrating 'n)ury

Com+ination



Thoracic Trauma

Anatomical 'n)uries Thoracic Cage .(keletal3

Car$iovascular

Pleural an$ Pulmonary

Me$iastinal

Diaphragmatic

>sophageal Penetrating Car$iac



Thoracic Trauma

#ypoia hypovolemia pulmonary VBP mismatch ∆ in intrathoracic pressure relationships

#ypercar+ia ∆ in intrathoracic pressure relationships ↓ level of consciousness

'mpairments to car$iac output +loo$ loss increase$ intrapleural pressures

+loo$ in pericar$ial sac myocar$ial valve $amage

Aci$osis " Gnal result hypoperfusion of tissues



Thoracic Trauma

'nitial eam $irecte$ towar$ lifethreatening* 'n)uries

Open pneumothora

-lail chest Tension pneumothora

Massive hemothora

Car$iac tampona$e



Thoracic Trauma

Assessment -in$ings Mental (tatus $ecrease$

Pulse

a+sent, tachy or +ra$y &P narrow PP, hyper4 or hypotension, pulsus para$ous

Ventilatory rate H eIort tachy4 or +ra$ypnea, la+ore$, retractions

(kin $iaphoresis, pallor, cyanosis, open in)ury,

ecchymosis



Thoracic Trauma

Assessment -in$ings Neck tracheal position, (J emph, FVD, open in)ury

Chest contusions, ten$erness, asymmetry, a+N aBe,

+owel soun$s, a+normal percussion, openin)ury, impale$ o+)ect, crepitus, hemoptysis

#eart (oun$s

muKe$, $istant, regurgitant murmur Epper a+$omen contusion, open in)ury





Thoracic Trauma

(peciGc 'n)uries





Ri+ -racture

-ractures of /st an$ ?n$ secon$reuire high force -reuently have in)ury to aorta or

+ronchi

Occur in 078 of patients with tracheo4+ronchial rupture

May in)ure su+clavian arteryBvein;78 will $ie



Ri+ -racture

-ractures of /7 to /?th ri+s can cause$amage to un$erlying a+$ominalsoli$ organs* !iver

(pleen

Li$neys



Ri+ -racture

Management PPV

Analgesics for isolate$ trauma

Non4circumferential splinting

Monitor el$erly an$ COPD patientsclosely Broken ribs can cause decompensation

Patients will fail to breathe deeply and cough,

resulting in poor clearance of secretions



(ternal -racture

Encommon, 148 in +lunt chesttrauma

!arge traumatic forceDirect +low to front of chest +y Deceleration

steering wheel

$ash+oar$

Other o+)ect





(ternal -racture

Management >sta+lish airway

#igh concentration oygen

Assist ventilations as nee$e$

'V N(B!R Restrict ui$s

Rule out associate$ in)uries



-lail Chest

Esually secon$ary to +lunt trauma Most commonly in MVA

Also results from falls from heights

in$ustrial acci$ents

assault

+irth trauma

More common in ol$er patients



-lail Chest

Mortality rates ?7478 $ue toassociate$ in)uries

Mortality increase$ with a$vance$ age

seven or more ri+ fractures

three or more associate$ in)uries

shock hea$ in)uries



-lail Chest

Conseuences of ail chest Respiratory failure $ue to

pulmonary contusion

ina$euate $iaphragm movement

Para$oical movement of the chest must +e large to compromise ventilation

'ncrease$ work of +reathing

$ecrease$ chest epansionpain



-lail Chest

(uspect spinal in)uries >sta+lish airway

Assist ventilation

Treat hypoxia from underlying contusion Promote full lung expansion

Consi$er nee$ for intu+ation an$ P>>P

Mechanically sta+ili:e chest wall uestiona+le value



-lail Chest

Management 'V of !RBN(

Avoid rapid replacement in hemodynamicallystable patient

Contused lung cannot handle uid load Monitor >L%

Chest trauma can cause dysrhythmias



(imple Pneumothora

'nci$ence /74;78 in +lunt chest trauma

almost /778 with penetrating chesttrauma

Mor+i$ity H Mortality $epen$ent on etent of atelectasis

associate$ in)uries



(imple Pneumothora

a ri+ lacerates lung

Esually well4tolerate$ in the young Hhealthy

(evere compromise can occur in theel$erly or patients with pulmonary$iseaseDegree of $istress $epen$s on amount

an$ spee$ of collapse



(imple Pneumothora

#D' an$ respiratory $istress

#igh in$e of suspicion

Chest tu+e when in $ou+t +efore CR



Open Pneumothora

'f the trauma patient $oes not ventilatewell with an open airway, look for a hole

May +e su+tle A+rasion with $eep punctures

Opening in the chest wall

(ucking soun$ on inhalation

#D'Bresp $istress (J >mphysema



Open Pneumothora

Profoun$ hypoventilation may occur

communication +etween pleural space

an$ atmosphere Prevents $evelopment of negativeintrapleural pressure

Results in ipsilateral lung collapse

ina+ility to ventilate aIecte$ lung



Open Pneumothora

VBJ Mismatch shunting

hypoventilation

hypoia

large functional $ea$ space

Pressure may +uil$ within pleuralspace

Return from Vena cava may +e

impaire$



Open Pneumothora

Cover chest opening with occlusive$ressing

Assist with positive pressureventilations prn

Monitor for progression to tensionpneumothora



Tension Pneumothora

'nci$ence Penetrating Trauma

&lunt Trauma

Mor+i$ityBMortality (evere hypoventilation

'mme$iate life4threat if not manage$early



Tension Pneumothora

Pathophysiology One4way valve forms in lung or chest wall Air enters pleural space, +ut cannot leave

Pressure collapses lung on aIecte$ si$e

Me$iastinal shift to contralateral si$e Re$uction in car$iac output

'ncrease$ intrathoracic pressure$eforme$ vena cava re$ucing preloa$



Tension Pneumothora

(evere $yspnea ⇒ etreme resp$istress

Restlessness, aniety, agitation

Decrease$Ba+sent +reath soun$s

orsening or (evere (hock

Car$iovascular collapse

Tachycar$ia eak pulse

#ypotension

Narrow pulse pressure



Tension Pneumothora

Fugular Vein Distension a+sent if also hypovolemic

#yperresonance to percussion

(u+cutaneous emphysema

!ate Tracheal shift away from in)ure$ si$e

Cyanosis



Tension Pneumothora

Recogni:e H Manage early

>sta+lish airway

Nee$le thoracostomy then chest tu+e



Tension Pneumothora

ecompress with !"g #lg bore$, %&inch needle

'idclavicular line( %nd intercostal space

'idaxillary line( "&)th intercostal space

*o over superior margin of rib to avoid bloodvessels

Be careful not to kink or bend needle orcatheter

+f available, attach a one&way valve



#emothora

Most common result of ma)or traumato the chest wall Present in =7 4 78 of penetrating an$

ma)or non4penetrating trauma cases

Associate$ with pneumothora

Ri+ fractures are freuent cause



#emothora

>ach can hol$ up to ;777 cc of +loo$ !ife4threatening often reuiring chest tu+e

an$Bor surgery 'f assoc6 with great vessel or car$iac in)ury

178 $ie imme$iately

?18 live Gve to ten minutes

?18 may live ;7 minutes or longer

&loo$ loss results in ypovolemia

ecreased ventilation of a-ected lung



#emothora

Accumulation of +loo$ in pleural space penetrating or +lunt lung in)ury

chest wall vessels

intercostal vessels

myocar$ium

Massive hemothora in$icates greatvessel or car$iac in)ury

'ntercostal artery can +lee$ 17 ccBmin



#emothora

Chest tu+e, go to OR if /777 cc out on insertion ?77 ccBh for hours



Pulmonary Contusion

Pathophysiology &lunt trauma to the chest

Rapi$ $eceleration forces cause lung to strike chestwall

high energy shock wave from eplosion

high velocity missile woun$

low velocity as with ice pick

Most common in)ury from +luntthoracic trauma ;74=18 of +lunt trauma

mortality /4?78

P l C i



Pulmonary Contusion

Pathophysiology Ri+ - in many +ut not all cases

Alveolar rupture with hemorrhage an$

e$ema increase$ capillary mem+rane permea+ility

!arge vascular shunts $evelop %as echange $istur+ances

#ypoemia

#ypercar+ia



Pulmonary Contusion

Assessment -in$ings >vi$ence of +lunt chest trauma

Cough an$Bor #emoptysis

Apprehension

Cyanosis

CR changes late



Pulmonary Contusion

Management (upportive therapy

>arly use of positive pressureventilation re$uces ventilator therapy

$uration Avoi$ aggressive crystalloi$ infusion

(evere cases may reuire ventilatortherapy



Myocar$ial Contusion

Most common +lunt in)ury to heart

Esually $ue to steering wheel

(igniGcant cause of mor+i$ity an$mortality in the +lunt traumapatient




Pathophysiology &ehaves like acute M'

#emorrhage with e$ema Cellular in)ury

vascular $amage may occur #emopericar$ium may occur from

lacerate$ epicar$ium May pro$uce arrhythmias

hypotension unresponsive to ui$ or$rug therapy




Car$iac arrhythmias following +luntchest trauma

Angina4like pain unresponsive to

nitroglycerin Precor$ial $iscomfort in$epen$ent of

respiratory movement

Pericar$ial friction ru+ .late3




>C% Changes Persistent tachycar$ia

(T elevation, T wave inversion

R&&&

Atrial utter, Atrial G+rillation

PVCs

PACs

M $i l C t i




'V !RBN( Cautious ui$ a$ministration $ue to in)ure$

myocar$ium

>C% (tan$ar$ $rug therapy for arrhythmias

/? !ea$ >C% if time permits

A$mit to monitore$ evironment



Pericar$ial Tampona$e

'nci$ence Esually associate$ with penetrating trauma

Rare in +lunt trauma

Occurs in Q ?8 of chest trauma

%( woun$s have higher mortality than sta+

woun$s

!ower mortality rate if isolate$ tampona$e



Tampona$e is har$ to $iagnose #ypotension is common in chest trauma

#eart soun$s are $i@cult to hear

&ulging neck veins may +e a+sent if

hypovolemia is present #igh in$e of suspicion is reuire$




Pathophysiology (pace normally Glle$ with ;7417 ml of

straw4colore$ ui$ lu+rication

lymphatic $ischarge immunologic protection for the heart

Rapi$ accumulation of +loo$ in theinelastic pericar$ium




Pathophysiology #eart is compresse$ $ecreasing +loo$

entering heart Decrease$ $iastolic epansion an$ Glling

#in$ere$ venous return .preloa$3 Myocar$ial perfusion $ecrease$ $ue to

pressure eIects on walls of heart

$ecrease$ $iastolic pressures

Removal of as little as ?7 ml of +loo$may $rastically improve car$iac output




&ecks Tria$.esistant hypotension +ncreased central venous

pressuredistended neck/arm veins inpresence of decreased arterial BP

0mall 1uiet heart

decreased heart sounds




(igns an$ (ymptoms Narrowing pulse pressure

Pulsus para$oicus

.adial pulse becomes weak ordisappears when patient inhales

+ncreased intrathoracic pressureon inhalation causes blood to be

trapped in lungs temporarily





Management

>C#O if sta+le to $iagnose 'n >R " consi$er pericar$iocentesis

Pericar$ial win$ow followe$ +ysternotomy in OR





T i A i Di i BR



Traumatic Aortic DissectionBRupture

Cause$ &y* Motor Vehicle Collisions

-alls from heights

Crushing chest trauma Animal Licks

&lunt chest trauma

/18 of all +lunt trauma $eaths




/ of 2 persons $ying in MVCs hasaortic rupture 18 $ie instantaneously

/74/18 survive to hospital /B; $ie within si hours

/B; $ie within ? hours

/B; survive ; $ays or longer

Must have high in$e of suspicion

T ti A ti Di ti BR t




(eparation of the aortic intima an$ me$ia Tear ?S high spee$ $eceleration at points of

relative Gation

&loo$ enters me$ia through a smallintima tear Thinne$ layer may rupture

Descen$ing aorta at the isthmus $istal to

left su+clavian artery most common siteof rupture ligamentum arteriosom




Assessment -in$ings Retrosternal or interscapular pain Pain in lower +ack or one leg

Respiratory $istress Asymmetrical arm &Ps Epper etremity hypertension with

Decrease$ femoral pulses, OR A+sent femoral pulses

Dysphagia

CR



CR

k



ork up

CTA Angio is rarely use$

A$$ress other in)uries Grst

'$eally, repaire when sta+le

(tent vs open

Di h ti P t ti



Diaphragmatic Penetration

(uspect intra4a+$ominal trauma with any

in)ury +elow th 'C( (uspect intrathoracic trauma with any

a+$ominal in)ury a+ove um+ilicus

Di h ti R t



Diaphragmatic Rupture

Esually $ue to +lunt trauma +utmay occur with penetrating trauma

Esually life4threatening

!ikely to +e associate$ with othersevere in)uries





Pathophysiology Compression to a+$omen resulting inincrease$ intra4a+$ominal pressure a+$ominal contents rupture through $iaphragm into

chest +owel o+struction an$ strangulation

restriction of lung epansion

me$iastinal shift

078 occur on left si$e $ue toprotection of right si$e +y liver





Assessment -in$ings Decrease$ +reath soun$s

Esually unilateral Dullness to percussion

Dyspnea or Respiratory Distress (caphoi$ A+$omen Esually impossi+le to hear +owel soun$s

Management suspect N% tu+e CT

!aparoscopy (ensitive an$ speciGc

> h l ' )



>sophageal 'n)ury

Penetrating 'n)ury most freuentcause Rare in +lunt trauma

Can perforate spontaneously violent emesis

carcinoma

>sophageal 'n)ury



Assessment -in$ings Pain, local ten$erness #oarseness, Dysphagia, Respiratory

$istress Me$iastinal esophageal perforation

me$iastinal emphysema B me$iastinal crunch (J >mphysema

(hock A+

resuscitation >arly $iagnosis %astrographin 45 $ilute &a Repair vs eclu$e

Tracheo+ronchial Rupture




Encommon in)uryless than ;8 of chest trauma

Occurs with penetrating or +lunt chesttrauma

#igh mortality rate .5;783Respiratory Distress

O+vious (J emphysema

#emoptysis 2specially of bright red blood

(igns of tension pneumothoraunresponsive to nee$le $ecompression





Ma)ority .783 occur at or near carina

rapi$ movement of air into pleuralspace

Tension pneumothora refractory to

nee$le $ecompression Consi$er early intu+ation

intu+ating right or left mainstem may +e life saving

'f arrest an$ suspect air em+olysm, may have to $o>RT<

Damage control



Damage control

Damage control principle



Damage control principle<







>D Thoractomy



>D Thoractomy

Thoracotomy performe$ in >R

for resuscitation of patients arriving inetremis

Plan to take to OR afterwar$s

A'M* >pe$itious control of hemorrhage

Maimi:ation of coronary an$ cere+ral perfusion

Release of pericar$ial tampona$e

T of massive air4em+olysm

Proce$ure " !eft AnterolateralThoracotomy

http://eresources.library.mssm.edu:2560/content/vol22/issue1/images/large/em12963.f3.jpeg





Thoracotomy

Clamshell Thoracotomy





Clamshell Thoracotomy





Release Pericar$ial Tampona$e

Control 'ntrathoracic #emorrhage



Control 'ntrathoracic #emorrhage

>liminate massive air em+olism or+ronchopleural Gstula



+ronchopleural Gstula

Post intu+ation H positive pressureventilation

%et air transfer across traumaticalveolovenous channels

Pulmonary hilar cross clamping Air aspirate$ from ! ventricular ape an$

aortic root

Car$iac massage



Perform Open Car$iac Massage



Perform Open Car$iac Massage

&imanual internal massage with han$s in ahinge$ clapping motion

Ventricular compression procee$ing fromape to +ase of heart

Occlu$e Descen$ing Thoracic Aorta



Occlu$e Descen$ing Thoracic Aorta

-utile9



-utile9

Overall survival 418 !ittle to !ose

risk to #ealth care workers Risk +loo$ contact ?28 trauma pts #'VU or #epatitisU

#ealth care costs

F Trauma6 /00 Ful1./3*=40

(elective Application of >DThoracotomy



Thoracotomy

Mechanism of 'n)ury

Presence of Vital (igns !ocation of 'n)ury

Other (igns of !ife

(urvival +ase$ on mechanism



(urvival +ase$ on mechanism


Presence of vital signs



Presence of vital signs


(urvival +ase$ on organ in)ure$



(urvival +ase$ on organ in)ure$

FAC( ?777 Mar/07.;3*?406

Other (igns of !ife .(O!3



O e ( g s o e .(O 3

FAC( ?777 Mar/07.;3*?406

hat a+out P>A9



FAC( /00*?//4?/1, ?77

?2B2? .?83 >D Thoracotomy survivors ha$ P>A reuiring CPR

Conclusions



>R thoracotomy consi$ere$ in pts wB*

Presence of vital signs in Gel$ or hospital &etter results in penetrating car$iac in)ury Results wB &lunt trauma poor, +ut survivors eist P>A after penetrating trauma from sta+s

Ep to =78 goo$ outcomes

Contrain$icate$ in pts with* No vital signs, prolonge$ asystole an$ unwitnesse$

arrestBloss of (O!

FAC( /00*?//4?/1, ?77

-inally<



y

P>A after +lunt trauma9

Typically poor outcome, +ut occasionallywill have a survivor

'f CPR 5 1 min, contrain$icate$

References an$ thanks



Thank %o$ for internet an$ %oogle

several we+sites speciGcally* http*BBwww6a$h+6govt6n:BtraumaBpresentationsB-orumsBma)or8?7

chest8?7in)uriesBsl$77/6htm http*BBwww6temple)c6e$uB$eptBemsBPagesBPowerPoint6html http*BBwww6mssurg6net

www6nor$ictraumara$6comB(ylla+us72Bmo8?7/1BNORDT>Rpenetrating6p$f www6iformi6comBspuBchest3trauma4ppt *reen5eld textbook of surgery

http://www.adhb.govt.nz/trauma/presentations/Forums/major%20chest%20injuries/sld001.htm


http://www.templejc.edu/dept/ems/Pages/PowerPoint.html

http://www.mssurg.net/

http://www.iformix.com/spu/chest_trauma.ppt









http://www.mssurg.net/

http://www.templejc.edu/dept/ems/Pages/PowerPoint.html



Documents

Neck Chest Trauma