Chest Trauma Principles / Operative Management

Chest trauma

Immediate life threatening injuries identified by primary survey:

· Tension pneumothorax -

· Open pneumothorax: when wound exceed 2/3 size of trachea. Cover on ¾ sides with occlusive dressing. Chest drain. Delayed formal repair.

· Massive haemorthoax – penetrating injury usually intercostals or IMA. Any volume exceeding 250ml apparent on CXR.

· Pericardial tamponade – diagnosis clinically or by FAST/echo. Treated with needle pericardiocentesis initially then L thoracotomy + pericardial window

· Airway disruption/obstruction.

· Flail chest + massive pulmonary contusion – paradoxical movement can impair ventilation. Usually it is the pulmonary contusion which results in respiratory failure. Intubation and ventilation according to standard guidelines.

Potentially life-threatening – identified in secondary survey:

· Pulmonary contusion – usually deteriorate in first 48 hours.

· Penumothorax without tension – drain any lesion visible on CT.

If there is no pneumothorax on an upright CXR at 6 hours post injury a delayed pneumothorax is very unlikely and the patient may be discharged. Prophylactic abx are probably useful to reduce the risk of empyema following chest drain.

· Myocardial contusion – see below

· Diaphragmatic injury

· Major airway injury – injuries above the pleural reflection cause mediastinal and cervical emphysema, below cause pneumothorax. Continuous air leak or failure to re-expand the lung suggest a major bronchial injury

· Esophageal injury – see below

· Aortic disruption – see below


When to operate on haemohorax

· If the patient is unstable

· In penetrating trauma If the volume >1500ml on placing chest drain, or if >200ml/hr for 2-4 hours (EMST protocol)

· Blunt trauma: the drain output is less critical in blunt trauma – first correct coagulaopathy, hypothermia and acidosis.


Injury in the BOX

· Mid-clavicular lines from clavicle to costal margin

· Any patient with a penetrating injury in this region should have an echo to look for pericardial tamponade.

· If there is a tamponade then percutaneous ultrasound-guided pericardiocentesis should be performed to allow safe transport to the operating room.

· 18G canula. 3-way tape. 20ml syringe. ECG monitoring. Sterile prep and drape.

· Sit the patient up. Introduce needle just to the left of xiphoid and aim at left shoulder aspirating. If ectopics on ECG then withdraw slightly.

· Evacuate blood using the 3 way tap. This is usually preferable to sub-xiphoid pericardial window.


Transmediastinal GSW

Exploration only required in 35% - not go through the mediasterneum

CXR may show furry bullet in mediasternum – bullet inside the mediasterneum

History, examination, CT and endoscopic or fluoroscopic studies will identify the patients that need exploration and the appropriate approach.


Bronchvenous air embolism

· Air leaks from a lacerated bronchus (usually under positive pressure ventilation) into an adjacent lacerated pulmonary vein.

· The air travels from the pulmonary vein into the LV and then coronary arteries where ischaemia causes arrest, to brain causing stroke. Froth on ABG also suggest air-embolism.

· Diagnosis: clinical – arrest after intubation and positive pressure ventilation in penetrating chest trauma.

· Treatment: Head down, right side down. Left Thoracotomy, aspiration of LV apex, aortic root and coronary arteries as required. Squeeze ascending aorta between finger and thumb to force air out of coronary arteries.

 

Tube thoracostomy

Indications

Unstable: patients with chest injury, decreased breath sounds or increased tympany without prior CXR

Stable: Patients with pneumothorax on CXR

Prophylactic: patient with pulmonary contusion requiring ventilation or air transport.

· Incision: transverse just anterior to mid-axillary line at level of 6th intercostals space (one interspace lower than anticipated level of entry).

· Local anesthetic infiltrated to skin and muscle just above rib.

· Skin incision widened to 3cm. Sharp dissection down to intercostals muscle.

· Use Roberts to bluntly dissect the tissues from upper surface of rib.

· Use blunt finger dissection to enter pleural space and confirm no adherent lung or viscera

· Insert the 32F tube directing postero-superiorly with trocar removed.

· Suture the margins of wound around tube with O silk.

· Place purse string suture to allow wound closure

· Suture the tube in using two 0 silk ties.

· Connect to under water seal system and confirm swinging of water level in tube


Thoracoscopy

· Indications: evacuation of haemothorax and drainage of empyema. Inspecting for diaphragmatic injury

· GA using a double lumen tube. Lateral position as for posterolateral thoracotomy.

· Insert the first port in the 7th intercostals space in the anterior axillary line.

· A 1cm incision is made

· Daithermy dissection down to intercostals muscle.

· Use Roberts to bluntly dissect the tissues from upper surface of rib.

· Use blunt finger dissection to enter pleural space and confirm no adherent lung or viscera

· I use a 30 degree thoracoscope and place additional ports under vision.

· I insert drainage tubes upon closure.

 

Median Sternotomy

Indications

· exposure ascending aorta and great vessels

· anterior mediastinal neoplasms

· cardiac operations/trauma

· pericardectomy

· bilateral lung operations (multiple neoplasms)

Advantages

· Rapid, less blood loss

· Good exposure heart, aorta and branches (except L subclav)

· Less post op pain

· Access to both pleural spaces

Disadvantages

· Poor exposure to posterior mediasternum: thoracic oesophagus, L subclav and desc aorta

· Inadequate for most pulmonary procedures

· Lower trachea is inaccessible

· Requires sternal saw

Preop

· “In an appropriately Ix, prepared and consented patient”

· Supine, sandbag transversely beneath shoulders, Prepped neck to umbilicus. Antibiotics

considered, 2 lumen ET considered, cell saver, bypass

Operation

· Incision Midline, 2cm below sternal notch to xiphoid

· Diathermy to and through periosteum, and usually a transverse vein near the sternal notch

· Finger into retrosternal space from above and below, sternal saw tilted backwards, sternal hooks to elevate sternal side while diathermy and wax is used for haemostasis, repeated for other side, Sternal retractor inserted.

v NB upper incision + transverse sternal transection at 3rd interspace and extended 5-8cm into 3rd interspace for access to great vessels/thyroid

Closure

· Haemostasis, pleural tube each side, drainage tube in midline, No 22 Steel wire passed

through sternum 2cm lateral from midline, awl and spoon, ends twisted and buried. 1 Vicryl to periosteum, 2.0 SC vicryl for skin.

 

Posterolateral thoracotomy

Indications

· Most frequently used thoracic incision. Pulmonary, oesophagus,

Disadvantages

· Patient should be haemodynamically stable as the lateral position is not well tolerated

· Anterior structures are difficult to see.

Preop

· “In an appropriately Ix, prepared and consented patient”

· Operative side up, down leg flexed 90 degrees, pillow between the legs, folded towel under axilla to prevent neurovascular compression, Free arm supported anteriorly. Strap across hips. Consideration of antibiotics and double lumen ET tube.

Operation

· Incision in 5th ics – mark skin incision with pen

   Anterior axillary line: Inframammary fold in woman or 6cm inferior to nipple in man.

   Posterior axillary line: level of nipple

   Tip of scapula: two cm below the tip of scapula

   Lateral end: midway between the scapula border and the vertebral column at T6 level.

· Divide skin and subcutaneous fat down to muscle

· Muscles divided

— Superficial layer consists of  latissimus dorsi ± Pec major anteriorly and Trapezius laterally.

— Deep layer consists of  serratus anterior (ant) and Rhomboids (laterally). DO NOT EXTEND INTO PARASPINAL MUSCLES POSTERIORLY.

· Scapula is retracted and hand used to palpate the ribs (second rib is the highest that can be felt) to determine 5th ics

· Incise periosteum on rib below in the region of auscultatory triangle just below the tip of scapula.

· Periosteum reflected and stripped from superior surface of the rib

— Use curved rougine. Ask anaesthetist to drop lung

· Pleura incised and finger inserted and pleura dissected from top of rib with diathermy onto finger to protect the lung, Finochietto retractor inserted.

v NB formal transection of lower rib to prevent fracture and decrease tension on the posterior attachments of the rib.

Closure

· 2 Chest drains (apical anterior and posterior basal – exiting in the anterior mid-axillary line), 1 Vicryl to re approximate the rib space (figure of 8 pericostal 0 vicryl), intercostal muscle sutured with 2.0 vicryl, closure of the muscle layers with running 1 vicryl, staples to skin.

 

Anterolateral thoracotomy

Indications

· Performing open lung biopsies, pericardial window and minimal access CABG.

Most common use is trauma thoracotomy.

v NB access to the posterior and apical thorax is limited.

Pre op

· In an appropriately Ix, informed and consented patient.

· Supine, arm abducted to 90 degress or flexed above the head across the axilla, antibiotics considered, double lumen ET tube considered

Operation

· In females a sub mammary incision, in males an incision over the rib space to be entered (usually 4th or 5th)

· Begins at the sternal edge and runs laterally to mid-axillary line.

· Incision through pec major and then through intercostal space as for lateral thoracotomy.

· Finochietto or Cooley (rib spreaders, looks similar) is palced with the handle away from sternum.

· Can be extended through costal cartilages with tying off internal mammary vessels (if in 3rd, 4th spaces)

· Can be extended to bilateral transverse thoracotomy (CLAM-SHELL THORACOTOMY) with division of sternum after tying off internal mammary structures. (useful for multi chest trauma)

 

FIVE ESSENTIAL MANEOUVRES OF CRASH THORACOTOMY

1. Cut the inferior pulmonary ligament up to the inferior pulmonary vein

Stop ventilation for a short period

Make window immediately anterior to pericardium to other side of chest. If there is significant bleeding then extend incision to other side

2. Make a pericardiotomy 1cm anterior to the phrenic nerve

If blood comes from pericardim during right lateral thoracotmomy then extend to clamshell as heart cannot be fixed from the right

3. Massive bleeding from hilum requires lung mobilization and 180 degree twist of hilum to control bleeding or application of hilar clamp

4. Make a hole in the parietal pleura either side of aorta and apply clamp to arrest catastrophic infra-diaphragmatic haemorrhage

5. Perform open cardiac massage if there is cardiac arrest.

· Closure as before

 

Operative thoracic vascular trauma

Heart

· Pre-cordial stab in stable patient – median sternotomy

· GSW or unstable – left antero-lateral

· Temporary control: ventricle – Foley or skin stapler; atrium – Statinsky

· Inflow occlusion: press the RA against the heart to occlude SVO and IVC.

· Suture heart with 4/0 prolene with Teflon pledgets

Thoracic outlet

Median sternotomy

Find and ligate the left brachiocephalic vein

Open pericardium and follow aortic arch up into haematoma

Follow the brachiocephalic artery to its bifurcation and identify the right vagus passing over right subclavian.

Extend the incision into the neck either along SCM or clavicle to treat injuries to thoracic outlet

Knitted darcon interposition graft is best option

Subclavian vessels

Proximal control: median sternotomy on right and high anterolateral thoracotomy on left

Access through the bed of clavicle. Remove a segment of clavicle by subperiosteal resection. Identify the phrenic nerve and divide the anterior scalene.

Damage control: ligate subclavian artery

Definitive: interposition Dacron graft.

 

 

Choice of thoracotomy in trauma

Influenced by pattern of injury, equipment, patient stability and experience

Pattern of injury

 

· Anterolateral thoracotomy: crash operation in unstable patient. Allows simultaneous access to abdomen (as supine). Requires no sternal saw. Cannot access posterior mediastinal structure or posterior chest wall. Can be extended across midline as clamshell. Any injury to left thorax or an injury above the nipple line in right thorax. Below the nipple line in right thorax use a laparotomy.

 

· Median sternotomy: Penetrating injuries between the nipple lines – heart, great vessels and upper mediastinum are accessible. Can be extended into the abdomen or neck. Lung hilum is accessible but the lung peripherary and posterior mediastinum are inaccessible. Cannot access the left subclavian artery through this wound. So avoid in penetrating injury above or below the left clavicle (use high anterior anterolateral thoracotomy).

 

· Postero-lateral thoracotomy: stable patients where the target is known and need for extension into the abdomen or neck is not likely. Good access to the posterior mediastinal structures (aorta and esophagus). 4th space for descending aortic injury (left) and 5th for tracheal injury (right); left eighth space for lower esophageal injuries.

 

ED thoracotomy

· 30% survival for extremis pts in penetrating chest injury

Indications

· ALL Penetrating trauma and Isolated thoracic blunt trauma with

— cardiac arrest with EMD and recent commencement of CPR (<10mins tubed or <6mins not tubed on arrival)

— BP < 60mmHg ( BP>70mmHg to keep coronary perfusion, so go to threatre)

Contraindications:

· No trauma

· Blunt trauma with:

            Isolated thoracic injury with no witnessed cardiac activity pre-hospital

Multiple system

            Severe Head Injury

 

Objectives

Relieve tamponade

Open cardiac massage

Control intra-thoracic bleeding

Treat air embolism

Allow for aortic clamping to control infra-diaphragmatic haemorrhage

Technique

· L 5th ICS

· Finochietto

· Displace lung medially

· Therapeuic manoeuvres

   Release Inferior pulmonary ligament

 Release cardiac tampanade: 1cm Anterior to phrenic nerve

 Suture cardiac or lung lacerations

 Control bleeding lung: Twisting helium

 Clamp descending aorta: below the L pulmonary helium or just above the diaphragm

 Internal cardiac massage

 

Cardiac

· Beck’s triad

— symptoms of cardiac tamponade

— raised CVP; low BP; muffled heart sounds

· Kussmaul’s sign

— jugular venous distension on inspiration

· slow bleeding into the pericardium can be tolerated to an extent but rapid bleeding compresses the R ventricle with decreased filling, CO etc.

· tamponade at some point does have a protective role against further exsanguination

· any penetrating injury inferior to the clavicles, superior to the costal margins and medial to the midclavicular lines should be suspected of having a cardiac injury

· sub-xiphoid window is one way of establishing the presence or absence of pericardial blood and is very reliable

· echo may be a less invasive alternative

 

Blunt cardiac trauma

· ECG on admission

If normal have a very low chance of significant arrhythmia. Can be observed for 24 hours with cardiac monitoring

— If abnormal ® observe 24 hrs with cardiac monitoring

— If unstable ® ECHO

· Trop I , CK

— Not useful

· Sternal #

— Does not predict

 

Oesophageal

· Most injuries due to penetrating trauma

· Suspected on basis of missile trajectory

· Most thoracic perforations present late with mediastinitis and surgical emphysema of the deep subcutaneous tissues of the neck.

· Gastrograffin swallow will mist 15% of injuries; if negative use thin barium

· Combined esophagoscopy and contrast study has the greatest accuracy

Principles of repair

· Access: 4th space right postero-lateral thoracotomy for proximal esophagus, left 7th space for distal.

· Control leak, debride and drain all suppuration, nutritional support with jejunostomy feeding tube.

· <6 hours, minimal devitilization and tissue losss: two layer repair

· Use a tissue flap to cover the anastomosis

· delayed recognition ® closure over a T-tube or large JP drain.

· muscle flaps (eg. Lat dorsi) are advocated by some

· Always drain pleural space with two drains and perform decortication to allow the lung to re-expand.

 

Parenchymal injury to lung

· 30% of patients undergoing thoracotomy for trauma will require lung resection – that is 2% of blunt trauma and 6% of penetrating trauma.

·

Peripheral injuries:

wedge resection with linear cutting stapler (TLC) or TA to excise the entire wound tract.

Deep lobar injuries:

tractotomy – insert one limb of TLC into wound (vascular reload) and apply the other limb to the surface and fire the stapler laying the tract open to the lung surface. Oversew any bleeding vessels with 4/0 Prolene.

· Central lung injuries:

Twist hilum for damage control. divide the inferior pulmonary lig. Up to inferior pulmonary vein and twist hilum 90 degree to control haemorrhage.

Stapled lobectomy with 90mm linear stapler (TA)

if no joy ® stapled pneumonectomy (50-70 mortality from right heart failure).

 

 

Vascular

· external haemorrhage

· internal haemorrhage

— haemothorax

— mediastinal haematoma

— cardiac tamponade

· pseudoaneurysm

· occlusion

— thrombosis

— intimal flap

Rx

Prehospital

· avoid intravenous access in the limb on the side of the injury

· transport to the nearest centre able to deal with the problem

Exposure

· arteriography is not possible in the unstable patient

· groins prepped to allow for harvesting of saphenous vein (for vessels <5mm)

· for the patient in extremis a L anterolateral thoracotomy with R extension into a higher interspace is a good choice; separate supraclavicular incisions can be included as appropriate; cross clamping of the aorta can then be done

· lacerations of the great vessels can be repaired with partial occlusion by a Satinsky clamp

· extensive injury of the aorta may require interposition graft with DACRON

· azygous vein is treated with ligation

· subclavian and carotid injuries are treated with primary repair or interposition graft; temporary flow with a carotid shunt may be required with delayed definitive repair

— care must be taken to avoid damage to the surrounding brachial plexus

· innominate and jugular veins can be tied off

· SVC should be repaired or interposition graft placed

 


 

Chest trauma in children

· ¯er incidence

· Marker of injury severity

Contusions

· Plasticity of chest wall

· ° evidence for use of Ab prophylaxis

· run N volaemic

Airway

· Tongue larger

· Larynx more anterior

· Trachea shorter

v If can put down airway then consider ETT