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Traumatismes Thoraciques (Antoine MONSEL, Pitié-Salpêtrière)

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Traumatismes Thoraciques (Antoine MONSEL, Pitié-Salpêtrière) Traumatismes fermés du thorax Dr Antoine MONSEL Réanimation Chirurgicale Polyvalente (Pr Puybasset) Département d’Anesthésie-Réanimation (Pr Puybasset) DMU « DREAM » Hôpital Pitié-Salpêtrière Journée « traumatologie » 11 Avril 2019 prérequis Trauma thoracique Trauma fermé Trauma ouvert « blunt trauma » « penetrating trauma » • Lésions associés • E = ½ mV2 • balistique = fermé • polytraumatisme • Arme blanche → chirurgie +++ prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis « Déchoc ou SSPI » prérequis prérequis Hiérarchisation lésionnelle Damage control ✓ HED ✓ Plaie de rate ✓ Bassin ✓ Rupture de l’isthme aortique ? ✓ Fracture ouverte déplacée du fémur prérequis The confluence of variables and a proposed mechanism necessary for commotio cordis to occur. Mark S. Link Circ Arrhythm Electrophysiol. 2012;5:425-432 Copyright © American Heart Association, Inc. All rights reserved. The confluence of variables and a proposed mechanism necessary for commotio cordis to occur. registre de Mineapolis 200 cas 25% de survie si une RCP est entreprise Mark S. Link Circ Arrhythm Electrophysiol. 2012;5:425-432 Copyright © American Heart Association, Inc. All rights reserved. The confluence of variables and a proposed mechanism necessary for commotio cordis to occur. registre de Mineapolis 200 cas 25% de survie si une RCP est entreprise Mark S. Link Circ Arrhythm Electrophysiol. 2012;5:425-432 Copyright © American Heart Association, Inc. All rights reserved. Trauma fermé • Épidémiologie • Biomécanique • Gestion initiale (phase hospitalière) • Lésions de premières lignes • Lésions de secondes lignes Trauma fermé • Épidémiologie • Biomécanique • Gestion initiale (phase hospitalière) • Lésions de premières lignes • Lésions de secondes lignes Epidémiologie • USA – 1ère cause de décès < 40 ans • 1/3 des admissions • 3ème cause de mortalité traumatique – Après choc hémorragique et TC • Chez les décédés: – Présents dans 50% des cas – 25% des cas → cause directe du décès • Sévérité – Hémodynamique – respiratoire Epidémiologie • 25-30% de mortalité • Polytraumatisés dans 70% des cas – Membres 50% – Crâne 40% – Abdomen 25% Epidémiologie • 30% décès précoces évitables – Délai → chirurgie +++ Kreis et al. J Trauma 1986 Epidémiologie Trauma fermé • Épidémiologie • Biomécanique • Gestion initiale (phase hospitalière) • Lésions de premières lignes • Lésions de secondes lignes Biomécanique Biomécanique Biomécanique • E = ½ mV2 Biomécanique • E = ½ mV2 x10 x90 Trauma fermé • Épidémiologie • Biomécanique • Gestion initiale (phase hospitalière) • Lésions de premières lignes • Lésions de secondes lignes Gestion initiale patient instable Accueil- recueil données anamnestiques Examen clinique Mise en condition 30 min ✓ Thorax face ✓ monitoring ✓ Bassin face ✓ KT ✓ FAST écho ✓ Collier ✓ VAS ✓ monobloc ✓ hématose ✓ hémodynamique ETT Echo pulmonaire Stratégie gestion lésionnelle Intubation-ventilation artificielle • Critères • ZEEP initialement • 6 mL/Kg Analgésie • Standard – Paracétamol – Nefopam – Tramadol – Morphine titrée puis PCA – Kétamine 0.15-0.5 mg/kg → 1 mg/Kg/24h IVSE • ALR – Après stabilisation Trauma fermé • Épidémiologie • Biomécanique • Gestion initiale (phase hospitalière) • Lésions de premières lignes • Lésions de secondes lignes Lésions de premières lignes: 30 premières minutes ✓ Thorax face ✓ Bassin face ✓ FAST écho Lésions de premières lignes: 30 premières minutes ✓ Thorax face ✓ Bassin face ✓ FAST écho Drainage thoracique immédiat Lésions de premières lignes: 30 premières minutes ✓ Thorax face ✓ Bassin face ✓ FAST écho bloc pneumothorax • 20-40% • Bilatéral: 20% • Hypoxémie • Choc obstructif = « tamponnade gazeuse » • Lésion primitive – Compression alvéolaire – Fractures costales – Lacérations pulmonaires – barautrauma pneumothorax • 20-40% • Bilatéral: 20% • Hypoxémie • Choc obstructif = « tamponnade gazeuse » • Lésion primitive – Compression alvéolaire – Fractures costales – Lacérations pulmonaires – barautrauma pneumothorax • 20-40% • Bilatéral: 20% • Hypoxémie • Choc obstructif30-50% = « méconnustamponnade gazeusesur le » • Lésion primitivecliché thorax de face – Compression alvéolaire – Fractures costales – Lacérations pulmonaires – barautrauma Radiological diagnosis of partial pneumothorax Bedside chest Thoracic computed radiography tomophraphy Increased sharpness of the diaphragmatic contour Kaewlai R et al, RadioGraphics 2008; 28:1555–1570 JJR 24 04 2014 In the absence of « comet tails », the absence of lung sliding is evocative of pneumothorax D Lichtenstein et al Intensive Care Medicine 25 : 383-388 , 1999 http://www.reapitie-univparis6.aphp.fr JJR 24 04 2014 Each of the 18 intercostal spaces has to be explored in its anterior and lateral parts (in multiple trauma patients, the lateral position is contra-indicated until spine fracture has been ruled out by CT) Examination of both lungs takes around 5 min International Evidence-based Recommendations for Point-of-Care Lung Utrasound Intensive Care Medicine 2012 (in press) http://www.reapitie-univparis6.aphp.fr JJR 24 04 2014 Diagnostic performance of lung ultrasound for diagnosing pneumothorax in multiple trauma patients with thoracic trauma Zhang M et al Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma Critical Care 10: R 112, 2006 In 135 patients with multiple trauma, the time needed for diagnosis of pneumothorax (n=29) was significantly shorter with lung ultrasound compared to chest radiography (2 versus 20 minutes, p < 0.001) and the diagnostic performance was much higher. http://www.reapitie-univparis6.aphp.fr JJR 2’ 04 2014 bloc IOT sélective ou Carlens hémothorax • 30-50% des trauma thoraciques • Lésions primitives – Lésions pleurales – Lacérations pulmonaires – Fractures costales – Artères mammaires internes – Artères intercostales – Gros vaisseaux – Rate + brèche diaphragmatique • Choc hémorragique • Choc obstructif possible hémothorax Pneumothorax-hémothorax • Technique de drainage: – Percutanée (4ème-5ème EIC) – Dissection digitale – Voies axillaire moyenne – Drain de monod +++ Lésions de premières lignes ✓ Thorax face ✓ Bassin face ✓ FAST écho bloc tamponnade • Rare car létale – 90% décèdent sur place • Lésions primitives: – Dissection aortique antérograde – Ruptures sinus coronaire – Rupture artère coronaire – Contusion myocardique – Rupture auriculaire – Rupture ventriculaire tamponnade bloc Ponction sous-xyphoïdienne tamponnade bloc Ponction sous-xyphoïdienne sternotomie thoracotomie Hémi-Clamshell tamponnade bloc Ponction sous-xyphoïdienne sternotomie thoracotomie Hémi-Clamshell Trauma fermé • Épidémiologie • Biomécanique • Gestion initiale (phase hospitalière) • Lésions de premières lignes • Lésions de secondes lignes Patient stabilisé Accueil- recueil données anamnestiques Examen clinique Mise en condition 30 min ✓ monitoring ✓ Thorax face ✓ KT ✓ Bassin face ✓ Collier ✓ FAST écho ✓ monobloc ✓ VAS ✓ hématose ✓ hémodynamique ETT Echo pulmonaire Stratégie gestion lésionnelle Total body TDM Contusion pulmonaire • 20-70% des trauma thoraciques • Alvéolites hémorragiques • Œdème péri lésionnel • Dans les 5 heures post trauma – Acmé à H24-48-H72 – Résolution en 7 jours • Shunt→hypoxémie • Surinfection • SDRA Contusion pulmonaire Contusion pulmonaire • Opacités en verre dépoli – Non ou mal systématisées – Mal limitées – Confluentes – « Patchy » – Bilatérales – Cotonneuses avec flou péri lésionnel – Bronchogramme aérique +/- Contusion pulmonaire: imagerie Radiological diagnosis of lung contusion Contusion pulmonaire • Facteurs de gravité – >20% du parenchyme – P/F < 300 >20% → ARDS Becher et al. J Trauma Acute Care Surg, 2012 Miller et al. J Trauma, 2001 Miller et al. Am Surg, 2002 Ultrasound diagnosis of lung ComputedContusion Tomography pulmonaire:contusion diagnosis échographie of lung contusion Coalescent B-lines issued from pleural line are representative of traumatic ground glass areas (alveolar space partially filled with blood) Soldati G et al Chest 130 : 533-538, 2006 Kaewlai R et al, RadioGraphics 2008; 28:1555– http://www.reapitie-univparis6.aphp.fr 1570 Ultrasound diagnosis of lung Contusion pulmonaire: échographie Computed Tomographycontusion diagnosis of lung contusion Coalescent B-lines issued from juxta-pleural consolidations are representative of traumatic peripheral lung hematoma Soldati G et al Chest 130 : 533-538, 2006 Elmali M et al, Diagn Interv Radiol 2007; 13:179– http://www.reapitie-univparis6.aphp.fr 182 Ultrasound diagnosis of lung Contusion pulmonaire: échographie Computed Tomographycontusion diagnosis of lung contusion Lobar consolidations without persisting regional blood flow are representative of traumatic lobar hematoma Soldati G et al Chest 130 : 533-538, 2006 http://www.reapitie-univparis6.aphp.fr DiagnosticComputedContusion performance Tomography pulmonaire: of lung diagnosis ultrasound échographie of lungfor contusiondiagnosing lung contusion in multiple trauma patients with thoracic t In 121 patients with multiple trauma, the time needed for diagnosis of lung contusion (n= 37) was significantly shorter with lung ultrasound compared to thoracic CT (3 versus 22 minutes, p < 0.001) and the diagnostic performance was much higher than for anterior chest radiography. Alveolar-interstitial syndrome+ Alveolar-interstitial syndrome - Peripheral pulmonary lesion + Peripheral pulmonary lesion - Soldati G et al. Chest, 2006
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