10/1/2018 Outline ● Emergency Department Thoracotomy ● REBOA ● Lung ● Trachea Thoracic Trauma ● Esophagus ● Heart Tessa Woods, DO ● Thoracic Vascular Injuries EAST Practice Management Guidelines ● EDT Survival Predictors ○ 1. Injury mechanism ○ 2. Anatomic injury location ○ 3. Presence of life on presentation ED Thoracotomy EAST Scenarios EAST Scenarios ● Patient 1: Pulseless to ED with signs of life after penetrating thoracic injury? ● Patient 5: Pulseless to the ED with signs of life after blunt injury? ○ Yes ○ Yes, Conditionally ● Patient 2: Pulseless to ED without signs of life after penetrating thoracic ● Patient 6: Pulseless to the ED without signs of life after blunt injury? injury? ○ No ○ Yes, conditionally ■ Some voting “conditionally” ● Patient 3: Pulseless to the ED with signs of life after penetrating extrathoracic ■ Low quality of evidence injury? ○ Yes, conditionally ■ Does not pertain to cranial injuries ● Patient 4: Pulseless to the ED without signs of life after penetrating extrathoracic injury? ○ Yes, conditionally ■ Low quality of evidence 1 10/1/2018 Resuscitative Endovascular Balloon Occlusion of the Aorta2-12 ● Benefits: ○ Maximizes cerebral and coronary perfusion ○ Limits infradiaphragmatic hemorrhage REBOA ○ Avoids thoracotomy ● Limitations/complications: ○ Vascular injury ○ Time consumptive? ○ Learning curve ○ Appropriate setting/provider ● https://youtu.be/L3z5utZvnq4 Upcoming studies ● EPR-CAT (Emergency Preservation and Resuscitation for Cardiac Arrest From Trauma) ○ Compares pulseless penetrating trauma victims with scene signs of life who undergo standard resuscitative efforts including EDT compared to arterial cath placement to induce hypothermia followed by resuscitative surgery then cardiopulmonary bypass Lung Trauma Intro Lung Trauma ● Mechanism ● Injury to the bony thorax? ○ Blunt thoracic trauma ○ Suspect possible pulmonary injury ■ 8% of all thoracic trauma admits in US1 ○ Opposite in children due to greater chest wall elasticity ○ Penetrating thoracic trauma ● Alveoli rupture - pneumothorax 2 ■ 7% of all thoracic trauma admits and 16% of penetrating trauma admissions overall ○ Larger injuries - continued air leak ● Management ● Lung parenchyma damage ○ 18-40% managed with chest tube alone ○ Bleeding ■ 3-9% require thoracotomy ○ Bruising ● 30% will require pulmonary resection ● Chest wall bleeding ○ Intercostal arteries ○ Mammary arteries 1. Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl Surg. 2004;41(3): 211-380. 2. Demetriades D, Velmahos GC. Penetrating injuries of the chest: indications for operation. Scand J Surg. 2002;91(1)41-45. 2 10/1/2018 Lung Trauma Lung Trauma ● Pneumothorax ● Presentation/Evaluation ○ Large - tension physiology ○ Distended neck veins ■ Increased intrathoracic pressure ○ Tracheal deviation ■ Decreased venous return ○ Subcutaneous emphysema ■ Decreased cardiac output ○ Chest wall instability ■ Cardiac arrest ○ Absent breath sounds ● Hemothorax ○ Muffled heart sounds ○ Large ● Monitor vitals ■ Hypovolemia ○ Work of breathing, sats ■ Eventually tension physiology ● No time for radiographs Lung Trauma Lung Trauma ● Penetrating trauma in hemodynamically unstable patient ● CT imaging ○ Generally go to OR ○ Three dimensional recon ● Workup: ■ Aorta, great vessels ○ ABG ○ Pneumothorax on ct? 1 ■ Oxygenation, ventilation, shock ■ Small and asymptomatic - observation ○ E-FAST ● Maybe 15.9 mm - not found to be an independent predictor for failure ○ CXR ● Positive pressure ■ Though some question in the stable patient1 ○ Still monitor ● E-FAST as sensitive ○ Hemothorax on ct? ○ CT ■ Moderate or large - drain ○ If indicated ● Blood in pleural cavity may progress to fibrothorax with lung entrapment or ■ thoracic us, esophagoscopy, bronchoscopy, echocardiogram infection leading to empyema 1. Simon B, Ebert J, et al. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery. 1. Moore, F. O., Goslar, P. W., Coimbra, R., Velmahos, G., Brown, C. V. R., Coopwood, T. B., … Haan, J. M. (2011). Blunt traumatic occult pneumothorax: Is observation safe?-results of a prospective, AAST multicenter study. Journal of 2012;73(5):S351-S361. Trauma - Injury, Infection and Critical Care, 70(5), 1019–1025. https://doi.org/10.1097/TA.0b013e318213f727 Lung Trauma Lung Trauma ● Lung lacerations ● Rib fractures ○ Symptoms ○ Flail chest - 3 or more adjacent ribs are segmentally fractured ■ Large air leaks ■ Leading to paradoxical chest wall motion ■ Hemoptysis ■ High rate of resp failure, underlying pulm contusion, infection ○ Dx ○ Tx: supportive ■ Bronchoscopy ■ Plating - still determining role ● Careful control of airway - double lumen tube, etc ● EAST practice management guidelines 20171 ■ OR ○ Meta-analysis with 22 studies, 3 prospective randomized trials ○ Tx ○ Flail chest - conditional recommendation to: ■ Majority - non-op ■ Decrease mortality, hospital LOS, ICU LOS, duration of mechanical ● Tube thoracostomy for air/blood ventilation, incidence of pneumonia, need for mechanical ventilation ■ Symptomatic - OR ■ Bleeding: transcatheter embolization if poor operative candidate 1. Kasotakis, G., Hasenboehler, E. A., Streib, E. W., Patel, N., Patel, M. B., Alarcon, L., … Como, J. J. (2017). Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 82(3), 618–626. https://doi.org/10.1097/TA.0000000000001350 3 10/1/2018 Lung Trauma Lung Trauma ● Pulmonary contusion ● Indications for operation ○ Symptoms ○ Massive hemothorax ■ Clinically silent to severe ■ 1500 cc or more upon initial tube placement ■ Evolve over 3 days - resolve at about 1 week ■ 200-250 cc/hr over 3 consecutive hours ○ May exacerbate hypoxia and shunting ○ Thoracic trauma with persistent hemodynamic instability ■ Upright positioning ● Monitor chest tubes closely ■ IS ○ Cessation of bleeding - clotted chest tube, poor positioning ■ Analgesia - epidural, medications ■ Consider CXR ● Early VATS/thoracotomy Lung Trauma Lung Trauma ● Operative notes ● Operative Notes ○ Single lung ventilation not warranted in hemodynamically unstable patients ○ Lung repair ■ Unless massive hemoptysis ■ Pneumorrhaphy - running simple or mattress suture ○ Evacuate blood and clot ■ Resection ○ Incise inferior pulmonary ligament ● Tractotomy ○ Lyse adhesions ● Excision ○ Control bleeding ○ Hilar Injuries ■ Finger compression ■ Proximal ■ Hilar bleeding ● Need inflow occlusion to assess extent of injury ● Finger occlusion ○ Open pericardium and control intrapericardial pulmonary artery and vein ● Penrose around hilum ■ May require pneumonectomy ● Hilar vascular clamp ● Mortality approaches 100% if in shock ● Twist on itself ● Perform early and treat right heart failure ○ Occludes pulmonary artery, vein and mainstem bronchus ○ Maybe ECMO - some improvement in outcomes Lung Trauma Lung Trauma ● Resection complications ● Damage Control in the Chest ○ Bronchial stump dehiscence ○ Pack and leave chest open ■ Devastating complication ■ Does not interfere with cardiac or pulmonary function ■ Some reinforce bronchial stump with viable tissue ■ Series of 44 patients1 ● Muscle ● Mean pH 7.07, ISS 29 ○ Intercostal muscle flap ● Mortality 23% ○ Diaphragmatic flap ● All physiologically normal at time of chest closure ○ Pedicled pericardial flap ○ Average 2-3 days ○ Pericardial fat pad ○ Mediastinal pleura ● Later ○ Omentum ○ Lat dorsi flap 1. O’Connor JV, DuBose JJ, Scalea TM. Damage-control thoracic surgery: Management and outcome. J Trauma Acute Care Surg. 2014;77(5):660-665. 4 10/1/2018 Lung Trauma Lung Trauma ● Video-Assisted Thoracoscopic Surgery ● Complications ○ Indications ○ Pneumonia ■ Alternative for diaphragm repair ■ Thoracic injury requiring intubation? ■ Empyema, retained hemothorax, persistent air leak ● 7 times more likely to develop pneumonia ■ Similar to open ■ Pulm contusion? ○ Lung isolate ● 50% will develop pneumonia, barotrauma, and or major atelectasis ○ First port - 4th or 5th intercostal space in mid or anterior axillary line ● 25% ARDS ■ Tip of scapula - good landmark ○ Retained hemothorax ○ Additional ports under visualization ■ Failed to be drained by tube in 5% ■ Repeat chest CT ● Less than 300 cc retained? Monitor ● Early VATS Lung Trauma Lung Trauma ● Complications ● Complications ○ Empyema ○ Persistent air leak and bronchopleural fistula ■ Dx - positive pleural cultures or frank purulence in the pleural space ■ True bronchopleural fistula - centrally located communication between a lobar or ■ Develops in around 26.8% of patients with a retained traumatic hemothorax1 segmental bronchi and the pleural cavity ■ Stages ■ Most resolve by 7 days ● Exudative ■ Dx: bronch ● Fibrinopurulent ■ Tx: autologous blood pleurodesis, sealants, endobronchial one-way valves, Heimlich ● Organizing valves, OR ■ Tx: VATS/thoracotomy ○ Chylothorax ■ Milky chest tube output ● Triglyceride level greater than 110 ■ Tx 1 . DuBose J, Inaba K, Okoye O, et al. Development of post-traumatic empyema in patients with retained hemothorax: Results of a prospective, observational AAST Study. J Trauma Acute Care Surg. 2012:73(3):752- ● Nonop: tpn, enteral medium-chain triglycerides, octreotide 757. ● Beyond 7 days: operative - maybe embolize thoracic duct or direct ligation Tracheobronchial Injuries Tracheobronchial Injuries ● Be aware of cervical tracheal injuries ● TX ○ Underlying esophageal, vascular thoracic duct