Keith Boniface, MD Professor of Emergency Medicine, EVALUATION OF George Washington University, Director, Emergency Ultrasound George Washington University CHEST TRAUMA Hospital Washington, DC Outline 1. TTE IMAGING OF THE AORTA 2. PRE-EXISTING CONDITIONS 3. INJURY TO MAJOR VESSELS 4. TAMPONADE 5. CARDIAC INJURIES • CARDIAC CONTUSION • OTHERS Outline 1. TTE IMAGING OF THE AORTA 2. PRE-EXISTING CONDITIONS 3. INJURY TO MAJOR VESSELS 4. TAMPONADE 5. CARDIAC INJURIES • CARDIAC CONTUSION • OTHERS Aortic Imaging - TTE Parasternal long-and-short axis views: • Proximal ascending aorta • Descending thoracic aorta (cross section of the aorta) Parasternal Long Axis View Ascending aorta Descending aorta Aortic Imaging - TTE Additional segments of the ascending aorta: move transducer one or two interspace cephalad Parasternal Long Axis View: 1-2 Ribs Spaces Up Ascending Ao Aortic Imaging - TTE Suprasternal notch: aortic arch Suprasternal Notch Aortic arch Aortic Imaging - TTE • Subcostal view: distal thoracic and proximal abdominal aorta • Combining images from multiple windows allows for visualization of much of the aorta Subcostal Outline 1. TTE IMAGING OF THE AORTA 2. PRE-EXISTING CONDITIONS 3. INJURY TO MAJOR VESSELS 4. TAMPONADE 5. CARDIAC INJURIES 1. CARDIAC CONTUSION 2. OTHERS Preexisting Conditions Trauma is increasingly a disease of the elderly Case 1 • 86 y.o. F seen in the ED s/p fall 5-7 stairs • Injuries: ✍ Right 8th-10th rib fracture ✍ Probably eventration of right hemidiaphragm • PMHx ✍ HTN ✍ GERD ✍ Hypercholesterolemia ✍ Alzheimer dementia Case 1 • In ED: 4 mg of morphine ➙ hypotension • Admitted to T/SICU • 1 hour after ICU admission ✍ “I’m going to die” rolled her eyes and went into PEA arrest • CPR, ACLS, TEE…. Case 1 Case 1 Case 1 Case 1 Case 1 RA AV RV Outline 1. TTE IMAGING OF THE AORTA 2. PRE-EXISTING CONDITIONS 3. INJURY TO MAJOR VESSELS 4. TAMPONADE 5. CARDIAC INJURIES 1. CARDIAC CONTUSION 2. OTHERS Major Vascular Injury • Aorta is the most common injury • Rupture: most patients will not reach hospital • Dissection • Pulmonary artery • Inferior and superior vena cava Aortic Rupture • Leads to death in 75-90% of cases at the time of injury • Rapid chest deceleration/compression induces torsion and shearing forces that results in transverse laceration and rupture of the aorta • Most commonly – in isthmus (inherently vulnerable) ✍ Occurs usually just distal to the origin of the left subclavian artery Aortic Rupture • Survivors have intact adventitia • Hematoma contained by parietal pleura and surrounding tissue: “false aneurysm” • Most common distal to left subclavian: 65-93% • Other sites of injury: ✍ Ascending/Arch: 7-14% ✍ Mid or distal descending: 4-12% ✍ Multiple sites: 4-13% Aortic Dissection • Life-threatening condition • An intimal tear in the aortic wall ➙ passage of blood into a “false” channel between the intima and media • This false channel may be localized or may propagate downstream • Complications: ✍ Expansion with compression of the true aortic lumen (supplies major branch vessels) ✍ Propagation down major branch vessels ✍ Thrombosis ✍ Rupture ✍ Tamponade Role of Echo in Aortic Dissection • Detection and grading of aortic insufficiency • Detection of side branch involvement • Detection of pericardial effusion Aortic Dissection - PLA View Aortic Dissection - PLA View Flap Aortic Dissection - PSA View Dissection Aortic Dissection Suprasternal View Dissection Aortic Dissection - Descending Aorta Dissection Aortic Dissection - Subcostal Hematoma Dissection Aortic Dissection - Subcostal Dissection flap TEE in blunt aortic trauma • 209 blunt trauma patients suspected of having traumatic aortic injury ✍ 42 patients (20%) diagnosed as traumatic aortic injury ✍ Angiography ‣ Sensitivity: 83%; specificity 100% ✍ TEE ‣ Sensitivity: 98%; specificity:100% ‣ Angiography failed to diagnose most intramural hematomas or small intimal flap that TEE demonstrated Goarin, J.P., et al. Anesthesiology, 2000. 93(6) Case I • 86 y.o. F seen in the ED s/p fall 5-7 stairs • One hour after ICU admission: PEA arrest • CPR ➙ ACLS ➙ TEE: critical aortic stenosis Case I Outline 1. TTE IMAGING OF THE AORTA 2. PRE-EXISTING CONDITIONS 3. INJURY TO MAJOR VESSELS 4. TAMPONADE 5. CARDIAC INJURIES 1. CARDIAC CONTUSION 2. OTHERS Tamponade • Discussed previously in the course • With blunt trauma: mostly hemoperricardium • Do not forget patients with underlying pathology (pericardial effusion) Hemopericardium Case 2: Trauma activation • EMS call: ✍ 40-ish year old man collapsed at Lincoln Memorial ✍ Hit his head on the marble steps ✍ Recent flight to DC from China ✍ Tachycardic, normal blood pressure, unresponsive ✍ 5 minute ETA • EMS call with update 3 minutes later: • BP now 86/40 • EMS arrival: • CPR initiated • Trauma steps back, ACLS, PEA, intubation, epi, IVF • ? PE vs intraabdominal bleeding Echo during pulse check Case 2: Trauma activation • Pericardial fluid collection with internal mobile echoes consistent with blood • Thoracotomy • Pericardial sac opened and 500 cc clotted blood evacuated • ROSC • To OR, found type A dissection • CT surgery called in for repair Outline 1. TTE IMAGING OF THE AORTA 2. PRE-EXISTING CONDITIONS 3. INJURY TO MAJOR VESSELS 4. TAMPONADE 5. CARDIAC INJURIES • CARDIAC CONTUSION • OTHERS Cardiac Injuries • May be blunt or penetrating • Single chamber injuries – stab wound (RV) • Multiple chambers – most likely from a gunshot wounds • Echo is useful in injury localization ✍ Rarely isolated injury ✍ Valvular injuries ✍ Great vessels Blunt Cardiac Injuries • Thoracic aorta injury • Myocardial Rupture (free wall vs VSD) Genoni, et al. Heart 1997;78:316-8 Pereira, et al. J Am Soc Echocardiogram 2000;13:64-5 Pillai et al. Ann Thorax Surg 2013;96(1):297-8 • Cavo-atrial tear Gajjar AH et al. J of Surg Case Reports 2011;8(8):1-4 Barranco et al. Rom J Leg Med 2017;25:346-350 • Valvular injury Nelson, et al. J Am Soc Echocardiogram 2007;20:198.e4-e5 Pasquier et al. J Trauma 2010;68:243-246 • Coronary artery injury Meluzin, et al. J Am Soc Echocardiogram 2000;13:1043-6 Al-Aqeedi et al. Heart Views 2011;12(2):71-3 • Cardiac Contusion Shapiro et al. J of Trauma 1991;31:835-840 Clancy et al. J of Trauma 2012;73(5):S301-S306 • Dysrhythmias/Commotio Cordis Cardiac Contusion • Right ventricle • Etiology: trauma, CPR • Incidence: 30% after MVA Karalis et al. J Trauma 1994;36:53-8 • Manifestation: ✍ Hypotension, arrhythmia, ST changes —> Echo: - RV free wall hypokinesis - RWMA of free wall - Improves within 1-2 weeks Cardiac Contusion TEE: Ruptured Tricuspid Valve RV Interesting Case 42 year old male Boston Marathon runner Collapsed during the race Acute shortness Intubatedof breath in ER Froth from ET tube Hypoxia Hypoxia‣ Ruptured Papillary muscle No‣ history Severe Mitral of cardiac Regurgitation problems ‣ Required“First hospitalMitral Valve visit!!” Repair Outline 1. TTE IMAGING OF THE AORTA 2. PRE-EXISTING CONDITIONS 3. INJURY TO MAJOR VESSELS 4. TAMPONADE 5. CARDIAC INJURIES • CARDIAC CONTUSION • OTHERS.