Download chest injuries

CHEST INJURIES
Philippe SCHERPEREEL
Professor Emeritus
TBILISI 2014
Centre Hospitalier Universitaire
59037 LILLE France
E-mail : [email protected]
CHEST INJURIES
• MAIN CAUSE OF 25% OF DEATHS FROM TRAUMATIC
ORIGIN: SECOND CAUSE OF MORTALITY
• IMPORTANT PROGRESSES OF IMAGING FOR THE
DIAGNOSIS: ECHOGRAPHY, SPIRALED CT SCAN, NMR
• CONSERVATIVE TREATMENT:
– CLOSED INJURIES: < 10% NEED SURGERY
– PENETRATING WOUNDS: 15-30% REQUEST SURGERY BUT NON
SURGICAL TECHNIQUES ARE MORE AND MORE USED
– DAMAGE CONTROL SURGERY FOR THORACIC INJURIES:
PACKING, OPEN CHEST, PULMONARY HILUM TWIST…
• DEATHS
– INMEDIATE: HEART AND MAJOR VESSELS RUPTURES
– DELAYED: AIRWAY OBSTRUCTION, CARDIAC TAMPONADE,
ASPIRATION BRONCHOPNEUMONITIS…
TRAUMA LESIONS
• THORACIC WALL:RIBS, STERNAL FRACTURES,
FLAIL CHEST
• PNEUMOTHORAX, HEMOTHORAX
• DIAPHRAGM RUPTURE
• PULMONARY CONTUSION
• TRACHEO BRONCHIAL LESIONS
• CARDIAC CONTUSION
• CARDIAC TAMPONADE
• AORTIC RUPTURE
• MEDIASTINAL LESIONS
FOUR STEPS
1. EVALUATION AND MANAGEMENT ON SITE
(15 min )
2. INITIAL EVALUATION AND MANAGEMENT AT
THE EMERGENCY DEPARTMENT (30 min)
3. COMPLETE EVALUATION (1 – 3 HOURS)
4. FREQUENT RE-EVALUATIONS (24 HOURS)
1. EVALUATION AND IMMEDIATE
MANAGEMENT
• CLINICAL EXAMINATION: LIFE-THREATENING
LESIONS
– NEUROLOGICAL: CONSCIOUSNESS (Glasgow score)
– CARDIO VASCULAR:
• HEMORRHAGE
• ARTERIAL PRESSURE
• PERIPHERICAL PULSES
– RESPIRATORY : VENTILATION
• FIRST ACTIONS:
–
–
–
–
AIRWAY
VENOUS ACCESS
ARTERIAL BLOOD PRESSURE CATHETER
BIOLOGY: HEMOGLOBIN
BLOOD GROUP
CRITERIA OF INTUBATION IN CASE
OF CHEST INJURY
• VENTILATORY RATE > 25/min
• HEART RATE > 100/min
• SYSTOLIC ARTERIAL PRESSURE < 100 mmHg
• RESPIRATORY FAILURE: PaO2 < 60 mmHg
•
and/or PaCO2 > 45 mmHg and/or pH < 7,20
ASSOCIATED LESIONS:
– ABDOMINAL
– NEUROLOGICAL (Glasgow Score ≤ 7)
INTUBATION IF THE NUMBER OF CRITERIA ≥ 3
2. INITIAL EVALUATION AND
MANAGEMENT
• THORAX X RAY
• ECHOGRAPHY
– THORAX
– HEART
TOMODENSITOMETRY IS NOT PART OF
THE INITIAL EVALUATION
RIB, STERNUM AND SCAPULA
FRACTURES
• RIBS 1 - 3:
– VIOLENT TRAUMA
– ASSOCIATED LESIONS: HIGH MORTALITY
 Major vessels ruptures
 Medullary wounds, spinal lesions
• RIBS 4 - 9 :
– PULMONARY CONTUSION
– HEMO, PNEUMOTHORAX
• RIBS 10 – 12 :
– ABOMINAL LESIONS?
TENSION PNEUMOTHORAX
SYMPTOMS:
• SLIPPED MEDIASTIN
• RESPIRATORY FAILURE
• HYPOTENSION, TACHYCARDIA
• HYPER SONORITY
• JUGULAR DISTENSION
• DELAYED CYANOSIS
IMMEDIATE DECOMPRESSION
MASSIVE HEMOTHORAX
SYMPTOMS
– Shock
– Dull noise without
ventilation
– Cervical veins
– Empty or distended
MANAGEMENT
– Fast fluid challenge
– Drainage and X Ray ±
auto transfusion
– Surgery if the initial
drainage is over 1 500 ml
DIAPHRAGM RUPTURE
CLINICAL SYMPTOMS
• 5 TIMES MORE FREQUENT IN LEFT
vs RIGHT SIDE
• ASSOCIATION
- 2/3 RIB FRACTURES
± FLAIL CHEST
- ½ ABDOMINAL LESIONS
LIVER, SPLEEN
- < 5% SEVERE INTRA THORACIC
WOUNDS
• IMAGING
- EMPTY VISCERA: BRIGHTNESS
- SOLID VISCERA: OPAQUENESS
RIGHT DIAPHRAGMATIC RUPTURE
SURGERY
RIGHT INTRA
THORACIC
OPAQUENESS
LEFT DIAPHRAGMATIC RUPTURE
STANDARD
X - RAY
WITH PRODUCT
OF CONTRAST
ASSOCIATION
WITH AN
HEMOTORAX
DIAPHRAGMATIC RUPTURE
TOMODENSITOMETRY
FLAIL CHEST
• DYSFUNCTION OF VENTILATORY MECHANISM
PARADOXICAL MOVEMENTS OF THORAX :
CHEST WALL DEPRESSION AT INSPIRATION
• MANAGEMENT
 ANALGESIA : THORACIC EPIDURAL ANALGESIA
 INTERNAL PNEUMATIC STABILIZATION
 CONTINUOUS POSITIVE PRESSURE VENTILATION
 SURGICAL FIXATION
 FRACTURE OF THE STERNUM: HOOPING
 JUDET, SANCHEZ CLIPS, PINS
PARADOXICAL
VENTILATION
FRACTURE OF THE STERNUM
• SEAT BELT
• STRONG IMPACT
TRACHEO BRONCHIAL LESIONS
 PARTIAL OR COMPLETE LESIONS
• FISSURE
• FRACTURE
• RUPTURE
RARE OCCURENCE (1%), DIFFICULT
DIAGNOSIS, MORE DELAYED, MORE
FREQUENT LOCALIZATION: CARENA
TRACHEO BRONCHIAL LESIONS
CLINICAL SIGNS
• TENSION PNEUMOTHORAX
• CERVICO FACIAL SUBCUTANEOUS
EMPHYSEMA THORACIC OR EXTENSIVE:
SNOWY CREPITATION
• MEDIASTINAL EMPHYSEMA
• HEMOPTYSIA WHATEVER THE QUANTITY
TRACHEO BRONCHIAL LESIONS
TRACHEO BRONCHIAL LESIONS
FIBEROPTIC ENDO SCOPY
• INDICATIONS
– Persistant air leakage
– Isolated pneumothorax
– Hemoptysis
– Early ventilation failure
• MANAGED IN A PATIENT
– Hemodinamically stable
– After pleural drainage
– In the immediate vicinity of an operative
theater  thoracotomy in emergency
DECISIONAL ALGORITHM
SIGNS OF TRACHEAL BRONCHIAL LESIONS
PNEUMOTHORAX
DRAINAGE
CONTROL
OBSERVATION
FIBEROPTIC ENDOSCOPY
• FISSURE
WITHOUT
AIR LEAKAGE
• DISTAL OR
PARTIAL
RUPTURE
CONTROL
• RUPTURE OR
• COMPLETE
FRACTURE
• PROXIMAL
THORACOTOMY
LUNG CONTUSION
CINICAL SIGNS
• HEMOPTYSIS, HEMOPTOIC EDEMA
IMAGING
– Inhomogenous, glurred opacities, aeric
bronchogrammes
• GAZOMETRY: Hypoxemia
• HEMOSTASIS: Frequent biological disseminated
intra vascular coagulations (DIVC)
• EVOLUTION:
– SPONTANEOUS: Disappearance within 24-72
HOURS
– COMPLICATIONS:
• Broncho pulmonary infections
• Air leakage
• Pulmonary fibrosis
LUNG CONTUSION
INTEREST OF THE THORACIC
TOMODENSITOMETRY
Front pneumothorax
Pulmonary contusion
and hemotHorax
EVOLUTION OF A LUNG
CONTUSION
PERICARDIAC LESIONS
• PERICARDIAC RUPTURES
 RISK OF HEART LUXATION, IMMEDIATE
OR DELAYED
• CARDIAC TAMPONADE
 RISK OF SUDDEN DEATH
- HYPOTENSION
- DILATED CERVICAL VEINS
- CARDIAC PULSELESS ACTIVITY
 MANAGEMENT
- PERICARDIOCENTESIS
- PERICARDIOTOMY
PERICARDIAC
EFFUSION
CARDIAC CONTUSION FOLLOWING
BLUNT CHEST TRAUMA
DIAGNOSIS BASED UPON:
1.
2.
3.
4.
CLINICAL SIGNS: PAIN, ARRYTHMIAS…
E.C.G.
BIOCHEMISTRY: CPK MB, TROPONIN E
ECHOCARDIOGRAPHY+++
• SIZE AND KINETICS OF THE VENTRICLE, AKINESIA
• SEARCH OF ASSOCIATED LESIONS
5. CORONARY ANGIOGRAPHY RADIONUCLIDE
IMAGING ISOTOPIC ANGIOGRAPHY WITH
TECHNECIUM
CARDIAC CONTUSION
EVOLUTION OF CARDIAC CONTUSIONS
• USUALY FAVOURABLE WITHOUT CLINICAL OR
•
ELECTRICAL SEQUELAE
COMPLICATIONS
– EARLY:
 CARDIOGENIC SHOCK
 ARRITHMIAS AND ALTERATIONS OF
CONDUCTION
 THROMBO EMBOLIES
 HEMOPERICARDIC TAMPONADE
 CARDIAC RUPTURES: SEPTUM, VALVULES
– DELAYED:
 CARDIAC FAILURE
 VENTRICULAR ANEURYSM
HEMOMEDIASTINUM
• CLINICAL SIGNS
– NON SPECIFIC: Retrosternal pain
Interscapular pain
Dyspnoea
Collapse
– EVOCATING:
• DISPARITY IN PERIPHERAL PULSES ( MS,  MI)
• SYSTOLIC HEART MURMUR
• NEUROLOGICAL DEFECT IN THE LOWER LEGS
• ANURIA
– LATELY: SIGNS OF COMPRESSION
• OESOPHAGUS: DYSPHAGIA
• TRACHEO BRONCHIAL: DYSPNOEA
EVALUATION OF THE
HEMOMEDIASTINUM
ENLARGEMENT OF THE MEDIASTINUM
TRAUMATIC LESIONS OF THE AORTA
• FREQUENCE: 0,2 -2% OF THE THORACIC BLUNT
•
•
TRAUMA
SEVERITY: 12-20% OF THE DEATHS
EVOLUTION
BEFORE
AORTIC RUPTURE
AORTOGRAPHY
SURGERY IN EMERGENCY
SURGICAL TREATMENT
TO-DAY
AORTIC TRAUMA
TOE – Trans Oesophageal
Echography or Multislice
computed tomography
DELAYED SURGERY
MEDICO SURGICAL TREATMENT
MECHANISMS OF TRAUMATIC
AORTIC LESIONS
POLYTRAUMATISM AND
DECELERATION
ORGAN
SPEED
(km/h)
REAL WEIGHT
(kg)
PARR Y GRANDE 1993
MASS IN DECELERATION (kg)
0
36
72
108
SPLEEN
0,25
2,5
10
22,5
HEART
0,35
2,5
14
31,5
BRAIN
1,5
15
60
135
LIVER
1,8
18
72
162
TOTAL
BODY
70
700
2 800
6 300
RATIO
1
X10
X40
X90
STANDARD X - RAY
• ENLARGEMENT OF THE
UPPER MEDIASTINUM
(67-80%)
• DISAPPEARANCE OF THE
AORTIC BUTTON
(21-24%)
• TRACHEAL DISPLACEMENT
(3-12%)
• HEMATOMA OF THE APEX
OF THE LUNG
(4-19%)
•
LEFT HEMOTHORAX
(7-19%)
TRAUMATIC RUPTURE OF THE AORTIC
ISTHMUS
AORTOGRAPHY
ANGIO SCANNER
RUPTURE OF THE AORTIC ISTHMUS
NUCLEAR MAGNETIC
RESONNANCE
AORTOGRAPHY
ENDOLEAK HEMATOMA
TRANS OESOPHAGEAL
IRM
ECHOCARDIOGRAPHY
MANAGEMENT BY ENDOSVASCULAR
STENT
• SUBACUTE OR CHRONIC
AORTIC TRAUMA
• WITHOUT SECONDARY
RUPTURE
• POSSIBLE COMPLICATIONS
• OCCLUSION SUBCLAVIAN
• ATELECTASIS
• RISK ON THE LONG TERM
(RUPTURE, PARAPLEGIA…)
RUPTURE OF THE VESSELS OF THE BASIS
OF THE NECK
ANGIOGRAPHY
SUMMARY
• VERY FREQUENT, MOST OFTEN NON-LIFE-
•
•
•
•
•
THREATENING: THE RISK OF THE THORACIC TRAUMA
IS THE DIFFICULTY TO RECOGNISE LESIONS:
 RARE (ex: Oesophagus)
 LIFE THREATENING (ex: rupture of vessels)
IMPORTANCE OF THE INITIAL EVALUATION
IMAGING
 ULTRASONOGRAPHY
 COMPUTED TOMOGRAPHY, N M R
 ANGIOGRAPHY
NEED FOR ANALGESIA
MANAGEMENT USUALY MORE CONSERVATIVE THAN
SURGICAL, ENDOVASCULAR STENT
NECESSITY OF PERMANENT RE ASSESSMENT OF THE
PATIENT