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Chest Trauma and Indication For Thoracotomy
Chest Trauma and Indication For Thoracotomy
Dr.Sami Alnassar
Primary survey
Aim to identify life threatening chest injury
– Tension pnemothorax
– Massive hemothorax
– Cardiac temponade
– Flail chest
– Open pneumothrax
EXAMINATION
LOOK
FEEL
LIESTEN
PERCUSS
EXAMINATION
LOOK
FEEL
LISTEN
PERCUSS
Examination
Don’t forget to examine the back??
DIAGNOSTIC IMIGING
CXR
FAST
secondary survey
Is more detailed and completed
examination to Identified :
Possible thoracotomy
or thoracoscopy
Tracheo-broncheal injury
Its rare ,from 0.2 to 4%
DIAGNOSTIC APPLICATIONS :
DIAGNOSIS OF DIAPHRAGMATIC INJURIES
DIAGNOSIS OF PERSISTENT HEMORRHAGE
DIAGNOSIS OF BRONCHOPLEURAL FISTULAS
ASSESSMENT OF CARDIAC AND MEDIASTINAL
STRUCTURES
THERAPEUTIC APPLICATIONS
MANAGEMENT OF RETAINED THORACIC
COLLECTIONS
REPAIR OF DIAPHRAGMATIC INJURIES
Emergency Department
Thoracotomy
Accepted Indications :
– Penetrating thoracic injury :
Traumatic arrest with previously witnessed cardiac
activity
Unresponsive hypotension (BP < 70mmHg)
– Blunt thoracic injury
Unresponsive hypotension (BP < 70mmHg)
Rapid exsanguination from chest tube (>1500ml)
Emergency Department
Thoracotomy
Relative Indications :
– Penetrating thoracic injury
Traumatic arrest without previously witnessed
cardiac activity
– Penetrating non-thoracic injury :
Traumatic arrest with previously witnessed cardiac
activity
– Blunt thoracic injuries:
Traumatic arrest with previously witnessed cardiac
activity
Emergency Department
Thoracotomy
Contraindications :
– Blunt injuries:
Blunt thoracic injuries with no witnessed cardiac
activity
Multiple blunt trauma
Severe head injury
Emergency Department
Thoracotomy
Rationale
Overall survival of patients undergoing
emergency thoracotomy is between 4 and
33%
The main determinants for survivability
are the mechanism of injury
For penetrating thoracic injury the survival
rate is fairly uniform at 18-33%
Emergency Department
Thoracotomy
Rationale
Blunt trauma survival rates vary between 0 and 2.5%
The presence of cardiac activity, consistently related to
the outcome following emergency thoracotomy
In one study of 152 patients (Tyburski) survival rates
were 0% for those patients arresting at scene, 4% when
arrest occurred in the ambulance, 19% for emergency
department arrest
Survival for blunt trauma patients who never exhibited
any signs of life is almost uniformly zero. Survival for
penetrating trauma patients without signs of life is
between 0 and 5%.
Emergency Department
Thoracotomy
Operative Technique
The primary aims of emergency
thoractomy are:
Release of cardiac tamponade
Control of haemorrhage
Allow access for internal cardiac massage
Secondary manoeuvers
cross-clamping of the descending thoracic aorta.
Emergency Department
Thoracotomy
Operative Technique
Approach :
– A supine anterolateral thoracotomy
– left sided approach is used in all patients and
with injuries to the left chest
– Patients who are not arrested but with
profound hypotension and right sided injuries
have their right chest opened first.
Emergency Department
Thoracotomy
Operative Technique
Emergency Department
Thoracotomy
Operative Technique
Approach :
– In both cases it may become necessary to
extend the incision across the sternum
– skin incision is made in the 5th intercostal
space
Relief of tamponade :
– The pericardium is opened longitudinally to
avoid damage to the phrenic nerve,
Emergency Department
Thoracotomy
Operative Technique
Control of haemorrhage :
– Cardiac wounds :
controlled initially with direct finger pressure.
sutured using non-absorbable 3/0 sutures
mattress sutures are used to avoid obstructing
coronary flow
– Pulmonary & Hilar injuries.
temporarily controlled with finger pressure at the
pulmonary hilum.
Emergency Department
Thoracotomy
Operative Technique
Control of haemorrhage:
– Pulmonary & Hilar injuries :
This may be augmented by placement of a
Satinsky clamp across the hilum
Lesser haemorrhage from the lung parenchymas
can be controlled with a temporary clamp
– Great vessel injuries :
Small aortic injuries can be sutured directly using
the 3/0
Emergency Department
Thoracotomy
Operative Technique