PENETRATING CHEST TRAUMA Navy 2

Views:
 
Category: Entertainment
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

PENETRATING CHEST TRAUMA: Early Management:

PENETRATING CHEST TRAUMA: Early Management Steven R. Shackford, MD FACS Attending Trauma Surgeon Scripps Mercy Clinical Professor of Surgery UCSD

OBJECTIVES :

OBJECTIVES Epidemiology Clinical Approach Initial evaluation and management Indications for tube thoracostomy Indications for thoracotomy

EPIDEMIOLOGY:

EPIDEMIOLOGY Chest trauma: 16,000 deaths/year Early: hemorrhage Late: Multiorgan failure Most common injury: rib fracture Intervention is uncommon 85% are managed by tube thoracostomy Pain control is critical in management

CLINICAL APPROACH:

CLINICAL APPROACH History Mechanism (stab, GSW, SGW, fragment) Caliber and range Gender of assailant Description of the scene Duration of transport ED thoracotomy Penetrating with signs of life Intubation in the field -> better outcome

INITIAL MANAGEMENT:

INITIAL MANAGEMENT ATLS protocol Primary survey: Breath sounds Subcutaneous emphysema Tracheal deviation JVD Secondary survey: Path of the bullet or SW: mark all wounds ? Thoracoabdominal ? Axial traverse

Clinical Presentation: Thoracoabdominal axial travense:

Clinical Presentation: Thoracoabdominal axial travense Penetrating trauma GSW Transaxial Hypotensive with minimal response to fluid or moribund

IMAGING (1):

IMAGING (1) CXR: after marking wounds Position of ET tube Lung parenchyma: Contusion PTX HTX Mediastinal width

IMAGING (2):

IMAGING (2) FAST Subxiphoid/thoracic: Cardiac motion Pericardial fluid stripe PTX CT HTX vs contusion HTX with blush Anterior PTX-for pt to have GET

IMAGING (3):

IMAGING (3) Angiography More for blunt injuries Zone I injury (thoracic outlet)

INITIAL RESUSCITATION:

INITIAL RESUSCITATION Driven by clinical parameters, not BP! Transmural Δ P: “pop the clot” Mental status Urine output Limit crystalloid Early use of PRBC, FFP and platelets 1:1:1 is our preference

TUBE THORACOSTOMY (1):

TUBE THORACOSTOMY (1) 36 Fr Argyle ™ 5 th intercostal space Lower: risk of going through diaphragm Mid-axillary line No trocar: 15% of patients have pleural symphysis Direct tube posteriorly, apically

TUBE THORACOSTOMY (2):

TUBE THORACOSTOMY (2) Use autotranfusion set up for major HTX Assure that drainage system is connected correctly 30% are not connected correctly 20 cm H2O negative pressure Removal: Absence of air leak Minimal chest drainage

DIRTY HARRY’S LAW:

DIRTY HARRY’S LAW “A man has got to know his limitations.” Penetrating chest trauma has a high “pucker factor”…not a time to learn new techniques High index of suspicion The most experienced person should direct therapy Get help when needed

INDICATIONS FOR THORACOTOMY:

INDICATIONS FOR THORACOTOMY PEA after truncal trauma Cardiac tamponade Massive hemothorax Tube output: 1500 ml initially Tube output: 250 ml/hr Vascular injury to the thoracic outlet in unstable patient Massive air leak True mediastinal traverse (?)

2/4/09: Prehospital & Arrival:

2/4/09: Prehospital & Arrival 20 y/o male, multiple stable wounds Scooped, moribund, no BP, palpable carotid pulse SWs: face, chest, both arms, Left axilla At Mercy Trauma: Palpable femoral pulse Covered with blood Decreased breath sounds, right; O2 sat = NR Now what?

Mercy Trauma Bay:

Mercy Trauma Bay Intubated SW: slashes of face, right chest, left thigh near ASIC, right arm, left axilla. Right femoral venous 8 fr Initiate 1:1 resus; BP  ‘s to 70 torr CXR

OR:

OR Moving patient to the OR table Anesthesia: “We have lost the pulse.” Now what?

Hospital Course:

Hospital Course Chest & mediatstinal tubes out day 4 PT/OT/COG cleared day 5 Home day 6 Attending (SRS) testifies at trial of assailant (9/14/09)

5/25/09:Prehospital & Arrival:

5/25/09:Prehospital & Arrival Radio room: 16 y/o male multiple SWs No BP, in transit Arrival: covered with blood No radial pulse Thready femoral pulse Clear BS bilaterally Chest: multiple SWs, 2 in the “box” Abdomen: multiple SWs viscerated omentum What now?

Resuscitation:

Resuscitation Intubated, ABG: 407/26/6.84/-25 1:1 resuscitation (eventually 9u) BP 90/40, p120, T:34.7 Nurses: TV news say: “much blood at scene” Now what?

Dx/Rx:

Dx/Rx FAST: moderate hemopericardium, no blood in abdomen Repeat CXR w/ nl BP: ET tube OK, no HTX OR: median sternotomy, fix RV, left chest tube, minimal blood Explore abdomen: large SW-> hernia, no injuries

Postoperative Course:

Postoperative Course Extubated day 1 Mediastinal tubes out day 2 Left CT out day 3, diet started Ambulation, PT day 4 Discharge day 5 Conclusions: 1:1 resuscitation is the bomb-this is my first admission pH of 6.8 to do well!

SUMMARY:

SUMMARY Penetrating wounds of the chest are challenging Most are managed with a chest tube only autotransfuser Beware: transaxial / thoracoabdominal injuries Learn life saving techniques

authorStream Live Help