logging in or signing up PENETRATING CHEST TRAUMA Navy 2 chaoa Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 80 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: September 26, 2011 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member 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 UCSDOBJECTIVES : OBJECTIVES Epidemiology Clinical Approach Initial evaluation and management Indications for tube thoracostomy Indications for thoracotomyEPIDEMIOLOGY: 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 managementCLINICAL 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 outcomeINITIAL 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 traverseClinical Presentation: Thoracoabdominal axial travense: Clinical Presentation: Thoracoabdominal axial travense Penetrating trauma GSW Transaxial Hypotensive with minimal response to fluid or moribundIMAGING (1): IMAGING (1) CXR: after marking wounds Position of ET tube Lung parenchyma: Contusion PTX HTX Mediastinal widthIMAGING (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 GETIMAGING (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 preferenceTUBE 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, apicallyTUBE 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 drainageDIRTY 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 neededINDICATIONS 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 CXROR: 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 injuriesPostoperative 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 You do not have the permission to view this presentation. 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PENETRATING CHEST TRAUMA Navy 2 chaoa Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 80 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: September 26, 2011 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member 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 UCSDOBJECTIVES : OBJECTIVES Epidemiology Clinical Approach Initial evaluation and management Indications for tube thoracostomy Indications for thoracotomyEPIDEMIOLOGY: 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 managementCLINICAL 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 outcomeINITIAL 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 traverseClinical Presentation: Thoracoabdominal axial travense: Clinical Presentation: Thoracoabdominal axial travense Penetrating trauma GSW Transaxial Hypotensive with minimal response to fluid or moribundIMAGING (1): IMAGING (1) CXR: after marking wounds Position of ET tube Lung parenchyma: Contusion PTX HTX Mediastinal widthIMAGING (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 GETIMAGING (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 preferenceTUBE 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, apicallyTUBE 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 drainageDIRTY 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 neededINDICATIONS 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 CXROR: 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 injuriesPostoperative 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