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Emergency Anaesthetic Management of Extensive Thoracic Trauma HOSAM M ATEF

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 Non-cardiac: which includes  1. Chest wall.  2. Pleural space.  3. Lung parenchymal contusion.  4. Tracheobronchial.  5. Diaphragmatic.

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 . Cardiac – which includes  1. Tamponade.  2. Coronary artery.  3. Cardiac chambers.  4. Great vessels.

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 1.Chest wall: Chest wall injury -- a single rib fracture to multiple rib fractures ---flail chest.  Fractured ribs---severe pain-- limiting the respiratory movements leading to hypoventilation--deleterious in pre-existing COPD.  X-ray chest is required to rule out atelectasis or pneumothorax.

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 Treatment: Surgical fixation or even strapping is  rarely required-- lead to atelectasis.  Ventilation can be improved by pain relief with   Analgesics   Intercostal nerve blocks interpleural catheters  epidural narcotics and PCA.   In case of persistent hypoxemia 5 cm CPAP via mask may be required.

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  Surgical repair may necessitate intubation G.A. and mechanical ventilation.  Sternal fracture with “Steering Wheel Syndrome” now has been replaced by “Seat Belt Syndrome” in motor vehicle accidents. Steering wheel impact on sternum causes rapid deceleration leading to deeper thoracic structure injuries

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 2.Pleural space: Athoracic injury can give rise to  Pneumothorax PNT  Tension PNT TNT  Simple open PNT  Haemothorax

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 Pneumothorax PNT:An opening in the chest wall allows atmospheric air to enter the pleural space permitting the interpleural pressure to equalize atmosphere pressure producing PNT and pressure collapse of the lung.  A sort of ‘sucking wound’ i.e. air entering pleural space during inspiration and exiting during expiration

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 The air may also enter pleural space from inside.  Air may leak into it from tracheobronchial or lung parenchymal injury.  TNT occurs--air enters the pleural space during inspiration -- cannot escape during expiration.  TNT compresses ipsilateral lung directly and opposite lung by mediastinal shift.  Increase in pleural pressure decreases venous return and COP.

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 Cardinal signs of TNT are  Rapid deterioration of vital signs  Decreased pulmonary compliance  Decreased or no breath sounds on affected sides  Tracheal deviation towards normal side  Occassionally the air leak may also cause pneumomediastinum and pneumopericardium.

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 Diagnosis: PNT less than 20 is not detectable  clinically. PNT more than 20 causes chest pain that increases on breathing. PNT more than 40 may cause cyanosis and tracheal deviation.  Clinical findings with rib fracture are suggestive and CXR in expiration confirms it.

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 Treatment:  A simple open PNT--- chest tube drainage ICD  Small wounds --sealed by dressing  TNT suspected ---- immediate decompression by insertion of a 14G needle in the second intercostal space ICS in midclavicular line MCL followed by ICD.  If patient --transported by air even a minor PNT should be drained as P 1/VBoyle’s law i.e. air volume increases with decreasing pressure  at heights.

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 GA is indicated --debridement and primary closure.  ICD tube is inserted under local anaesthesia.  Anaesthesiologist must be very cautious considering  the possibilities of converting a small untreated simple PNT into a large TNT during induction and IPPV.  Avoid nitrous oxide.  Monitor chest tube for continued function. Specific anaesthetic considerations

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 Haemothorax:  Only about 400ml or more blood in pleural space can be detected in upright CXR.  One side pleural space can easily accommodate 30-40 1.5L of victims’ blood.  The consequences are-  Hypotension  Compression of ipsilateral lung  Mediastinal shift followed by  Compression of contralateral lung  Ventilatory impairment

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 Treatment:   Tube thoracostomy in 6th intercostal space in midaxillary line.  If the source of bleeding is pulmonary vessel low  perfusion pressure only tube drainage is enough  but bleeding from systemic vessel if 300 ml.hr-1 or more after initial drainage will require emergency thoracotomy.  Sometimes a chest tube may release a tamponade --massive haemorrhage.

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 A fast transfusion with the help of pump may be required.  Acute respiratory failure prior to surgery ---intubation and PPV.  Double lumen tube DLT may be considered if  there is : Large air leak from chest tube tracheobronchial injury  Haemoptysis or a significant amount of blood in airways Specific anaesthetic considerations

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 3.Pulmonary contusions:  Pulmonary contusion--both penetrating--rapid deceleration conditions.  Rib fractures--50 of such cases.  Initial CXR is not helpful and CT Scan is required to know the extent.  Progressive decrease of pulmonary compliance and PaO2 and increase in alveolar oedema.  PaO2/FiO2 250 is the best indicator of poor outcome.

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 oedema phase-- treated with application  of PEEP diuretics and controlled fluid administration.  Colloid versus crystalloid infusion is not an important issue as the area has to become oedematous due to deranged pulmonary characteristics.  Pulmonary laceration is infrequent with blunt chest trauma but blunt shearing or the ends of the broken ribs can cause it.

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 4.Tracheobronchial disruption TBD:  TBD should be suspected with penetrating or blunt injury to the neck or chest. Subcutaneous or mediastinal emphysema haemoptysis PNT bronchopleural fistulas BPF or persistent air leak after tube insertion are the definite signs of TBD.

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 A knife laceration to lung may transect many bronchioles behaving like BPFs.  Flexible bronchoscopy should be performed to assess the level of disruption

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 Treatment: Only few distal tears with minimal air leak or major bronchus tear involving less than one third of circumference and in apposition can be treated nonsurgically.  Small to moderate high tracheal tear --ETT with cuff reaching distal to tear.  Tracheostomy is indicated in high tracheolaryngeal disruptions.  Majority of TBD require surgery.

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 Intubation is done depending upon  in awake or anaesthetized relaxed or spontaneously ventilated patient  using a single lumen tube SLT or double lumen tube DLT over a fiberscope to reach distal to tear and avoiding further tear by blind advancement of ETT.  DLT should be used when separation of lung is life saving and PPV of the affected lung may convert a simple mucosal tear to a major BPF.  It is also indicated in injuries at or below carina. Specific anaesthetic considerations

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 In case of SLT:  Maintain spontaneous ventilation during induction intubation and maintenance of anaesthesia.  If required a gentle PPV can be given when chest is opened.  As an alternative to ETT a small catheter can be passed beyond the injury for High Frequency Ventilation and High FlowApnoeic Ventilation.  Sterile ETTs of different sizes should be kept ready  for intraoperative bronchial placement from within during airway repair.

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 5.Esophageal injury:  Blunt forces--a sudden rise in intraluminal pressure or esophagus may be crushed between trachea and vertebral bodies but more common cause is penetrating trauma.  Injury to esophagus from outside or within is not immediately life threatening but untreated  and unrecognized esophageal injury has an extremely  high mortality due to mediastinitis empyema and sepsis.  Repair within 24 hrs remarkably reduces mortality.

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 Diagnosis:  Clinically chest pain dysphagia hematemesis emphysema  and fever.  Oesophagography Oesophagoscopy is not always necessary.  Treatment:  Surgery--a minor primary repair to resection of oesophagusmay.  Tears of upper and middle thirds are repaired from right and lower one third from left thoracotomies.

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 Respiratory hemodynamic and GI considerations.  Use of DLT and one lung ventilation facilitate surgery.  No esophageal instrumentation -- gently guiding a nasogastric tube beyond repair at the end of operation by surgeon. Special anesthetic considerations

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 6.Diaphragmatic injury:  Blunt forces or gunshots from chest or abdomen can disrupt diaphragm.  Abdominal viscera may be pushed up to the chest causing respiratory embarrassment.  A ‘Cork Screw’ position allows exploration of abdomen  and thorax if required simultaneously.  If the injury is to be approached by thoracotomy the surgical exposure -- DLT

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 7.Cardiovascular injuries  Blunt trauma may cause cardiac contusion or aortic disruption at isthmus with fractured sternum.  Cardiac arrhythmias and ST changes on ECG may indicate cardiac contusions but rise in troponin I is more specific.  Penetrating cardiac injuries –gunshots or stab wounds to neck precordium or upper left abdomen.

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 Gunshot wounds are more devastating can injure one or more cardiac chambers .  Right ventricle with its anterior placement is more prone to injury.  Several serious effects may result from penetrating cardiac injury but the commonest one is cardiac tamponade

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 Pericardial space normally contains 60 ml of serous Fluid  A relatively non-stretchable structure if filled with 100 – 200ml of blood may limit diastolic expansion of the heart.  Gradually if allowed it can accommodate up to 2 L of blood severely affecting the cardiac output.  Diagnosis: It can be diagnosed by  Site of wound  Beck’s triad of – distended neck veins hypotension  Muffled heart sounds Cardiac tamponade

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 Kussmaul’s sign paradoxic filling of neck veins on inspiration.  Pulses paradoxus.  ECG – Pulsus alternans.  Shock and raised CVP.  Treatment: The definitive treatment is surgery but  pericardiocentesis may be done first to relieve rapidly  increasing tapenade. Cardiac tamponade

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 In a moribund and unconscious patient  pericardiocentesis is done only under local anaesthesia  Oxygen and/or PPV.  Administration of GA with a significant tamponade is potentially lethal. Special anaesthetic considerations

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 In a conscious restless non-cooperative patient GA is required even for pericardiocentesis followed by surgical correction.  Rapid supine horizontal incision in left 4th/5th ICS is given after anesthesia.  Maintain CVP 15cm H2O avoid peripheral vasodilatation myocardial depression and arrhythmias. Special anaesthetic considerations

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 Ketamine vecuronium high FiO2 are the choices.  If patient deteriorates before tamponade is relieved isoproterenol infusion is started  Conservative anaesthetic management must be followed even after tamponade is relieved but narcotics e.g. fentanyl can be added. Special anaesthetic considerations

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 Coronary artery injury: Being anterior usually left coronary artery is involved. It may lead to hemorrhage infarction or tamponade. From an-aesthetic view point these patients should be managed similarly to the patients with acute MI.  Cardiac chamber injury: Immediate surgery for  repair of hole is required. Management is planned  General anesthetic considerations as discussed earlier with special management of hemorrhagic shock --Great vessels’ injury:

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 Aort ic injury – It leads to devastating haemorrhage and only 15 reaches hospital alive.  The signs are:-  Mediastinal widening  Haemothorax  Tracheal deviation  Caval injuries -  Most difficult to deal surgically  Extremely high mortality

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 Depending upon the condition the general anaesthetic management plan is employed.  Fore most goal is to maintain a rapid fluid replacement.  Cardiopulmonary bypass is rarely required but always better to keep the facility available. Special anaesthetic considerations

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 Extensive chest trauma is always life threatening due to respiratory and haemorrhage problems.  The anesthesiologist must be able to initiate primary resuscitation diagnose life threatening chest injuries and plan the anaesthetic management of any surgical  intervention if required.

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 Non-penetrating usually caused by blunt trauma deceleration or blast forces.  Penetrating injuries caused by gunshots stabs arrows  Most of the deaths in these cases are due to asphyxia and hemorrhage and are avoidable.

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 Extensive thoracic injuries are always life threatening and they should be managed aggressively  The amount of destruction of the organ is proportional to the shearing forces  Tissue destruction following a gun shot depends upon the kinetic energy KE transmitted to the tissues

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 Assessment and resuscitation: patient should be scaled on injury severity score ISS. Any ISS more than 25 is severe .  physical examination involving one side of chest or transmediastinal gun shot wound  Diagnostic studies  Life-saving surgery Principles ofmanagement

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 A. Establish airway and ventilation.  B. Maintain circulation in terms of cardiac function and intravascular volume.  C. Check neurological status GCS  D. Determine the mechanism of injury. Primary survey

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 Airway: Intubate an unconscious shocked and hypoxic patient immediately.  If there is neck injury or bleeding do cricothyroidotomy or tracheotomy.  B.Patient with collapsed neck veins is assumed to be in hypovolemic shock.

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 C. Neurologic status: Glasgow Coma Scale is only important when there are associated head and neck injuries or air in cerebral circulation.  D. Mechanism: It may be penetrating blunt with high velocity low velocity or crushing factor.

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 Patient with distended neck veins but hypotensive may  have thepossibilities of:  Myocardial contusion or MI  Tension pneumothorax TNT  Air embolism  Pericardial tamponade

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 penetrating thoracic injury PTI who has no obvious head injury but has focal neurological signs may have air bubbles occluding the cerebral circulation.  Fundoscopy showing air bubbles in retinal vessels may confirm it.  Intubated patient on IPPV who develops sudden

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 cardiovascular collapse ----- either TNT or coronary air embolism.  The definitive treatment is emergency thoracotomy in ‘steep head down ’position.  Pericardial tamponade is a frequent--- pericardiocentesis can be done as life saving measure but immediate thoracotomy is the definitive treatment.

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 If patient becomes haemodynamically stable after initial resuscitation then a secondary survey for diagnostic studies and surgical priorities should be followed Secondary Survey

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 Pre-operative assessment:  Monitoring  Induction:  Unconscious moribund patient should be intubated and surgery is performed without anesthesia.  When vital signs and consciousness improve anesthetics can be added to start with lower doses.  Ketamine is the drug of choice.

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 Avoid thiopentone and like drugs including inhalational agents in shocked patients. They should be used only after correction ofBP with adequate fluid replacement.  Excessive crystalloids may lead to hypoproteinemia and further pharmacokinetic disturbances

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 after adequate hydration colloids should be added as plasma expanders.  Consider full stomach and delayed gastric emptying.  Pre-curarization and rapid sequence induction and  intubation is a must with succinylcholine  Apply cricoid pressure from intubation to cuff inflation

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 In a stable patient it is left to the discretion of the anaesthesiologist.  O2/air mixtures muscle relaxants narcotics amnestics and minimal inhalational agents can be used.  Avoid N2O .  Intraoperatively watch for the development of any other unwanted new sign e.g. TNT or tamponade. Maintenance

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 Non-responding fluid replacement therapy from  upper veins may indicate towards possibility of tear in SVC

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 Muscle relaxant :  Avoid succinylcholine in massive trauma fearing hyperkalemia  Vecuroniumor rocuronium are cardiovascularly stable and relaxants of choice.  Avoid atracurium due to rapidly changing acidbase status and due to its hypotensive effect.

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 Observe for drug interactions e.g. antibiotic vs relaxants.  Hypothermia is hazardous.  Awareness is a major but almost unavoidable hazard5 .

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 Respiratory support  Fluid replacement  Hypothermia Post operative care

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