EAST Guidelines for Pneumo/Hemothorax
(The Journal of TRAUMA 2011;70(2):510)
1. Ultrasound can reliably be used to identify pneumothorax and pleural effusion (Level 2).
2. CT of the chest is indicated in patients with persistent opacity on chest radiograph after tube thoracostomy to determine whether significant undrained fluid exists (Level 2)
3. Primary VATS of stable penetrating thoracoabdominal wounds is safe and effective for the diagnosis and management of selected diaphragm and pulmonary injuries
(Level 2).Management of Massive Hemothorax1. Patient physiology should be the primary indications forsurgical intervention rather than absolute numbers of initial or persistent output (Level 2).2. 1500 mL via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgicalexploration (Level II). Management of Hemothorax1. All hemothoraces, regardless of size, should be consideredfor drainage (Level 3).2. Attempt of initial drainage of hemothorax should be witha tube thoracostomy (Level 3).3. Persistent retained hemothorax, seen on plain films, afterplacement of a thoracostomy tube should be treated withearly VATS, not a second chest tube (Level 1). 4. VATS should be done in the first 3 days to 7 days ofhospitalization to decrease the risk of infection and conversionto thoracotomy (Level 2).5. Intrapleural thrombolytic may be used to improve drainageof subacute (6-day to 13-day duration) loculated orexudative collections, particularly patients where risks ofthoracotomy are significant (Level 3).Management of Occult Pneumothorax1. Occult pneumothorax, those not seen on chest radiograph, may be observed in a stable patient regardless of positivepressure ventilation (Level 3).
3. Scoring systems are not accurate in predicting whichpatients will need a tube thoracostomy for occult pneumothorax(Level 3).4. A persistent air leak on postinjury day 3 should prompt aVATS evaluation (Level 2)
Tube Drainage Indications for Thoracotomy
20 cc per kilo initially or 5 cc/kg/hr or 25 cc/kg total to OR
1.5 liters initially or 350 (200) cc/hr or 2 1/2 liters total.
The presence of more than 1500 mL of blood in the initial chest tube drainage, drainage of more than 200 mL an hour for 2-4 hours, or ongoing transfusion requirements mandate surgical exploration with open thoracotomy
CT Chest is useful (J Am Surgeon 2001;67:660-664)
West Study on Retained Hemothorax
RH <=300 cc and pneumothorax as initial indication for trauma thoracostomy tube placement.
Issue: Volume 84(3), March 2018, p 454–458
Notch and Clavicles (roof), Nipple line are lateral (sides), Costal Margins (bottom)
Echo initially and repeat in 6 hours. C-XR initially and in 6 hours. Can use helical CT to evaluate for pericardial fluid, just as good.
The box: definition of proximity to the heart for penetrating injuries. X = wounds that produced cardiac injuries (Nagy KK, J Trauma 1995)
Nipple Line to costal margins/below the scapula
Both cavities and worry about the diaphragm
DPL is good here, use low cut-off 5000 RBCs per cc
7% risk of occult diaphragmatic injury (J Trauma 2003;55(4):646)
- J Trauma. 1997 Oct;43(4):624-6.Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. OBJECTIVE: The objective of this study was to (1) determine the incidence of diaphragmatic injuries in penetrating left thoracoabdominal trauma and (2) evaluate the role of laparoscopy in detecting clinically occult diaphragmatic injuries. PATIENTS AND METHODS: One hundred nineteen consecutive patients with penetrating injuries to the left thoracoabdominal region presenting to Los Angeles County-University of Southern California Medical Center were prospectively evaluated during an 8-month period. Either celiotomy (with hemodynamic instability or peritonitis) or laparoscopy was performed. Results of the clinical examination and roentgenographic findings were recorded preoperatively. RESULTS: One hundred seven patients were fully evaluated. Fifty patients required emergent celiotomy. Fifty-seven patients underwent laparoscopy. The overall incidence of diaphragmatic injuries was 42% (59% for gunshot wounds, 32% for stab wounds). Among the 45 patients with diaphragmatic injuries, 31% had no abdominal tenderness, 40% had a normal chest roentgenogram, and 49% had an associated hemopneumothorax. Fifteen of the patients undergoing laparoscopy (26%) had occult diaphragm injuries. CONCLUSION: (1) The incidence of diaphragmatic injuries in association with penetrating left thoracoabdominal trauma is high. (2) The clinical and roentgenographic findings are unreliable at detecting occult diaphragmatic injuries. (3) Laparoscopy is a vital tool for detecting occult diaphragmatic injuries among patients who have no other indications for formal celiotomy.
X-Ray if ribs 1-2, 9-12, pathological fx, or elderly
1st or 2nd rib is fx along with another rib-get angio
Flail-3 ribs in two places
Epidural analgesia probably reduces vent days and nosocomial pneumonia (J Surg 2004;136(2):426)
A Prospective Randomized Trial of Nebulized Morphine Compared with Patient-Controlled Analgesia Morphine in the Management of Acute Thoracic Pain [Original Articles] Fulda, Gerard J. MD, FACS, FCCM; Giberson, Frederick MD, FACS; Fagraeus, Lennart MD, PhD From the Departments of Surgical Intensive Care (F.G. and G.J.F.) and Anesthesia (L.F.), Christiana Care Health Services, Newark, Delaware. Submitted for publication October 26, 2004. Accepted for publication May 10, 2005. Presented at the 63rd Annual Meeting of the American Association of the Surgery of Trauma, September 29October 2, 2004, Maui, Hawaii. Address for reprints: Gerard J. Fulda, MD, FACS, FCCM, Director, Surgical Intensive Care, Associate Director of Trauma, Christiana Care Health Services, Room 2325, 4755 Ogletown-Stanton Road, Newark, DE 19718; email: email@example.com. Abstract Background: Successfully managing pain for the trauma patient decreases morbidity, improves patient satisfaction, and is an essential component of critical care. Using patient-controlled analgesia (PCA) morphine to control pain may be complicated by concerns of respiratory depression, hemodynamic instability, addiction, urinary retention, and drug-induced ileus. Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract, achieving systemic concentrations equal to 20% of equivalent intravenous doses. The purpose of this study was to evaluate the safety, efficacy, and utility of nebulized morphine in patients with posttraumatic thoracic pain. Methods: This double-blinded, prospective study randomized patients with severe posttraumatic thoracic pain into two groups. The experimental group (NMS) received nebulized morphine every 4 hours and normal saline by PCA. The control group (PCA) received nebulized saline every 4 hours and morphine by PCA. Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale (VAS) for pain. Pulmonary function, pain relief (VAS), level of sedation (03), total drug administration, and systematic side effects were recorded. Results: Forty-four patients were randomized (22 per group). Seven hundred seventy observations were made. The mean 4-hour dose of morphine was 11.96 ± 3.4 mg for NMS and 6.22 ± 4.7 mg for PCA (p < 0.001). Patients with NMS had lower heart rates compared with PCA (79 ± 11 bpm versus 92 ± 12 bpm; p < 0.001) and were less sedated ( 0.33 ± 0.7 versus 0.56 ± 0.9; p = 0.03). The mean pain level (VAS) was 3.38 ± 1.8 for NMS and 3.84 ± 2.7 for PCA (p = 0.2). There was no difference between pain levels before and after dosing. There were no differences between groups with respect to arterial blood pressure, respiratory rate, vital capacity, mean forced expiratory volume in 1 second, spirometric volumes, or Sao 2. Conclusion: Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain. Pain can be successfully managed while vital capacity, mean forced expiratory volume in one second, and spirometric volumes are maintained. Compared with PCA morphine, nebulized morphine provides equivalent pain relief with less sedative effects. Treatment and Dosing All patients had, at baseline, pulmonary function assessments before study initiation. Pulmonary function assessments consisted of forced expiratory volume in 1 second (FEV 1), maximum spirometric capacity, vital capacity, pulse oximetry, arterial blood pressure, and heart rate. Each patient then received an intravenous loading dose of morphine sulfate 0.07 mg/kg (approximately 5 mg). This was to provide all patients with a baseline level of pain control. Patients then received a continuous intravenous infusion of study medication, either morphine 1 mg/h (PCA group) with no on-demand morphine or an equivalent amount of 0.9% saline solution via PCA (NMS group). Both groups also received a nebulized study drug of either 0.9% saline solution (PCA group) or morphine sulfate 8 mg/mL Normal Saline (NSS) (NMS group) every 4 hours around the clock (ATC). In summary, the PCA group received nebulized saline every 4 hours with PCA morphine, and the NMS Group received nebulized morphine every 4 hours with PCA saline. The rational for the initial doses and interval was based on published pharmacokinetic data. 4,5 This data suggest that inhaled morphine administered every 4 hours follows similar kinetics and elimination as a single intravenous injection. However, the dose of nebulized morphine needs to exceed twice the intravenous dose to provide similar bioavailability and half-life. Nebulized morphine was prepared and administered as follows. Morphine and placebo vials were prepared and blinded by the pharmacist. Standard injectable morphine sulfate with preservative was used (Abbott Labs, Chicago, IL). The patient’s nurse provided the correct dosage of study medication to the respiratory therapist. The nurse and therapist were responsible for ensuring that normal saline was added to the study medication to equal a 3 ml total volume. The solution was nebulized using a Respirguard II nebulizer system with the Acorn II nebulizer (Vital Signs, Inc., Totowa, NJ). This system produces an aerosol with a mass median aerodynamic diameter of 1.67 µm with an output of 0.34 mL/min at 8 L/min. The patient received the nebulizer treatment for 10 to 12 minutes. (J Trauma 2005;59(2)
OLD Folks do poorly with Rib Fractures
Bergeron E et al: Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma 54:478, 2003;
Small RCT shows NIV staves off intubation (CHEST January 2010 vol. 137 no. 1 74-80 )
Chest. 2010 Jan;137(1):74-80. Epub 2009 Sep 11.Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial. Hernandez G, Fernandez R, Lopez-Reina P, Cuena R, Pedrosa A, Ortiz R, Hiradier P.Critical Care Medicine, Hospital Virgen de la Salud, Toledo, Mezquite n degrees 12, 6 degrees A, 28045, Madrid, Spain. firstname.lastname@example.orgBACKGROUND: Guidelines for noninvasive mechanical ventilation (NIMV) recommend continuous positive airway pressure in patients with thoracic trauma who remain hypoxic despite regional anesthesia. This recommendation is rated only by level C evidence because randomized controlled trials in this specific population are lacking. Our aim was to determine whether NIMV reduces intubation in severe trauma-related hypoxemia. METHODS: This was a single-center randomized clinical trial in a nine-bed ICU of a level I trauma hospital. Inclusion criteria were patients with Pao(2)/Fio(2)<200 for >8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma. Patients were randomized to remain on high-flow oxygen mask or to receive NIMV. The interface was selected based on the associated injuries. Thoracic anesthesia was universally supplied unless contraindicated. The primary end point was intubation; secondary end points included length of hospital stay and survival. Statistical analysis was based on multivariate analysis. RESULTS: After 25 patients were enrolled in each group, the trial was prematurely stopped for efficacy because the intubation rate was much higher in controls than in NIMV patients (10 [40%] vs 3 [12%], P = .02). Multivariate analysis adjusted for age, gender, chronic heart failure, and Acute Physiology and Chronic Health Evaluation II at admission revealed NIMV as the only variable independently related to intubation (odds ratio, 0.12; 95% CI, 0.02-0.61; P = .01). Length of hospital stay was shorter in NIMV patients (14 vs 21 days P = .001), but no differences were observed in survival or other secondary end points. CONCLUSION: NIMV reduced intubation compared with oxygen therapy in severe thoracic trauma-related hypoxemia.PMID: 19749006 [PubMed – indexed for MEDLINE]
Thoracotomy-20 cc/kg of initial blood, >7cc/kg/hr, decompensation, increased hemothorax
If you get supine AP x-ray, look for deep sulcus sign
1.25% of percent of Pneumo spontaneously absorbed each day, more c 100% O2
Can get a delayed Pneumo up to 4 days post line placement
Normally film 6 hours after initial chest x-ray in trauma, but article suggests 3 hours sufficient (JEM 20:3) and a second prospective trial (J Trauma 65(3):549)
One shot of manual aspiration is supported and efficacious. If it fails, dont try again, move on to chest tube or Heimlich valve (Am J Resp Crit Care Med 165:1240, 2002)
Author, country, date Patient group Study type Outcomes Key results Study weaknesses
Garramone et al, 1991, USA 26 trauma patients aged 1465 with occult pneumothorax (OPTX) on abdominal CT. Classified as <5×80 mm or > = 5×80 mm Retrospective chart review Complications of OPTX, respiratory or haemodynamic compromise No patient had haemodynamic or respiratory complications. Retrospective Small numbers Of 18 with small OPTX: 2 had chest drains for increasing subcutaneous emphysema, 1 for increasing PTX. Of 13 patients with larger OPTX 4 had prophylactic chest drains, 3 for increasing subcutaneous emphysema 2 for increasing effusion Collins et al, 1992, USA 23 patients aged 1882 with occult pneumothorax Retrospective chart review Length of hospital stay (mean) 13.4 days vs 8.8 days Small study Retrospective Length if ICU stay 6.3 days vs 3.3 days Not randomised Immediate chest tube (n = 12) vs observation (n = 11) Complications 1 pt in immediate chest tube group: had laceration of intercostal artery. 2 observed pts had eventual chest tubes for enlarging pneumothorax or haemothorax Enderson et al 1993 USA 40 adult trauma patients PRCT Length of hospital stay 12.9 vs 17.6 days Small study Randomized to immediate chest tube (n = 19) or observation (n = 21) Length of ICU stay 2.8 vs 3.2 days Complications Immediate chest tube: 1 pneumonia, 8 atelectasis. Observation group 3 tension pneumothorax, 5 progression pneumothorax, 1 pneumonia, 1 empyema, 3 atelectasis Wolfman et al 1998 , USA 44 pts aged 17 months 70 yrs with occult pneumothorax, classified according to size into miniscule, anterior or anterolateral. Chest tube inserted dependent on size and at trauma surgeons discretion Prospective non-randomized Complications 15/16 with miniscule observed, 2 had delayed chest drain for pneumothorax progression. 12/20 anterior observed 1 developed tension pneumothorax. 8 with anterolateral had immediate chest drain, no complications Small numbers Both adults and children Brasel et al 1999 , USA 39 adult patients with occult pneumothorax randomised to chest tube (n = 18) or observation (n = 21) PRCT Respiratory distress 1 pt with chest tube was intubated for stridor. 3 observed pts had resp distress with pneumothorax progression Only 39 of 86 eligible pts recruited Holmes et al2000 , USA 11 children <16yrs with occult pneumothorax presenting to level 1 trauma centre. 1 had chest tube, 10 observed Prospective observational cohort study Complications No haemodynamic or respiratory complications Small numbers paediatric population
J Trauma. 1993 Nov;35(5):726-9; discussion 729-30.Links Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville. Occult pneumothorax is defined as a pneumothorax that is detected by abdominal computed tomographic (CT) scanning, but not routine supine screening chest roentgenograms. Forty trauma patients with occult pneumothorax were prospectively randomized to management with tube thoracostomy (n = 19) or observation (n = 21) without regard to the possible need for positive pressure ventilation, to test the hypothesis that tube thoracostomy is unnecessary in this entity. Eight of the 21 patients observed had progression of their pneumothoraces on positive pressure ventilation, with three developing tension pneumothorax. None of the patients with tube thoracostomy suffered major complications as a result of the procedure. Hospital and ICU lengths of stay were not increased by tube thoracostomy. Patients with occult pneumothorax who require positive pressure ventilation should undergo tube thoracostomy.
Prospective multicenter of occult pneumo (J Trauma 2011;70:1019)
Only 14% failed obs approach on mech vent
no patient developed tension or decompensation
True Pathophysiology of Tension
Emerg Med J 2005;22:8–16.
Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury.
Karmy-Jones R, Holevar M, Sullivan RJ, Fleisig A, Jurkovich GJ.
Department of Surgery, Harborview Medical Center, Seattle, Washington 98664, USA. email@example.com
BACKGROUND: Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies. OBJECTIVE: To determine whether residual hemothorax detected by chest x-ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema. METHODS: A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score. RESULTS: A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4+/-26) versus those who did not (22.6+/-13; P=0.03). CONCLUSIONS: The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach.
Small hemothoraces can probably be left undrained (< 1.5 cm), if there is a coincident pneumo, then probably put it in (Am J of Surgery 2006;192:722)
Risk of post-traumatic empyema in pt’s with retained hemothorax (J Trauma 2012;73:752) 26.8% rate of empyema. Go after the blood.
but newer study disagrees
Journal of Trauma and Acute Care Surgery
Issue: Volume 84(3), March 2018, p 454–458
Brief dysrhythmia, hypotension or LOC c no lasting effects, no autopsy evidence
Most commonly from mva
Can cause vasospasm or thromboembolism
Pericardial effusion +- friction rub, S3 gallop, rales, elevated CVP
2 mechanisms of injury: transient reduction in bloodflow and transient dysrhythmias
70% of pts have tachycardia
EKG is the screening exam, if negative, do not have to admit
Common ekg abnormalities are PVCs, 1st degree av block, RBBB (Right ventricle is closest to anterior chest wall)
It is possible to have problems 12-72 hours after injury
If available, gated radionucleotide angiography is excellent test
Thalium also good
Monitor for 12 hours then can send home, b/c no life threatening problems seen after this time
If decreased cardiac output, can use dobutamine or IABP
Send 1 Troponin and get EKG: both normal, young patient, send home (Journal of Trauma 50:237 2001) 100% sensitivity
Another study used 0 and 8 hour trops (J Trauma 2003;54:45-51.)
Abnormal Admit to Tele Bed
If the patient is unstable, get an echo
troponin specific but insensitive for myo injury in trauma (Anesthesiology 2004;101:1262)
Excellent Blunt Cardiac Injury Review (Crit Care Clin 2004;20:57)
New Guidelines from EAST
The Eastern Association for the Surgery of Trauma recently released an update of their practice guideline for screening for blunt cardiac injury. Although the bulk of the guideline remains the same, a few areas have been updated to reflect advances since its original 1998 release.
Here is a quick summary of the new guidelines. Level 1 (best data):
- If blunt cardiac injury is suspected, an EKG should be obtained (no change)
Level 2 (okay data):
- If a new arrhythmia is seen on EKG, admit for monitoring. If not new, compare with an old EKG to determine need for admission. (updated)
- If the EKG is normal and troponin I is normal, BCI is ruled out. If the EKG is normal and troponin I is abnormal, admit for monitoring. (new)
- If the patient is unstable or the arrhythmia persists, obtain a cardiac echo. (updated)
- Sternal fracture is not predictive of BCI (moved from level 3)
- CPK should not be obtained (modified and moved from level 3)
- Nuclear medicine studies should not be obtained (no change)
Level 3 (data not so good):
- Elderly patients with known cardiac disease, unstable patients, and those with abnormal EKG can safely undergo surgery with appropriate monitoring (no change)
- Troponin I should be measured routinely in suspected BCI, and if elevated should prompt monitoring and serial testing (new)
- Cardiac CT or MRI may help differentiate acute MI from BCI to determine need for catheterization and/or anti-coagulation (new)
The EAST guidelines are just that, guidelines. They are not a complete management algorithm. I have combined this new information with an existing algorithm based on the old EAST guidelines. Feel free to download this algorithm using the link below. As always, I welcome any comments.
Reference: Screening for by cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 73:(5) Supplement 4, S301-S306, 2012.
Acute Pericardial Tamponade
2% of penetrating chest trauma
CVP increases to greater than 15
Becks triad-distant heart sounds, JVD, hypotension. Also see pulsus paradoxus
EKG-electric alternans-alternates amplitude every other beat from decreased oscillation of heart, much more common in chronic effusion.
Chronic=water bottle heart on X-ray
Possible complication of CPR
in stable patients, a 24 hour period of observation can screen for patients who may be able to get pericardial window rather than sternotomy ( Annals of Surgery Issue: Volume 259(3), March 2014, p 438–442)
Computed tomography screens stable patients at risk for penetrating cardiac injury
KK Nagy, SH Gilkey, RR Roberts, JJ Fildes and J Barrett Department of Trauma, Cook County Hospital, Chicago, IL, USA. firstname.lastname@example.org
OBJECTIVE: To determine the accuracy of CT of the chest in diagnosing thepresence of cardiac injury in stable patients with penetrating chestinjuries. METHODS: A retrospective chart review of a convenience sample ofstable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center. RESULTS:60 stable patients with penetrating wounds in proximity to the heartunderwent CT. Three patients had radiographic evidence of pericardialfluid, and 1 had an equivocal study. These 4 patients underwent subxiphoidpericardial window exploration: 2 had only clear fluid present, the other 2had hemopericardium. The latter patients had a total of 3 cardiac and 1diaphragmatic injuries, which were repaired at subsequent sternotomy. Noneof the 56 patients who had negative CTs had further clinical evidence ofcardiac injury. The sensitivity, specificity, and accuracy of CT in thissetting for hemopericardium are 100% (95% CI 18-100%), 96.6% (95% CI88-100%), and 96.7% (95% CI 89- 100%), respectively. CONCLUSION: Chest CTmay be a useful test for diagnosing the presence of hemopericardium in thesetting of penetrating thoracic injury. With the caveat that the patientmust be removed from a closely monitored environment, the authors the useof CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.
Go to source: Computed tomography screens stable patients at risk for penetrating cardiac injury — Nagy et al. 3 (11): 1024 — Academic Emergency Medicine
Intubation of Tamponade
(Resus 2008 Ho AM Timing of tracheal intubation in traumatic cardiac tampondade)
Esophageal and Diaphragmatic Trauma
Barium is the only acceptable contrast for esophageal perf (Acta radiologica 2000;41:482)
Esophageal Perforation (Boerhaave’s)
Esophagus has no serosa, so perf = direct access to mediastinum
DX by pain, possibly pleuritic
Hammans crunch from air surrounding heart
C-XR: mediastinal air, L pleural effusion, pneumothorax, increased mediastinum
Get Esophogram 1st gastro then barium
Rx: Broad spectrum ABX, NGT
In a message dated 7/19/2006 3:20:07 P.M. Central Standard Time,email@example.com writes: And I have just as valid anecdotes–at least two of our tubed patients—NOT trickled but given full esophageal contrast swallows with barium–injuries found, and in our institution in 21 years one never yet missed with it–so–what does that prove–as …… The issue here might be with the medium used. BARIUM is the only acceptable medium to use in esophagograms to look for leaks. I have never understood, nor can I find any scientific reason or support for, the urban legend that one should use gastrographin for an esophagogram. Gastrographin is DANGEROUS, in that if aspirated, can cause chemical pneumonitis. It also has a significant false negative rate. Virtually every trauma and thoracic surgery textbook chapter that I can find recommends BARIUM. Thoracic and trauma surgeons who present at national meetings recommend BARIUM, and ridicule gastrographin. SO…………………………… the contrarian views on this link server might be due to the fact that those reporting false negative results with esophagograms were using the wrong media. k mattox
andre consider yourself fortunate to have never had a significant aspiration of gastrografin i have practiced radiology for 35 years and have never had a fatal complication of intravascular contrast administration. i have had, very early in my career before I knew better, two deaths caused by aspiration of gastrografin. The use of barium is reliable and barium is inert in the neck and mediastinum. Could not the inflammation that you describe have been caused by the leakage from the perforation rather than the barium? HOWEVER, barium comes in all sizes and flavors. Barium paste would be unlikely to be reliable. Too thick to exit many of the perforation sites. Same goes for thick barium suspension. A moderately dilute “full strength” barium (30-40%) is likely to be the best option for finding holes. a CAVEAT i have mentioned here before bears repeating. If there are penetrations near the EG junction or if you are doing a esophagogram in a patient who might have a concomitant intraperitoneal perforation, start with gastrografin since barium does sometimes cause a severe peritonitis. sal
Penetrating Esophageal Injuries
From: McSwain, Norman E Jr. <firstname.lastname@example.org> Date: May 29, 2008 3:33 PM Subject: RE: Delayed oesophageal injury To: “Trauma & Critical Care mailing list” <email@example.com>I would have closed the injury, pulled muscle over the areas of repair and WOULD NOT have place any drains. Drains create fistulae. Muscle provides sealing coverage. NPO x 48 hours of antibiotics. IV fluids. Esophageal swallow to access the repair in 48-72 hours. This is assuming a standard sized stab wound < 2 cm on each side and no vascular injury I would not have created a spit fistula nor a jejunostomy I would have treated a GSW the same way unless massive tissue destruction
L much weaker than right in blunt trauma b/c liver protects right. Most likely sight of injury posterio-lateral portion of L diaphragm
Diaphragm can extend to L2/L3 posteriorly
15 year review of all patients with blunt diaphragm injury [n=13]: Results: 77% left, 23% right 30% missed during the initial evaluation Delay 1 one 10 years (Patselas TN. Am Surg 2002; 68:633-9.)
Laparoscopy study in 110 patients with left-chest penetrating trauma and no indications for laparotomy: Diaphragm injury in 24% 21% of these had a normal CXR 31% of these had hemo/pneumothorax (Murray JA. J Am Coll Surg 1998; 187:626-30.) (Gibb’s Lecture)
Most commonly aortic
Cervicothoracic Seatbelt Sign
Not necessarily indicative of underlying injury. Most of those with injury will have some other physical sign (J Trauma 52:618 2002) (Am Surg 68:441, 2002)
may have no signs on initial x-ray
opacities appear at 6 hours and usually resolve by 72 hours.
Am Surg. 1996 Nov;62(11):967-72. Survival after trauma pneumonectomy: the pathophysiologic balance of shock resuscitation with right heart failure. Baumgartner F, Omari B, Lee J, Bleiweis M, Snyder R, Robertson J, Sheppard B, Milliken J. Division of Cardiothoracic Surgery, Harbor-UCLA Medical Center, Torrance, California, USA. Emergency pneumonectomy for trauma has a high mortality. Although exsanguination is a major factor leading to death, mortality remains high even after adequate resuscitation and is thought to be related to pulmonary edema and right heart failure. We present a series of nine patients who underwent pneumonectomy at Harbor-UCLA from penetrating (7) and blunt (2) trauma. Two patients survived; three initially survived the surgery but died postoperatively of hypoxemia and right heart failure; four died intraoperatively (2 from right heart failure and 2 from exsanguination). One survivor required open cardiac massage for asystole. Careful attention to prevent volume overloading before and during trauma pneumonectomy and maintaining a negative fluid balance postoperatively may contribute to survival in these patients.
Always Consider Bronchial Injuries if Mediastinal Damage (Ann Thorac Surg 2004;78:2157)
Penetrating Esophageal Injuries
Rare. Article on factors affecting outcome (Br J Surg 2004;91:1513)
can do tractotomy for gunshot wound to the lung use a GIA 80 stapler across the tract to open it up nicely
Can use endobronchial blockers to isolate (J Trauma 2006;61:755)
it’s a big deal. Albumin in the blood destroys surfactant
Lung Sequestration Syndrome
oversew area of dead lung
Penetrating Cardiac Trauma
Injury 2005;36(6):745-750 Haemopericardium in stable patients after penetrating injury: Is subxiphoid pericardial window and drainage enough?–Small study (14 patients) of conservative management of pericardial blood
Study of blind subxiphoid pericardiotomy (J Trauma 2006;61:582)
Do we need a chest xray
absence of palpation tenderness and hypoxia identified most of pathology (Ann Emerg Med 2006;47(5):415)
Macklin effect: a peripheral alveolus ruptures and the air tracks centrally along the interstitium into the mediastinum and soft tissues (NEJM, May 17, 2007, pg. 2083).
if the patient is stable, may not need an extensive workup (DOI: 10.1097/TA.0000000000000714)
Intercostal Bleeding can be ameloriated with a foley (Injury 42 (2011) 958959)
intrathoracic tracheal injuries will need 4th ICS posterolateral thoracotomy
fix posterior wall through an incision in the anterior wall
segmental blood supply at 4 o’clock and 8 o’clock
You can use lung windows on CT C-Spine to diagnose pneumothorax (Injury (2012) 43:51–54)