anesthesia for cardiothoracic trauma charles e. smith, md department of anesthesia metrohealth...

Anesthesia for Cardiothoracic Trauma

Charles E. Smith, MD

Department of Anesthesia

MetroHealth Medical Center

Case Western Reserve University

Cleveland, Ohio

Email: csmith@metrohealth.org

Objectives

• Incidence

• Pathophysiology

• Specific injuries

ATLS Provider Manual

Trauma

• Leading cause of death, ages 1 - 44 yrs

• 60 million injuries annually in USA– 30 million require medical care– 3.6 million require hospitalization– 9 million are disabling

• 300 k = permanent; 8.7 million= temporary

• Costs are staggering: > $100 billion annually, or 40% of health care $

Cardiothoracic Injuries

• Accounts for 20% trauma deaths in US

• Contributing factor in additional 25%

• Immediate deaths: massive injury heart, great vessels, lungs

• Early deaths: airway, hypoxia, hemorrhage, tamponade, aspiration

Pathophysiology

• Respiratory insufficiency + hypoxia– chest wall injury, rib fx, flail, airway– hemothorax, pneumo, contusion, aspiration

• Hemodynamic collapse + shock– massive hemothorax– cardiogenic shock: tamponade or blunt cardiac– mediastinal shock: tension pneumo

Siegel JH et al: Trauma: Emergency Surgery + Critical Care, 1987:201-284

Devitt: CJA 1991;38:506. Incidence of injuries in patients presenting to OR emergently

Blunt Chest Injuries

Incidence

0

25

50

75

%

Besson + Saegesser 1983; Switzerland, N= 1485 chest injuries

Blunt Chest Trauma: Extra-thoracic Injuries

Incidence

0

25

50

%

Initial Evaluation

• History of traumatic event:

– mechanism of injury: mva, mca, assault, fall, blasts, pedestrian struck, gsw, stab

– energy exchange: speed of vehicle, distance of fall, weapon caliber, entry + exit wounds

• Review of systems:

– allergies, meds, PMH, last meal, events before + after injury: AMPLE

1o Survey

• Airway + c-spine control

• Breathing, O2 sat

• Circulation, pulse, stop external bleeding

• Disability: Rapid neuro exam– alert, v. responds to verbal, to pain, unresponsive

• Exposure/ environmental control

2o Survey

• Rest of vital signs

• Physical exam

• Xrays: lat c-spine, chest, pelvis

• FAST, DPL, CT, other studies

• Done only after 1o survey completed + resuscitation begun

Case: Hemopneumothorax

• 26 yo female, initially stable after high speed MVA

• During CT, had dyspnea, tachypnea, tachycardia, hypotension, BS left

• Transferred emergently to OR

Hemothorax

Which is true?1. Bleeding usually continues after chest tube

insertion + lung re-expansion2. Respiratory failure + shock may occur 3. Hypoxia, breath sounds + hyper-resonance to

percussion are usual findings4. Hemothorax is unlikely to occur in the setting of

penetrating thoracic trauma5. Emergency thoracotomy + OLV often required

Blunt thoracoabdominal trauma, hemopneumo, fx ribs

Grade IV splenic laceration, ruptured diaphragm, contrast in stomach

Case Management

• Transferred to OR: – RSI: ketamine, succinylcholine– Chest tube– Fluid + blood resuscitation (type specific

uncrossmatched, Level 1 warmer)– Splenectomy, repair of ruptured diaphragm– ICU x 24 hours

• Full recovery

Tension Pneumothorax

Which is true?1. Hypoxia, BS, BP, dullness to

percussion, + Paw are diagnostic clues2. N2O is contraindicated3. ETCO2 is with bilateral tension px4. Thoracic decompression with a large-bore

needle is best done in the 4rth intercostal space, mid-clavicular line

Tension Pneumothorax

• Pathophysiology:– accumulation of air under pressure – compression of contralateral lung, vena cava,

cavo-atrial junction

• Dx:– hypoxia, BS, hyper-resonance, hypotension,

tracheal deviation, JVD Paw (volume controlled ventilation)

Management Tension Pneumo

• Large bore needle – 2nd IC space, mid-clavicular line– Converts to simple px

• Chest tube– 5th IC space, mid-axillary line

• Avoid N2O + PEEP

• High index suspicion, especially with PPV

Avoid N2O

Dietrich: Anesthesiology 2001;95:1028

Case: Undiagnosed Traumatic Diaphragmatic Hernia

• 19 yo parturient, active labor, term, transferred to MHMC, non-reassuring FH trace

• Anesthesia preop assessment: LUQ pain, dyspnea, tachypnea, tachycardia, BS left, tracheal deviation to right

• PMH: stab wound left chest 3 yrs prior, no rx required

• Surgery delayed: trauma/thoracic consult

Traumatic Diaphragmatic Rupture

Which is true?

1. It is self-limiting + heals spontaneously

2. Stomach and abdominal viscera may herniate, collapse the lung, and risk of aspiration

3. It is more common after blunt than after penetrating thoraco-abdominal trauma

4. It is more common on the right than left side

Daiphragmatic hernia in a parturient at term

Saggital reconstrcution showing diaphragmatic hernia

Dietrich: Anesthesiology 2001;95:128

Management

• C-section w spinal anesthesia• Complicated postop course b/c collapsed lung,

pericardial effusion, compression of heart, strangulated + perforated bowel

• Tx: Pericardial window, antibiotics, prolonged mechanical ventilation, ARDS, repair of bowel + hernia after improved pulmonary fct

• Discharge to home 4 months post delivery

Lim et al: Ann Thorac Surg 2001;71:1714 + 2002;73:342

Case: Penetrating Cardiac Trauma

• 29 yo male, stab wound to heart

• RSI

• ED thoracotomy: 1 inch entry wound in LV

• Transferred to OR, BP 80/50, HR 130-150

Lim et al: Ann Thorac Surg 2001;71:1714

Management

• Art line

• Scopolamine, muscle relaxant, PPV

• Adenosine 12 mg IV bolus (x 3) to HR

• Transient asystole: allowed accurate placement of sutures; bypass avoided

• Full recovery

Cardiac Injuries

Which is true?

1. Tamponade is best treated by pericardiocentesis in the ED

2. JVD is an important clue for tamponade

3. Echo is reliable method for detecting functional + structural cardiac abnormalities

4. CPB is frequently (>50%) required to repair cardiac injuries

Penetrating Cardiac Injuries

• GSW: usually die• Stab: usually present

with tamponade• Dx: history, JVD,

BP, pulsus, echo• JVD- may be absent if

hypovolemic• Tx: surgical drainage

+ repair, + bypass

www.trauma.org/thoracic/index.html

Blunt Cardiac Injury (Myocardial Contusion)

• Spectrum of problems– enzyme abnormalities, ST segment – arrhythmias: PVCs, RBBB, VT– wall motion abnormalities– cardiac failure– cardiac rupture

• Dx: history, ECG, echo

Echo

Flancbaum L: J Trauma 1986;26:795; Ross P: Arch Surg 1989;124:506

Risk of Surgery with BCI: No Deaths, but...

1986 n=19 1989, n=30

PAC- 12 13% had complications

Inotropes- 11 VF

Arrhythmias- 8 Pulmonary edema

IABP- 1 Nodal or PVCs

Malangoni et al: Surgery 1994;116:628

Serious BCI @ MHMC

• Specific injuries– acute myocardial rupture– valve disruption– contusion w CHF or complex arrhythmias– delayed myocardial rupture (44 d)– coronary art thrombosis

• ECG suggested cardiac injuries in all

• Echo useful for dx

Pitfalls in Cardiothoracic Trauma

• Failure to appreciate severity of– pulmonary contusion– cardiac injury (blunt + penetrating)– blood loss– other injuries

• Simple pneumo tension pneumo with PPV• Endobronchial intub can mimic tension pneumo• Failure to optimize ventilation, oxygenation, organ

perfusion, + circulating blood volume