Anesthesia for Cardiothoracic Trauma
Charles E. Smith, MD
Department of Anesthesia
MetroHealth Medical Center
Case Western Reserve University
Cleveland, Ohio
Email: [email protected]
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