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Arun Nagdev, MD Department of Emergency Medicine

Highland General Hospital Director, Emergency Ultrasound

Thoracic Trauma

Overview

• Overview

• Penetrating Thoracic Trauma

• Blunt Thoracic Trauma

• Bedside Ultrasound for Thoracic Trauma

Chest Trauma

Severe Hypoxia

Massive Blood Loss

Reduced Cariac Output

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ED Goal - Trauma

• Stabilize the Very Sick (thorocostomy, ED thorocotomy, etc.)

• Image the Sick

• Send home the Well

go over basic ATLS including slide on the sick vs not sick slide transition for sick with thorocostomy or edt

Penetrating Chest Trauma

Unstable Stable

ATLS

ECHO ED

Thoracotomy

MDCT

Full Examination ECHO

“B” before “A”

EDT - Why? • Release Pericardial Tamponade

• Control Intrathoracic vascular hemorrhage

• Control Massive Air Emboli / Bronchopleural Fistula

• Permit Cardiac Massage

• Occlude Descending Thoracic Aorta to limit subdiaphragmatic blood loss

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When - Selective

• Signs of life* in the ED

• No obvious Non-survivable Injuries

•  very low survival rates

• Signs of life in the field or ED

• SW (10%)

• GSW (1-5%)

Blunt Penetrating

J Trauma. 1993 May;34(5):711-5; discussion 715-6.

Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination. Macho JR, Markison RE, Schecter WP.

Department of Surgery, University of California, San Francisco.

EDT - Why? • Release Pericardial Tamponade

• Control Intrathoracic vascular hemorrhage

• Control Massive Air Emboli / Bronchopleural Fistula

• Permit Cardiac Massage

• Occlude Descending Thoracic Aorta to limit subdiaphragmatic blood loss

Release Pericardial Tamponade

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ED ECHO

• A needed tool for ALL EM physicians managing Thoracoabdominal Trauma

• Not difficult to determine Pos vs Neg pericardial Effusion

• Game Changer

Oakland 911

• 23 ym s/p left sided SW

• Hypotensive in the field, cool, clammy, diaphoretic but GCS 15

• ABC intact, BG 111

• BP?

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Dispo?

• Pressures + trauma surgeon = OR

• PEA and/or no trauma surgeon = volume + ED thoracotomy

Subxiphoid / Subcostal

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RV

LV RA

LA

Liver COPD

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Parasternal Long

LV

RV Mitral Valve

Ao

Pericardium

Young and Healthy

DTA

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• Residents and Attendings

• 1h didactic and 4 h hands-on

• N=515

• Sens = 96%

• Spec 98%

• Accuracy = 97.5%

Quick Penetrating Chest Trauma Points

• Below the Nipple = think about the abdomen

• Chest tube with lots of blood (>1-1.5L) think OR

• Air leak from Chest Tube w/ continued pneumo = tracheobronchial injury

• Bedside ECHO mandatory

Blunt Thoracic Injury

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Stable

1. Lost Pulses - EDT 2. Pneumo - Needle vs Thorocostomy 3. Hemo - Thorocostomy 4. Pericardial Effusion -Pericardiocentesis vs EDT

ABC

Persistent Hypo or Blood Loss

OR Thoracotomy

MDCT

Secondary Survey CXR?

“B” before “A”

Done

No

MDCT

Improved

????

Yes

• N=492 patients

• 31/492 had injury

• Palpable Chest Tenderness or Hypoxia identified all SIGNIFICANT injuries

• Potential = 46% reduction of CXR

• No f/u after D/C

Ann EM 2006

• Retro Trauma Registry = 1989 (2.7%) to 2004 (28.7%) - N=1873

• Normal CXR then MDCT = sig number of occult injuries (hemo/pneumo, rib fractures, etc.)

• 6 BAI w/ normal CXR

• ? Need for all Thoracic Trauma to get MDCT

J Trauma 2007

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Non-trauma Centers

• EM Docs = highly sensitivity

• Large trauma center is very different than a single coverage ED

• Goal = Emergent Intervention vs Further Imaging vs nothing

• Associations - for the “in between” group�

EMS Questions / Pretest

• Vehicle Speed ? High Speed (>40mph)

• Restraints? (seat belts and airbag deployment)

• Extensive vehicle damage with intrusion?

• Steering Wheel Deformity

H&P

• Obvious injuries = imaging

• Vital Signs

• Patient’s complaints / clinical appearance

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Imaging

• CXR vs Chest CT

• Low risk (no tenderness or hypoxia) - as per Rodriguez, we may not even need a CXR

• Really Sick / High Mechanism = Stabilize and CT

• In Between - look for Associated Injuries

Blunt Thoracic Trauma

CXR

• AP vs PA

• Sensitivity, Specificity

• No need?

• Done after CXR

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CRX : Bad • Wide Mediastinum

• Obscured Aortic Knob

• Left Apical Cap

• Large Left hemothorax

• Deviation of NGT

• Deviation of trachea rightward and/or right mainstem bronchus downward

• Wide Paravertebral Stripe

Chest CT

• Gold Standard

• Radiation?

• All Blunt Thoracic Injuries?

Difficult Injuries • Occult Hemothorax

• Occult Pneumothorax

• Aortic Injury

• Cardiac Contusion

• Pulmonary Contusion

• Diaphragmatic Injury

• Multiple Rib Fracture / Sternal Fracture

label Easy, Med, Difficult

Concept - Need to know they exist and how your tests sens/spec to pick one up

Example - bowel injury Ovarian Torsion

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Occult Hemothorax

• defined - missed by supine CXR

• 300 cc on upright CXR

• 20-30% not identified on Supine CXR

• What to do with them?

• Association with other thoracic injuries?

Rithlin, et al 1993 Pro Sens 81%

Ma, et al. 1995 Cohort Sens 96% Spec 100%

Ma / Mateer, et al. 1997 Retro Sens 96.2% Spec 100%

Sisley, et al. 1998 Pro Sens 97.5% Spec 99.7%

Abboud, et al. 2003 Pro Sens 12.5% Spec 98.4%

Brooks, et al. 2004 Pro Sens 92% Spec 100%

Author Year Type Result

US for Hemothorax

Hemothorax�(Beginner)

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Probe Selection

Low Freq

Curvilinear

Supine Chest

Air

Blood

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Rationale

Hemothorax - Landmarks

• Always Identify the Diaphragm

• Look Above and Below the Diaphragm

• Practice on Normal

• Black / Anechoic stripe = Blood

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Acoustic Window

retroperitoneal tilt

Morison’s Pouch

Costophrenic Recess

RUQ/Perihepatic view:�Normal

Morison’s Pouch

Costophrenic Recess

Diaphragm

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Hemothorax Data

• Ma, Mateer, et al. Trauma Ultrasound Examination Versus Chest Radiography in the Detection of Hemothorax. Ann Emerg Med 1997

• Abboud et al. Emergency Department Ultrasound For Hemothorax After Blunt Traumatic Injury. JEM 2003

• Brooks et al. Emergency Ultrasound in the Acute Assesment of Haemothorax. EMJ 2004

Poor Sensitivity for Small Volumes?

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What to do with Occult Hemo?

• Bllello, et al. “Occult Traumatic Hemothorax: when can sleeping dogs lie?” AM J Surg 2005

• Stafford, et al. “Incidence and management of occult hemothoraces” AM J Surg 2006

• Small = leave alone

• Large (>1.5cm) = drain

• ABX for Thorocostomy- ?

Clinical Relevance

• Like FAST, large/clinically significant should be clearly visible*

• Does a small hemothorax warrant further CT imaging?

• Associations

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Associations

• No prospective data regarding associations between hemothorax and other more serious Intrthoracic injuries

• Further imaging may be warranted

• You know your next step

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Pneumothorax

sens of AP cxr sens of us when do you place a chest tube abx for chest tube

easy

Pneumothorax�(Intermediate)

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86-98%

97-100%

CXR US

Sens

Spec

AEM Jan 2010

4 prospective observational studies

Supine Chest

Air

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Hilum B A

V

V

L

1980

Lams et al. 1982 Radiology;142:309-312

Inferior Pulmonary Ligament

Pleural Space

Mediastinum

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Probe Selection

10-15 MHz 38 mm

10-15 MHz 25 mm

(image acquisition - for the beginner)

98.1%

99.2%

CXR US

Sens

Spec

B-mode

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Probe Marker to Head

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Rib Rib Normal

Lung

Rib

Alveoli

Rib Shadow

Normal Lung: Sliding Visceral Pleura

Normal Lung

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Rib 1 2 3 4 5 6 7 8 9 10 11

Normal Lung: Comet Tails

Rib Rib Parietal Pleura

Visceral Pleura Comet Tails (Artifact)

Normal Lung

Lung Sliding Comet Tails

B-Mode

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Rib

AIR

Rib

Abnormal Lung: Pneumothorax

Parietal Pleura

Visceral Pleura

Parietal Pleura

Air (Scatter)

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Normal Abnormal

REVIEW

Back to our CASE

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Pneumo - No lung Sliding Normal

What to do?

2009

Much Debate - positive and negative data in small studies

Watch all non-ventilated patients

Intubation = Chest Tube

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US for Occult Pneumo

• Practice on Normals

• Look for Lung Sliding

• Supine CXR does not R/O a Pneumo

• Associated Injuries with ? need for further imaging

Sternal Fracture • Mech - Hig energy, rapid decel with chest

hitting steering column

• AP CXR = 50% sensitive

• CT Chest - much more sensitive, but no definitive studies

• Again - standard imaging Not Sens

US?

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Association

• High associations with intrathoracic injuries

• CT Chest, ECG, +/- cardiac biomarkers

• No data on ED US

Blunt Cardiac Injury

• No standard definition with unknown incidence

• Mechanism - Same as before

• Presentation - CP, SOB, Sinus tach, cardiac ectopy/dysrythmia, hypotension

Mechanism

• Significant Chest Trauma

• Pain and Tenderness over the Mid-anterior Chest

• Sternal Fracture

• Mech (rollover, high speed, fatality at scene)

Mechanism for Blunt Cardiac Injury?�Physical Findings? Seat Belt Sign?

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Data?

• Single ECG vs Serial ECGs?

• Troponins? - Biffl vs Rajan

• Biffl - Useless, and screening ECG best test

• Rajan - Elevated Trop at 6h correlated with increased risk for dysrhythmia and low EF

• No clear standard

What to do?

• Screen with ECG = pain or tenderness over anterior Chest, sternal fracture, history of cardiac disease (accident precipitated by cardiac dysfunction, major mechanism)

• ECG - persistent tachycardia, new bundle branch block or dysrhythmia

• Abnormality = ECHO (valvular, septum or ventricular wall injury) for low output

Treatment

• Persistent Tachycardia - Look for other signs of hemorrhage (chest, abdomen, etc.)

• High-grade Dysrhythmia - ECHO and ? treatment via ACLS

• My Case

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Normal Low EF

Function?

Blunt Cardiac Injury

• Mechanism + pain = screening ECG

• 4-6 hour Trop?

• Bedside ECHO may be useful

• Remember to look for Non-cardiac causes

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Blunt Diaphragmatic Injuries

• Incidence = low (1%) with increasing rates secondary to more sensitive CT

• Left (80%) > Right (20%)

• Right = 50% liver injury

Mechanism

• High Impact MVC

• Head on collision

• >30cm intrusion

• rapid deceleration >40mph

Other Injuries

• Spleen and Liver

• Clinical - epigastric/abdominal pain, referred shoulder pain, SOB, vomiting, dysphagia, etc

• Least Urgent injury in Multiple Trauma

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Diagnosis • CXR - 50% sensitive

• Specific = NGT or Viscera in Chest

• Nonspecific = atelectasis, pleural effusion, loss of contour, hemo/pneumo

• MDCT - increasing with coronal and sagittal recons (not 100% sensitive)

• Thoracoscopy/Laproscopy - TOC

CT data for diaphragmatic injury?

Normal

Abnormal

Specific, Not Sensitive!

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Associations

• Treat - NGT decompression

• Look for other associated injuries

• Very Difficult Diagnosis - Missed Often

Blunt Aortic Injury

• 80% die on scene

• Tear usually at the Isthmus (just distal to left subclavian artery)

• Can be very subtle in those that reach the ED

• Pseudocoarctation - Elevated BP in UE and lower BP in lower extermities

difficult

data any associations? cxr findings? how sensitive? ed treatment - BP control

Mechanism

• Fall 10 feet

• MVC > 40 mph

• Any blunt trauma with rapid deceleration

• Crush Injuries

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Presentation

• Chest Wall tenderness

• Other Skeletal Injuries

• Mechanism should be the trigger

• Associated Injuries Common

CXR

• Widened Mediastinum

• Deviation of NG Tube

• Apical Capping

• Depressed Left Main Stem Bronchus

• Widened Paratracheal Stripe

• Loss of Aortic Knob Contour

Widened Mediastinum

• No exact Widths (no consensus)

• CXR (especially supine AP) cannot “rule out” the disease

• Mechanism and associated injuries should trigger further investigation

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Imaging

• Newer generation MDCT = 100% sensitivity

• TEE - useful, but impractical

• TTE - not sensitive (no data)

• Maintain High Clinical Suspicion

• Associated Injuries

Treatment • Prevent propagation of adventitial

dissection by reducing wall stress

• Decrease HR = Esmolol

• Decreasing Blood Pressure = nitroprusside or nitrglycerin

• *diltiazem if beta blocker contraindicated

• Goal = SBP 100mmHg

dose?

Review

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Penetrating Chest Trauma

Unstable Stable

ED Thoracotomy

MDCT

Full Examination

“B” before “A”

ECHO

ECHO

Blunt

1. Lost Pulses - EDT 2. Pneumo - Needle vs Thorocostomy 3. Hemo - Thorocostomy 4. Pericardial Effusion -Pericardiocentesis vs EDT

ABC

Persistent Hypo or Blood Loss

OR Thoracotomy

MDCT

Secondary Survey CXR?

“B” before “A”

Done

Not Stable

MDCT

Improved

????

Stable

ABC

MDCT

Secondary Survey

Done

Normal CXR Normal US low Mech

High Mechanism Abn US

Diaphragmatic Injuries Cardiac Contusion

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Summary

• Look for occult Associated Injuries

• Use Ultrasound

• Neg CT does not rule out all disease

END