O’Connor – Thoracic Complications of Trauma

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James O’Connor, M.D., FACS, FCCP, Professor of Surgery, Department of Surgery at the University of Maryland SOM; Chief, Thoracic and Vascular Trauma at the R Adams Cowley Shock Trauma Center/UMMC; and Executive Medical Director at Shock Trauma Associates, P.A., presents the weekly multi-departmental critical care fellows’ lecture on “Thoracic Complications of Trauma: Empyema, Hemothorax, Bronchopleural Fistula.”

Lecture summary by Dr. Jason Nam

Introduction

Thoracic trauma quite common. Blunt more than penetrating. 25% of deaths. 2nd leading cause of death in first hour after injury. 85% non-operative management.

Initial Management

  • What to do on Initial Evaluation:
    • Admission ABCs- vital signs, exam to include LOC. Shock is defined by physiology and not BP.
    • GSW: # wounds + retained bullets= even number
    • eFAST- abdominal, thoracic, cardiac views
    • Get a CXR
    • Labs- ABG, lactate, coags, TEG
    • CT, bronch, EGD, esophogram?
    • Simple interventions may be lifesaving- airway, chest tube, bronchoscopy
  • What are the indications for immediate thoracotomy?
    • Shock, initial chest tube output >1,500mL, chest tube output >200cc/hr x 2-4 hours, aerodigestive injury
  • What are the indications for delayed thoracotomy/VATS?
    • Retained hemothorax, empyema, persistent air leak, bronchopleural fistula, chest wall stabilization

Rib fractures

  • They are no not just a simple injury. 
  • Marker for greater injuries in polytrauma patient, intra-thoracic and non-thoracic injuries.
  • Location provides information about associated injuries.
  • 1st rib fracture means high energy injury.
  • Mortality from complications not the fracture.
  • Complications all related to increased work of breathing, shunting, and hypoxemia.
  • Mortality increases with number of rib fractures and age.
  • Odds ratio of 2 for death >=3 rib fractures.
  • Increased mortality >=65, odds ratio for death 1.98.

Treatment of rib fractures

  • The goal of the treatment if to avoid complications.
  • Epidural and paravertebral blocks/analgesia- studies show mortality data not compelling except in elderly. Anticoagulation, DVT, and antiplatelet concerns. Pulmonary hygiene- IS. Fever complications with combined IS and mobilization. Multimodal anesthesia- poor data. Operative fixation- limited poor data and selection bias. Decreased LOS and vent days. Possible complications. Needs early aggressive management. 
  • Flail chest- >=3 rib fractures in 2 or more locations. Paradoxical movement. Causes respiratory distress. Treatment is similar to rib fractures, selective mechanical ventilation, and rib stabilization for decreased morbidity and mortality.

Hemothorax

  • Layers posterior when supine. Large cavity= large volume. Treatment depends on size and hemodynamics. Unable to tamponade large vessels there. 25% will develop an empyema. Classification based on CT: small, medium, and large. Management- observe, additional chest tube, intrapleural fibrinolytics, VATS, or thoracotomy. Observe- 80% successful for hemothorax <300 mL.
  • Why not additional chest tube? Blood does not stay liquid and patients end up requiring VATS. Intrapleural fibrinolytics good for parapneumonic effusion/empyema. Limited data for post-trauma hemothorax.
  • VATS remains the procedure of choice for 300-900cc hemothorax. Timing remains controversial. Use general anesthesia and double lumen ETT (don’t want lung in way), and ports. Earlier VATS tends to be easier due to decreased fibrin. Absence of diaphragm injury and use of periprocedural antibiotics for chest tube placement are independent predictors of successful VATS.

Empyema

  • Pus in any cavity. Causes are post-pneumonic, post-resection, or post-traumatic.
  • Stages: I. Exudative- liquid, II. Fibrinopurulent- pus, loculations +/- peel, III. Organizing- thick peel restricts lung expansion.
  • 3-4% of trauma patients develop empyema.
  • The risk factors are pulmonary contusion, pleural effusion, multiple chest tubes and duration, exploratory laparotomy, and retained hemothorax.
  • Diagnosis is made 7-14 days post injury.
  • Microbiology= 50/50 mono and polymicrobial. Mostly GPC (staph and strep).
  • Pleural drainage and antibiotics not as successful for post-traumatic empyema. VATS in earlier stages. Thoracotomy needed for later stages.

Air leaks and bronchopleural fistula

  • Very common.
  • Most are uncomplicated and treated with chest tube.
  • Debate regarding suction vs. seal.
  • Persistent air leak lasts longer than 5 days.
  • Different than post-lung resection or spontaneous PTX parents.
  • For persistent air leak, consider chest CT on day 3.
  • Operate/intervene for large lung laceration.
  • Some will lead to bronchopleural fistula.
  • Significant lung injuries may require exploration or rib stabilization if indicated, autologous blood, VATS/thoracotomy, endobronchial valves (interventional pulmonary), or Heimlich valve.

References

Uploaded by Sami Safadi, MD

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