ESSENTIAL FEATURES
• Air in pleural space
• Breach in parietal or visceral pleura
• Described as percentage of chest cavity involved
• Open pneumothorax is associated with open sucking chest wound
• Tension pneumothorax causes shift in mediastinum toward contralateral lung
• 5–10% small pleural effusion present, may be hemorrhagic
EPIDEMIOLOGY
• Etiologies of spontaneous pneumothorax include:
–Secondary to some pathologic process
–Rupture of bleb is most common
–Male:female ratio 6:1
–Age 16 to 24 years, tall, thin, smoking are risk factors
–Apical bullae (patients with chronic obstructive pulmonary disease [COPD])
–Pneumocystic pneumonia
–Metastatic cancer
–Rupture of esophagus
–Lung abscess
–Cystic fibrosis
CLINICAL FINDINGS
SYMPTOMS AND SIGNS
• Pleuritic chest pain
• Dyspnea, hypoxia, hypocapnia
• Diaphoresis, cyanosis, weakness, hypotension, cardiovascular collapse
• Tachypnea, tachycardia, deviation of trachea away (tension)
• Decreased breath sounds, hyperresonance, diminished local fremitus
LABORATORY FINDINGS
• ECG: May show nonspecific axis deviation, ST changes, T wave inversion
IMAGING FINDINGS
• Chest x-ray: Diagnostic
• CT scan: May help differentiate pneumothorax from apical pleural bleb
DIAGNOSTIC CONSIDERATIONS
• 1 cm pneumothorax correlates with 25% loss of lung volume
WORK-UP
• Chest x-ray
WHEN TO refer
• Patients with cystic fibrosis
• Patients with AIDS and pneumocystis pneumonia
TREATMENT AND MANAGEMENT
• Small (< 25%), minimal symptoms: Can be monitored conservatively
• Larger asymptomatic, symptomatic, increasing pneumothorax, or associated with effusion:
–Insert chest tube
–Underwater suction drainage or Heimlich (can treat as outpatient)
• Select patients can get aspiration without chest tube, but 20–50% have recurrence
• Patients with AIDS and pneumocystis pneumonia has high failure rate and mortality
Surgery urgery
• Pleurodesis with doxycycline or talc
• Axillary thoracotomy with apical bullectomy, parietal pleurectomy, and pleurodesis (preferred technique)
• Complete parietal pleurectomy
• Transplantation: Patients with cystic fibrosis or severe COPD; pleurodesis may be contraindicated in these patients
Indications
• Pleurodesis:
–Air leaks > 7 days
–Lung does not fully expand
–High-risk occupation (scuba divers, pilots)
Contraindications
• Pleurodesis:
–Cystic fibrosis, severe COPD (relative)
TREATMENT MONITORING
• Repeat chest film mandatory within 24 hours of chest tube removal due to recurrence
Complications omplications
• Recurrence
–Spontaneous, 50%
–After 2 episodes, 75%
–After 3 episodes, > 80%
RESOURCES
REFERENCES
• Brasel KJ et al: Treatment of occult pneumothoraces from blunt trauma. J Trauma 1999;46:987.
• Cothren C et al: Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma 2002;53:483.
• Dulchavsky SA et al: Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001;50:201.
• Karmy-Jones R et al: Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma 2004;56:664.
• Lowdermilk GA, Naunheim KS: Thoracoscopic evaluation and treatment of thoracic trauma. Surg Clin North Am 2000;80:1535.
• Mayberry JC et al: Absorbable plates for rib fracture repair: preliminary experience. J Trauma 2003;55:835.
• Meredith JW, Hoth JJ: Thoracic trauma: when and how to intervene. Surg Clin N Am 2007;87:95.
• Richardson JD et al: Operative fixation of chest wall fractures and underused procedure? Am Surg 2007;73:591.
Sunday, February 20, 2011
Thursday, February 17, 2011
Abdominal Injuries
ESSENTIAL FEATURES
• Mechanism of injury in blunt trauma is rapid deceleration with noncompliant organs most at risk (kidney, liver, spleen, pancreas)
Penetrating Injuries
• May cause sepsis if a hollow viscus is penetrated
• Severe and early shock if major vessel or liver is involved
• Injuries of the kidney, spleen, or pancreas do not usually bleed massively unless a major vessel is involved
Blunt Injuries
• Focused Assessment with Sonography for Trauma (FAST) exam is important management tool
• Nonsurgical therapy used in more than 80% of blunt liver and spleen injuries
EPIDEMIOLOGY
• 30% of patients with “seatbelt signs” have internal injury
• 85% of patients with blunt liver injury stabilize with resuscitation alone
CLINICAL FINDINGS
SYMPTOMS AND SIGNS
• 35% of patients with hemoperitoneum may not manifest clinical signs of peritoneal irritation
• Elevated WBC count and fever appearing several hours later
DIAGNOSTIC CONSIDERATIONS
• Do not obtain CT scan in an unstable patient
• CT has primary role in defining the location and magnitude of intra-abdominal injuries related to blunt trauma
• Diagnostic laparoscopy has an important role in cases of penetrating abdominal trauma
• Exploratory laparotomy has 3 main indications following blunt injury: peritonitis, unexplained hypovolemia, and the presence of other injuries know to be associated with intra-abdominal injuries
WORK-UP
• Local wound exploration may rule out peritoneal penetration
• FAST exam used to identify abnormal collections of blood or fluid and obviates need for diagnostic peritoneal lavage (DPL)
• CT is noninvasive, qualitative, sensitive, and accurate for the diagnosis of intra-abdominal injury
TREATMENT AND MANAGEMENT
Abdominal Wall Injuries
• Caused by blunt trauma are most often due to shear forces that devitalize the subcutaneous tissue and skin; debridement is necessary to avoid serious infection
• Caused by penetrating trauma, debridement and irrigation may be necessary
Liver Injuries
• Control hemorrhage at laparotomy
• Initial techniques to control hemorrhage include manual compression, perihepatic packing, and Pringle maneuver
• Do not use Pringle maneuver for more than 1 hour
• Hepatic bleeding can be controlled by suture ligation or clip application
• Electrocautery or the argon beam coagulator can be used to control bleeding from the raw surface of the liver
• Microfibrillar collagen or hemostatic thrombin soaked gel foam can be applied to bleeding areas with pressure
Fibrin glue can be used to treat superficial and deep liver lacerations
• If massive blood loss has already occurred at time of surgery, consider packing the liver and reexploring in 24—48 hrs
• Rarely, selective hepatic artery ligation, resectional debridement, or hepatic lobectomy may be required to control hemorrhage
• Drains should always be used
• Decompression of the biliary system is contraindicated
• Suspect hepatic vein injuries when the Pringle maneuver fails to stop hemorrhage; mortality is very high
• Nonoperative management is superior in the hemodynamically stable patient and is successful in more than 90% of cases
Biliary Tract Injuries
• Treat gallbladder injuries with cholecystectomy, except when minor lacerations can be primary closed
• Most injuries to the common bile duct (CBD) can be treated by suture closure and insertion of a T tube
• Avulsion of the CBD due to duodenal or ampullary trauma may require choledochojejeunosotomy with total or partial pancreatectomy, duodenectomy, or other diversion procedures
Splenic Injuries
• Most common in blunt abdominal trauma
• 50—80% can be managed nonoperatively
• Severity of splenic injury evident on CT staging is used to guide nonoperative management
• High-grade injuries are better managed with surgery
Pancreatic Injuries
• May present with few clinical manifestations
• Suspect injury when upper abdomen has been traumatized, especially when serum amylase remains persistently elevated
• CT is best diagnostic method
• Minor injuries not involving the duct can be managed nonoperatively
• Moderate injuries usually require operative exploration, debridement, and the placement of external drains
• Severe injuries may require distal resection or external drainage
• Traumatic injuries to the pancreatic head often associated with vascular injury and carry high mortality; in most cases pancreaticoduodenectomy should not be attempted initially
GI Tract Injuries
• Most injuries of the stomach can be repaired; some large injuries may require subtotal or total resection
• Duodenal injury may not be evident on initial exam or x-ray studies
• Abdominal films will show retroperitoneal air within 6 hrs in most cases
• CT with oral contrast will often identify site of perforation
• Most injuries can be treated with lateral repair but some require resection with end-to-end anastamosis
• Pancreaticoduodenectomy may rarely be required to manage a severe injury
• Duodenal hematomas usually resolve with nonoperative management
• Large hematomas causing obstruction for more than 10—14 days may require operative evacuation
• Most small bowel injures can be treated with a 2-layer sutured closure
• The standard approach for colon injuries has been to divert the fecal stream or exteriorize the injury
• Consider primary closure for wounds that involve less than 50% of colon circumference
• Primary repair should not be done in hypotensive patients, those requiring multiple transfusions, or if there has been a delay of more than 6 hrs after injury or in the face of gross contamination
• Wounds extensive enough to require resection should not be closed primarily
• Small, clean rectal injuries may be closed primarily if conditions are favorable
• Treat large rectal wounds with diversion and insertion of presacral drains
• Irrigation of the distal stump should be done unless it would further contaminate the pelvic space
Genitourinary Injuries
• Most commonly injured organs are male genitalia, uterus, urethra, bladder, ureters, and kidneys
• Male genitalia injuries usually limited to skin loss only and should be treated with primary skin graft
• Treat scrotal skin loss with delayed reconstruction; testis can be temporarily protected by placing it subcutaneously in the thigh
• Uterine injuries are infrequent and can usually be repaired with absorbable suture; drainage is not necessary
• Hysterectomy may be necessary in more extensive injuries
• Urethral injuries associated with pelvic fractures or deceleration injuries
• Blood at the meatus is classic sign of injury
• Prostate may be elevated superiorly by hematoma and will be free-riding and high on rectal examination; urethrography should be performed before Foley placement
• Penetrating injuries are best treated with primary repair
• Suprapubic bladder drainage and delayed reconstruction of blunt urethral disruption injuries are safe and effective in most cases
• Major injuries to the bulbous or penile urethra should be managed by suprapubic urinary diversion
• Bladder rupture is frequently associated with pelvic fractures
• 75% of ruptures are extraperitoneal, and 25% are intraperitoneal
• Repair should be done through a midline abdominal incision
• Divert urine postoperatively for at least 7 days via a suprapubic cystostomy
• More than 50% of kidney injuries can be treated nonoperatively
• Nonoperative treatment of penetrating renal lacerations is appropriate in stable patients without other injuries
• Severe injuries carry high risk of delayed bleeding and should be treated operatively
• Consider renal exploration if laparotomy is indicated for associated injuries
• Renal vascular injuries require immediate operation to save the kidney
• Perirenal hematomas found incidentally at laparotomy should be explored if they are expanding, pulsatile, or not contained by retroperitioneal tissues or if preexploration urogram shows extensive urinary extravasation
• Ureteral injuries are easily missed; most can be reconstructed by primary repair, ureteroureterostomy, or ureteral reimplantations
SURGERY
Indications
• If the abdomen is likely source of exsanguinating hemorrhage, immediate laparotomy is indicated
• Most stab wounds of the lower chest or abdomen should be explored
• All gunshot wounds of lower chest and abdomen should be explored as incidence of injury to major structures exceeds 90%
• Patients in shock after 4 L crystalloid resuscitation with penetrating abdominal injury requires emergent laparotomy
• Unstable patients with positive FAST
Prognosis
• Deaths principally from hemorrhage or sepsis
RESOURCES
REFERENCES
• Asensio JA et al: Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps. J Trauma 2003;54:647.
• Mohr AM et al: Angiographic embolization for liver injuries: low mortality, high morbidity. J Trauma 2003;55:1077.
• Wahl WL et al: Diagnosis and management of bile leaks after blunt liver injury. Surgery 2005;138:742.
• Wei B et al: Angioembolization reduces operative intervention for blunt splenic injury. J Trauma 2008;64:1472.
• Jacobs IA et al. Nonoperative management of blunt splenic and hepatic trauma in the pediatric population: significant differences between adult and pediatric surgeons? Am Surg. 2001;67:149.
• Mechanism of injury in blunt trauma is rapid deceleration with noncompliant organs most at risk (kidney, liver, spleen, pancreas)
Penetrating Injuries
• May cause sepsis if a hollow viscus is penetrated
• Severe and early shock if major vessel or liver is involved
• Injuries of the kidney, spleen, or pancreas do not usually bleed massively unless a major vessel is involved
Blunt Injuries
• Focused Assessment with Sonography for Trauma (FAST) exam is important management tool
• Nonsurgical therapy used in more than 80% of blunt liver and spleen injuries
EPIDEMIOLOGY
• 30% of patients with “seatbelt signs” have internal injury
• 85% of patients with blunt liver injury stabilize with resuscitation alone
CLINICAL FINDINGS
SYMPTOMS AND SIGNS
• 35% of patients with hemoperitoneum may not manifest clinical signs of peritoneal irritation
• Elevated WBC count and fever appearing several hours later
DIAGNOSTIC CONSIDERATIONS
• Do not obtain CT scan in an unstable patient
• CT has primary role in defining the location and magnitude of intra-abdominal injuries related to blunt trauma
• Diagnostic laparoscopy has an important role in cases of penetrating abdominal trauma
• Exploratory laparotomy has 3 main indications following blunt injury: peritonitis, unexplained hypovolemia, and the presence of other injuries know to be associated with intra-abdominal injuries
WORK-UP
• Local wound exploration may rule out peritoneal penetration
• FAST exam used to identify abnormal collections of blood or fluid and obviates need for diagnostic peritoneal lavage (DPL)
• CT is noninvasive, qualitative, sensitive, and accurate for the diagnosis of intra-abdominal injury
TREATMENT AND MANAGEMENT
Abdominal Wall Injuries
• Caused by blunt trauma are most often due to shear forces that devitalize the subcutaneous tissue and skin; debridement is necessary to avoid serious infection
• Caused by penetrating trauma, debridement and irrigation may be necessary
Liver Injuries
• Control hemorrhage at laparotomy
• Initial techniques to control hemorrhage include manual compression, perihepatic packing, and Pringle maneuver
• Do not use Pringle maneuver for more than 1 hour
• Hepatic bleeding can be controlled by suture ligation or clip application
• Electrocautery or the argon beam coagulator can be used to control bleeding from the raw surface of the liver
• Microfibrillar collagen or hemostatic thrombin soaked gel foam can be applied to bleeding areas with pressure
Fibrin glue can be used to treat superficial and deep liver lacerations
• If massive blood loss has already occurred at time of surgery, consider packing the liver and reexploring in 24—48 hrs
• Rarely, selective hepatic artery ligation, resectional debridement, or hepatic lobectomy may be required to control hemorrhage
• Drains should always be used
• Decompression of the biliary system is contraindicated
• Suspect hepatic vein injuries when the Pringle maneuver fails to stop hemorrhage; mortality is very high
• Nonoperative management is superior in the hemodynamically stable patient and is successful in more than 90% of cases
Biliary Tract Injuries
• Treat gallbladder injuries with cholecystectomy, except when minor lacerations can be primary closed
• Most injuries to the common bile duct (CBD) can be treated by suture closure and insertion of a T tube
• Avulsion of the CBD due to duodenal or ampullary trauma may require choledochojejeunosotomy with total or partial pancreatectomy, duodenectomy, or other diversion procedures
Splenic Injuries
• Most common in blunt abdominal trauma
• 50—80% can be managed nonoperatively
• Severity of splenic injury evident on CT staging is used to guide nonoperative management
• High-grade injuries are better managed with surgery
Pancreatic Injuries
• May present with few clinical manifestations
• Suspect injury when upper abdomen has been traumatized, especially when serum amylase remains persistently elevated
• CT is best diagnostic method
• Minor injuries not involving the duct can be managed nonoperatively
• Moderate injuries usually require operative exploration, debridement, and the placement of external drains
• Severe injuries may require distal resection or external drainage
• Traumatic injuries to the pancreatic head often associated with vascular injury and carry high mortality; in most cases pancreaticoduodenectomy should not be attempted initially
GI Tract Injuries
• Most injuries of the stomach can be repaired; some large injuries may require subtotal or total resection
• Duodenal injury may not be evident on initial exam or x-ray studies
• Abdominal films will show retroperitoneal air within 6 hrs in most cases
• CT with oral contrast will often identify site of perforation
• Most injuries can be treated with lateral repair but some require resection with end-to-end anastamosis
• Pancreaticoduodenectomy may rarely be required to manage a severe injury
• Duodenal hematomas usually resolve with nonoperative management
• Large hematomas causing obstruction for more than 10—14 days may require operative evacuation
• Most small bowel injures can be treated with a 2-layer sutured closure
• The standard approach for colon injuries has been to divert the fecal stream or exteriorize the injury
• Consider primary closure for wounds that involve less than 50% of colon circumference
• Primary repair should not be done in hypotensive patients, those requiring multiple transfusions, or if there has been a delay of more than 6 hrs after injury or in the face of gross contamination
• Wounds extensive enough to require resection should not be closed primarily
• Small, clean rectal injuries may be closed primarily if conditions are favorable
• Treat large rectal wounds with diversion and insertion of presacral drains
• Irrigation of the distal stump should be done unless it would further contaminate the pelvic space
Genitourinary Injuries
• Most commonly injured organs are male genitalia, uterus, urethra, bladder, ureters, and kidneys
• Male genitalia injuries usually limited to skin loss only and should be treated with primary skin graft
• Treat scrotal skin loss with delayed reconstruction; testis can be temporarily protected by placing it subcutaneously in the thigh
• Uterine injuries are infrequent and can usually be repaired with absorbable suture; drainage is not necessary
• Hysterectomy may be necessary in more extensive injuries
• Urethral injuries associated with pelvic fractures or deceleration injuries
• Blood at the meatus is classic sign of injury
• Prostate may be elevated superiorly by hematoma and will be free-riding and high on rectal examination; urethrography should be performed before Foley placement
• Penetrating injuries are best treated with primary repair
• Suprapubic bladder drainage and delayed reconstruction of blunt urethral disruption injuries are safe and effective in most cases
• Major injuries to the bulbous or penile urethra should be managed by suprapubic urinary diversion
• Bladder rupture is frequently associated with pelvic fractures
• 75% of ruptures are extraperitoneal, and 25% are intraperitoneal
• Repair should be done through a midline abdominal incision
• Divert urine postoperatively for at least 7 days via a suprapubic cystostomy
• More than 50% of kidney injuries can be treated nonoperatively
• Nonoperative treatment of penetrating renal lacerations is appropriate in stable patients without other injuries
• Severe injuries carry high risk of delayed bleeding and should be treated operatively
• Consider renal exploration if laparotomy is indicated for associated injuries
• Renal vascular injuries require immediate operation to save the kidney
• Perirenal hematomas found incidentally at laparotomy should be explored if they are expanding, pulsatile, or not contained by retroperitioneal tissues or if preexploration urogram shows extensive urinary extravasation
• Ureteral injuries are easily missed; most can be reconstructed by primary repair, ureteroureterostomy, or ureteral reimplantations
SURGERY
Indications
• If the abdomen is likely source of exsanguinating hemorrhage, immediate laparotomy is indicated
• Most stab wounds of the lower chest or abdomen should be explored
• All gunshot wounds of lower chest and abdomen should be explored as incidence of injury to major structures exceeds 90%
• Patients in shock after 4 L crystalloid resuscitation with penetrating abdominal injury requires emergent laparotomy
• Unstable patients with positive FAST
Prognosis
• Deaths principally from hemorrhage or sepsis
RESOURCES
REFERENCES
• Asensio JA et al: Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps. J Trauma 2003;54:647.
• Mohr AM et al: Angiographic embolization for liver injuries: low mortality, high morbidity. J Trauma 2003;55:1077.
• Wahl WL et al: Diagnosis and management of bile leaks after blunt liver injury. Surgery 2005;138:742.
• Wei B et al: Angioembolization reduces operative intervention for blunt splenic injury. J Trauma 2008;64:1472.
• Jacobs IA et al. Nonoperative management of blunt splenic and hepatic trauma in the pediatric population: significant differences between adult and pediatric surgeons? Am Surg. 2001;67:149.
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