CARDIOTHORACIC SURGERY Dr Mohammed J Jameel FIBMS Th
CARDIOTHORACIC SURGERY Dr. Mohammed J. Jameel FIBMS. Th. CVS. Senior Lecturer. Department of Surgery, College of Medicine, Al-Mustansiriyah University, Baghdad, Iarq.
LCE : 9 Thoracic Injuries : - Account for 25% of all injuries, usually they life-threatening and occur due to bleeding but fourtunately 80% can be manged conservatively by proper Dx and resuscitation. Immediate Life Threatening Injuries : - 1. Air Way Obstruction : - Early preventable trauma deaths are usually dueto lack of or delay in air way control. Air way obstruction in trauma usuallycaused by : 1. Dentures , teeth , secreation and blood 2. Bilateral mandibular fracture. 3. expanding neck hematoma cause compression and deviation of trachea. 4. Laryngeal or Tracheal injuries. Mx : - Early endotracheal intubationis important especially in case of neck hematoma or air-way edema with protection of cervical spine if their injury is suspected to prevent damage to cervical cord. 2. Cardiac Temponade : - Lec 4
3. Tension Pneumothorax : - develops when a one-way valve air leak occurs either from the lung or through the chest wall , air is forced into the thoracic cavity without any mean of escape, completely collapsing the affected lung, the Mediastinum is displaced to the opposite side , decreasing the venous return and compressing the opposite lung. Etiology : - 1. Penterating chest trauma 2. Blunt chest trauma with parenchymal lung injury and air leak that did not close spontenously 3. Iatrogenic lung puncture e. g from Subclavian central venous insertion. 4. mechanical positive pressure ventilation. C. F : - 1. The Pt. is panicky with dypnea , tachypnea and distended neck veins with cyanosis. O/E : - tracheal deviation , hyperresonant and absent breath sounds over the affected hemithorax Tension Pneumothorax is a clinical Dx. And Rx must not be delayed waiting for Radiological confirmation. Rx : - 1. Rapid insertion of large bore needle into 2 nd intercostal space in the Mid-clavicular line of the affected hemithorax. 2. insertion of chest tube through 5 th ICS between anterior and mid axillary line and direct it to apex of hemithorax.
4. Open Pneumothorax : - is due to large defect in the chest wall > 3 cm leading to equilibration between intrathoracic and atmospheric pressure , air accumulate in hemithorax with each inspiration leading to profound hypoventilation on the affected side and hypoxia. Mx : - 1. close the defect with a sterile occlusive plastic dressing taped on three sides act as a flatter-type valve. 2. a large bore chest tube is inserted in a site away from the site of injury , if the lung doesnot expand the drain must be connected to low pressure suction , a 2 nd drain is sometimes necessary 3. debridement and closure of chest wall defect usually done in the operative room. 5. Massive Heamothorax : - in blunt trauma is caused by continous bleeding from torn intercostal or internal mammary artery. Accumulation of blood in the hemithorax compress the lung and prevent adequate ventilation. C. Fs : - pt. present with signs of heamorrhagic shock (tachycardia and hypotension) with flat neck veins , unilateral absence of breath sounds and dullness to percussion.
Rx : - 1. insertion of chest tube to remove the blood completely 2. correct hypovolemic state by using central venous line and replacement by crystalloid and colloids , sometimes Endotracheal intubation may be necessary. 3. initial drain > 1500 ml or continous bleeding > 200 ml /hr. for 3 hr. s indicates urgent Thoracotomy 6. Flial chest : - usually result from blunt trauma when 3 or more ribs fractured at 2 or more places producing a loose segment of chest wall moves paradoxically with respiration i. e moves inwards during inspiration this together with lung contusion and pain result in hypoxia , a heamo and /or pneumothorax may be associated. Mx 1. Oxygen administration 2. Adequate analgesia and physiotherapy 3. chest tube insertion when necessary.
Potenially Life Threatening injuries : - 1. Thoracic Aortic disruption : - Traumatic aortic rupture is common cause of sudden death after Blunt trauma e. g automobile collision or fall from height , with deceleration the aortic arch moves anteriorly while the descending aorta is relatively fixed distal to ligamentum arteriosum just distal to origin of subclavian A. this will produce a shearing forces from the sudden impact will disrupt the intima and media, if the adventetia is intact the Pt. may remain stable but require Urgent Rx. Dx : - Pt. with blunt chest trauma + Asymmetry of upper and Lower limb Pressure + widen Pulse pressure , We must suspect the injury , CXR in erect position shows Widen Mediastinum Dx is confirmed by Arch Aortography OR CT angiography Mx : - 1. control systolic BP < 100 mm Hg. 2. Use of Endovascular intra-Aortic Stent can be placed or by surgery either repair OR Excision and grafting using a Dacron graft.
2. Tracheobronchial injuries : - Pt. present with severe subcutaneous emphysema withrespiratory compromise , chest tube shows massive air leak and lung fail to expand , Bronchoscopy is diagnostic Rx : - ETI of unaffected side followed by operative repair of the injury. 3. Blunt Myocardial injury : 4. Diaphragmatic injury : - any penetrating injury below 5 th ICS suspect it and Dxic Laproscope m. b required. Blunt chest trauma can cause diaphragm rupture which may be missed , it occurs mostly on left side. Dx : - CXR after placement of Nasogastric tube can show the stomach herniated to chest Rx : - Diaphragm rupture when Dxed Acutely must be repaired through laprotomy this will help toexamin abdominal structures to exclude injury , but when Dx is missed initially and injury discovered later it must be repaired by thoracotomy.
5. Esophageal injury : - mostly caused by penetrating trauma , it must be kept in mind , Pt. presnt with odynophagia (pain on swallowing of food or fluids ) , subcutaneous or mediastinal emphysema, pleural effusion, air in retroesophageal space and unexplained fever with in 24 hours of onset of injury. Dx: - Esophagogram in supine position + Esophagoscopy Rx : - Operative repair and drainage. 6. Pulmonary contusion : - caused by bleeding into lung parenchyma secondary to blunt trauma , Pt. present with hypoxemia with in 24 – 48 hours of injury , sometimes with hemoptasis. Dx by CXR which shows opacified lung. Rx O 2 adminstration + analgesia + chest physiotherapy , in severe casesmechanical ventilation is required.
- Slides: 8