Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1348 - файл.pdf
Transesophageal echocardiography
Transesophageal echocardiography (TEE) has been extensively studied
for use in the workup of possible blunt rupture of the thoracic aorta.
Its sensitivity, specificity, and accuracy in the diagnosis of this injury
are each approximately 93-96%. Its advantages include the easy
portability, no requisite contrast, minimal invasiveness, and short time
required to perform. TEE can also be used intraoperatively to help
identify cardiac abnormalities and monitor cardiac function.
The disadvantages include operator expertise, long learning curve, and
the fact that it is relatively weak at helping identify injuries of the
descending aorta.
Transthoracic echocardiography
Transthoracic echocardiography (TTE) can help identify pericardial
effusions and tamponade, valvular abnormalities, and disturbances in
cardiac wall motion. TTEs are also performed in cases of patients with
possible blunt myocardial injuries and abnormal ECG findings.
Flexible or rigid esophagoscopy
Esophagoscopy is the initial diagnostic procedure of choice in patients
with possible esophageal injuries. Either flexible or rigid esophagoscopy
is appropriate, and the choice depends on the experience of the
clinician. Some authors prefer rigid esophagoscopy to evaluate the
cervical esophagus and flexible esophagoscopy for possible injuries of
the thoracic and abdominal esophagus. If esophagoscopy findings are
negative, esophagography should be performed as outlined above.
Fiberoptic or rigid bronchoscopy
Fiberoptic or rigid bronchoscopy is performed in patients with possible
tracheobronchial injuries. Both techniques are extremely sensitive for
90
the diagnosis of these injuries. Fiberoptic bronchoscopy offers the
advantage of allowing an endotracheal tube to be loaded onto the
scope and the endotracheal intubation to be performed under direct
visualization if necessary.
Thoracotomy may be indicated for acute or chronic conditions.
A. Acute indications include the following:
1. Cardiac tamponade.
2. Acute hemodynamic deterioration/cardiac arrest in the trauma center.
3. Penetrating truncal trauma (resuscitative thoracotomy) .
4. Vascular injury at the thoracic outlet.
5. Loss of chest wall substance (traumatic thoracotomy).
6. Massive air leak .
7. Endoscopic or radiographic evidence of significant tracheal or
bronchial injury
8. Endoscopic or radiographic evidence of esophageal injury
9. Radiographic evidence of great vessel injury
10. Mediastinal passage of a penetrating object
11. Significant missile embolism to the heart or pulmonary artery
12. Transcardiac placement of an inferior vena caval shunt for hepatic
vascular wounds
Patients who arrive in cardiac arrest or who arrest shortly after arrival
may be candidates for emergency resuscitative thoracotomy. A right
chest tube must be placed simultaneously. The use of emergency
resuscitative thoracotomy has been reported to result in survival rates
of 9-57% for patients with penetrating cardiac injuries and survival
rates of 0-66% for patients with noncardiac thoracic injuries, but
overall survival rates are approximately 8%.
The proportion of patients with PCT who can be treated without
operation vary from 29-94% of chest trauma cases.
91
B. Chronic indications for thoracotomy include the following:
1. Nonevacuated clotted hemothorax
2. Chronic traumatic diaphragmatic hernia
3. Traumatic cardiac septal or valvular lesion
4. Chronic traumatic thoracic aortic pseudoaneurysm
5. Nonclosing thoracic duct fistula
6. Chronic (or neglected) posttraumatic empyema
7. Infected intrapulmonary hematoma, e.g. traumatic lung abscess
8. Missed tracheal or bronchial injury
9. Tracheoesophageal fistula
10. Innominate artery/tracheal fistula
11. Traumatic arterial/venous fistula
Another indication for acute thoracostomy is often based on chest tube
output. Immediate evacuation of 1500 mL of blood is a sufficient
indication; however, the trend in output is more important. If bleeding
persists with a steady trend of more than 250 mL/h, thoracotomy is
probably indicated.
Thoracoscopy
The role of video-assisted thoracoscopic surgery in the management
of penetrating chest trauma is expanding rapidly. Initially promoted
for the management of retained hemothoraces and the diagnosis of
diaphragmatic injury, trauma and thoracic surgeons are now using
thoracoscopy for treatment of chest wall bleeding, diagnosis of
transmediastinal injuries, pericardial window, and persistent
pneumothoraces.
Blunt injuries of the heart, great arteries, veins, and lymphatics
Indications for immediate surgery include (1) cardiac tamponade, (2)
radiographic confirmation of a great vessel injury, and (3) an
embolism into the pulmonary artery or heart.
92
Relatively immediate and long-term indications for surgery include
the late recognition of a great vessel injury (eg, development of traumatic
pseudoaneurysm).
Contraindications
No distinct, absolute contraindications exist for surgery in blunt thoracic
trauma. Rather, guidelines have been instituted to define which patients
have clear indications for surgery (eg, massive hemothorax, continued
high rates of blood loss via chest tube).
A controversial area has been the use of ED thoracotomy in patients
with blunt trauma presenting without vital signs. The results of this
approach in this particular patient population have been dismal and
have led many authors to condemn it.
Blunt Thoracic Injuries and their Treatment.
Chest Wall Fractures, Dislocations, and Barotrauma (Including
Diaphragmatic Injuries)
I. Rib fractures
Rib fractures are the most common blunt thoracic injuries. Ribs 4-10
are most frequently involved. Patients usually report inspiratory chest
pain and discomfort over the fractured rib or ribs. Physical findings
include local tenderness and crepitus over the site of the fracture. If a
pneumothorax is present, breath sounds may be decreased and resonance
to percussion may be increased. Rib fractures may also be a marker for
other associated significant injury, both intrathoracic and extrathoracic. In
one report, 50% of patients with blunt cardiac injury have rib fractures.
Fractures of ribs 8-12 should raise the suggestion of associated
abdominal injuries. Lee and colleagues reported a 1.4- and 1.7-fold
increase in the incidence of splenic and hepatic injury, respectively, in
those with rib fractures.
93
Elderly patients with 3 or more rib fractures have been shown to have
a 5-fold increased mortality rate and a 4-fold increased incidence of
pneumonia. Effective pain control is the cornerstone of medical
therapy for patients with rib fractures. For most patients, this consists
of oral or parenteral analgesic agents. Intercostal nerve blocks may be
feasible for those with severe pain who do not have numerous rib
fractures. A local anesthetic with a relatively long duration of action
(eg, bupivacaine) can be used. Patients with multiple rib fractures
whose pain is difficult to control can be treated with epidural analgesia.
Adjunctive measures in the care of these patients include early
mobilization and aggressive pulmonary toilet. Rib fractures do not
require surgery. Pain relief and the establishment of adequate ventilation
are the therapeutic goals for this injury. Rarely, a fractured rib lacerates
an intercostal artery or other vessel, which requires surgical control to
achieve hemostasis acutely. In the chronic phase, nonunion and persistent
pain may also require an operation.
.
Chest trauma with multiple rib fractures left side.
94
II. Flail chest
A flail chest, by definition, involves 3 or more consecutive rib fractures
in 2 or more places, which produces a free-floating, unstable segment
of chest wall. Separation of the bony ribs from their cartilaginous
attachments, termed costochondral separation, can also cause flail chest.
Patients report pain at the fracture sites, pain upon inspiration, and,
frequently, dyspnea. Physical examination reveals paradoxical motion
of the flail segment. The chest wall moves inward with inspiration and
outward with expiration. Tenderness at the fracture sites is the rule.
Dyspnea, tachypnea, and tachycardia may be present. The patient may
overtly exhibit labored respiration due to the increased work of breathing
induced by the paradoxical motion of the flail segment. A significant
amount of force is required to produce a flail segment. Therefore,
associated injuries are common and should be aggressively sought.
The clinician should specifically be aware of the high incidence of
associated thoracic injuries such as pulmonary contusions and closed
head injuries, which, in combination, significantly increase the mortality
associated with flail chest.
All of the treatment modalities mentioned above for patients with rib
fractures are appropriate for those with flail chest. Respiratory distress
or insufficiency can ensue in some patients with flail chest because of
severe pain secondary to the multiple rib fractures, the increased work
of breathing, and the associated pulmonary contusion. This may
necessitate endotracheal intubation and positive pressure mechanical
ventilation. Intravenous fluids are administered judiciously because
fluid overloading can precipitate respiratory failure, especially in
patients with significant pulmonary contusions.
In an attempt to stabilize the chest wall and to avoid endotracheal
intubation and mechanical ventilation, various operations have been
95
devised for correcting flail chest. These include pericostal sutures, the
application of external fixation devices, or the placement of plates or
pins for internal fixation. With improved understanding of pulmonary
mechanics and better mechanical ventilatory support, surgical therapy
has not been proven superior to the supportive and medical measures
discussed. However, most authors would agree that stabilization is
warranted if a thoracotomy is indicated for another reason.
III. First and second rib fractures
First and second rib fractures are considered a separate entity from
other rib fractures because of the excessive energy transfer required to
injure these sturdy and well-protected structures. First and second rib
fractures are harbingers of associated cranial, major vascular, thoracic,
and abdominal injuries. The clinician should aggressively seek to
exclude the presence of these other injuries. Pain control and pulmonary
toilet are the specific treatment measures for rib fractures. First and
second rib fractures do not require surgical therapy. An exception to
this would be the need to excise a greatly displaced bone fragment.
Serial rib fractures.
96
IV. Clavicular fractures
Clavicular fractures are one of the most common injuries to the
shoulder girdle area. Common mechanisms include a direct blow to
the shaft of the bone, a fall on an outstretched hand, or a direct lateral
fall against the shoulder. Approximately 75-80% of clavicular
fractures occur in the middle third of the bone. Patients report
tenderness over the fracture site and pain with movement of the
ipsilateral shoulder or arm. Physical findings include anteroinferior
positioning of the ipsilateral compared to the contralateral arm. The
proximal segment of the clavicle is displaced superiorly because of the
action of the sternocleidomastoid muscle.
Nearly all clavicular fractures can be managed without surgery.
Primary treatment consists of immobilization with a figure-of-eight
dressing, clavicle strap, or similar dressing or sling. Oral analgesics
can be used to control pain. Surgery is rarely indicated. Surgical
intervention is occasionally indicated for the reduction of a badly
displaced fracture.
V. Sternoclavicular joint dislocations
Strong lateral compressive forces against the shoulder can cause
sternoclavicular joint dislocation. Anterior dislocation of the joint is
more common than posterior dislocation. Patients report pain with arm
motion or when a compressive force is applied against the affected
shoulder. The ipsilateral arm and shoulder may be anteroinferiorly
displaced. With anterior dislocations, the medial end of the clavicle
can become more prominent. In posterior dislocations, a depression
may be discernible adjacent to the sternum. Associated injuries to the
trachea, subclavian vessels, or brachial plexus can occur with
posterior dislocations. Closed or open reduction is generally advised.
Treatment strategies depend on whether the patient has an anterior or
97
posterior dislocation. For anterior dislocations, local anesthesia and
sedative medications are administered, and lateral traction is applied
to the affected arm that is placed in abduction and extension. This
maneuver, combined with direct pressure over the medial clavicle, can
occasionally reduce an anterior dislocation. For posterior dislocations,
a penetrating towel clip can be used to grasp the medial clavicle to
provide the necessary purchase for anterior manual traction to reduce
the joint. Proper levels of pain control, up to and including general
anesthesia, are provided. If closed reduction fails, open reduction is
performed.
VI. Sternal fractures
Most sternal fractures are caused by MVAs. The upper and middle
thirds of the bone are most commonly affected in a transverse fashion.
Patients report pain around the injured area. Inspiratory pain or a sense
of dyspnea may be present.
Physical examination reveals local tenderness and swelling. Ecchymosis
is noted in the area around the fracture. A palpable defect or fracturerelated crepitus may be present. Associated injuries occur in 55-70%
of patients with sternal fractures. The most common associated injuries
are rib fractures, long bone fractures, and closed head injuries. The
association of blunt cardiac injuries with sternal fractures has been a
source of great debate. Blunt cardiac injuries are diagnosed in fewer
than 20% of patients with sternal fractures. Caution should be used
before completely excluding myocardial injury. The workup should
begin with an ECG.
Most sternal fractures require no therapy specifically directed at
correcting the injury. Patients are treated with analgesics and are advised
to minimize activities that involve the use of pectoral and shoulder
98
girdle muscles. The most important aspect of the care for these patients is
to exclude blunt myocardial and other associated injuries. Patients
who are experiencing severe pain related to the fracture and those with
a badly displaced fracture are candidates for open reduction and internal
fixation. Various techniques have been described, including wire
suturing and the placement of plates and screws. The latter technique
is associated with better outcomes.
VII. Scapular fractures
Scapular fractures are uncommon. Their main clinical importance is
the high-energy forces required to produce them and the attendant
high incidence of associated injuries. The rate of associated injuries is
75-100%, most commonly involving the head, chest, or abdomen.
Patients with scapular fractures report pain around the scapula.
Tenderness, swelling, ecchymosis, and fracture-related crepitus can all
be present. The fracture is most frequently located in the body or neck
of the scapula. More than 30% of scapular fractures are missed during
the initial patient evaluation. The discovery of a scapular fracture
should prompt a concerted effort to exclude major vascular injuries and
injuries of the thorax, abdomen, and neurovascular bundle of the
ipsilateral arm. Shoulder immobilization is the standard initial treatment.
This can be accomplished by placing the arm in a sling or shoulder
harness. Range-of-motion exercises are started as soon as possible to
help prevent loss of shoulder mobility. Surgery is infrequently indicated.
Involvement of the glenoid, acromion, or coracoid may require open
reduction and internal fixation with the goal of maintaining proper
shoulder mobility.
VIII. Scapulothoracic dissociation
Sometimes called flail shoulder, this rare injury occurs when very strong
traction forces pull the scapula and other elements of the shoulder
99