Anesthetic Management of Thoracic Trauma

Abstract

Thoracic trauma is a morbid business. The American College of Surgeons estimates it is associated with a 10% mortality [1] with 16,000 deaths annually. That represents 25% of all trauma deaths. Considering that injury is the leading cause of death from ages 1 to 45 (more than half of all deaths ages 13–32 and 80% in teenage years) [2] and the leading cause of years of life lost before 75, its impact is enormous [3]. In one analysis, if injury is taken into account, the life expectancy in the United States rockets from 19th in the developed world to first [4]. Since the vital structures in the chest are so well protected by the bony thorax, a great deal of force is required to disrupt them, and they are uncommonly injured in isolation in blunt trauma. Indeed, 70% of the time, insults to the chest are associated with multisystem injury.

Clinical Case Discussion

Case Pt is a 27-year-old male who was stabbed at the base of the neck and thrown off the top of a three-story building. He arrives in the emergency room intoxicated but awake and alert. He is hemodynamically stable. His past medical history is noncontributory. He is extremely tachypnic, anxious, and complaining of shortness of breath. He is coughing up a small amount of blood. He is wearing a cervical collar. On secondary survey he is found to have subcutaneous emphysema.

Questions

• 1. What are the anesthesiologists concerns?

• 2. Should any further imaging be obtained prior to intubation?

• 3. What airway device should be placed?

• 4. What technique should be used to intubate the patient?

Given the mechanism of injury and the presence of subcutaneous emphysema and hemoptysis, the anesthesiologist should be concerned that there is an injury to the airway. While under ideal conditions an awake fiberoptic intubation would be preferred, the scenario presented describes a patient who is in respiratory distress and could not be expected to participate in an awake fiberoptic intubation. No further imaging should be necessary in this patient who clearly needs urgent control of the airway. Rapid sequence intubation with in-line stabilization remains the standard of care and should be performed without delay. Strict attention should be made to the patient’s hemodynamics after intubation, since converting a presumed pneumothorax to a tension pneumothorax is possible in this scenario. Every attempt must be made to place the endotracheal tube with great care in an effort not to disrupt a potential injury to the trachea.

Scenario continues: The patient is successfully intubated, and a chest tube is placed for decreased breath sounds over the right chest. A large air leak is found. The following CXR is obtained.

Fig. 51.12

Chest X-ray shows a patient with a persistent right pneumothorax despite a well-positioned thoracotomy tube and an endotracheal tube above the carina

Questions

• 1. What would be the next step in the evaluation of this patient?

• 2. How can the anesthesiologist manage the air leak?

• 3. The patient is being taken to the operating room for surgical repair. What form of lung isolation should be used?

Fig. 51.13

Computed tomography scan demonstrating posterior tracheal tear, subcutaneous emphysema and persistent right pneumothorax. Subcutaneous emphysema is also demonstrated

Fig. 51.14

Intraoperative view of posterior tracheal injury seen through a right thoracotomy. (Photo courtesy of Thomas NG, MD, thoracic surgery, Rhode Island Hospital)

Questions

• Would you extubate this patient at the end of the case?

• How would you control his pain from the rib fractures?

These are both difficult questions. In general, every effort to extubate the patient as soon as possible should be made given his tracheal repair. Managing the pain of his rib fractures may be difficult. If he is awake and cooperative post extubation, an epidural can be considered. If not, paravertebral blocks or a catheter may be an option since the rib fractures are unilateral.