Skip to main content Accessibility help
×
Hostname: page-component-8448b6f56d-c4f8m Total loading time: 0 Render date: 2024-04-25T06:18:14.164Z Has data issue: false hasContentIssue false

18 - Anesthesia Considerations for Cardiothoracic Trauma

Published online by Cambridge University Press:  18 January 2010

Mark A. Gerhardt
Affiliation:
Department of Anesthesiology, Ohio State University Medical Center, Columbus, Ohio
Glenn P. Gravlee
Affiliation:
Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, Colorado
Charles E. Smith
Affiliation:
Case Western Reserve University, Ohio
Get access

Summary

Objectives

  1. Understand the pathophysiology and treatment of trauma to the heart and great vessels.

  2. Understand the pathology and treatment of trauma to the lungs and thoracic wall.

  3. Understand trauma to the larynx, trachea, and bronchial tree.

  4. Understand the anesthetic implications of all of the above pathologies.

INTRODUCTION

Trauma is one of the leading causes of death in the world. Thoracic trauma, particularly to the heart or great vessels, accounts for 20–25 percent of the trauma mortality. Although most significant injuries to the cardiac or great vessel structures are immediately fatal, some very common traumatic clinical scenarios can result in excellent outcomes with appropriate diagnosis and rapid institution of treatment [1]. Hypovolemia has been implicated as a primary factor in traumatic fatalities, [1] a clinical problem that is integral to an anesthesiologist's resuscitative attempts. When compared with out-of-hospital cardiopulmonary arrest, survival following traumatic cardiopulmonary arrest may be similar [1] and reversible problems should be considered. It is imperative that anesthesiologists understand trauma of the heart and great vessels so that appropriate and expeditious care can be provided. Supplemental material can be accessed via the Internet at the Web sites shown in Table 18.1 (see also Chapter 17).

CARDIOTHORACIC ANATOMY

The thorax contains vital organs and vasculature that are protected by the bone structure of the vertebral column, sternum, and ribs. Inferiorly the thorax is demarcated by the diaphragm, whereas the structures of the neck and lung apices are found superiorly.

Type
Chapter
Information
Trauma Anesthesia , pp. 279 - 299
Publisher: Cambridge University Press
Print publication year: 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Lockey, D, Crewdson, K, and Davies, G.Traumatic cardiac arrest: Who are the survivors?Ann Emerg Med 2006;48(3):240–4.CrossRefGoogle ScholarPubMed
Orliaguet, G, Ferjani, M, Riou, B.The heart in blunt trauma. Anesthesiology 2001;95(2):544–8.CrossRefGoogle ScholarPubMed
Bertinchant, JP, Robert, E, Polge, A, et al. Release kinetics of cardiac troponin I and cardiac troponin T in effluents from isolated perfused rabbit hearts after graded experimental myocardial contusion. J Trauma 1999;47(3):474–80.CrossRefGoogle ScholarPubMed
Pretre, R, Chilcott, M.Blunt trauma to the heart and great vessels. N Engl J Med 1997;336(9):626–32.CrossRefGoogle ScholarPubMed
Sutherland, GR, Calvin, JE, Driedger, AA, et al. Anatomic and cardiopulmonary responses to trauma with associated blunt chest injury. J Trauma 1981;21(1):1–12.CrossRefGoogle ScholarPubMed
Robert, E, Coussaye, JE, Aya, AG, et al. Mechanisms of ventricular arrhythmias induced by myocardial contusion: A high-resolution mapping study in left ventricular rabbit heart. Anesthesiology 2000;92(4):1132–43.CrossRefGoogle ScholarPubMed
Chirillo, F, Totis, O, De, Cavarzerani A, et al. Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma. Heart 1996;75(3):301–6.CrossRefGoogle ScholarPubMed
Wall, MJ Jr, Mattox, KL, Chen, CD, et al. Acute management of complex cardiac injuries. J Trauma 1997;42(5):905–12.CrossRefGoogle ScholarPubMed
Degiannis, E, Loogna, P, Doll, D, Bonnano, F, Bowley, DM, Smith, MD.Penetrating cardiac injuries: Recent experience in South Africa. World J Surg 2006;30(7):1258–64.CrossRefGoogle ScholarPubMed
Hunt, PA, Greaves, I, Owens, WA.Emergency thoracotomy in thoracic trauma-a review. Injury 2006;37(1):1–19.CrossRefGoogle ScholarPubMed
Lim, R, Gill, IS, Temes, RT, Smith, CE.The use of adenosine for repair of penetrating cardiac injuries: A novel method. Ann Thorac Surg 2001;71:1714–5.CrossRefGoogle ScholarPubMed
Kouchoukos, NT, Dougenis, D.Surgery of the thoracic aorta. N Engl J Med 1997;336(26):1876–88.CrossRefGoogle ScholarPubMed
Williams, JS, Graff, JA, Uku, JM, Steinig, JP.Aortic injury in vehicular trauma. Ann Thorac Surg 1994;57(3):726–30.CrossRefGoogle ScholarPubMed
Fann, JI, Miller, DC.Aortic dissection. Ann Vasc Surg 1995;9(3):311–23.CrossRefGoogle ScholarPubMed
Ledbetter, S, Stuk, JL, Kaufman, JA.Helical (spiral) CT in the evaluation of emergent thoracic aortic syndromes. Traumatic aortic rupture, aortic aneurysm, aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. Radiol Clin N Am 1999;37(3):575–89.CrossRefGoogle ScholarPubMed
Shanewise, JS, Cheung, AT, Aronson, S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999;89(4):870–84.CrossRefGoogle Scholar
Karski, JM.Transesophageal echocardiography in the intensive care unit. Semin Cardiothorac Vasc Anesth 2006;10(2):162–6.CrossRefGoogle ScholarPubMed
Burns, JM, Sing, RF, Mostafa, G, Huynh, TT, Jacobs, DG, Miles, WS, Thomason, MH.The role of transesophageal echocardiography in optimizing resuscitation in acutely injured patients. J Trauma 2005;59(1):36–40; discussion 40–2.CrossRefGoogle ScholarPubMed
Ben-Menachem, Y.Assessment of blunt aortic-brachiocephalic trauma: Should angiography be supplanted by transesophageal echocardiography?J Trauma 1997;42:969–72.CrossRefGoogle ScholarPubMed
Eggebrecht, H, Nienaber, CA, Neuhauser, M.Endovascular stent-graft placement in aortic dissection: A meta-analysis. Eur Heart J 2006;27(4):489–98.CrossRefGoogle ScholarPubMed
Karmy-Jones, R, Hoffer, E, Meissner, M, Bloch, RD.Management of traumatic rupture of the thoracic aorta in pediatric patients. Ann Thorac Surg 2003;75(5):1513–7.CrossRefGoogle ScholarPubMed
Murphy, MB, Murray, C, Shorten, GD.Fenoldopam: A selective peripheral dopamine-receptor agonist for the treatment of severe hypertension. N Engl J Med 2001;345(21):1548–57.CrossRefGoogle ScholarPubMed
Nichols, AJ, Ruffolo, RR Jr, Brooks, DP.The pharmacology of fenoldopam. Am J Hypertens 1990;3(6 Pt 2):116S–9S.CrossRefGoogle ScholarPubMed
Halpenny, M, Rushe, C, Breen, P, et al. The effects of fenoldopam on renal function in patients undergoing elective aortic surgery. Eur J Anaesthesiol 2002;19(1):32–9.CrossRefGoogle ScholarPubMed
Gilbert, TB, Hasnain, JU, Flinn, WR, et al. Fenoldopam infusion associated with preserving renal function after aortic cross-clamping for aneurysm repair. J Cardiovasc Pharmacol Ther 2001;6(1):31–6.CrossRefGoogle ScholarPubMed
Papia, G.Klein, D, Lindsay, TF.Intensive care of the patient following open abdominal aortic surgery. Curr Opin Crit Care 2006;12(4):340–5.CrossRefGoogle ScholarPubMed
Sheinbaum, R, Ignacio, C, Safi, HJ, Estrera, A.Contemporary strategies to preserve renal function during cardiac and vascular surgery. Rev Cardiovasc Med 2003;4(Suppl 1):S21–8.Google ScholarPubMed
Oliver, WC Jr, Nuttall, GA, Cherry, KJ, Decker, PA, Bower, T, Ereth, MH.A comparison of fenoldopam with dopamine and sodium nitroprusside in patients undergoing cross-clamping of the abdominal aorta. Anesth Analg 2006;103(4):833–40.CrossRefGoogle ScholarPubMed
Gerlach, AT, Dasta, JF.Dexmedetomidine: An updated review. Ann Pharmacother 2007;41(2):245–52.CrossRefGoogle Scholar
Kirton, OC, Civetta, JM.Do pulmonary artery catheters alter outcome in trauma patients?New Horiz 1997;5(3):222–7.Google ScholarPubMed
Shoemaker, WC, Wo, CC, Chien, LC, Lu, K, Ahmadpour, N, Belzberg, H, Demetriades, D.Evaluation of invasive and noninvasive hemodynamic monitoring in trauma patients. J Trauma 2006;61(4):844–53; discussion 853–4.CrossRefGoogle ScholarPubMed
Campos, JH.Lung isolation techniques. Anesthesiol Clin N Am 2001;19(3):455–74.CrossRefGoogle ScholarPubMed
Campos, JH.Current techniques for perioperative lung isolation in adults. Anesthesiology 2002;97(5):1295–301.Google ScholarPubMed
Campos, JH.Which device should be considered the best for lung isolation: Double-lumen endotracheal tube versus bronchial blockers. Curr Opin Anaesthesiol 2007;20(1):27–31.CrossRefGoogle ScholarPubMed
Sessler, DI.Complications and treatment of mild hypothermia. Anesthesiology 2001;95(2):531–43.CrossRefGoogle ScholarPubMed
Shore-Lesserson, L.Evidence based coagulation monitors: Heparin monitoring, thromboelastography, and platelet function. Semin Cardiothorac Vasc Anesth 2005;9(1):41–52.CrossRefGoogle ScholarPubMed
Davies, RG, Myles, PS, Graham, JM.A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy – a systematic review and meta-analysis of randomized trials, Br J Anaesth 2006; 96:418–26.CrossRefGoogle ScholarPubMed
Casati A, Alessandrini P, Nuzzi M, Tosi M, Iotti E, Ampollini L, Bobbio A, Rossini E, Fanelli G. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. 2006 Dec;23(12):999–1004.
Mattox, KL, Feliciano, DV, Burch, J, et al. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 1989;209(6):698–705; discussion 706–7.CrossRefGoogle ScholarPubMed
Leissner, KB, Ortega, R, Beattie, WS. Anesthesia implications of blast injury. J Cardiothorac Vasc Anesth. 2006;20:872–80.CrossRefGoogle ScholarPubMed
Ceballos, Gutierrez JP, Fuentes, FT, Diaz, DP, et al. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33(1 Suppl):S107–12.CrossRefGoogle Scholar
DePalma, RG, Burris, DG, Champion, HR, Hodgson, MJ.Blast Injuries. N Engl J Med 2005;352:1335–42.CrossRefGoogle ScholarPubMed
Mayorga, MA.The pathology of primary blast overpressure injury. Toxicology 1997;121(1):17–28.CrossRefGoogle ScholarPubMed
Biocina, B, Sutlic, Z, Husedzinovic, I, et al. Penetrating cardiothoracic war wounds. Eur. J. Cardiothorac. Surg 1997;11:399–405.CrossRefGoogle ScholarPubMed
Shamir, MY, Weiss, YG, Willner, D, et al. Multiple casualty terror events: The anesthesiologist's perspective. Anesth Analg 2004;98(6):1746–52.CrossRefGoogle ScholarPubMed
Wolf, YG, Rivkind, A.Vascular trauma in high-velocity gunshot wounds and shrapnel-blast injuries in Israel. Surg Clin N Am 2002;82(1):237–44.CrossRefGoogle ScholarPubMed
Wall MJ, Storey JH, Mattox KL. Indications for thoracotomy. In Mattox KL, Feliciano DV, Moore EE, ed. Trauma, 4th edition. New York: McGraw-Hill, 2000, pp 473–82.
Lowdermilk, GA, Naunheim, KS.Minimal access surgery. Thoracoscopic evaluation and treatment of thoracic trauma. Surg Clin N Am 2000;80(5):14–36.CrossRefGoogle Scholar
Devitt, JH, McLean, RF, Koch, JP.Anaesthetic management of acute blunt thoracic trauma. Can J Anaesth 1991;38:506–10.CrossRefGoogle ScholarPubMed
Besson, A, Saegesser, F.Color Atlas of Chest Trauma and Associated Injuries. Oradell, NJ: Medical Economics Books, 1983, pp 12–14.Google Scholar
Hanowell LH. Perioperative anesthetic management of thoracoabdominal trauma. In Grande, CM, ed. Textbook of Trauma Anesthesia and Critical Care. St Louis: Mosby-Year Book Inc., 1993, pp 559–82.Google Scholar
Ho, AM-H, Ling, E.Systemic air embolism after lung trauma. Anesthesiology 1999;90:564–75.CrossRefGoogle ScholarPubMed
Ho, AM, Lee, S, Tay, BA, Chung, DC.Lung isolation for the prevention of air embolism in penetrating lung trauma. A case report. Can J Anaesth 2000;47:1256–8.CrossRefGoogle ScholarPubMed
Schaefer, SD.The treatment of acute external laryngeal injuries. Arch Otolaryngol Head Neck Surg 1991;117:35–9.CrossRefGoogle ScholarPubMed
Meredith JW, Riley RD. Injury to the esophagus, trachea, and bronchus. In Mattox KL, Feliciano DV, Moore EE, ed. Trauma, 4th edition. New York: McGraw-Hill, 2000, pp 473–82.
Jewett, BS, Shockley, WW, Rutledge, R.External laryngeal trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg 1999;125:877–80.CrossRefGoogle Scholar
Raoof, S.Role of bronchoscopy in modern medical intensive care unit. Clin Chest Med 2001;22:241–61.CrossRefGoogle ScholarPubMed
Devitt, JH, Boulanger, BR.Lower airway injuries and anaesthesia. Can J Anaesth 1996;43:148–59.CrossRefGoogle ScholarPubMed
Brasel, K, Stafford, RE, Weigelt, JA, et al. Treatment of occult pneumothoraces from blunt trauma. J Trauma 1999;46:987–99.CrossRefGoogle ScholarPubMed
Cohn, SM.Pulmonary contusion: A review of the clinical entity. J Trauma 1997;42:973–9.CrossRefGoogle ScholarPubMed
Schweiger, JHW.The pathophysiology, diagnosis and management strategies for flail chest injury and pulmonary contusion: A review. Anesth Analg 2001 Review Course Lectures: 86–93.CrossRefGoogle Scholar
Amato, MBP, Barbas, CSV, Medeiros, DM, et al. Effect of a protective-ventilation strategy on mortality in the respiratory distress syndrome. N Engl J Med 1998;338:347–54.CrossRefGoogle ScholarPubMed
Eberhard, LW, Morabito, DJ, Matthay, MA, et al. Initial severity of metabolic acidosis predicts the development of acute lung injury in severely traumatized patients. Crit Care Med 2000;28:37–47.CrossRefGoogle ScholarPubMed
Karmy-Jones, R, Jurkovich, J, Shatz, DV, et al. Management of traumatic lung injury: A western trauma association multicenter review. J Trauma 2001;51:1049–53.Google ScholarPubMed
Cogbill TH, Landercasper J. Injury to the chest wall. In Mattox KL, Feliciano DV, Moore EE, ed. Trauma, 4th edition. New York: McGraw-Hill, 2000, pp 483–505.
Jougon, J, Gallon, P, Dubrez, J, Velley, JF.Perforation oesophagienne au decours de l'echocardiographie transesophagienne. Arch Mal Coeur Vaiss 2000;93:1235–7.Google Scholar
Vezina, D, Lessard, MR, Bussieres, J, Topping, C, Trepanier, CA.Complications associated with the use of the esophageal-tracheal Combitube. Can J Anaesth 1998;45:76–80.CrossRefGoogle ScholarPubMed
Branthwaite, MA.An unexpected complication of the intubating laryngeal mask. Anaesthesia 1999;54:166–7.CrossRefGoogle ScholarPubMed
Bulger, EM, Arneson, MA, Mock, CN, Jurkovich, GJ.Rib fractures in the elderly. J Trauma 2000;48(6):1040–7.CrossRefGoogle ScholarPubMed
Karmakar, MK, Ho, AM-H.Acute pain management of patients with multiple fractured ribs. J Trauma 2003;54(3):615–25.CrossRefGoogle ScholarPubMed
Alexander, JQ, Gutierrez, CJ, Mariano, MC, et al. Blunt chest trauma in the elderly patient: How cardiopulmonary disease affects outcome. Am Surg 2000;66:855–7.Google ScholarPubMed
Mackersie, RC, Shackford, SR, Hoyt, DB, et al. Continuous epidural fentanyl analgesia: Ventilatory function improvement with routine use in treatment of blunt chest trauma. J Trauma 1987;27:1207–12.CrossRefGoogle Scholar
Kavanagh, BP, Katz, J, Sandler, AN.Pain control after thoracic surgery: A review of current techniques. Anesthesiology 1994;81:737–59.CrossRefGoogle ScholarPubMed
Orliaguet G, Carli P. Thoracic blocks. In Rosenberg, AD, Grande, CM, Bernstein, RL, ed. Pain Management and Regional Anesthesia in Trauma. London: WB Saunders, 2000, pp 239–51.Google Scholar
Sinatra RS, Ennevor SJ. Trauma patient with thoracic and abdominal injuries. In Rosenberg, AD, Grande, CM, Bernstein, RL, ed. Pain Management and Regional Anesthesia in Trauma. London: WB Saunders, 2000, pp 310–38.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×