In industrialized countries, the incidence of injury and mortality in all diseases are located in the first place. In all trauma patients died, 25% is a direct result of chest trauma, and another 25% of chest trauma is an important factor leading to death. The most common cause of chest trauma due to motor vehicle accidents, about 70% -80%, followed by falls stab injuries, of which> 90% off all thoracic injuries, open wounds and about 8% – 10 percent. Cardiothoracic Surgery, Hospital of Weifang Huang Yang
severe chest trauma is still a major factor in traumatic deaths. Post-traumatic pneumonia, acute lung injury, ARDS affect the recovery of severe trauma. In the past 15 years, CT of the chest trauma can be applied to make faster, more accurate diagnosis. New surgical techniques such as the development of thoracic surgery reduces mortality in chest trauma. Most patients with chest trauma or non-surgical treatment can lead tube closed thoracic surgery cure, there are some patients need emergency open heart surgery. Pok for hemodynamic instability in patients with penetrating injury of the chest need to control the bleeding by clamping the artery, pericardial incision, intrathoracic press, hilar clamp and other methods. Early repair of damage control, including chest tracheobronchial injury, severe laceration of lung repair.
at the time of injury or transfer and the process of looting salvage deaths occurred in patients whose often due to cardiac tamponade caused by rupture of large blood vessels or the need for emergency open heart surgery patients, such patients is often due to the great vessels or lung parenchyma damage caused by Pok hemodynamic instability, or esophagus, large bronchial injury patients with stable vital signs, only to be seen, or placed thoracic drainage for treatment of patients, accounting for all the chest trauma, 80% -90% of the total due to bleeding, persistent pneumothorax, hemothorax coagulation, empyema, and other injuries of the need for secondary surgery.
rib fractures in which the majority of chest trauma. After injury, pneumonia, pulmonary insufficiency fracture of the rib complex. Brasel of 17 308 patients with rib fractures in the multivariable analysis showed that age, ISS for pneumonia after injury, the mortality rate is an independent risk factor Yan. In simple chest trauma, pneumonia increase mortality. Rib fractures in patients with effective analgesia can reduce atelectasis and improve functional residual capacity and the ability to clear respiratory secretions.
flail chest for three or more than two rib fractures occur, leading caused by lack of chest wall integrity. Flail chest is a high mortality rate of severe trauma. Borman analysis of 11,966 chest trauma in 262 patients with flail chest, the mortality rate was 20.6%, the elderly (> 65 years) was 28.8%. Unilateral flail chest is not a common cause of death, and the concurrent intrathoracic, chest injuries can increase mortality. Flail chest fixed in the past 30 years has been controversial.
rib fracture fixation indications associated with thoracic viscera injury or disease control, have absolute indications for chest, ribs and internal fixation was the collapse of the chest wall surgery as an additional threshold to soften, patients with progressive increase in shortness of breath, even under conditions of oxygen PaO 2 ≤ 7.98 Kpa (60mmHg) rib fractures caused by intractable chest wall pain associated with chest organ damage, the need to stabilize the chest early cases, surgery to other organs of the other two row fixation methods
for no shift or a slight displacement of the sternum fractures, general surgery without surgical indications: ① severe chest pain; ② fracture end clear shift; ③ associated with flail chest; ④ associated with other parts of the injury, the need to stabilize the chest early case
For conventional X-ray did not find the occult pneumothorax, hemothorax. CT can improve the diagnostic rate. Most of pneumothorax by simple drainage treatment, however, is not the correct location or the lung parenchyma laceration may lead to treatment after 72 hours still leak, lung recruitment failure, resulting in persistent pneumothorax. Chest drainage in patients with chest trauma and antibiotic prophylaxis is still controversial, according to Sanabria of five randomized trials of meta-analysis of Zhao, prophylactic antibiotics can reduce post-traumatic empyema and pneumonia. For a small asymptomatic pneumothorax whether drainage is still controversial. Hemothorax without drainage or residual hemothorax (secondary to rib dislocation, the chest tube blockage cited) will lead to empyema or lung fiber wrapped. In view of this situation can thoracotomy, but there are certain complication rate, nearly 10 years, is gradually being early (48 hours after injury)-assisted thoracic surgery to replace.
VATS in chest trauma indications
healing After the residual hemothorax / hemothorax coagulation treatment of persistent post-traumatic pneumothorax diagnosis and treatment of traumatic diaphragmatic injury after traumatic empyema of pleural hemorrhage after trauma to the chest foreign body removal and treatment of coagulation traumatic chylothorax
; can not tolerate one-lung ventilation, or can not use the lateral position of the patient (such as unstable vertebral fractures) suspected or confirmed to have a large vascular / heart injury in patients with suspected or confirmed damage to the trachea or large bronchi in patients with widened mediastinum in patients with chest more than 8cm in patients with massive bleeding, The initial thoracic drainage> 1500ml, or into the thoracic drainage tube per hour bleeding> 200ml, last more than three hours of severe adhesion or who have had previous ipsilateral lung pleural fusion surgery severe chest is too small or anatomic variations were
VATS surgery itself is safe, The complication rate is low, large sample data suggest that the mortality rate of <1% of the most common complication of persistent pneumothorax, followed by bleeding
residual hemothorax, pneumothorax, diagnosis and treatment of persistent post-traumatic empyema, diaphragmatic injury ; the pleural thoracic duct injury and pleural hemorrhage foreign
; for residual hemothorax diagnosis, CT is higher than the accuracy of X-ray film after closed thoracic drainage tube placement, CT prompt chest still> 500ml of liquid is not leads, or pleural fluid volume occupied cross-sectional area of 1 / 3 or 72 hours after placing the chest drainage tube no significant decrease in blood, could carry out surgical treatment for patients with residual hemothorax should be used early VATS treatment (removal plot blood, endoscopic hemostasis)
thoracic drainage tube placed more than 3 days , there are still those defined as persistent pneumothorax pneumothorax, with an incidence between 4% to 23% VATS thoracic drainage tube can reduce the storage time and reduce postoperative pain medication use and hospital stay and accelerate the rehabilitation process of patients
for traumatic diaphragmatic injury, VATS the sensitivity was 98% -100 % and a specificity of 90% -98%, and accuracy of 94% -100% VATS exploration diaphragm best view, select the first four or five more into the thoracic intercostal VATS found that the use of diaphragmatic injury after laparotomy, open thoracic surgical repair, endoscopic repair minor damage also can be used
the incidence of post-traumatic empyema rate of 2% -25% antibiotics can reduce the incidence of post-traumatic empyema VATS can be used as prevention, treatment of empyema effective and safe method, especially for early or purulent fibrin period empyema rate was 60% -100%
for pleural hemorrhage
; VATS for the treatment of persistent thoracic bleeding indications more stringent requirements of the patient’s vital signs were stable, and 24 hours of closed thoracic drainage does not exceed 1500ml, or 100-200ml / h, such as the drainage volume, or patients Pok unstable hemodynamic performance, VATS should be used to stop bleeding chest bleeding coagulation method, titanium clamp resistance, linear cutter or endoscopic resection of lung injury, such as suture repair
chest thoracic duct injury and foreign body
VATS can be used to clear the chest of chylous fluid, found the damage location and be neutered, and its success rate is about 80% -90%, but the lack of a large sample of data and evaluation of long-term effects reported VATS can be used to remove intrathoracic foreign body