Page 1641 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1160 PART 10: The Surgical Patient

replaced angiography because of its accuracy and relative noninvasive- of admission, after the patient is resuscitated. Repair is done through
ness, but there still remains a worrisome incidence of false positivity a midline upper abdominal incision. This approach allows complete
with this diagnostic tool. examination of the abdominal cavity. The hernia can be reduced quite
The approach to management of the patient with aortic rupture is easily and the repair conducted from within the abdomen. Associated
early surgical repair unless contraindicated by significant associated injuries, such as splenic rupture, also can be treated easily during the
life-threatening injuries such as major head injuries. Resection with laparotomy. If the diagnosis is made several weeks after the injury, then
placement of a prosthetic graft frequently is necessary, although direct it is preferable to approach the lesion through a thoracotomy because
repair without the use of a prosthetic graft is sometimes possible. As any intra-abdominal injury would have declared itself already; also, it
soon as immediate life-threatening injuries have been addressed, the will be much easier to reduce the hernia from within the thoracic cavity.
aortic lesion should be treated surgically. If surgical treatment is delayed Although laparoscopy increases the risk of tension pneumothorax in
because of associated major injuries, then treatment and close monitor- the presence of a diaphragmatic rupture, recent reports have suggested
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ing in the ICU with afterload reduction, β blockade, and maintenance that this technique may be employed cautiously in the diagnosis and
of borderline hypotension are appropriate. Increasingly, endovas- treatment of diaphragmatic rupture when the laparoscope is used in
2
cular stenting is being used for treating chronic post traumatic false assessment of the traumatized abdomen. Thoracoscopic repair in the
aneurysms in patients who survived the aortic injury and who have sig- otherwise stable patient is also an option.
nificant associated or comorbidities that precluded urgent surgical repair. ■
■ ESOPHAGEAL DISRUPTION RIB FRACTURES

The most common cause of esophageal rupture is iatrogenic injury Rib fractures are very common with chest injuries. Frequently they are
missed on x-ray examination unless special rib views are taken; ultra-
during endoscopic maneuvers. However, this injury may result from sound is becoming an alternate approach for diagnosis of rib fractures.
both penetrating and blunt injury. A severe blow to the upper abdomen However, the diagnosis is suspected when there is localized chest wall
in the presence of a closed glottis can result in a sudden increase in pain. The diagnosis is also suggested when one is able to elicit crepitus
intraesophageal pressure with rupture. The resulting tear allows leakage over the fracture site or auscultate a “click” with inspiration over the
of gastric contents into the mediastinum, causing severe mediastinitis. fracture site. Tenderness on compression of the chest wall is also sug-
The patient presents with severe retrosternal chest pain and very gestive of rib fractures.
soon develops profound hypotension and tachycardia. Frequently, The treatment of rib fractures consists of analgesics, which may be
pneumothorax or hemothorax is evident without a rib fracture, and if administered orally, parenterally, or epidurally, depending on the degree
a chest tube is inserted, particulate matter may appear in the drainage. of discomfort and the number of ribs involved. In the ICU setting,
The drainage of pleural fluid with a very low pH and a high amylase parenteral analgesics or regional blocks are preferable. Generally, the
content also should suggest the diagnosis. Other radiologic signs include fractured ribs do not require any specific treatment. However, in the set-
the presence of mediastinal air. The diagnosis may be confirmed by ting of a patient with preexisting pulmonary dysfunction, the restriction
Gastrografin swallow or esophagoscopy. produced by fractured ribs can make the difference between normal gas
Treatment consists of infusion of crystalloid to maintain euvolemia, exchange and severe respiratory failure. Maintenance of adequate respi-
antibiotic coverage, and early thoracotomy with repair of the lesion. If the ratory function therefore is the mainstay of treatment in these patients.
diagnosis is made late in the onset of the disease, direct repair of the lacera-
tion may not be possible, and esophageal diversion techniques may become ■ SIMPLE HEMOPNEUMOTHORAX
necessary as part of the surgical therapy. This may require the formation In contrast to a tension pneumothorax, the simple hemopneumotho-
of an esophagostomy in the neck, as well as a gastrostomy, pleural drainage rax usually is diagnosed by a combination of physical examination
through chest tubes, and parenteral nutrition and antibiotic therapy. and chest x-ray. Although it has been suggested recently that small
■ DIAPHRAGMATIC RUPTURE pneumothoraces or occult pneumothoraces may be treated by close

Lacerations of the diaphragm may occur from blunt and penetrating monitoring in the ICU without chest tube insertion, generally, if a
hemothorax or pneumothorax is noted following trauma, a chest tube
injuries, and the injury may originate from either the thorax or the is inserted regardless of the size of the air or blood collection. This
abdomen. The injury is diagnosed most frequently on the left side but allows decompression of the pleural space, as well as monitoring of the
may occur with equal frequency on the right side. Penetrating injuries drainage from the pleural space. It is particularly important that chest
tend to be small and sharply demarcated, whereas blunt injuries often tube decompression of the pleural space be secured before mechanical
result in large, irregular lacerations with herniation of intra-abdominal ventilation is instituted or a general anesthetic administered.
contents into the chest. 3
The diagnosis is missed frequently because of misinterpretation of the
chest film, often thought to represent an elevated left hemidiaphragm, ABDOMINAL INJURIES
placement of a nasogastric tube with its location above the diaphragm ■ GENERAL PRINCIPLES
gastric dilation, or loculated hemopneumothorax or hematoma. The
after entry into the stomach suggests the diagnosis. Apart from patients with pericardial tamponade or traumatic air embo-
Depending on the degree to which abdominal contents herniate lism, any hemodynamically compromised patient with torso trauma in
into the thoracic cavity, the symptoms may be very minimal or very whom adequately functioning chest tubes demonstrate no free pleural
significant. A patient with blunt chest or abdominal trauma who exhib- blood or continued major air leakage must be considered to have an
its sudden deterioration in respiratory status when intra-abdominal intra-abdominal source of blood loss until another cause is proven. Hence,
pressure is increased should be considered as having a ruptured dia- when the decision is unclear in a hemodynamically compromised patient
phragm. This was noted frequently when the abdominal compartment with torso trauma, the combination of physical examination, chest x-ray,
of the pneumatic antishock garment was used in the past. During perito- and chest tube insertion frequently will allow one to determine whether
neal lavage, drainage of lavage fluid through a chest tube that is in place the lesion is located in the chest. With a negative chest film and no chest
also indicates that diaphragmatic rupture is present. tube drainage in the absence of cardiac tamponade or air embolism, lapa-
The urgency of treatment depends on the degree to which the patient’s rotomy frequently is required in the unstable patient with torso trauma.
hemodynamic and respiratory status is compromised. In most instances, In the OR, all such patients should have the entire abdomen and
an isolated diaphragmatic rupture can be repaired within several hours chest prepared and draped. They also should receive preoperative

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