Case Profile
Patient Li, male, 76 years old, was admitted to the hospital at 3-21 17:44 due to "multiple injuries to the whole body caused by trauma in a car accident for 2 hours".
Anamnesis: hypertension for 3 years, no regular oral medication, control unknown.
7 years ago, he underwent surgery for prostatic hyperplasia.
Admission diagnosis: 1. Multiple rib fractures on the right side 2. Flail chest on the right side 3. Fluid pneumothorax on the right side 4. Subcutaneous emphysema on the right neck and back of the chest 5. Traumatic subdural hemorrhage 6. Traumatic subarachnoid hemorrhage? 7. Right temporal bone fracture 8. Cerebrospinal fluid otorrhea 9. Traumatic intracranial pneumotrium
Physical examination: the patient is conscious, T: 35.9°C P: 60 beats/min BP: 152/82mmHg. Difficult sideways coordination, mouth opening 3 fingers, Mallampati airway grade L, good neck mobility; There were no significant abnormalities in cardiopulmonary evaluation.
Proposed surgery: emergency thoracic exploration + thoracoplasty
Bedside visit in the emergency department: height 173cm, weight 80kg; severe hearing impairment in both ears; Bp130/98mmHg P112bpm R22 times/min SpO2 92% (nasal cannula 2L/min pure oxygen); Complaints: severe chest pain on the right side, worse when taking a deep breath or getting up, accompanied by chest tightness and breathlessness;
Physical examination: clear consciousness, poor spirit, acute illness, painful expression, pale blood discharge in the right ear, palpable subcutaneous emphysema in the right chest and back and neck, collapse of the right chest, normal left chest, asymmetrical breathing movements on both sides, shortness of breath, abnormal breathing on the right chest wall. Breath sounds are low in the right lung, coarse in the left lung, and scattered wet rales may be heard.
辅助检查：血常规 Hb141g/L 肝肾功+电解质 Cr 73.0 umol/L K 3.9mmol/L Na 132.1mmol/L 凝血五项 D-二聚体26.28 ug/m l余检验结果未见明显异常
ECG: sinus tachycardia (129bpm)
Noncontrast chest scan (3-21): multiple rib fractures on the right side, bone irregularity of the ribs on the left side, exudative lesions of the right lung, fluid pneumothorax on the right side, subcutaneous pneumoptica in the back of the right cervicothohorax
Noncontrast CT scan of the brain (3-21): subdural hemorrhage A small amount of subarachnoid hemorrhage is not excluded Right temporal bone fracture Intracranial pneumophalus A small amount of blood in the right mastoid process
Neurosurgical consultation: the patient currently has intracranial hemorrhage and no indication for surgery, and the possibility of cerebrospinal fluid otorrhea is considered based on examination.
Thoracic surgeons recommend: Internal fixation of rib fractures should be performed as soon as possible to eliminate paradoxical breathing and stop the vicious cycle. In consultation with the thoracic surgeon and CT considerations, the patient's lung injury was mild and the hemopneumothorax was relatively simple, and lung isolation was not required during the operation
Preoperative evaluation Mahalanobis grade I mouth opening>3 fingers Teeth are absent Head and neck range of motion is normal
ASA Grading IV E NYHA Grading II MET > 3 points
Rapid induction of endotracheal intubation, general anesthesia (single-lumen endotracheal tube)
Anesthesia process
19:20 患者入室，左侧头高卧位，痛苦面容。 HR 112bpm BP115/80mmHg 血氧92％（鼻导管2L/min纯氧）
19:25 Before anesthesia induction, mask pure oxygen, 6L/min, SPO2 97% pre-ultrasound-guided left radial artery puncture catheterization, the patient did not cooperate.
19:40 Anesthesia induction + radial artery catheterization The head is high, and the annular joint is pressed during intubation during induction. Rocuronium bromide 10mg sufentanil 15ug, etomidate + propofol 10ml, rocuronium bromide 40mg, implanted into a 6.5 booster endotracheal tube tidal volume 350ml, frequency 14 times/min, airway pressure 12cmH2O, after induction, blood pressure dropped, as low as 65/35mmHg, HR 90bpm norepinephrine intermittent bolus, blood pressure gradually rose
麻醉维持：瑞芬太尼0.1ug/kg/min，七氟烷1.5％ 去甲肾上腺素0.1-0.2ug/kg/min
19:50 Position: Left side decubitus position
20:00 Before surgery: Add sufentanil 5ug
20:10 5% sodium bicarbonate injection 150ml
20:20 探查胸腔时 SPO2 骤降,最低下降至83%,给予5cmH2O PEEP,1分钟后SPO2 回升至99%
21:25 End of surgery
Surgical method: reduction and internal fixation of right 3-8 rib fractures + thoracic cavity exploration + lung surface laceration repair
21:35 End of anesthesia
→ ICU with endotracheal tube, arterial indwelling catheter, and continuous pumping of norepinephrine
Intraoperative rehydration: Ringer's solution 1000ml, hydroxyethyl starch 500ml, sodium bicarbonate injection 150ml, total volume 1650ml
Bleeding volume: 100ml
Urine output: 250ml
术中血压维持在110/60mmHg HR80次/分 SPO299％ T 36.0℃
Postoperative supplemental examinations
Cardiac ultrasound (3-22): ventricular septal hypertrophy Left ventricular wall segmental dyskinesia Mitral regurgitation (mild) Aortic regurgitation (mild) Tricuspid regurgitation (mild) Abnormal left ventricular distension LVEF 58%
Rib reconstruction (3-22): multiple rib fractures on the right side and some postoperative findings Bone irregularity in the left part of the rib
Postoperative prognosis
Preoperative X-ray
Postoperative X-ray
3-23 (Day 2 postoperatively) In the weaned oxygen state, SpO2 96%, and the endotracheal tube was removed
3-26 Transfer to a general ward
4-10 Recovered and discharged
Case analysis
1. What is the pathophysiology of flail chest? What are the processing principles?
Flail chest refers to the occurrence of two or more fractures of 3 or more adjacent ribs and/or costal cartilage, and the local chest wall is softened due to the loss of rib support, and abnormal breathing movements occur, that is, the chest wall of the softened area is inverted during inhalation and does not expand outward with the rest of the rib cage, and the softened area protrudes outward during exhalation.
Pathology:
The paradoxical respiratory movements caused by large and bilateral flail chests severely limit the adequate negative pressure generated in the pleural space, limit the ventilatory function of the lungs, and if not treated in a timely and effective manner, respiratory failure will quickly occur. In addition, flail chest destroys the stability of thoracic movement, causes the pressure of the pleural cavity on both sides to lose balance, the mediastinum swings back and forth with respiratory movement, and the superior and inferior vena cava is repeatedly twisted and straightened to varying degrees, thus affecting venous blood return and eventually causing circulatory failure. In the early post-injury period, due to the severe pain at the fracture site, the injured muscles are in a state of spasm and fixation, and the body compensates for it, and abnormal breathing movements are mostly not obvious. Later, the muscles gradually relax due to fatigue, and the respiratory secretions are retained, resulting in an increase in the work of the respiratory muscles and an increase in the amplitude of respiratory movements, and abnormal respiratory movements and their consequences become more and more obvious.
Processing Principles:
Surgical treatment of traumatic rib fractures, the Chinese expert consensus recommends that internal fixation of rib fractures (SSRF) should be considered for all patients with flail chest. SSRF can be considered for non-flail thoracic rib fractures in the following situations: (1) 3 non-flail thoracic rib fractures ≥ with displaced ends (grade IIB recommendation); (2) Non-flail thoracic rib fracture, combined with other patients requiring thoracic exploratory surgery; (3) Patients with non-flail chest rib fracture with severe pain and ineffective early non-surgical treatment; Severe pulmonary contusion or severe head injury should not be considered an absolute contraindication to SSRF; SSRF should be assessed on an individual basis. 3D post-injury SSRF is also recommended; When rib fracture is combined with other fatal injuries other than the chest, the principle of damage control surgery should be adopted to give priority to fatal injuries and initial resuscitation, and SSRF should be considered if conditions permit, that is, surgery within 3~7 days.
2. Why did the patient suffer from hypoxemia in this case? How to do a good job of lung protection in such patients?
Analysis of the causes of hypoxemia:
The patient had flail chest resulting in ineffective ventilation, pulmonary contusion, atelectasis, and closed pneumothorax; V/Q disorders such as disappearance of negative thoracic pressure, decrease of blood volume back to the heart, surgical extrusion, hypovolemia, arrhythmia, lateral decubitus position, etc., after thoracotomy; Degenerative changes of the senile respiratory system, often combined with respiratory diseases, can increase the risk of hypoxemia.
Perioperative lung protection mainly includes the following aspects:
a. Reduce tidal volume: 6-8ml/kg (ideal body weight), reduce airway pressure, thereby reducing mechanical damage and lung inflammation caused by pressure and scissor force;
b. Use PEEP (Intermediate Level): Reach