recognizing and dealing with these emergencies is life saving

1. EVALUATION & TREATMENT
of THORACIC EMERGENCIES
Mr T Abbass
DR S Khizar

2. IMPORTANCE
 Important public health problem
 Common surgical emergency
 Identify underlying mechanism of injury
 Important cause of preventable deaths if
recognized and treated early
 Correlate history and physical exam to predict
occult injuries

3. HISTORY
 Injury mechanism
 Prehospital events
 Trends of events since injury
 Obtain AMPLE
(allergies,medications,past medical
illnesses, last meal and events
preceding)

4. PHYSICAL EXAM
 Airway with cervical spine
 Breathing
 Circulation with haemorrhage control
 Neck Veins
 Breath Sounds, Subcutaneous emphysema
 Cardiac sounds
 Vitals
 GCS

5. PHYSICAL EXAM
Consider conditions masking
examination signs
 Head trauma
 Alcohol intoxication
 Distracting multisystem injuries

6. RESUSCITATION
ATLS PROTOCOL;
 Airway with cervical spine control
 Breathing and ventilation
 Circulation with haemorrhage control
 Disability
 Exposure
 Secondary survey

7. RESUSCITATION
 Intubation
 IV fluids
 O-ve blood transfusion
 CVP measurement
 Foley catheterisation
 Tube thoractomy as discussed later

8. LAB INVESTIGATIONS
 CBC
 Arterial blood gases
 Clotting
 Blood group and cross match

9. RADIOLOGICAL
INVESTIGATIONS
 CXR

10. CLASSIFICATION
 Respiratory Emergencies
 Respiratory and Circulatory
Emergencies
 Circulatory Emergencies

11. RESPIRATORY
EMERGENCIES
 Tracheobronchial disruption
 Open Pneumothorax
 Flail Chest

12. TRACHEOBRONCHIAL
DISRUPTION
EVALUATION
 Hypoxia
 Chest not moving with ventilation
 Haemoptysis
 Subcutaneous emphysema

13. TRACHEOBRONCHIAL
DISRUPTION
TREATMENT
 Intubate using flexible bronchoscope
 Tracheostomy

14. OPEN PNEUMOTHORAX
EVALUATION
 Hypoxia
 Chest wound
 Air passing in and out of chest wound

15. OPEN PNEUMOTHORAX
TREATMENT
 Apply occlusive dressing using vaseline
gauze and sponge
 Chest drain insertion away from chest
wound

16. FLAIL CHEST
EVALUATION
 Hypoxia
 Impaired ventilation
 Paradoxical Chest movements
 Multiple rib fractures at 2 or more places

17. FLAIL CHEST
TREATMENT
 Consider ET intubation if respiratory
compromise
 Symptomatic treatment with observations
and analgesia if no ventilatory compromise

18. CIRCULATORY&RESPIRAT
ORY EMERGENCIES
 Tension pneumothorax
 Massive Hemothorax

19. TENSION
PNEUMOTHORAX
EVALUATION
 Dyspnoea
 Hypoxia
 Unilateral absence of breath sounds
 Distended neck veins
 Tracheal deviation to opposite side
 Hypotension
 Cyanosis

20. TENSION
PNEUMOTHORAX
TREATMENT
 Consider Thoracocentesis with 18G cannula
in 2nd intercostal space at MCL
 Chest drain insertion in 5th intercostal space
if findings confirmed on needle
thoracocentesis

21. MASSIVE HEMOTHORAX
EVALUATION
 Dyspnoea
 Hypoxia
 Hypotension
 Decreased breath sounds
 Dull percussion note
 Positive CXR

22. MASSIVE HEMOTHORAX
TREATMENT
 Replace Blood Volume loss
 Insert Chest tube
 Consider thoracotomy if blood loss>1500ml
initially or >250ml per hour after initial
evacuation

23. CIRCULATORY
EMERGENCIES
 Cardiac Tamponade
 Aortic disruption
 Myocardial contusion

24. CARDIAC TAMPONADE
EVALUATION
 Hypotension
 Tachycardia
 Distended neck veins
 Cyanosis
 Presence of bilateral breath sounds

25. CARDIAC TAMPONADE
TREATMENT
 Consider Pericardiocentesis as temporary
measure
 Thoracotomy as definitive measure for
hemostasis

26. AORTIC DISRUPTION
EVALUATION
 Blunt chest injury
 Shock
 CXR
 CT Aortography/axial tomography

27. CXR SIGNS(Aortic
Disruption)
 Widened mediastinum
 Fracture of 1st & 2nd ribs
 Obliteration of aortic knob
 Tracheal deviation to right
 Elevation of right main stem bronchus
 Depression of left main stem bronchus
 Obliteration of space b/w pulmonary artery
and aorta
 Oesophageal deviation to right

28. AORTIC DISRUPTION
TREATMENT
 Emergency Operative repair

29. MYOCARDIAL
CONTUSION
EVALUATION
 Blunt chest injury
 Chest pain
 Hypotension
 Dysrrhythmia

30. MYOCARDIAL
CONTUSION
EVALUATION
 ECG
 Echocardiography
 Cardiac Enzymes
Consistent with myocardial injury

31. MYOCARDIAL
CONTUSION
TREATMENT
 Consider symptomatic treatment
 Close cardiac monitoring
 Serial clinical and enzymatic evaluation

32. Thanks for ATTENTION