Thoracic trauma

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Thoracic trauma

  1. 1. Thoracic Trauma Dr Shankar Hippargi A & E Consultant MMHRC 1
  2. 2. Chest Trauma Second leading cause of deaths due to trauma About 20% of all trauma deaths About 80% of thoracic traumas do not need surgery 2
  3. 3. Chest Trauma Initial examination directed towards identification and treatment of: • Tension pneumothorax • Cardiac tamponade • Open pneumothorax • Flail chest • Massive hemothorax 3
  4. 4. Rib Fracture Most common chest injury More common in adults than children Especially common in elderly Ribs form rings- Consider possibility of break at two places 30% - 40% rib #s missed on CXR 4
  5. 5. Rib Fracture Most commonly 5th to 9th ribs Poorly protected 5
  6. 6. Rib Fracture Fractures of 1st, 2nd ribs require great force Frequently have injury to aorta, subclavian artery / vein or bronchi Look for swelling in supraclavicular fossa Compare the radial pulses, urgent intervention needed if unequal / absent 30% of the patients will die 6
  7. 7. Rib Fracture Fractures of 7th to 12th ribs can damage underlying abdominal solid organs: • Liver • Spleen • Kidneys 7
  8. 8. Rib Fracture Management • High concentration O2 • Adequate pain relief • Encourage patient to breath deeply 8
  9. 9. Rib FractureManagement • Monitor elderly and COPD patients carefully o Broken ribs can cause decompensation. o Patients will fail to breath deeply and cough, resulting in poor clearance of secretions. 9
  10. 10. Flail Chest Three or more adjacent ribs broken at two or more places Produces free-floating chest wall segment (Flail segment) Secondary to blunt trauma More common in older patients 10
  11. 11. 11
  12. 12. Paradoxical respiration 12
  13. 13. Flail Chest Signs and Symptoms • Paradoxical movement oMay NOT be present initially due to intercostal muscle spasms 13
  14. 14. Flail Chest Consequences • The major complication is respiratory failure due to the underlying lung contusion • Increased work of breathing (exhaustion) 14
  15. 15. Flail Chest Management • Establish airway, breathing & circulation • Suspect spinal injuries • Stabilize chest wall • Pain relief • IV fluidsConsider early intubation and ventilation 15
  16. 16. 16
  17. 17. Simple Pneumothorax Air in pleural space Partial or complete lung collapse occurs 17
  18. 18. Simple PneumothoraxCauses • Chest wall penetration • Fractured rib lacerating lung • May occur spontaneously following: o Exertion o Coughing o Air Travel 18
  19. 19. Simple pneumothorax 19
  20. 20. Simple Pneumothorax Signs and Symptoms • Pain on inhalation • Difficulty breathing • Tachypnea • Decreased or absent breath sounds • Hyper resonant to percussion Severity of symptoms depends on size of pneumothorax, speed of lung collapse, and patient’s health status 20
  21. 21. Simple Pneumothorax Management • Establish ABC • Suspect spinal injury based on mechanism • High concentration O2 with NRB • Assist decreased or rapid respirations with BVM • Monitor for tension pneumothorax • ICD depending on patient’s condition & amount of air in pleural cavity 21
  22. 22. Intercostal drainage 22
  23. 23. Open Pneumothorax Hole in chest wall Allows air to enter pleural space Larger hole = Greater chance of air entering through it Frothy blood at wound site “Sucking Chest Wound” 23
  24. 24. 24
  25. 25. 25
  26. 26. Open Pneumothorax Management • Close hole with 3 way occlusive dressing • High concentration O2 • Assist ventilations • Watch for tension pneumothorax 26
  27. 27. 27
  28. 28. Sealing all the 4 sides may causetension pneumothorax if an ICD is not inplace 28
  29. 29. Tension Pneumothorax One-way valve forms in lung or chest wall Air enters pleural space; cannot leave Air is trapped in pleural space Pressure rises Pressure collapses lung 29
  30. 30. Tension Pneumothorax Trapped air pushes heart, lungs away from injured side Venacava become kinked Blood cannot return to heart Cardiac output falls 30
  31. 31. 31
  32. 32. 32
  33. 33. 33
  34. 34. Tension PneumothoraxSigns and Symptoms • Extreme dyspnea • Restlessness, anxiety, agitation • Absent breath sounds • Hyper resonance to percussion • Cyanosis • Subcutaneous emphysema 34
  35. 35. Tension PneumothoraxSigns and Symptoms • Rapid, weak pulse • Decreased BP • Tracheal shifts away from injured side • Jugular vein distension Early dyspnea/hypoxia - Late shock 35
  36. 36. Tension PneumothoraxManagement • Secure airway • High concentration O2 with NRB • Needle decompression (temporary measure) • Pain relief • ICD (definitive treatment) 36
  37. 37. Needle decompression 37
  38. 38. Subcutaneous emphysema Can be due to rib fracture, injury to lungs or airway Can extend to neck, face, abdomen, and upper limbs May require ICD if source is in lungs. 38
  39. 39. 39
  40. 40. Hemothorax Blood in pleura space Most common result of major chest wall trauma Present in 70 to 80% of penetrating, major non-penetrating chest trauma 40
  41. 41. 41
  42. 42. Hemothorax 42
  43. 43. Hemothorax Signs and Symptoms • Rapid, weak pulse • Dyspnea • Cool, clammy skin • Restlessness, anxiety • Hypotension 43
  44. 44. Hemothorax Signs and Symptoms • Decreased breath sounds • Dullness to percussion • Ventilatory failure Shock precedes respiratory failure 44
  45. 45. Hemothorax Management • Secure airway • Assist breathing with high concentration O 2 • Aggressive fluid resuscitation • Transfuse blood as soon as possible • ICD insertion 45
  46. 46. Indications for thoracotomy Thoracotomy is indicated if there is >1500ml blood loss or <1500 ml with continuous loss > 200ml/hr Penetrating anterior wound medial to nipple line or posterior wound medial to scapula may need thoracotomy due to damage to great vessels, hilar structures or heart 46
  47. 47. Traumatic Asphyxia Blunt force to chest causes • Increased intrathoracic pressure • Backward flow of blood out of heart into vessels of upper chest, neck, head 47
  48. 48. Traumatic Asphyxia Signs and Symptoms • Possible sternal fracture or central flail chest • Shock • Purplish-red discoloration of: o Head o Neck o Shoulders • Protruding eyes • Swollen, cyanotic lips 48
  49. 49. Traumatic Asphyxia Name given because patients look like they had been strangled or hanged 49
  50. 50. Traumatic Asphyxia Management • Airway with C-spine control • Assist ventilations with high concentration O 2 • IV fluids 50
  51. 51. Do not forget the underlyingstructures 51
  52. 52. Cardiovascular Trauma Any patient with significant blunt or penetrating trauma to chest has heart / great vessel injury until proven otherwise. 52
  53. 53. Myocardial Contusion Bruise of heart muscle Most common blunt cardiac injury Usually due to steering wheel impact 53
  54. 54. Myocardial Contusion Behaves like acute MI • May produce arrhythmias • May cause cardiogenic shock, hypotension 54
  55. 55. Myocardial Contusion Signs and Symptoms • Cardiac arrhythmias after blunt chest trauma • Angina-like pain unresponsive to nitroglycerin • Chest pain independent of respiratory movement Suspect in all blunt chest trauma 55
  56. 56. Myocardial Contusion Management • High concentration O 2 • Cardiac monitoring • Consider ACLS intercept 56
  57. 57. Cardiac Tamponade Rapid accumulation of blood / air in space between heart & pericardium Heart compressed Blood entering heart decreases Cardiac output falls 57
  58. 58. Cardiac Tamponade 58
  59. 59. Cardiac Tamponade Signs and Symptoms • Hypotension unresponsive to treatment • Increased central venous pressure (distended neck/arm veins in presence of decreased arterial BP) • Muffled heart sounds Beck’s Triad 59
  60. 60. Cardiac Tamponade Signs and Symptoms • Narrowing pulse pressure • Pulsus paradoxicus • Radial pulse becomes weak or disappears when patient inhales • ECG shows low amplitude complexes 60
  61. 61. Cardiac Tamponade Management • Secure airway • High concentration O2 • IV fluids • Definitive treatment is pericardiocentesis followed by surgery 61
  62. 62. Penetrating injury 62
  63. 63. Penetrating chest injuries Never try to remove penetrating foreign objects from the wound. May cause severe uncontrollable bleeding, tension pneumothorax, cardiac tamponade and sudden death. Maintain ABCs in ED 63
  64. 64. Treatment Should be shifted to OT immediately and object removed under direct vision in a controlled environment. 64
  65. 65. Other thoracic injuries Aortic rupture Esophageal rupture 65
  66. 66. Aortic rupture 66
  67. 67. Associated Abdominal Trauma Diaphragm forms dome that extends up into rib cage - Diaphragmatic rupture Trauma to chest below 4th rib indicates abdominal injury until proven otherwise 67
  68. 68. Diaphragmatic rupture 68
  69. 69. Questions ? ? ? 69

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