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Thoracic trauma
 

Thoracic trauma

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    Thoracic trauma Thoracic trauma Presentation Transcript

    • Thoracic Trauma Dr Shankar Hippargi A & E Consultant MMHRC 1
    • 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
    • Chest Trauma Initial examination directed towards identification and treatment of: • Tension pneumothorax • Cardiac tamponade • Open pneumothorax • Flail chest • Massive hemothorax 3
    • 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
    • Rib Fracture Most commonly 5th to 9th ribs Poorly protected 5
    • 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
    • Rib Fracture Fractures of 7th to 12th ribs can damage underlying abdominal solid organs: • Liver • Spleen • Kidneys 7
    • Rib Fracture Management • High concentration O2 • Adequate pain relief • Encourage patient to breath deeply 8
    • 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
    • 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
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    • Paradoxical respiration 12
    • Flail Chest Signs and Symptoms • Paradoxical movement oMay NOT be present initially due to intercostal muscle spasms 13
    • Flail Chest Consequences • The major complication is respiratory failure due to the underlying lung contusion • Increased work of breathing (exhaustion) 14
    • Flail Chest Management • Establish airway, breathing & circulation • Suspect spinal injuries • Stabilize chest wall • Pain relief • IV fluidsConsider early intubation and ventilation 15
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    • Simple Pneumothorax Air in pleural space Partial or complete lung collapse occurs 17
    • Simple PneumothoraxCauses • Chest wall penetration • Fractured rib lacerating lung • May occur spontaneously following: o Exertion o Coughing o Air Travel 18
    • Simple pneumothorax 19
    • 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
    • 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
    • Intercostal drainage 22
    • 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
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    • Open Pneumothorax Management • Close hole with 3 way occlusive dressing • High concentration O2 • Assist ventilations • Watch for tension pneumothorax 26
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    • Sealing all the 4 sides may causetension pneumothorax if an ICD is not inplace 28
    • 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
    • Tension Pneumothorax Trapped air pushes heart, lungs away from injured side Venacava become kinked Blood cannot return to heart Cardiac output falls 30
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    • Tension PneumothoraxSigns and Symptoms • Extreme dyspnea • Restlessness, anxiety, agitation • Absent breath sounds • Hyper resonance to percussion • Cyanosis • Subcutaneous emphysema 34
    • 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
    • Tension PneumothoraxManagement • Secure airway • High concentration O2 with NRB • Needle decompression (temporary measure) • Pain relief • ICD (definitive treatment) 36
    • Needle decompression 37
    • 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
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    • 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
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    • Hemothorax 42
    • Hemothorax Signs and Symptoms • Rapid, weak pulse • Dyspnea • Cool, clammy skin • Restlessness, anxiety • Hypotension 43
    • Hemothorax Signs and Symptoms • Decreased breath sounds • Dullness to percussion • Ventilatory failure Shock precedes respiratory failure 44
    • Hemothorax Management • Secure airway • Assist breathing with high concentration O 2 • Aggressive fluid resuscitation • Transfuse blood as soon as possible • ICD insertion 45
    • 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
    • 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
    • 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
    • Traumatic Asphyxia Name given because patients look like they had been strangled or hanged 49
    • Traumatic Asphyxia Management • Airway with C-spine control • Assist ventilations with high concentration O 2 • IV fluids 50
    • Do not forget the underlyingstructures 51
    • Cardiovascular Trauma Any patient with significant blunt or penetrating trauma to chest has heart / great vessel injury until proven otherwise. 52
    • Myocardial Contusion Bruise of heart muscle Most common blunt cardiac injury Usually due to steering wheel impact 53
    • Myocardial Contusion Behaves like acute MI • May produce arrhythmias • May cause cardiogenic shock, hypotension 54
    • 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
    • Myocardial Contusion Management • High concentration O 2 • Cardiac monitoring • Consider ACLS intercept 56
    • Cardiac Tamponade Rapid accumulation of blood / air in space between heart & pericardium Heart compressed Blood entering heart decreases Cardiac output falls 57
    • Cardiac Tamponade 58
    • 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
    • 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
    • Cardiac Tamponade Management • Secure airway • High concentration O2 • IV fluids • Definitive treatment is pericardiocentesis followed by surgery 61
    • Penetrating injury 62
    • 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
    • Treatment Should be shifted to OT immediately and object removed under direct vision in a controlled environment. 64
    • Other thoracic injuries Aortic rupture Esophageal rupture 65
    • Aortic rupture 66
    • 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
    • Diaphragmatic rupture 68
    • Questions ? ? ? 69