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Chest trauma

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  • 1. Chest Trauma Gráinne Murphy Final Med April 2002
  • 2. Rib fractures
    • Most common thoracic injury
    • Localised pain, tenderness, crepitus
    • CXR to exclude other injuries
    • Analgesia..avoid taping
    • Underestimation of effect
    • Upper ribs, clavicle or scapula fracture: suspect vascular injury
  • 3. Mechanism of Injury
    • Penetrating injuries
    • E.g. stab wounds etc.
    • Primarily peripheral lung
    • Haemothorax
    • Pneumothorax
    • Cardiac, great vessel or oesophageal injury
  • 4. Chest wall injuries
    • Rib fractures
    • Flail chest
    • Open pneumothorax
  • 5. Introduction
    • Chest trauma is often sudden and dramatic
    • Accounts for 25% of all trauma deaths
    • 2/3 of deaths occur after reaching hospital
    • Serious pathological consequnces: -hypoxia, hypovolaemia, myocardial failure
  • 6.
    • Either: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury
    • Rib fracture is the most common sign of blunt thoracic trauma
    • Fracture of scapula, sternum, or first rib suggests massive force of injury
    Blunt injuries
  • 7. Flail chest
    • Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration
    • Significant force required
    • Usually diagnosed clinically
    • Rx: ABC Analgesia
  • 8. Flail chest
  • 9. Flail Chest - detail
  • 10. Open pneumothorax
    • Defect in chest wall provides a direct communication between the pleural space and the environment
    • Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax
    • “ Sucking chest wound”
    • Rx: ABCs…closure of wound…chest drain
  • 11. Lung injury
    • Pulmonary contusion
    • Pneumothorax
    • Haemothorax
    • Parenchymal injury
    • Trachea and bronchial injuries
    • Pneumomediastinum
  • 12. Pneumothorax
    • Air in the pleural cavity
    • Blunt or penetrating injury that disrupts the parietal or visceral pleura
    • Unilateral signs:  movement and breath sounds, resonant to percussion
    • Confirmed by CXR
    • Rx: chest drain
  • 13. Pneumothorax
  • 14. Tension pneumothorax
    • Air enters pleural space and cannot escape
    • P/C: chest pain, dyspnoea
    • Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension
  • 15.
    • Surgical emergency
    • Rx: emergency decompression before CXR
    • Either large bore cannula in 2nd ICS, MCL or insert chest tube
    • CXR to confirm site of insertion
  • 16. Haemothorax
    • Blunt or penetrating trauma
    • Requires rapid decompression and fluid resuscitation
    • May require surgical intervention
    • Clinically: hypovolaemia absence of breath sounds dullness to percussion
    • CXR may be confused with collapse
  • 17. Heart, Aorta & Diaphragm
    • Blunt cardiac injury - contusion - ventricular, septal or valvular rupture
    • Cardiac tamponade
    • Ruptured thoracic aorta
    • Diaphragmatic rupture
  • 18. Cardiac Tamponade
    • Blood in the pericardial sac
    • Most frequently penetrating injuries
    • Shock,  JVP, PEA, pulsus paradoxus
    • Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension
    • Rx: Volume resuscitation Pericardiocentesis
  • 19. Cardiac tamponade
  • 20. Aortic rupture
    • Usually blunt trauma involving deceleration forces; especially RTAs
    • ~90% die within minutes
    • Most common site near ligamentum arteriosum
    • Dx: clinical suspicion, CXR, aortography, contrast CT or TOE
    • Rx: surgical…poor prognosis
  • 21. Aortic rupture
  • 22. Iatrogenic trauma
    • NG tubes: -coiling -endobronchial placement -pneumothorax
    • Chest tubes: - subcutaneous - intraparenchymal - intrafissural
    • Central lines: - neck - coronary sinus - pneumothorax
  • 23. Misplaced nasogastric tube
  • 24. Chest trauma: summary
    • Common
    • Serious
    • Primary goal is to provide oxygen to vital organs
    • Remember A irway B reathing C irculation
    • Be alert to change in clinical condition
  • 25. Line in jugular vein
  • 26. Chest Trauma Gráinne Murphy Final Med April 2002
  • 27. Rib fractures
    • Most common thoracic injury
    • Localised pain, tenderness, crepitus
    • CXR to exclude other injuries
    • Analgesia..avoid taping
    • Underestimation of effect
    • Upper ribs, clavicle or scapula fracture: suspect vascular injury
  • 28. Mechanism of Injury
    • Penetrating injuries
    • E.g. stab wounds etc.
    • Primarily peripheral lung
    • Haemothorax
    • Pneumothorax
    • Cardiac, great vessel or oesophageal injury
  • 29. Chest wall injuries
    • Rib fractures
    • Flail chest
    • Open pneumothorax
  • 30. Introduction
    • Chest trauma is often sudden and dramatic
    • Accounts for 25% of all trauma deaths
    • 2/3 of deaths occur after reaching hospital
    • Serious pathological consequnces: -hypoxia, hypovolaemia, myocardial failure
  • 31.
    • Either: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury
    • Rib fracture is the most common sign of blunt thoracic trauma
    • Fracture of scapula, sternum, or first rib suggests massive force of injury
    Blunt injuries
  • 32. Flail chest
    • Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration
    • Significant force required
    • Usually diagnosed clinically
    • Rx: ABC Analgesia
  • 33. Flail chest
  • 34. Flail Chest - detail
  • 35. Open pneumothorax
    • Defect in chest wall provides a direct communication between the pleural space and the environment
    • Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax
    • “ Sucking chest wound”
    • Rx: ABCs…closure of wound…chest drain
  • 36. Lung injury
    • Pulmonary contusion
    • Pneumothorax
    • Haemothorax
    • Parenchymal injury
    • Trachea and bronchial injuries
    • Pneumomediastinum
  • 37. Pneumothorax
    • Air in the pleural cavity
    • Blunt or penetrating injury that disrupts the parietal or visceral pleura
    • Unilateral signs:  movement and breath sounds, resonant to percussion
    • Confirmed by CXR
    • Rx: chest drain
  • 38. Pneumothorax
  • 39. Tension pneumothorax
    • Air enters pleural space and cannot escape
    • P/C: chest pain, dyspnoea
    • Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension
  • 40.
    • Surgical emergency
    • Rx: emergency decompression before CXR
    • Either large bore cannula in 2nd ICS, MCL or insert chest tube
    • CXR to confirm site of insertion
  • 41. Haemothorax
    • Blunt or penetrating trauma
    • Requires rapid decompression and fluid resuscitation
    • May require surgical intervention
    • Clinically: hypovolaemia absence of breath sounds dullness to percussion
    • CXR may be confused with collapse
  • 42. Heart, Aorta & Diaphragm
    • Blunt cardiac injury - contusion - ventricular, septal or valvular rupture
    • Cardiac tamponade
    • Ruptured thoracic aorta
    • Diaphragmatic rupture
  • 43. Cardiac Tamponade
    • Blood in the pericardial sac
    • Most frequently penetrating injuries
    • Shock,  JVP, PEA, pulsus paradoxus
    • Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension
    • Rx: Volume resuscitation Pericardiocentesis
  • 44. Cardiac tamponade
  • 45. Aortic rupture
    • Usually blunt trauma involving deceleration forces; especially RTAs
    • ~90% die within minutes
    • Most common site near ligamentum arteriosum
    • Dx: clinical suspicion, CXR, aortography, contrast CT or TOE
    • Rx: surgical…poor prognosis
  • 46. Aortic rupture
  • 47. Iatrogenic trauma
    • NG tubes: -coiling -endobronchial placement -pneumothorax
    • Chest tubes: - subcutaneous - intraparenchymal - intrafissural
    • Central lines: - neck - coronary sinus - pneumothorax
  • 48. Misplaced nasogastric tube
  • 49. Chest trauma: summary
    • Common
    • Serious
    • Primary goal is to provide oxygen to vital organs
    • Remember A irway B reathing C irculation
    • Be alert to change in clinical condition
  • 50. Line in jugular vein