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Chest trauma

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  • 1. Dr Mukhilesh R MS PG
  • 3. Salient Features of Chest Trauma• Most commonly missed injury• Most common cause of death in thoracic injury is hemorraghe• Clinical examination + chest radiography – to detect chest injury• USG supplements the diagnosis• Resuscitation to be done , without waiting for radiological investigations.• Chest drain – therapeutic as well as diagnostic
  • 4. Chest Anatomy • 12 pair of ribs with intercostal muscles. • The lungs occupy the majority of the thoracic volume. • Mediastinum - heart and great vessels. • DiaphragmMechanisms of Injury – Blunt Injury • Deceleration • Compression – Penetrating Injury – Both
  • 5. Red flag signs of chest injury Hemoptysis. Chest wall contusion. Flail chest. Open wounds. Jugular vein distention (JVD). Subcutaneous empysema. Tracheal deviation.Respiratory rate and effort: Lung sounds: Tachypnea Absent or Bradypnea decreased Labored Unilateral Retractions Bilateral Progressive respiratory Bowel sounds in distress chest.
  • 6. Assess the Chest Wall  Contusions.  Tenderness.  Asymmetry.  Open wounds or impaled objects.  Crepitation.  Paradoxical movement.  Compare both sides of the chest at the same time when assessing for asymmetry. Lung sounds – Percussion. Hyperresonance Pneumothorax Tension pneumothorax Hyporesonance (hemothorax)
  • 7. “DEADLY DOZEN” Threats to life from chest injury
  • 8. Opening pneumothorax - Sucking Chest Wound • Defect in chest > 3cm • Not to be fully closed • Closed on three sides – acts as one way valve • Controlled chest drain must • Formal debridment and closure.
  • 9. Tension pneumothorax – oneway valveCLINICAL DIAGNOSIS – NO NEED FOR RADIOLOGICAL DEMONSTRATIONS Each time we inhale, the lung collapses further. There is no place for the air to escape.. Clinical features tacypnoea/dyspnoea distended neck veins hyperresonance absent breath sounds
  • 10. Contd..Immediate decompression – needle 2nd IC space midclavicular line Definitive Rx Chest tube drain – 5th intercostal space
  • 11. Pericardial tamponadePenetrating injury near heart + Shock – R/O TamponadePericardial sac – non distensibleBECK’S TRIAD increased CVP fall in BP muffled heart soundsCXR – widened heart shadowECHOCentral venous line – increased CVP Sternotomoy / thoracotomy – repair of heart
  • 12. Hemothorax Most common in blunt injury Intercostal vessel & internal mammary art Clinical features Shock with flat neck veins Absent breath sounds dull on percussion Mediastinal shift – respiratory distress ICD
  • 13. Flail Chest Segment of chest wall doesnot have bony continuity with the rest of thoracic cage 3 0r more ribs # in 2 or more places Clinical diagnosis paradoxical chest wall movement Rx analgesia O2 intrapleural local anesthetics ventilator support internal fixation
  • 14. Thoracic aorta disruption – DIRE EMERGENCY Sudden death in chest injury Relatively fixed distal to ligamentum arterisoum Sudden impact – disrupt intima and media Tunica adventia intact – pt may be stable Interscapular pain RF delay / assymetrical BP CXR – widened mediastinum CECT mediastinum / Transesophageal ECHO Rx endovascular intra-aorticc stent tear can be repaired surgically dacron graftin
  • 15. Tracheobronchial injury• Severe subcutaneous empysema with respiratory compromise• Hemoptysis• Immediate chest drain• Early intubation.• Bronchoscopy is diagnostic• Operative repair – definitvie RX
  • 16. Oseophageal injuries • Mostly from penetrating trauma • HIGH INDEX OF SUSPICION • C/F • Odynophagia • Mediastinal emphysema / mediastinitis • Unexplained fever within 24 hours • OGD – confirms diagnosis • Operative repair and drainageMediastinal emphysema – evidence of aerodigestive tract injury until provedotherwise
  • 17. Blunt myocardial injury • Most common finding – ECG abnormality • ACUTE MI • Hypotension • 2 D ECHO • Tranesophageal ECHO • Increased risk of arrhythmia – first 24 hours hence ICU observation necessary
  • 18. Diaphragmatic Injuries • Penetrating injuries to or below 5th IC space – R/O diaphramatic and abdomen injury • Dyspnoea / absent breath sounds • Hollow abdomen/absent bowel sounds in abdomen • No single standard investigation • CXR with NG tube • Contrast studies / CECT • VATS / D- LAP – most accurate assesment • Operative repair – Abdominal approach
  • 19. Pulmonary contusion • Most common cause for hypoxia • Hemorrhage into lung parenchyma • Hemoptysis + blood in ET tube = R/O Lung contusion • Worsening hypoxemia • CXR – delayed finidings • CECT – Confirms • Rx • Nasal O2 • Analgesia • Antibiotics • Pulmonary toileting • Ventilator support - PEEP.
  • 20. Rib fractures Most common finding in chest injury 1st and 2nd rib – Violent injuries Rule out vascular injuries 5th to 9th ribs most commonly affected 10th to 12th rib fracture – R/O abdomen injuries Rx adequate analgesia O2 conservative management. ROLE OF ICD IN RIB FRACTURE????
  • 21. Operative treatment for chest injuries • Initial tube thoracostomy - >1000ml (penetrating injury) or >1500ml (blunt injury) • >200ml/hr for 3 consecutive hours • Caked hemothorax • Great vessel injury (endovascular option) • Pericardial tamponade • Cardiac herniation • Massive air leak from the chest tube • Open pneumothorax • Esophageal perforation • Tracheal or main stem bronchial injury diagnosed by endoscopy or imaging
  • 22. Emergency room thoracotomy – life threatening bleeding Indications Internal cardiac massage Control of hemorrhage – heart / lung or other sites Control of massive air leak Hemodynamically unstable patient as a last resort – usually unsuccessful Left anterolateral thoracotomy Usually futile : CPR >10 minutes blunt trauma with no signs of life at scene
  • 23. Clamshell thoracotomy • Bilateral anterolateral thoracotomy + transverse sternotomy = "clamshell" incision • The largest incision commonly used in thoracic surgery.