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chest trauma
1. Dr Lalit K Shah
Resident 1st year
General Surgery
Chest Trauma
2. Introduction
• Trauma is the study of medical problems
associated with physical injury
• Injury is the adverse effect of a physical
force upon a person
• The most common force involved in most
injuries are mechanical
3. • Trauma is most common cause of death
and disability in the first four decades of
life
• Third most common cause of death
regardless of age
• Overall chest injuries are responsible for
20-25 % of deaths
7. EPIDEMIOLOGY
• Motor vehicle collisions (MVCs) is most
common cause of major chest injury
• Up to 20 percent of deaths from MVCs -
blunt cardiac injuries
9. • High-risk collision characteristics include:
Front- or near-side MVC
Abrupt speed ≥40 km/hour
Crushing of the vehicle ( ≥40 cm)
10.
11. • The ATLS principles are aimed primarily at
the early group of patients
• It helps to optimise the speed and
accuracy of the initial assessment and
management and so reduce subsequent
morbidity and mortality
12. Approach
• Primary survey
A- airway with cervical spine protection
B- breathing and ventilation
C- circulation with haemorrhage control
D- disability
E- exposure
13. Airway
• In all trauma patients cervical spine injury
should be suspected and cervical spine
immobilization should be done
• Assess the patency of airway
14. • Indication of airway management
- obstruction of airway
- mental status depression
- noisy breathing
- facial trauma
- GCS less than or equal to 8
15. • Stepwise progression
in compromised
airway
1 Clear the airway- by
suctioning of secretion
or blood
2 Chin lift/ jaw thrust
3Insertion of
oropharyngeal or
nasopharyngeal airway
16. Breathing
• Assess breathing by visualizing chest
movement
• Assess rate and depth by percussion and
auscultation
• 02 saturation
• Adequate oxygenation and ventilation
17. • Conditions constitute an immediate threat
to life d/t inadequate ventilation during
primary survey :
Tension pneumothorax
Open pneumothorax
Flail chest with pulmonary contusion
Massive hemothorax
Major air leak d/t Tracheobrochial injury
19. Open pneumothorax
• “sucking chest wound”
• Occurs with full thickness loss of chest
wall
• Free communication between pleural
space and atmosphere
22. Management
• The defect is temporarily managed with an
occlusive dressing that is taped on three
sides
23. Management
• Temporary management :
Dressing tapped on three sides
Acts as flutter valve
Permits effective ventilation on inspiration
Accumulated air escapes from the untapped side
Tension pneumothorax is prevented
• Definitive : closure of chest wall defect and ICD insertion
24. Tension pneumothorax
• Etiology- usually traumatic
• Pathophysiology
Parenchymal tear in lungs act as a one way valve
With each inhalation additional air is accumulated without any
means of escape
Leads to increased intrathoracic pressure with mediastinal content shift
to contralateral chest causing decrease in venous return
26. Management
• Emergency treatment:
Immediate needle thoracostomy decompression
14 gauze catheter
in second intercostal space in midclavicular line
(According to ATLS manual 10th edition recent
evidence supports placing large bore needle in 5th
intercostal space slightly anterior to mid axillary
line)
27. Conclusions: In a cadaveric model, needle thoracostomy was successfully placed in
100% of attempts at the fifth intercostal space but in only 58% at the traditional
second intercostal position. On average, the chest wall was 1 cm thinner at this
position and may improve successful needle placement. Live patient validation of
30. A. Tube thoracostomy is performed in the
midaxillary or anterior axillar line
B. Heavy scissors/Artery Foep
are used to cut through the intercostal muscle
into the pleural space
C. The incision is digitally explored
to confirm intrathoracic location and identify
pleural adhesions
D. Chest tube is directed superiorly and
posteriorly
31. Pulmonary contusion
• Direct bruise of the lung
• Leads to alveolar hemorrhage and edema
• Dyspnea, hypoxia, tachypnea, and
hemoptysis
• Progress during the first 12 hour
32.
33. Management
• Close monitor and frequent clinical re
evaluation
• Pain control
• Pulmonary hygiene
• Hypoxia or difficulty ventilating require
airway management
34. Flail chest
• Two or more consecutive ribs are each fractured
in two or more places (ATLS 10th edition)
• occurs when segment of chest wall doesnt have
bony continuity with rest of thoracic cage
• Dignosed clinically- ask the patient to cough
chest cavity moves in while the flail segment
moves out (paradoxical motion)
35. Pressure within the chest is negative during inspiration, causing the flail segment to
retract.
With expiration, intrathoracic pressure becomes positive and the flail segment bulges.
36. Management
• O2 administration + adequate analgesia for pain
control + physiotherapy
• For flail chest + respiratory failure- Noninvasive
positive airway pressure by mask
37. • Opearative management :
• Open reduction and internal fixation can
decrease :
1. Mortality in flail chest
2. Duration of mechanical ventilation
3. Reduce hospital and intensive care length of
stay
38. Circulation
• Four life threatning injuries
• Should be identified prompltly during circulation
section of primary survey
1.Massive hemothorax
2.Cardiac tamponade
3.Massive hemoperitoneum
4.Mechanically unstable pelvic fracture with
bleeding
39.
40. Hemothorax
• Collection of blood in pleural space
• Most common cause- Trauma
• Massive Hemothorax , defined as >1500 ml of
blood
• In peaditric population, >25% of blood volume in
pleural space
41. Pathophysiology
• Multiple rib fractures with severed intercostal
vessels
• Bleeding from lacerated lung parenchyma
• A great vessel or pulmonary hilar vessel injury
after penetrating trauma
42. • In the supine position, blood tracks along the entire posterior section
of the chest and is most notable pushing the lung away from the
chest wall.
43. • In the upright position, blood is visible dependently in the right
pleural space.
45. • Indications of thoracotomy
initial tube thoracostomy drainage >1000ml in
penetrating trauma and >1500ml in blunt trauma
ongoing tube thoracostomy drainage
>200ml/hour for consecutive 3 hours in non-
coagulopathic patients
Tracheobronchial injury
Pericardial tamponade
massive air leak from chest tube with inadequate
ventilation
46. Cardiac tamponade
• Rapid accumulation of blood or fluid in
pericardial space
• Most commonly after penetrating thoracic
wounds
• Acutely ,< 100 ml of pericardial blood may cause
tamponade
• Classical Becks Triad: distended neck vein
,muffled heart sound ,hypotension
47. Pathophysiology
• Low distensible property of pericardium
• Pressure in pericardial sac rises to match injured
chamber
• When pressure exceeds that of right atrium
• RA filling is impaired
• RV preload is reduced
48. • Diagnosis of hemopericardium - best achieved by usg scan
49. Management
• Pericardiocentesis :succesful in decompression
of tamponade (80 % cases)
• Failure : Due to presence of clotted blood in
pericardium
• Persistent SBP <60 mm of hg – Resuscitative
thoractomy
50. • Access to the pericardium
• Through a subxiphoid approach, with the needle angled 45° up
from the chest wall and toward the left shoulder.
51. • Seldinger technique :
• used to place a pigtail catheter. Blood can be repeatedly aspirated
with a syringe, or the tubing may be attached to a gravity drain.
53. Exposure
• All clothing of patient should be removed
for adequate examination
• core body temperature should be obtained
• Keep the patient warm
54.
55.
56. References
• Bailey & Love 27th edition
• Sabiston Textbook Of Surgery 21st edition
• ATLS guidlines 10th edition
• Washington manual of surgery 8th edition
• Pubmed
