all bones should b palpated throughout its length compression test is positive
AWARENESS• Mortality: Thoracic injuries are responsible for 25% of trauma deaths (UK)• Thoracotomy is required in – 10% of blunt injuries – 20% of penetrating injuries• Early recognition and management are key to patient survival
Tri-modal peak of Mortality• 1st peak: Non-survivable severe CNS or CVS injuries – Location of death: Pre-hospital environment• 2nd peak: First few hours after injury, most often due to hypoxiais referred to as Hence this and hypovolemic shock “THE GOLDEN HOUR” – Large proportion(1/3) of these patients can be saved by EMS (Emergency Medical Services).• 3rd peak: Within 6 weeks of injury – Cause: Multisystem failure and sepsis
The ATLS concept• Advanced Trauma Life Support (ATLSTM) by the American College of Surgeons Committee on Trauma• Originated 1976, Dr. James Styner.
Three Stage Approach1. Primary Survey: Rapid Assessment and treatment of immediately life threatening injuries2. Secondary Survey: Detailed head-to toe assessment of potentially life threatening injuries3. Definitive Care: Specialist treatment of identified injuries
Initial AssessmentA. Airway with cervical spine protectionB. BreathingC. Circulation with haemorrhage controlD. Disability or neurological statusE. Exposure and Environment – remove clothing, but keep warm
B-Breathing and Chest Injuries Primary Survey: ARM approach1. Awareness,2. Recognition3. and Management
Introduction• 1st and 2nd ribs , protected by clavicle: when fractured are very ominous as they indicate transection of thoracic aorta or damage to brachial plexus or subclavian vein• 11th and 12th ribs are floating ribs, usually not fractured• Ribs in children are more elastic thus great force needed
Types of trauma• Closed injury to the chest Direct trauma • Single or multiple ribs fractured at the point of contact Crush injury • Usually causes flail chest due to multiple sites of fracture of ribs Steering wheel injury • In head on car accidents where fracture of sternum and bilateral fractures of ribs at costochondral junction Minor trauma • In osteoporotic ribs, sometimes even a cough can cause a rib fracture
Clinical features• In rib fracture without complication: Pain while taking a deep breath and exaggerated pain during coughing• Inspection: Bruising• Palpation: Bony irregularity, Tenderness and Crepitus• X-ray usually shows a fracture rib but may miss a hairline fracture• Radioscintigraphy: Detected a week or two after injury• Always rule out the presence of complications and monitor the patient before diagnosing an isolated rib #
Treatment of uncomplicated rib fracture• Reduction of pain with 2 week follow up• Analgesics : – Opiods – NSAID’s• Intercostal Blocks• Strapping of chest: relieves pain by immobilizing the ribs• Breathing exercises
• Strapping Disadvantages: decreases respiratory movement (elderly) force broken ends inwards (if applied duringexpiration) Strapping should include two ribs above and below the affected area and should cross midline Elastic corset can be used Local strapping
Indications for thoracotomy1. Internal cardiac massage2. Control of haemorrhage from injury to the heart3. Control of haemorrhage from injury to the lungs/intrapleural haemorrhage4. Cardiac tamponade5. Ruptured oesophagus6. Aortic transection7. Control of massive air leak8. Traumatic diaphragmatic tear
• Thoracotomy can be Emergency:-for control of life threatening bleeding Planned:-for repair of specific injury
FLAIL CHESTDefinition: “A flail chest segment is formedwhen two or more consecutive ribs, with eachrib being fractured at two or more sites”Stove-in-chest: “Depression of a portion of thechest wall due to severe chest injury, whichcontributes to forming a flail segment.”
Significance• The real signiﬁcance of the detection of paradoxical movement lies in the fact that the severity of trauma necessary to produce a ﬂail segment has implications with respect to damage of underlying intrathoracic structures (Trinkle et al., 1975).
Pathophysiology1. Paradoxical Respiration2. Mediastinal Flutter3. Pendular Movement of air4. Associated injuries: Pulmonary Contusion!5. Hypoventilation
Complications• The early mortality attributable to the ﬂail chest syndrome is due to – Massive haemothorax and Pulmonary contusion,• Whereas late mortality is largely due to – Adult respiratory distress syndrome (ARDS) and associated infection. Tsai et al., 1999
M anagement of ﬂail chest Management 241 Table 3 Principles of the initial management of simple rib fractures with ﬂail segments Minimise further lung injury Analgesia Ventilation and re-expansion of the lung if appropriate Administration of high ﬂow humidiﬁed oxygen and cautious ﬂuid resuscitation Ranasinghe A, Trauma 2001; 3: 235–247further injury to theunderlying lung, provideadequat
Stabilization of the ﬂail segment by the application of a sandbag or by extensivestrapping is contraindicated in the hospital environment as this leads to restriction of thoracic wall movement Myllynen et al., 1983
carried out intermittent positive pressure ventilation(IPPV) on a consecutivefor Ventilation with ﬂail Indications series of 35 patients Table 4 Potential indications for ventilation in patients with ﬂail chest Shock Several associated injuries Severe head injuries Previous pulmonary disease Fracture of eight or more ribs Age > 65 years Trauma 2001; 3: 235–247 Ranasinghe A, Trauma 2001; 3: 235–247
Trinkle’s Regime Ranasinghe A, Trauma 2001; 3: 235–247
Surgical Intervention• Internal fixation of flail segment• Indication: Patients suffering from pulmonary contusion with progressive thoracic cage collapse during weaning from the ventilator after resolution of the pulmonary contusion.