2. OBJECTIVES
Students should be able to:
1. Describe clinical presentation of the
immediately life-threatening chest injuries
2. Describe management of the
immediately life-threatening chest injuries
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4. INTRODUCTION
•The chest wall, defined as the bony and muscular
structures covering the entire thoracic cavity.
•Protects internal thoracic organs (heart and lungs),
mediastinal structures (esophagus and trachea), and
major vasculature (aorta and vena cava).
•Damage to the chest wall may coincide with significant
injury to these structures and thus, warrants careful
evaluation.
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5. EPIDEMIOLOGY
•Trauma is responsible for more than 100,000
deaths annually in the United States.
•Estimates of thoracic trauma frequency indicate
that injuries occur in 12 persons per 1 million
population per day.
•Chest trauma is a significant cause of mortality
which is account for 25% of all trauma deaths.
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6. Epidemiology cont.
•Many patients approximately (2/3) with chest
trauma die after reaching hospital; however many
of these deaths could have been prevented with
prompt diagnosis and treatment.
•Approximately 10% of blunt chest injuries and 15%-
30% of penetrating chest injuries require operative
intervention (thoracotomy).
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7. CLASSIFICATION OF CHEST TRAUMA
•Blunt chest trauma:
•Compression force where the chest is caught
between two objects and compressed
•Penetrating trauma:
•An object enters the chest causing small or
large hole
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9. CAUSES OF BLUNT CHEST TRAUMA
•MVAs account for 70-80% of such injuries.
•Preventive strategies to reduce MVAs have
been instituted in the form of speed limit
restriction and the use of restraints.
•Other causes include;
• Pedestrians struck by vehicles
• Falls
• Acts of violence .
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10. PATHOPHYSIOLOGY
•The clinical consequences depend on the.
mechanism of the injury, the location of the
injury, associated injuries, and underlying
illnesses
•Chest injuries adversely affect pulmonary
function by three separate mechanisms:
•altered mechanics of breathing,
•ventilation/perfusion imbalance, and
•Reduced lung compliance
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11. VARIOUS CONSEQUENCES OF CHEST
TRAUMA
Immediately life
threatening
•Airway obstruction
•Tension pneumothorax
•Pericardial tamponade
•Open pneumothorax
•Massive haemothorax
•Flail chest
Potentially life
threatening
•Tracheobronchial
injuries
•Myocardial contusion
•Rupture of diaphragm
•Oesophageal injuries
•Pulmonary contusion
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12. 1. OPEN PNEUMOTHORAX
•Wound opening into chest cavity that allows air to enter
pleural space.
•Causes the lung to collapse due to increased pressure in
pleural space
•Can be life threatening and patient can deteriorate
rapidly.
•Stab, gunshot injuries cause chest wall defects that are
significantly large resulting into an open pneumothorax.
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14. Open Pneumothorax cont.
Pathophysiology
•An open defect in the chest wall (>3 cm)
•Defect >2/3 the diameter of the trachea, air follows
the path of least resistance through the chest wall
with each inspiration.
•As the air accumulates, the ipsilateral lung
collapses and begins to shift towards the uninjured
side.
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20. CLINICAL FEATURES
Symptoms
•Difficult in breathing
•Sudden sharp pain
•History of trauma
On examination
Inspection:
•Dyspnoea
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21. Clinical Features cont.
Air bubbles on exhalation from the wound
(sucking chest wound)
On palpation:
•Subcutaneous Emphysema
On auscultation:
•Decreased breath sounds on affected side
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22. TREATMENT
•ABC’s with c-spine control as indicated
•Initial management consists of promptly closing
the defect- flutter-type valve.
•Tube thoracostomy as soon as possible-remote
site.
•Definitive treatment -debridement and closure,
•Early referral.
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24. 2. TENSION PNEUMOTHORAX
Pathophysiology
•Air enters the pleural space from a lung injury or
through the chest wall without a means of exit.
•Leads to an increase in the pleural pressure.
•Ipsilateral lung collapses, and the mediastinum
shifts to the opposite side.
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25. Tension Pneumothorax cont.
Pathophysiology..
•Mediastinal shift results in:
•Compression of the uninjured lung
•Kinking of the superior and inferior vena
cava,
• decreasing venous return to the heart,
• subsequently decreasing cardiac output.
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26. CLINICAL FEATURES.
Symptoms
•Severe difficult in breathing
•On general examination
•Anxiety/restlessness
•Cyanosis
•Tachycardia
•Narrow pulse pressure
•Hypotension
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27. Clinical Features cont.
On inspection:
•Severe dyspnea
•Tachypnea
•Distended neck veins
•Reduced chest movement ipsilaterally
On palpation:
•Tracheal deviation to contralateral side
•Reduced chest expansion ipsilaterally
•Reduced tactile vocal fremitus ipsilaterally
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28. Clinical Features cont.
On percussion
•Hyperresonant percusion note ipsilaterally
On auscultation
•Reduced/absent vocal resonance
•Absent Breath sounds on affected side
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29. AN X RAY OF TENSION PNEUMOTHORAX
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30. AN X RAY OF TENSION PNEUMOTHORAX
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32. 3. MASSIVE HEMOTHORAX
•Results from collection of > 1,500 mL of blood
(30% to 40% of total blood volume) rapidly in
the pleural space.
•CAUSES:
•Penetrating injuries.
• Blunt chest trauma and rib fracture.
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34. Clinical Presentation cont.
On inspection:
•Severe Dyspnea
•Tachypnea
•Flat neck veins
•Reduced chest movement ipsilaterally
On palpation:
•Tracheal deviation to contralateral side
•Reduced chest expansion ipsilaterally
•Reduced tactile vocal fremitus ipsilaterally
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35. Clinical Presentation cont.
On percussion
•Stony dull percussion note ipsilaterally
On auscultation
•Reduced/absent vocal resonance
•Absent breath sounds on affected side
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36. Trauma.org
AN XRAY OF MASSIVE HEMOTHORAX
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38. 4. FLAIL CHEST
•Segment of the chest that becomes free to move
with the pressure changes of respiration
•Three or more adjacent rib fracture in two or more
places
•Serious chest wall injury with underlying pulmonary
injury:
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39. Flail Chest cont.
•Reduced volume of respiration
•Adds to increased mortality
•Paradoxical flail segment movement
•Positive pressure ventilation can restore
tidal volume.
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41. Flail Chest; Pathophysiology
A: Inspiratory phase:
•Chest wall collapses inward
•Air move out of the bronchus of the involved lung
into the trachea and bronchus of the uninvolved
lung.
•Causing a shift of mediastinum to the
uninvolved side.
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42. Flail Chest; Pathophysiology
B: Expiratory phase:
•Chest wall balloons outward
•Air is expelled from the lung on the uninvolved
side and enters the lung on the involved side with
an associated shift of mediastinum to the involved
side.
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44. Respiratory System Examination
On inspection:
•Dyspnoea
•Tachypnoea
•Bruising/swelling
•Paradoxical chest movement
On palpation:
•Crepitus.
On auscultation:
•Crepitations
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45. MANAGEMENT
•ABC’s with c-spine control if indicated
•Oxygen therapy.
•Analgesia
•Use Trauma bandage and Triangular
Bandages to splint ribs.
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47. 5. PERICARDIAL TAMPONADE
•Occurs when there is small pericardial
laceration
•Blood accumulates within the pericardial
cavity.
•The distended pericardium may contain
blood clot equivalent to between 500 -
1500 ml of blood.
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48. Pericardial Tamponade; Pathophysiology
•Blood leak into the pericardial cavity.
•Causes the cavity to expand until it cannot
expand anymore
•Interpericardial blood starts putting
pressure on the heart
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49. Pericardial Tamponade cont.
•Ineffective heart pumping
•Blood pressure starts to drop.
•Heart rate increases to compensate but is
unable.
•Level of consciousness drops-cardiac arrest.
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50. CLINICAL PRESENTATION
History:
•History of trauma
•Chest pain
On examination:
•Cyanosis
•Distended Neck Veins
•Tachypnea
•Tachycardia
•Hypotension
•Weak pulse pressure
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51. Clinical Presentation cont.
Beck’s triad:
•Muffled heart sounds,
•Jugular venous distention, and
•Pulsus paradoxus
• Present in only 15% of patients who
are later judged to have tamponade.
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52. MANAGEMENT OF PERICARDIAL
TAMPONADE
Investigations
•Chest radiography showing an enlarged
heart shadow.
•Cardiac echo showing fluid in the pericardial
sac,
• Insertion of a central line with a rising
central venous pressure
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54. 6. DIAPHRAGMATIC INJURIES
•Any penetrating injury to or below the fifth
intercostal space should raise the suspicion
of diaphragmatic injury.
•The diaphragmatic rupture is usually large,
with herniation of the abdominal contents
into the chest.
•Most diaphragmatic injuries are silent.
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55. Diaphragmatic Injury cont.
Investigations:
•CXR+/- after placement of NGT
•Contrast studies of the upper or lower GIT
•CT scan of the chest
• Video-assisted thoracoscopy (VATS)
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56. AN XRAY OF DIAPHRAGMATIC
RUPTURE
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57. AN XRAY OF DIAPHRAGMATIC
RUPTURE
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58. DIAPHRAGMATIC INJURY
Treatment
•Operative repair is recommended in all
cases.
•All penetrating diaphragmatic injury must be
repaired via the abdomen and not the chest
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59. Summary
•Chest trauma is a significant cause of
mortality which is account for 25% of all
trauma deaths
•MVAs account for 70-80% of blunt chest
injuries
•Immediately life threatening consequences
are surgical emergencies.
•Once Tension pneumothorax is suspected
Do Not wait for radiographs.
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60. References
•Bailey & Love’s, SHORT PRACTICE of
SURGERY 27th Edition.
•Schwartz’s Principles of Surgery,11th Edition
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Editor's Notes
If a weapon is still in place, it should be removed in the operating room, because it could be tamponading a lacerated blood vessel.
Subcutaneous emphysema=Air collects in subcutaneous fat from pressure of air in pleural cavity. Feels like rice crispies or bubble wrap
Can be seen from neck to groin area
Initial management consists of promptly closing the defect with a sterile occlusive plastic dressing (e.g. Opsite®), taped on three sides to act as a flutter-type valve. A chest tube is inserted as soon as possible in a site remote from the injury site. Definitive treatment may warrant formal debridement and closure, and early referral.
As the patient breathes in, the dressing occludes the wound, preventing air entry through the chest wall.
When the patient exhales, the open end of the dressing allows air to escape from the pleural space.
A chest tube is placed remotely from the wound.
After initial stabilization, operative wound debridement and closure is done.
Circulation—treat for shock with crystalloid infusion.
Needle Decompression
Locate 2nd Intercostal space midclavicular line
Cleanse area using aseptic technique
Insert catheter ( 14G or larger) at least 3” in length over the top of the 3rd rib ( nerve, artery, vein lie along bottom of rib)
Remove Stylette and listen for rush of air
Place Flutter valve over catheter
Reasses for Improvement
tube inserted in the 5th intercostal space mid-axillary line.
Blood transfusion depending on class of bloss
Crepitus- grinding of bones ends together on palpation
With improved understanding of pulmonary mechanics and better mechanical ventilatory support, surgical therapy has not proved superior to supportive and medical measures.
Application of external fixation devices, and placement of plates or pins for internal fixation). --
classically described in three phases:
First phase
Rising pericardial pressure restricts ventricular diastolic filling & reduces subendocardial blood flow.
Output is maintained by compensatory tachycardia, increased systemic vascular resistance, and elevated ventricular filling pressure.
Second phase
Rising pericardial pressure further compromises diastolic filling, stroke volume, and coronary perfusion, resulting in diminished cardiac output.
Initial signs of shock such as anxiety, diaphoresis, and cyanosis become evident in this phase.
Third phase
compensatory mechanisms fail as the intrapericardial pressure approaches the ventricular filling pressure.
Cardiac arrest results as profound coronary hypoperfusion occurs.
Using aseptic technique, Insert needle at the angle of the Xiphoid process at the 7th rib
Advance needle at 45 degree towards the tip of the shoulder while aspirating syringe till blood return is seen
Continue to Aspirate till syringe is full then discard blood and attempt again till signs of no more blood
Closely monitor patient
