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- 2. • Superiorly - Clavicles • Inferiorly - Diaphragm • Laterally - Rib cage 2 Boundaries of Chest
- 3. • Chest wall and ribs • Lungs and pleura • Thoracic vessels • Heart and mediastinal structures • Diaphragm • Oesophagus • Thoracic duct • Tracheo-bronchial system 3 Contents- Thoracic cavity
- 4. Epidemiology • Incidence of chest trauma varies from 12 to 25% • Chest injuries are the second leading cause of trauma deaths • Directly attributing to 9.9% of all trauma related deaths • Majority of the deaths are preventable • 90% of blunt trauma and 70% to 85% of penetrating trauma can be managed without surgery.
- 5. Deadly dozen Immediately life threatening • Airway obstruction • Tension pneumothorax • Pericardial tamponade • Open pneumothorax • Massive hemothorax • Flail chest Potentially life threatening • Aortic injuries • Tracheobronchial injuries • Myocardial contusion • Diphragmatic rupture • Esophgeal rupture • Pulmonary contusion
- 6. Mechanism of thoracic trauma • Blunt trauma injury • Penetrating injury
- 7. Initial Management – Primary Survey (ATLS protocol) • Airway • Trachea, bronchial disruption • Breathing • Chest wall injury, pneumothorax, flail chest • Pulmonary contusions • Circulation • Tamponade, hemothorax, tension pneumothorax • Cardiac, Great vessel injury
- 8. Investigation of thoracic trauma • Chest x ray –AP view • e-FAST
- 9. Rib fracture Most common cause of thoracic trauma More common in adult,less common in children Clinical feature- pain and bruising Management- Adequate analgesia -no strapping During CPR most common fracture are 3rd-5th rib Fracture of floating rib(occur in high velocity impact) splenic and liver injury are common
- 10. Flial chest Fracture of two or more consecutive rib at two or more places Clinical feature- pain Respiratory difficulty paradoxical chest wall movement Management of flial chest Adequate analgesia 02 need to be given If initial management fail( if repiratory rate >20/min or pO2<60 mmhg) Intermittent positive pressure ventilation is given as pneumatic splint
- 11. Pneumothorax • Simple pneumothorax • Tension pneumothorax TENSION PNEUMOTHORAX Develops when 1.Trachebronchial injury 2.If there is large pulmonary laceration with air leak(closed pneumothorax) or IPPV is done without chest tube insertionin a closed pneumothorax
- 13. Clinical feature Tachypnoea Tachycardia Tracheal sift Tympanic note Totally absent breath sound on affected side Diagnosis Xray e-FAST
- 14. Management of tension pneumothorax • Emergency management- Needle thoracocentesis in adult -5th intercoastal space just anterior to mid axillary line In children- 2nd intercoastal space in mid-clavicular line .Definitive management Tube thoracocentesis
- 15. Open pneumothorax Pneumothorax with no hemodynamic compromise Due to large open defect in the chest(.>3 cm) Leading to immediate equilibrium between intrathoracic and atmospheric pressure Management – Closing defect (flutter type valve) Insertion of ICT in triangle of safety.
- 16. Haemothorax Accumulation of blood in pleural space Source of blood : Intercoastal vessels Clinical feature- fall in systolic BP -Tachycardia sign- Dull percussion note(blood in pleural space) Absent breath sound xray- Air fluid level Mangement – insertion of ICT in triangle of safety
- 17. Chest tube Functioning of chest tube checked by movement of column of fluid in the water seal bag Position of the chest tube checked bytaking chest xray -assessed based on the break in the radio opaque line,which denotes the hole in the chest tube - The holes in the chest tube should be inside the thoracic cavity or the chest tube will leak
- 18. In some patient emergency thoracotomy is to be carried out • >1-1.5L blood at insertion • >200 cc/hour for 3 consecutive hour • Cardiac tamponade • Tracheobronchial injury • Esophageal injury • Aortic injury
- 19. • Chest tube is removed -lung has expanded: Breath sound are heard and x-ray supports it -output< 100 cc/24 hrs the chest tube is removed at the peak of inspiration , when the patient is holding his/her breath
- 20. Cardiac tamponade Rapid accumulation of blood in pericardial space. Clinical feature Hypotension Raised jvp muffled heart sound Diagnosis is clinical that should be differentiated from tension pneumothorax
- 21. Emergency management • Needle pericardiocentesis insertion of needle under ECG/ECHO control in the sub-xiphoid space at 45 angle to skin , directed to left shoulder tip. Definitive management-Emergency thoracotomy( repair the tear and insert pericardial drain)
- 22. Pulmonary Contusion • A pulmonary contusion is one of the common potentially lethal chest injury. • The most common injury from blunt thoracic trauma • 30% to 75% of patients with blunt trauma have pulmonary contusion • Commonly associated with - Rib fracture - High-energy shock waves from explosion - High-velocity missile wounds - Rapid deceleration
- 23. Pulmonary Contusion Assessment Findings • Tachypnea • Tachycardia • Cough • Hemoptysis • Respiratory distress • Dyspnea • Evidence of blunt chest trauma • Cyanosis
- 24. Pulmonary Contusion Management • Airway and ventilation: • High-concentration oxygen • Positive-pressure ventilation if necessary • Circulation—restrict IV fluids (use caution restricting fluids in hypovolemic patients).
- 25. Traumatic thoracic aortic injury • Following blunt or penetrative thoracic trauma • Site- Distal to ligamentum arteriosum(MC), Left subclavian artery • Clinical feature-Chest pain -Difference in blood pressure between two limbs -Absent pulsation in one limb
- 26. X ray- widened mediastinum IOC - Transesophageal ECHO Management - Permissive hypotension - short acting b blocker - HR kept < 80/min - BP control with MAP 60-70 mmHg (Tear in the aorta can enlarge with rapid fluid correction ,as the bp increases ,this is counter –productive to the management Followed by graft repair
- 27. Sternal fracture • Made by high velocity impact • Cause myocardial contusion if it occurs increased cardiac enzymes • Serial 12 lead ECG done to monitor cardiac changes • No surgical management is required for sternal fracture
- 28. Traumatic diaphragmatic injury Following blunt or penetrating injury More common on left> right Clinical features- early or delayed presentation - breathlessness -Dullness on percussion -Tachypnea -Tachycardia Management: -laparotomy :Reduced the bowel :Repair diaphragm using prolene suture :ICT in chest
Editor's Notes
- The evaluation of the patient's chest trauma is only a part of the total assessment and the basic ABC’s of the primary survey and resuscitation cannot be overlooked. It is important to keep several special factors in mind when dealing with a patient with potential thoracic injuries because thoracic injuries are severe and potentially lethal and the diagnosis and therapy go hand in hand as there can be unique mechanical factors that cause the alterations in vital signs. Injuries such as tension pneumothorax can be rapidly fatal if missed but treated and cured in a matter of moments when recognized. In unstable and critical patients quick decisions based on check of the following vital signs are required. Airway patency: in the initial survey is mandatory to control the airway patency. Patency of the airway does not necessarily assure adequate ventilation in patients with chest injuries unless the airway is in continuity with the lungs. Patients may be ventilated without oxygenating their blood with chest injuries due to pulmonary contusions or airway disruption. All the airway manipulations must be performed with respect to potential cervical spinal injuries. Breathing: in order to know if patient is breathing is necessary to check respiratory movement, and their extension which can be compromised by chest wall integrity. Cyanosis appears very late in hypoxia due to a thoracic trauma because in shocky patients the skin blood flow depends on blood redistribution in the body. Circulation: the state of the circulation is evaluated by assessing patient's pulses (radial, carotid or femoral). The blood pressure is evaluated by width of pulse. In hypovolemic shock radial pulse becomes small; may be absent when blood pressure is below 60 mm/Hg. In thoracic trauma is important to assess the neck veins that are flat in hypovolemia are distended when there is cardiac tamponade. But if cardiac tamponade is associated with hypovolemic shock distension of the neck veins may be absent. Thoracic cavity is constituted from two structures: the first, rigid, comprehending the rib cage, clavicle, sternum, scapula and the second comprehending respiratory muscles. Adequate ventilation and oxygenation depends on an intact chest wall. Significant injury with fracture and muscular disruption may allow direct injury to the underlying lungs, heart, great vessels and upper abdominal viscera. In addition, respiration may be seriously impaired by effective or paradoxical motion of a portion of the thoracic cage (as in flail chest) and the result is respiratory insufficiency.