Chest trauma


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Emergency Specialist
General Surgery Acting Consultant

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Chest trauma

  1. 1. ER APPROACH TO A PATIENT WITH CHEST EMERGENCIES DR. TAREK SILEM AL-NOGOMI Emergency Specialist General Surgery Acting Consultant
  2. 2. CHEST TRAUMA Chest trauma
  3. 3. This study includes all polytrauma patientswith chest injury treated between 1992 and 2002at a major urban trauma center Department of Traumatology, Medical University of Vienna, Vienna, Austria May 2005
  4. 4. 332 out of 501 polytrauma patients, 228 males and 104females, had a coexisting chest injury. Mean age at thetime of injury was 37.7 years, and 258 patients wereintubated before admission. Average period on ICU was15.4 days, and 35.9 days for total hospital stay. Regardingthe injury pattern in 143 patients a combinedhemo-/pneumothorax was seen, 109 patients had either ahemothorax or a pneumothorax, in 155 patients aunilateral and in 52 patients a bilateral serial rib fracturewas diagnosed, in 28 patients either sternal or singular ribfractures were determined, in a total of 23 patients anunstable thorax or a flail chest was seen, 105 patients hada unilateral pulmonary contusion, and in 79 patients abilateral pulmonary contusion was diagnosed. Finally, atotal of eleven patients with a traumatic aortic disruptionwere identified
  5. 5. Who Survive85% Need conservative treatment & or simple maneuvers 15% will need surgery
  6. 6. Types of InjuryDirect … blunt … penetrating … cruch • • Indirect … blast … deceleration •
  7. 7. TRAUMATIC CHEST PROBLEM THREATENING LIFE NEEDS IMMEDIATE MANAGEMENT– ABCD Dyspnea, tachypnea, hypotension, ABG changes Expose chest and neck completely, observe, palpate and listen. Cyanosis is a late symptom of hypoxia.
  8. 8. ?? VITAL SIGNSHemodynamically instability associated with chest trauma represent A life-threatening emergency.
  9. 9. O2 INHALATIONABG , if patient is desaturated.
  10. 10. SELECTIVE PHYSICAL EXAMINATIONPulse evaluation, regular, irregular, strong orweak.Neck, congested neck veins.Heart sound .Respirations … one side dullness or Hyperresonance by percussion.
  11. 11. TraumaDysnea …. Desaturation
  12. 12. (TENSION PNEUMOTHORAX (TNOne way valve air leak occurs from lung or from chest wall – complete collapse of lung, mediastinal displacement to opposite sides compressing the opposite lung with low venous rectum. 1. Penetrating chest trauma 2. Blunt chest trauma 3. Marked displaced thoracic spine fractures.TN is a clinical diagnosis and treated without waiting any investigation.Patient with chest pain, tachypnea, tachycardia, distended vein, absent breath sound affected side. Hyper resonance to percussion.Immediate decompression with second intercostals space mid clavicular line needle no. 14 and then ICT 5th ICS (nipple level) ant. to midaxillary line.
  13. 13. OPEN PNEUMOTHORAX Large defect of chest wall.If defect is 2/3, the diameter oftrachea, air passes through chest wall with each respiration so effective ventilation is impaired with hypoxia and hypercarbia.
  14. 14. MANAGEMENTClosing the defect with sterile adhesive dressing taped on three sides, then ICT & surgical closure of the defect.
  15. 15. FLAIL CHESTTwo or more ribs fractured in two or more places.Paradoxical movement will follow. This alone does notcause hypoxia, but pain and underlying lung contusion.Diagnosed by paradoxical movement ± palpation ofabnormal respiratory motion and crepitous of ribs orcartilage fracture.CXR (Multiple fracture ribs)ABG– Analgesics– Adequate ventilation with humidified oxygen.– Fluid resuscitation if hypotension.Short period of intubation and ventilation may benecessary.
  16. 16. MASSIVE HEMOTHORAXHypotension with the affected side dullness to percussion.Criteria: - More than (1-1.5L) of blood when inserting ICT. - Continuing blood loss 200 ml/ hour for 2 – 4 hours.
  17. 17. MANAGEMENTo ICT no. 38 Fo Management of hypovolemiao Consider for thoracotomy
  18. 18. CXR - widening of uppermediastinum and distortion ofaortic knuckles (60%).Left side pleural effusion iscommon.CT scan is very helpful indiagnosis.
  19. 19. Normal ECG
  20. 20. o Congested neck veinso Decline in arterial pressureo Muffled heart sounds o Patient not respond to unusual measures of resuscitation.o Kussmaul’s signo PEA in the absence of hypovolemia and TN.o
  21. 21. Echocardiogram (falsenegative in 5%) If monitor shows premature ventricular contraction. ( Common dysrhythmia to myocardial injury.) Lidocaine bolus 1 mg/kg, followed by lidocaine drip 2-4 mg/min.
  22. 22. CARDIAC TAMPONADECommon in penetrating injuries but may occur with blunt trauma.Removal of as little as 15-20 ml by pericardiocentesis, may result in immediate hemodynamic improvement.
  23. 23. INDICATION THORACOTOMY1. Cardiac arrest or PEA inhypovolemic patient withpenetrating chest trauma(resuscitative thoracotomy).2. Massive hemothorax3. Penetrating chest traumaanteriorly medial to the nipple lineand posteriorly medial to thescapula with hypotension.
  24. 24. Tension pneumothoraxOpen pneumothoraxFlail chestHemothoraxCardiac tamponade
  25. 25. ‫) ومن يتقايجعل له مخرجا ويرزقه من‬ ‫حيث ليحتسب ( صدقا م‬ ‫العظي‬AND WHOSOEVER FEARS ALLAH AND KEEPSHIS DUTY TO HIM , GOD WILL MAKE A WAYFOR HIM TO GET OUT (from ever difficulty).AND WILL PROVIDE ( HIM l HER ) FROM (SOURCES ) HE l SHE NEVER COULDIMAGINE. ( THE NOBLE QURAN )