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  • Uncommon injury less than 3% of chest trauma Occurs with penetrating or blunt chest trauma High mortality rate (>30%) May involve fracture of upper 3 ribs Pathophysiology Majority (80%) occur at or near carina rapid movement of air into pleural space Tension pneumothorax refractory to needle decompression continuous flow of air from needle of decompressed chest
  • 1 of 6 persons dying in MVC’s has aortic rupture 85% die instantaneously 10-15% survive to hospital 1/3 die within six hours 1/3 die within 24 hours 1/3 survive 3 days or longer Must have high index of suspicion Separation of the aortic intima and media Tear 2° high speed deceleration at points of relative fixation Blood enters media through a small intima tear Thinned layer may rupture Descending aorta at the isthmus distal to left subclavian artery most common site of rupture ligamentum arteriosom
  • Pathophysiology Behaves like acute MI Hemorrhage with edema Cellular injury vascular damage may occur Hemopericardium may occur from lacerated epicardium or endocardium May produce arrhythmias May cause hypotension unresponsive to fluid or drug therapy
  • Pathophysiology Accumulation of blood in pleural space penetrating or blunt lung injury chest wall vessels intercostal vessels myocardium Massive hemothorax indicates great vessel or cardiac injury Intercostal artery can bleed 50 cc/min Results in collapse of lung
  • Chesttrauma

    1. 1. Thoracic Trauma Jeannouel van Leeuwen MD General Surgeon Trauma in the Caribbean II November 6-8 , 2009 Sint Maarten
    2. 2. Chest Trauma <ul><li>The fact that it has become possible in recent decades for millions of people to travel at high speed had led to a phenomenal increase in blunt injury to the chest - a most lethal type of injury. </li></ul>Epidemiology Everything gets worse at night
    3. 3. Introduction <ul><li>Chest trauma is often sudden and dramatic </li></ul><ul><li>Accounts for 25% of all trauma deaths </li></ul><ul><li>2/3 of deaths occur after reaching hospital </li></ul><ul><li>Major thoracic trauma is associated with multisystem injuries in 70% of cases. 16,000 deaths per year in the US </li></ul><ul><li>2/3 of victims of major blunt trauma suffer from thoracic injury. </li></ul><ul><li>Second leading cause of trauma deaths after head injury (in USA) </li></ul><ul><li> </li></ul>
    4. 4. Introduction to Thoracic Injury <ul><li>Vital Structures </li></ul><ul><ul><li>Heart, Great Vessels, Esophagus, Tracheobronchial Tree, & Lungs </li></ul></ul><ul><li>25% of MVC deaths are due to thoracic trauma </li></ul><ul><ul><li>12,000 annually in US </li></ul></ul><ul><li>Abdominal injuries are common with chest trauma. </li></ul><ul><li>Prevention Focus </li></ul><ul><ul><li>Gun Control Legislation </li></ul></ul><ul><ul><li>Improved motor vehicle restraint systems </li></ul></ul><ul><ul><ul><li>Passive Restraint Systems </li></ul></ul></ul><ul><ul><ul><li>Airbags </li></ul></ul></ul>
    5. 5. Thoracic Trauma <ul><li>Anatomical Injuries </li></ul><ul><ul><li>Thoracic Cage (Skeletal) </li></ul></ul><ul><ul><li>Cardiovascular </li></ul></ul><ul><ul><li>Pleural and Pulmonary </li></ul></ul><ul><ul><li>Mediastinal </li></ul></ul><ul><ul><li>Diaphragmatic </li></ul></ul><ul><ul><li>Esophageal </li></ul></ul><ul><ul><li>Penetrating Cardiac </li></ul></ul>Never operate on a patient who is getting rapidly better or rapidly worse What structures may be involved with each injury?
    6. 6. Mechanism of Injury <ul><li>Blunt thoracic injuries </li></ul><ul><ul><li>Forces distributed over large area </li></ul></ul><ul><li>Penetrating thoracic injuries </li></ul><ul><ul><li>Forces distributed over small area </li></ul></ul><ul><ul><li>Organs injured usually those that lie along path of penetrating object </li></ul></ul>Nothing spoils good results as much as follow-up
    7. 7. CAUSES OF CHEST INJURIES <ul><li>BLUNT TRAUMA </li></ul><ul><ul><li>Motor vehicle accidents </li></ul></ul><ul><ul><li>Auto vs. pedestrian </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Blast injuries </li></ul></ul><ul><li>PENETRATING TRAUMA </li></ul><ul><ul><li>Gunshot wounds </li></ul></ul><ul><ul><li>Stab wounds </li></ul></ul><ul><ul><li>Shrapnel wounds </li></ul></ul>
    8. 8. Pathophysiology of Thoracic Trauma <ul><li>Blunt Trauma </li></ul><ul><ul><li>Results from kinetic energy forces </li></ul></ul><ul><ul><li>Subdivision Mechanisms </li></ul></ul><ul><ul><ul><li>Blast </li></ul></ul></ul><ul><ul><ul><ul><li>Pressure wave causes tissue disruption </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tear blood vessels & disrupt alveolar tissue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Disruption of tracheobronchial tree </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Traumatic diaphragm rupture </li></ul></ul></ul></ul><ul><ul><ul><li>Crush (Compression) </li></ul></ul></ul><ul><ul><ul><ul><li>Body is compressed between an object and a hard surface </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Direct injury of chest wall and internal structures </li></ul></ul></ul></ul><ul><ul><ul><li>Deceleration </li></ul></ul></ul><ul><ul><ul><ul><li>Body in motion strikes a fixed object </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blunt trauma to chest wall </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Internal structures continue in motion </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ligamentum Arteriosum shears aorta </li></ul></ul></ul></ul></ul><ul><ul><li>Age Factors </li></ul></ul><ul><ul><ul><li>Pediatric Thorax: More cartilage = Absorbs forces </li></ul></ul></ul><ul><ul><ul><li>Geriatric Thorax: Calcification & osteoporosis = More fractures </li></ul></ul></ul>
    9. 9. <ul><li>Either: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury </li></ul><ul><li>Rib fracture is the most common sign of blunt thoracic trauma </li></ul><ul><li>Fracture of scapula, sternum, or first rib suggests massive force of injury </li></ul>Blunt injuries
    10. 10. Mechanism of Injury <ul><li>Penetrating injuries </li></ul><ul><li>E.g. stab wounds etc. </li></ul><ul><li>Primarily peripheral lung </li></ul><ul><li>Haemothorax </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Cardiac, great vessel or oesophageal injury </li></ul>
    11. 11. Pathophysiology of Thoracic Trauma <ul><li>Penetrating Trauma </li></ul><ul><ul><li>Low Energy </li></ul></ul><ul><ul><ul><li>Arrows, knives, handguns </li></ul></ul></ul><ul><ul><ul><li>Injury caused by direct contact and cavitation </li></ul></ul></ul><ul><ul><li>High Energy </li></ul></ul><ul><ul><ul><li>Military, hunting rifles & high powered hand guns </li></ul></ul></ul><ul><ul><ul><li>Extensive injury due to high pressure cavitation </li></ul></ul></ul>
    12. 12. Pathophysiology of Thoracic Trauma <ul><li>Penetrating Injuries (cont.) </li></ul><ul><ul><li>Shotgun </li></ul></ul><ul><ul><ul><li>Injury severity based upon the distance between the victim and shotgun & caliber of shot </li></ul></ul></ul><ul><ul><ul><li>Type I: >7 meters from the weapon </li></ul></ul></ul><ul><ul><ul><ul><li>Soft tissue injury </li></ul></ul></ul></ul><ul><ul><ul><li>Type II: 3-7 meters from weapon </li></ul></ul></ul><ul><ul><ul><ul><li>Penetration into deep fascia and some internal organs </li></ul></ul></ul></ul><ul><ul><ul><li>Type III: <3 meters from weapon </li></ul></ul></ul><ul><ul><ul><ul><li>Massive tissue destruction </li></ul></ul></ul></ul>
    13. 13. <ul><li>The first step is to make a rough estimate of the status of the circulatory and respiratory systems. This provides the first diagnostic clues and often determines which therapeutic action is to be taken. Specific questions are then posed pertaining to individual injuries or their consequences. </li></ul>Assessment of patient with Thoracic injury
    14. 14. <ul><li>The treatment of polytraumatized patient must follow a certain protocol which includes. </li></ul><ul><ul><li>Adequate oxygenation. </li></ul></ul><ul><ul><li>Fluid replacement. </li></ul></ul><ul><ul><li>Surgical intervention. </li></ul></ul><ul><ul><li>Treatment of septic complications. </li></ul></ul><ul><ul><li>Adequate caloric and substrate supplementation. </li></ul></ul><ul><ul><li>Prevention of stress bleeding. </li></ul></ul><ul><ul><li>Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis. </li></ul></ul>Management of patients with Thoracic Trauma
    15. 15. <ul><li>The evaluation of thoracic injuries is only one aspect of the total assessment of severely injured patients. </li></ul><ul><li>Both diagnosis and therapy go hand in hand. </li></ul><ul><li>The basic principle of elective surgery - “ First investigate and make the diagnosis, then treat the illness ” - is a dangerous illusion. </li></ul>Assessment of patient with Thoracic injury
    16. 16. Monitoring and evaluating the patient with Thoracic trauma <ul><li>Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles). </li></ul><ul><ul><li>Mediastinum (wide or normal) shifted or not. </li></ul></ul><ul><ul><li>Lung parenchyma (Contusion). </li></ul></ul><ul><ul><li>The heart (cardiac tamponade). </li></ul></ul><ul><ul><li>Diaphragm. </li></ul></ul><ul><ul><li>Pneumothorax, hemothorax. </li></ul></ul><ul><li>ECG </li></ul><ul><li>CVP </li></ul><ul><li>Arterial blood gases. </li></ul><ul><li>Urine output. </li></ul><ul><li>Lab. Investigations. </li></ul><ul><li>Others. </li></ul>
    17. 17. <ul><li>     1. Hypovolemia? </li></ul><ul><li>    2. Respiratory insufficiency? </li></ul><ul><li>    3. Tension pneumothorax? </li></ul><ul><li>    4. Cardiac tamponade </li></ul>Immediately life- threatening; diagnosis and therapy before taking roentgenograms TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries
    18. 18. <ul><li>Multiple rib fractures? (Paradoxical respiration?) </li></ul><ul><li>Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?) </li></ul><ul><li>Hemothorax? </li></ul><ul><li>Diaphragmatic rupture? </li></ul><ul><li>Aortic rupture? </li></ul><ul><li>Cardiac contusion? </li></ul>TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries If you are not sure, it isn’t
    19. 19. Common Injuries Develop After Blunt Chest Trauma <ul><li>Thoracic cage fractures </li></ul><ul><li>Lung contusion and tears </li></ul><ul><li>Myocardium contusion </li></ul><ul><li>Aortic rupture </li></ul>
    20. 20. Thoracic Trauma <ul><li>Initial exam directed toward life threatening: </li></ul><ul><ul><li>Injuries </li></ul></ul><ul><ul><ul><li>Open pneumothorax </li></ul></ul></ul><ul><ul><ul><li>Flail chest </li></ul></ul></ul><ul><ul><ul><li>Tension pneumothorax </li></ul></ul></ul><ul><ul><ul><li>Massive hemothorax </li></ul></ul></ul><ul><ul><ul><li>Cardiac tamponade </li></ul></ul></ul><ul><ul><li>Conditions </li></ul></ul><ul><ul><ul><li>Apnea </li></ul></ul></ul><ul><ul><ul><li>Respiratory Distress </li></ul></ul></ul>
    21. 21. TRAUMA DEATHS EARLY 30%-35% Within Hours (Golden Hour) Thoracic Trauma Liver/Spleen Injuries Multiple Pelvic Fractures Others Optimum Initial Care IMMEDIATE 50% Seconds or Minutes Spinal Cord Injuries Severe Brain Injuries Lesions to Great Vessels Prevention Optimum Prehospital Care LATE 15%-20% 2-3 Weeks Sepsis Multiple Organ Failure Optimum Initial Care (Future?)
    22. 22. Injuries Associated with Penetrating Thoracic Trauma <ul><li>Closed pneumothorax </li></ul><ul><li>Open pneumothorax (including sucking chest wound) </li></ul><ul><li>Tension pneumothorax </li></ul><ul><li>Pneumomediastinum </li></ul><ul><li>Hemothorax </li></ul><ul><li>Hemopneumothorax </li></ul><ul><li>Laceration of vascular structures </li></ul><ul><li>Tracheobronchial tree lacerations </li></ul><ul><li>Esophageal lacerations </li></ul><ul><li>Penetrating cardiac injuries </li></ul><ul><li>Pericardial tamponade </li></ul><ul><li>Spinal cord injuries </li></ul><ul><li>Diaphragm trauma </li></ul><ul><li>Intra-abdominal penetration with associated organ injury </li></ul>
    23. 23. Imaging Survey <ul><li>Chest x-ray : serve as a screening rather than a definite test  repeat radiography should be ordered if suspicious </li></ul><ul><li>Computed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray  recommended in patients with multiple trauma and suspected chest trauma </li></ul><ul><li>Angiogram : for suspicious great vessel injuries </li></ul><ul><li>Chest ultrasound : detect hemothorax, FAST </li></ul>2003-3-31
    24. 24. Massive Hemothorax <ul><li>Need for thoracotomy if: </li></ul><ul><li>Immediate evacuation of 1500 mL of blood </li></ul><ul><li>steady trend of more than 250 mL/h </li></ul>
    25. 25. Indications for Thoracotomy in Chest Trauma <ul><li>Cardiac tamponade </li></ul><ul><li>Acute hemodynamic deterioration/cardiac arrest in the trauma center </li></ul><ul><li>Penetrating truncal trauma (resuscitative thoracotomy) </li></ul><ul><li>Vascular injury at the thoracic outlet </li></ul><ul><li>Loss of chest wall substance (traumatic thoracotomy) </li></ul><ul><li>Massive air leak </li></ul><ul><li>Endoscopic or radiographic evidence of significant tracheal or bronchial injury </li></ul><ul><li>Endoscopic or radiographic evidence of esophageal injury </li></ul><ul><li>Radiographic evidence of great vessel injury </li></ul><ul><li>Mediastinal passage of a penetrating object </li></ul><ul><li>Significant missile embolism to the heart or pulmonary artery </li></ul>
    26. 26. Big Trouble <ul><li>Central lung injuries are deadly because they are difficult to control and repair. </li></ul><ul><li>When confronted control the pulmonary hilum between thumb and forefinger or clamp it. </li></ul><ul><li>Suture , lobectomy or pneumonectomy </li></ul>
    27. 27. Rib Fracture <ul><li>Fractures of 1st and 2nd second require high force </li></ul><ul><ul><li>Frequently have injury to aorta or bronchi </li></ul></ul><ul><ul><li>Occur in 90% of patients with tracheo-bronchial rupture </li></ul></ul><ul><ul><li>May injure subclavian artery/vein </li></ul></ul><ul><ul><li>May result in pneumothorax </li></ul></ul><ul><li>30% will die </li></ul>
    28. 28. Rib Fracture <ul><li>Most common chest wall injury from direct trauma </li></ul><ul><li>More common in adults than children </li></ul><ul><li>Especially common in elderly </li></ul><ul><li>Ribs form rings </li></ul><ul><ul><li>Possibility of break in two places </li></ul></ul><ul><li>Most commonly 5th - 9th ribs </li></ul><ul><ul><li>Poor protection </li></ul></ul>
    29. 29. Pitfalls to Avoid <ul><li>Elderly do not tolerate relatively minor chest injuries </li></ul><ul><ul><li>Anticipate progression to acute respiratory insufficiency </li></ul></ul><ul><li>Children may sustain significant intrathoracic injury w/o evidence of thoracic skeletal trauma </li></ul><ul><ul><li>Maintain a high index of suspicion </li></ul></ul>
    30. 30. Tracheobronchial Rupture <ul><li>Assessment Findings </li></ul><ul><ul><li>Respiratory Distress </li></ul></ul><ul><ul><ul><li>Dyspnea </li></ul></ul></ul><ul><ul><ul><li>Tachypnea </li></ul></ul></ul><ul><ul><li>Obvious SQ emphysema </li></ul></ul><ul><ul><li>Hemoptysis </li></ul></ul><ul><ul><ul><li>Especially of bright red blood </li></ul></ul></ul><ul><ul><li>Signs of tension pneumothorax unresponsive to needle decompression </li></ul></ul>
    31. 31. Diaphragmatic Penetration <ul><li>Suspect intra-abdominal trauma with any injury below 4th ICS </li></ul><ul><li>Suspect intrathoracic trauma with any abdominal injury above umbilicus </li></ul>
    32. 32. Traumatic Aortic Dissection/Rupture <ul><li>Assessment Findings </li></ul><ul><ul><li>Retrosternal or interscapular pain </li></ul></ul><ul><ul><li>Pain in lower back or one leg </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Asymmetrical arm BPs </li></ul></ul><ul><ul><li>Upper extremity hypertension with </li></ul></ul><ul><ul><ul><li>Decreased femoral pulses, OR </li></ul></ul></ul><ul><ul><ul><li>Absent femoral pulses </li></ul></ul></ul><ul><ul><li>Dysphagia </li></ul></ul>
    33. 33. Myocardial Contusion <ul><li>Assessment Findings </li></ul><ul><ul><li>Cardiac arrhythmias following blunt chest trauma </li></ul></ul><ul><ul><li>Angina-like pain unresponsive to nitroglycerin </li></ul></ul><ul><ul><li>Precordial discomfort independent of respiratory movement </li></ul></ul><ul><ul><li>Pericardial friction rub (late) </li></ul></ul>
    34. 34. Pulmonary Contusion <ul><li>Management </li></ul><ul><ul><li>Supportive therapy </li></ul></ul><ul><ul><li>Early use of positive pressure ventilation reduces ventilator therapy duration </li></ul></ul><ul><ul><li>Avoid aggressive crystalloid infusion </li></ul></ul><ul><ul><li>Severe cases may require ventilator therapy </li></ul></ul><ul><ul><li>Emergent Transport </li></ul></ul><ul><ul><ul><li>Hospital </li></ul></ul></ul>
    35. 35. Hemothorax <ul><li>Assessment Findings </li></ul><ul><ul><li>Tachypnea or respiratory distress </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><ul><li>Rapid, weak pulse </li></ul></ul></ul><ul><ul><ul><li>Hypotension, narrow pulse pressure </li></ul></ul></ul><ul><ul><ul><li>Restlessness, anxiety </li></ul></ul></ul><ul><ul><ul><li>Cool, pale, clammy skin </li></ul></ul></ul><ul><ul><ul><li>Thirst </li></ul></ul></ul><ul><ul><li>Pleuritic chest pain </li></ul></ul><ul><ul><li>Decreased lung sounds </li></ul></ul><ul><ul><li>Collapsed neck veins </li></ul></ul><ul><ul><li>Dullness on percussion </li></ul></ul>
    36. 36. Open Pneumothorax <ul><li>Assessment Findings </li></ul><ul><ul><li>Opening in the chest wall </li></ul></ul><ul><ul><li>Sucking sound on inhalation </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>SQ Emphysema </li></ul></ul><ul><ul><li>Decreased lung sounds on affected side </li></ul></ul>
    37. 37. CATEGORIES OF CHEST WOUNDS <ul><li>OPEN </li></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Sucking chest wound </li></ul></ul><ul><ul><li>Hemothorax </li></ul></ul><ul><ul><li>Impaled object </li></ul></ul><ul><li>CLOSED </li></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Hemothorax </li></ul></ul><ul><ul><li>Flail chest </li></ul></ul><ul><ul><li>Rib fractures </li></ul></ul>
    38. 38. Simple Pneumothorax <ul><li>Causes </li></ul><ul><ul><li>Commonly a fx rib lacerates lung </li></ul></ul><ul><ul><li>Paper bag effect </li></ul></ul><ul><ul><li>May occur spontaneously in tall, thin young males following: </li></ul></ul><ul><ul><ul><li>Exertion </li></ul></ul></ul><ul><ul><ul><li>Coughing </li></ul></ul></ul>
    39. 39. Simple Pneumothorax <ul><li>Incidence </li></ul><ul><ul><li>10-30% in blunt chest trauma </li></ul></ul><ul><ul><li>almost 100% with penetrating chest trauma </li></ul></ul><ul><ul><li>Morbidity & Mortality dependent on </li></ul></ul><ul><ul><ul><li>extent of atelectasis </li></ul></ul></ul><ul><ul><ul><li>associated injuries </li></ul></ul></ul>
    40. 40. Flail Chest <ul><li>Mortality rates 20-40% due to associated injuries </li></ul><ul><li>Mortality increased with </li></ul><ul><ul><li>advanced age </li></ul></ul><ul><ul><li>seven or more rib fractures </li></ul></ul><ul><ul><li>three or more associated injuries </li></ul></ul><ul><ul><li>shock </li></ul></ul><ul><ul><li>head injuries </li></ul></ul>
    41. 41. Flail Chest <ul><li>Usually secondary to blunt trauma </li></ul><ul><ul><li>Most commonly in MVC </li></ul></ul><ul><ul><li>Also results from </li></ul></ul><ul><ul><ul><li>falls from heights </li></ul></ul></ul><ul><ul><ul><li>industrial accidents </li></ul></ul></ul><ul><ul><ul><li>assault </li></ul></ul></ul><ul><ul><ul><li>More common in older patients </li></ul></ul></ul>
    42. 42. Sternal Fracture <ul><li>Uncommon, 5-8% in blunt chest trauma </li></ul><ul><li>Large traumatic force </li></ul><ul><li>Direct blow to front of chest by </li></ul><ul><ul><li>Deceleration </li></ul></ul><ul><ul><ul><li>steering wheel </li></ul></ul></ul><ul><ul><ul><li>dashboard </li></ul></ul></ul><ul><ul><li>Other object </li></ul></ul>
    43. 43. Cardiac Tamponade <ul><li>Beck’s triad: </li></ul><ul><li>- hypotension, jugular venous distention, and muffled heart sounds </li></ul><ul><li>- causes decreased diastolic ventricular filling and resultant hypotension </li></ul><ul><li>- echocardiogram shows impaired diastolic filling of right atrium initially (1 st sign) </li></ul>
    44. 44. Cardiac Tamponade
    45. 45. Hemopericardium with tamponade
    46. 46. Troublesome Injuries <ul><li>Blunt cardiac trauma - management </li></ul><ul><li>Most cases do not require Tx; Symptomatic arrhythmia (2-5%)  antiarrthythmics </li></ul><ul><li>Abnormal ECG and cardiac enzymes almost return to normal within one week. </li></ul><ul><li>Patients with abnormal cardiac echo finding or MUGA  keep hospitalization till a repeat test show acceptable finding </li></ul><ul><li>Cardiac rupture  prompt surgical repair </li></ul>
    47. 47. Troublesome Injuries <ul><li>Lung contusion </li></ul><ul><li>CxR finding may range from minimal interstitial infiltrate to extensive lobar consolidation </li></ul><ul><li>Chest CT is accurate diagnostic tool but not always mandatory </li></ul><ul><li>Tx : same as flail chest , but pay attention to avoid overhydration; use of steroid and prophylactic antibiotic are still controversial </li></ul>
    48. 48. Aortic Transection <ul><li>Signs: </li></ul><ul><li>- widened mediastinum, 1 st rib fx, apical capping, left hemothorax, tracheal deviation to right </li></ul><ul><li>- widening from bridging veins and arteries, not aorta itself </li></ul><ul><li>- need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears at ligamentum </li></ul><ul><li>- 90% of patients die at the scene </li></ul>
    49. 49. Thoracic Aorta Injury <ul><li>90% lethal before receiving emergency care </li></ul><ul><li>Usually a transverse laceration of part or all of aortic circumference </li></ul><ul><li>60% have adventia intact = pseudoaneurysm </li></ul><ul><li>Injury to root or ascending aorta is nearly 100% fatal </li></ul><ul><li>~90% occur at aortic isthmus just distal to left subclavian </li></ul><ul><li>4-10% of cases have concomitant great vessel injury </li></ul>
    50. 50. Airway Injury <ul><li>Tracheobronchial tears are uncommon </li></ul><ul><ul><li>< 0.35-1.5% of BCT </li></ul></ul><ul><ul><li>bronchial > tracheal </li></ul></ul><ul><ul><li>75% at R mainstem usually within 2.5 cm of carina </li></ul></ul><ul><li>Leads to persistent PTX </li></ul><ul><li>Specific Symptom: persistent PTX after chest tube placement </li></ul><ul><li>Finding: “Fallen Lung Sign”, pneumomediastinum, pneumopericardium, sub cut. Emphysema </li></ul><ul><li>ET Tube balloon inflation >2.8cm implies tracheal rupture </li></ul>
    51. 51. Open Pneumothorax <ul><li>Opening in chest cavity that allows air to enter pleural cavity </li></ul><ul><li>Causes the lung to collapse due to increased pressure in pleural cavity </li></ul><ul><li>Can be life threatening and can deteriorate rapidly </li></ul>
    52. 52. TENSION PNEUMOTHORAX <ul><li>33% of preventable combat deaths </li></ul><ul><li>Injured chest or lung acts as one-way valve </li></ul><ul><li>Air becomes trapped between the lung and chest wall causing the lung to collapse </li></ul><ul><li>The heart is pushed to the other side causing blood vessels to kink </li></ul><ul><li>Death will result if not quickly recognized and treated with needle decompression </li></ul><ul><li>May occur in open and closed chest wounds </li></ul>
    53. 53. Tension Pneumothorax Air collapses lung and pushes heart to other side Blood return to heart restricted by kinked vessels, heart unable to pump Air between lung and chest wall
    54. 54. OTHER SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX <ul><li>Difficulty breathing </li></ul><ul><li>Chest pain </li></ul><ul><li>Unilateral decreased/absent breath sounds </li></ul><ul><li>Anxiety or agitation </li></ul><ul><li>Increased pulse </li></ul><ul><li>Tracheal deviation </li></ul><ul><li>Jugular venous distention (JVD) </li></ul><ul><li>Cyanosis </li></ul>
    56. 56. SUCKING CHEST WOUND (OPEN PNEUMOTHORAX) <ul><li>Open chest wound allows air entry into chest and escape </li></ul><ul><li>Although lung is collapsed (pneumothorax), pressure is relieved by air escape and tension pneumothorax is avoided </li></ul><ul><li>Tension pneumothorax may develop later </li></ul><ul><li>Continually reassess the casualty for signs and symptoms of tension pneumothorax </li></ul>
    57. 57. OPEN CHEST WOUND
    58. 58. Esophageal Injury <ul><li><10% of esophageal rupture is caused by trauma </li></ul><ul><li>< 1% of BCT’s </li></ul><ul><li>Findings: </li></ul><ul><ul><li>Pneumomediastinum </li></ul></ul><ul><ul><li>Left PTX </li></ul></ul><ul><ul><li>Left pleural effusion </li></ul></ul><ul><ul><li>Sub cut emphysema </li></ul></ul><ul><ul><li>Left lower lobe atelectasis </li></ul></ul>
    59. 59. Traumatic Asphyxia
    60. 60. MANAGEMENT OF IMPALED OBJECT IN THE CHEST <ul><li>Immobilize the impaled object </li></ul><ul><li>Stabilize object with support dressings </li></ul><ul><ul><li>Use bulky dressings </li></ul></ul><ul><ul><li>Construct protective structure using splint or sling </li></ul></ul><ul><li>Cover and dress open wounds </li></ul>
    61. 63. Conclusion <ul><li>Chest injuries are directly responsible for more than 20% of all traumatic deaths (regardless of mechanism) and account for about 16,000 deaths per year in the United States. The risk of death can be reduced by early recognition of serious signs and symptoms and rapid treatment. </li></ul>