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Chest trauma
1. APPROACH TO A PATIENT OF
CHEST INJURY
BY:DR SHAMA PARVEEN
2. • Thoracic injury accounts for 25% of all severe
injuries
• Blunt chest trauma- 90% incidence; <10%
require any surgical intervention
• RTA- commonest cause
• Most common cause of death: haemorrhage
3. Types of chest injury
• 1. Blunt : (closed injury)
e.g RTA , fall
associated with multiple injuries such as head,
limb, abdomen
2. Penetrating : (open injury)
-mostly by assault (stabbing, gunshot etc)
- usually associated with chest wall damage,
open pneumothorax, organ injuries
3. Compression/crush injury
9. Airway with cervical spine
protection:
• Airway obstruction: Early
intubation particularly in neck
haematoma/edematous airway
10. Breathing
• Give 100% oxygen at high flow
• Inspect/percuss & auscultate
chest
• Check for tension
pneumothorax - immediately
decompress if suspected
Circulation
• Cardiac monitor – vitals
• Pressure at sites of external
haemorrhage
• Secure 2 large bore i.v
cannulae-commence fluid
resuscitation
• Examine for evidence of blood
loss-arrange blood
• Catheterise-IO monitoring
11.
12. Disability :
• neurological status should be
rapidly assessed
• pupils- size & reactivity
• GCS to be measured &
repeated regularly for tracking
change in the score- determine
severity of injury
Exposure :
• Fully expose the patient ;
examine front & logroll to
inspect back
• Prevent hypothermia: warm
blankets
13. Secondary survey:
• Can start after normalizing vital signs by
resuscitation
• Include complete history & head to toe
evaluation including rectal examination
• AMPLE history- allergies, medications, past
medical history, last meal, events:related to
injury
14. Clinical features
h/o trauma
Symptoms: painful breathing, pain in the chest
wall, or injury
Signs-
Features of shock(when major vessels involved):
tachycardia, hypotension,cold extremities
Respiratory distress: tachypnoea, cyanosis,
respiratory difficulties
18. eFAST: examination of both lungs by adding b/l
anterior thoracic sonography to the FAST exam
• 4 areas: perihepatic & hepatorenal
• Perisplenic
• Pericardium
• Pelvis
• eFAST can provide accurate estimation of
pneumothorax size: sensitivity 88%,specificity
upto 99% for p.tx(c/w 52% and 100% for CXR)
• Haemothorax
• Pleural effusion
• Lodged foreign body
19. CT Scan
• Investigation of choice in trauma
Indicated in suspected
• diaphragmatic injury
• tracheobronchial injury
• Pulmonary lacerations & pneumothoraces
• Can detect even subtle aortic tears
• Thoracic spine fractures
• Detects retroperitoneal bleed in other associated
trauma ;not detected by FAST
20. Management
Most chest injuries can well be treated with simple
measures such as
• O2 therapy
• Chest tube insertion
• Adequate pain control
• Antibiotics
• Chest physiotherapy
21. Indications for chest tube insertion
• Tension pneumothorax
• For evacuation of haemothorax & simple
pneumothorax
• Traumatic lung contusion
• Post thoracotomy, to drain pleural cavity
22. Procedure
• An ICT (28-32 Fr) is placed in 4th or
5th ICS in mid axillary line – triangle
of safety
- Lateral border of pectoralis major
anteriorly
- Lateral border of latissimus dorsi
laterally
- Line superior to horizontal level of
nipple inferiorly
- Base of axilla superiorly
• Position:sitting/supine. Most
preferred is supine position, slightly
rotated to the opposite side with
ipsilateral arm behind head
• Under LA, small incision made
parallel & in lower part of ICS,just
above the rib
• Tube with side openings pushed
into pleural cavity. Other end is
connected to under water seal.
• CXR : ensure correct positioning
23. Indications for thoracotomy
• Massive or continued haemothorax: blood loss
over the chest TD≥1500 ml initially or >200
ml/hour over 2-4 hours
• Cardiac tamponade
• Tracheobronchial tree injury
• Traumatic rupture of esophagus
• Large vessel injury
• Diaphragmatic injury
• Weapon in-situ/penetrating chest trauma
25. Fracture rib
• Common in elderly; rare in
children
• 3rd-8th rib fractures-more
common
• Localized tenderness, chest
pain during
inspiration/coughing,
CREPITUS on palpation
• CXR- diagnostic
• CT scan-when suspected
associated injuries
t/t : conservative
• Good analgesics
• Incentive
spirometry- Deep
breathing excercises
• t/t of complications-
hemo/pneumothorax
: ICTD
26. Flail chest :Fracture of two or more consecutive
ribs with each rib having two or more fracture sites
C/F:
• Shortness of breath-rapid,
shallow respiration
• Paradoxical respiration
• Tenderness & crepitus near
fractured ribs
• CXR- fractured ribs,
subcutaneous emphysema
• CT scan- identification of early
pulmonary contusion
• Complications:
pneumothorax,hemothorax,
pulmonary contusion,
respiratory insufficiency
t/t:
• Antibiotics ; adequate
analgesics
• Pressure over flail segment
• Intercostal tube drainage with
resuscitatory measures
• Ventilatory support
• Surgical exploration &
stabilization of flail segment:
in cases with paradoxical
movement area> 10x10 cm.
27.
28.
29. Pneumothorax: air in the pleural cavity
Types :
• Spontaneous
• Traumatic
• Iatrogenic
30.
31. Tension Pneumothorax
• Increased pressure collapses
lung & shifts mediastinum to
unaffected side
• Increased dyspnoea &
compressed heart & great
vessels leads to decreased
cardiac output
• Leads to cardiogenic shock
C/F (5 T’S):
• Tachycardia
• Tachypnoea
• Tracheal shift
• Tympanic note
• Totally absent breath
sounds on affected side
32. Management
• Tension p.tx is a clinical diagnosis- radiological
confirmation not needed
• Needle thoracocentesis: life saving but temporary Mx ( a
large bore 14-16 gauge needle; atleast 5cm length inserted
in 2nd ICS in MCL or 4th -5th ICS in AAL just above the rib)
• Supplemental oxygen: avoid positive PPV
• Definitive Mx: Chest tube placement on affected side-once
the patient is stabilized. It restores negative pleural
pressure
33.
34. Hemothorax: blood in pleural space
• Possible sources: intercostal vessels, internal mammary artery,
pulmonary vessels, lung parenchyma
• Can lead to tension pneumothorax
C/F:
• Dyspnoea
• Chest pain, tenderness
• Dullness on percussion; diminished/absent breath sounds on
affected side
• Features of shock
CXR- unilateral ‘white out’(opacification)
35.
36. Management
• Antibiotics; bronchodilators
• ICT placement: in mid axillary line in 5th or 6th
ics. Usually kept for 4-6 days or until it stops
draining
• Thoracotomy done if:
- Initial chest tube output of 1500 ml blood or
200-300 ml/hr
- Failure to completely drain hemothorax
37. Cardiac tamponade:
accumulation of fluid in pericardial space compression of cardiac chambers
decreased cardiac output; life threatening
C/F: SOB, features of shock
hypotension
muffled
heart raised
sounds JVP
Others: pulsus paradoxus
Ix. : CXR : cardiomegaly/’money
bag/water bottle appearance’
FAST: pericardial fluid
ECHO: diagnostic test of
choice; stable pts
ECG- sinus tachycardia, low
voltage QRS complexes,
electrical alterans
BECK’S
TRIAD
38.
39. Management
• Assess the need for intubation; oxygenate & start
volume resuscitation
• TxOC- needle pericardiocentesis ; life saving
procedure used to relieve tamponade before
definitive repair
• Ideal management is emergency left antero-
lateral thoracotomy to relieve tamponade
