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Chest trauma pg

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Basic chest trauma
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Chest trauma pg

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Chest injuries ranks 3rd after head injuries and extremity injuries in a case of multisystem trauma.It is of two types blunt chest trauma and peneterating chest trauma.The main cause of blunt chest trauma is road side accidents due to vehicles. Peneterating chest trauma is more dangerous and is common in war injuries and civilian terroism.In this ppp I have discussed some useful uncommon and important aspects of chest injuries

Chest injuries ranks 3rd after head injuries and extremity injuries in a case of multisystem trauma.It is of two types blunt chest trauma and peneterating chest trauma.The main cause of blunt chest trauma is road side accidents due to vehicles. Peneterating chest trauma is more dangerous and is common in war injuries and civilian terroism.In this ppp I have discussed some useful uncommon and important aspects of chest injuries

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Chest trauma pg

  1. 1. Chest Injuries Dr R S Dhaliwal MS,MNAMS (Surgery ) MCh,DNB (CTVS), FACS, FCCP,FAMS,FICA,FNCCP,FIACS Former , Prof & HOD, CTV Surgery, PGIMER , Chandigarh
  2. 2. CHEST INJURIES 1. Blunt Injuries 2. Penetrating Injuries
  3. 3. Blunt Chest Injuries • Rank Third after Head and Limb Injuries • Commonest Cause – RSA -Vehicular Accidents ( 70%) , Other causes are fall from height , compression of body • 4 - 10 % Mortality in isolated Blunt Chest Injury • Directly cause 25% mortality in Vehicle Accidents
  4. 4. Chest Injuries • The earliest recorded reference to thoracic trauma - Edwin Smith Surgical Papyrus was written around 3000 BC. • Closed I/C chest tube drainage developed around 1st world war made marked impact on out come of pts • Thoracotomy for clotted hemothorax and empyema started in IInd world war with very good results
  5. 5. Blunt Chest Injuries • Blunt chest Injury fatal in about 10% cases • Incidence of mortality rises to 50% if there are associated injuries • Chest injury is the cause of death in 25% of all deaths due to trauma • . Respiratory problems following chest injuries contribute to 75% of deaths
  6. 6. Incidence of Specific Thoracic Organ Injury Chest wall 31 Flail chest 13 Pneumothorax 18 Hemothorax 19 Pulmonary 16 Miscellaneous 17
  7. 7. Incidence of Injuries In Vehicle Accidents Extremities 34% Head and neck 31% Chest 21% Abdomen 14%
  8. 8. How children are different • The chest wall is more compliant due to more elasticity of ribs, so fractures are less common and internal organs injury is more common • They have more cardiopulmonary reserve and it may mask hypovolemia and respiratory dist ress, drop in B.P. is very late sign indicating imminet death • Aerophagia is common response to injury causing acute gastric dilatation and ileus, this compromise respiratory functions further.
  9. 9. How old patients are different • Old patients are fragile biologically and physiologically so a minor trauma can cause # ribs easily and flail chest is more common • Medical disease are quite common in elderly like CAD, COPD, BHP , hearing and vision problems. All these effect the treatment and prognosis of old patients • Cerebral problems -confusion ,Ch hematomas are common. Osteoprosis leads to fractures of spine or ribs and limb bones easily.
  10. 10. Surgical Emphysema • Air collection in subcutaneous tissues due to inury of lung parenchyma or tracheo - bronchial tree or oesophagus • Mediastinal Emphysema in Tracheo-Bronchial or Oesophageal injury • “Present in about 27% of patients with blunt or penetrating chest injury” • Patient’s appearance quite distorted & puffy • No Specific treatment, Treat the cause
  11. 11. Surgical Emphysema
  12. 12. Life threatening Chest injuries –The Deadly Dozen • Immediate life threatening Airway obstruction Tension pneumothorax Cardiac injury – Frank bleeding or Pericardial tamponade , Massive Hemothorax, Open pneumothorax, Flail Chest • Potentially life threatening Aortic rupture Tracheobronchial injury Myocardial contusion Diaphragm tear Oesophageal injury Pulmonary contusion /laceration
  13. 13. Flail Chest - Treatment • WITH RESPIRATORY FAILURE Selective Endotracheal Intubation and Mechanical Ventilation • NO RESPIRATORY INSUFFIENCY Analgesics , Oxygen inhalation , Fluid Restriction , Colloids, Steroids ,Chest Physiotherapy
  14. 14. Flail Chest
  15. 15. Indications For Ventilation • Respiratory Failure • Clinically Severe Shock • Associated head injury with need for hyperventilation • Associated Injury requiring Surgery • Airway Obstruction • Significant associated COPD
  16. 16. Diaphragmatic Injury • More common after blunt chest injury • More common to left diaphragm , abdominal organ injuries common • Respiratory distress, bowel sounds in chest , mediastinal shift, visceral obstr. • Xray chest, CT Scan, Contrast study • Treatment - Laparotomy > Left Acute Thoracotomy - Rt side Chronic
  17. 17. Traumatic Diaphragmatic Rupture
  18. 18. PENETRATING CHEST INJURIES {PCI} • Due to Gun Shots, Stab injuries with Sharp Objects & Sharpnels • Common in wars, civialian teroism • Central or Peripheral • Superior or Inferior
  19. 19. Patterns of P C I • Pneumothorax and Hemothorax more common along with Sucking Wounds • Pericardial Tamponade- common in P C I Becks Triad (Pulsus paradoxus, rasised JVP, quiet precordium) only in 40% cases • 2-D ECHO diagnostic for it • Sub Xiphoid Pericardiostomy in OT is both diagnostic and therapeutic
  20. 20. Subxiphoid pericardial window
  21. 21. RESUSCITATION • A B C PRINCIPLE • A- ESTABLISHMENT OF A FUNCTIONAL AIRWAY - Clear mouth and pharynx of blood & secretions - Check for tongue falling back -Mouth gag - Oral Or Nasal Intubation - Cricothyroidotmy or Tracheostomy
  22. 22. Resuscitation • B- RESTORE MECHANICS OF BREATHING - Artificial Breathing , - Drainage of Pneumo or Hemothorax - Stabilize Chest Wall - in flail - Mechanical Ventilation
  23. 23. Resuscitation C- CARDIOVASCULAR RESUSCITATION - Volume Replacement - Central Line - Ionotropic (Dopamine ,Adrenaline drip) Support for low B.P. - Correction of Acid Base Status & Electrolytes - External or Internal Cardiac Massage - Control of major life threatening hemmorhage Emergency Thoracotomy
  24. 24. Resusciation THOROUGH EXAMINATION OF PATIENT Look for - - Head injury , orthopedic(limb) injuries or abdominal trauma • Past history of significant Medical Disease IHD, DM, Hypertension, Renal problem Drug allergy, alcohol or narcotic use
  25. 25. Primary survey and resuscitation ABCD of Trauma Care This is the core of ATLS system by ACS • A- Airway maintaince and Cervical spine protection • B - Breathing and ventilation • C - Circulation with hemorrhage control • D - Disability ; neurological status • E - Exposure – Thorough examination of pt after complete undressing
  26. 26. ABCD of Trauma care • Airway assessment - . Check verbal response . Clear mouth and airway with sucksion . If GCS < 8 consider deffinite airway . Breathing and ventilation - . Give 100% oxygen at high flow . Check for tension pneumothorax , if suspected immediate decompression
  27. 27. ABCD of trauma care • Circulation and control of bleeding . Circulation assessment and warning signs - Deteriorating concious level, Increasing pallor, Rapid thready pulse . Control the ongoing bleeding quickly instead of giving fluid and blood aggressively • Disability and neurological status The Glassgow Coma Score (GCS) gives a rapid assessment of patient’s conciousness level and is a good prognostic indicator Hypoglycema, alcohol and drug abuse also alter the level of conciousness and must be excluded in trauma pts. • Exposure - Patient should be fully exposed and examined front and back, keeping in mind cervical spine injury . Hypothermia is common after trauma and should be treated in time properly
  28. 28. Adjuncts to primary survey • Full blood count ,urea and electrolytes, coagulation studies , blood group and cross match, toxicology • 12 lead ECG • Two wide bore IV canulae or Central line • Urinary catheter and Ryle,s tube placement • Xrays of Chest and cervical spine –once pt is stable hemodynamically
  29. 29. Secondary Survey • This is done once primary survey and initial resuscitative measures have been completed • Review of patient,s history – AMPLE . Allergy . Past medical history . Medication taken- Tetanus status . Last meal taken . Event of incidence • Re-evaluation- urine out put 0.5-1ml/kg/hr Pulse oximetry . Analgesia • Documentation and legal consideratins • Transfer and definitive care - Once intial resusci tation is done and pt is stable, transfer may be required for specilised care like Cardiothoracic or Neuro surgical interventation
  30. 30. INTERCOSTAL CHEST TUBE DRAINAGE • INDICATIONS - Pneumothorax, Hemothorax Empyema Pleural Effusion • SITE - Decided from Chest X-ray or Ultra sound 4th -5TH I/C space in midaxillary line . Use artery Forceps and Finger - Avoid Trocar & Canula - Chest Tube Size 26- 32 F --Basal - for blood & fluid - Apical for air
  31. 31. Intercostal Chest Tube- IC D
  32. 32. Emergency Thoracotomy • Required in 5% patients of Blunt Chest trauma , more common in P C I • Acute Pericardial Tamponade -Cardiac Injury PCI • Massive Hemothorax - >1500 CC after I/C D or > 300 ml/hr for 3 hrs • Cardiac arrest – In presence of Fracture Sternum or Flail Chest • IInternal cardiac massage- failed External Massage • Massive intra- abdominal bleeding – cross clamp of intathoracic aorta
  33. 33. Urgent Thoracotmy • Intrathoracic great vessel injury • Thoracic inlet vascular injury • Esophageal Injury • Traumatic diaphragmatic hernia (Acute) • Bullet embolism and systemic air embolism • Mediastinal traversing Injury • Massive air leakage Tracheobronchial Injury Lung parenchymal Injury
  34. 34. Delayed Thoracotomy • Clotted hemothorax • Chronic empyema • Chronic traumatic diaphragmatic hernia • Cardiac septal or valvular lesions • Missed Tracheobronchial injury • Traumatic A.V. fistula • Delayed Aneurysms • Non closing thoracic duct fistula • Infected intrapulmonary hematoma
  35. 35. CONTRAINDICATIONS TO THORACOTOMY • Small volume hemothorax • Pneumomediastinum • Tension or simple pneumothorax • Bullet or pellet in chest wall or lung parenchyma or a major vesssel
  36. 36. SURGICAL INCISIONS • Anterolateral Thoracotomy • Midsternotomy • B/L Transternal Thoracotomy • Posterolateral Thoracotomy • Subxiphoid Pericardiostomy • Neckincision + Midsternotomy • Division or partial removal of Clavicle
  37. 37. Surgical Incisions • Incisions
  38. 38. Anterio lateral thoracotomy -Lt
  39. 39. Midsternotomy
  40. 40. Useful Measures • Autotransfusion • CP Bypass & IABP, LVAD, RVAD • ECMO– Extra Corporeal Memberane Oxygenation • Thoracoscopy • Digital Exploration ?
  41. 41. COMPLICATIONS OF CHEST TRAUMA • Lung Atelectasis ( lobe) • INFECTION – Bronchopneumonia – Empyema – Clotted Hemothorax – Br Pl Fistula – Bronchial Stenosis – Chylothorax
  42. 42. CONCLUSIONS • Blunt Chest injuries more common than peneterating injuries, road traffic accidents commonest cause , young mobile males • 80- 85% Chest injuries can be managed conservatively in small hospitals • Only 10-15% Chest injury Pts require Thoracotomy , more in PCI • Flail Chest - selective use of Ventilation
  43. 43. RECOMMENDATIONS • Desperate need for more trauma centers • Educating public about traffic rules and importance of safe driving • Training children in schools about this
  44. 44. RECOMMENDATIONS • Strict implementation of rules against driving after consuming alcohol &/or narcotics • Quick transportation - efficient ambulance services, More blood banks • Widespread C P R training to people
  45. 45. How this is allowed ?
  46. 46. THANK YOU

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