Chest I jury

1. DR.K.SENTHIL_KUMAR
M . S . , F M A S . , F I A G E S . ,
S E N I O R A S S T P R O F E S S O R
I N S T I T U T E O F G E N E R A L S U R G E R Y
M M C , R G G G H . C H E N N A I
THORACIC INJURIES

2. INTRODUCTION
 Chest injuries contribute to 25% to 60%of trauma
deaths.
 It affeccts airway, breathing, circulation,and
sometimes altered sensorium because of hypoxia
 Resuscitative measures, airway management and
tube thoracostomy can salvage about 80% of all
thoracic injuries.

3. ANATOMY AND PHYSIOLOGY

4. PATHOPHYSIOLOGY
 It affects both oxygenation and perfusion and can
cause hypoxia, hypercarbia and acidosis
 Hypoxia occurs due to inadequate oxygen delivery,
inadequate ventilation, VP mismatch, and decreased
oxygen carrying capacity

5. MODE OF INJURY
 Blunt injury
 Penetrating injury
 Deceleration and compression injuries

6. OBJECTIVES OF CHEST TRAUMA CARE
 Primary survey & Resuscitation
life threatening injuries
 Secondary survey
Potentially life threatening injuries

7. NELS APPROACH
look
listen
feel

8. Assesment and treatment
 Assess ABC and attach monitors
 LOOK for
Signs of laboured or abnormal breathing
Rate and depth of respiration
Symmetry of chest movements
Use of accessory muscles
Distended neck veins
Open chest injury
Flail segment and chest deformity
Cyanosis and CRT

9.  LISTEN for
Stridor, snoring and gurgling sounds-
obstructed airway
Hyperresonant/dull/normal percussion note
Air entry and adventitious sounds/ absent
breath sounds.
Heart sounds

10.  FEEL for
Position of trachea
Subcutaneous emphysema
Bony crepitations and tenderness

11. Immediately life threatening injuries
 AIRWAY OBSTRUCTION
 TENSION PNEUMOTHORAX
 OPEN PNEUMOTHORAX
 FLAIL CHEST
 MASSIVE HEMOTHORAX
 CARDIAC TAMPONADE

12. Potentially life threatening injuries
 SIMPLE PNEUMOTHORAX
 PULMONARY CONTUSION’
 TRACHEOBRONCHIAL TREE INJURY
 BLUNT CARDIAC INJURY
 TRAUMATIC DIAPHRAGMATIC AND AORTIC
INJURY
 BLUNT ESOPHAGEAL RUPTURE

13. Treatment
 Maintain a patent airway
 Oxygen administration and SpO2 monitoring
 Assist ventilation with BMV with oxygen at high flow[12-
15l/min] if breathing is rapid,shallow
ineffective/apnoeic
 Definitive airway- secure airway with cuffed
ETT/cricothyroidotomy and maintain EtCO2of 35 to
45mmHg

14. Airway obstruction
 Edema,bleeding,vomitus

 Look for other asso injuries- laryngeal inj.
 Reduce # dislocation of sterno clavicular
disruption,clavicle #

15. TENSION PNEUMOTHORAX

16. TENSION PNEUMOTHORAX
 “ One way air leak “
 Chest pain, anxiety, dyspnea and tachypnea
 Hyper-resonant chest on the affected side with
diminished/absent breath sounds
 Late findings
Tracheal deviation to opposite side
Engorged neck veins with elevated JVP
Hypotension and cyanosis
Air hunger
Decreased level of conciousness

17. Management
 Needle thoracostomy at 5th ICS at midaxillary
line with 16G needle
 Finger thoracostomy
 It must be followed by tube thoracostomy
 Take surgical consult –if necessary

18. OPEN PNEUMOTHORAX
(SUCKING CHEST WOUND) defect >2/3 dia of
trachea

19. Three sided dressing- flutter valve on the non
taped side and allows air to escape duriing
expiration followed by ICD

20. FLAIL CHEST

21. Flail chest
 This occurs when fracture of two or more ribs occurs
at two or more sites.
 A bony segment moves independent of chest wall
and moves paradoxically during ventilation
 This leads to impaired gas exchange, hypoxia,
hypercarbia, increased pulmonary vascular
resistance, decreased lung compliance and finally
respiratory failure.

23. Flail chest
 There will be tachypnea, dyspnea and severe pain
 Paradoxical chest wall movements, splinting of chest
wall and tenderness on affected side
 Cyanosis/hypotension and anaemia may or may not
be present

24. flail chest
 Oxygen supplementation .
 Reassess RR, SpO2, EtCO2, sweating and colour of
the patient. If possible do ABG.
 Intubation if RR more than 40 or PaO2 less than
60mmHg with FiO2 of 60%
 Multimodal delivery of analgesics
 Surgical fixation rarely

25. MASSIVE HEMOTHORAX

26. Massive hemothorax
 more than 1500 ml of blood in the thoracic cavity following
injury to systemic or hilar vessel
 penetrating injury
 High degree of suspicion is needed in injuries mediastinal
box medial to nipple line and scapula
 Patient will be dyspneoic,tachypneoic ,pale, hypotensive with
flat neck veins
 Decreased chest movements and absent breath sounds and
dull note on percussions

27. Indications for thoracotomy
 Initial output of 1500 or more
 When initial output is < 1500ml – continuing blood
loss of more than 200ml/hr for 2-4 hrs.
 Persistent need of blood transfusion.

28. CARDIAC TAMPONADE
 Impairs venous return and cardiac filling
leading to hypotension, narrow pulse
pressure, PEA
 “Beck’s Triad” –
Hypotension,
Neck vein distension,
Muffled/absent heart tones
 Signs and symptoms masked by hypovolemia.

29. Management of cardiac tamponade
 Treat with immediate volume replacement to
↑ CVP, pericardial decompression
 Pericardiocentesis
 Can be done under USG guidance and cardiac
monitor attached
 Needle inserted inferior to xiphoid directed
towards the left shoulder.
 Observe for hemodynamic improvement

30. Traumatic circulatory arrest
 Unconcious & no pulse – PEA,VF,ASYSTOLE
 CAUSES = Hypoxia, card tamponade,card
herniation,severe myocardial contusion.
 Diagnosed clinically
 Start Closed CPR ,Secure definitive airway
,mechanical ventilation ,Epinephrine 1mg ,& if VF
Treat them ACLS PROTOCOLS
 RESUSIATIVE THORACOTOMY – NO ROSC

31. Secondary survey
 In depth physical examination
 Adjuncts
 Upright chest X ray
 ABG, pulse oximetry and ECG monitoring
 eFAST (USG)
 CT chest

32. Pulmonary contusion
 Commonest potentially lethal chest injury can occur
with or without fracture ribs
 Respiratory failure is subtle and occurs over time
 These patients needs to be constantly reevaluated
 Intubation and ventilation –significant hypoxia on
room air

33. Simple pneumothorax
 Lung laceration with air leakage is the commonest
cause
 Diminished breath sounds with hyper-resonant
chest-causes ventilation perfusion mismatch
 Upright chest X ray helps in diagnosis
 ICD insertion at 4th or 5th ICS followed by check Xray
 Always place ICD insertion before IPPV/GA

34. Simple hemothorax
 Caused by lung laceration or bleeding
vessel[intercostal or internal mammary]
 Usually self limited and no operative treatment is
needed
 36 to 40 fr ICD for large hemothorax on CXR
 Persistent bleeding or drainage of more than
200ml/hr for 4hrs-thoracotomy

35. Blunt cardiac injury
 Difficult to diagnose - chest pain is attributed to
musculoskeleletal injury
 Multiple PVC, unexplained sinus tachycardia,AF,
BBB, ST segment changes
 Requires monitoring for sudden dysrhythmias for
24hrsMay manifest as hypotension, dysrhythmias
and wall motion abnormalities

36. Traumatic aortic disruption
 RTA or FALL from height.
 Cause sudden death
 Survivors – incomplete laceration near the lig
arteriosus ,Contained hematoma
 High index of suspicion with H/O deceleration with
characteristic X ray signs
 Helical CT 100% Sensitivity & specificity.
 PERMISSIVE HYPOTENSION
 Bb,CCB ,NTG/NITRORUSIDE # HR <80,MAP<60-
70 CMMH.

37.  Open repair
 Endovascular repair
 If no expertise is available – refer

38. Diaphragmatic rupture
 penetrating injury>Blunt trauma
 Appearance of NG tube in the thorax on Xrays
should rise the suspicion
 Treatment is direct repair

39. Tracheo bronchial injury
 Occur within 1 inch of carina following a blunt
trauma
 Patient presents with hemoptysis, subcutaneous
emphysema/tension pneumothorax
 Inadequate expansion after ICD or persistent
leak/placement of more than one ICD is needed
 Bronchoscopy confirms the diagnosis
 Temporary intubation of opposite mainstem
bronchus
 Immediate operative intervention is needed

40. Oesophageal trauma
 Most commonly follows penetrating injury
 Blunt trauma to upper abdomen –linear tear in
oesophagus-mediastinitis
 Suspect in patients with left hemo/pneumothorax
without rib fracture, shock or pain out of proportion to
injury and those who received severe blow to lower
sternum or upper abdomen
 Presence of food particle in ICD/presence of mediastinal
air
 Esophagoscopy /contrast studies
 Wide drainage of mediastinum and pleural space and
primary repair

41. Rib fractures
 Rib fractures results in splinting and decreased
ventilation
 Fractures of 1 to 3 ribs –look for severe associated
injury
 4th to 9th ribs sustain most of the fractures
 Localised pain, tenderness and crepitations
 Pain relief by multimodal approach

43. Management of rib fractures
 Analgesics
 Intercostal blocks
 Chest physiotheraphy
 Incentive spirometry
 Strapping of chest : should include 2 ribs above and
2 ribs below crossing the midline.
 Disadvantage of strapping respiratory movement.
#segment moves inward if applied during expiration.

44. Scenario 1
 An adult male motorcyclist had a head on
collision with a truck.he is complaining of
difficulty in breathing,severe chest pain and is
very restless and smelling of alchohol.
On examination:
pt dyspnoeic,tachypnoeic, engorged neck veins with L
tracheal deviation, hypotension and cyanosis.
Hyper resonant on percussion. Absent breath sounds on R
side

45. Chest x ray

46. APPROACH
 Airway-patent(patient is talking.)
 Spo2 85%
 Administer oxygen through high flow NRM
 Breathing-
 RR-40,shallow,patient is disterssed.neck veins
appear distended.trachea shifted to left.hyper
resonant percussion notes,no breath sounds on rt
side of chest.

47. CIRCULATION
 Initial bp 80/40,pulse 120,after ICD pulse 95 and bp
110/70mmhg
 Secure iv access and give crystalloids.
 Administer analgesics and antibiotics.
 Take surgical opinion.
 Investigations-blood gp&cross matching,x ray.

48.  Patient has TENSION PNEUMOTHORAX RIGHT.
 Immediately rt sided needle thoracocentesis
done,followed by rt ICD connected to a underwater
sael.
 On reassessing,improvement in breathing,pt feels
comfortable,sop2 95%,air entry improves on right
side.

49. SCENARIO 2
 A middle aged man gets stabbed with a knife over
fight in gambling on the back of right upper half of
chest. The attacker pulls out the knife and leaves the
man bleeding on the roadside. A bystander brings
him to hospital. He looks dusky,is complaining of
difficulty in breathing,anxious and saying ‘please
save me or i will die’. A large sucking wound is seen
on the back of rt upper half of chest.

50. ASSESS
 ABC
 Airway –patent as pt is talking.
 Breathing is rapid and shallow RR-40/MIN
 Air entering wound is making a rapid sucking sound.
 Accessory muscles working –respiratory
distress.spo2 78%
 Patient is dusky.

51. TREATMENT
 Administer oxygen through high flow NRM
 Maintain spo2>94%.
 Apply occlusive dressing on three sides leaving the
lower side free.
 Put ICD away from the wound to decompress pleural
cavity.
 Definitive treatment-surgical closure.

52. THANK YOU