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Chest trauma
This document provides an overview of chest trauma, including: - Common injuries like pneumothorax, hemothorax, flail chest and their signs and symptoms. - Assessment involves clinical exam, chest x-ray and ultrasound to detect injuries. Chest tube insertion can be both therapeutic and diagnostic. - "Deadly dozen" life-threatening injuries from chest trauma include tension pneumothorax, cardiac tamponade, aortic disruption and others that often require emergency procedures or surgery. - Management involves airway control, ventilation, chest tube drainage, analgesia and monitoring for complications like respiratory failure. Operative treatment is indicated for severe injuries or those not responding to initial management.
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Chest trauma
- 1. Dr Mukhilesh RMS PG
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- 3. Salient Features ofChest Trauma • Most commonly missed injury • Most common cause of death in thoracic injury is hemorraghe • Clinical examination + chest radiography – to detect chest injury • USG supplements the diagnosis • Resuscitation to be done , without waiting for radiological investigations. • Chest drain – therapeutic as well as diagnostic
- 4. Chest Anatomy •12 pair of ribs with intercostal muscles. • The lungs occupy the majority of the thoracic volume. • Mediastinum - heart and great vessels. • Diaphragm Mechanisms of Injury – Blunt Injury • Deceleration • Compression – Penetrating Injury – Both
- 5. Red flag signsof chest injury Hemoptysis. Chest wall contusion. Flail chest. Open wounds. Jugular vein distention (JVD). Subcutaneous empysema. Tracheal deviation. Respiratory rate and effort: Lung sounds: Tachypnea Absent or Bradypnea decreased Labored Unilateral Retractions Bilateral Progressive respiratory Bowel sounds in distress chest.
- 6. Assess the ChestWall Contusions. Tenderness. Asymmetry. Open wounds or impaled objects. Crepitation. Paradoxical movement. Compare both sides of the chest at the same time when assessing for asymmetry. Lung sounds – Percussion. Hyperresonance Pneumothorax Tension pneumothorax Hyporesonance (hemothorax)
- 7. “DEADLY DOZEN” Threatsto life from chest injury
- 9. Opening pneumothorax -Sucking Chest Wound • Defect in chest > 3cm • Not to be fully closed • Closed on three sides – acts as one way valve • Controlled chest drain must • Formal debridment and closure.
- 10. Tension pneumothorax –oneway valve CLINICAL DIAGNOSIS – NO NEED FOR RADIOLOGICAL DEMONSTRATIONS Each time we inhale, the lung collapses further. There is no place for the air to escape.. Clinical features tacypnoea/dyspnoea distended neck veins hyperresonance absent breath sounds
- 11. Contd.. Immediate decompression –needle 2nd IC space midclavicular line Definitive Rx Chest tube drain – 5th intercostal space
- 12. Pericardial tamponade Penetrating injurynear heart + Shock – R/O Tamponade Pericardial sac – non distensible BECK’S TRIAD increased CVP fall in BP muffled heart sounds CXR – widened heart shadow ECHO Central venous line – increased CVP Sternotomoy / thoracotomy – repair of heart
- 13. Hemothorax Most commonin blunt injury Intercostal vessel & internal mammary art Clinical features Shock with flat neck veins Absent breath sounds dull on percussion Mediastinal shift – respiratory distress ICD
- 14. Flail Chest Segmentof chest wall doesnot have bony continuity with the rest of thoracic cage 3 0r more ribs # in 2 or more places Clinical diagnosis paradoxical chest wall movement Rx analgesia O2 intrapleural local anesthetics ventilator support internal fixation
- 15. Thoracic aorta disruption– DIRE EMERGENCY Sudden death in chest injury Relatively fixed distal to ligamentum arterisoum Sudden impact – disrupt intima and media Tunica adventia intact – pt may be stable Interscapular pain RF delay / assymetrical BP CXR – widened mediastinum CECT mediastinum / Transesophageal ECHO Rx endovascular intra-aorticc stent tear can be repaired surgically dacron graftin
- 16. Tracheobronchial injury • Severe subcutaneous empysema with respiratory compromise • Hemoptysis • Immediate chest drain • Early intubation. • Bronchoscopy is diagnostic • Operative repair – definitvie RX
- 17. Oseophageal injuries • Mostly from penetrating trauma • HIGH INDEX OF SUSPICION • C/F • Odynophagia • Mediastinal emphysema / mediastinitis • Unexplained fever within 24 hours • OGD – confirms diagnosis • Operative repair and drainage Mediastinal emphysema – evidence of aerodigestive tract injury until proved otherwise
- 18. Blunt myocardial injury • Most common finding – ECG abnormality • ACUTE MI • Hypotension • 2 D ECHO • Tranesophageal ECHO • Increased risk of arrhythmia – first 24 hours hence ICU observation necessary
- 19. Diaphragmatic Injuries •Penetrating injuries to or below 5th IC space – R/O diaphramatic and abdomen injury • Dyspnoea / absent breath sounds • Hollow abdomen/absent bowel sounds in abdomen • No single standard investigation • CXR with NG tube • Contrast studies / CECT • VATS / D- LAP – most accurate assesment • Operative repair – Abdominal approach
- 20. Pulmonary contusion •Most common cause for hypoxia • Hemorrhage into lung parenchyma • Hemoptysis + blood in ET tube = R/O Lung contusion • Worsening hypoxemia • CXR – delayed finidings • CECT – Confirms • Rx • Nasal O2 • Analgesia • Antibiotics • Pulmonary toileting • Ventilator support - PEEP.
- 21. Rib fractures Mostcommon finding in chest injury 1st and 2nd rib – Violent injuries Rule out vascular injuries 5th to 9th ribs most commonly affected 10th to 12th rib fracture – R/O abdomen injuries Rx adequate analgesia O2 conservative management. ROLE OF ICD IN RIB FRACTURE????
- 22. Operative treatment forchest injuries • Initial tube thoracostomy - >1000ml (penetrating injury) or >1500ml (blunt injury) • >200ml/hr for 3 consecutive hours • Caked hemothorax • Great vessel injury (endovascular option) • Pericardial tamponade • Cardiac herniation • Massive air leak from the chest tube • Open pneumothorax • Esophageal perforation • Tracheal or main stem bronchial injury diagnosed by endoscopy or imaging
- 23. Emergency room thoracotomy– life threatening bleeding Indications Internal cardiac massage Control of hemorrhage – heart / lung or other sites Control of massive air leak Hemodynamically unstable patient as a last resort – usually unsuccessful Left anterolateral thoracotomy Usually futile : CPR >10 minutes blunt trauma with no signs of life at scene
- 24. Clamshell thoracotomy •Bilateral anterolateral thoracotomy + transverse sternotomy = "clamshell" incision • The largest incision commonly used in thoracic surgery.