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Chest trauma
- 1. CHEST TRAUMA Dr. Rajneesh Rawat Junior resident, Gen Sx IGGMC Nagpur
- 2. INTRODUCTION Second leading cause of trauma deaths Around 65 -70% of chest injuries are due to RTAs Approx. 25% of deaths are due to chest injuries 50 % of patients who die from poly trauma have significant chest injuries.
- 4. Mechanism of Chest Injury Body acceleration and deceleration : Organ inertia lags behind the skeletal acceleration or deceleration. Ex : RTA Body compression : Ex : Chest injury and falls Penetrating wounds : Ex : Assaults – Stab and Missile injuries
- 5. Types of Chest Injuries 1) Blunt Chest Injury ( Closed Chest injury) Ex : RTA , Fall , Crush Injury Associated with multiple injuries such as head, limb, abdomen 2) Penetrating Chest Injury ( Open Chest Injury) Ex : Seen in assaults Associated with chest wall damage, open pneumothorax and organ injury
- 6. Mode of Death IMMEDIATE • Within seconds to minutes • Disruption of heart or great vessels injury EARLY • Within few minutes to hours • Airway obstruction, tension pneumothorax, pulmonary contusion or cardiac tamponade LATE • Within few days to weeks • Pulmonary complications, sepsis and missed injuries
- 7. CLASSIFICATION Lethal (Immediate life threatening) • Airway obstruction • Tension Pneumothorax • Open Pnuemothorax • Massive Hemothorax • Flail Chest • Cardiac Tamponade Hidden (Potential life threatening) • Cardiac Contusion • Aortic Disruption • Diaphragmatic rupture • Esophageal Injury • Pulmonary Contusion • Tracheobronchial injury
- 8. CLINICAL APPROACH Primary survey -Evaluate for six conditions that results from immediate life threatening (Lethal six) Assessment of hemodynamic stability and stablisation of Airway ,Breathing and Circulation proceed for secondary survey
- 9. History and Symptoms What was the mechanism of injury? If RTA, details obtained from paramedics Patient complaints ; localization of pain AMPLE Allergies, Medications , Past medical history, Last meal, Events leading to presentation
- 10. Physical examination/Signs Head to toe physical examination(secondary surveys) Evaluate and reevaluate Vs and pulse oximetry, observe chest wall motion, flail segment, or sucking wound, pulsus paradoxsus Interrupt physical examination if a life saving procedure such as airway or chest tube placement is needed
- 11. Evaluate and reevaluate area of on going blood loss, including open wound and fracture. Also, are there associated abdominal , pelvic or other extremity injuries that could account for blood loss
- 12. Investigations • Evaluate : Pneumothorax, tension pneumothorax, hemothorax, chest wall fractures etcCXR • Evaluate cardiac tamponadeFAST • Only for stable patients • Reliable for lacerations and contussions CT chest abdomen & pelvis • Can be performed at the same time as routine CTCT Angiography • Gold standard for evaluation of aortic injuries Catheter Angiography
- 14. Management Chest wall fractures -AP Chest x ray : For initial assessment -CT chest : Provides specific information regarding extent of specific injuries Treatment : -Pain control and observation with simple chest wall # -Analgesic agents – intercostal nerve block, epidural analgesia -Aggressive pulmonary toilet to prevent atelectasis and pneumonia - Surgery is rarely needed for simple fractures, required in right and left lower rib fractures involving liver & spleen lacerations
- 15. CXR
- 16. Flail Chest Involves 3 or more consecutive rib # in two or more locations, Produces a comminuted # with a free floating unstable bony segment that is detached from the remaining chest wall.
- 17. SO ,WHAT HAPPENS?? FLAIL CHEST : PARADOXICAL CHEST MOVEMENTS The fractured segment will sink into the chest with inspiration and expand out of chest wall with expiration opposite to the normal chest wall mechanics.
- 18. Respiratory distress – mc initial presentation Dyspnea, tachycardia, tachypnea, pain & tenderness usually present. On auscultation : Decreased breath sounds over the affected area. Dx : Physical examination & CXR CT: identification of early pulmonary contusion
- 19. Treatment of Flail chest Rx modalities for patients with chest wall fractures are appropriate for flail chest Pain control, pulmonary toilet, Oxygen : Primary therapy for pulmonary contusion Severity of flail injuries & associated contusions may require endotracheal intubation & IPPV Optimal ventilatory management is crucial
- 20. SIMPLE PNEUMOTHORAX • Defined as accumulation of air within the pleural space producing a collapsed lung. • Air leak is secondary to a fractured rib penetrating the lung or stab wound through the parietal & visceral pleura • On percussion : Hyper resonance on the affected side • On Auscultation : Decreased breath sounds on affected side Rx : Chest tube placement
- 22. Skin preparation & marking Administration of anesthetic agent Skin incision Blunt dissection down to the intercostal muscle Digital examination along the tract into pleural space Withdrawal of central trochar & positioning of drain Suture taken to secure chest tube to skin CXR to ensure correct positioning of the chest tube & to look for lung re expansion.
- 25. Open Pneumothorax More common in penetrating injuries than blunt thoracic injuries. Cfs :Typically presents with respiratory distress On exam : Obvious chest wall defect On auscultation : Complete or near complete loss of breath sounds Diagnosis : Physical exam and CXR
- 26. Treatment : Sucking chest wound : Placing a three way occlusive dressing. Intent is to prevent the rise of intrathoracic pressures in the affected hemothorax A chest tube is then placed. After initial stabilization, definitive chest wall closure is planned.
- 27. TREATMENT • Sucking chest wound : Placing a three way occlusive dressing. • Intent is to prevent the rise of intrathoracic pressures in the affected hemothorax • A chest tube is then placed. After initial stabilization, definitive chest wall closure is planned.
- 28. TENSION PNEUMOTHORAX -Develops when a lung or chest wall injury is such that it allows air into the pleural space but not out of it ( a one way valve) -As a result, air accumulates & compresses the lung, resulting into : - Shifting of mediastinum -Compression of contralateral lung Cfs :Sharp & stabbing chest pain, dyspnea, cyanosis, sweating ,fainting
- 29. • Distended neck veins • Hypotension or evidence of hypo perfusion, • Diminished or absent breath sounds on affected side, • Tracheal deviation to the contralateral side • Diagnosis : Clinically before the CXR is obtained.
- 30. TREATMENT Immediate needle decompression of the chest with a 16G in 2nd intercostal space, midclavicular space. Once accomplished, a chest tube is placed.
- 31. HEMOTHORAX -Hemothorax following a blunt/penetrating wound to the chest can be caused by bleeding from any structure in the thorax : the intercostal arteries, lung, great vessels or heart. -CFs : Anxiety, dyspnea ,tachypnea & tachycardia -On percussion : Diminished breath sounds & dullness to percussion over affected hemi thorax -Massive hemothorax can produce significant hemodynamic instability secondary to hemorrhagic shock.
- 32. TREATMENT • Diagnosis: -CXR -Tube thoracostomy :blood • Massive hemothorax: -Replace blood volume loss -Insert chest tube -Consider thoracotomy if blood loss > 1500 ml initially or 250 ml/hr after initial evacuation
- 33. Cardiac Tamponade Life threatening complication caused by excessive accumulation of fluid in the pericardium leading to : -Compression of cardiac chambers -Impaired cardiac filling -Reduction in stroke volume CFS : Beck’s traid --Distant heart sounds Distended jugular veins Decreased arterial pressure Other symptoms : Dyspnoea, restlessness, tachycardia, narrow pulse pressure.
- 34. MANAGEMENT • Diagnosis : Clinical examination -FAST : pericardial fluid -ECHO (stable patients) • Cardiac tamponade due to -Blunt trauma : Pericardiocentesis -Penetrating trauma : Exploration & repair of source of bleeding • Fluid resuscitation -To maintain preload & cardiac output
- 35. Tracheo-bronchial Injuries Rapid deceleration or severe compression applied directly results in tracheobronchial disruption Viscera are crushed between anterior chest wall & posterior vertebrae Most patients with severe injuries die from airway obstruction or associated injuries CFs : mostly presents with respiratory distress If a chest tube has been placed, massive air leak seen Pneumothorax & subcutaneous emphysema : almost universally present
- 36. After resuscitation, CXR and/or CT identifies this major injury Bronchoscopy : may be required in sub acute cases. Surgical repair : standard of care In case of airway compromise, endotracheal intubation should be done. Flexible bronchoscopy permits the tube to guide distal to the site of injury
- 37. Tracheo bronchial tree disruption
- 38. TRAUMATIC AORTIC RUPTURE -Life threatening surgical emergency -Accounts for 20% 0f deaths in all RTAs -90% have other organ injuries -Mc involved : proximal descending aorta at ligamentum arteriosum -Findings : Infrascapular murmur, upper extremity hypertension, unequal BP or pulses in the extremities -Aortography : gold std for
- 40. Treatment Prompt diagnosis Strict blood pressure monitoring Potentially urgent operative repair Open surgical repair options -Clamp and sew -Cardiopulmonary bypass Endovascular stent therapy
- 41. Diaphragmatic Injury Any penetrating injury below the 5 th ICS should raise a suspicion of diaphragmatic penetration Blunt injury : caused by a compressive force applied to the pelvis & abdomen Mostly injuries are silent, easily missed in acute phase & may be discovered during surgery or can present through complications.
- 43. Accurate investigation : Video assisted thoracoscopy (VATS) or laproscopy. Operative repair is recommended in all cases. All penetrating diaphragmatic injuries must be repaired via abdomen & not the chest, to rule out penetrating hollow viscus injury.
- 44. Emergency department thoracotomy Should be reserved in patients with penetrating injury in whom signs of life are still present Aim of EDT : - Internal cardiac massage -Control of hemorrhage from injury to the heart or lung -Control of intrathoracic hemorrhage from other sources -Control of massive leak - Clamping of the thoracic aorta to preserve blood supply to the heart & brain.