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Chest trauma
Chest injuries account for 25% of severe injuries and are usually caused by road traffic accidents. The primary survey focuses on the airway, breathing, circulation, disability and exposure to identify and treat immediate life threats like tension pneumothorax. Secondary survey involves a full history, examination and investigations like CXR and CT scan to evaluate injuries. Most chest injuries are managed conservatively but conditions like massive hemothorax or cardiac tamponade may require chest tube insertion or thoracotomy.
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Chest trauma
- 1. APPROACH TO APATIENT OF CHEST INJURY BY:DR SHAMA PARVEEN
- 2. • Thoracic injuryaccounts 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 chestinjury • 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
- 4. Pathophysiological sequence Flail chestrespiratory acidosis Contusion alveolar hypoxia ventilation Pneumothorax death Hemothorax Heart & vessel injury shock tissue hypo perfusion Associated injury metabolic acidosis
- 5. Classification • Immediate life-threateninginjuries • Potentially life-threatening injuries
- 6. The ‘deadly dozen’threats to life Immediate life threatening Potential life threatening Airway obstruction Tracheo-bronchial injuries Tension pneumothorax Diaphragmatic rupture Open pneumothorax Aortic injuries Massive hemothorax Esophageal injuries Cardiac tamponade myocardial contusion Flail chest Pulmonary contusion
- 7. Management I. Primary surveyby ATLS guidelines II. Detailed secondary survey III. Definitive care
- 8. Primary survey: initialresuscitation & management based upon ATLS protocols Aim: to identify & treat immediately life- threatening conditions • Airway • Breathing • Circulation • Disability(neurology) • Exposure & environment
- 9. Airway with cervicalspine 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
- 12. Disability : • neurologicalstatus 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: • Canstart 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
- 15. Local examination- Inspection • Bruisingor contusion/penetrating injury • Unequal chest inflation: flail chest/pneumothorax Palpation • Tracheal deviation: mediastinal shift • Tenderness : rib fracture/chest wall contusion • Crepitus : rib fracture
- 16. Auscultation: • Absent breathsounds: apnoea/tension pneumothorax • Stridor/crepitations: partially obstructed airway • Reduced air entry: pneumothorax/ hemothorax/ hemo-pneumothorax/ flail chest
- 17. Monitoring Investigations Arterialblood gases Haematocrit Cardiac monitoring-ECG CVP Urine output • CXR : fracture ribs, pneumo/hemothorax • USG FAST: detects free fluid in pericardium & abdomen (more than 100 ml) • CT chest: investigation of choice • Other radiographs- pelvis, cervical spine
- 18. eFAST: examination ofboth 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 • Investigationof 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 injuriescan well be treated with simple measures such as • O2 therapy • Chest tube insertion • Adequate pain control • Antibiotics • Chest physiotherapy
- 21. Indications for chesttube 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
- 24. Definitive care Chest wall •Rib fractures • Flail chest • Haemato mas lungs • Pneumotho rax • Haemothor ax • Haemo- pneumotho rax • Airway obstruction • Tracheo- bronchial tear cardiovascular • Cardiac tamponade • Myocardial contusion • Traumatic arrest others • Esophageal injury • Diaphragm atic injury
- 25. Fracture rib • Commonin 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 :Fractureof 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.
- 29. Pneumothorax: air inthe pleural cavity Types : • Spontaneous • Traumatic • Iatrogenic
- 31. Tension Pneumothorax • Increasedpressure 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.txis 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
- 34. Hemothorax: blood inpleural 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)
- 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 offluid 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
- 39. Management • Assess theneed 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