Ppt for lecture class

1. Assessment and management of chest
trauma as a cause of respiratory distress
By. Teshome B.(MD,Assistant Professor
of Surgery)

2. INTRODUCTION
• Trauma, or injury, is defined as cellular disruption caused by
environmental energy that is beyond the body’s resilience,
which is compounded by cell death due to
ischemia/reperfusion.
• Trauma is the most common cause of death for all individuals
between the ages of 1 and 44 years, and is the third most
common cause of death regardless of age.
• 25% of all trauma deaths are the result of chest injuries alone.
• It is also the leading cause of years of productive life lost.

3. Causes
• Road traffic accidents
• Bullet injuries
• Blast injuries
• Industrial accidents
• Stab injuries.

4. Types of Chest Trauma
• Blunt Trauma(>80% of all chest injuries.)
=> Blunt force to chest.
– Motor vehicle accidents(2/3)
– Fall & crush injuries
– Blast injuries
• Penetrating Trauma- Projectile that enters chest
causing small or large hole.
– Gunshot wounds
– Stab wounds
– Shrapnel wounds
• Compression Injury- Chest is caught between two
objects and chest is compressed.
The most
common
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5. INITIAL EVALUATION AND RESUSCITATION OF
THE INJURED PATIENT
Primary Survey
• ATLS (Advanced Trauma Life Support)
• Provides a structured approach to the trauma patient
with standard algorithms of care
• It emphasizes the “golden hour” concept that timely,
prioritized interventions are necessary to prevent death
and disability

6. The initial management of seriously injured patients
consists of phases that include
• The primary survey/concurrent resuscitation,
• The secondary survey/diagnostic evaluation,
• Definitive care
• The tertiary survey.

7. • The first step in patient management is performing the
primary survey. Goal?
• The ATLS course refers to the primary survey as
assessment of the “ABCs” (Airway with cervical spine
protection, Breathing, and Circulation).

8. Components of Primary Survey
• Airway(A)=Asses airway and Cervical spine
• Breathing(B)=Asses breathing by checking breathing pattern,
RR,SPO2, air entry
• Circulation(C)=Asses for hemodynamic status and bleeding. Hence,
check BP,PR and potential site of bleeding
• Disablity(D)=Asses neurologic status(GCS,Pupil,power,sensory)
• Exposure(E)=Bridge to secondary survey

10. Clinical Features of Thoracic Injuries
• H/O trauma, painful breathing, cough, haemoptysis, pain
in the chest wall, external wound on the chest wall
• Features of shock, may be seen, i.e. tachycardia,
hypotension, cold periphery.
• May present with respiratory distress tachypnea,
cyanosis, respiratory difficulties

11. EXAMINATION IN CHEST INJURIES
• Detailed history of trauma should be asked.
• History of breathlessness, chest pain, haemoptysis/cough
with blood (lung trauma), air way block should be asked.
• Pain in the ribs may be due to rib fracture.
• Excruciating pain on deep breathing suggests rib fracture.

12. Examination
• General Examination
• Pulse, blood pressure, cyanosis, tachypnea, features of
shock should be checked.
• Abdomen, limbs, head and neurological systems also be
examined.

13. Inspection
• Chest, abdomen and neck should be exposed for proper
inspection.
• Ecchymosis, bruises in the skin over chest wall should be
inspected.

14. • Wound may often look small superficially but may be
deep penetrating into the thoracic cavity.
• Air may be bubbling through the wound with noise.
• Blood, clot may be present in such wounds.
• Such patient often may need emergency resuscitation to
maintain adequate ventilation.

15. • Type of breathing – abdominal or thoracic and its
character should be checked.
• Hyperpnea, dyspnea, altered breathing should be
observed.
• Collapse of chest wall during inspiration and distension of
part of chest wall during expiration suggests flail chest
with paradoxical breathing, mediastinal flutter and
pendular movement of the air.

16. • If patient develop sudden distress in breathing and
sudden respiratory arrest, it suggest likely the cause is
tension pneumothorax .
• Localized swelling due to hematoma may be evident.
• Diffuse puffy look suggests surgical emphysema. It may
be in the chest wall, abdomen, neck both sides.

17. Palpation
• Rib tenderness, bone
irregularity, crepitus should
be checked for fracture rib.
• If there is diffuse swelling
over the chest and if crepitus
felt under palpation, It
suggests surgical
emphysema

18. Percussion
• Resonant on percussion in case of pneumothorax and
dull in hemothorax.
Auscultation
• Breath sounds is reduced in pneumothorax or
hemothorax

19. Investigations
• Baseline =HCT,BG&RH
• Chest X-ray
– To see fracture ribs, pneumothorax, haemothorax,
haemopneumothorax.
• Ultrasound of the chest wall to confirm fluid/blood/air

20. General mgt of chest trauma patient
• Secure IV line (give fluid if needed)
• Analgesics(strong antipain)
• Antibiotics(if patient have wound)
• Chest physiotherapy
• Chest tube care (if in place)
• Oxygen and frequent monitoring
• NB: All the above mgt shouldn`t delay patient from
treatment of underlying condition

21. Management of specific injuries
Pneumothorax
• Air in pleural space
• Many are caused by trauma but from primary problem in lung
• Causes collapse of a lung on the affected side
• May be caused by fractures of ribs, stab or bullet

22. Types
Tension pneumothorax
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23. Clinical features
• Tachypnoea
• Dyspnea
• Distended neck veins
• Tachycardia
• Use of acce. Muscles
• Hypotension
• Tracheal deviation
• Hyperresonance
• Absent breath sound
• Failure of chest
expansion
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24. Diagnosis
• Clinical
Management
• Don’t wait for CXR!!!!!!
• Consult Physician
• Immediate decompression-Insert needle in 2nd ICS to convert
tension pneumothorax to simple pneumothorax
– Definitive mgt for both is chest tube drainge
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25. 25

26. Open pneumothorax(sucking chest wound)
• Due to a large defect (>3cm)
• Air enters and leaves pleural space but
not as in tension pneumothorax
• Can be changed to tension
• Signs & sym. Proportional to size of defect
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27. Open Pneumothorax
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28. 28

29. Clinical features
 Dyspnea
 Sudden sharp pain
 Subcutaneous emphysema
 Decreased breath sound on affected side
 Red Bubbles on Exhalation from wound (Sucking chest
wound)
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30. Mgt
• 3 sided dressing
• Link or refer for chest tube
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31. Haemothorax
• More commonly secondary to penetrating than blunt
• Small or massive
• Can be with pneum-
Thorax
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32. Clinical features
 Anxiety/Restlessness
 Tachypnea
 Tachycardia
 Signs of Shock
 Flat neck veins
 Resp. distress
 Reduced chest expansion
 Diminished Breath Sounds on Affected Side
 Dullness to percussion
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33. Management
• Put on fluid to correct hypovolemia
• Consult or link or refer for chest tube.
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34. Cardiac Tamponade
• Mostly follow penetrating injury
• Acutely,<100ml of pericardial blood can cause tamponade
• Impairs atrial filling and also cause myocardial ischemia
• Beck`s triad?
• Ix-Pericardial ultrasound
• Mgt-removing 15-20ml blood can alleviate smx
hence early consultation or referral

35. Thank you