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chest truma Kamal.ppt
- 1. CHEST TRAUMA Dr: KamalAbu Alrish ER consultant
- 2. Trauma is predominantlyblunt, and primarily result of MVA and falls 8-10% chest trauma is penetrating Chest wall trauma is most frequent injury after blunt thoracic trauma Chest trauma is predictor of more serious injury elsewhere Most chest injuries managed with observation, analgesia, thoracentesis, and respiratory support 15-20% require thoracotomy Operation rate <5% in blunt trauma and has poorer outcome Overall thoracic trauma mortality 10% Accounts for ¼ trauma deaths
- 3. GOLDEN HOUR Early deaths(within golden hour) caused by; .Airway obstruction .Tension pneumothorax .Massive haemothorax .Cardiac tamponade . Open pneumothorax . .Flail chest
- 4. INITIAL ASSESSMENT AND MANAGEMENT .PRIMARYSURVEY .RESUSCITATION .SECONDARY SURVEY .DEFINITIVE CARE
- 5. PRIMARY SURVEY :LIFE- THREATENING INJURIES Major problems should be corrected as they are identified
- 6. SECONDARY SURVEY Identify andinitiate treatment of following; .Simple pneumothorax .Hemothorax .Pulmonary contusion .Tracheobronchial disruption .Blunt cardiac injury .Traumatic aortic disruption .Traumatic diaphragmatic injury .Mediastinal traversing wounds
- 7. PRIMARY SURVEY AIRWAY +C-SPINE protection Observation – maxillofacial trauma, neck trauma, laryngeal trauma Talking – airway patent and not compromised Signs airway obstruction – look, listen, feel • Look - obtunded, agitated, cyanosis, accessory muscles • Listen - noisy breathing = obstructed breathing (snoring, gurgling, stridor), hoarseness • Feel - tracheal deviation
- 8. PRIMARY SURVEY AIRWAY MAINTENANCE .Chinlift .Jaw thrust .Oropharyngeal airway .Nasopharyngeal airway .Definitive airway - ETT - Surgical airway .Prehospital ETT confers no survival advantage over BVM and slightly increases prehospital time .
- 9. PRIMARY SURVEY C-SPINE CT significantlyout performs, plain X-ray as screening tool for very high risk C-spine injury CT should be initial screening tool in those with significantly depressed mental status Plain x- ray still recommended as initial screening test for low risk patients
- 10. PRIMARY SURVEY BREATHING Look –symmetrical chest movements asymmetry or splinting or flail Listen – breath sound both sides Feel : abnormalities .Oxygen .Suction .Pulse oximetry
- 11. PRIMARY SURVEY BREATHING Sensitivity physicalexamination in trauma Auscultation 100% sensitive in detecting HPX in blunt chest trauma, and only 50% sensitive in penetrating trauma, but 100% specific In presence of unequal BS, CXR unnecessary to confirm HPX, and ICC can be inserted on basis of auscultation. Auscultation poor screening tool for HPX in penetrating trauma .Blunt chest trauma patients who are stable with normal physical examination do not need routine CXR All victims penetrating trauma require CXR because many will have hemothorax in absence of clinical findings.
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- 13. Clinical diagnosis May arrivein ER dead or dying Most easily treatable life-threatening surgical emergency in the ER Characterized by chest pain, air hunger, respiratory distress, tachycardia, hypotension, tracheal deviation to contralateral side, ipsilateral side decreased BS and percussion tympany, neck vein distention, cyanosis Treatment should not be delayed for radiology Requires immediate needle decompression MCL 2nd ICS followed by ICC 5th ICS
- 14. OPEN PNEUMOTHORAX If openingin chest wall 2/3 diameter trachea, air passes preferentially through defect with each respiratory effort
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- 16. 2 or more# ribs in 2 or more places Severe disruption normal chest wall movement with paradoxical movements If significant underlying lung injury exists, serious hypoxia may result Diagnosis made by clinical examination, CXR, CT ABG required to assess need for mechanical ventilation TREATMENT humidified O2, analgesia, judicious fluids, mechanical ventilation (PEEP, SIMV, PSV), bronchoscopic aspiration, chest physiotherapy, +/- IV Atb Indication for mechanical ventilation; Pa02<60mmHg, PaC02>50mmHg, assoc severe trauma with LOC +/- shock, airway obstruction or repeated atelectasis Surgical stabilization – indicated if prolonged ventilatory assistance expected; benefits include - less ventilatory support and pneumonia, shorter ICU stay, cost effective, improved FVC, faster return to work
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- 18. >1500ml blood inchest cavity, or <1500ml initially, but 200ml/h for 2-4hr Signs; shock, absence breath sounds +/- dullness percussion on one side chest, ventilatory embarrassment, shift mediastinum Management; restoration blood volume (crystalloids + blood/autotransfusion), decompression chest cavity (#38F ICC 5th ICS) – may need to clamp tube and consider autotransfusion Do not wait for CXR to confirm diagnosis Indication for urgent thoracotomy, esp. if ongoing transfusion requirements 85% cases due to injured systemic vessel; intercostal or internal mammary artery, less commonly hilum of lung or myocardium 15% cases due to deep pulmonary lacerations – treated by oversewing or resection segment or lobe Beware penetrating wounds medial to nipple anteriorly, or scapula posteriorly as may require ER or urgent thoracotomy for possible damage to great vessels, hilar structures, or heart, with potential for cardiac tamponade Definition
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- 20. Pericardium fills withblood from heart, pericardial vessels, or great vessels 15-20ml may be enough to cause haemodynamic compromise Most commonly from penetrating injuries Any patient with penetrating thoracic injury has cardiac injury until proven otherwise Wounded heart will follow on of two courses; exsanguination or tamponade (80%) Exsanguination group - most die in field or in ER – if survive show signs hemorrhagic shock Definition
- 21. PRESENTATION Beck’s triad (over90% cases) .venous pressure elevation • .decline arterial pressure • .muffled heart sounds (hypotension may be due to hypovolaemia, neck veins may not be distended due to hypovolaemia) May be restless and anxious and refuse to lie supine Pulsus paradoxis >10mm Hg (10% cases) Kusssmaul’s sign – rise in venous pressure with inspiration PEA in absence of hypovolaemia or tension pneumothorax suggest cardiac tamponade
- 22. Pericardiocentesis indicated ifhigh index suspicion and failure to respond to resuscitation for hemorrhagic shock All patients with positive pericardiocentesis require open thoracotomy. Management
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- 24. ER THORACOTOMY Dismal survival Bestoutcomes with ; • Isolated chest injury • Single vs multiple chest injuries • Penetrating injury • Stab rather than gunshot • Right sided, single chamber heart injuries • Major factor in outcome is presenting physiology - Better outcome if vital signs present on admission • If BP present on arrival ER – survival advantage if thoracotomy performed in theatre • Prehospital intubation • Cardiac tamponade • Presence mentation in field or on arrival in ER
- 25. ER THORACOTOMY Six potentialtherapeutic goals; Control bleeding (cardiac or thoracic) Effective cardiac compressions Relief pericardial tamponade Cross clamp lung hilum after suspected air embolism Cross clamp descending aorta for lower torso hemorrhage control Confirm ETT placement
- 26. URGENT THORACOTOMY INDICATIONS; Massive hemothorax >1500mlblood from ICC immediately >200- 300ml blood from ICC after initial drainage persistent blood transfusion requirements Penetrating injury to anterior chest with cardiac tamponade Cardiac arrest (resuscitative thoracotomy) Large open wounds of thoracic cage Major thoracic vascular injuries with hemodynamic instability Major trachiobronchial injury Evidence osophageal perforation Bullet embolism to heart/pulmonary artery ? Mediastinal traverse with penetrating object .
- 27. SECONDARY SURVEY Deep physical examination(ABCDE)– CXR.widenedmediastinum - shift of midline ABG Pulse oximetry ECG
- 28. SECONDARY SURVEY 8 lethalinjuries considered here; Simple pneumothorax Hemothorax Pulmonary contusion Tracheobronchial tree injury Blunt cardiac injury Traumatic aortic disruption Traumatic diaphragmatic injury Mediastinal traversing wounds
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- 30. Second most commoninjury from chest trauma after #ribs Upto 50% occult and not seen on initial CXR 20% have accompanying hemothorax From both penetrating and blunt trauma Signs; decreased BS on affected side hyperesonance on affected side Erect CXR required for diagnosis Managed by ICC 5th ICS (28Fr) ICC is safest option, irrespective of size, because unpredictable progression to tension pneumothorax Observation +/- aspiration risky! and 10% fail conservative Rx Always needs ICC if undergoing transport, GA, or PPV( 40% increase size) Small bore pleural catheters assoc with increased incidence recurrence and complications
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- 32. Blunt or penetratingtrauma Bleeding from; lung laceration, intercostal vessel, internal mammary artery, T-spine # Usually self-limiting if large enough to appear on CXR needs ICC ICC reduces late incidence of empyema or fibrothorax.
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- 34. Most common potentiallylethal chest injury Damage to parenchyma from passage shock wave through tissue CXR – may be normal, but usually shows opacity in lung field, lags 12-24hr behind clinical picture Respiratory failure subtle and develops over time. ABG worsens at day 2-3 as oedema increases, careful monitoring and reevaluation. Intubation and ventilation if Sao2<90% especially if co- morbidities, or being transported In multi-injured trauma patient pulmonary contusion may be superimposed by sepsis, SIRS, MODS, ARDS Definition
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- 36. TRACHEOBRONCHIAL TREE INJURY Uncommoninjury (<2% major thoracic injuries) Often overlooked on initial assessment In blunt trauma the majority injuries occur within 2.5cm carina Most die at scene If survive - high mortality from associated injuries SIGNS; hemoptysis, subcutaneous emphysema, tension pneumothorax with mediastinal shift, progressive mediastinal air Suspect if persistent large air leak after tube thoracostomy or if surgical emphysema
- 37. TRACHEOBRONCHIAL TREE INJURY Morthan one ICC may be needed to overcome leak and expand the lung. Confirmed on bronchoscopy Opposite main stem bronchial intubation may be temporarily required TREATMENT; Distal bronchus – usually close with chest tube drainage alone within days Proximal bronchus – posterolateral thoracotomy – repair bronchus with monofilament if possible, otherwise segmentectomy or lobectomy required
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- 39. BLUNT CARDIAC INJURY Suspectin any patient who sustains high energy impact to thorax May cause; myocardial contusion, cardiac chamber rupture, valvular disruption Assoc injuries common – sternal #, #ribs, flail chest, seatbelt sign over precordium May be asymptomatic Chamber rupture – most die in field, typically presents with cardiac tamponade (mostly R side) – presentation and treatment similar to penetrating injuries Myocardial contusion may present with chest discomfort, hypotension, conduction abnormalities, valvular dysfunction, papillary muscle rupture, raised CVP (due to RV dysfunction)
- 40. BLUNT CARDIAC INJURY DIAGNOSIS– goal is to identify patients who need treatment (few) ECG variable, multiple PVC’s, sinus tacchycardia, AF, BBB usually R, ST segment ∆ (ST or T-wave ∆ more specific than arrhythmia) negative ECG predicts absence of contusion, and even more strongly suggests patient not likely to suffer cardiac complication Troponin no correlation with level and severity injury, reports vary as to whether it adds any more info to ECG Transthoracic Echo as part of FAST in all patients with truncal trauma in some centres indicated if clinical, biochemical, ECG abnormality, wall motion abnormality, thrombi, pericardial effusion Less commonly – radionuclide angiography, TOE
- 41. BLUNT CARDIAC TRAUMA IfECG, Troponin, and FAST normal, and no clinical signs or cardiac dysfunction – do not pursue diagnosis further Second troponin and ECG 8hr after injury required to reliably exclude significant myocardial injury If clinical, ECG, or chemical evidence of cardiac contusion, then monitor in HDU/CCU/ICU until resolution clinical signs and return ECG/Troponin to normal Unstable patients admitted to ICU Overall prognosis after cardiac contusion is good
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- 43. Common cause ofsudden death after MVA or fall from height – 80-85% mortality before reaching hospital If survive tend to have incomplete laceration near ligamentum arteriosum at aortic isthmus (95%), just distal to LSCA – fixed nature at this point All survivors have contained hematoma -intact adventitial layer or contained mediastinal hematoma prevent immediate death If survive to hospital – 30% mortality in 6hr, 40-50% mortality in 24hr Persistent or recurrent hypotension is usually due to other cause If ruptures into L chest is fatal within minutes Specific signs and symptoms frequently absent Diagnosis made by high index suspicion, mechanism injury (deceleration), characteristic radiological findings, TOE, CT angiogram, arteriography
- 44. Signs on CXR; Widenedmediastinum (>8cm, or M/C ratio >0.3) Obliteration aortic knob Deviation trachea to Rt Obliteration space between pulmonary artery and aorta Depression L main stem bronchus Deviation esophagus to R (NGT) Widened paratracheal stripe Widened paraspinal interfaces Presence of pleural or apical cap Left hemothorax #1st or 2nd rib or scapula Angiography should be performed liberally
- 45. 1-2% cases havenormal CXR If suspicion exists, patient should be evaluated at facility capable of repairing injury Angiography is gold standard Multi- detector row CT Angiogram – • faster time to diagnosis than angiogram • non- invasive • emerging as gold standard • Normal mediastinum with no hematoma, and regular aorta surrounded by normal fat has 100% NPV for aortic injury • most authors recommend abnormalities on CT be followed by angiogram
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- 47. TRAUMATIC DIAPHRAGMATIC INJURY Diaphragmatic injurymost common injury requiring surgery after blunt trauma More commonly diagnosed on L, but near equal incidence Diagnosed by physical examination, CXR – elevated or indistinct hemidiaphragm, bowel, stomach, NGT in chest (20% CXR normal) CT scan, US Liver obliterates defect or protects it on R side – more difficult to detect initially, 75% delayed diagnosis, MRI helpful in R sided injuries Elevated R hemi diaphragm may be only finding on CXR
- 48. TRAUMATIC DIAPHRAGMATIC INJURY Blunt traumaproduces radial tears that lead to herniation Penetrating trauma produces small perforations that often take time, even years to develop If injury suspected on left side – NGT should be inserted Upper GIT contrast study necessary if diagnosis unclear Laparoscopy or Thoracoscopy may be useful if diagnosis unclear Laparotomy for other causes may reveal diaphragmatic injury
- 49. TRAUMATIC DIAPHRAGMATIC INJURY TREATMENT All diaphragmaticinjuries should be repaired even if small and of no apparent importance, due to risk herniation and incarceration Preferred closure is direct repair with interrupted non- absorbable sutures Synthetic materials may be required to close large defects
- 50. MEDIASTINAL TRAVERSING WOUNDS Penetrating objectsthat traverse mediastinum may injure heart, great vessels, tracheobronchial tree, esophagus Diagnosis made when examination or CXR reveals entrance wound in one hemithorax and exit wound or missile lodged in opposite side or mediastinum If hemodynamically abnormal consider exsanguinating thoracic hemorrhage, tension pneumothorax, pericardial tamponade Bilateral ICC’s necessary Indications for urgent thoracotomy similar for massive hemothorax Both sides may need thoracotomy but start with side with most blood
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- 52. OSOPHAGEAL RUPTURE Most commonlypenetrating Blunt trauma causes forceful expulsion stomach contents into esophagus – linear tear in lower esophagus which may leak into mediastinum Mediastinitis with immediate or delayed rupture into pleural space causes empyema Mortality >20% Prompt recognition and initiation treatment mandatory Delays in treatment assoc with higher morbidity and mortality Primary closure within 24hr best outcome Needs to be excluded in all patients with traversing mediastinal injuries May present with painful swallowing, hematemesis, subcutaneous emphysema, SOB, fever
- 53. OESOPHAGEAL RUPTURE Consider inall patients with; • L pneumothorax or hemothorax without rib # • Blow to sternum or epigastrium with pain +/- shock inconsistent with apparent injury • Food or particulate matter in ICC • Mediastinal air on CXR • Persistent pneumothorax Confirm with esophagogram or esophagoscopy Esophagogram difficult in intoxicated, combative, unprotected airway, poor view cervical esophagus if intubated Endoscopy – sens and spec 90-100%, performed in ER or at bedside Endoscopy all patients with signs and symptoms or suspicious nature of injury May be role for VAT in diagnosis and treatment
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- 55. Most common injuredpart of chest Pain impairs ventilation and effective coughing which may lead to atelectasis and pneumonia especially with pre-existing lung disease # scapula, 1st or 2nd rib may have severe associated injuries with mortality up to 35% Ribs 4-9 sustain majority of blunt trauma More force required in younger patients # ribs 10-12 should raise suspicion for hepatosplenic injury
- 56. Likelihood of hepatosplenicinjury; 10-16% rib #’ have concomitant intra-abdominal injury to liver or spleen Liver injury increased with low rib # (8-12), R sided rib # Splenic injury increased with low rib #.lt sided.
- 57. IMAGING CXR has poorsensitivity, and rarely influences management # anterior cartilages or separation costochondral junctions may not be seen on CXR Special rib view Xrays unnecessary as may not ∆ management Ultrasound reveals rib # more accurately than X-ray and clinical acumen, specificity 85% USS superior to CT scan without radiation dose Follow-up USS at 3/52 post injury is gold standard May impact on patients with higher levels of activity such as manual workers or athletes wrt return to work and physical activity
- 58. SIGNS localized pain, tenderness,and crepitus TREATMENT Goal of treatment is to exclude underlying more serious injury, and ensure adequate analgesia Analgesia with; PO and IV analgesics, PCA, intercostal block, epidural Oxygen Physiotherapy SURGERY Surgical stabilization may reduce pain and ventilator requirements Methods ; fixator plates, intramedullary wires or nails, struts Indications ; select group with flail chest not weaning from mechanical ventilation after 5-7/7 with only moderate extrathoracic injuries and no HI, pulmonary contusion, or ARDS.
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- 60. Usually result ofdirect blow May be accompanied by pulmonary contusion Consider blunt cardiac injury with all sternal # Does not necessarily require monitoring Operative repair needed . posterior sternoclavicular dislocation may cause SVC obstruction needs reduction.