Chest Trauma

CHEST TRAUMA INTRO 25% of all trauma related deaths

Mechanism of injury

Blunt trauma >Blunt force injuries from assault or fall from height

Penetrating trauma

High velocity

>Gunshot wound

Low velocity

> Stab wound Acceleration and deceleration injuries

Blunt truama is more common in sri lanka Goals

Improved field diagnosis and treatment of life threatening conditions

Rapid evacuation to higher level of care

High risk of death despite acute intervention

Need for prompt diagnosis and treatment

Anatomy of the chest

Common injuries overview

Bony fractures

Lung injuries

Cardiac contusion

Common Injuries

Rib fractures

>Sternal fractures

>Open or Closed Pneumothorax

- unilateral / bilateral

>Hemothorax

>Hemopneumothorax

Clinical consequences associated with:

Mechanism of injury

Location of injury

Associated injuries

Co-morbidities

Blunt injuries can managed non-operatively

Management of airway / oxygenation

Analgesia

Intubation and ventilator support if needed

Chest tubes if needed for pneumothorax or hemothorax

PENETRATING INJURIES

Trajectory across chest

Mechanism due to knife or gunshot

Type of bullet

INITIAL MANAGEMENT

Airway, Breathing, Circulation

PRIMARY SURVEY

>Identify & treat immediately life threatening conditions

Early intervention directed toward diagnosing and treating:

The Five Killers of thorax

1Tension pneumothorax B

2Massive hemothorax C

3Open pneumothorax B

4Cardiac tamponade C

5Flail chest B

plus airway laryngotracheal injury A and correlate with ABC

RADIOLOGIC TESTS

Chest X-ray, usually portable

USS of thorax ( New advancement)

Abdominal KUB and FAST Ultrasound Exam

CAT scan, and CT Angiogram if needed

COMPLETE MANAGEMENT STORY??List of all chest trauma conditions?

Flail chest Hemothorax

Pneumothorax Cardiac Tamponade

Rib fractures Pulmonary Contusion Myocardial Contusion Aortic Rupture Diaphragm Rupture Oesophageal injuryProcedure lists: Needle thoracotomy Chest tube insertion Thoracotomy. Pericadiocentesis

Pathophysiological consequences

Hypoxia

Hypercarbia

Metabolic Acidosis

Hypovolaemia

Reduction in venous return

Myocardial Failure

Reduced cardiac output

Shock

INITIAL MANAGEMENT

Follow the ATLS protocols “ ABCDE”

Evaluation

Look

Seat belt mark, Abrasions, Wounds, Bruises

Respiratory rate, O2 saturation, respiratory distress, cyanosis, JVP

Listen

Breath sounds, percussion notes, heart sounds

Feel

Bony crepitus, emphysema, tracheal deviation, peripheral pulses

Other chest injuries picked up on Secondary Survey

Simple Pneumothorax

Haemothorax

Pulmonary contusion

Tracheobronchial Tree Injury

Blunt Cardiac Injury

Traumatic Aortic Disruption

Traumatic Diaphragmatic injury

Mediastinal Traversing Wounds

overall objectives • Identify life- threatening injuries during Primary survey and treat them immediately • Identify the patient requiring surgical intervention *Identify other potentially life threatening injuries and manage them * Maintain adequate gas exchange Immediate Surgery may be required in the following conditions. If facilities are not available patient needs to be transferred to the nearest hospital after resuscitation.

Initial intra thoracic bleeding is massive i.e. >1000cc

Continuous bleed from IC tube approximately about 200ml of blood per hour.

Cardiac tamponade.

Penetrating cardiac injuries.

When internal cardiac massage is required.

If massive air embolism is suspected.

Basic info

6.1.1 Tension Pneumothorax, decompress with needle in second intercostal space mid clavicular line, followed by chest drain insertion.

6.1.2 Massive haemothorax, large chest drain (minimum size 32FG) is inserted along side with fluid resuscitation.

6.1.3 Cardiac Tamponade, pericardiocentesis: a wide bore needle is inserted into pericardium (L/S Sub-costal angle at 45 degrees to thee skin directed at L/S Inferior scapular angle) while applying suction throughout, preferably with cardiac monitoring. Thoracic surgeon is informed immediately or thoracotomy should be performed at the treating institution if cardiac tamponade is diagnosed.

Rib fractures

Physical Diagnosis:

Deformity

Localized pain

Crepitus Compression test?

Treatment:

Analgesia (PCA)

Pulmonary toilet

Observe for pneumothorax

FLAIL CHEST

Definition and description

Segment of chest wall that does not have

continuity with rest of thoracic cage

Usually 2 fractures per rib in at least 2 ribs

Segment does not contribute to lung expansion

Disrupts normal pulmonary mechanics

Accompanied by pulmonary contusion in 50% of patients

Paradoxical motion of the chest wall is hallmark

Underlying lung contusion along with pain (which reduces chest wall movement) → Hypoxia

Diagnosis:

Paradoxical chest wall movement

Poor air movement

Hypoxia

Therapy:

Adequate ventilation

Administration of Humidified Oxygen

Fluid resuscitation

Adequate pain relief- Epidural analgesia

Definitive (Re expand the lung)

–Mechanical ventilation •Pulmonary & physical therapy

PULMONARY CONTUSION

Common with blunt trauma

May be associated with laceration of lung parenchyma

Leakage of blood and fluid into interstitial spaces of lung

Significant inflammatory reaction to blood components in the lung

Parenchymal infiltrate seen on CXR adjacent to injured chest wall

Indications for intubation

Respiratory distress

Hypoxia

Other injuries which compromise respiratory effort, such as abdominal or neurologic

MYOCARDIAL CONTUSION

Physical bruising of the cardiac muscle

Associated

with fractures of the sternum

>Any severe anterior chest injury

DIAGNOSIS:

Ectopy

ST elevation

Tachycardia

Friction rub

CPK enzymes, Troponin

Management

Monitor in ICU & treat dysrhythmias

Serial enzymes

Analgesia

Massive Hemothorax

From

blunt or penetrating injuries

200cc – 1L in chest cavity seen on CXR

Treat with chest tube, if immediate drainage is 1500 cc or if 250 cc/hr for 4 hours, then immediate thoracotomy

Bleeding may be from ribs, lung, blood vessels

Insult

–Blood loss and hypoxia

Diagnosis

Shock

Absent breath sounds

Dullness to percussion

MANAGEMENTi

AORTIC RUPTURE

Mechanism

Abrupt deceleration or compression injury

Sudden motion of heart / great vessels in chest

Great vessel injury may occur in 0.3 => 10% penetrating trauma

Prognosis

Often rapidly fatal

10% survive to hospital

20% survive > 1 hour

90% who reach hospital will die

Early diagnosis and treatment

Radiology

Widened mediastinum on CXR

CT with contrast angiogram

Treatment

Contained injury treat with BP control

Operative repair

Aortic laceration repair?

Cardiac injury and tamponade

Fatality rates > 80%

Mostly ventricular, right > leftBlood in pericardial sac causes tamponade

Occurs withpenetrating injuries

2% incidence after penetrating trauma, rare with blunt trauma

Heart, pericardial vessels or great vessels

Relatively small amount of blood can restrict cardiac activity and ↓ cardiac filling Diagnosis:

Hypotension, distended neck veins, muffled heart sounds (Becks triad)

Most reliable sign is CVP >15 with associated hypotension & tachycardia

Pulsus paradoxus: decline in systolic BP >10 mmHg on inspiration

Ultrasound: sensitivity 98% Specificity 99.9%

Management

–

Volume expansion with crystalloid

–Pericardiocentesis if clinical deterioration; aspiration of 5-10 mL may cause improvement

–Pericardiocentesis should be done under ultrasound if available and with ECG monitoring

–Thoracotomy indications as described earlier

Ventricular laceration and repair?

Coronary artery adjacent laeration and repair?

Internal paddles for direct cardioversion?

DIAPHRAGM RUPTURE

Associated with blunt trauma or blast injury

Can be due to stab wounds

Treatment

Surgical repair to replace herniated contents back into abdomen

Close muscular diaphragm to restore pulmonary function

Chest tube to treat pneumothorax

OESOPHAGEAL INJURY

Most due

to penetrating trauma

Difficult to diagnosis

If delayed or missed, rapid sepsis & high mortalityInvestigations:

Radiography

Endoscopy

Thoracoscopy

Treatment:surgical repair via thoracotomy

EMERGENCY THORACOTOMY Indications:

Cardiac tamponade (relieved)

Vascular injury to thoracic outlet

Massive air leak

Endoscopic / radiographic evidence of tracheal or bronchial injury

Oesophageal injury

Chest tube output

immediate evacuation of 1500ml blood

or > 250cc/ hour *to perform open CPR

BLUNT injury with arrest

Arriving without pulse/BP

Penetrating injury with arrest

High likelihood of isolated / correctable intra-thoracic injury

ER THORACOTOMY in presence of :

pulse

blood pressure

organized cardiac activity (but if asystole then should have tamponade) Other c/i => more than 15mins CPR. Massive non survivable injuries. No thoracic or trauma surgeon within 45 mins.

Needle thoracotomy and chest tube insertionCriteria for insertion of an intercostal tube • presence of significant pnemothorax.

Preoperatively if the situation is likely lead to development of pneumothorax during surgery or IPPV.

Severe chest injuries prophylactically.

Before transfer of patient with chest injury if there is possibility of developing pneumothorax.

Haemothorax

Insertion Site

mid or anterior axillary line behind pectoralis major

above 5th rib avoid diaphragm

Connect tube to underwater seal and suture in place

Examine chest to check effect

CXR to check placement and position

STUFF TO BE CHECKED AND DONE WHEN HAVE CHEST TUBE? HOW TO KNOW WHETHER DRAINING? PUTTING AND REMOVING DRAINS? ------------------------------------------------------ MANAGEMENT OF TENSION PNEUMOTHORAX

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Needle thoracostomy

Decompression of

Tension Pneumothorax

large bore needle (14F to 18F)

2nd intercostal space

midclavicular line

Chest tube as definitive treatment

Procedure

The preferred insertion site is the 2nd intercostal space in the mid-clavicular line in the affected hemithorax. However, insertion of the needle virtually anywhere in the correct hemothorax will decompress a tension pneumothorax.

If time permits, prepare the area at and around the insertion site using an antiseptic solution such as chlorhexidine.

There is rarely time to provide local anesthesia, but if there is, inject 1% lidocaine into the skin, subcutaneous tissue, rib periosteum (of the rib below the insertion site), and the parietal pleura. Inject a large amount of local anesthetic around the highly pain-sensitive periosteum and parietal pleura. Aspirate with the syringe before injecting lidocaine to avoid injection into a blood vessel. Proper location is confirmed by return of air in the anesthetic syringe when entering the pleural space.

Insert the thoracostomy needle, piercing the skin over the rib below the target interspace, then directing the needle cephalad over the rib until the pleura is punctured (usually indicated by a pop and/or sudden decrease in resistance).

After doing a needle thoracostomy, insert a chest tube as soon as possible.

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Complications

Pulmonary or diaphragmatic laceration

Intercostal neuralgia due to injury of the neurovascular bundle below a rib

Bleeding

Infection

Pneumothorax (if the procedure was done because of falsely suspected pneumothorax)

Rarely, perforation of other structures in the chest or abdomen

Neurovascular bundles are located at the lower edge of each rib. Therefore, the needle must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle

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Tension Pneumothorax

“One-way-valve”/air leak occurs from the lung or chest wall without any escape causing collapse of the lung, mediastinum displacement, decreasing venous return, & compressing the opposite lungClinical features