CHEST TRAuMA i : CHEST TRAuMA i Dr. Assaad Samaha
Chest Trauma : Chest Trauma Introduction
Anatomy
Pathophysiology
Causes
Symptoms
Diagnosis
Management
Complications
Introduction : Introduction Chest injuries are serious injuries
First report case 3000BC
STAB WOUND TO THE STERNUM
Vital Structures
Heart, Great Vessels, Esophagus,
Tracheobronchial Tree, & Lungs
Thoracic trauma is 25% for all trauma death 160 000/y
70% of thoracic trauma result from automobile accidents
Why...? : Why...?
Anatomy : Anatomy Thoracic Skeleton
12 Pair of C-shaped ribs
Sternum
Manubrium , Body Xiphoid process Intercostal space
Artery, Vein and Nerve on inferior margin of each rib
Thoracic Inlet
Thoracic Outlet
Topographical Thoracic
Reference Lines
Midclavicular line
Anterior axillary line
Mid-axillary line
Posterior axillary line
Anatomy : Anatomy Diaphragm
Muscular, Separates abdomen from the thoracic cavity
Affixed to the lower border of the rib cage Muscles of respiration
Diaphragm
Intercostal muscles
Contract to elevate the ribs and increase thoracic diameter
Increase depth of respiration
Sternocleidomastoid
Raise upper rib and sternum
Anatomy : Anatomy Major muscle of respiration
Draws downward during inspiration
Moves upward during exhalation
Anatomy : Anatomy Mediastinum
Central space within thoracic cavity
Boundaries
Lateral: Lungs
Inferior: Diaphragm
Superior: Thoracic outlet
Structures
Heart
Great Vessels
Esophagus
Trachea
Nerves
Vagus
Phrenic
Thoracic Duct
Anatomy : Anatomy Trachea
Hollow & cartilage supported structure
Bronchi
Right & left extend for 3 centimeters
Enters lungs at Pulmonary Hilum
Also where pulmonary arteries & veins enter
Further subdivide and terminate as alveoli
Basic unit of structure & function in the lungs
Single cell membrane
Anatomy : Anatomy
Physiology of Respiration : Physiology of Respiration Inhalation
Diaphragm contracts and flattens
Intercostals contract expanding ribcage
Thorax volume increases
Less internal pressure than atmospheric
Air enters lungs
Exhalation
Musculature relaxes
Diaphragm & intercostals return to normal
Greater internal pressure than atmospheric
Air exits lungs
Pathophysiology : Pathophysiology Blunt Trauma
Results from kinetic energy forces
Age Factors
Pediatric Thorax: More cartilage = Absorbs forces
Geriatric Thorax: Calcification & osteoporosis = More fractures
Blunt trauma : Blunt trauma Subdivision Mechanisms
Blast
Pressure wave causes tissue disruption
Tear blood vessels & disrupt alveolar tissue
Disruption of tracheobronchial tree
Traumatic diaphragm rupture
Crush (Compression)
Body is compressed between an object and a hard surface
Direct injury of chest wall and internal structures
Deceleration
Body in motion strikes a fixed object
Blunt trauma to chest wall
Internal structures continue in motion
Ligamentum Arteriosum shears aorta
Pathophysiology : Pathophysiology Penetrating Trauma
Low Energy
Arrows, knives, handguns
Injury caused by direct contact and cavitation
High Energy
Military, hunting rifles & high powered hand guns
Extensive injury due to high pressure cavitation
Penetrating Injuries : Penetrating Injuries 3 meters from weapon
Massive tissue destruction weapon
Injuries Associated with Thoracic Trauma : Injuries Associated with Thoracic Trauma 1 rib fracture
2 Flail chest
3 Closed pneumothorax
4 Open pneumothorax (including sucking chest wound)
5 Tension pneumothorax
6 Pneumomediastinum
7 Hemothorax
8 Hemopneumothorax
9 Laceration of vascular structures 10 Tracheobronchial tree
lacerations
11 Esophageal lacerations
12 Penetrating cardiac
injuries
13 Pericardial tamponade
14Spinal cord injuries
15 Diaphragm trauma
16 Intra-abdominal
penetration with associated
organ injury
Chest trauma causes : Chest trauma causes Accidents (car , motorbike…)
Fall
Bullet
Knife blade
Shrapnel
Blast
Iatrogenic chest trauma
Chest trauma causes : Chest trauma causes Bullet
Iatrogenic chest trauma : Iatrogenic chest trauma
Signs & Symptoms : Signs & Symptoms 1 Breathing difficulties
2 Pain at site. This usually increases with movement
3 Bruising
4 Deformity
5 Paradoxical breathing
6 Severe breathing difficulties
7 Bluish skin colour due to decreased levels of oxygen in blood
8 Reduced levels of consciousness
9 Enlarged neck veins
10 Reduced chest movement (injured side)
11 Cyanosis 12 Severe Dyspnea
13 Absent Breath sounds
14 Tachypnea
15 Tachycardia 16 Accessory Muscle Use
17 Hypotension
18 Tracheal Deviation
Signs & Symptoms : Signs & Symptoms Cyanosis Enlarged neck veins
Diagnosis : Diagnosis Quick history
Quick physical exam
CXR
LAB
CT Scan
Angiography
Echocardiography
taping
Management : Management Prehospital care
A B C
1 Assess any dangers to yourself, others and victim
2 Check for victim response .
3 Check airways by look, listen and feel.
4 Assess possible signs and symptoms.
5 Help casualty into a comfortable position. This can be a semi-sitting position which will assist in breathing
6 Ensure the injured side is facing downwards
Management : Management 8 Stabilise the injured site by placing a pillow, pad or hand over injured area.
9 Secure the upper arm on the injured side with broad bandage. Tie off on other side of body.
10 An elevation sling can assist the arm on the injured side.
12 Reassure the casualty
13 Flutter-Valve Seal Prehospital care 7 Call an ambulance
Call OR team 14 Provide oxygen if available
Management : Management Flutter-Valve Seal
Management : Management Hospital care
True diagnosis (X RAY , LAB...)
Blood transfusion
Needle decompresion
Chest tube
Intubation
Bronchoscopy
Operative repair
Management : Management Surgery department
1 Continuous and vigilant respiratory assessment
2 Optimizing oxygenation and ventilation,
3 Maintaining the chest tube system
4 Providing comfort and emotional support
5 Maintaining surveillance for complications
Complications of thoracic trauma : Complications of thoracic trauma Atelectasis
ARDS
Pneumonia
Infarction
Lung abscess
Arteriovenous fistula
Bronchial stenosis
Tracheoesophageal fistula
Empyema
Chylothorax
Diaphragmatic hernias
Air embolism
Pseudoaneurysm
Needle decompresion : Needle decompresion
Chest drain : Chest drain
hemothorax : hemothorax
Needle decompression : Needle decompression
thanks : thanks