Thoracic Trauma: 1 Thoracic Trauma Dr Shankar Hippargi A & E Consultant MMHRC Chest Trauma: 2 Chest Trauma Second leading cause of deaths due to trauma About 20% of all trauma deaths About 80% of thoracic traumas do not need surgery Chest Trauma: 3 Chest Trauma Initial examination directed towards identification and treatment of: Tension pneumothorax Cardiac tamponade Open pneumothorax Flail chest Massive hemothorax Rib Fracture: 4 Rib Fracture Most common chest injury More common in adults than children Especially common in elderly Ribs form rings- Consider possibility of break at two places 30% - 40% rib #s missed on CXR Rib Fracture: 5 Rib Fracture Most commonly 5th to 9th ribs Poorly protected Rib Fracture: 6 Rib Fracture Fractures of 1st, 2nd ribs require great force Frequently have injury to aorta, subclavian artery / vein or bronchi Look for swelling in supraclavicular fossa Compare the radial pulses, urgent intervention needed if unequal / absent 30% of the patients will die Rib Fracture: 7 Rib Fracture Fractures of 7th to 12th ribs can damage underlying abdominal solid organs: Liver Spleen Kidneys Rib Fracture: 8 Rib Fracture Management High concentration O 2 Adequate pain relief Encourage patient to breath deeply Rib Fracture: 9 Rib Fracture Management Monitor elderly and COPD patients carefully Broken ribs can cause decompensation. Patients will fail to breath deeply and cough, resulting in poor clearance of secretions. Flail Chest: 10 Flail Chest Three or more adjacent ribs broken at two or more places Produces free-floating chest wall segment (Flail segment) Secondary to blunt trauma More common in older patients PowerPoint Presentation: 11 Paradoxical respiration: 12 Paradoxical respiration Flail Chest: 13 Flail Chest Signs and Symptoms Paradoxical movement May NOT be present initially due to intercostal muscle spasms Flail Chest: 14 Flail Chest Consequences The major complication is respiratory failure due to the underlying lung contusion Increased work of breathing (exhaustion) Flail Chest: 15 Flail Chest Management Establish airway, breathing & circulation Suspect spinal injuries Stabilize chest wall Pain relief IV fluids Consider early intubation and ventilation PowerPoint Presentation: 16 Simple Pneumothorax: 17 Simple Pneumothorax Air in pleural space Partial or complete lung collapse occurs Simple Pneumothorax: 18 Simple Pneumothorax Causes Chest wall penetration Fractured rib lacerating lung May occur spontaneously following: Exertion Coughing Air Travel Simple pneumothorax: 19 Simple pneumothorax Simple Pneumothorax: 20 Simple Pneumothorax Signs and Symptoms Pain on inhalation Difficulty breathing Tachypnea Decreased or absent breath sounds Hyper resonant to percussion Severity of symptoms depends on size of pneumothorax, speed of lung collapse, and patient’s health status Simple Pneumothorax: 21 Simple Pneumothorax Management Establish ABC Suspect spinal injury based on mechanism High concentration O 2 with NRB Assist decreased or rapid respirations with BVM Monitor for tension pneumothorax ICD depending on patient’s condition & amount of air in pleural cavity Intercostal drainage: 22 Intercostal drainage Open Pneumothorax: 23 Open Pneumothorax Hole in chest wall Allows air to enter pleural space Larger hole = Greater chance of air entering through it Frothy blood at wound site “Sucking Chest Wound” PowerPoint Presentation: 24 PowerPoint Presentation: 25 Open Pneumothorax: 26 Open Pneumothorax Management Close hole with 3 way occlusive dressing High concentration O 2 Assist ventilations Watch for tension pneumothorax PowerPoint Presentation: 27 PowerPoint Presentation: 28 Sealing all the 4 sides may cause tension pneumothorax if an ICD is not in place Tension Pneumothorax: 29 Tension Pneumothorax One-way valve forms in lung or chest wall Air enters pleural space; cannot leave Air is trapped in pleural space Pressure rises Pressure collapses lung Tension Pneumothorax: 30 Tension Pneumothorax Trapped air pushes heart, lungs away from injured side Venacava become kinked Blood cannot return to heart Cardiac output falls PowerPoint Presentation: 31 PowerPoint Presentation: 32 PowerPoint Presentation: 33 Tension Pneumothorax: 34 Tension Pneumothorax Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitation Absent breath sounds Hyper resonance to percussion Cyanosis Subcutaneous emphysema Tension Pneumothorax: 35 Tension Pneumothorax Signs and Symptoms Rapid, weak pulse Decreased BP Tracheal shifts away from injured side Jugular vein distension Early dyspnea/hypoxia - Late shock Tension Pneumothorax: 36 Tension Pneumothorax Management Secure airway High concentration O 2 with NRB Needle decompression (temporary measure) Pain relief ICD (definitive treatment) Needle decompression: 37 Needle decompression Subcutaneous emphysema: 38 Subcutaneous emphysema Can be due to rib fracture, injury to lungs or airway Can extend to neck, face, abdomen, and upper limbs May require ICD if source is in lungs. PowerPoint Presentation: 39 Hemothorax: 40 Hemothorax Blood in pleura space Most common result of major chest wall trauma Present in 70 to 80% of penetrating, major non-penetrating chest trauma PowerPoint Presentation: 41 Hemothorax : 42 Hemothorax Hemothorax: 43 Hemothorax Signs and Symptoms Rapid, weak pulse Dyspnea Cool, clammy skin Restlessness, anxiety Hypotension Hemothorax: 44 Hemothorax Signs and Symptoms Decreased breath sounds Dullness to percussion Ventilatory failure Shock precedes respiratory failure Hemothorax: 45 Hemothorax Management Secure airway Assist breathing with high concentration O 2 Aggressive fluid resuscitation Transfuse blood as soon as possible ICD insertion Indications for thoracotomy: 46 Indications for thoracotomy Thoracotomy is indicated if there is >1500ml blood loss or <1500 ml with continuous loss > 200ml/hr Penetrating anterior wound medial to nipple line or posterior wound medial to scapula may need thoracotomy due to damage to great vessels, hilar structures or heart Traumatic Asphyxia: 47 Traumatic Asphyxia Blunt force to chest causes Increased intrathoracic pressure Backward flow of blood out of heart into vessels of upper chest, neck, head Traumatic Asphyxia: 48 Traumatic Asphyxia Signs and Symptoms Possible sternal fracture or central flail chest Shock Purplish-red discoloration of: Head Neck Shoulders Protruding eyes Swollen, cyanotic lips Traumatic Asphyxia: 49 Traumatic Asphyxia Name given because patients look like they had been strangled or hanged Traumatic Asphyxia: 50 Traumatic Asphyxia Management Airway with C-spine control Assist ventilations with high concentration O 2 IV fluids Do not forget the underlying structures: 51 Do not forget the underlying structures Cardiovascular Trauma: 52 Cardiovascular Trauma Any patient with significant blunt or penetrating trauma to chest has heart / great vessel injury until proven otherwise. Myocardial Contusion: 53 Myocardial Contusion Bruise of heart muscle Most common blunt cardiac injury Usually due to steering wheel impact Myocardial Contusion: 54 Myocardial Contusion Behaves like acute MI May produce arrhythmias May cause cardiogenic shock, hypotension Myocardial Contusion: 55 Myocardial Contusion Signs and Symptoms Cardiac arrhythmias after blunt chest trauma Angina-like pain unresponsive to nitroglycerin Chest pain independent of respiratory movement Suspect in all blunt chest trauma Myocardial Contusion: 56 Myocardial Contusion Management High concentration O 2 Cardiac monitoring Consider ACLS intercept Cardiac Tamponade: 57 Cardiac Tamponade Rapid accumulation of blood / air in space between heart & pericardium Heart compressed Blood entering heart decreases Cardiac output falls Cardiac Tamponade: 58 Cardiac Tamponade Cardiac Tamponade: 59 Cardiac Tamponade Signs and Symptoms Hypotension unresponsive to treatment Increased central venous pressure (distended neck/arm veins in presence of decreased arterial BP) Muffled heart sounds Beck’s Triad Cardiac Tamponade: 60 Cardiac Tamponade Signs and Symptoms Narrowing pulse pressure Pulsus paradoxicus Radial pulse becomes weak or disappears when patient inhales ECG shows low amplitude complexes Cardiac Tamponade: 61 Cardiac Tamponade Management Secure airway High concentration O 2 IV fluids Definitive treatment is pericardiocentesis followed by surgery Penetrating injury: 62 Penetrating injury Penetrating chest injuries: 63 Penetrating chest injuries Never try to remove penetrating foreign objects from the wound. May cause severe uncontrollable bleeding, tension pneumothorax, cardiac tamponade and sudden death. Maintain ABCs in ED Treatment : 64 Treatment Should be shifted to OT immediately and object removed under direct vision in a controlled environment. Other thoracic injuries: 65 Other thoracic injuries Aortic rupture Esophageal rupture Aortic rupture: 66 Aortic rupture Associated Abdominal Trauma: 67 Associated Abdominal Trauma Diaphragm forms dome that extends up into rib cage - Diaphragmatic rupture Trauma to chest below 4th rib indicates a bdominal injury until proven otherwise Diaphragmatic rupture: 68 Diaphragmatic rupture PowerPoint Presentation: 69 Questions ? ? ?