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Premium member Presentation Transcript Thoracic Trauma: 1 Thoracic Trauma Dr Shankar Hippargi A & E Consultant MMHRCChest 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 surgeryChest Trauma: 3 Chest Trauma Initial examination directed towards identification and treatment of: Tension pneumothorax Cardiac tamponade Open pneumothorax Flail chest Massive hemothoraxRib 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 CXRRib Fracture: 5 Rib Fracture Most commonly 5th to 9th ribs Poorly protectedRib 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 dieRib Fracture: 7 Rib Fracture Fractures of 7th to 12th ribs can damage underlying abdominal solid organs: Liver Spleen KidneysRib Fracture: 8 Rib Fracture Management High concentration O 2 Adequate pain relief Encourage patient to breath deeplyRib 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 patientsPowerPoint Presentation: 11Paradoxical respiration: 12 Paradoxical respirationFlail Chest: 13 Flail Chest Signs and Symptoms Paradoxical movement May NOT be present initially due to intercostal muscle spasmsFlail 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 ventilationPowerPoint Presentation: 16Simple Pneumothorax: 17 Simple Pneumothorax Air in pleural space Partial or complete lung collapse occursSimple Pneumothorax: 18 Simple Pneumothorax Causes Chest wall penetration Fractured rib lacerating lung May occur spontaneously following: Exertion Coughing Air TravelSimple pneumothorax: 19 Simple pneumothoraxSimple 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 statusSimple 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 cavityIntercostal drainage: 22 Intercostal drainageOpen 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: 24PowerPoint Presentation: 25Open Pneumothorax: 26 Open Pneumothorax Management Close hole with 3 way occlusive dressing High concentration O 2 Assist ventilations Watch for tension pneumothoraxPowerPoint Presentation: 27PowerPoint Presentation: 28 Sealing all the 4 sides may cause tension pneumothorax if an ICD is not in placeTension 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 lungTension Pneumothorax: 30 Tension Pneumothorax Trapped air pushes heart, lungs away from injured side Venacava become kinked Blood cannot return to heart Cardiac output fallsPowerPoint Presentation: 31PowerPoint Presentation: 32PowerPoint Presentation: 33Tension Pneumothorax: 34 Tension Pneumothorax Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitation Absent breath sounds Hyper resonance to percussion Cyanosis Subcutaneous emphysemaTension 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 shockTension 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 decompressionSubcutaneous 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: 39Hemothorax: 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 traumaPowerPoint Presentation: 41 Hemothorax : 42 HemothoraxHemothorax: 43 Hemothorax Signs and Symptoms Rapid, weak pulse Dyspnea Cool, clammy skin Restlessness, anxiety HypotensionHemothorax: 44 Hemothorax Signs and Symptoms Decreased breath sounds Dullness to percussion Ventilatory failure Shock precedes respiratory failureHemothorax: 45 Hemothorax Management Secure airway Assist breathing with high concentration O 2 Aggressive fluid resuscitation Transfuse blood as soon as possible ICD insertionIndications 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 heartTraumatic 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, headTraumatic 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 lipsTraumatic Asphyxia: 49 Traumatic Asphyxia Name given because patients look like they had been strangled or hangedTraumatic Asphyxia: 50 Traumatic Asphyxia Management Airway with C-spine control Assist ventilations with high concentration O 2 IV fluidsDo not forget the underlying structures: 51 Do not forget the underlying structuresCardiovascular 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 impactMyocardial Contusion: 54 Myocardial Contusion Behaves like acute MI May produce arrhythmias May cause cardiogenic shock, hypotensionMyocardial 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 traumaMyocardial Contusion: 56 Myocardial Contusion Management High concentration O 2 Cardiac monitoring Consider ACLS interceptCardiac Tamponade: 57 Cardiac Tamponade Rapid accumulation of blood / air in space between heart & pericardium Heart compressed Blood entering heart decreases Cardiac output fallsCardiac Tamponade: 58 Cardiac TamponadeCardiac 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 TriadCardiac 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 complexesCardiac Tamponade: 61 Cardiac Tamponade Management Secure airway High concentration O 2 IV fluids Definitive treatment is pericardiocentesis followed by surgeryPenetrating injury: 62 Penetrating injuryPenetrating 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 EDTreatment : 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 ruptureAortic rupture: 66 Aortic ruptureAssociated 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 otherwiseDiaphragmatic rupture: 68 Diaphragmatic rupturePowerPoint Presentation: 69 Questions ? ? ? You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.