Chest Trauma : Chest Trauma Gráinne Murphy
Final Med
April 2002
Introduction : Introduction Chest trauma is often sudden and dramatic
Accounts for 25% of all trauma deaths
2/3 of deaths occur after reaching hospital
Serious pathological consequnces: -hypoxia, hypovolaemia, myocardial failure
Mechanism of Injury : Mechanism of Injury Penetrating injuries
E.g. stab wounds etc.
Primarily peripheral lung
Haemothorax
Pneumothorax
Cardiac, great vessel or oesophageal injury
: Either: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury
Rib fracture is the most common sign of blunt thoracic trauma
Fracture of scapula, sternum, or first rib suggests massive force of injury Blunt injuries
Chest wall injuries : Chest wall injuries Rib fractures
Flail chest
Open pneumothorax
Rib fractures : Rib fractures Most common thoracic injury
Localised pain, tenderness, crepitus
CXR to exclude other injuries
Analgesia..avoid taping
Underestimation of effect
Upper ribs, clavicle or scapula fracture: suspect vascular injury
Flail chest : Flail chest Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration
Significant force required
Usually diagnosed clinically
Rx: ABC Analgesia
Slide 8: Flail chest
Slide 9: Flail Chest - detail
Open pneumothorax : Open pneumothorax Defect in chest wall provides a direct communication between the pleural space and the environment
Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax
“Sucking chest wound”
Rx: ABCs…closure of wound…chest drain
Lung injury : Lung injury Pulmonary contusion
Pneumothorax
Haemothorax
Parenchymal injury
Trachea and bronchial injuries
Pneumomediastinum
Pneumothorax : Pneumothorax Air in the pleural cavity
Blunt or penetrating injury that disrupts the parietal or visceral pleura
Unilateral signs: movement and breath sounds, resonant to percussion
Confirmed by CXR
Rx: chest drain
Slide 13: Pneumothorax
Tension pneumothorax : Tension pneumothorax Air enters pleural space and cannot escape
P/C: chest pain, dyspnoea
Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension
Slide 15: Surgical emergency
Rx: emergency decompression before CXR
Either large bore cannula in 2nd ICS, MCL or insert chest tube
CXR to confirm site of insertion
Haemothorax : Haemothorax Blunt or penetrating trauma
Requires rapid decompression and fluid resuscitation
May require surgical intervention
Clinically: hypovolaemia absence of breath sounds dullness to percussion
CXR may be confused with collapse
Heart, Aorta & Diaphragm : Heart, Aorta & Diaphragm Blunt cardiac injury - contusion - ventricular, septal or valvular rupture
Cardiac tamponade
Ruptured thoracic aorta
Diaphragmatic rupture
Cardiac Tamponade : Cardiac Tamponade Blood in the pericardial sac
Most frequently penetrating injuries
Shock, JVP, PEA, pulsus paradoxus
Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension
Rx: Volume resuscitation Pericardiocentesis
Slide 19: Cardiac tamponade
Aortic rupture : Aortic rupture Usually blunt trauma involving deceleration forces; especially RTAs
~90% die within minutes
Most common site near ligamentum arteriosum
Dx: clinical suspicion, CXR, aortography, contrast CT or TOE
Rx: surgical…poor prognosis
Slide 21: Aortic rupture
Iatrogenic trauma : Iatrogenic trauma NG tubes: -coiling -endobronchial placement -pneumothorax
Chest tubes: - subcutaneous - intraparenchymal - intrafissural
Central lines: - neck - coronary sinus - pneumothorax
Slide 23: Line in jugular vein
Slide 24: Misplaced nasogastric tube
Chest trauma: summary : Chest trauma: summary Common
Serious
Primary goal is to provide oxygen to vital organs
Remember Airway Breathing Circulation
Be alert to change in clinical condition