Chest Trauma

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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

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