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CHEST TRAUMA : CHEST TRAUMA Incidence of Chest Trauma : Incidence of Chest Trauma Cause 1 of 4 American trauma deaths Many die after reaching hospital - could be prevented if recognized <10% of blunt chest trauma needs surgery 1/3 of penetrating trauma needs surgery Most life-saving procedures do NOT require a thoracic surgeon Slide 4: splinter Pathophysiology of Chest Trauma : Pathophysiology of Chest Trauma hypovolemia ventilation- perfusion mismatch changes in intrathoracic pressure relationships Inadequate oxygen delivery to tissues TISSUE HYPOXIA Pathophysiology of Chest Trauma : Pathophysiology of Chest Trauma Tissue hypoxia Hypercarbia Respiratory acidosis - inadequate ventilation Metabolic acidosis - tissue hypoperfusion (e.g., shock) Initial assessment and management : Initial assessment and management Primary survey Resuscitation of vital functions Detailed secondary survey Definitive care Initial assessment and management : Initial assessment and management Hypoxia is most serious problem - early interventions aimed at reversing Immediate life-threatening injuries treated quickly and simply - usually with a tube or a needle Secondary survey guided by high suspicion for specific injuries 6 Immediate Life Threats : 6 Immediate Life Threats Airway obstruction Tension pneumothorax Open pneumothorax “sucking chest wound” Massive hemothorax Flail chest Cardiac tamponade 6 Potential Life Threats : 6 Potential Life Threats Pulmonary contusion Myocardial contusion Traumatic aortic rupture Traumatic diaphragmatic rupture Tracheobronchial tree injury - larynx, trachea, bronchus Esophageal trauma 6 Other Frequent Injuries : 6 Other Frequent Injuries Subcutaneous emphysema Traumatic asphyxia Simple pneumothorax Hemothorax Scapula fracture Rib fractures 6 Immediate Life Threats : 6 Immediate Life Threats Airway obstruction Tension pneumothorax Open pneumothorax “sucking chest wound” Massive hemothorax Flail chest Cardiac tamponade Airway Obstruction : Airway Obstruction Chin-lift - fingers under mandible, lift forward so chin is anterior Airway Obstruction : Airway Obstruction Jaw thrust - grasp angles of mandible and bring the jaw forward Airway Obstruction : Airway Obstruction Oropharyngeal airway inserted in mouth behind tongue. DO NOT push tongue further back. Airway Obstruction : Airway Obstruction Nasopharyngeal airway - well lubricated “trumpet” gently inserted through nostril Airway Obstruction : Airway Obstruction Definitive management - tube in trachea through vocal cords with balloon inflated. Airway Obstruction : Airway Obstruction Orotracheal intubation Nasotracheal intubation - in breathing patient without major facial trauma surgical airways jet insufflation cricothyrotomy tracheostomy Airway Obstruction : Airway Obstruction Jet insufflation adapters Airway Obstruction : Airway Obstruction Tracheotomy tubes Tension pneumothorax : Tension pneumothorax Air leaks through lung or chest wall “One-way” valve with lung collapse Mediastinum shifts to opposite side Inferior vena cava “kinks” on diaphragm, leading to decreased venous return and cardiovascular collapse Tension Pneumothorax : Tension Pneumothorax Slide 24: Inferior vena cava Tension pneumothorax : Tension pneumothorax Tension pneumothorax is not an x-ray diagnosis - it MUST be recognized clinically Treatment is decompression - needle into 2nd intercostal space of mid-clavicular line - followed by thoracotomy tube Slide 26: Insert needle here Open pneumothorax : Open pneumothorax “Sucking Chest Wound” Normal ventilation requires negative intra-thoracic pressure Large open chest-wall defect leads to immediate equilibration of intra-thoracic and atmospheric pressures If hole is >2/3 tracheal diameter, air prefers chest defect Open pneumothorax : Open pneumothorax Initial treatment - seal defect and secure on three sides (total occlusion may lead to tension pneumothorax Definitive repair of defect in O.R. Massive hemothorax : Massive hemothorax Rapid accumulation of >1500 cc blood in chest cavity Hypovolemia & hypoxemia Neck veins may be: flat - from hypovolemia distended - intrathoracic blood Absent breath sounds, DULL to percussion Massive hemothorax - treatment : Massive hemothorax - treatment Large-bore (32 to 36 F) tube to drain blood If moderate sized - 500 to 1500 ml - and stops bleeding, closed drainage usually sufficient If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated Slide 33: ICD Chest Tube Placement : Chest Tube Placement Anterior axillary line, posterior to pectoralis major muscle 5th intercostal space (opposite the nipple) Flail chest : Flail chest “Free-floating” chest segment, usually from multiple ribs fractures Pain and restricted movement “Paradoxical movement” of chest wall with respiration Flail chest - treatment : Flail chest - treatment Adequate ventilation Humidified oxygen Fluid resuscitation PAIN MANAGEMENT Stabilize the chest internal - ventilator external - sand bags Obsolete Treatment : Obsolete Treatment http://www.trauma.org/imagebank/imagebank.html Stabilization Of The Ribs : Stabilization Of The Ribs Cardiac tamponade : Cardiac tamponade Usually from penetrating injuries Classic “Beck’s triad” elevated venous pressure - neck veins decreased arterial pressure - BP muffled heart sounds Blood in sac prevents cardiac activity Cardiac tamponade : Cardiac tamponade May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in systolic BP during inspiration Systolic to diastolic gradient of less than 30 mm Hg also suggestive Cardiac tamponade : Cardiac tamponade Treatment is removal of small amount of blood - 15 to 20 ml may be sufficient - from pericardial sac pericardiocentesis Slide 43: Stab wound to right ventricle Slide 44: pericardium epicardial fat 6 Potential Life Threats : 6 Potential Life Threats Pulmonary contusion Myocardial contusion Traumatic aortic rupture Traumatic diaphragmatic rupture Tracheobronchial tree injury - larynx, trachea, bronchus Esophageal trauma Pulmonary contusion : Pulmonary contusion Potentially life-threatening condition with insidious onset Parenchymal injury without laceration More than 50% will develop pneumonia, even with treatment Up to 50% have only hemoptysis as presenting symptom Components of Pulmonary Contusion : Components of Pulmonary Contusion http://www.cvmbs.colostate.edu/clinsci/wing/trauma/pulmcont.htm Pulmonary Contusion : Pulmonary Contusion A bruise to the lung Airspace opacification No air bronchogram Pulmonary contusion : Pulmonary contusion Patients with pre-existing conditions - emphysema, renal failure - need early intubation Treatment needs to occur over time as symptoms develop Myocardial contusion : Myocardial contusion Blunt precordial chest trauma Difficult to diagnose Risk for dysrhythmias sudden death, tamponade, pericarditis, ventricular aneurysm Myocardial contusion : Myocardial contusion Also may see: myocardial concussion - “stunned” myocardium with no cell death coronary artery laceration Diagnosis by: trans-esophageal echocardiogram serial cardiac enzymes Traumatic aortic rupture : Traumatic aortic rupture 90% or more dead at scene 90% mortality each undiagnosed day Must have high index of suspicion Disruption occurs at ligamentum arteriosum (ductus arteriosus) Contained hematoma of 500 to 1000 ml of blood Methods of Diagnosis : Methods of Diagnosis Arteriogram Helical CT TEE http://radiology.rsnajnls.org/ cgi/content/full/227/2/434 http://www.trauma.org/imagebank/imagebank.html Traumatic aortic rupture : Traumatic aortic rupture Radiographic signs wide mediastinum 1st & 2nd rib fx obliteration of aortic knob tracheal deviation to right depression left mainstem bronchus elevation and right shift mainstem bronchus obliteration “aortic window” deviation of esophagus to right Slide 58: dye leakage Traumatic aortic rupture : Traumatic aortic rupture Treatment - SURGICAL REPAIR Traumatic diaphragmatic rupture : Traumatic diaphragmatic rupture Blunt trauma - tears leading to immediate herniation Penetrating trauma - small tears which may take years to develop herniation Usually on left side Traumatic diaphragmatic rupture : Traumatic diaphragmatic rupture Treatment - surgical repair Ruptured Diaphragm : Ruptured Diaphragm Tracheobronchial tree injury : Tracheobronchial tree injury Larynx - rare hoarseness subcutaneous emphysema palpable crepitus Intubation may be difficult tracheostomy (not cricothyroidotomy) is treatment of choice Tracheobronchial tree injury : Tracheobronchial tree injury Trachea blunt or penetrating esophagus, carotid artery and jugular vein may be involved noisy breathing ? partial airway obstruction Tracheobronchial tree injury : Tracheobronchial tree injury Bronchus rare and lethal usually BLUNT trauma within one inch of carina Esophageal trauma : Esophageal trauma Most commonly penetrating May be lethal if not recognized High suspicion if left pneumothorax and hemothorax without rib fracture shock out of proportion to apparent blunt chest trauma particulate matter in chest tube Esophageal trauma : Esophageal trauma If blunt trauma, linear tear in lower esophagus with leakage of stomach contents into mediastinum 6 Other Frequent Injuries : 6 Other Frequent Injuries Subcutaneous emphysema Traumatic asphyxia Simple pneumothorax Hemothorax Scapula fracture Rib fractures Subcutaneous emphysema : Subcutaneous emphysema “Rice Krispies” May result from airway injury lung injury blast injury No treatment required Traumatic asphyxia : Traumatic asphyxia “Masque ecchymotique” - purple face from extravasation of blood Major damage is to underlying structures Purple face fades over time in survivors Simple pneumothorax : Simple pneumothorax Air enters potential space between visceral and parietal pleura Breath sounds down on affected side Percussion shows hyper-resonance Treatment: chest tube in 4th or 5th intercostal space anterior to mid-axillary line Scapula fractures : Scapula fractures Fractures of scapula or 1st & 2nd ribs may indicate major mechanism of injury Rib fractures : Rib fractures Ribs - most frequently injured part of thoracic cage Most commonly injured - 4th ? 9th If 10th/11th/12th, be suspicious for liver or spleen injuries If 1st/2nd/3rd, worry about injury to head, neck, spinal cord, lungs, and great vessels Rib fractures : Rib fractures Treatment consists of… intercostal blocks epidural anesthesia systemic analgesics Contraindications include… taping rib belts external splints Summary : Summary ABCDE Diagnoses to make in the Primary Survey Simple/Tension Pneumothorax Open Pneumothorax Hemothorax Flail Chest Cardiac Tamponade Stage of Resuscitation Pulmonary contusion Ruptured Diaphragm Ruptured bronchus Summary : Summary Diagnoses to make in the Secondary Survey Blunt Cardiac Injury Blunt Injury to the Aorta Esophageal Injury (rare) INTERESTING X-RAYS : INTERESTING X-RAYS Slide 88: Thank You You do not have the permission to view this presentation. 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