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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