Thoracic Trauma: Blunt and Penetrating Injuries

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Questions and Answers

What percentage of thoracic deaths worldwide are accounted for by thoracic injury?

  • 15-20%
  • 20-25% (correct)
  • 30-35%
  • 25-30%

What type of injury is caused by falls, MVA, acceleration-deceleration injuries, crush injuries, and shearing forces?

  • Penetrating injury
  • Transfixing injury
  • Blunt injury (correct)
  • Deceleration injury

What is a unique feature of the pediatric thorax that helps it absorb forces?

  • More fat
  • More cartilage (correct)
  • More bone
  • More muscles

What is the goal of the initial evaluation in thoracic trauma?

<p>To identify life-threatening injuries (C)</p> Signup and view all the answers

Which of the following is NOT a physiological cause of death in thoracic trauma?

<p>Metabolic alkalosis (D)</p> Signup and view all the answers

What is the primary survey in ATLS?

<p>Airway-breathing-circulation (C)</p> Signup and view all the answers

What is the treatment for flail chest?

<p>Supportive care (A)</p> Signup and view all the answers

What is a common associated injury with sternal fractures?

<p>Myocardial contusion (A)</p> Signup and view all the answers

What is the prevalence of myocardial contusion in autopsy series of patients with blunt cardiac injury?

<p>60-100% (D)</p> Signup and view all the answers

What is the recommended management for myocardial contusion?

<p>ECG and cardiac enzymes monitoring (C)</p> Signup and view all the answers

What is the mortality rate in blunt aortic injuries?

<p>85-95% (C)</p> Signup and view all the answers

What is the typical site of blunt aortic injuries?

<p>Isthmus, near ligamentum arteriosum (A)</p> Signup and view all the answers

What is a radiographic feature associated with thoracic aortic injury?

<p>All of the above (D)</p> Signup and view all the answers

What is a clinical feature of blunt aortic injuries?

<p>Hypotension (C)</p> Signup and view all the answers

What is a management option for blunt aortic injuries?

<p>Both endovascular stents and open surgical procedures (D)</p> Signup and view all the answers

What is the mortality rate in blunt aortic injuries within 6 hours?

<p>30% (D)</p> Signup and view all the answers

What is the most common site of tracheobronchial tree injuries?

<p>Cervical trachea (D)</p> Signup and view all the answers

What is the percentage of patients with tracheobronchial tree injuries that can be missed for years?

<p>&gt;30% (A)</p> Signup and view all the answers

What is the main difference between pulmonary contusion and pulmonary hematoma?

<p>Discrete mass with discrete margins (C)</p> Signup and view all the answers

What is the mortality rate associated with sternal fractures?

<p>10% (C)</p> Signup and view all the answers

What is the main mechanism of tracheobronchial tree injuries?

<p>All of the above (D)</p> Signup and view all the answers

What is the primary investigation for tracheobronchial tree injuries?

<p>CXR (A)</p> Signup and view all the answers

What is the treatment for haemothorax?

<p>ICD for complete evacuation (C)</p> Signup and view all the answers

What is the indication for surgical exploration in haemothorax?

<p>Both A and B (C)</p> Signup and view all the answers

What is the percentage of tracheobronchial tree injuries that reach hospital setting?

<p>2-3% (B)</p> Signup and view all the answers

What is the complication of pulmonary hematoma?

<p>Abscess formation (A)</p> Signup and view all the answers

What is the primary approach for managing tracheobronchial tree injuries based on the location and extension?

<p>Cervical collar incision for proximal trachea, Right postero-lateral thoracotomy for lower trachea, Carina, RMB and proximal LMB (C)</p> Signup and view all the answers

What is the primary management for acute foreign body in the airway?

<p>Urgent bronchoscopy +/- bronchotomy (C)</p> Signup and view all the answers

What is the most common type of esophageal injury?

<p>Cervical esophageal injury (D)</p> Signup and view all the answers

What is the primary diagnostic investigation for esophageal injuries?

<p>Combination of clinical suspicion, CXR, Water soluble contrast swallow and oesophogram, and oesophogoscopy (C)</p> Signup and view all the answers

What is the primary management for esophageal injuries within 24 hours?

<p>Debridement and drainage (D)</p> Signup and view all the answers

What is the primary complication of esophageal injuries?

<p>All of the above (D)</p> Signup and view all the answers

What is the most common type of foreign body in the esophagus?

<p>All of the above (D)</p> Signup and view all the answers

What is the primary diagnostic investigation for diaphragmatic injuries?

<p>All of the above (D)</p> Signup and view all the answers

What is the primary management for cardiac injuries?

<p>All of the above (D)</p> Signup and view all the answers

What is the primary pathology of blunt cardiac injuries?

<p>All of the above (D)</p> Signup and view all the answers

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Study Notes

Thoracic Trauma

  • Thoracic trauma accounts for 20-25% of traumatic deaths worldwide
  • Male and female distributions are equal, with a peak incidence in the 20-30 age group
  • Mechanisms of injury: penetrating, blunt, and transfixing
    • Penetrating: high velocity (gunshot wounds) and low velocity (stab wounds)
    • Blunt: direct (assault and blast), indirect (falls, MVA, crush injuries, and shearing forces)
    • Transfixing

Pediatric and Geriatric Thorax

  • Pediatric thorax: more cartilage, absorbs forces, and has a higher incidence of respiratory failure
  • Geriatric thorax: calcification and osteoporosis, more fractures

Acceleration-Deceleration Injuries

  • Shearing, tearing, and traction forces on structures with varying degrees of fixation
  • Aorta, heart, and esophagus are susceptible to injury

Initial Evaluation

  • Goal: prompt identification of life-threatening injuries
  • Physiological causes of death: tissue hypoxia, hypercarbia, metabolic acidosis
  • ATLS primary survey: airway, breathing, circulation
  • Secondary survey: systematic evaluation with imaging

Traumatic Rib Fractures

  • Sternal fractures: 4%, transverse, in the upper or mid-portions
  • Associated injuries: myocardium, scapula, and clavicle
  • Mortality: 10%

Pleura

  • Traumatic pneumothorax: may be missed initially, erect CXR must exclude during 2nd survey
  • Haemothorax: associated with penetrating or blunt chest trauma with bony injury

Lung Injury

  • Clinical: haemoptysis, pneumothorax, haemothorax
  • Management: severity of injury, ICD, and chest physiotherapy
  • Surgery: suture, wedge resection, pulmonary tractotomy, lobectomy, and pneumonectomy

Pulmonary Contusion

  • Blunt trauma, high-energy impact, and potential lethality
  • Clinical features: subsequent respiratory failure, slow progression
  • Diagnosis: CXR/CT chest
  • Management: supportive, oxygen, analgesia, pulmonary toilet, intubation (significant hypoxia, pre-existing conditions)

Tracheobronchial Tree Injuries

  • Central airways, common after blunt injury, high-energy impact
  • Mechanism: forceful AP compression, high airway pressure, and rapid deceleration injury
  • Site: cervical trachea most common
  • Clinical features: missed in >30% of patients, high suspicion in mediastinal emphysema, subcutaneous emphysema, pneumothorax, and haemoptysis

Esophageal Injuries

  • Rare, blunt trauma, and penetrating (stab or trans-mediastinal gunshot injury)
  • Clinical features: pneumothorax, haemothorax without rib fractures, lower sternum or epigastric pain
  • Investigations: combination of clinical suspicion, CXR, water-soluble contrast swallow, oesophagogram, and oesophagoscopy
  • Management: surgical repair or resection with delayed reconstruction

Diaphragmatic Injuries

  • Often occult, easily missed, and detected on the left
  • Marker of severe thoracoabdominal trauma
  • Clinical features: with or without signs of bowel obstruction, drainage of peritoneal content via chest drain
  • Investigations: CXR, swallow and follow-through, contrast-enhanced CT scan
  • Management: surgical repair = thoracotomy vs. thoraco-abdominal incision vs. laparotomy, laparoscopy

Cardiac Injuries

  • Penetrating and blunt cardiac injuries
  • Pathology: patchy areas of muscle necrosis, hemorrhagic infiltrate, rupture of small vessels
  • Clinical features: cardiac tamponade, arrhythmias, and heart failure
  • Investigations: ECG, cardiac enzymes, formal ECHO/TEE

Surgery

  • Elective or urgent, depending on the severity of injury
  • Myocardial rupture: simple cardiorrhaphy, pledgetted sutured
  • Mitral valve: repair/replacement
  • Tricuspid: repair
  • IVS: traumatic VSD-closure

Great Vessel Injuries

  • Aorta most commonly injured in severe blunt or penetrating trauma
  • 85-95% mortality, typically patients survive the initial injury insult
  • Mechanisms: acceleration-deceleration, shearing forces, and direct luminal compression
  • Site: isthmus, near ligamentum arteriosum
  • Clinical features: death on the scene, rapid exsanguination, expanding thoracic inlet hematoma, bruit, hypotension, pulse deficit

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