Thoracic Trauma

Thoracic Trauma

• Thoracic trauma accounts for over 70% of deaths after RTAs.
• Blunt chest trauma alone has a fatality rate of 10%, increasing to 30% if other injuries are present.
• Penetrating wounds show mortality rates from 3% for simple stabbings to 15% for gunshot wounds.
• Chest trauma involves blunt or penetrating injuries.
• The proper emergency care and resuscitation are vital

Blunt Thoracic Trauma

• Blunt thoracic trauma can result in:
  • Chest Wall Injuries
  • Pulmonary Injuries
  • Tracheal/Bronchial Injuries
  • Cardiac/Great Vessel Injuries
  • Diaphragm Rupture

Chest Wall Injuries

• Rib fracture is the most common thoracic injury.
• Flail chest is another common problem
• Intrathoracic injuries are possible without rib fractures in children due to rib cage elasticity.
• Pain management for simple rib fractures involves narcotics and intercostal nerve blocks.
• Tracheostomy may be necessary for prolonged intubation to reduce laryngeal injury and aid pulmonary care.
• First rib fractures indicate significant force; aortography is needed if there is brachial plexus deficit, absent radial pulse, pulsating supraclavicular mass, or a widened mediastinum.

Pulmonary Contusion

• Pulmonary contusion can be potentially lethal.
• It stands as the most common type of chest injury in the US.
• Interstitial and intra-alveolar hemorrhage can occur.
• Pulmonary compliance and gas exchange decrease.
• Increased secretions and hemoptysis are symptoms.
• It may progress to respiratory failure
• Hazy opacity appears on a Chest x-ray
• Treatment includes ventilation and O2, a central line and restricted fluids
• Watch out for development of ARDS

Rib Fractures

• Rib fractures are the second most common chest injury.
• It can result from blunt trauma.
• It causes Pneumothorax.
• Physiologic splinting reduces ventilation.
• Adequate pain relief is necessary to improve ventilation.
• Uncomplicated fractures are usually not splinted
• Rib belts should not be used, because they decrease expansion

Flail Chest

• Flail chest is one of the most critical injuries.
• It has a 40% mortality rate.
• It can be a result of direct blunt trauma.
• It may consequently lead to hemothorax.

Paradoxical Respiration

• Paradoxical respiration includes inward chest movement during inspiration.
• Outward movement occurs during expiration.
• This usually impacts only one side of the chest.
• It happens when a loose segment of the chest wall is left because of fractures of two or more adjacent ribs.
• Movement of this segment becomes paradoxica.

Flail Chest Assessment

• Assessment of flail chest may include:
  • Paradoxical Chest Movement
  • Dyspnea
  • Cyanosis
  • Tachycardia
  • Hypotension
  • Shallow respirations
  • Tachypnea
  • Chest pain
  • Diminished Breath Sounds

Flail Chest Interventions

• Flial chest interventions includes
  • Humidified Oxygen
  • Pain management
  • Promote lung expansion with deep breathing
  • Secretion clearance by cough & suction
  • Bedrest, limit activity
  • Preparation for intubation/ventilation

Pneumothorax

• Pneumothorax is a thoracic injury which allows atmospheric air to enter pleural space
• It is a Rise in intrathoracic pressure and reduced vital capacity
• Diagnosed by chest x-ray

Pneumothorax Types

• Open pneumothorax is an opening through the chest wall.
• Tension pneumothorax can derive from blunt trauma or mechanical ventilation with PEEP.
• It is a buildup of positive pressure in the pleural space with tracheal deviation on the unaffected side, chest tubes, or central line/line insertion.
• Spontaneous pneumothorax is the rupture of a bleb, which is the accumulation of fluid under the skin.

Open Pneumothorax

• Open pneumothorax means air moves in and out, with no shift.

Tension Pneumothorax

• Tension pneumothorax indicates air only moves in.
• The pressure pushes toward the unaffected side, creating a mediastinal shift.

Pneumothorax Assessment

• Symptoms of pneumothorax include; diminished breath sounds on auscultation
  • Hyperresonance on percussion
  • Decreased chest expansion unilaterally
  • Dyspnea and/or cyanosis.
  • Tachycardia and Tachypnea (shift of PMI)
  • Hypotension
  • Subcutaneous emphysema
  • Sucking sound with open wound

Pneumothorax Interventions

• Interventions of Pneumothorax include:
  • Pressure dressing to open wound
  • Oxygen
  • Prepare for chest tube insertion
  • Monitor chest tube with water seal until fully expanded
  • Monitor for subcutaneous emphysema (crepitus)

Rib fractures & Flail Chest

• The most significant sign of flail chest is the potential presence of pulmonary contusion.
• Diagnosis involves physical examination, looking for bruising or seat-belt signs, and palpation to reveal crepitus.

Tension Pneumothorax

• Tension pneumothorax extends behind the liver

Hemothorax Definition

• Simple hemothorax = blood loss of under 1500ml into the thoracic cavity.
• Massive hemothorax = blood loss of over 1500 ml.
• It is due to blunt trauma or penetrating injury.
• It relates to pulmonary contusions or lacerations or rib fractures.

Hemothorax Assessment

• There may be no indications.
• Respiratory problems can develop
• Diminished sounds
• Dull on percussion
• This condition requires that blood in the pleural space is confirmed by Chest x-ray

Hemothorax Interventions

• Chest tubes are used to evacuate blood.
• Careful monitoring of drainage is needed..
• Thoracotomy is possible if drainage exceeds >1500 ml initially or persistent bleeding is more than 200ml over 3 hours.
• Frequent vital signs, Intake and Output check
• Patient response evalutation is needed
• IV fluids, blood/reinfusion of drainage (after filtering).

Chest Tube Insertion Site

• It must be in the mid- or anterior- axillary line, behind the pectoralis major
• Place it above the 5th rib (to prevent diaphragm injury).

Chest Tube Insertion, procedure

• Use local anaesthetic
• Scrub, and drape.
• Create an incision along the upper border of the rib.
• Creating a blunt dissection with a curved clamp to split the fibres.
• A track developed with the operator's finger.
• Angle the clamp over the rib, proceed dissection continued until pleura is entered.
• Pass a chest tube through to the pleural cavity using a large bore tube, 32F or 36F.
• Tube is connected to an underwater seal, sutured/secured in place with a U-stitch.
• Confirmation of placement by chest X-ray.

Cardiac/Great Vessel Injuries

• Myocardial contusion is most common one and is suspected with ECG changes and serial enzyme elevations
• Coronary artery injury can result in thrombosis or myocardial infarction
• Atrial or ventricular rupture is usually fatal, the pericardium may restrict bleeding enough for survival to the ER

Cardiac/Great Vessel Injuries

• The patient should be monitored in ICU, and may require heparin for coronary thrombosis and anti-arrhythmic therapy.
• Echo and angiography are indicated for tamponade and post-injury murmurs, which suggest valvular insufficiency or septal defect.
• Aortic rupture is often fatal, but can result in formation of a false aneurysm, typically at the aortic isthmus.

Cardiac/Great Vessel Injuries

• Pt. is the case where a widened mediastinum on CXR must have prompt aortography, which will demonstrate an intimal tear
• If Surgical repair is required it should be done promptly, because fatal hemorrhage can occur any time
• Techniques include LA-FA bypass, proximal aorta-distal aorta shunting, and cross-clamping without cardiopulmonary bypass

Diaphragm Rupture

• Most lacerations occur on the left hemidiaphragm and can be a result of automobile accidents
• Frequently, stomach herniates and develops volvulus, heavily dilates, resulting left lung collapse and mediastinal shift towards right
• Gastric distension should be prevented by NG tube placement Diaphragm Rupture
• Diaphragm Rupture doesn't occur in isolation, associate it with thoracic aorta, liver&spleen with pelvic injury
• 35% of patients are initially normal
• Repairs can be made through the chest or abdomen, close all tears in a dual layer fashion

Cardiac/Great Vessel Injuries Percentages

• The right ventricle is commonly injured (43%)
• The left ventricle (34%)
• Right (16%)
• and left atrium(7%).
• Ventricular septal defect is the most commonly found injury

Cardiac/Great Vessel Injuries Findings

• Most patients cannot make it to the hospital with the injury in the pericardium leads to exsanguination.
• Patients with Hypotension that does not respond to replacement should suggest injury.
• CXR, ECG and echocardiography do not hold much use for patients.
• A needle inserted in the heart Subxiphoid pericardiocentesis is utilized for diagnosis; negative deflection of the QRS complex should create a drain.

Cardiac/Great Vessel Injuries Intervention

• Subxiphoid pericardial window should be the tamponade
• EDT is suggested to use only for patients that risk of rapid decline
• Median sternotomy is the recommended approach
• Repair of ventricular lacerations with pledgetted horizontal mattress sutures

Initial Management in Thoracic Trauma

• Establish ABCs
• Assess the airway and establish adequate ventilation
• Maintain O2 Saturation at >94%
• Keep sys. BP at a minimum of 110 mmHg
• Obtain IV Access
• Indications for endotracheal intubation are - Apnea - RR > 30 - Profound Shock - Inadequate ventilation with a PaO2 <60 or PaCO2 >

Indications of a Thoracotomy

• Acute indications
• Cardiac tamponade
• Acute hemodynamic deterioration or for an arrest
• Vascular injury at the thoracic outlet
• Loss of substance
• A significant tracheal or bronchial injury

Emergency Thoracotomy

• Goals of this procedure are: -Release pericardial tamponade -Control cardiac or great vessel bleeding -Control Hiliar Bleeding -Perform Open Cardiac Massage -Redistribute blood to myocardium -Limit sub-diaphragmatic hemorrhage