2.Thoracic Trauma .pdf

Thoracic Trauma Dr. Bashar Hanna Azar ® Consultant Thoracic and Cardiovascular Surgery ® Objectives Identify and initiate Treatment of the following injuries during the primary survey: 1-Airway obstruction 2-Tension pneumothorax 3- Open pneumothorax 4- Flail chest and pulmonary contusion 5- Mas...

Thoracic Trauma Dr. Bashar Hanna Azar ® Consultant Thoracic and Cardiovascular Surgery ® Objectives Identify and initiate Treatment of the following injuries during the primary survey: 1-Airway obstruction 2-Tension pneumothorax 3- Open pneumothorax 4- Flail chest and pulmonary contusion 5- Massive hemothorax 6- Cardiac tamponade Objectives Identify and initiate treatment of the following potentially life- threatening injuries during the secondary survey: 1- Simple pneumothorax 2- Hemothorax 3- Pulmonary contusion 4- Tracheobronchial tree injury 5- Blunt cardiac injury 6- Traumatic aortic disruption 7- Traumatic diaphragmatic injury 8- Blunt esophageal rupture Objectives Describe the significance and treatment of subcutaneous emphysema, thoracic crush injuries, and sternal, rib, and clavicular fractures. Introduction What life-threatening injuries should I recognize as causing major pathophysiologic events? - Thoracic trauma is significant cause of mortality - - lest than 10% of blunt chest injuries and only 15% to - 30% of penetrating chest injuries require thoracotomy. - hypoxia, hypercarbia, and acidosis - - hypovolemia ( blood loss) - - primary survey– resuscitation of vital functions - - secondary survey – and definitive care -  Primary survey: Life-threatening injuries What are the significant pathophysiologic effects of chest injuries that I should identify in the primary survey, and when and how do I correct them? Major problems should be corrected as they are identified. Airway - Major injuries - - airway patency and air exchange - - nose, mouth and lung fields - - laryngeal injuries - - injuries to the upper chest can create a palpable defect - - stridor - - if the patient is able to talk - Breathing - Chest and neck should be completely exposed- - - increase in the respiratory rate and change in the - breathing pattern Normal RR ( 12 -20 or 24) - cyanosis - - sucking chest wound Open - pneumothorax - flail chest - - pulmonary contusion - - massive hemothorax - https://youtu.be/5QiQj8cBsAA Pitfall After intubation, one of the common reason for loss of breath sounds in the left thorax is the right main-stem intubation. During the reassessment be sure to check the position of the endotracheal tube before assuming that the change in physical examination results is due to a pneumothorax or hemothorax. Tension pneumothorax Is a clinical diagnosis reflecting air under pressure in the pleural space. Treatment should not be delayed to wait for radiologic confirmation. Immediate decompression by inserting a large caliber needle into the second intercostal space in the midclavicular line of the affected hemithorax. Open pneumothorax ( sucking chest wound) - Promptly closing the defect with a sterile occlusive dressing. - A chest tube remote from the wound should be placed as soon as possible. Flail chest and pulmonary contusion - Multiple rib fractures, two or more ribs fractured in two or more place - Serious hypoxia may result - Arterial blood gas analysis - Adequate ventilation, administration of humidified oxygen, and fluid resuscitation. - Analgesia – intravenous narcotics - Short period of intubation and ventilation may be necessary Massive hemothorax Pitfall: Both tension pneumothorax and massive hemothorax are associated with decrease breath sounds on auscultation. Differeentiation on physical examination is made by percussion, hyperresonance confirms a pneumothorax, whereas dullness confirms a massive hemothorax. Circulation Patient pulse - blood pressure - neck veins should be assessed - cardiac monitor and pulse oximeter - dysrythmias Massive hemothorax - blood loss more than1500ml - blood loss is complicated by hypoxia - manage by: simultaneous restoration of blood volume and decompression of chest cavity - a single chest tube (38FG) is inserted usually at the nipple level, just anterior to the midaxillary line, and rapid restoration of volume continues as decompression of chest cavity is completed. Thoracotomy is not indicated unless a surgeon, qualified by training and experience, is present. Cardiac tamponade Becks triad: --venous pressure elevation --Decline in arterial pressure --Muffled heart tones Diagnostic methods include: Echocardiogram Focused assessment sonogram in trauma (FAST) Pericardial window If surgical intervention is not available, pericardiocentesis can be diagnostic as well as therapeutic, but is not definitive treatment of cardiac tamponade Resuscitive thoracotomy A qualified surgeon must be present at the time of patient arrival to determine the need and potential for success of a resuscitive thoracotomy in the ED; Evacuation of pericardial blood causing tamponade Direct control of exsanguinating intrathoracic hemorrhage Open cardiac massage Cross-clamping of the ascending aorta to slow the blood loss below the diaphragm and increase perfusion to the brain and heart. Secondary survey: potentially life-threatening chest injuries What adjunctive tests are used during the secondary survey to allow complete evaluation for potentially life- threatening thoracic injuries? Lethal injuries: Simple pneumothorax Any pneumothorax is best treated with a - chest tube placed in the fourth or fifth intercostal space , just anterior to the midaxillary line.Observation and aspiration of an asymptomatic pneumothorax may be appropriate, but the choice should be made by a qualified doctor, otherwise, placement of a chest tube should be performed. Pitfall: - A simple pneumothorax in a trauma patient - should not be ignored or overlooked, it may progress to a tension pneumothorax hemothorax Best treated by a large caliber chest tube ( =>36FG) - Pitfall: - A simple hemothrax, not fully evacuated, may result in a - retained , clotted hemothorax with lung entrapment or, if infected, develop into an empyema. Pulmonary contusion Patient with significant hypoxia, PaO2< 65, may require - an intubation and ventilation within the first hour after the injury. - pulse oximetry monitoring, ABG determination, ECG - monitoring, and appropriate ventilator equipment are necessary for optimal treatment. Tracheobronchial tree injury Hemoptysis - Subcutaneous emphysema - Tension pneumothorax with a mediastinal shift. - Blunt cardiac injury - - hypotension, dysrhythmias, or wall motion abnormality - on Echo - the presence of cardiac troponins may be diagnostic of - MI.  Traumatic aortic dysruption Common cause of sudden death - signs - --widened mediastinum - -- obliteration of the aortic knob - -- diviation of the trachea to the right - -- depression of the left mainstem bronchus - -- elevation of the right mainstem bronchus - --obliteration of the space between the pulmonary artery and the aorta - -- deviation of the esophagus to the right - -- widened paratracheal stripe - -- widened paraspinal interfaces - -- presence of pleural or apical cap - -- left hemothorax - -- fracture of the first or second rib or scapula - Helical contrast- enhanced computed tomography (CT) The treatment is either primary repair o resection of the torn segment and replacement with an interposition graft. Traumatic diaphragmatic injury Commonly left side , perhaps because the liver obliterates the defect or protects it on the right side of the diaphragm. Diaphragmatic injuries are frequently missed initially. Blunt Esophageal Rupture Most commonly penetrating in nature. Esophageal injuries should be considered in any patient who: - Has a left pneumothorax or hemothorax without a rib - fracture. - has received a severe blow to the lower sternum or - epigastrium and is in pain and shock out of proportion to the apparent injury, - has particulate matter in the chest tube after the blood - begins to clear. - mediastinal air - Other manifestatios of chest injuries - Subcutaneous emphysema - - crushing injuries to the chest - - rib, sternum, and scapular fractures - Pitfall: - Underestimating the severe pathophysiology of rib - fractures is a common pitfall, particularly in patients at the extremes of age, aggressive pain control without respiratory depression is the key management principle.