Chest Trauma PDF

Chest Trauma  INTRODUCTION Responsible directly for 25% of mortality from RTAs. Contributes to mortality in another 25% Most injuries do not require operative intervention for successful management Injury recognition and basic trauma skills save majority of salvageable...

Chest Trauma  INTRODUCTION Responsible directly for 25% of mortality from RTAs. Contributes to mortality in another 25% Most injuries do not require operative intervention for successful management Injury recognition and basic trauma skills save majority of salvageable patients  MECHANISM OF INJURY Blunt or Penetrating Different pathophysiologies Different clinical courses Blunt injuries tend to be managed conservatively Penetrating injuries more likely to require operative intervention 80-90% of chest injuries do not require operative intervention  INITIAL EVALUATION Hypoxia and hypoventilation are the primary killers of acute trauma patients Life-threatening injuries should be identified and treated immediately. Injuries may develop over time, and become life-threatening during the course of resuscitation. Re-assessment and evaluation is therefore extremely important, especially if the patient's condition deteriorates.  EVALUATION PLAN Primary survey – Identify and treat immediately life-threatening conditions Secondary survey – Identify all injuries and plan further investigation and treatment Re-assess especially if condition deteriorates or patient fails to improve  PHYSICAL EXAMINATION This is the primary tool for diagnosis of acute thoracic trauma. An adequate exam may be difficult in the ER – noise, uncooperative patient. Signs of significant thoracic injury may be subtle or even absent. An initial normal examination does not exclude thoracic injury or any other injury.  THE DEADLY DOZEN –THE LETHAL SIX –THE HIDDEN SIX  THE LETHAL SIX Airway Obstruction Tension Pneumothorax Open Pneumothorax Massive Haemothorax Flail Chest Cardiac Tamponade  THE HIDDEN SIX Pulmonary Contusion Myocardial Contusion Tracheobronchial Injuries Esophageal Perforation/Rupture Aortic Injury/Rupture Diaphragmatic Rupture THE LETHAL SIX  UPPER AIRWAY OBSTRUCTION Obstruction from the nose/mouth to the tracheal bifurcation CAUSES – Tongue falling back – Oral foreign bodies – debris, teeth, dentures – Laryngeal/Tracheal injury – Facial trauma (mandibular or maxillary fractures) – Haematoma  DIAGNOSIS OF UPPER AIRWAY OBSTRUCTION In a conscious patient: – Marked respiratory distress + stridor – Altered voice – Anxious and combative – Absent/Reduced air entry – Tachycardia (bradycardia + CV collapse occur late) In an unconscious patient: – Inability to ventilate with a bag-mask device  MANAGING THE OBSTRUCTED AIRWAY SUPPLEMENTAL OXYGEN – Nasal prongs, face mask, etc OPEN THE AIRWAY – Head tilt, chin lift, manual evacuation, suction MAINTAIN THE OPEN AIRWAY – Oropharyngeal/nasopharyngeal airway, laryngeal mask, endotracheal intubation  TENSION PNEUMOTHORAX Air under progressively increasing positive pressure in the pleural space Air-leak + ‘One-way-valve’ effect May develop insidiously It is a clinical diagnosis  DIAGNOSIS OF TENSION PNEUMOTHORAX Progressive respiratory distress Chest moves little with respiration. Raised JVP/distended neck veins Tracheal deviation away from lesion Increased percussion note Diminished or absent breath sounds TENSION PNEUMOTHORAX  MANAGEMENT OF TENSION PNEUMOTHORAX –Needle thoracostomy Large bore needle 2nd space, MCL + –Chest tube thoracostomy  OPEN PNEUMOTHORAX A pneumothorax associated with a through-and-through chest wall defect. The pneumothorax communicates with the exterior. SUCKING CHEST WOUND  TREATMENT OF OPEN PNEUMOTHORAX Place an occlusive dressing over the wound Place an intercostal chest drain. Oxygen supplementation Surgically close the defect  MASSIVE HAEMOTHORAX Accumulation of > 1.5litres of blood in the pleural cavity Patients usually in shock esp. if blood loss is rapid. May require surgical intervention MASSIVE HAEMOTHORAX Massive haemothorax Hypotension and tachycardia Ipsilateral lung collapse There may be mediastinal shift  TREATMENT OF MASSIVE HAEMOTHORAX ABC’s with spine control Replace blood loss (large peripheral cannula #14, #16 in adults) Chest tube thoracostomy – evacuates pleural space & monitors bleeding Control bleeder(s) if haemorrhage continues – requires surgery FLAIL CHEST f The fracture of 4 or more ribs in 2 or more places or the equivalent of bilateral costochondral #s  FLAIL CHEST Respiratory distress often extreme Paradoxical chest wall motion – “see-saw respiratory movements” Lung contusion is a frequent accompaniment Signs of respiratory insufficiency Pendelluft Mediastinal flutter  MANAGEMENT OF FLAIL CHEST Pulmonary Contusion Associated Haemopneumothorax Respiratory insufficiency Paradoxical breathing Management of other associated injuries  PULMONARY CONTUSION – Adequate pain control – Face mask oxygen – Fluid restriction ± diuretics – Manage airway secretions: chest physio, mucolytics – Antibiotics  ASSOCIATED HAEMOPNEUMOTHORAX – Chest tube thoracostomy RESPIRATORY INSUFFICIENCY – Mechanical ventilation PARADOXICAL BREATHING – Bulky dressing to flail segment – Internal pneumatic stabilization – Operative fixation?? BULKY DRESSING FOR SPLINT OF FLAIL CHEST Do not strangulate the chest!  CARDIAC TAMPONADE Requires only 150-200ml haemopericardium to attain significance The classic signs of distended neck veins and muffled heart sounds are almost universally absent Needle pericardiocentesis may be falsely negative (clotted haemopericardium)  DIAGNOSIS OF TRAUMATIC CARDIAC TAMPONADE High index of suspicion: – Hypotension out of proportion to estimated blood loss – Hypotension in spite of adequate volume status – Persistent hypotension with elevated venous pressure after fluid administration Echocardiogram if available MANAGEMENT OF TAMPONADE OPTIMIZATION – Fluid resuscitation – Pericardiocentesis (even 25-50ml is beneficial) – Transfer to appropriate facility OPTIONS FOR PERICARDIAL EVACUATION – Pericardiocentesis – Sub-xiphoid pericardial window – Exploration via sternotomy or thoracotomy SUB-XIPHOID PERICARDIAL WINDOW THE HIDDEN SIX  DIAPHRAGMATIC RUPTURE Frequent in thoracoabdominal trauma – Blunt trauma – Stab wounds – Gunshot wounds May be no immediate herniation of abdominal contents  DIAPHRAGMATIC RUPTURE No distinctive signs / symptoms seen Associated injuries are common May be asymptomatic SOL in chest Respiratory distress Bowel sounds in lower chest Mediastinal shift Shoulder tip pain occasionally CXR most helpful modality LEFT SIDED TEARS “Elevated hemidiaphragm” Obscuration of hemidiaphragm Extraneous shadows Air-fluid levels in hemithorax Mediastinal shift NG tube in chest NG TUBE Liver is “protective” on right side “Elevated hemidiaphragm” Mushroom hump over rt. hemidiaphragm Features similar to lt. sided tears  Treatment of Diaphragmatic Rupture Treatment is surgical no matter how small the perforation Surgery is on semi-urgent basis Nasogastric decompression Hemodynamic stabilization Approach – Left: thoracotomy or laparotomy – Right: thoracotomy + separate laparotomy to deal with intra-abdominal injury  PULMONARY CONTUSION Damage to lung parenchyma from compression -deccompression injury Pathology – edema, hemorrhage, patchy atelectasis Frequently progressive leading to respiratory insufficiency Mortality ranges from 14-40% PULMONARY CONTUSION EFFECTS - Poor gas exchange - Increased pulmonary vascular resistance - Decreased lung compliance ULTIMATELY PROGRESSES TO RESPIRATORY FAILURE  DIAGNOSIS OF PULMONARY CONTUSION – Clinical findings may be lacking initially (dyspnea, hemoptysis, crackles) – Blood gases worsen 2-3 days as edema increases – CXR changes may lag 12 - 48hrs behind – CXR may underestimate the true extent  TREATMENT OF PULMONARY CONTUSION Mostly supportive – resolution by 5-8 days Supplemental oxygen Pain control Fluid restriction ± diuretics Intubation and mechanical ventilation when indicated Management of secretions Antibiotics  MYOCARDIAL CONTUSION Physical bruising of the cardiac muscle Usually associated with fractures of the sternum Any severe anterior chest injury  DIAGNOSIS OF MYOCARDIAL CONTUSION Tachycardia Ectopic beats ST elevation Pump failure Enzymes may be normal  TREATMENT OF MYOCARDIAL CONTUSION Monitor Treat dysrhythmias* Analgesia Inotropic support  TRAUMATIC AORTIC RUPTURE Often rapidly fatal Only 10% survive to hospital Only 20% survive > 1 hour 90% who reach hospital will die EARLY DX and aggressive tx best chance  Aortic Rupture - Diagnosis – Widened mediastinum on CXR (>8cm) – 40% normalizes with sitting up – Blurring of aortic knob  Aortic Rupture - Treatment Contained injury => BP control Operative repair  TRACHEOBRONCHIAL DISRUPTION Most occur within 2.5cm of the carina Many affected patients have no other serious injury Tracheal tears occur at junction of membranous and cartilaginous trachea Bronchial tears are usually transverse, complete or incomplete  DIAGNOSIS OF TRACHEOBRONCHIAL TEARS TYPE 1 TYPE 2 Large pneumothorax Small or absent Profuse bubbling pneumothorax from intercostal drain Lung re-expands Failure of lung promptly after expansion even under intercostal drain suction Delayed but persistent Dyspnea, hemoptysis, atelectasis after 2 subcutaneous and -3weeks mediastinal emphysema TREATMENT OF TRACHEOBRONCHIAL TEARS Bronchoscopy on suspicion to delineate lesion Chest tube insertion to facilitate lung expansion Surgery to reconstruct tracheobronchial tree  ESOPHAGEAL INJURIES Most due to penetrating trauma Blunt trauma is rare Diagnosis often delayed: sepsis and high mortality Contrast studies Esophagoscopy Treatment – Expectant – Primary repair < 24hrs – Diversions + Gastrostomy after 24hrs