chest injuries
DESCRIPTION
A brief review of the management of Chest InjuriesTRANSCRIPT
CHEST INJURIES
AWARENESS
• Mortality: Thoracic injuries are responsible for 25% of trauma deaths (UK)
• Thoracotomy is required in– 10% of blunt injuries– 20% of penetrating injuries
• Early recognition and management are key to patient survival
Mortality1st peak
2nd peak 3rd peak
Tri-modal peak of Mortality
• 1st peak: Non-survivable severe CNS or CVS injuries– Location of death: Pre-hospital environment
• 2nd peak: First few hours after injury, most often due to hypoxia and hypovolemic shock– Large proportion(1/3) of these patients can be
saved by EMS (Emergency Medical Services).• 3rd peak: Within 6 weeks of injury– Cause: Multisystem failure and sepsis
Hence this is referred to as “THE GOLDEN HOUR”
The ATLS concept
• Advanced Trauma Life Support (ATLSTM) by the American College of Surgeons Committee on Trauma
• Originated 1976, Dr. James Styner.
Three Stage Approach
1. Primary Survey: Rapid Assessment and treatment of immediately life threatening injuries
2. Secondary Survey: Detailed head-to toe assessment of potentially life threatening injuries
3. Definitive Care: Specialist treatment of identified injuries
Initial Assessment
A. Airway with cervical spine protectionB. BreathingC. Circulation with haemorrhage controlD. Disability or neurological statusE. Exposure and Environment – remove
clothing, but keep warm
B-Breathing and Chest Injuries
Primary Survey: ARM approach 1. Awareness, 2. Recognition 3. and Management
Recognition (Clinical Features)
Look
Listen
Feel
LOOK– Respiratory rate– Shallow, gasping or laboured breathing: Respiratory
failure?– Cyanosis: Hypoxia– Paradoxical Respiration: ‘Pendulum’ breathing with
asynchronisation of chest and abdomen: Respiratory failure or Structural damage.
– Unequal chest inflation: Pneumothorax or Flail chest– Bruising or contusion: ‘Seat-Belt’ sign.– Penetrating chest injury– Distended neck veins: venous return-Tension
pneumothorax or cardiac tamponade
LISTEN- Absent breath sounds: Apnoea or tension
pneumothorax- Noisy breathing/ Crepitations/ Stridor/ Wheeze:
Partially obstructed airway- Reduced air entry: Pneumothorax, Haemothorax,
Heamo-pnemothorax, flail chest
FEEL- Tracheal devitation: Mediastinal shift- Tenderness: Chest wall contusion and/ rib #- Crepitus/Instabilty: Underlying rib #- Surgical emphysema: ‘Bubble-wrap’ sign
Immediately Life-Threatening Chest Injuries (Primary Survey)
1. Tension Pneumothorax
2. Open Pneumothorax (sucking chest wound)
3. Massive Haemothorax
4. Cardiac Tamponade
5. Flail Chest
6. Disruption of Tracheo-Brochial tree
Potentially Life-Threatening Chest Injuries (Secondary Survey)
1. Pulmonary contusion
2. Myocardial contusion
3. Aortic disruption
4. Diaphragmatic rupture
5. Tracheobronchial rupture
6. Oesophageal rupture
Adjuncts
1. Vital signs2. ECG3. Pulse oximetry4. End-Tidal Carbon Dioxide5. Arterial Blood Gas6. Urinary output7. Urethral Catheterization8. Nasogastric tube9. Chest X-Ray10.Pelvic X-Ray
Rib fracture
Introduction
• 1st and 2nd ribs , protected by clavicle: when fractured are very ominous as they indicate transection of thoracic aorta or damage to brachial plexus or subclavian vein
• 11th and 12th ribs are floating ribs, usually not fractured
• Ribs in children are more elastic thus great force needed
Types of trauma• Closed injury to the chest Direct trauma• Single or multiple ribs fractured at the point of contact
Crush injury• Usually causes flail chest due to multiple sites of fracture of
ribs Steering wheel injury• In head on car accidents where fracture of sternum and
bilateral fractures of ribs at costochondral junction Minor trauma• In osteoporotic ribs, sometimes even a cough can cause a
rib fracture
Clinical features
• In rib fracture without complication: Pain while taking a deep breath and exaggerated pain during coughing
• Inspection: Bruising• Palpation: Bony irregularity, Tenderness and Crepitus • X-ray usually shows a fracture rib but may miss a hairline
fracture• Radioscintigraphy: Detected a week or two after injury• Always rule out the presence of complications and
monitor the patient before diagnosing an isolated rib #
Treatment of uncomplicated rib fracture
• Reduction of pain with 2 week follow up• Analgesics : – Opiods– NSAID’s
• Intercostal Blocks• Strapping of chest: relieves pain by immobilizing the ribs• Breathing exercises
• Strapping Disadvantages: decreases respiratory movement (elderly) force broken ends inwards (if applied during expiration) Strapping should include two ribs above and below the
affected area and should cross midline Elastic corset can be used Local strapping
Surgical treatment
• Previously
PENETRATING TRAUMA
Causes
• High speed projectiles like gunshot• Splinters from blasts• Stab injury
Consequences
• Pneumothorax• Hemothorax• Trauma to the heart and great vessels• Pericardial tamponade• Oesophagial injury• Pulmonary contusion• Lung laceration• Rupture of the diaphragm
Consequences
Indications for thoracotomy1. Internal cardiac massage2. Control of haemorrhage from injury to the heart3. Control of haemorrhage from injury to the
lungs/intrapleural haemorrhage4. Cardiac tamponade5. Ruptured oesophagus6. Aortic transection7. Control of massive air leak8. Traumatic diaphragmatic tear
• Thoracotomy can be Emergency:-for control of life threatening
bleeding Planned:-for repair of specific injury
• Approaches:Left anterolateralRight anterolateralMedian sternotomy
FLAIL CHEST
Definition: “A flail chest segment is formed when two or more consecutive ribs, with each rib being fractured at two or more sites”
Stove-in-chest: “Depression of a portion of the chest wall due to severe chest injury, which contributes to forming a flail segment.”
Significance
• The real significance of the detection of paradoxical movement lies in the fact that the severity of trauma necessary to produce a flail segment has implications with respect to damage of underlying intrathoracic structures (Trinkle et al., 1975).
Pathophysiology
1. Paradoxical Respiration2. Mediastinal Flutter3. Pendular Movement of air4. Associated injuries: Pulmonary Contusion!5. Hypoventilation
• The early mortality attributable to the flail chest syndrome is due to – Massive haemothorax and Pulmonary contusion,
• Whereas late mortality is largely due to – Adult respiratory distress syndrome (ARDS) and
associated infection.
Tsai et al., 1999
Complications
Adjuncts
1. Vital signs2. Chest X-Ray3. ECG4. Pulse oximetry5. End-Tidal Carbon Dioxide6. Arterial Blood Gas7. Urinary output8. Urethral Catheterization9. Nasogastric tube10.Pelvic X-Ray
Management
Ranasinghe A, Trauma 2001; 3: 235–247
Stabilization of the flail segment by the application of a sandbag or by extensive strapping is
contraindicated in the hospital environment as this leads to restriction of thoracic wall movement
Myllynen et al., 1983
Indications for Ventilation
Ranasinghe A, Trauma 2001; 3: 235–247
Trinkle’s Regime
Ranasinghe A, Trauma 2001; 3: 235–247
Surgical Intervention
• Internal fixation of flail segment
• Indication: Patients suffering from pulmonary contusion with progressive thoracic cage collapse during weaning from the ventilator after resolution of the pulmonary contusion.