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Chest Trauma

Dr Csaba Dioszeghy MD PhD FRCEM FFICM FERC

East Surrey Hospital Emergency Department

Scope• Thoracic injuries are common and can be life threatening

• In ESH we usually see blunt chest trauma but penetrating injuries also treated here (usually as single injuries, like stab wound)

• Most acutely life threatening injuries are usually identified and dealt with during the primary survey – often needs relatively simple intervention to save the life

• Blunt chest trauma can be deceptive: severe injuries with grave consequences might be missed unless specifically looked for

• Approximately 12 / million population per day (US)

• 20-25% of trauma related death

Fatal outcome often occurs early: 30 min – 3 hrs

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Life threatening injuries• Airway obstruction

Direct laryngo-tracheal or trachea-bronchial injury

External compression due to soft tissue swelling/haematoma

• Tension or open pneumothorax

Respiratory failure (open)

Respiratory and circulatory failure (tension)

• Flail chest

Respiratory failure

• Massive haemothorax

Circulatory and respiratory failure

• Cardiac tamponade

Circulatory failure

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Life threatening injuries• Airway obstruction

Direct laryngo-tracheal or tracheo-bronchial injury

External compression due to soft tissue swelling/haematoma

• Tension or open pneumothorax

Respiratory failure (open)

Respiratory and circulatory failure (tension)

• Flail chest

Respiratory failure

• Massive haemothorax

Circulatory and respiratory failure

• Cardiac tamponade

Circulatory failure

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Airway• Look: bruise, injuries, surgical emphysema

• Listen: stridor, hoarseness

• Feel: Surgical emphysema, tracheal deviation

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Airway• Look: bruise, injuries, surgical emphysema

• Listen: stridor, hoarseness

• Feel: Surgical emphysema, tracheal deviation

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CD1

Slide 6

CD1 Csaba Dioszeghy, 16/11/2016

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Tension pneumothorax• Clinical diagnosis (challenge)

• Respiratory distress

• Asymmetrical chest movement

• Distended neck veins, tracheal deviation

• Absent breath sounds, hyper-resonance

• Clinical signs are different and more rapid in the ventilated patient leading to circulatory collapse

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EMJ 2005; 22:8-16

Clinical diagnosis ? DDX:Haemothorax

Flail chestRib fractures

Sternal fracturePrev.chest / lung disease 8

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RADIOLOGYIs this a clinical failure to have these images taken?

What is the specificity and sensitivity of radiology for TPT?

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Ultrasound

Better clinical sensitivity than supine chest X-Ray

Easy, fast and safe method but needs trained operator

LUNG SLIDING

NO LUNG SLIDING

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TPTX: decompression (1/2)• Needle decompression

Needs long enough needle! 1/3 of trauma patients have chest wall > 5 cm.

38% unsuccessful (Barton, 1995) needs finger thoracostomy

Re-tension

2nd ICS Midclavicular line

Most likely to reach the air

Longer needle might be needed

Mamillar artery, intercostal aretry

4th or 5th ICS Mid-axillary line (ATLS)

Less fat – shorter needle might be enough

Increased risk of lung damage

Intercostal artery

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TPTX: decompression (2/2)• Finger or tube thoracostomy

Needle decompression is often unsuccessful

Safe and effective, even in pre-hospital care

1% complication on insertion

Less likely to develop re-tension

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Open PTX• Usually obvious clinical signs

• Ventilation is ineffective

• Occlusive dressing (first aid)

• Chest tube

Inserted different site

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Passive suction (underwater)

The level of suction2-5 cm

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Passive suction (underwater)

The level of suction2-5 cm

NEVER EVER CLAMP A BUBLING CHEST DRAIN.SERIOUSLY. NEVER EVER.

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Suction and drain for haemo-PTX

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BLOODcollected

WATER(safety)Suction pressure will not

exceed the wcm set here (A)WATER

This is the negative pressure (B) set in wcm for the chest

A

-A

B

-A-B

Atm Suction (any)Suction (-A-B wcm)

-A

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Flail chest• Three or more adjacent ribs fractured in two places creating a floating segment

• Multiple broken ribs lots of pain

• Destroy chest mechanism respiratory failure

Clinical signs:

• Distress +++

• Pain +++

• Paradox chest wall movement

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Flail chest: management• Analgesia (thoracic epidural) and chest physiotherapy

• Evaluate and monitor ventilation regularly (pCO2)

• Might need RSI and ventilation

• Surgical fixation might be considered

Not enough good quality evidence…

Always look for further injuries:

• Lung contusion

• Pneumothorax

• Haemothorax

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Massive haemothorax

• Massive amount of blood loss (>1500ml)

• Circulatory failure

• Ventilation mechanics respiratory distress

• No breathing sound

• Dull percussion

Management:

• Chest drain (large calibre)

• Massive Haemorrhage Protocol as required

• If blood loss is ≥ 20 ml/kg /24 hr or 200 ml/hr for successive hours Thoracotomy or video assisted thoracoscopic surgery (VATS)

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Cardiac tamponade• Haemodynaimc collapse

• Distended neck veins

• ECG signs

• FAST Scan

Management

• Pericardiocentesis is useless

• EMERGENCY SURGERY

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Traumatic aortic rupture• Deceleration injury

• Usually at the site of the lig. arteriosum

• Usually fatal (80% on scene) – 15% of all RTC death

• Survivals might developed a pseudoaneurysm

• Management: urgent surgical

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Further injuries of blunt chest trauma

• Tracheo-bronchial injuries

• PTX, HTX

• Lung contusion

• Blunt cardiac injury (cardiac contusion)

• Rib fractures

• Sternal fracture

• Diaphragmatic injuries

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Tracheo-bronchial injuries• Less than 1% of blunt chest trauma

• Persistent PTX / air leak

• Pneumo-mediastimum

• Surgical emphysema

Diagnosis

• CT, bronchoscopy

Management

• Depends on the site and extent of injury

• Selective lung ventilation

• Thoracic surgery

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Tracheo-bronchial injuries• Less than 1% of blunt chest trauma

• Persistent PTX / air leak

• Pneumo-mediastimum

• Surgical emphysema

Diagnosis

• CT, bronchoscopy

Management

• Depends on the site and extent of injury

• Selective lung ventilation

• Thoracic surgery

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Pulmonary contusion• Common in blunt chest trauma

• Develops over the first 24 hrs

• Resolves in about a week

• Might cause respiratory failure (rarely need intubation)

• Possible complications are pneumonia, ARDS

Diagnosis

• Chest XRay

Management:

• Analgesia, chest physiotherapy

• Normal fluid therapy (no need for fluid restriction)

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Blunt Cardiac Injury• Direct hit over the heart

• Range of pathology: arrhythmia, contusion, wall rupture, septal or valvular rupture, myocardial infarction (coronary dissection)

• Cardiac contusion: probably the most common but not clear definition !

Diagnosis:

• ECG: arrhythmia (most common: ST and AF) nonspecific signs, T / ST segment changes, RBBB

• Echo: RWMA, pericardial effusion

• Biomarkers (troponin): not needed and no added value (does not change management, not reliable for prognostication either)

Management:

• Cases of wall rupture, septal or valvular rupture will need cardiac surgery

• Cardiac contusion: serial ECG and monitoring for 4-6 hrs if haemodynamically stable

• Unstable patients needs HDU for haemodynamic monitoring and support as required

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Rib fractures• 4th-10th rib fractures are the most

common

• 1st-3rd rib fractures are associated with high energy trauma CT scan is mandatory to evaluate

associated injuries

• Lower rib fractures (10-12) might be associated with liver / spleen injuries

• Chest X-Ray (AP) will likely miss 50% of fractures Rib fracture is not X-Ray indication

unless other injuries are suspected

• Clinical diagnosis: point tenderness, deformity

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Fact:Most common site of rib# in blunt chest trauma (RTC): anterior and lateral ribs

Fact:CXR is better to detect

fractures on the posterior ribs and misses the rest!

Rib fracturesRed flags:

• Multiple rib fractures

• Elderly

• Co-morbidity especially lung disease

• Associated injuries

Management:

• Analgesia

• Chest physiotherapy

• Surgery is very rarely indicated

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Sternal fracture• 3-7% occurrence in blunt anterior chest trauma

• Mortality is low (0.7%)

• Localized sternal pain

• Shortness of breath (15-20%)

• Local bruising (55%)

• Lateral (sternal) view X-Ray

• ECG is indicated

• Consider cardiac contusion

But if ECG normal and patient is stable, no further testing is necessary

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Diaphragmatic injury• Less than 1% of blunt chest injuries

• Happens mostly on the left side

• Chest and abdominal pain with SOB Pain may get better when upright

• Bowel sounds and reduced/missing breath sounds on the left side

• Diagnosis: Chest X-ray / CT scan

Management

• NG tube to decompress

• Chest drain might be considered (avoid viscera!)

• Surgical repair early is better

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Summary

• Chest injury is very common

• Life threatening injuries are often identified and treated during the Primary Survey

• Initial stabilization usually requires simple maneuvers: Difficulty is the decision making!

• Stable patients with blunt thoracic trauma might still have serious injuries and therefore careful evaluation and targeted investigations are mandatory

• Remember the limitations of X-Ray and use of U/S and CT

• Remember to look outside the box: associated injuries are common!

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