Chest TraumaChest Trauma

Surgery department Surgery department № 2№ 2 DSMA DSMA

IntroductionIntroduction

Chest trauma is often sudden and Chest trauma is often sudden and dramaticdramatic

Accounts for 25% of all trauma deathsAccounts for 25% of all trauma deaths 2/3 of deaths occur after reaching 2/3 of deaths occur after reaching

hospitalhospital Serious pathological consequnces:Serious pathological consequnces:

-hypoxia, hypovolaemia, myocardial-hypoxia, hypovolaemia, myocardial failure failure

Mechanism of InjuryMechanism of Injury

Penetrating injuriesPenetrating injuries E.g. stab wounds etc.E.g. stab wounds etc. Primarily peripheral lungPrimarily peripheral lung HaemothoraxHaemothorax PneumothoraxPneumothorax Cardiac, great vessel or oesophageal Cardiac, great vessel or oesophageal

injuryinjury

Either:Either: direct blow (e.g. rib fracture)direct blow (e.g. rib fracture) deceleration injury deceleration injury compression injurycompression injury Rib fracture is the most common sign Rib fracture is the most common sign

of blunt thoracic traumaof blunt thoracic trauma Fracture of scapula, sternum, or first Fracture of scapula, sternum, or first

rib suggests massive force of injuryrib suggests massive force of injury

Blunt injuriesBlunt injuries

Chest wall injuries Chest wall injuries

Rib fractures Rib fractures

Flail chestFlail chest

Open pneumothoraxOpen pneumothorax

Rib fracturesRib fractures

Most common thoracic injuryMost common thoracic injury Localised pain, tenderness, crepitusLocalised pain, tenderness, crepitus CXR to exclude other injuriesCXR to exclude other injuries Analgesia avoid tapingAnalgesia avoid taping Underestimation of effectUnderestimation of effect Upper ribs, clavicle or scapula Upper ribs, clavicle or scapula

fracture: suspect vascular injuryfracture: suspect vascular injury

Flail chestFlail chest

Multiple rib fractures produce a Multiple rib fractures produce a mobile fragment which moves mobile fragment which moves paradoxically with respirationparadoxically with respiration

Significant force requiredSignificant force required Usually diagnosed clinicallyUsually diagnosed clinically Rx: ABCRx: ABC

Analgesia Analgesia

Flail chestFlail chest

Flail Chest - detail

Open pneumothoraxOpen pneumothorax

Defect in chest wall provides a direct Defect in chest wall provides a direct communication between the pleural communication between the pleural space and the environmentspace and the environment

Lung collapse and paroxysmal shifting of Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort mediastinum with each respiratory effort ± tension pneumothorax± tension pneumothorax

““Sucking chest wound”Sucking chest wound” Rx: ABCs…closure of wound…chest Rx: ABCs…closure of wound…chest

drain drain

Lung injuryLung injury

Pulmonary contusionPulmonary contusion Pneumothorax Pneumothorax HaemothoraxHaemothorax Parenchymal injuryParenchymal injury Trachea and bronchial injuriesTrachea and bronchial injuries PneumomediastinumPneumomediastinum

PneumothoraxPneumothorax

Air in the pleural cavityAir in the pleural cavity Blunt or penetrating injury that Blunt or penetrating injury that

disrupts the parietal or visceral pleuradisrupts the parietal or visceral pleura Unilateral signs: Unilateral signs: movement and movement and

breath sounds, resonant to percussionbreath sounds, resonant to percussion Confirmed by CXRConfirmed by CXR Rx: chest drainRx: chest drain

Pneumothorax Pneumothorax classificationclassificationBy side:By side:

left or rightleft or right in both sidein both side

By lung collapse degree:By lung collapse degree: Partial (paracostal)Partial (paracostal) Subtotal (smaller than 2/3 of lung volume)Subtotal (smaller than 2/3 of lung volume) Total (more than 2/3 of lung volume)Total (more than 2/3 of lung volume)

By mechanism of formation:By mechanism of formation:

- open - open

- closed- closed

- tension- tension

PneumothoraxPneumothorax

Tension pneumothorax Tension pneumothorax

Air enters pleural space and cannot Air enters pleural space and cannot escapeescape

P/C: chest pain, dyspnoeaP/C: chest pain, dyspnoea Dx: - respiratory distress Dx: - respiratory distress

- tracheal deviation (away) - tracheal deviation (away) - absence of breath - absence of breath

soundssounds - distended neck - distended neck veinsveins - hypotension - hypotension

Surgical emergencySurgical emergency

Rx: emergency decompression Rx: emergency decompression

before CXRbefore CXR

Either large bore cannula in 2nd ICS, Either large bore cannula in 2nd ICS,

MCL or insert chest tubeMCL or insert chest tube

CXR to confirm site of insertionCXR to confirm site of insertion

HaemothoraxHaemothorax

Blunt or penetrating traumaBlunt or penetrating trauma Requires rapid decompression and fluid Requires rapid decompression and fluid

resuscitationresuscitation May require surgical interventionMay require surgical intervention Clinically: hypovolaemiaClinically: hypovolaemia absence of absence of

breath soundsbreath sounds dullness to percussion dullness to percussion CXR may be confused with collapseCXR may be confused with collapse Decompression always by chest catchment in 7 Decompression always by chest catchment in 7

ICS on middle or posterior axillary lineICS on middle or posterior axillary line

Hemothorax classificationHemothorax classificationBy side:By side:

left or rightleft or right in both sidein both side

By blood lost volume :By blood lost volume : Small (< 10% of BCV, or <500 ml)Small (< 10% of BCV, or <500 ml) Middle (10-20 % of BCV, or 500-1000ml)Middle (10-20 % of BCV, or 500-1000ml) Big (10-20 % of BCV, or 500-1000ml)Big (10-20 % of BCV, or 500-1000ml) Total ( > 40 % of BCV, or >2000ml)Total ( > 40 % of BCV, or >2000ml)

By bleeding presence:By bleeding presence:

- stopped (Reviloi – Gregoire test negative)- stopped (Reviloi – Gregoire test negative)

- continues (Reviloi – Gregoire test positive)- continues (Reviloi – Gregoire test positive)

By clots By clots presence:presence:

- clotted- clotted

- unclotted- unclotted

By infection complication presence:By infection complication presence:

- non-infected- non-infected

- infected- infected

Indication for urgent Indication for urgent thoracotomythoracotomy

In In pneumothoraxpneumothorax:: Absence of active air catchment during Absence of active air catchment during

more than 2 days (presence of more than 2 days (presence of pneumothoraz on CXR)pneumothoraz on CXR)

In In hemothoraxhemothorax:: Evacuation of > 1000ml blood Evacuation of > 1000ml blood

simultaneously or bleeding continues during simultaneously or bleeding continues during 4 hours with blood loss > 200 ml per hour4 hours with blood loss > 200 ml per hour

Heart, Aorta & DiaphragmHeart, Aorta & Diaphragm

Blunt cardiac injuryBlunt cardiac injury- contusion- contusion- ventricular, septal or valvular - ventricular, septal or valvular

rupture rupture Cardiac tamponade Cardiac tamponade Ruptured thoracic aortaRuptured thoracic aorta Diaphragmatic ruptureDiaphragmatic rupture

Cardiac TamponadeCardiac Tamponade Blood in the pericardial sac Blood in the pericardial sac Most frequently penetrating injuriesMost frequently penetrating injuries Shock, Shock, JVP, PEA, pulsus paradoxusJVP, PEA, pulsus paradoxus Classically, Beck’s triad:Classically, Beck’s triad:

- distended neck veins- distended neck veins- muffled heart sounds- muffled heart sounds

- hypotension- hypotension Rx: Volume resuscitationRx: Volume resuscitation

Pericardiocentesis Pericardiocentesis

Cardiac Cardiac tamponadetamponade

Aortic ruptureAortic rupture

Usually blunt trauma involving Usually blunt trauma involving deceleration forces; especially RTAsdeceleration forces; especially RTAs

~90% die within minutes~90% die within minutes Most common site near ligamentum Most common site near ligamentum

arteriosumarteriosum Dx: clinical suspicion, CXR, aortography, Dx: clinical suspicion, CXR, aortography,

contrast CT or TOE contrast CT or TOE Rx: surgical…poor prognosisRx: surgical…poor prognosis

Aortic ruptureAortic rupture

Iatrogenic traumaIatrogenic trauma

NG tubes: - coilingNG tubes: - coiling - - endobronchial placementendobronchial placement - - pneumothoraxpneumothorax

Chest tubes: - subcutaneousChest tubes: - subcutaneous - - intraparenchymalintraparenchymal - - intrafissuralintrafissural

Central lines: - neckCentral lines: - neck - - coronary sinuscoronary sinus

- pneumothorax- pneumothorax

Line in jugular vein Line in jugular vein

Misplaced nasogastric Misplaced nasogastric tubetube

Chest trauma: summaryChest trauma: summary CommonCommon SeriousSerious Primary goal is to provide oxygen Primary goal is to provide oxygen

to vital organsto vital organs RememberRemember

AAirwayirwayBBreathingreathing

CCirculationirculation Be alert to change in clinical Be alert to change in clinical

condition condition