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.