Chest InjuriesChest Injuries

IntroductionIntroduction Chest trauma is often sudden and dramaticChest trauma is often sudden and dramatic Accounts for 25% of all trauma deathsAccounts for 25% of all trauma deaths 2/3 of deaths occur after reaching hospital2/3 of deaths occur after reaching hospital Serious pathological consequences; hypoxia, Serious pathological consequences; hypoxia,

hypovolaemia, myocardial failure hypovolaemia, myocardial failure The most common type of injuries is blunt.The most common type of injuries is blunt. Fracture of scapula, sternum, or first rib Fracture of scapula, sternum, or first rib

suggests massive force of injury suggests massive force of injury

Blunt injuries: can fracture ribs, Blunt injuries: can fracture ribs, sternum and costal cartilage, sternum and costal cartilage, damage airways, lungs, great damage airways, lungs, great vessels and heart.vessels and heart.

Penetrating injuries: bullets, knives, Penetrating injuries: bullets, knives, … can damage internal organs. … can damage internal organs.

Compression: ribs and sternum Compression: ribs and sternum fracture, internal organ injuries.fracture, internal organ injuries.

Types of chest injuriesTypes of chest injuries

Closed chest injuriesClosed chest injuries– Ribs and sternum fracture Ribs and sternum fracture – Flail chest Flail chest

Open chest injuriesOpen chest injuries– Pneumothorax Pneumothorax – Tension pneumothorax Tension pneumothorax

Injuries within the chest cavityInjuries within the chest cavity– Pneumothorax Pneumothorax – Tension pneumothorax Tension pneumothorax – Hemothorax Hemothorax – Traumatic asphyxia Traumatic asphyxia – Cardiac tamponade Cardiac tamponade – Aortic injury and dissectionAortic injury and dissection

Rib & sternal fracturesRib & sternal fractures

Most common thoracic injuryMost common thoracic injury S&S: Localised pain, dyspnes, S&S: Localised pain, dyspnes,

tenderness, crepitus, chest wall tenderness, crepitus, chest wall ecchymosis ecchymosis

Dx Studies: CXR to exclude other Dx Studies: CXR to exclude other injuriesinjuries

Rx: Analgesia. avoid tapingRx: Analgesia. avoid taping Underestimation of effectUnderestimation of effect Upper ribs, clavicle or scapula fracture: Upper ribs, clavicle or scapula fracture:

suspect vascular injurysuspect vascular injury

Flail ChestFlail Chest

It is fracture of two or more adjacent ribs in two or It is fracture of two or more adjacent ribs in two or more places that allows for free movement of more places that allows for free movement of fractures segmentfractures segment

S & S: S & S: – Paradoxical chest movements Paradoxical chest movements – Dyspnea Dyspnea – Chest pain Chest pain

Care:Care:– ABC ABC – Analgesics Analgesics – Early assessment Early assessment – Administer oxygen Administer oxygen – Stabilize area with bulky dressing Stabilize area with bulky dressing – MonitoringMonitoring

Flail ChestFlail Chest

Open Chest WoundOpen Chest Wound Sucking chest wound: is an open chest wound Sucking chest wound: is an open chest wound

in which air is sucked into the chest cavity. in which air is sucked into the chest cavity. S & S: S & S:

– Presence of chest wound Presence of chest wound – Sucking chest wound may or may be not available Sucking chest wound may or may be not available – Patient may be gasping for air Patient may be gasping for air

Care: Care: – ABCABC– Seal open chest wound quickly Seal open chest wound quickly – Apply occlusive dressing Apply occlusive dressing – Administer high concentrated oxygen Administer high concentrated oxygen – Care for shock Care for shock – Transport as soon as possible Transport as soon as possible

Sucking Chest WoundSucking Chest Wound

Pneumothorax Pneumothorax

Pneumothorax: air in the chest cavityPneumothorax: air in the chest cavity Tension pneumothorax: air in the chest Tension pneumothorax: air in the chest

cavity prevented from escaping. cavity prevented from escaping. S & S: respiratory difficulty, rapid weak S & S: respiratory difficulty, rapid weak

pulse, cyanosis, low BP, narrow pulse pulse, cyanosis, low BP, narrow pulse pressure, distended neck vein, tracheal pressure, distended neck vein, tracheal deviation, reduced breathing sounds, deviation, reduced breathing sounds, hyper resonance,hyper resonance,

Rx: ABC, closure of wound, chest drain. Rx: ABC, closure of wound, chest drain.

Cont. PneumothoraxCont. Pneumothorax

Surgical emergencySurgical emergency

Rx: emergency Rx: emergency

decompression before decompression before

CXRCXR

Either large bore cannula Either large bore cannula

in 2nd ICS, MCL or insert in 2nd ICS, MCL or insert

chest tubechest tube

CXR to confirm site of CXR to confirm site of

insertioninsertion

HemothoraxHemothorax

Blood collection in the pleural space. Blood collection in the pleural space. S & S: Dyspnea, tachypnea, Chest S & S: Dyspnea, tachypnea, Chest

pain, Signs of shock, Tracheal pain, Signs of shock, Tracheal deviation, Decreased breath sounds deviation, Decreased breath sounds on the injured side, coughing up on the injured side, coughing up blood, dullness. blood, dullness.

Rx: Rx: rapid decompression and fluid rapid decompression and fluid resuscitationresuscitation

Traumatic AsphyxiaTraumatic Asphyxia

Caused by sudden compression of Caused by sudden compression of chestchest

S & S: distended neck veins, dark S & S: distended neck veins, dark blue upper body, bloodshot and blue upper body, bloodshot and bulging of eyes, swollen blue bulging of eyes, swollen blue tongue and lips, chest deformity tongue and lips, chest deformity

Rx: ABC, relieve pressure Rx: ABC, relieve pressure

Cardiac Tamponade Cardiac Tamponade

Blood collection within pericardial sacBlood collection within pericardial sac S & S: S & S: Beck’s triad: (distended neck Beck’s triad: (distended neck

veins, muffled heart sounds, low BP), veins, muffled heart sounds, low BP), very weak pulse, decreasing pulse very weak pulse, decreasing pulse pressure, PEA, Shock.pressure, PEA, Shock.

Rx: Volume resuscitation, Rx: Volume resuscitation, PericardiocentesisPericardiocentesis

Cardiac Cardiac TamponadeTamponade

Aortic Injury and Aortic Injury and DissectionDissection

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

~90% die within minutes~90% die within minutes S & S: tearing chest pain radiating S & S: tearing chest pain radiating

to the back, difference in BP to the back, difference in BP between Rt & Lt arm, palpable between Rt & Lt arm, palpable pulsating mass, cardiac arrest.pulsating mass, cardiac arrest.

Rx: surgical…poor prognosisRx: surgical…poor prognosis

Aortic RuptureAortic Rupture

Care of injuries within chest Care of injuries within chest cavitycavity

Maintain open airwayMaintain open airway Administer high concentration Administer high concentration

oxygen oxygen Care of shock Care of shock Transport Transport

Iatrogenic traumaIatrogenic trauma NG tubes: -coilingNG tubes: -coiling

-endobronchial placement -endobronchial placement -pneumothorax -pneumothorax

Chest tubes: - subcutaneousChest tubes: - subcutaneous - intraparenchymal - intraparenchymal

- intrafissural - intrafissural Central lines: - neckCentral lines: - neck

- coronary sinus - coronary sinus - pneumothorax - pneumothorax

Ruptured DiaphragmRuptured Diaphragm It is a potentially life-threatening injury that may It is a potentially life-threatening injury that may

result from forces that penetrate the body, such result from forces that penetrate the body, such as gunshot wounds, or from acceleration or as gunshot wounds, or from acceleration or deceleration forces, such as motor vehicle deceleration forces, such as motor vehicle crashes.crashes.

Blunt injuries are more likely to injure the left leaf Blunt injuries are more likely to injure the left leaf of the diaphragm since the right leaf is somewhat of the diaphragm since the right leaf is somewhat protected by the liver. protected by the liver.

A rupture or tear of the diaphragm may allow A rupture or tear of the diaphragm may allow Herniation of abdominal contents into the thorax. Herniation of abdominal contents into the thorax.

Herniation may result in respiratory' compromise.Herniation may result in respiratory' compromise. Mediastinal structures may shift lo the opposite Mediastinal structures may shift lo the opposite

side of the injury. side of the injury.

S & S of Ruptured S & S of Ruptured DiaphragmDiaphragm

Dyspnea or orthopneaDyspnea or orthopnea DysphagiaDysphagia Abdominal painAbdominal pain Sharp epigastric or chest Sharp epigastric or chest

pain radiating to the left pain radiating to the left shoulder shoulder (Kehr's(Kehr's sign)sign)

Bowel sounds in the Bowel sounds in the lower to the middle chestlower to the middle chest

Decreased breath sounds Decreased breath sounds on the injured sideon the injured side

Line in jugular vein & Misplaced Line in jugular vein & Misplaced NGTNGT