Chest injuries

Supervised by:Dr. Waseem

Hajjar

INTRODUCTION

►The chest contains vital organs.►Damage to vital organs threatens life.►Most common consequence is hypoxia.►Chest injuries result in a significant number of

deaths each year.►One in every 4 cases of trauma death caused by

chest injury.

*Chest injuries can be divided into: -Immediate life threatening injuries -Potentially life threatening injuries

Immediate life threatening injuries

Injuries that can cause death in a matter of minutes and, therefore, must be identified and treated during

the initial evaluation and resuscitation.

• Airway obstruction

• Tension pneumothorax

• Open pneumothorax

• Massive heamothorax

• Cardiac tamponad

• Flial chest

Potentially life threatening injuries

Injuries that, left untreated, would likely result in death but that usually allow several hours to establish a

definitive diagnosis and institute appropriate treatment

• Traumatic aortic rupture.

• Myocardial contusion.

• Tracheal bronchial injury.

• Rupture diaphragm.

• Esophageal trauma.

• Pulmonary contusion.

►Mechanism of injury :►

1) Blunt chest trauma Most common cause of serious chest injuries. Post RTA, falls, direct blows, and crushing injuries. Many injuries are not immediately apparent

in physical exam. 2) Penetrating trauma

Immediate result can be severe bleeding or impaired breathing.

Any chest wound can involve underlying organ injury. No matter how superficial it looks. Injuries to the heart, lungs, and great vessels can quickly

lead to shock and cardiac arrest.

3) Iatrogenic

►Signs and symptoms:• Most common symptoms: pain and difficulty

breathing.• Signs are obvious injury to the chest wall

( looking at both the front and back of the chest).• Note any subcutaneous emphysema, or air

present under the skin

►Assessment:Follow all steps in the assessment of the trauma

patient:• Primary survey( A. Airway B. Breathing C.

Circulation).• Resuscitation.• Detailed secondary survey (CXR , ABG ,ECG , CT

Chest , Aortogram).

►Management

• Ensure patient has adequate oxygenation and perfusion

• Provide high-flow oxygen, ventilating when necessary

• Halt any obvious bleeding• Support circulation when needed• Rapidly transport patient to definitive care

Rib fracture• Simple rib fractures are the most common injury

sustained following blunt chest trauma • More common in adults than children.• The most common mechanism of injury for rib

fractures in elderly persons is a fall from height or from standing. In adults, motor vehicle accident (MVA) is the most common mechanism.

►Ribs commonly fracture at the point of impact or at the posterior angle (structurally their weakest area(.

►Ribs four through nine (4-9) are the most commonly injured.

Signs and Symptoms:

►Pain when breathing or with movement►Patient often presents with guarding and

shallow breathing ►Chest wall instability►Deformity, discoloration►Local swelling and tenderness may be the

only sing of broken rib

Complication s of rib fracture:

►Chronic chest pain►Lung contusion►Pneumo or hemothorax►Injury to aorta or bronci►Flail chest►Fracture of the 8th to 12th ribs can damage

underlying abdominal solid organs:

liver, spleen or kidneyes

Management:

• Move the patient carefully to prevent the bone ends from puncturing the lung.

• Administer O2.• Allow patient to self-splint by assuming the

most comfortable position possible.• Encourage patient to limit movement.• Analgesia like Morphine, PCA, Epidural.• Evaluation: hx, px and tests (CBC, CXR and

MRI)

FLAIL CHEST

Blunt chest trauma, causing extensive anterior and posterior rib fractures or sternocostal disconnection,

results in paradoxical chest wall movement

Management:

►Adequate pain control ►Quickly stabilize flial segment by placing gloved

hand over injured area►After manual stabilization, place folded

universal dressing over segment and tape securely.

►Fixation (external, internal)►Chest tube as required ►Mechanical ventilation may be required in

severe cases.

Paradoxical chest movement

Post Traumatic Pneumothorax

►Types:Opened pneumothorax.Close pneumothorax.

Open PneumothoraxAn injury in which an open wound in the chest wall

has exposed the pleura space to the atmosphere.The open wound allows air movement through the

defect during spontaneous respiration, causing ineffective alveolar ventilation.

Signs:

►difficulty breathing►Cyanosis►Diminished breath sounds on the affected side

Management:

►Cover open chest wounds with occlusive dressing and inserting a thoracostomy tube

►Gloved hand is an effective temporary occlusive dressing

►High flow oxygen ►Transport with unaffected side slightly elevated►Later closure of the wound may be necessary

Tension Pneumothorax

• Potentially life-threatening condition that must be treated immediately.

• Can occur in blunt or penetrating chest trauma.

http://www.trauma.org/thoracic/CHESTtension.html

What Happen in Tension Pneumothorax

►One-way valve forms in lung or chest wall ►Air enters pleural space; cannot leave►Air is trapped in pleural space►Pressure rises►Pressure collapses lung►Shifting of the mediastinum to the contralateral

side, which compreses the vena cava and obstructs venous return to the heart.

Signs and Symptoms

• Extreme dyspnea• Restlessness, anxiety, agitation• Decreased breath sounds• Hyperresonance to percussion • Cyanosis• Subcutaneous emphysema• Rapid, weak pulse• Decreased BP• Tracheal shift away from injured side• Jugular vein distension• Early dyspnea/hypoxia - Late shock

Management:

The thorax must be decompressed with a needle, which is replaced by an intercostal tube with

underwater seal and suction.

Hemothorax► Blood in the pleural space .► Most common result of major chest

wall trauma► Present in 70 to 80 % of penetrating

and major non penetrating trauma .

►Sign & symptoms :► Signs of Shock , Frothy Bloody

sputum , collapsed neck veins ,cool, clammy skin, chills and restlessness

►Source of bleeding :► intercostal vessels, internal

mammary vessels , lung parenchyma, bronchial arteries, major pulmonary vessels ,heart and great vessels

http://www.trauma.org/imagebank/chest/images/chest0033.html

Management

► ABC’s : secure airway , assist the breathing with high o2 .

►Rapid transport .►A hemothorax is managed by removing the source

of bleeding and by draining the blood.

*Indications for urgent thoracotomy►Chest drainage >1250 ml ►or >1000 ml with hypotension► or >200 ml per hour for 3 hours

Chest tube indicated to drain the contents of the pleural space , usually air or blood ,but may include other contents .

Absoluteindications

►Pneumothorax (tension , open or closed )►Hemothorax .►Bilateral traumatic arrest

Relative indication

►Rib fracture & positive.►pressure ventilation.►Profound hypoxia/ hypotension and penetrating injury.► Profound hypoxia / hypotension and unilateral hemothorax.

Contra-indication: ►Refractory 

coagulopathy .►lack of cooperation by the patient►diaphragmatic hernia

Pulmonary contusion► Bleeding into the lung itself is a pulmonary

contusion► The excess fluid interferes with gas exchange ,

potentially leading to inadequate oxygen levels (hypoxia) .

► occurs in 25–35% of all blunt chest trauma .► About 70% of cases result from motor vehicle

collision .

Sign & symptoms:►Soft crackles may be heard over injury site►Chest pain, point tenderness, and localized

swelling over area of impact

Diagnosis :►X-ray ►CT is a more sensitive test for pulmonary

contusion

►A CT scan showing a pulmonary contusion (red arrow) accompanied by a rib fracture

(blue arrow)

Management :

►Supply high-flow supplemental oxygen .►analgesics.►Support ventilation as needed with

Mechanical ventilation (in the patient with worsening pulmonary insufficiency).

Cadiac inuries 1 )Pericardial tamponade :► Emergency condition in which fluid accumulates in

the pericardium (the sac in which the heart is enclosed).

►Usually result from a penetrating chest trauma with laceration to the heart itself .

►Blood filling the pericardial sac compresses the heart, witch prevents the heart's ventricles from filling properly. This in turn leads to a low stroke volume

►The end result is ineffective pumping of blood , shock , and often death.

Sign & symptoms:

The classical cardiac tamponade presents three signs known as Beck's triad. (Hypotension , jugular-venous distension , and muffled heart sounds )  .

other signs , like pulses paradoxux and ECG changes as well as general signs & symptoms of shock .

Management : ABC’s With High Flow oxygen .Treat S/S of shock .Notify Hospital and ALS Unit as soon as possiblePericardiocentesis :Using aseptic technique, Insert at

least 3” needle at the angle of the Xiphoid Cartilage at the 7th rib.

2 ) Myocardial contusion :►Common site: Rt ventricle►Considered in trauma patients with blunt chest

injury and unexplained hypotension or ECG abnormalities

Diagnosis :► clinical eg: fractured sternum►ECG: (arrhythmia, ST elevation).►CPK-MB►Echocardiography

Management :

►ABC + high flow o2, ventilation support as needed►Cardiac monitor►Antiarrhythmic drugs.►Inotropic support.►request ALS backup .

Blood vessel injuriesAortic injury (Traumatic aortic

rupture) : The aorta is torn or ruptured as the

result of trauma. It s frequently fatal due to the

profuse bleeding  Occurs when the body suddenly

decelerates but the organs continue to move.

Common sites: The most common site of injury is the aortic isthmus ,

Symptoms-signs: sever chest or back pain, weak or absent femoral pulses, unequal arm BPs .

Diagnosis►After a clinical evaluation, most patients are best

evaluated wit CXR followed by Chest CT or Angiography.

► however CXR demonistrat a classical finding

► widened widened mediastinum.mediastinum.

► blurred aortic blurred aortic knob.knob.

► Aortopulmonary Aortopulmonary window window opacification.opacification.

► First or second First or second rib #.rib #.

► NG tube NG tube deviation.deviation.

► Depressed Lt Depressed Lt mainstem mainstem bronchus.bronchus.

► Pleural apical Pleural apical capping.capping.

► Widened Widened paratracheal paratracheal stripe.stripe.

Management►ABC’s ►Surgical repair, usually with cardiopulmonary

bypass technique

Diaphragmatic Rupture

►Common site: Lt hemidiaphragm

►Symptoms-signs: dyspnea, orthopnea, chest pain, bowel sounds in the chest

DiagnosisCXR: NG tube or bowel in the chest, gastric

distention with ipsilateral lung collapse.

Management ► surgical repair

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