Chest trauma by dr.damodhar.m.v

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Chest Trauma

Dr.Damodhar.M.V

Resident Surgeon,

Security Forces Hospital Dammam,

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Injuries to chest: • Pnuemothorax• Haemothorax• Flail chest• Diaphragmatic injury• Aortic tear• Oesophageal rupture• Pulmonary contusion• Cardiac tamponade

Procedures:• Intercostal Drains• Tracheostomy

Contents

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Sudden and dramatic

Directly -20 – 25% (1 in every 4) trauma deaths*

Contribute to 25-50% of the remaining deaths*

>16,000 deaths per year in west*

*Source: Brunicardi FC, Anderson DK, Billar TR, Dunn DL, Hunter JG, Mathews JB, Pollock RE: Schwartz Priniciples of Surgery, 9 th edition. HTTP: www.accessmedicine.com

Chest Trauma - Incidence

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Superiorly - Clavicles

Inferiorly- Diaphragm

Laterally- Rib cage

Boundaries of Chest

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Anteriorly- Sternum

Posteriorly- Vertebral bodies & ribs

Boundaries of Chest

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Chest wall and ribs

Lungs and pleura

Great and thoracic vessels

Heart and mediastinal structures

Diaphragm

Oesophagus

Thoracic duct

Tracheobronchial system

Contents- Thoracic cavity

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Related to:

Mechanism of injury Location of injury Associated injuries Co-morbidities

Chest Trauma- Clinical Consequences

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Blunt:

Mostly managed non-operatively

• Simple intubation & ventilation or• Chest tube placement

Mechanism of Injury

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Penetrating:

• Low energy• Medium energy• High energy

Mechanism of Injury

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• Rib fractures• Sternal fractures

• Open or Closed Pneumothorax • Unilateral / bilateral

• Hemothorax• Hemopneumothorax

Resulting Injuries

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• Pneumo-mediastinum

• Pulmonary contusion

• Aortic Rupture

• Myocardial contusion

• Diaphragmatic rupture

Resulting Injuries

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Primary acute killer of trauma patients inadequate delivery of O2 to tissues

HYPOXIA / HYPO-VENTILATION

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Inadequate intravascular volume

BLOOD LOSS

Hypovolemia

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Contusion Hematoma Alveolar collapse

Ventilation / Perfusion Mismatch

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- Tension pneumothorax

- Open pneumothorax

CHANGES IN INTRATHORACICPRESSURE RELATIONSHIPS

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Hypo perfusion of tissues (shock)

METABOLIC ACIDOSIS

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ABCs

PRIMARY SURVEYAim to identify & treat immediately life threatening conditions

Management - Chest Trauma

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- Resuscitation of vital functions

- Most life threatening injuries treated by- Airway control - Chest tube

Management - Chest Trauma

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• Influenced by:• Mechanism of injury• High level of suspicion

• May show: Simple pneumothorax Hemothorax Pulmonary contusion Myocardial contusion Blunt aortic injury Rib fractures Diaphragmatic rupture

Detailed Secondary Survey

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Adjuncts

CXR- basis for initiating other investigations

ALL wounds to thoracic cavity bounded back & front by

Neck & umbilicus for stabs Neck & pelvis for GSW

• MUST HAVE CXR, UPRIGHT if possible

Management- Chest Trauma

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Focused Abdominal Sonography forTrauma (FAST)

All hemodynamically unstable blunt trauma patients

Adjuncts - FAST

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Becoming a primary diagnostic tool fast (spiral) allow for reconstruction

Adjuncts - Cat Scan- (CT angio)

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Penumothorax

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Air in the pleural cavity is called Pneumothorax and when it is due to trauma it is called Traumatic Pneumothorax.

Types:

• Closed pneumothorax

• Open pneumothorax

• Tension pneumothorax

Pneumothorax

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Air accumulates in pleural cavity through small rent in the lung due to fractured ribs.

Such rent in the lung subsequently closes and is known as pneumothorax.

Closed Pneumothorax

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Closed Pneumothorax

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Air enter the pleural cavity through a wound in the chest wall.

With each inspiration wound sucked into the pleural cavity.

• Sucking chest wound• Air enters pleural space• Ventilation impaired • Hypoxia results

Open Pneumothorax

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Open Pneumothorax

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Open Pneumothorax

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Lacerated lung communicates with branch of brachial tree.

This permits air to enter pleural cavity during inspiration, but does not permit the air to escape during expiration as rent in the lung becomes closed and the rent in the lung acts like a valve.

This causes collapse of lung on affected side.

Tension Pneumothorax

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5T’s- Tachycardia

Tachyapnea

Tracheal shift

Tympanic note

Totally absent breath sounds on affected side

Clinical features of Pneumothorax

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Bilateral Tension Pneumothorax

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Treatment : Closed pneumothorax: no active treatment. Air gets absorbed.

Open pneumothorax:Closure of the chest wall wound

Tension Pneumothorax:•Required urgent surgical intervention:•Wide bore needle inserted into pleural cavity into 2nd intercostal space 1 ½ inch lateral to sternum.

•This is followed by Underseal Intercostal Drainage.

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Wide bore needle inserted into pleural cavity into 2nd intercostal space 1 ½ inch lateral to sternum


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Accumulation of blood in the pleural cavity due to trauma to the chest. Blood comes from

Contusion of lung Injury to parietal vessels Injury to heart and great vessels

HAEMOTHORAX

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Clinical features

Dysponea Pain Cyanosis Decreased breath sounds Investigation- Chest X ray

Treatment ICD

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HAEMOTHORAX

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HAEMOTHORAX

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Flail Chest

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Flail chest occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage.

Usually defined as at least 2 fractures per rib (producing a free segment), in at least 2 ribs.

Develops in multiple rib fractures

Fracture occurs anteriorly at or near costochondral junction and posteriorly near the angles of the rib

This results in fragment of chest wall which becomes unstable having no bony connection & unable to contribute to lung expansion.

Flail Chest

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The floating segment moves in during inspiration due to negative pressure in the pleural cavity

The floating segment moves out during expiration due to positive pressure in the pleural cavity

This results in paradoxical movement of the floating segment of the chest wall.

Known as Paradoxical respiration - that means floating segment moves in the opposite direction as the movement of the normal chest wall.

Flail Chest

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Types

Anterior

Lateral

Posterior

Flail Chest

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Anterior type:

Anterior ends of few ribs on both sides are fractured.

Hence, sternum along the anterior fragments of ribs of both sides becomes floating segment

Flail Chest

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Lateral type:

Multiple rib fractures anteriorly and posteriorly.

Posterior type: Multiple ribs are fractured at their posterior angles on both sides Spinal column along with posterior fragments of ribs becomes

floating segments The effect of paradoxical movement is minimal.

Flail Chest

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Flail Chest

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Hypoventilation- Hypoxia

Mediastinal Flutter Mediastinum moves towards sound side during inspiration. Mediastinum moves towards affected side during expiration.

As the contents of Mediastinum are heart & great vessels, their movements result in severe shock.

Effects of Paradoxical Respiration

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Mechanical ventilation highly effective in Flail chest.

It minimizes paradoxical respiration

Also acts as an effective “Internal Pneumatic Fixation” of the floating chest.

Treatment

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DiaphragmaticRupture

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- Rupture diaphragm may occur from:- Penetrating injuries - Crush injuries

- Left hemidiaphragm Ruptured more frquently by blunt trauma ( 9:1) Posterolaterally weakened due to gap for abdominal aorta & oesophageal hiatus

- Right Hemidiaphragm – protected by liver

Diaphragmatic Rupture

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Left hemidiaphragm rupture Herniation of stomach , spleen , left transverse colon/ omentum

Right Hemidiaphragm rupture Herniation of liver

In penetrating injuries, herniation occurs rarely and slowly


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The symptoms of diaphragmatic rupture are similar to pneumothrax as the lung is compressed and hypoxemia develops

Chest x-ray Loss of the diaphragmatic contour Presence of bowel or NG tube in the chest Elevation of the hemidiaphragm

Intubation / mechanical ventilation needed for adequate oxygenation.


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Management Intubation / mechanical ventilation needed for adequate oxygenation.

Operative repair indicated in all cases.

All penetrating diaphragmatic injuries repaired via abdomen and not chest, to rule out hollow viscus injury.


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Diaphragmatic RupturePost traumatic air-filled viscus above the left hemidiaphragm as a consequence of diaphragmatic rupture.

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Aortic Tear

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• Most common cause of immediate death Motor-vehicle collisions or falls from heights 90% die immediately

The rupture is usually at the ligamentum arteriosum just distal to the left subclavian artery.

Clinical signs of traumatic aortic injury rarely present

Diagnosis based on high index of suspicion based on mechanism of injury, and imaging studies

Aortic Tear

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Investigations:

Chest x-ray CT scan Aortography

Surgical Repair performed immediately due to fatal risk of haemorrhage.

Aortic Tear

Findings on Chest Radiograph Suggestive of a Descending Thoracic Aortic Tear

1. Widened mediastinum 2. Loss of aortic contour 3. Tracheal shift to right 4. Nasogastric tube shift 5. Left apical cap 6. Depression of the left main bronchus 7. Elevation of right main stem bronchus. 8. Obliteration of the aorticopulmonary window 9.Left sided haemothorax

Aortic Tear

Chest film findings associated with descending torn aorta include apical capping (arrows) and tracheal shift

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Oesophageal Rupture

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Oesophageal rupture

Most oesophageal injuries due to penetrating trauma

High index of suspicion necessary to diagnose

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Clinical features:

Odynophagia

Subcutaneous/Mediastinal emphysema

Pleural effusion

Air in retro-oesophageal sapce

Unexplained fever within 24hrs of injury

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Oesophageal rupture

Mortality rate rises exponentially if treatment delayed for more than 12-24 hrs.

Chest xray

Oesophagogram & Oesophagoscopy confirm diagnosis

Treatment: Operative repair & Drainage.

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Widened mediastinum Bilateral airspace disease and pleural effusion

Left sided pleural effusion,

Subcutaneous emphysema

Pneumomediastinum

Left lower lobe atelectasis

Pulmonary edema

Oesophageal rupture

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Esophagogram

Extravasation of dye into mediastinum and presence of a perforation in the lower left portion of the esophagus.

Oesophageal rupture

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Pulmonary Contusion

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• Pulmonary Contusion

• Term used to indicate consequences of blunt trauma to lung

Causes:

• Rapid deceleration of chest against automobile steering wheel

• Fall from height

• Blast injuries

• Fracture ribs / sternum

• Flail chest without any evidence of rib fracture

Pulmonary contusion

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Contused lung characterized by:

Capillary disruption

Intra alveolar & interstitial haemorrhage

Oedema

Fluid obstruction of small airways

Leucocyte infiltration

Pulmonary contusion

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Pulmonary contusion

Chest x ray- Fluffy infiltrate in contused lung

Increases in density within a day or two

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- Pulmonary contusion frequently manifests itself as

Hypoxemia.

- May cause serious depression of respiratory function or loss of pulmonary compliance.

Treatment

- Contusion results in areas of consolidation & resolves spontaneously.

- Oxygen therapy

- Positive pressure with CPAP mask / Intubation and mechanical ventilation with PEEP.

- Adequate analgesia

Pulmonary contusion

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Cardiac Tamponade

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• Most frequently caused by penetrating thoracic injuries

• Blunt trauma- Myocardial rupture

Coronary artery laceration

Ascending dissection of aortic tear

• Accumulation of as little as 150ml may impair diastolic filling.

Cardiac Tamponade

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• Beck’s triad Hypotension Neck veins distended Heart sounds muffled

• Paradoxical pulse

• Breath sounds equal

Cardiac Tamponade

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Investigations:

Echo

Angiography

Treatment

• Treat for shock

• Fluid administration Titrate to peripheral pulse (90–100 mmHg)

• Monitor and treat dysrhythmias

• Monitor for: Hemothorax Pneumothorax

Cardiac Tamponade

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Cardiac Tamponade

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Myocardial Contusion

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• Most common cardiac injury Blunt anterior chest injury

• May vary from superficial epicardial petechiae to transmural damage

• Same as myocardial infarction Chest pain Dysrhythmias Cardiogenic shock (rare)

• ECG- non specific ST-T wave changes

• ICU monitoring for 24hrs

• Treat as cardiac tamponade

Myocardial contusion

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Myocardial contusion

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Movement of diaphragm and thoracic structures causes partial defibrination of blood that is accumulated in pleural cavity.

So blood remains in liquid state for considerable period of time without being clotted.

Pleural enzymes in the cavity produces a clot lysin within few hours after bleeding stops.

Why blood in the pleural cavity will not clot?

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Indications:

Pneumothorax

Haemothorax

Empyema thoracis

Massive pleural effusion

Intercostal drainage tube

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•Procedure done local anesthesia

•Chest tube introduced into pleural cavity and connected to underwater drainage tube.

•For Pneumothorax- 2nd Intercostal space,mid clavicular line

•For Haemothorax-6th Intercostal space mid axillary line

Intercostal drainage

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Mid-axillary line

Site:

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Hemothorax – usually laceration of intercostals vessel, may require thoracotomy

Lung laceration especially when adhesions present

Diaphragm / abdominal cavity penetration - placed too low

Stomach colon injury - diaphragmatic hernia not recognizedTube placedsubcutaneously – not inpleural cavity

Tube placed too far = pain

Tube falls out = not secured properly

Chest tube insertion-complications

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Subcutaneous emphysema

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Tracheostomy

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Tracheostomy (also referred to as pharyngotomy, laryngotomy, and tracheotomy)

A surgical procedure in which an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea is made.

Relieves airway obstruction/protects airway

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• Emergency Tracheostomy

• Elective Tracheostomy

Tracheostomy

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Indications for tracheostomy Relief of Acute upper airway obstruction (Inhaled foreign body, large pharyngolaryngeal tumour ,acute

pharyngolaryngeal infections in children)

Potential upper airway obstruction (after major surgery involving the oral cavity,pharynx, larynx or neck)

Protection of the lower airway

Control of secretions

Ventilatory support in respiratory failure

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Short horizontal incision made over 2nd or 3rd tracheal ring

Neck extended

2nd and 3rd tracheal rings incised vertically

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Complications

Intraoperative complications

•Haemorrhage

•Injury to paratracheal structures, particularly the carotid artery, recurrent laryngeal nerve and oesophagus

•Damage to the trachea

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ComplicationsEarly postoperative complications •Apnoea caused by a fall in the PCO2•Haemorrhage•Subcutaneous emphysema, pneumomediastinum and pneumothorax•Accidental extubation•Anterior displacement of the tube •Obstruction of the tube lumen •Tip occlusion against the tracheal wall•Infection•Swallowing dysfunction

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ComplicationsLate postoperative complications

• Difficult decannulation

•Tracheocutaneous fistula

•Tracheo-oesophageal fistula

•Tracheal stenosis

Wishing you all a blessed time during the holy month of Ramadan

Dr.Damodhar.M.V

Chest trauma by dr.damodhar.m.v

Health & Medicine

Transcript of Chest trauma by dr.damodhar.m.v