CHEST TRAUMAEmergency Management

Dr .Shabbir2nd year PG

MD Emergency Medicine

Objectives

• Anatomy of Thorax• Main Causes of Chest Injuries• S/S of Chest Injuries• Different Types of Chest Injuries• Emergency department care of Chest Injuries

Anatomy of the chest

• It provides protection to vital organs ( heart and major vessels, lungs, liver) and provides stability for movement of the shoulder girdles and upper arms.

• thoracic skeleton consists of 12 thoracic vertebrae bones, Twelve ribs , neurovascular bundles arising from the spine (Brachial plexus), Muscles…

GROSS ANATOMY

Physiology

BRAIN STEM• Respiratory centres pons

and medulla -autonomic-central chemoreceptors(h+)-periphral

chemoreceptors(paco2)

Respiratory mechanic-muscular forces-mechanic’s of ventilation• Compliance• Gas liquid interference • Airway resistance

EPIDEMIOLGY

• Chest trauma ranks third behind head and extremity trauma in major accidents in the United States.

• The motor vehicle accident is the most common etiology (70 per cent).

• Many of these injuries are of moderate severity and rarely require surgical intervention.

• *chest -[33.33%] in RTA cases.

• The majority of such injuries may be diagnosed with relatively simple tests such as chest radiographs.

• *JRFMT-2016Month :December Volume :2 Issue:2 Page :8-13

Main Causes of Chest Trauma

• *Blunt Trauma- Blunt force to chest.

• Penetrating Trauma- Projectile that enters chest causing small or large hole.

• Compression Injury- Chest is caught between two objects and chest is compressed.

“DEADLY DOZEN”

Immediately life threatening – primary survey

Airway obstruction

Tension pneumothorax

Pericardial tamponade

Open pneumothorax

Massive hemothorax

Flail chest

Classification of chest trauma

RUTHERFORD’S SIX ABNORMALITY FOLLOWING CHEST TRAUMA

• Airway obstruction• Flail chest• Suckling chest wound• Massive hemothorax• Tension pneumothorax• Cardiac tamponade• Air embolism

Asses the chest wall Contusions. Tenderness. Asymmetry. Open wounds or

impaled objects. Crepitation. Paradoxical movement

• Lung sounds – Percussion.Hyperresonance

• Pneumothorax• Tension pneumothorax

Hyporesonance (hemothorax )• Compare both sides of the chest

at the same time when assessing for asymmetry

Red flag signs of chest injury Hemoptysis. Chest wall contusion. Flail chest. Open wounds. Jugular vein distention (JVD). Subcutaneous empysema. Tracheal deviation.

Respiratory rate and effort:TachypneaBradypneaLaboredRetractionsProgressive respiratory distress

Lung sounds:Absent or decreased

UnilateralBilateral

Bowel sounds in chest.

Airway obstruction

• Injury of chest can disrupt the airway continuity in it course through the upper mediastinum.

• Devastating injury.

Patho-physology

• Airway obstruction injuries the patient via hypoventilation and elevation of pco2.

• Impairs minute volume..

Diagnosis

• Clinical diagnosis …• Chest x-ray• Abg• Rigid bronchoscopy

Treatment

• Upper airway obstruction- treat the cause for emergency (tracheostomy).

• Lower airway obstruction- bronchoscopy.

Basic techniques

• Chin lift• Jaw thrust

Adjuncts

• Oropharyngeal airway (Guedel)• Nasopharyngeal airway• Supraglottic airway devices

• Laryngeal mask airway (LMA)• I-gel• Laryngeal tube (LT)

• Orotracheal intubation• Surgical airway

• Needle or surgical cricothyroidotomy

• Mechanical ventilation

Flail chest

The breaking of 2 or more ribs in 2 or more places

Patho-physology

• Tidal volume is wasted in moving the chest wall in and out.

• Increased work of breathing• hypoventilation

Diagnosis

• Shortness of Breath• Paradoxical Movement• Bruising/Swelling• Crepitus( Grinding of bone ends on palpation)

Flail chest x-ray

Treatment

• ABC’s with c-spine control as indicated• High Flow oxygen that may include BVM• Monitor Cardiac Rhythm• Establish IV access• Bulky Dressing for splint of Flail Chest.• Intubation and positive pressure ventilation.

Bulky Dressing for splint of Flail Chest

Use Trauma bandage and Triangular Bandages to splint ribs.

Can also place a bag of D5W on area and tape down.

• Observe for signs of Pneumothorax or Tension Pneumothorax.

• Late complication pulmonary contusion.

Suckling chest wound

• Suckling wound results from a loss of integrity of the chest wall so that air is free to move in and out of pleural space to atmosphere.

• Example- chest tube

Patho-physology

• Tidal volume wasted• Bigger the defect- more ventilator burden• Hypoventilation and high pco2

Diagnosis

• Clinical diagnosis• Supportive …ABG ,x-ray

Treatment

• Chest tube place and Occlusive dressing.

Massive hemothorax

• Occurs when pleural space fills with blood• Usually occurs due to lacerated blood vessel in

thorax• As blood increases, it puts pressure on heart

and other vessels in chest cavity• Each Lung can hold 1.5 liters of blood

Patho-physology

• hemothorax is manifested in two major areas: hemodynamic and respiratory.

• Hemodynamic changes vary, depending on the amount of bleeding and the rapidity of blood loss.

• The space-occupying effect of a large accumulation of blood may hamper normal respiratory movement, may result dyspnea.

HemothoraxWhere does the blood come from.

Hemothorax

May put pressure on the heart

Blood in pleural space

S/S of Hemothorax

• Anxiety/Restlessness• Tachypnea• Signs of Shock• Frothy, Bloody Sputum• Diminished Breath Sounds on Affected Side• Tachycardia• Flat Neck Veins

• Plain chest radiograph.• USG AND CT THORAX may sometimes be

required for identification and quantification of a hemothorax .

• Nontraumatic hemothorax- diagnostic needle aspiration is performed.

• pleural effusion with a hematocrit value more than 50% of that of the circulating hematocrit is considered a hemothorax.

Right hemothorax.

Treatment

• ABC’s with c-spine control as indicated• Secure Airway assist ventilation if necessary • Monitor Cardiac Rhythm.• Establish Large Bore IV preferably 2 and draw

blood samples.• General Shock Care due to Blood loss.• Consider Left Lateral Recumbent position if

not contraindicated

• Diagnostic needle aspiration is performed.• if the patient has any respiratory distress, perform

thoracostomy.( ICD PLACEMENT).• Surgical exploration in cases of traumatic

hemothorax-1. Evacuation of more than 1000 mL of blood2. Continued bleeding from the chest, 150-200

mL/hr for 2-4 hours3. Repeated blood transfusion..

Insertion of chest tube.

Tension pneumothorax

• presence of air or gas in the pleural cavity.

• life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function.

Tension PneumothoraxEach time we inhale,

the lung collapses further. Thereis no place for the air to

escape..

left-sided tension pneumothorax,

Patho-physology

• disruption involves the visceral pleura, parietal pleura, or the tracheobronchial tree.

• injured tissue forms a one-way valve... pressure rises within the affected hemithorax. Leads to hypoxia.

• mediastinum to shift toward the contralateral side impair the venous return to the right atrium.

S/S of Tension Pneumothorax

• Anxiety/Restlessness• Severe Dyspnea• Absent Breath sounds on affected side• Tachypnea• Tachycardia

• Accessory Muscle Use• JVD• Narrowing Pulse Pressures• Hypotension• Tracheal Deviation(late if seen at all)

• Tension pneumothorax primarily is a clinical diagnosis .

• chest radiography CT THORAX.

• ABG analysis may be useful in evaluating hypoxia and hypercarbia and respiratory acidosis.

Treatment

• ABC’s with c-spine as indicated• High Flow oxygen including BVM• Monitor Cardiac Rhythm• Establish IV access and Draw Blood Samples• Treat for S/S of Shock• Needle Decompression of Affected Side

Needle Decompression

• Locate 2-3 Intercostal space midclavicular line• Cleanse area using aseptic technique• Insert catheter ( 14g or larger) at least 3” in length

over the top of the 3rd rib( nerve, artery, vein lie along bottom of rib)

• Remove Stylette and listen for rush of air• Place Flutter valve over catheter• Reassess for Improvement

Needle Decompression

Classic examination findings

Cardiac tamponade

• accumulation of fluid in the pericardial space.

• reduced ventricular filling and subsequent hemodynamic compromise.

• complications of which include pulmonary edema, shock, and death.

Patho-physology

• The pericardium, which is the membrane surrounding the heart, is composed of 2 layers.

• thicker parietal pericardium & thinner visceral pericardium

• The pericardial space normally contains 20-50mL of fluid.

Reddy -3 phases of hemodynamic changes

• Phase I - pericardial fluid impairs relaxation and filling of the ventricles, requiring a higher filling pressure; the left and right ventricular filling pressures are higher than the intrapericardial pressure.

• Phase II - With further fluid accumulation, the pericardial pressure increases above the ventricular filling pressure, resulting in reduced cardiac output

• Phase III - A further decrease in cardiac output occurs, which is due to the equilibration of pericardial and left ventricular (LV) filling pressures

• The amount of pericardial fluid needed to impair diastolic filling of the heart depends on the rate of fluid accumulation and the compliance of the pericardium.

• Rapid accumulation of as little as 150mL of fluid -impede cardiac output

• 1000 mL of fluid may accumulate over a longer period without any significant effect.

S/S of Pericardial Tamponade

• Distended Neck Veins• Increased Heart Rate• Respiratory Rate increases• Narrowing Pulse Pressures• Hypotension

• Chest radiography findings may show cardiomegaly .

• Echocardiography• 12-lead electrocardiogram-

• Sinus tachycardia• Low-voltage QRS complexes

• Electrical alternans -• PR segment depression

Pericardial Tamponade

sinus tachycardia with electrical alternans

Treatment

• ABC’s with c-spine control as indicated• High Flow oxygen which may include BVM• Cardiac Monitor• Large Bore IV access • Treat S/S of shock• What patient needs is pericardiocentesis

Pericardiocentesis• Using aseptic technique, Insert at least 3” needle at

the angle of the Xiphoid Cartilage at the 7th rib• Advance needle at 45 degree towards the clavicle

while aspirating syringe till blood return is seen• Continue to Aspirate till syringe is full then discard

blood and attempt again till signs of no more blood• Closely monitor patient due to small about of blood

aspirated can cause a rapid change in blood pressure

Pericardiocentesis

systemic Air embolism

• Systemic air or gas embolism has been increasingly recognized as a complication of serious chest trauma and often presents with catastrophic circulatory and cerebral events.

• The classic findings are hemoptysis, sudden cardiac or cerebral dysfunction after initiation of PPV, air in retinal vessels, and air in arterial aspirations.

• Several diagnostic tools (TEE, Doppler, CT) can detect intracardiac and cerebral air, but they may not be necessary to confirm the diagnosis of SAE.

• Spontaneous ventilation is preferred . • When PPV is necessary ,isolate the injured

lung.

ADDITIONAL POINTS

• Stab wound any where in “thoracic mantle” should be suspected of producing cardiac injury.

• Gun wounds anywhere in vicinity of the chest should be suspected of producing cardiac injury because of the unpredictable of bullets in the body.

• Finger control can stop bleeding from most wounds of the atria ,ventricles and aorta. application of clamps and instruments urgently is usually not necessary and can cause severe injury.

• Because of the position of the diaphragm in expiration, injuries anywhere below the nipples may produce intra-abdominal as well as intrathoaracic injury.

• Emergency room thoracotomy is indicated only for penetrating cardiac injuries in patients in extremis.

• The approach to transmediastinal gun shot wounds does not always mandate surgery.

• “focussed assessment with sonography in trauma” can detect blood not only in pericardium but also in abdomen and chest.

•Thank you