CLINIC OF THORACIC SURGERY IASICLINIC OF THORACIC SURGERY IASI

Dr.Cristina GrigorescuDr.Cristina Grigorescu

BLUNT and PENETRATING BLUNT and PENETRATING

INJURIES of the CHEST WALL,INJURIES of the CHEST WALL,

PLEURA, and LUNG PLEURA, and LUNG

INCIDENCEINCIDENCE

150.000 DEATH/YEAR (USA)150.000 DEATH/YEAR (USA) <40 YEARS OLD,traumatic injury- most <40 YEARS OLD,traumatic injury- most

common cause of death.common cause of death. THORACIC INJURIES ¼ of deathsTHORACIC INJURIES ¼ of deaths

EVALUATION and MANAGEMENTEVALUATION and MANAGEMENT

Initial evaluation- correcting life-Initial evaluation- correcting life-threatening conditions immediately and threatening conditions immediately and documenting the less serious injury for documenting the less serious injury for later correction.later correction.

Primary survey – airway, breathing and Primary survey – airway, breathing and circulation to be stabilized immediately.circulation to be stabilized immediately.

All parts of the physical examination are All parts of the physical examination are conducted in a focused manner to identify conducted in a focused manner to identify and correct potentially lethal conditions and correct potentially lethal conditions immediately. immediately.

EVALUATION and MANAGEMENTEVALUATION and MANAGEMENT ExaminationExamination-mouth, neck focuses on identifying -mouth, neck focuses on identifying

any symptoms of air airway obstruction.any symptoms of air airway obstruction. Neck veins- distention/collapse.Neck veins- distention/collapse. Respiratory mechanism of chest wall motion- to Respiratory mechanism of chest wall motion- to

detect detect inhibitioninhibition due to rib fractures or due to rib fractures or paradoxical motionparadoxical motion due to flail chest. due to flail chest.

AuscultationAuscultation- distribution of brath sounds, their - distribution of brath sounds, their character, any crepitus present in the chest wall.character, any crepitus present in the chest wall.

Percussion-Percussion- notes areas of hiperresonance notes areas of hiperresonance /dullness./dullness.

PalpationPalpation – identification of any areas of crepitus, – identification of any areas of crepitus, hematomas, irregularities due to rib fractures, areas hematomas, irregularities due to rib fractures, areas of point of tenderness due to fracturesof point of tenderness due to fractures

EVALUATION and MANAGEMENTEVALUATION and MANAGEMENT

Imaging modalities are used to confirm diagnosis Imaging modalities are used to confirm diagnosis suspected and to assess the efficacy of suspected and to assess the efficacy of therapeutic interventions .therapeutic interventions .

Chest X-Ray,Chest X-Ray, CT,CT, Ultrasonography,Ultrasonography, Blood tests,Blood tests, Arterial presure,Arterial presure, PulsoximetryPulsoximetry Arterial blood gases.Arterial blood gases.

Injuries sustained as the result of Injuries sustained as the result of thoracic traumathoracic trauma

Traumatic asphyxia,Traumatic asphyxia, Mediastinal and subcutaneous Mediastinal and subcutaneous

emphysemaemphysema Rib fractures,Rib fractures, Sternal fractures,Sternal fractures, Open wounds of the chest wall:sucking Open wounds of the chest wall:sucking

wounds,wounds, Minnor penetrating wound of the thorax’Minnor penetrating wound of the thorax’ Pulmonary contusion,Pulmonary contusion, Pulmonary hematoma,Pulmonary hematoma,

TRAUMATIC ASPHYXIATRAUMATIC ASPHYXIA

Severe blunt injury of the thorax.Severe blunt injury of the thorax. - Facial and upper chest petechiae, - Facial and upper chest petechiae, - subconjuctival hemorrages, cervical cyanosis, - subconjuctival hemorrages, cervical cyanosis,

occasionally neurologic symptoms.occasionally neurologic symptoms. Temporary impairment/loss of vision , presumed Temporary impairment/loss of vision , presumed

to be due to retinal edema.to be due to retinal edema. Factors: thoracoabdominal compression after Factors: thoracoabdominal compression after

deep inspiration against closed glottis,results in deep inspiration against closed glottis,results in venous hypertension in the valveless cervicofacial venous hypertension in the valveless cervicofacial venous system.venous system.

No special treatment is required.No special treatment is required.

Mediastinal and Subcutaneous EmphysemaMediastinal and Subcutaneous Emphysema

Injuries to the traheobronchial Injuries to the traheobronchial tree,esophagus,and lungs can lead mediastinal tree,esophagus,and lungs can lead mediastinal emphysema.emphysema.

Rupture of the lung substance leads to a Rupture of the lung substance leads to a pneumothorax.pneumothorax.

Severe blunt trauma- lacaration/rupture of a Severe blunt trauma- lacaration/rupture of a central airway.central airway.

The air may dissect back along the bronchi, The air may dissect back along the bronchi, vessels into mediastinum.vessels into mediastinum.

Large leak- air migration in the subcutaneous Large leak- air migration in the subcutaneous space of the neck, face, chest wall, down to the space of the neck, face, chest wall, down to the inguinal ligament, external genitalia.inguinal ligament, external genitalia.

Mediastinal and Subcutaneous EmphysemaMediastinal and Subcutaneous Emphysema

Tracheobronchial injury-suspected when a Tracheobronchial injury-suspected when a large amount of mediastinal air is present, large amount of mediastinal air is present, especially if the pneumomediastinum especially if the pneumomediastinum seems to increase with mechanical seems to increase with mechanical ventilation- inspection of the bronchial ventilation- inspection of the bronchial tree (bronchoscopy).tree (bronchoscopy).

Treatment and management should Treatment and management should address the etiology of the mediastinal address the etiology of the mediastinal and subcutaneuos emphysema.(suture of and subcutaneuos emphysema.(suture of the bronchia, decompression incisions in the bronchia, decompression incisions in the skin)the skin)

RIB FRACTURESRIB FRACTURES

Fracture of the one or two ribs unilaterallyFracture of the one or two ribs unilaterally -identifying any associated injury,-identifying any associated injury, - chest pain control, to prevent hypoventilation,- chest pain control, to prevent hypoventilation, - decreased excursions of the chest wall and poor - decreased excursions of the chest wall and poor

pulmonary hygiene may lead: pulmonary hygiene may lead: atelectasis,pneumonia,respiratory failure.atelectasis,pneumonia,respiratory failure.

Terapy:epidural analgesia, early mobilization,deep Terapy:epidural analgesia, early mobilization,deep respiratory efforts, frequent coughing.respiratory efforts, frequent coughing.

Pulmonary physiotherapy,nasotraheal Pulmonary physiotherapy,nasotraheal suctioning,promt bronchoscopy for the patient suctioning,promt bronchoscopy for the patient enable to clear secretions.enable to clear secretions.

Intercostal nerve blocks, intrapleural catheter Intercostal nerve blocks, intrapleural catheter analgesia, transcutaneous electric nerve stimulationanalgesia, transcutaneous electric nerve stimulation

Fractures of the first and second ribsFractures of the first and second ribs

Indicate the possible existence of Indicate the possible existence of additional serious intrathoracic injury.additional serious intrathoracic injury.

Routine aortography-to rule out associated Routine aortography-to rule out associated vascular injuries.vascular injuries.

Mortality rate 36%,concomitant injuries to Mortality rate 36%,concomitant injuries to the head (53%), abdomen(33%), other the head (53%), abdomen(33%), other structure within the thorax (64%).structure within the thorax (64%).

Multiple or bilateral rib fracturesMultiple or bilateral rib fractures

Prognosis is related to the number of ribs Prognosis is related to the number of ribs injured, patient”s age, underlying injured, patient”s age, underlying pulmonary status.pulmonary status.

Mortality rate in elederly patient with Mortality rate in elederly patient with isolated rib fracture is 10-20%isolated rib fracture is 10-20%

Flail chestFlail chest

Instability of the chest wall from unilateral Instability of the chest wall from unilateral bilateral multiple rib fractures, or from disruptions bilateral multiple rib fractures, or from disruptions of the costochondral junctions.of the costochondral junctions.

Paradoxic chest wall motion lead to the reduction Paradoxic chest wall motion lead to the reduction in vital capacity and to ineffective ventilation, in vital capacity and to ineffective ventilation, along with associated pulmonary contusion—along with associated pulmonary contusion—ARDS.ARDS.

T:external stabilization:sandbags,towel T:external stabilization:sandbags,towel clips,internal stabilization using PEEP(mechanical clips,internal stabilization using PEEP(mechanical ventilation),ventilation),

Operative fixation of flail segment,Operative fixation of flail segment, Mortality rate:15-20%, but survivors may have Mortality rate:15-20%, but survivors may have

long-term consequences:impared pulmonary long-term consequences:impared pulmonary function: dyspnea(63%),persistent pain(49%). function: dyspnea(63%),persistent pain(49%).

Sternal fracturesSternal fractures

4% in major motor vehicle crashes.4% in major motor vehicle crashes. Transverse, in the upper or midportions of the Transverse, in the upper or midportions of the

body of the sternum.body of the sternum. Localized tenderness, swelling, deformity.Localized tenderness, swelling, deformity. X-ray confirm(in lateral view).X-ray confirm(in lateral view). CT examination injures of the adjacent organs CT examination injures of the adjacent organs

and others skeletal structures.and others skeletal structures. T:pain control and appropiate pulmonary hygiene.T:pain control and appropiate pulmonary hygiene. Severe displace require open reduction with Severe displace require open reduction with

internal fixation using cross wires.internal fixation using cross wires.

Open wounds of the chest wall: sucking Open wounds of the chest wall: sucking wounds of the chestwounds of the chest

Loss of an area of the entire chest wall.Loss of an area of the entire chest wall. Air can freely flow in and out of the pleural space.Air can freely flow in and out of the pleural space. Life-threatening emergencies.Life-threatening emergencies. Associated with devastating intrathoracic injuries.Associated with devastating intrathoracic injuries. Collaps of the ipsilateral lung,open Collaps of the ipsilateral lung,open

pneumothorax,pneumothorax, T:cover the defect with an impermeable dressing T:cover the defect with an impermeable dressing

till the operative room.till the operative room. Operation:removal the devitalized tissue and Operation:removal the devitalized tissue and

foreign bodies and closure the wound with foreign bodies and closure the wound with muscle, musculocutaneous flap or syntetic muscle, musculocutaneous flap or syntetic materials for chest wall recosntruction.materials for chest wall recosntruction.

PneumothoraxPneumothorax

Simple pneumothoraxSimple pneumothorax X-rayX-ray Chest tube drainageChest tube drainage Large air leak or difficult reexpansion Large air leak or difficult reexpansion

trahcheobronchial injuries should suspected trahcheobronchial injuries should suspected (bronchoscopy)(bronchoscopy)

Tension pneumothoraxTension pneumothorax Severe respiratory distress,distended neck veins, Severe respiratory distress,distended neck veins,

deviated trachea and absent breath sounds on deviated trachea and absent breath sounds on the affected side.the affected side.

X-ray.X-ray. T:needle in the pleural space in emergency, chest T:needle in the pleural space in emergency, chest

tube drainage.tube drainage.

HemothoraxHemothorax

Indication of Thoracoscopy in Thoracic Indication of Thoracoscopy in Thoracic trauma:trauma:

Persistent minor hemorrhage,Persistent minor hemorrhage, Retaines hemothorax,Retaines hemothorax, Empyema,Empyema, Chylothorax,Chylothorax, Retained foreign bodies,Retained foreign bodies, Treatment of persistent air leak.Treatment of persistent air leak.

Pulmonary contusionPulmonary contusion

Hemorrage into the alveolar and Hemorrage into the alveolar and interstitial spaces.interstitial spaces.

Mortality rate : 22-30%.Mortality rate : 22-30%. CT:pulmonary lacerations, infiltrate,CT:pulmonary lacerations, infiltrate, T: ventilatory support, fluids (with T: ventilatory support, fluids (with

diuretics), oxygen,diuretics), oxygen,

Pulmonary hematomaPulmonary hematoma

CT : opacities developed into discrete CT : opacities developed into discrete mass with distinct margins.mass with distinct margins.

T: antibiotic prophylactic,antiinflamatory,T: antibiotic prophylactic,antiinflamatory, Pain control, hemoptysis control.Pain control, hemoptysis control. If is large require surgery:pulmonary If is large require surgery:pulmonary

resection.resection.