Lecture 1 Chest Trauma
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CLINIC OF THORACIC SURGERY IASI Dr.Cristina Grigorescu
BLUNT and PENETRATING INJURIES of the CHEST WALL, PLEURA, and LUNG
INCIDENCE 150.000 DEATH/YEAR (USA) <40 YEARS OLD,traumatic injury- most common cause of death. THORACIC INJURIES ¼ of deaths
EVALUATION and MANAGEMENT Initial evaluation- correcting lifethreatening conditions immediately and documenting the less serious injury for later correction. Primary survey – airway, breathing and circulation to be stabilized immediately. All parts of the physical examination are conducted in a focused manner to identify and correct potentially lethal conditions immediately.
EVALUATION and MANAGEMENT
Examination-mouth, neck focuses on identifying any symptoms of air airway obstruction. Neck veins- distention/collapse. Respiratory mechanism of chest wall motion- to detect inhibition due to rib fractures or paradoxical motion due to flail chest. Auscultation- distribution of brath sounds, their character, any crepitus present in the chest wall. Percussion- notes areas of hiperresonance /dullness. Palpation – identification of any areas of crepitus, hematomas, irregularities due to rib fractures, areas of point of tenderness due to fractures
EVALUATION and MANAGEMENT
Imaging modalities are used to confirm diagnosis suspected and to assess the efficacy of therapeutic interventions . Chest X-Ray, CT, Ultrasonography, Blood tests, Arterial presure, Pulsoximetry Arterial blood gases.
Injuries sustained as the result of thoracic trauma Traumatic asphyxia, Mediastinal and subcutaneous emphysema Rib fractures, Sternal fractures, Open wounds of the chest wall:sucking wounds, Minnor penetrating wound of the thorax’ Pulmonary contusion, Pulmonary hematoma,
TRAUMATIC ASPHYXIA
Severe blunt injury of the thorax. - Facial and upper chest petechiae, - subconjuctival hemorrages, cervical cyanosis, occasionally neurologic symptoms. Temporary impairment/loss of vision , presumed to be due to retinal edema. Factors: thoracoabdominal compression after deep inspiration against closed glottis,results in venous hypertension in the valveless cervicofacial venous system. No special treatment is required.
Mediastinal and Subcutaneous Emphysema
Injuries to the traheobronchial tree,esophagus,and lungs can lead mediastinal emphysema. Rupture of the lung substance leads to a pneumothorax. Severe blunt trauma- lacaration/rupture of a central airway. The air may dissect back along the bronchi, vessels into mediastinum. Large leak- air migration in the subcutaneous space of the neck, face, chest wall, down to the inguinal ligament, external genitalia.
Mediastinal and Subcutaneous Emphysema Tracheobronchial injury-suspected when a large amount of mediastinal air is present, especially if the pneumomediastinum seems to increase with mechanical ventilationinspection of the bronchial tree (bronchoscopy). Treatment and management should address the etiology of the mediastinal and subcutaneuos emphysema.(suture of the bronchia, decompression incisions in the skin)
RIB FRACTURES
Fracture of the one or two ribs unilaterally -identifying any associated injury, - chest pain control, to prevent hypoventilation, - decreased excursions of the chest wall and poor pulmonary hygiene may lead: atelectasis,pneumonia,respiratory failure. Terapy:epidural analgesia, early mobilization,deep respiratory efforts, frequent coughing. Pulmonary physiotherapy,nasotraheal suctioning,promt bronchoscopy for the patient enable to clear secretions. Intercostal nerve blocks, intrapleural catheter analgesia, transcutaneous electric nerve stimulation
Fractures of the first and second ribs Indicate the possible existence of additional serious intrathoracic injury. Routine aortography-to rule out associated vascular injuries. Mortality rate 36%,concomitant injuries to the head (53%), abdomen(33%), other structure within the thorax (64%).
Multiple or bilateral rib fractures Prognosis is related to the number of ribs injured, patient”s age, underlying pulmonary status. Mortality rate in elederly patient with isolated rib fracture is 10-20%
Flail chest
Instability of the chest wall from unilateral bilateral multiple rib fractures, or from disruptions of the costochondral junctions. Paradoxic chest wall motion lead to the reduction in vital capacity and to ineffective ventilation, along with associated pulmonary contusion— ARDS. T:external stabilization:sandbags,towel clips,internal stabilization using PEEP(mechanical ventilation), Operative fixation of flail segment, Mortality rate:15-20%, but survivors may have long-term consequences:impared pulmonary function: dyspnea(63%),persistent pain(49%).
Sternal fractures
4% in major motor vehicle crashes. Transverse, in the upper or midportions of the body of the sternum. Localized tenderness, swelling, deformity. X-ray confirm(in lateral view). CT examination injures of the adjacent organs and others skeletal structures. T:pain control and appropiate pulmonary hygiene. Severe displace require open reduction with internal fixation using cross wires.
Open wounds of the chest wall: sucking wounds of the chest
Loss of an area of the entire chest wall. Air can freely flow in and out of the pleural space. Life-threatening emergencies. Associated with devastating intrathoracic injuries. Collaps of the ipsilateral lung,open pneumothorax, T:cover the defect with an impermeable dressing till the operative room. Operation:removal the devitalized tissue and foreign bodies and closure the wound with muscle, musculocutaneous flap or syntetic materials for chest wall recosntruction.
Pneumothorax
Simple pneumothorax X-ray Chest tube drainage Large air leak or difficult reexpansion trahcheobronchial injuries should suspected (bronchoscopy) Tension pneumothorax Severe respiratory distress,distended neck veins, deviated trachea and absent breath sounds on the affected side. X-ray. T:needle in the pleural space in emergency, chest tube drainage.
Hemothorax Indication of Thoracoscopy in Thoracic trauma: Persistent minor hemorrhage, Retaines hemothorax, Empyema, Chylothorax, Retained foreign bodies, Treatment of persistent air leak.
Pulmonary contusion Hemorrage into the alveolar and interstitial spaces. Mortality rate : 22-30%. CT:pulmonary lacerations, infiltrate, T: ventilatory support, fluids (with diuretics), oxygen,
Pulmonary hematoma CT : opacities developed into discrete mass with distinct margins. T: antibiotic prophylactic,antiinflamatory, Pain control, hemoptysis control. If is large require surgery:pulmonary resection.
BLUNT and PENETRATING INJURIES of the CHEST WALL, PLEURA, and LUNG
INCIDENCE 150.000 DEATH/YEAR (USA) <40 YEARS OLD,traumatic injury- most common cause of death. THORACIC INJURIES ¼ of deaths
EVALUATION and MANAGEMENT Initial evaluation- correcting lifethreatening conditions immediately and documenting the less serious injury for later correction. Primary survey – airway, breathing and circulation to be stabilized immediately. All parts of the physical examination are conducted in a focused manner to identify and correct potentially lethal conditions immediately.
EVALUATION and MANAGEMENT
Examination-mouth, neck focuses on identifying any symptoms of air airway obstruction. Neck veins- distention/collapse. Respiratory mechanism of chest wall motion- to detect inhibition due to rib fractures or paradoxical motion due to flail chest. Auscultation- distribution of brath sounds, their character, any crepitus present in the chest wall. Percussion- notes areas of hiperresonance /dullness. Palpation – identification of any areas of crepitus, hematomas, irregularities due to rib fractures, areas of point of tenderness due to fractures
EVALUATION and MANAGEMENT
Imaging modalities are used to confirm diagnosis suspected and to assess the efficacy of therapeutic interventions . Chest X-Ray, CT, Ultrasonography, Blood tests, Arterial presure, Pulsoximetry Arterial blood gases.
Injuries sustained as the result of thoracic trauma Traumatic asphyxia, Mediastinal and subcutaneous emphysema Rib fractures, Sternal fractures, Open wounds of the chest wall:sucking wounds, Minnor penetrating wound of the thorax’ Pulmonary contusion, Pulmonary hematoma,
TRAUMATIC ASPHYXIA
Severe blunt injury of the thorax. - Facial and upper chest petechiae, - subconjuctival hemorrages, cervical cyanosis, occasionally neurologic symptoms. Temporary impairment/loss of vision , presumed to be due to retinal edema. Factors: thoracoabdominal compression after deep inspiration against closed glottis,results in venous hypertension in the valveless cervicofacial venous system. No special treatment is required.
Mediastinal and Subcutaneous Emphysema
Injuries to the traheobronchial tree,esophagus,and lungs can lead mediastinal emphysema. Rupture of the lung substance leads to a pneumothorax. Severe blunt trauma- lacaration/rupture of a central airway. The air may dissect back along the bronchi, vessels into mediastinum. Large leak- air migration in the subcutaneous space of the neck, face, chest wall, down to the inguinal ligament, external genitalia.
Mediastinal and Subcutaneous Emphysema Tracheobronchial injury-suspected when a large amount of mediastinal air is present, especially if the pneumomediastinum seems to increase with mechanical ventilationinspection of the bronchial tree (bronchoscopy). Treatment and management should address the etiology of the mediastinal and subcutaneuos emphysema.(suture of the bronchia, decompression incisions in the skin)
RIB FRACTURES
Fracture of the one or two ribs unilaterally -identifying any associated injury, - chest pain control, to prevent hypoventilation, - decreased excursions of the chest wall and poor pulmonary hygiene may lead: atelectasis,pneumonia,respiratory failure. Terapy:epidural analgesia, early mobilization,deep respiratory efforts, frequent coughing. Pulmonary physiotherapy,nasotraheal suctioning,promt bronchoscopy for the patient enable to clear secretions. Intercostal nerve blocks, intrapleural catheter analgesia, transcutaneous electric nerve stimulation
Fractures of the first and second ribs Indicate the possible existence of additional serious intrathoracic injury. Routine aortography-to rule out associated vascular injuries. Mortality rate 36%,concomitant injuries to the head (53%), abdomen(33%), other structure within the thorax (64%).
Multiple or bilateral rib fractures Prognosis is related to the number of ribs injured, patient”s age, underlying pulmonary status. Mortality rate in elederly patient with isolated rib fracture is 10-20%
Flail chest
Instability of the chest wall from unilateral bilateral multiple rib fractures, or from disruptions of the costochondral junctions. Paradoxic chest wall motion lead to the reduction in vital capacity and to ineffective ventilation, along with associated pulmonary contusion— ARDS. T:external stabilization:sandbags,towel clips,internal stabilization using PEEP(mechanical ventilation), Operative fixation of flail segment, Mortality rate:15-20%, but survivors may have long-term consequences:impared pulmonary function: dyspnea(63%),persistent pain(49%).
Sternal fractures
4% in major motor vehicle crashes. Transverse, in the upper or midportions of the body of the sternum. Localized tenderness, swelling, deformity. X-ray confirm(in lateral view). CT examination injures of the adjacent organs and others skeletal structures. T:pain control and appropiate pulmonary hygiene. Severe displace require open reduction with internal fixation using cross wires.
Open wounds of the chest wall: sucking wounds of the chest
Loss of an area of the entire chest wall. Air can freely flow in and out of the pleural space. Life-threatening emergencies. Associated with devastating intrathoracic injuries. Collaps of the ipsilateral lung,open pneumothorax, T:cover the defect with an impermeable dressing till the operative room. Operation:removal the devitalized tissue and foreign bodies and closure the wound with muscle, musculocutaneous flap or syntetic materials for chest wall recosntruction.
Pneumothorax
Simple pneumothorax X-ray Chest tube drainage Large air leak or difficult reexpansion trahcheobronchial injuries should suspected (bronchoscopy) Tension pneumothorax Severe respiratory distress,distended neck veins, deviated trachea and absent breath sounds on the affected side. X-ray. T:needle in the pleural space in emergency, chest tube drainage.
Hemothorax Indication of Thoracoscopy in Thoracic trauma: Persistent minor hemorrhage, Retaines hemothorax, Empyema, Chylothorax, Retained foreign bodies, Treatment of persistent air leak.
Pulmonary contusion Hemorrage into the alveolar and interstitial spaces. Mortality rate : 22-30%. CT:pulmonary lacerations, infiltrate, T: ventilatory support, fluids (with diuretics), oxygen,
Pulmonary hematoma CT : opacities developed into discrete mass with distinct margins. T: antibiotic prophylactic,antiinflamatory, Pain control, hemoptysis control. If is large require surgery:pulmonary resection.
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