Thoracic Trauma

Thoracic Trauma

Learning Objectives Identify & initiate the Management of Immediately Life Threatening Injuries 1. Airway Obstruction 2. Tension Pneumothorax 3. Open Pneumothorax 4. Massive Hemothorax 5. Flail Chest 6. Cardiac Tamponade

Learning Objectives Identify & initiate the Management of

Potentially Life Threatening Injuries 1. Pulmonary Contusion 2. Myocardial Contusion 3. Aortic Disruption 4. Diaphragmatic Rupture 5. Tracheobronchial Disruption 6. Esophageal Disruption

Learning Objectives - Skills Ability to perform recognizing indications & complications of  Thoracic needle decompression  Chest tube insertion  Pericardiocentesis

Introduction Thoracic Injuries cause 1 out of 4 trauma deaths

Pathophysiology 

Hypoxia



Hypercarbia



Acidosis

Majority require simple procedures 

Blunt

< 10 % require operation



Penetrating

15 - 30 % require operation

Initial Assessment Primary Survey for  Airway  Breathing  Circulation Resuscitate

Hypoxia is the most serious feature of chest injury so early interventions to ensure adequate oxygenation is needed. Most life threatening injuries are treated by an appropriately placed chest tube or needle

Primary Survey of Life-Threatening Injuries  Airway

Listen for air movement at nose and mouth Assess for supracostal & intercostal retractions Assess the oropharynx for Foreign Body Obstruction

 Breathing

Expose the chest Look feel and listen for respiratory movement Tachypnea change of breathing pattern esp. shallow breathing

 Circulation

Pulse volume, rate and regularity (attach monitor) Skin color and temp BP Neck veins engorged?

Pulse Oximetry

Life Threatening Chest Injuries

Tension Pneumothorax  "One way valve" air leak from

the lung or chest, Collapse of ipsilateral lung, shift of mediastinum and collapse of opposite lung



A Clinical Diagnosis (not by radiology) Respiratory distress, tachyc ardia, hypotension tracheal deviation and neck vein distension unilateral absence of breath sounds, may be confused with cardiac tamponade, hyperresonance may help diffentiate

Management of Tension Pneumothorax Immediate decompression Needle in 2nd space followed by chest tube

Chest intubation

Open Pneumothorax  "Sucking Chest Wound"

If the opening in chest wall is equal to 2/3 of tracheal diameter, air passes preferentially through the defect

 Hypoxia due to lack of effective ventilation  Management

Promptly close the defect by sterile dressing taping on three sides to prevent tension Chest tube remote from defect Definitive repair of defect is usually required

Massive Hemothorax  Pathophysiology

Rapid accumulation of ≥ 1500 ml blood penetrating wounds disrupting systemic or hilar vessels, sometimes blunt trauma Blood loss  hypoxia

 Diagnosis

Shock + dullness + absent breath sounds Flat or distended neck veins

Massive Hemothorax Management  Restoration of blood volume (2 I/V lines)  Chest decompression (# 38 French

tube)

 If 1500 ml evacuated, or > 200 ml/hour

continous loss, operative intervention is likely required

Flail Chest  Pathophysiology

A segment of chest wall looses continuity with rest Major difficulty is Hypoxia from injury to underlying lung

 Diagnosis

Asymmetric & ncoordinated movement of chest Palpation of abnormal motion and crepitus aid diagnosis Xray chest --> # ribs ABG --> hypoxia and acidosis

Flail Chest  Management

Oxygen Re-expand lung Judicious fluid administration Intubation as indicated Analgesia

Cardiac Tamponade  Pathophysiology

Penetrating trauma Human pericardium is a fixed fibrous structure, small amount of blood required to restrict cardiac activity

 Diagnosis

Beck's Triad ( ↑ venous pressure, BP, muffled sounds) Tension Pneumothorax on left may mimmic tamponade

Look for tamponade or myocardial damage in # sternum

Cardiac Tamponade  Management

High index of suspicion is all that is needde to initiate Pericardiocentesis in patients who don't respond to usual treatment for shock and have the potential for tamponade All +ve pericardiocentesis require open pericardotomy

Technique of Pericardiocentesis

Emergency Department Resuscitative Thoracotomy  Patients with exsanguinating, penetrating precordial

injury who arrive pulseless but with electrical activity may be candidates for Emergency Department Thoracotomy

 Qualified operator, Left ant thoracotomy to gain

access, restoration of IV volume continues, endotracheal tube with ventilation is essential

Resuscitative Thoracotomy

Secondary Survey  In-depth Physical Examination  Upright Xray Chest

ABG ECG

 Detection of potentially lethal injuries 

Simple Pneumothorax Pulmonary Contusion Myocardial Contusion Aortic Rupture Diaphragmatic rupture Tracheobronchial Disruption Esophageal Disruption

Simple Pneumothorax

Hemo-pneumothorax

Pulmonary Contusion  Most common potentially lethal injury  Maintain Adequate Ventilation  Selective Intubation & Ventilation if significant

Hypoxia

 Equipment needed

Pulse Oximetry ABG determination ECG monitoring Ventilator

Myocardial Contusion  Blunt Trauma  History  Associated with sternal #  ECG changes  2D Echo  Treat Complications

Risk of sudden arrhythmias (CCU observation)

Traumatic Aortic Rupture • Most common cause • Autocrash • Fall from great height • Site: Ligamentum Arteriosum (contained hematoma)

Traumatic Aortic Rupture • Signs • Widened Mediastinum • # first & second ribs • Pleural Cap • Obliterated knuckle • Deviations of trachea, esophagus and bronchi • Obliteration of space between aorta & pulmonary artery • Salvage possible if identified early by Aortography

Tracheobronchial Tree Injuries •

Larynx • Rare • Hoarsness, Emphysema, palpable # • Treat by Intubation & Tracheostomy

•

Trachea • Partial versus complete obstruction • Endoscopy .. Diagnostic Aid • Treatment is by operation

•

Bronchi • Frequently missed, Blunt trauma • Massive air leak • Endoscopy .. Diagnostic Aid • Airway Maintanence & Operation

Esophageal Rupture 

Blunt vs Penetrating



Severe epigastric blow



Pain / Shock > Injury



Pneumothorax Without #



Chest tube --> Particulate matter



Mediastinal Air



Confirm by Contrast swallow / Esophagoscopy



Treatment by operative repair

Other manifestations of Chest Injury •

Subcutaneous Emphysema

•

Traumatic Asphyxia

•

Rib Fracture • Pain / Splinting • Impaired Ventilation & Increased secretions • Atelectasis / Pneumonia

•

Site of Rib Fracture • 1-3 ribs & Scapula # .. Severe blow, high mortality • 4-9 ribs # .. Intrathoracic injury • 10 -12 # ... Suspect abdominal Injury

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Summary • Thoracic injuries are common in polytrauma • Life-threatening Injuries need immediate attention • Potentially lethal injuries need to be looked for • Usually simple measures required

• Intubation and ventilation • Chest tube • Needle Pericardiocentesis

• Develop skills to treat • Monitoring using appropriate equipment