Chest Trauma Final

Chest Trauma

M. Asim Vine2011-007

ATOM FC oA – airway obstruction oT – tension pneumothorax oO – Open pneumothorax oM – massive hemothorax oF – flail chest oC – cardiac tamponade

Immediate Life-Threatening Injuries

ATOM PDoA – aortic disruption oT – tracheobronchial injury oO – esophageal injury oM – myocardial contusion oP – pulmonary contusion and

pneumothorax oD – diaphragmatic rupture

Potentially Life-Threatening Injuries

A 65-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation on the seventh rib, at the level of the anterior axillary line. Chest x-ray confirms the presence of a rib fracture, with no other abdominal findings

Rib Fracture

Lead to Pneumothorax (rib fragments lacerate lung parenchyma) Hemothorax (rib fragments lacerate intercostal vessels) Pain hypoventilation atelectasis

pneumonia

Rib Fracture

May indicate other potential injuries Ribs 1-3

head injury, spinal injury, great vessel injury

Ribs 10-12 hepatosplenic injury

Rib Fracture

Management Analgesia – oral, i.v., intercostal block

with L.A, epidural Chest drain (if associated with

pneumo/hemothorax) Chest physiotherapy Frequent ABGs in the elderly or patients

with coexistent lung disease to assess impending respiratory failure

Rib Fracture

A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. There are no breath sounds on the right which is hyper resonant to percussion.

Plain Pneumothorax

Penetrating trauma

Laceration of lung parenchyma

Air entry into pleural space

Loss of negative intrapleural pressure

Lung collapse

V/Q mismatching

Hypoxia

Plain Pneumothorax

Signs: Shortness of breath Tachypnea Cyanosis Use of accessory muscles Absent breath sounds Hyper resonant to percussion

Management: CXR Chest tube

Plain Pneumothorax

• A 25-year-old man is stabbed in the right chest. He is moderately short of breath and has stable vital signs. The base of the right chest has no breath sounds and is dull to percussion. He has faint distant breath sounds at the apex.

• A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood pressure of 95 over 70, pulse rate of 100. No breath sounds are heard over the right chest, which is dull to percussion. Chest x-ray shows a large hemothorax on the right. A chest tube placed at the right pleural base recovers 1,250 ml of blood.

Hemothorax

Signs: Dull to percussion

Diagnosis: CXR

Hemothorax

Treatment: Evacuation of blood to prevent empyema

(chest tube) Bleeding in lung usually stops by itself (low

pressure system) If systemic vessel is the source of bleeding,

thoracotomy is needed Indications for surgery:

1,500 ml ore more with chest tube insertion Collection of 600 ml in tube drainage over

next 6 hours

Hemothorax

Obvious injuries + hidden injuries Blood gases + CXR pulmonary

contusions Cardiac enzymes (troponins) + ECG

myocardial contusions

Severe Blunt Trauma to Chest

A worker has been injured at an explosion in a factory. He has multiple cuts and lacerations from flying debris, and he is obviously short of breath. The paramedics at the scene of the accident ascertain that he has a large, flap like wound in the chest wall, about 5 cm in diameter, and he sucks air through it with every inspiratory effort.

Tension Pneumothorax

Flap that sucks air with inspiration and closes during expiration

Tension Pneumothorax

Management Placement of a wide bore cannula in the

2nd intercostal space in the mid-clavicular line

Replacement of cannula with chest drain Tension pneumothorax has been

converted to a simple pneumothorax

Tension Pneumothorax

Signs and Symptoms Tachypnea Use of accessory muscles Cyanosis Hypotension (due to kinking of vena cava and

decreased venous return) Deviated trachea (away from affected side) Distended neck veins Hyper-resonant percussion Absent breath sounds

Tension Pneumothorax

Produced by injuries that cause large defects of the chest wall i.e. gunshot wound

Equalization of intra-thoracic and atmospheric pressure

If defect is >2/3 diameter of trachea, air enters defect and bypasses lung, with resultant hypoxia

Open (Sucking) Pneumothorax

Management Dressing secured on three sides to create

a ‘flutter-valve’ Chest drain distant from the injury

Open (Sucking) Pneumothorax

• A 54-year-old woman crashes her car against a telephone pole at high speed. On arrival at the ER she is in moderate respiratory distress. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales.

Flail Chest

Occurs with multiple rib fractures Segment of chest wall caves in during inspiration

and bulge out during expiration (paradoxic breathing)

Flail Chest

Signs and Symptoms • Pain • Bruising • Tachypnea • Paradoxical respiratory movement

Underlying pulmonary contusion (sensitive to fluid overload)

Flail Chest

Monitoring of blood gases

• Bilateral chest tubes

• Investigate traumatic transection of aorta

– X-ray: wide mediastinum

if -ve

spiral CT: aortic lesion

if +ve x-ray and –ve CT

arteriogram

Flail Chest

Management • Analgesia • High flow oxygen

Treatment Fluid restriction Colloids (plasma or albumin) Diuretics

Flail Chest

Beck Triad Shock Distended Neck Veins Diminished heart sounds Transesophageal Echocardiagraphy,

Subxiphoid pericardial exploration Surgical treatment via Median sternotomy

Pericardial Temponade

A 54-year-old woman crashes her car against a telephone pole at high speed. On arrival at the ER she is breathing well. She has multiple bruises over the chest, and multiple sites of point tenderness over the ribs. X-ray shows multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white-out” on x-rays and she is in respiratory distress

Pulmonary Contusion

Occurs with chest trauma Hemorrhage and edema in lung

parenchyma,

impairment of gas exchange respiratory failure

Pulmonary Contusion

Deteriorating blood gases CXR: white out of lungs (may appear 48 hours later) Treatment:

Same as for flail chest

Pulmonary Contusion

A 54-year-old woman crashes her car against a telephone pole at high speed. On arrival at the ER she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a gritty feeling of bone grafting on bone, elicited by palpation

Myocardial Contusion

The most common causes are: Auto-pedestrian accident injuries Cardiopulmonary resuscitation Falls from heights greater than 20 feet Motor vehicle accidents (usually due to the driver coming into contact

with the steering wheel)

Myocardial Contusion

A severe myocardial contusion may lead to signs and symptoms of a heart attack

Pain in the breastbone (sternum) or front of the ribs alerts the physician that there may have been an injury. There may also be a feeling that your heart is racing

Other symptoms may include: Light-headedness Nausea or vomiting Shortness of breath Weakness

Myocardial Contusion

Physical exams may show: Bruises (contusions) or scrapes (abrasions) of

the chest wall Crepitus Tachycardia Irregular heartbeat Low blood pressure Rapid or shallow breathing Tenderness to the touch Visible abnormal chest wall movement from

rib fractures (flail segment)

Myocardial Contusion

Suspected in sternal fractures ECG monitoring

Multiple ectopics Sinus tachycardia Atrial fibrillation Raised ST segment (similar to an MI)

Troponin levels Treatment for complications such as

arrhythmias

Myocardial Contusion

• Ultimate ‘hidden’ injury • Junction of the arch and descending aorta • Hard to break bones– Sternum – 1st rib – Scapula

• Suspicion– Fracture of above bones – Big deceleration injury

Traumatic Rupture of Aorta

CXR Transesophageal echocardiography Spiral CT scan MRI angiography If wide mediastinum aortogram Treatment: surgery

Traumatic Rupture of Aorta

A 34-year-old woman suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, head trauma, and pneumothorax on the left side. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck.

Traumatic Rupture of Trachea or Major Bronchus

Larynx Hoarseness, stridor, subcutaneous

emphysema Management: intubation

Trachea Noisy breathing and visible bubbles from a

neck wound Management: surgical repair

Traumatic Rupture of Trachea or Major Bronchus

Bronchi Usually fatal at the scene Deceleration injury Hemoptysis, subcutaneous emphysema,

tension pneumothorax, large air leak after chest drain insertion

Management: bronchoscopy is diagnostic, intubation of the opposite bronchi if acutely hypoxic, surgical repair

Traumatic Rupture of Trachea or Major Bronchus

Subcutaneous emphysema in upper chest and lower neck

Large ‘air leak’ from a chest tube CXR – air in tissues Fiberoptic bronchoscopy – identification of

lesion + intubation to secure airway Surgical repair

Traumatic Rupture of Trachea or Major Bronchus

A patient who sustained a penetrating injury of the chest has been intubated and placed on a respiratory, and a chest tube has been placed in the appropriate pleural cavity. The patient had been hemodynamically stable throughout, but then suddenly goes into cardiac arrest.

Air Embolism

Sudden death in chest trauma patient who is intubated and on a respirator

Subclavian vein open to air Supraclavicular node biopsies Central venous line placement

Immediate management Cardiac massage with patient positioned with

the left side down

Air Embolism

Due to deceleration injury Most common point of

rupture is ligamentum arteriosum

Tear may be contained by adventitia (but in general is universally fatal at the scene)

Aortic Disruption

Signs and Symptoms Decreased or absent femoral pulses Unequal arm BPs Widened mediastinum on CXR

Management Arch aortagram (gold standard) CT angiogram Surgical repair

Aortic Disruption

Signs Shock Hemothorax Investigations Aortography Endoscopy with radiographic swallow study Echocardiography Intervention Median Sternotomy

Penetrating TraumaGreat Vessels

A 53-year-old man is involved in high-speed automobile collision. He has moderate respiratory distress. Physical examination shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest x-ray shows multiple air fluid levels in the left chest.

Traumatic Rupture of Diaphragm

Caused by Blunt and penetrating trauma Accompanied by other injuries In Chest Xray – Mediastinal shift, raised

diaphragm and air fluid levels in chest Usually on left Repaired during laprotomy Herniation of abdominal viscera possible

Traumatic Rupture of Diaphragm

Thank you!