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THORACIC TRAUMATHORACIC TRAUMA
Dr Phillipo Leo ChalyaDr Phillipo Leo ChalyaM.D. [Dar]; M.MED surg [Mak]M.D. [Dar]; M.MED surg [Mak]
Surgeon Specialist - BMCSurgeon Specialist - BMC
11
22
OUTLINEOUTLINE
DefinitionDefinition EpidemiologyEpidemiology Etiology Etiology Mechanism of injuryMechanism of injury ClassificationClassification PathophysiologyPathophysiology Clinical presentationClinical presentation Workup Workup ManagementManagement ComplicationsComplications Summary Summary
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DEFINITIONDEFINITION
Thoracic trauma is not a Thoracic trauma is not a single entitysingle entity
It refers to as injuries of the It refers to as injuries of the thoracic cage and its internal thoracic cage and its internal and associated structuresand associated structures
It is one of the surgical It is one of the surgical emergenciesemergencies
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EPIDEMIOLOGYEPIDEMIOLOGY
IncidenceIncidenceMorbidity / mortalityMorbidity / mortalityAge Age Sex Sex Race Race
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IncidenceIncidence
Varies both geographically and Varies both geographically and with SESwith SES
In the US, S/America, Africa and In the US, S/America, Africa and Asia incidence of penetrating Asia incidence of penetrating injuries is injuries is ↑ due to criminal or ↑ due to criminal or military activitiesmilitary activities
In Europe blunt injuries is In Europe blunt injuries is ↑ ↑ mainly due to RTAmainly due to RTA
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Morbidity / mortalityMorbidity / mortality Thoracic trauma is associated with Thoracic trauma is associated with
significant mortality and morbiditysignificant mortality and morbidity Chest trauma accounts for 25% of all Chest trauma accounts for 25% of all
trauma deathstrauma deaths 2/3 of deaths occur after reaching hospital2/3 of deaths occur after reaching hospital Serious pathological consequences:Serious pathological consequences:
-- HypoxiaHypoxia HypovolaemiaHypovolaemia Myocardial failureMyocardial failure
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AgeAge
Trauma including chest Trauma including chest trauma is the leading trauma is the leading cause of deaths among cause of deaths among people between 1-44 people between 1-44 years of ageyears of age
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Race Race Studies reported no racial Studies reported no racial predilection to thoracic predilection to thoracic injuriesinjuries
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AETIOLOGYAETIOLOGYRoad traffic accidentRoad traffic accidentAssaultAssaultWar injuriesWar injuriesFallsFallsSport injuriesSport injuriesAircraft accidentAircraft accidentStab woundStab woundBullet injuriesBullet injuriesetcetc
1111
MECHANISM OF INJURYMECHANISM OF INJURY
Blunt thoracic injuriesBlunt thoracic injuriesPenetrating thoracic Penetrating thoracic injuriesinjuries
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Blunt thoracic injuriesBlunt thoracic injuries
Direct trauma to the chest cageDirect trauma to the chest cage The victim is struck in the chest by a moving The victim is struck in the chest by a moving
object object →→fractures of the ribs, contused lungs fractures of the ribs, contused lungs etcetc
Compression thoracic injuriesCompression thoracic injuries The chest is injured by compression The chest is injured by compression → →
diaphragmatic rupture, cardiac & lung diaphragmatic rupture, cardiac & lung contusioncontusion
Deceleration thoracic injuriesDeceleration thoracic injuries These are injuries resulting from rapid These are injuries resulting from rapid
deceleration of the body with continuing deceleration of the body with continuing moving of the internal thoracic organsmoving of the internal thoracic organs→ → aortic aortic rupture (tear), cardiac and pulmonary contusionrupture (tear), cardiac and pulmonary contusion
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Penetrating thoracic injuriesPenetrating thoracic injuriesThe degree of tissue damage is The degree of tissue damage is
proportional to the Kinetic Energy proportional to the Kinetic Energy [K.E.] of the penetrating object[K.E.] of the penetrating object
K.E. = 1/2mvK.E. = 1/2mv22, therefore K.E. , therefore K.E. αα mv mv22 The velocity of the penetrating object The velocity of the penetrating object
is the major determinant of tissue is the major determinant of tissue damage than the mass of an objectdamage than the mass of an object
The high the velocity the more energy The high the velocity the more energy generated and therefore more tissue generated and therefore more tissue damagedamage
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Penetrating injuries [cont] Penetrating injuries [cont]
The mechanism of injury in The mechanism of injury in penetrating thoracic injuries can penetrating thoracic injuries can categorized as:-categorized as:- Low velocity thoracic injuriesLow velocity thoracic injuries
E.g. stab woundsE.g. stab wounds Velocity < 1200ft/s injuriesVelocity < 1200ft/s injuries
Medium velocity thoracic injuriesMedium velocity thoracic injuries E.g. Most handgunsE.g. Most handguns Velocity 1200-2000ft/sVelocity 1200-2000ft/s
High velocity thoracic injuriesHigh velocity thoracic injuries E.g. most war weapons eg riflesE.g. most war weapons eg rifles Velocity > 2000ft/sVelocity > 2000ft/s
1515
CLASSIFICATIONSCLASSIFICATIONS
Classified according to:-Classified according to:-Mechanism of injuryMechanism of injurySite of injuries/anatomical Site of injuries/anatomical
classificationclassification
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Mechanism of injuryMechanism of injury
Blunt thoracic injuriesBlunt thoracic injuriesPenetrating thoracic injuriesPenetrating thoracic injuries
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Site of injuries/anatomical classification
Site of injuries/anatomical classification
Chest wall injuriesChest wall injuriesPleural injuriesPleural injuriesPulmonary injuriesPulmonary injuriesMediastinal injuriesMediastinal injuries
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Chest wall injuriesChest wall injuries
Soft tissue injuriesSoft tissue injuriesBony injuriesBony injuries
Rib #sRib #sFlail chestFlail chestSternum #Sternum #Clavicle #Clavicle #Thoracic spine injuryThoracic spine injury
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Pleural injuriesPleural injuries
PneumothoraxPneumothoraxClosed pneumothoraxClosed pneumothoraxOpen pneumothoraxOpen pneumothoraxTension pneumothoraxTension pneumothorax
HemothoraxHemothoraxPneumohemothorax Pneumohemothorax
2020
Pulmonary injuriesPulmonary injuries
Laceration Laceration ContusionContusionHaematoma Haematoma Crush injury with fragmentation of Crush injury with fragmentation of
the lungthe lung
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Mediastinal injuriesMediastinal injuries
Cardiac injuryCardiac injuryTracheo-broncheal injuryTracheo-broncheal injuryCardio-pulmonary injuryCardio-pulmonary injuryThoracic duct injuryThoracic duct injuryDiaphragmatic injuryDiaphragmatic injury
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PATHOPHYSIOLOGY PATHOPHYSIOLOGY
Thoracic injury results into Thoracic injury results into three pathophysiological three pathophysiological consequencesconsequences
These are:-These are:-HypoxemiaHypoxemiaHypovolaemiaHypovolaemiaMyocardial failureMyocardial failure
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Hypoxaemia Hypoxaemia Refers to Refers to PaOPaO2 2 or or O2 contents in arterial O2 contents in arterial
bloodblood Results from any injury that disturbs Results from any injury that disturbs
airway or ventilation including:-airway or ventilation including:- Airway obstructionAirway obstruction PneumothoraxPneumothorax Flail chestFlail chest Lung contusionLung contusion Tracheobroncheal injuryTracheobroncheal injury Diaphragmatic rupture Diaphragmatic rupture
Each of these injuries limits the Each of these injuries limits the physiologic function of air exchangephysiologic function of air exchange
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Hypovolaemia Hypovolaemia
Refers to as Refers to as in blood volume in blood volumeResults from intrathoracic Results from intrathoracic haemorrhage secondary to haemorrhage secondary to rib #s, injury to the lung rib #s, injury to the lung parenchyma or intercostal parenchyma or intercostal vesselsvessels
2525
Myocardial failureMyocardial failure
Refers to as failure of the heart to Refers to as failure of the heart to pump blood to the general circulationpump blood to the general circulation
May be caused by either May be caused by either blunt blunt or or penetrating thoracic injurypenetrating thoracic injury
Causes of myocardial failure include:-Causes of myocardial failure include:-Cardiac contusionCardiac contusionPericardial effusionPericardial effusionRupture of ventricular septum or Rupture of ventricular septum or
vulvular muscle vulvular muscle Coronary air embolusCoronary air embolus
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CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS
History History Physical examinationPhysical examination
General examinationGeneral examinationSystemic examinationSystemic examinationLocal examinationLocal examination
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History History
History of chest traumaHistory of chest traumaChest painChest painDifficulty in breathingDifficulty in breathing±Haemoptysis±Haemoptysis±Cough ±Cough
2828
Physical examinationPhysical examinationGeneral examinationGeneral examination
Dyspnoea Dyspnoea Cyanosis Cyanosis Anemia Anemia ShockShock Level of consciousnessLevel of consciousnessPuffy appearance of surgical Puffy appearance of surgical emphysemaemphysema
Restless and gaspingRestless and gasping
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Physical examination [cont]
Physical examination [cont]
Local examinationLocal examinationOpen Chest woundOpen Chest wound →→assess assess the depththe depth
Bruises and lacerations on Bruises and lacerations on the chest wall the chest wall
Thoracic spine tendernessThoracic spine tenderness
3030
Physical examination [cont]
Physical examination [cont]
Systemic examinationSystemic examinationRespiratory systemRespiratory systemCardiovascular systemCardiovascular systemAbdominal examinationAbdominal examinationCNS examinationCNS examination
3131
WORKUPWORKUP
Laboratory studiesLaboratory studiesImaging studiesImaging studiesEndoscopic studiesEndoscopic studiesDiagnostic proceduresDiagnostic proceduresOthers Others
3232
Laboratory studiesLaboratory studies
Non- specific Non- specific Adds little informationAdds little information
Hemoglobin estimationHemoglobin estimationBlood grouping and cross-Blood grouping and cross-matchingmatching
Blood gaseous analysisBlood gaseous analysisPaCO2 PaCO2 PaO2PaO2
3333
Imaging studiesImaging studies
Plain CXR to rule out:-Plain CXR to rule out:-Rib fracturesRib fracturesHaemothoraxHaemothoraxPneumothoraxPneumothoraxHaemopneumothoraxHaemopneumothoraxCardiac temponadeCardiac temponade
3434
Imaging studies [cont]
Imaging studies [cont]
Abdominal USS [FAST]Abdominal USS [FAST]To rule out associated abdominal To rule out associated abdominal visceral injury and pleural visceral injury and pleural effusioneffusion
CT scan – CT scan – chest, brain, abdomen chest, brain, abdomen Aortogram – Aortogram – to rule out aorta to rule out aorta rupturerupture
3737
ManagementManagement
The mgt is divided into 5 phases The mgt is divided into 5 phases according to ATLS (Advanced according to ATLS (Advanced Trauma Life Support)Trauma Life Support) Phase I: Primary survey phasePhase I: Primary survey phase Phase II: Resuscitation phasePhase II: Resuscitation phase Phase III :Secondary survey phasePhase III :Secondary survey phase Phase IV: Supportive care phasePhase IV: Supportive care phase Phase V: DefinitivePhase V: Definitive treatment phase treatment phase
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Phase I: Primary survey phasePhase I: Primary survey phase
Aim: to identify life threatening Aim: to identify life threatening conditionsconditions
The life threatening conditions The life threatening conditions include:-include:- A=AirwayA=Airway B=BreathingB=Breathing C=CirculationC=Circulation D=DisabilityD=Disability E=Exposure E=Exposure
This should go hand in hand with the This should go hand in hand with the phase IIphase II
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Phase II. Resuscitation phasePhase II. Resuscitation phase
Aim: to treat the immediately life Aim: to treat the immediately life threatening conditionthreatening condition Airway –secure airway & Immobilize Airway –secure airway & Immobilize the cervical spinethe cervical spine
Breathing – optimize ventilationBreathing – optimize ventilation Circulation- establish i.v. accessCirculation- establish i.v. access Disability- assess neurological deficitDisability- assess neurological deficit Expose the patient to avoid missed Expose the patient to avoid missed injuryinjury
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Airway Airway
A clear patent and functional airway A clear patent and functional airway should be establishedshould be established
This can be achieved by:-This can be achieved by:-Use of airwaysUse of airwaysProper position of the patientProper position of the patientEndotracheal intubationEndotracheal intubationAmbubags Ambubags TracheostomyTracheostomy
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Breathing / VentilationBreathing / Ventilation
Achieved by:-Achieved by:- Make sure the patient is Make sure the patient is breathing properlybreathing properly use of oxygen masksuse of oxygen masksMechanical ventilatorsMechanical ventilators
4242
Circulation Circulation Patients with thoracic trauma may Patients with thoracic trauma may
be associated with massive blood be associated with massive blood loss leading to hemorrhagic shockloss leading to hemorrhagic shock
A functional i.v. fluid should be A functional i.v. fluid should be established to restore blood volume established to restore blood volume and prevent irreversible shockand prevent irreversible shock
During the shock state use During the shock state use crystalloid fluidcrystalloid fluid
BT should be given in case of BT should be given in case of hemorrhagic shockhemorrhagic shock
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Dysfunction of CNS Dysfunction of CNS
Neurologic evaluation should be Neurologic evaluation should be assessed as follows:-assessed as follows:-Levels of consciousness using GCSLevels of consciousness using GCSPupil size and response to lightPupil size and response to lightMotor activity and tactile sensationMotor activity and tactile sensationOculocephalic [doll’s eye]Oculocephalic [doll’s eye]
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Exposure of the patient
Exposure of the patient
TheThe patient should be fully patient should be fully exposed/ undressed to exposed/ undressed to avoid missed injuriesavoid missed injuries
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Phase III :Secondary survey phasePhase III :Secondary survey phase
Not started until phase I Not started until phase I &II are complete&II are complete
This include:-This include:- HistoryHistory Physical examinationPhysical examination Investigations Investigations
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History History
Take history from relatives, Take history from relatives, friends, ambulance staff, friends, ambulance staff, police etcpolice etc
Mechanism of injuryMechanism of injuryWhen was the injuryWhen was the injuryMechanism of impactMechanism of impactType of weaponType of weapon
4747
History [cont]History [cont]
AMPLE historyAMPLE historyA= history of allergies A= history of allergies M= medications M= medications P= pre-morbid illnessP= pre-morbid illnessL= last meal L= last meal E= events surrounding injuryE= events surrounding injury
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History [cont]History [cont]
Associated injuriesAssociated injuries HeadHead Abdominal injuriesAbdominal injuries Major long bone fracturesMajor long bone fractures SpinesSpines Pelvic fracturesPelvic fractures
4949
History [cont]History [cont]
Other symptoms Other symptoms Loss of consciousnessLoss of consciousness Bleeding from the ENTBleeding from the ENT
5050
Physical examinationPhysical examination
General examinationGeneral examination Local examinationLocal examination Systemic examinationSystemic examination
5151
General examinationGeneral examination
Dyspnoea Dyspnoea CyanosisCyanosis AnaemiaAnaemia Shock Shock Level of consciousness Level of consciousness etcetc
5252
Local examinationLocal examination
Look for:-Look for:- Open chest wound- assess Open chest wound- assess the depththe depth
Bruises and lacerations on Bruises and lacerations on the chest wallthe chest wall
Thoracic spines tendernessThoracic spines tenderness
5353
Systemic examinationSystemic examination
Respiration examinationRespiration examination Cardiovascular Cardiovascular examinationexamination
Abdominal examinationAbdominal examination etcetc
5454
Respiration examinationRespiration examination
Inspection Inspection Look for:-Look for:-
Decreased chest movementDecreased chest movement Paradoxical respirationParadoxical respiration
5555
Respiration examination [cont]
Respiration examination [cont]
Palpation Palpation Feel for:-Feel for:- Tracheal / Mediastinal shiftTracheal / Mediastinal shift Tenderness over the chest wallTenderness over the chest wall Creptus of rib fractures Creptus of rib fractures → do → do compression test to rule out rib #scompression test to rule out rib #s
SternumSternum Crackly feeling of surgical Crackly feeling of surgical emphysemaemphysema
5656
Respiration examination [cont]
Respiration examination [cont]
Percussion Percussion Should be done gentlyShould be done gently Dullness – haemothorax/lung Dullness – haemothorax/lung collapsecollapse
Hyper-resonant- pneumothoraxHyper-resonant- pneumothorax Increased cardiac dullness- Increased cardiac dullness- hemopericardiumhemopericardium
5757
Respiration examination [cont]
Respiration examination [cont]
AuscultationAuscultation Note the following:-Note the following:-
Clicking sounds from rib #Clicking sounds from rib # Course creptations of surgical emphysemaCourse creptations of surgical emphysema or absence of breath sounds on the or absence of breath sounds on the
affected side indicating fluid or air in the affected side indicating fluid or air in the pleural cavity or collapsed lungpleural cavity or collapsed lung
High pitched breath sounds suggesting High pitched breath sounds suggesting tension pneumothoraxtension pneumothorax
Presence of breath sounds suggesting Presence of breath sounds suggesting ruptured diaphragm ruptured diaphragm
5858
Cardiovascular examination
Cardiovascular examination
Look for:-Look for:- PulsePulse Blood pressureBlood pressure JVPJVP Apex beatApex beat ↑ ↑ cardiac dullnesscardiac dullness Pulsus paradoxicusPulsus paradoxicus
5959
Abdominal examinationAbdominal examination
Look for:-Look for:- Evidence of haematomaEvidence of haematoma Distended abdomenDistended abdomen Tenderness over the Tenderness over the epigastrium /Lt epigastrium /Lt hypochondriumhypochondrium
6060
Investigations Investigations
Lab investigationsLab investigationsHb, Blood grouping & X-Hb, Blood grouping & X-matching, blood gaseous matching, blood gaseous analysisanalysis
Imaging investigationsImaging investigationsCXR, CT scan, abdominal USCXR, CT scan, abdominal US
Aspiration tapAspiration tap
6161
Phase IV: Supportive care phase
Phase IV: Supportive care phase
Analgesics Analgesics AntibioticsAntibioticsToxiod prophylaxisToxiod prophylaxisUrethral catheterization Urethral catheterization Monitor:-Monitor:-
Vital signsVital signsInput/outputInput/output
6262
Phase V: Definitive treatment phase
Phase V: Definitive treatment phase
Depends on the type of injuryDepends on the type of injury Open chest woundOpen chest wound
Treatment: surgical toilet, Treatment: surgical toilet, closure of the woundclosure of the wound
Simple rib#Simple rib#Treatment: bed rest, Treatment: bed rest, analgesics, antibiotics, analgesics, antibiotics, physiotherapy as soon as pain physiotherapy as soon as pain
6363
Phase V: Definitive treatment phase [cont]Phase V: Definitive treatment phase [cont]
Flail chestFlail chest →→internal Pneumatic internal Pneumatic Fixation ±intubation or Fixation ±intubation or tracheostomy tracheostomy
Pneumothorax,Pneumothorax, haemothorax, haemothorax, pulmonary injuriespulmonary injuries →→UWSD ± UWSD ± pneumonectomy pneumonectomy
Cardiac injuryCardiac injury →cardiac →cardiac surgery, pericardiocentesissurgery, pericardiocentesis
6464
Phase V: Definitive treatment phase [cont]Phase V: Definitive treatment phase [cont]
Diaphragmatic rupture Diaphragmatic rupture → → RepairRepair
Esophageal ruptureEsophageal rupture → → RepairRepair
Associated injuriesAssociated injuries →→ should should be managed accordinglybe managed accordingly
6565
Complications Complications
General complicationsGeneral complicationsLocal complications Local complications
6666
General complicationsGeneral complications
Haemorrhagic shockHaemorrhagic shock Cardiopulmonary failureCardiopulmonary failure Cerebral hypoxiaCerebral hypoxia HypercapnoeaHypercapnoea Neurogenic shockNeurogenic shock
6767
Local complicationsLocal complications
Thoracic wall complicationsThoracic wall complications Rib #sRib #s Flail chestFlail chest Clavical / thoracic spines /sternal #sClavical / thoracic spines /sternal #s Surgical emphysemaSurgical emphysema
6868
Local complications [cont]Local complications [cont]
Pleural complicationsPleural complications PneumothoraxPneumothorax HaemothoraxHaemothorax HaemopneumothoraxHaemopneumothorax EmpyemaEmpyema thoracis thoracis
6969
Local complications [cont]Local complications [cont]
Pulmonary complicationsPulmonary complications Lung contusionLung contusion Lung lacerationLung laceration Lung fibrosisLung fibrosis
7070
Local complications [cont]Local complications [cont]
Mediastinal complicationsMediastinal complications Cardiac temponadeCardiac temponade Pericardial effusionPericardial effusion Myocardial failureMyocardial failure Cardiopulmonary injuriesCardiopulmonary injuries Diaphragmatic ruptureDiaphragmatic rupture Esophageal injuriesEsophageal injuries
Sub-diaphragmatic injuries Sub-diaphragmatic injuries eg ruptured spleen, eg ruptured spleen, liverliver
7171
Chest trauma- SummaryChest trauma- Summary
CommonCommon SeriousSerious Primary goal is to provide oxygen to vital Primary goal is to provide oxygen to vital
organsorgans RememberRememberAAirwayirwayBBreathingreathingCCirculationirculation
DDysfunction of CNSysfunction of CNS EExposure to avoid missed injuryxposure to avoid missed injury Be alert to change in clinical condition Be alert to change in clinical condition
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