CHEST TRAUMA

CDR JOHN P WEI, USN MC MD4th Medical Battallion, 4th MLG

BSRF-12

CHEST TRAUMA• Blunt versus penetrating traumaBlunt versus penetrating trauma• Injury dependent on mechanismInjury dependent on mechanism• Motor vehicle accidentMotor vehicle accident• Fall from heightFall from height• Physical assaultPhysical assault• Explosive blastExplosive blast• Gunshot woundGunshot wound• Stab woundStab wound

CHEST TRAUMABlunt force injuries from assault or fall from heightBony fracturesLung injuriesCardiac contusion

CHEST TRAUMA

Acceleration : Deceleration Injuries

CHEST TRAUMAPenetrating injuries:Gunshot woundsStabbing wounds

CHEST TRAUMA

• Improved field diagnosis and treatment of life threatening conditions

• Rapid evacuation to higher level of care• High risk of death despite acute

intervention• Need for prompt diagnosis and

treatment

CHEST TRAUMA

Chest wall and ribsLungs and pleuraGreat and thoracic

vesselsHeart and

mediastinal structures

Diaphragm

CHEST TRAUMA

Common Injuries• Rib fractures• Sternal fractures• Open or Closed Pneumothorax - unilateral / bilateral• Hemothorax• Hemopneumothorax

CHEST TRAUMA

Clinical consequences associated with:• Mechanism of injury• Location of injury• Associated injuries• Co-morbidities

CHEST TRAUMA

Blunt injuries managed non-operativelyManagement of airway / oxygenationAnalgesiaIntubation and ventilator support if

neededChest tubes if needed for pneumothorax

or hemothorax

CHEST TRAUMA

PENETRATING INJURIESPENETRATING INJURIESTrajectory across chestTrajectory across chestMechanism due to knife or gunshotMechanism due to knife or gunshotType of bulletType of bullet

CHEST TRAUMAINITIAL MANAGEMENT• Airway, Breathing, Circulation• PRIMARY SURVEY• Identify & treat immediately life threatening

conditions

CHEST TRAUMA

Early intervention directed toward diagnosing and treating:

• Tension pneumothorax• Massive hemothorax• Open pneumothorax• Cardiac tamponade• Flail chest

CHEST TRAUMA

RADIOLOGIC TESTS

Chest X-ray, usually portable

Abdominal KUB and FAST Ultrasound Exam

CAT scan, and CT Angiogram if needed

CHEST TRAUMA

Rib Fractures

Physical Diagnosis:DeformityLocalized painCrepitus

Treatment:Analgesia (PCA)Pulmonary toiletObserve for pneumothorax

CHEST TRAUMA

FLAIL CHEST

Segment of chest wall that does not havecontinuity with rest of thoracic cage• Usually 2 fractures per rib in at least 2 ribs• Segment does not contribute to lung expansion• Disrupts normal pulmonary mechanics• Accompanied by pulmonary contusion in 50% of

patients

CHEST TRAUMAFlail Chest Diagnosis:• Paradoxical chest wall movement• Poor air movement• Hypoxia

Therapy:• Pain control• Pulmonary & physical therapy• Intubation and ventilator support if needed• Fluid restriction if possible

CHEST TRAUMA

Pneumothorax or HemothoraxPneumothorax or Hemothorax• most treated with simple tube most treated with simple tube

thoracostomythoracostomy

CHEST TRAUMA Decompression of Tension Pneumothorax• large bore needle

2nd intercostal space midclavicular line

• Chest tube as definitive treatment

PULMONARY CONTUSION

• Common with blunt trauma• May be associated with laceration of

lung parenchyma• Leakage of blood and fluid into

interstitial spaces of lung• Significant inflammatory reaction to

blood components in the lung

PULMONARY CONTUSION

Parenchymal Parenchymal infiltrate seen on infiltrate seen on CXR adjacent to CXR adjacent to injured chest wallinjured chest wall

PULMONARY CONTUSION

Indications for intubation

• Respiratory distress• Hypoxia• Other injuries which compromise

respiratory effort, such as abdominal or neurologic

MYOCARDIAL CONTUSION• Physical bruising of

the cardiac muscle• Associated with

fractures of the sternum

• Any severe anterior chest injury

MYOCARDIAL CONTUSION

DIAGNOSIS: Ectopy ST elevation Tachycardia Friction rub CPK enzymes, Troponin

Monitor in ICU & treat dysrhythmias Serial enzymes Analgesia

MASSIVE HEMOTHORAXMASSIVE HEMOTHORAX• From blunt or penetrating injuries• 200cc – 1L in chest cavity seen on CXR• Treat with chest tube, if immediate drainage is

1500 cc or if 250 cc/hr for 4 hours, then immediate thoracotomy

• Bleeding may be from ribs, lung, blood vessels

AORTIC RUPTURE• Abrupt deceleration or compression injury• Sudden motion of heart / great vessels in chest• Great vessel injury may occur in 0.3 => 10%

penetrating trauma• Often rapidly fatal• 10% survive to hospital• 20% survive > 1 hour• 90% who reach hospital will die• Early diagnosis and treatment

AORTIC RUPTURE• mechanism of injury• widened

mediastinum on CXR

AORTIC RUPTURE

• CT with contrast angiogram

• Contained injury treat with BP control

• Operative repair

CARDIAC INJURY AND TAMPONADE

• Fatality rates > 80%• Mostly ventricular, right > left• Blood in pericardial sac causes tamponade• Occurs with penetrating injuries

DIAPHRAGM RUPTURE

• Associated with blunt trauma or blast injury

• Can be due to stab wounds

DIAPHRAGM RUPTURE• Surgical repair to replace herniated contents

back into abdomen• Close muscular diaphragm to restore

pulmonary function• Chest tube to treat pneumothorax

ESOPHAGEAL INJURY

Most due to penetrating traumaDifficult to diagnosisIf delayed or missed, rapid sepsis & high

mortalityRadiographyEndoscopyThoracoscopyTreatment: surgical repair via thoracotomy

EMERGENCY THORACOTOMYACUTE THORACOTOMY• Cardiac tamponade (relieved)• Vascular injury to thoracic outlet• Massive air leak• Endoscopic / radiographic evidence of

tracheal or bronchial injury• Esophageal injury• Chest tube output• immediate evacuation of 1500ml blood• or > 250cc/ hour

ER THORACOTOMY

survival rates < 8%

ER THORACOTOMY• BLUNT injury with arrest• Arriving without pulse/BP• Penetrating injury with arrest• High likelihood of isolated / correctable

intra-thoracic injury• ER THORACOTOMY in presence of : • pulse• blood pressure• organized cardiac activity

CHEST TUBE INSERTIONInsertion Site• mid or anterior axillary line behind pectoralis

major• above 5th rib avoid diaphragm

CHEST TUBE INSERTION

• Connect tube to underwater seal and suture in place

• Examine chest to check effect

• CXR to check placement and position

SUMMARY• Chest trauma may be due to blunt, Chest trauma may be due to blunt,

penetrating or combination of causespenetrating or combination of causes• Organs at risk include bony, hollow, as well Organs at risk include bony, hollow, as well

as cardiovascular structuresas cardiovascular structures• Immediate life threatening conditions need to Immediate life threatening conditions need to

be treatedbe treated• Maintenance of airway, oxygenation, and Maintenance of airway, oxygenation, and

control of hemorrhage are important goalscontrol of hemorrhage are important goals