Chest injuries

management of chest injuries

1. MANAGEMENT OF CHEST INJURIES BY DR. LAWAL GBENGA D. REGISTRAR, SURGERY DEPT. NATIONAL HOSPITAL ABUJA 28 /09/15

2. OUTLINE INTRODUCTION EPIDEMIOLOGY RELEVANT ANATOMY AETIOLOGY PATHOPHYSIOLOGY MANAGEMENT COMPLICATIONS CONCLUSION REFERENCES

3. INTRODUCTION Chest trauma is a significant source of morbidity and mortality in developed and developing nations Thoracic injuries account for 20-25% of deaths due to trauma They are either blunt or penetrating Less than 15% of chest trauma patients will require any procedure more invasive than the insertion of a chest tube

4. Epidemiology Trauma is the 4 rd commonest cause of death in US 45 % to 50% of unrestrained drivers involved in an accident have thoracic injury 25% of Motor vehicular accident (MVA) driver death due to thoracic injury Penetrating trauma, 30 % have thoracic injury Blunt trauma, 43 % have thoracic injury Associated e xtra thoracic Injuries occur in 68%-85% of chest trauma

5. Epidemiology Thomas o.m. & ogunleye o.e . Penetrating chest injuries; gunshots 60.1%, traffic accidents 27.3% Adegboye v.o . , Ladipo j.k . , Brimmo i.o . , adebo i.o. Blunt chest injuries 69% Majority of the blunt chest injuries were minor chest wall injuries 7.6% had major but stable chest wall injuries, 10.8% had flail chest injuries. Thoracic injuries without fractures of bony chest wall occurred in 13.6%. 59.1% had associated extra-thoracic injuries,

6. RELEVANT ANATOMY

7. APPROACHES TO CHEST CAVITY Median sternotomy Posterolateral thoracotomy Left anterolateral thoracotomy Clam-shell

8. THORACOTOMY INCISIONS

9. AETIOLOGY BLUNT CHEST INJURY PENETRATING CHEST INJURY MOTOR VEHICULAR ACCIDENT GUNSHOT PEDESTRIAN MOTOR VEHICULAR ACCIDENT KNIFES AND DAGGERS BLAST INJURY (IEDs & Grenades) BROKEN BOTTLE CONTACT SPORTS BLAST INJURY (IEDs & Grenades)

10. PATHOPHYSIOLOGY MECHANISM OF INJURY PENETRATING INJURY: lacerations, contusions, disruption and destruction of tissue. BLUNT INJURY: rupture, in addition to above making them more deadly For penetrating injuries, the trajectory defines the anatomical injury Low, medium or high velocity

11. PATHOPHYSIOLOGY CHEST WALL INJURY Grouped into three categories: chest wall fractures, dislocations, and barotrauma (including diaphragmatic injuries ) injuries of the pleurae, lungs, and aerodigestive tracts injuries of the heart, great arteries, veins, and lymphatics.

12. PATHOPHYSIOLOGY CHEST WALL INJURY CHEST WALL FRACTURES, DISLOCATIONS, AND BAROTRAUMA (INCLUDING DIAPHRAGMATIC INJURIES): Rib fractures and flail chest Clavicular, sternal and scapular fractures and sternoclavicular dislocations Diaphragmatic rupture

13. PATHOPHYSIOLOGY INJURIES OF THE PLEURAE, LUNGS, AND AERODIGESTIVE TRACTS: Simple / Tension / Open pneumothorax Haemothorax Pulmonary contusion and parenchymal injuries Tracheobronchial injuries Oesophageal injuries

14. PATHOPHYSIOLOGY INJURIES OF THE HEART, GREAT ARTERIES, VEINS, AND LYMPHATICS: Cardiac tamponade Cardial contusion Myocardial laceration /chamber rupture Intracardial injury: septal / valvular structural damage Coronary artery contusion / laceration Aorta, arch branches, SVC, IVC, brachiocephalic veins, pulmonary arteries and veins Commotio cordis

15. MAJOR THORACIC INJURY LETHAL SIX HIDDEN SIX AIRWAY OBSTRUCTION CONTAINED TRAUMATIC AORTIC RUPTURE FLAIL CHEST DIAPHRAGMATIC TEAR TENSION PNEUMOTHORAX ESOPHAGEAL PERFORATION OPEN PNEUMOTHORAX MAJOR TRACHEOBRONCHIAL DISRUPTION CARDIAC TAMPONADE BLUNT CARDIAC INJURY MASSIVE HEMOTHORAX PULMONARY CONTUSION

16. PATHOPHYSIOLOGY Derangements in the ventilation , perfusion, or both in combination. The pain associated with these injuries can make breathing difficult, and this may compromise ventilation. Shunting and dead space ventilation produced by these injuries can also impair oxygenation. Space-occupying lesion, such as pneumothorax, interferes with oxygenation and ventilation by compressing otherwise healthy lung parenchyma and can result in decreased blood return to the heart, circulatory compromise, and shock. Immediate and devastating exsanguination or loss of cardiac pump function can cause hypovolemic or cardiogenic shock and death.

17. MANAGEMENT ATLS protocol : Primary survey a nd Resuscitation; Secondary s urvey; Definitive Care History and examination Investigations Treatment

18. INVESTIGATIONS Laboratory Full blood count Serum chemistry Lactate levels Arterial blood gases Group and crossmatch

19. INVESTIGATIONS Imaging Trauma series; cervical spine X-ray, chest x-ray, pelvic x-ray Chest CT scan MRI Thoracic Ultrasound FAST Contrast Studies; Angiography and Esophagogram E chocardiography

20. INVESTIGATIONS 12 lead ECG Bronchoscopy Esophagoscopy Thoracoscopy

21. Cardiac tamponade

22. Diaphragm rupture

23. Tension pneumothorax

24. CLINICAL FEATURES KEY FEATURES OF CHEST WALL TRAUMA Respiratory distress Bruises on the chest wall Marks from seat belts or car tires Subcutaneous emphysema Sucking chest wound Paradoxical breathing

25. CLINICAL FEATURES Key Features of Major Vascular Injuries 10 % fortuitously reach the hospital Sentinel bleeding Radiological findings; ►mediastinal widening ►blurring of aortic outline ►tracheal shift to the right ►depression of left main bronchus

26. TREATMENT Mostly conservative Adequate analgesia Antibiotics Oxygen supplementation Tube thoracostomy - often required Chest physiotherapy Treat associated ailments

27. Flail chest Flail chest is traditionally described as the paradoxical movement of a segment of chest wall caused by fractures of 3 or more consecutive ribs anteriorly and posteriorly within each rib. Paradoxical breathing Variations include -Posterior flail segments, - Anterior flail segments, - Flail including the sternum with ribs on both sides of the thoracic cage fractured.

28. Mechanics of Flail C hest

29. Flail chest The degree of respiratory insufficiency is typically related to the underlying lung injury, rather than the chest wall abnormality. Investigations must include chest x-ray and arterial blood gases Treatment is mainly by adequate pain control and pulmonary toilet Mechanical ventilation is reserved for patients with respiratory insufficiency In general, operative fixation is most commonly performed in patients requiring a thoracotomy for other reasons or in cases of gross chest wall deformity

30. Tension pneumothorax EMERGENCY Respiratory distress Tracheal (Mediastinal) shift Hyperresonant percussion Decreased air entry Immediate needle decompression Subsequent tube thoracostomy

31. CARDIAC TAMPONADE Medical emergency Beck’s triad in less than 1/3 rd of patients Pulsus paradoxus Narrow pulse pressure Electrocardiography changes Echocardiography diagnostic

32. CARDIAC TAMPONADE MANAGEMENT: Oxygen Volume expansion Bed rest with elevation of lower limbs Inotropic drugs Avoid positive pressure mechanical ventilation Pericardiocentesis or pericardiotomy (Creation of pericardial window) Open thoracotomy and/or pericardiotomy

33. PERICARDIOCENTESIS

34. BLUNT CARDIAC INJURY Spectrum of Disease ranging from: concussion - manifested by arrhythmias, to cardiac rupture Cardiac Contusion –ECG evidence – Ultrasound evidence –Technetium Scan --Troponin

35. THORACIC AORTIC INJURY Spectrum of Injury •Intimal Tear •Tear of Intima and Media •Free Rupture

36. THORACIC AORTIC INJURY Ruptured Thoracic Aorta •90% of patients dead at the scene •50% of the patients who arrive at the hospital are dead within 24 hours without proper diagnosis and Rx.

37. THORACIC AORTIC INJURY Radiologic Signs Suggesting Ruptured Thoracic Aorta •Widened Mediastinum •Blurring of the Aorta Knob •Depression of left main stem bronchus •Ng tube shifted to the right •1st and 2nd rib fractures •Fractured sternum/scapula

38. THORACIC AORTIC INJURY Diagnosis and Rx of Ruptured Thoracic Aorta •High Index of Suspicion – Mechanism of Injury – Associated Radiologic Findings •Arterial Line •Beta Blockade •Additional blood pressure control

39. THORACIC AORTIC INJURY Methods of Diagnosis Arteriogram Helical CT Scan

40. THORACIC AORTIC INJURY Methods of Treatment •Observation with blood pressure and wall tension control •Repair – With or without graft – With or without cardiopulmonary bypass •Stent placement

41. TREATMENT (in general) Chest wall injury ; Techniques involving closure with autogenous tissue of myocutaneous flaps; where these fail prosthetic material (e.g., polypropylene mesh ,) may be used. DIAPHRAGMATIC INJURIES – Primary repair. *Approach – abdominal (in acute conditions) or thoracotomy incision

42. INDICATIONS FOR THORACOTOMY CLINICAL Massive hemothorax from tube of 1.5 litres or more Tube hourly drainage of 200ml per hour for 3 or more hours Cardiac tamponade Acute hemodynamic deterioration/cardiac arrest at trauma center Vascular injury at thoracic outlet Traumatic thoracotomy Massive air leak

43. INDICATIONS FOR THORACOTOMY RADIOLOGICAL Endoscopic/x-ray evidence of significant tracheal/bronchial injury Endoscopic/x-ray evidence of esophageal injury X-ray of great vessel injury Significant missile embolism to the heart or pulmonary artery Diaphragmatic rupture with herniation of abdominal contents.

44. EMERGENCY THORACOTOMY Thoracotomy performed at the emergency room Objectives: Release pericardial tamponade Control cardiac hemorrhage Control intrathoracic bleeding Evacuate massive air embolism Perform open cardiac massage Temporarily occlude descending aorta

45. POST OPERATIVE CARE ICU Admission AND MONITORING Analgesics and antibiotics Mechanical ventilation Inotropic support Extra Corporal Membrane Oxygenation Chest physiotherapy

46. COMPLICATIONS Wound Wound infection Wound dehiscence - particularly problematic in sternal wounds Cardiac Myocardial infarction Arrhythmias Pericarditis Ventricular aneurysm formation Septal defects Valvular insufficiency

47. COMPLICATIONS Pulmonary and bronchial Atelectasis Pneumonia Pulmonary abscess Empyema Pneumatocele, lung cyst Clotted hemothorax Fibrothorax Bronchial repair disruption Bronchopleural fistula Vascular Pseudoaneurysm Deep venous thrombosis Pulmonary embolism Missile embolism Graft infection Graft thrombosis

48. COMPLICATIONS Oesophageal Leakage of repair Mediastinitis Esophageal fistula Oesophageal stricture Bony skeleton Skeletal deformity Chronic pain Impaired pulmonary mechanics

49. PROGNOSIS The outcome and prognosis for the great majority of patients with blunt chest trauma are excellent. Most (>80%) require either no invasive therapy or, at most, a tube thoracostomy The most important determinant of outcome is the presence or absence of significant associated injuries of the central nervous system, abdomen, and pelvis.

50. CONCLUSION Chest injuries is common following incidence of trauma Most of these, arising from blunt injuries Management follows the ATLS protocol, with an index of suspicion needed for hidden but deadly injuries that may involve intrathoracic vital organs Non operative management (CTTD and oxygen therapy) is sufficient for most patients, with < 15% requiring surgical interventions

51. REFERENCES Schwartz principles of surgery, 10 th ed. Principles of surgery, Bailey & Loves , 25th ed. surgery in the tropics Badoe et al, 4th ed. Sabiston textbook of surgery, 19 th ed. Postgraduate surgery Al fallouji , 2 nd ed. www.ncbi.nlm.nih.gov.pubmed . www.emedicine.medscape.com ATLS student manual 9 th ed.