Chest injuries

A brief review of the management of Chest Injuries

1. CHEST INJURIES

2. AWARENESS Mortality: Thoracic injuries are responsible for 25% of trauma deaths (UK ) Thoracotomy is required in 10% of blunt injuries 20% of penetrating injuries Early recognition and management are key to patient survival

3. Mortality 1 st peak 2 nd peak 3 rd peak

4. Tri-modal peak of Mortality 1 st peak: Non-survivable severe CNS or CVS injuries Location of death: Pre-hospital environment 2 nd peak : First few hours after injury , most often due to hypoxia and hypovolemic shock Large proportion(1/3) of these patients can be saved by EMS (Emergency Medical Services). 3 rd peak: Within 6 weeks of injury Cause: Multisystem failure and sepsis Hence this is referred to as “THE GOLDEN HOUR”

5. The ATLS concept Advanced Trauma Life Support (ATLS TM ) by the American College of Surgeons Committee on Trauma Originated 1976, Dr. James Styner .

6. Three Stage Approach Primary Survey: Rapid Assessment and treatment of immediately life t hreatening injuries Secondary Survey: Detailed head-to toe assessment of potentially life threatening injuries Definitive Care: Specialist treatment of identified injuries

7. Initial Assessment A irway with cervical spine protection B reathing C irculation with haemorrhage control D isability or neurological status E xposure and Environment – remove clothing, but keep warm

8. B-Breathing and Chest Injuries Primary Survey: ARM approach Awareness, Recognition and Management

9. Recognition (Clinical Features) Look Listen Feel

10. LOOK Respiratory rate Shallow, gasping or laboured breathing : Respiratory failure? Cyanosis : Hypoxia Paradoxical Respiration: ‘Pendulum’ breathing with asynchronisation of chest and abdomen: Respiratory failure or Structural damage. Unequal chest inflation: Pneumothorax or Flail chest Bruising or contusion: ‘ Seat-Belt’ sign. Penetrating chest injury Distended neck veins :  venous return-Tension pneumothorax or cardiac tamponade

11. LISTEN Absent breath sounds : Apnoea or tension pneumothorax Noisy breathing/ Crepitations / Stridor/ Wheeze: Partially obstructed airway Reduced air entry: Pneumothorax, Haemothorax, Heamo-pnemothorax , flail chest FEEL Tracheal devitation : Mediastinal shift Tenderness: Chest wall contusion and/ rib # Crepitus/ Instabilty : Underlying rib # Surgical emphysema: ‘Bubble-wrap’ sign

12. Immediately Life-Threatening Chest Injuries (Primary Survey) 1. Tension Pneumothorax 2. Open Pneumothorax (sucking chest wound) 3. Massive Haemothorax 4. Cardiac Tamponade 5. Flail Chest 6. Disruption of Tracheo-Brochial tree

13. Potentially Life-Threatening Chest Injuries (Secondary Survey) 1. Pulmonary contusion 2. Myocardial contusion 3. Aortic disruption 4. Diaphragmatic rupture 5. Tracheobronchial rupture 6. Oesophageal rupture

14. Adjuncts Vital signs ECG Pulse oximetry End-Tidal Carbon Dioxide Arterial Blood Gas Urinary output Urethral Catheterization Nasogastric tube Chest X-Ray Pelvic X-Ray

15. Rib fracture

16. I ntroduction 1 st and 2nd ribs , protected by clavicle: when fractured are very ominous as they indicate transection of thoracic aorta or damage to brachial plexus or subclavian vein 11 th and 12 th ribs are floating ribs, usually not fractured Ribs in children are more elastic thus great force needed

17. Types of trauma Closed injury to the chest Direct trauma Single or multiple ribs fractured at the point of contact Crush injury Usually causes flail chest due to multiple sites of fracture of ribs Steering wheel injury In head on car accidents where fracture of sternum and bilateral fractures of ribs at costochondral junction Minor trauma In osteoporotic ribs, sometimes even a cough can cause a rib fracture

18. Clinical features In rib fracture without complication: Pain while taking a deep breath and exaggerated pain during coughing Inspection : Bruising Palpation : Bony irregularity, Tenderness and Crepitus X-ray usually shows a fracture rib but may miss a hairline fracture Radioscintigraphy : Detected a week or two after injury Always rule out the presence of complications and monitor the patient before diagnosing an isolated rib #

19. Treatment of uncomplicated rib fracture Reduction of pain with 2 week follow up Analgesics : Opiods NSAID’s Intercostal Blocks Strapping of chest: relieves pain by immobilizing the ribs Breathing exercises

20. Strapping Disadvantages: decreases respiratory movement (elderly) force broken ends inwards (if applied during expiration ) Strapping should include two ribs above and below the affected area and should cross midline Elastic corset can be used Local strapping

21. Surgical treatment Previously

22. PENETRATING TRAUMA

23. Causes High speed projectiles like gunshot Splinters from blasts Stab injury

24. Consequences Pneumothorax Hemothorax Trauma to the heart and great vessels Pericardial tamponade Oesophagial injury Pulmonary contusion Lung laceration Rupture of the diaphragm

25. Consequences

26. Indications for thoracotomy Internal cardiac massage Control of haemorrhage from injury to the heart Control of haemorrhage from injury to the lungs/ intrapleural haemorrhage Cardiac tamponade Ruptured oesophagus Aortic transection Control of massive air leak Traumatic diaphragmatic tear

27. Thoracotomy can be Emergency:-for control of life threatening bleeding P lanned:-for repair of specific injury

28. Approaches: Left anterolateral Right anterolateral Median sternotomy

29. FLAIL CHEST Definition: “A flail chest segment is formed when two or more consecutive ribs , with each rib being fractured at two or more sites ” Stove-in-chest: “ Depression of a portion of the chest wall due to severe chest injury, which contributes to forming a flail segment.”

30. Significance The real significance of the detection of paradoxical movement lies in the fact that the severity of trauma necessary to produce a flail segment has implications with respect to damage of underlying intrathoracic structures ( Trinkle et al., 1975).

31. Pathophysiology Paradoxical Respiration Mediastinal Flutter Pendular Movement of air Associated injuries: Pulmonary Contusion! Hypoventilation

32. The early mortality attributable to the flail chest syndrome is due to M assive haemothorax and Pulmonary contusion, W hereas late mortality is largely due to A dult respiratory distress syndrome (ARDS) and associated infection. Tsai et al., 1999 Complications

33. Adjuncts Vital signs Chest X-Ray ECG Pulse oximetry End-Tidal Carbon Dioxide Arterial Blood Gas Urinary output Urethral Catheterization Nasogastric tube Pelvic X-Ray

34. Management Ranasinghe A, Trauma 2001; 3: 235–247

35. Stabilization of the flail segment by the application of a sandbag or by extensive strapping is contraindicated in the hospital environment as this leads to restriction of thoracic wall movement Myllynen et al., 1983

36. Indications for Ventilation Ranasinghe A, Trauma 2001; 3: 235–247

37. Trinkle’s Regime Ranasinghe A, Trauma 2001; 3: 235–247

38. Surgical Intervention Internal fixation of flail segment Indication: Patients suffering from pulmonary contusion with progressive thoracic cage collapse during weaning from the ventilator after resolution of the pulmonary contusion .