Chest injuries & their Management lecture.ppt

Chest injuries & their Management lecture.ppt

1. Chest injuries & Management
20-sep-2009

2. 2
Introduction
Defn:-
-injury to one or all components of:-
A. Chest wall
B.Thoracic cavity.
Chest wall injuries :-
1.Rib # & Flial chest
2.Clav.,scap.,&sternal#es
3.Open pneumothorax

3. 3
Thoracic cavity injuries
Pleural space injuries:-
Pneumothorx
Hemothorax
Chylothorax
Lung parenchyma injuries
Pulmonary contusion
Pulmonary haematoma
Tracheobronchial injuries
Esophageal
Diaphragmatic
Cardiac injuries
Tamponad
Contusion
Ventricular rupture
Great vessel injuries

4. 4
Intro…conti
25% of all trauma deaths
Contributes to another 50%
Blunt: - 70%
-70% - MVA.
Penetrating :-30%
-60-70% - stab
Chest wall & soft tissues
Aorta & Great vessels

5. 5
…………chest trauma
Pathophsiology:-
-Hypoxia
-Hypercarbia
-Acidosis
Mechanisms;-
- Pain
-Comatose
-Blood loss
-↓ed venous
return
-Lung contusion.
→Hypoventilation
→Hypotension
→Ventilation perfusion
mismatch

6. 6
Chest wall injuries:-
Rib Fractures:-
Most common blunt injury
4-10 ribs
Post. Angle
N
o
of #ed Ribs ≈ Degree of underlying injury
Uncommon in children

-1
st
& 2
nd
rib # es:-
-excessive energy transfer
-harbingers of associated injury

7. 7
Flial Chest
3 or > , each at 2 or > places
Main insult ► underlying lung injury
► associated injury
Dx. C/Fs:-paradoxical breathing ,respiratory distress
hypoxia
Rx:- Aim
٭Conservative-Supp. o
2
-Effective Pain control
-Aggressive pul. Toilet
-Chest physiotherapy
-Early mobilization
٭Mechanical Ventilation
- < 50% of pts.

8. 8
Flail chestFlail chest

9. 9
Flail Chest - detail

10. 10

11. 11
Open Pneumothorax
By penetrating injury
Large chest wall defect
C/Fs.:- respiratory distress → Homodynamic instability
-”sucking” wound
Rx: - occlusive dressing → “flutter type” valve effect
-Chest tube
- treat the Defect

12. 12
Pneumothorax
Simple:- -By
a lung laceration : -# of a rib
- penetrating
- barotraumas -C/F :-chest
pain ,difficulty of breathing ,respiratory distress-Rx : -
Conservative: - Pain control
- Pul. Toilet
- Re-x-ray Ø 24hrs - Chest tube
- Enlarges
- Decompensate
- Going to be ventilated

13. 13
PneumothoraxPneumothorax

14. 14
Pneumothorax
Tension:- -
Same mechanism, but :-
-” one way valve”
- Continues air leak
- No means of escape
-C/F - IS A CLINICAL Dx-respiratory
distress ,mediastinal shift ,hypoxia
-Rx -Initially → Rapid decompression
→ Needle thoracostomy
-Definitive RX → Chest tube
pain control
pul. Toilet
Cxr

15. 15
Heamothorax
One of the commonest:-
Penetrating - 50 – 60 %
Blunt - 60 - 70 %
Major sources : - Chest wall vessels,
- Lung parenchyma
- Major Thoracic vessels
Majority are not massive
Dx. :- Clinical Exam findings

-Depended on extent
Rx:- Chest tube insertion -triangle of safety
-aggressive Pain control & pulmoary Toilet
monitoring output.
-Thoracotomy –Massive
-Continued
-Haemodynamic instability
-Large clotted hemothorax

16. 16
Lung Parenchyma injuries
-Pulmonary Contusion
Blunt :- 50-60%
-Pathophysiology:- Direct inj → Pul. Vas. Damage → 2
ry
alveolar Hrg
-Subsequently → -tissue infiltration-↓ed Compliance
-pulmonary Edema→↑ed Respiration
-↑ed mucous production →Atlectasis→↓ed Arterial
Oxygenation ► Hypoxemia
-Rx -Conservative
-Mechanical Ventilation
-Thoracotomy

17. 17
Tracheo-Bronchial injuries
Penetrating :- 75-80% → Cervical trachea
Blunt :- 75-80% → Bronchial
Frequently Fatal
Associated injuries
Rx. -ABCs
-Most →Urgent Repair.

18. 18
Cardiac injuries
Highly fatal
Penetrating →Stab & GSWs
Blunt →MVA
Frequency:- RV→LV→RA→LA
Presentation:-
-Cardiac Tamponade
-Myocardial Contusion
-Ventricular Rapture

19. 19
Cardiac Tamponade
Blood in the pericardial sac
Most frequently penetrating injuries
Classically, Beck’s triad:
- distended neck veins
- muffled heart sounds
- hypotension
Rx: Volume resuscitation
Pericardiocentesis

20. 20
Cardiac Cardiac
tamponadetamponade

21. 21
Thoracic Great Vessel injuries
8-9% - of all Vascular injuries
Prevalence - 0.3-10%
Mechanism:-Penetrating:- 90% GSWs,Stab
Blunt :- DecelerationChest compresion
15% reach care centre2/3
rd
die in 14 days
Physical clues:--Sig chest wall trauma-Massive heamothorax
-Excessive entry site bleeding-Expanding apical
chest heamatoma / neck mass
Gene.Principles of Mx.:-resuscitation
thoracotomy

22. 22
Esophageal injuries
Very rare; < 1%
Etiology:-Iatrogenic
-Traumatic
-Spontaneous
-Foreign body
 Majority – Cervical
Recognition is difficult
Aggressive Investigations
Rx.:- Repair
Complications :-
-Fistulae & leaks
-Mediastinits ,empayema
-Sepsis
-Stricture

23. 23
Diaphragmatic injuries
Rare; 1-3%
Blunt:-
33%
Left 4x
Larger tear
C/Fs Vary
Dx Cxr
Laparatomy
Rx. Gen. supportive
All tears→ Repair
Missed injuries
-~13%
-Visceral herniation

Penetrating:-
45% -GSW
15% -stab
15% > 2CM

24. 24
Chest trauma: summary
Common
Serious
Primary goal is to provide oxygen to
vital organs
Remember
Airway
Breathing
Circulation
Be alert to change in clinical condition