Chest injuries and hemothorax.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. Introduction

3. Introduction Chest injuries are the second leading cause of trauma deaths each year. 25% Most thoracic injuries (90% of blunt trauma and 70% to 85% of penetrating trauma) can be managed without surgery.

4. Known since ancient times. Hunter advocated I&D Others –Close the wound  Guthrie proposed early evacuation of blood through an existing chest wound thenwound should be closed  open later to evacuate the clot Trocar canula and Undeerwater seal described in 1880

5. Main Causes of Chest Trauma

6. Main Causes of Chest Trauma Blunt Trauma - Blunt force to chest. Penetrating Trauma - Projectile that enters chest causing small or large hole. Compression Injury - Chest is caught between two objects and chest is compressed.

7. Injuries of chest

8. Injuries of chest Rib Fracturesand Flail Chest Pneumothorax Hemothorax Diaphragmatic Rupture Pulmonary contusion Mediastinal injuries- Heart Cardiac temponade Myocardial contusion Oesophagus Aorta and its branches Trachea pneumomediastinum

9. Hemothorax

10. Hemothorax A life-threatening injury that frequently requires urgent chest tube placement and/or surgery Occurs when pleural space fills with blood As blood increases, it puts pressure on heart and other vessels in chest cavity

11. Hemothorax:Pathophysiology

12. Hemothorax:Pathophysiology Accumulation of blood in the pleural space caused by bleeding from Penetrating or blunt lung injury Chest wall vessels Intercostal vessels Associated with great vessel or cardiac injury 50% of these patients will die immediately. 25% of these patients live 5 to 10 minutes. 25% of these patients may live 30 minutes or longer.

13. Etiology

14. Etiology Idiopathic Congenital Traumatic Infections /Infestation Autoimmune Neoplastic (Benign/Malignant) Degenerative

15. Hemothorax:Etiology Blunt or penetrating trauma. Accident, assault Rib fractures associated with pneumothorax . Iatrogenic Spontaneous

16. Etiology Most common cause of hemothorax is trauma. Penetrating injuries of the lungs, heart, great vessels, or chest wall are obvious causes of hemothorax ; Accidental, deliberate, or iatrogenic in origin.     In particular, central venous catheter and thoracostomy tube placement

17. Etiology Nontraumatic or spontaneous hemothorax include the following: Neoplasia (primary or metastatic) Blood dyscrasias , including complications of anticoagulation Pulmonary embolism with infarction Torn pleural adhesions in association with spontaneous pneumothorax Bullous emphysema Necrotizing infections

18. Etiology Tuberculosis Pulmonary arteriovenous fistulae Hereditary hemorrhagic telangiectasia   [12] Nonpulmonary intrathoracic vascular pathology ( eg , thoracic aortic aneurysm or aneurysm of the internal mammary artery) Intralobar and extralobar sequestration  [4] Abdominal pathology ( eg , pancreatic pseudocyst , splenic artery aneurysm, or hemoperitoneum ) Catamenial

19. Pathophysiology

20. Pathophysiology Hemodynamic response –Hypovolemic shock rapid bleeding Respiratory response slow bleed Blood that enters the pleural cavity is exposed to the motion of the diaphragm, the lungs, and other intrathoracic structures. This results in some degree of defibrination of the blood so that incomplete clotting occurs

21. Hemothorax

22. Hemothorax

23. Hemothorax

24. Hemothorax

25. Hemothorax

26. Hemothorax May put pressure on the heart

27. Clinical Features

28. Clinical Features Demography Symptoms Signs Prognosis Complications

29. Clinical features

30. Hemothorax Clinical features Anxiety/Restlessness Hypovolemic shock Tachypnea Dyspnea Cyanosis Tracheal deviation to the unaffected side (rare) Hyporesonance (dullness on percussion) on the affected side Diminished or decreased breath sounds on the affected side

31. Hemothorax Clinical features B ruising , Tenderness Crepitus upon palpation over fractured ribs, Chest-wall deformity Paradoxical chest-wall movement

32. Hemothorax Clinical features Percussion and auscultation the upright patient and even then may be subtle. Many trauma victims are initially examined in the supine position. High degree of suspicion

33. Hemothorax Clinical features Delayed hemothorax can occur at some interval after blunt chest trauma

34. Prognosis

35. Prognosis At present, the general outcome for patients with traumatic hemothorax is good Empyema occurs in approximately 5% of cases. Fibrothorax occurs in about 1% of cases.

36. Complications

37. Complications Death A small and asymptomatic hemothorax can progress into a large and symptomatic bloody pleural effusion Empyema Fibrothorax . 

38. Investigations

39. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histlogy

40. Investigations X-ray chest upright/Lateral decubitus CT chest USG Thoracentesis .

41. USG Increasing role in trauma. Even with the use of chest radiography and helical CT, some injuries can remain undetected. In particular, patients with penetrating chest injuries may harbor serious cardiac injury and a pericardial effusion that may be clinically difficult to determine.

42. USG eFast . Extended FAST. FAST + Anterior BL Chest Sonography for lungs and heart.

43. USG Bony injuries, widened mediastinum , and pneumothorax , are not readily identifiable on chest ultrasonograms . Ultrasonography more likely plays a complementary role in specific cases where the chest x-ray findings of hemothorax are equivocal. Does not replace X-Ray.

44. CT Better in detecting . Not routine.

45. Laboratory Investigations  

46. Laboratory Investigations  Pleural effusion with a hematocrit value more than 50% of that of the circulating hematocrit is considered a hemothorax

47. Differential Diagnosis

48. Differential Diagnosis Emergent Management of Pleural Effusion Intrathoracic malignancy Mesothelioma Metastatic malignacy Pediatric Empyema

49. Management

50. Hemothorax Management ABCDE of resuscitation

51. Hemothorax Management ICD- Tube Thoracostomy Thoracotomy Video-assisted thoracoscopic surgery (VATS)

52. Management: ICD- tube thoracostomy Large bore tube in 5 th -7 th space between mid and posterior axillary lines. Triangle of Safety. Can be done even before X-ray. No data support routine antibiotic coverage of chest tubes in patients with hemothorax .

53. Management: Thoracotomy Early- For hemostasis Evacuation of more than 1000 mL of blood immediately after tube thoracostomy ; this is considered a massive hemothorax Continued bleeding from the chest, defined as 150-200 mL /hr for 2-4 hours Repeated blood transfusion is required to maintain hemodynamic stability

54. Management: Thoracotomy Empyema usually develops from superimposed infection in a retained collection of blood. It requires surgical drainage and, possibly, decortication . Fibrothorax is a late uncommon complication that can result from retained hemothorax . Thoracotomy and decortication are required for treatment.

55. Video-assisted thoracoscopic surgery (VATS) Early intervention in the case of a retained clot can be performed with thoracoscopy , provided that the operation is planned within 1 week of the bleeding episode.

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