chest injuries and the patient management

Chest

1. THORACIC INJURIES

2. INTRODUCTION Chest injuries contribute to 25% to 60% of trauma deaths. Resuscitative measures, airway management and tube thoracostomy can salvage about 80% of all thoracic injuries. Poor perfusion may affect airway, breathing, circulation and sensorium

3. ANATOMY

4. PATHOPHYSIOLOGY It affects both oxygenation and perfusion Results in hypoxia hypercarbia acidosis Myocardial contusion causing pump failure manifests as Cardiac Failure

5. CLASSIFICATION

6. IMMEDIATELY LIFE THREATENING INJURIES AIRWAY OBSTRUCTION TENSION PNEUMOTHORAX OPEN PNEUMOTHORAX FLAIL CHEST MASSIVE HEMOTHORAX CARDIAC TAMPONADE

7. POTENTIALLY LIFE THREATENING INJURIES SIMPLE PNEUMOTHORAX PULMONARY CONTUSION TRACHEOBRONCHIAL TREE INJURY BLUNT CARDIAC INJURY TRAUMATIC DIAPHRAGMATIC AND AORTIC INJURY BLUNT ESOPHAGEAL RUPTURE

8. MODE OF INJURY Blunt injury Penetrating injury Deceleration and compression injuries

9. CHEST TRAUMA CARE OBJECTIVES PRIMARY SURVEY AND RESUSCITATION SECONDARY SURVEY FOR POTENTIALLY LIFE THREATENING INJURIES

10. ASSESSMENT ABC

11. ASSESSMENT

12. ASSESMENT LOOK FOR Signs of laboured or abnormal breathing Rate and depth of respiration Symmetry of chest movements Use of accessory muscles Distended neck veins Open chest injury Flail segment and chest deformity Cyanosis and CRT

13. ASSESSMENT LISTEN FOR Stridor , snoring and gurgling sounds- obstructed airway Hyperresonant /dull/normal percussion note Air entry and adventitious sounds Heart sounds

14. ASSESSMENT FEEL FOR Position of trachea Subcutaneous emphysema Bony crepitations and tenderness

15. ACT Maintain a patent airway Oxygen administration and SpO2 monitoring Assist ventilation with BMV with oxygen at high flow[ 12-15l/min ] if breathing is rapid,shallow ineffective/ apnoeic Definitive airway- secure airway with cuffed ETT/ cricothyroidotomy and maintain EtCO2of 35 to 45mmHg

16. MANAGEMENT OF SPECIFIC SITUATIONS

17. TENSION PNEUMOTHORAX

18. TENSION PNEUMOTHORAX

19. TENSION PNEUMOTHORAX Chest pain, anxiety, dyspnea and tachypnea Hyper-resonant chest on the affected side with diminished/absent breath sounds Late findings Tracheal deviation to opposite side Engorged neck veins with elevated JVP Hypotension and cyanosis Air hunger Decreased level of conciousness

20. MANAGEMENT Needle thoracostomy at 5 th ICS at midaxillary line with 16G needle It must be followed by tube thoracostomy Secure vascular access and administer crystalloids Administer antibiotics and analgesics Take surgical consult

21. OPEN PNEUMOTHORAX

22. OPEN PNEUMOTHORAX (SUCKING CHEST WOUND)

23. MANAGEMENT If the defect is more than or equal to 2/3 diameter of trachea, air passes through the defect from atmosphere and impairs ventilation. Three sided dressing -putting a occlusive dressing which is taped on three sides This creates a flutter valve on the non taped side and allows air to escape during expiration Insert ICD away from the wound as soon as possible

24. OPEN PNEUMOTHORAX

25. MANAGEMENT

26. FLAIL CHEST

27. FLAIL CHEST This occurs when fracture of two or more ribs occurs at two or more sites. A bony segment moves independent of chest wall and moves paradoxically during ventilation Underlying lung injury leads to accumulation fluid and blood in alveolar spaces This leads to impaired gas exchange, hypoxia, hypercarbia , increased pulmonary vascular resistance, decreased lung compliance and finally respiratory failure

28. FLAIL CHEST

29. FLAIL CHEST There will be tachypnea , dyspnea and severe pain Paradoxical chest wall movements, splinting of chest wall and tenderness on affected side Cyanosis/hypotension and anaemia may or may not be present

30. FLAIL CHEST Appropriate Oxygen supplementation Ensure adequate ventilation. Reassess RR, SpO2, EtCO2, sweating and colour of the patient. If possible do ABG. Intubation if RR more than 40 or PaO2 less than 60mmHg with FiO2 of 60% Judicious use of IV fluids Multimodal delivery of analgesics Surgical fixation rarely

31. MASSIVE HEMOTHORAX

32. MASSIVE HEMOTHORAX Accumulation of more than 1500 ml of blood in the thoracic cavity following injury to systemic or hilar vessel Usually followed by penetrating injury High degree of suspicion is needed in injuries medial to nipple line and scapula Patient will be dyspneoic,tachypneoic ,pale, hypotensive with flat neck veins Decreased chest movements and absent breath sounds and dull note on percussions

33. TUBE THORACOSTOMY

34. CARDIAC TAMPONADE Pathophysiology - intra-pericardial pressure exceeds filling pressure of right heart. Impairs venous return and cardiac filling leading to hypotension, narrow pulse pressure, PEA “Beck’s Triad” – Hypotension, Neck vein distension, Muffled/absent heart tones Signs and symptoms masked by hypovolemia Treat with immediate volume replacement to ↑ CVP , pericardial decompression

35. Management of cardiac tamponade Pericardiocentesis Can be done under USG guidance and cardiac monitor attached Needle inserted inferior to xiphoid directed towards the left shoulder. Observe for hemodynamic improvement

36. Secondary survey Adjuncts In depth physical examination Upright chest X ray ABG, pulse oximetry and ECG monitoring USG

37. Pulmonary contusion Commonest potentially lethal chest injury can occur with or without fracture ribs Respiratory failure is subtle and occurs over time These patients needs to be constantly reevaluated Intubation and ventilation –significant hypoxia on room air

38. Simple pneumothorax Lung laceration with air leakage is the commonest cause Diminished breath sounds with hyper-resonant chest-causes ventilation perfusion mismatch Upright chest X ray helps in diagnosis ICD insertion at 4 th or 5 th ICS followed by check Xray Always place ICD insertion before IPPV/GA

39. Simple hemothorax Caused by lung laceration or bleeding vessel[ intercostal or internal mammary] Usually self limited and no operative treatment is needed 36 to 40 fr ICD for large hemothorax on CXR Persistent bleeding or drainage of more than 200ml/hr for 4hrs-thoracotomy

40. Myocardial contusion Difficult to diagnose, because patient’s complaints of chest pain is attributed to musculoskeletal Elevated CVP in the absence of obvious cause may indicate right heart contusion May manifest as hypotension, dysrhythmias and wall motion abnormalities Multiple PVC, unexplained sinus tachycardia,AF , BBB, ST segment changes Requires monitoring for sudden dysrhythmias for 24hrs

41. Diaphragmatic rupture More commonwith penetrating injury. Blunt trauma produces radial tears Appearance of NG tube in the thorax on Xrays should rise the suspicion Treatment is direct repair

42. Tracheo bronchial injury Occur within 1 inch of carina following a blunt trauma Patient presents with hemoptysis , subcutaneous emphysema/tension pneumothorax Inadequate expansion after ICD or persistent leak/placement of more than one ICD is needed Bronchoscopy confirms the diagnosis Temporary intubation of opposite mainstem bronchus Immediate operative intervention is needed

43. Oesophageal trauma Most commonly follows penetrating injury Blunt trauma to upper abdomen –linear tear in oesophagus-mediastinitis Suspect in patients with left hemo / pneumothorax without rib fracture, shock or pain out of proportion to injury and tose who received severe blow to lower sternum or upper abdomen Presence of food particle in ICD/presence of mediastinal air Esophagoscopy /contrast studies Wide drainage of mediastinum and pleural space and primary repair

44. Rib fractures Rib fractures results in splinting and decreased ventilation Fractures of 1 to 3 ribs –look for severe associated injury 4 th to 9 th ribs sustain most of the fractures Localised pain, tenderness and crepitations Pain relief by multimodal approach

45. Scenario 1 An adult male motorcyclist had a head on collision with a truck.he is complaining of difficulty in breathing,severe chest pain and is very restless and smelling of alchohol .

46. APPROACH Airway-patent(patient is talking.) Spo2 85% Administer oxygen through high flow NRM Breathing- RR-40,shallow,patient is disterssed.neck veins appear distended.trachea shifted to left.hyper resonant percussion notes,no breath sounds on rt side of chest.

47. Patient has TENSION PNEUMOTHORAX RIGHT. Immediately rt sided needle thoracocentesis done,followed by rt ICD connected to a underwater sael . On reassessing,improvement in breathing,pt feels comfortable,sop2 95%,air entry improves on right side.

48. CIRCULATION Initial bp 80/40,pulse 120,after ICD pulse 95 and bp 110/70mmhg Secure iv access and give crystalloids. Administer analgesics and antibiotics. Take surgical opinion. Investigations-blood gp&cross matching,x ray.

49. SCENARIO 2 A middle aged man gets stabbed with a knife over fight in gambling on the back of right upper half of chest. The attacker pulls out the knife and leaves the man bleeding on the roadside. A bystander brings him to hospital. He looks dusky,is complaining of difficulty in breathing,anxious and saying ‘please save me or i will die’. A large sucking wound is seen on the back of rt upper half of chest.

50. ASSESS ABC Airway –patent as pt is talking. B reathing is rapid and shallow RR-40/MIN Air entering wound is making a rapid sucking sound. Accessory muscles working –respiratory distress.spo2 78% Patient is dusky.

51. TREATMENT Administer oxygen through high flow NRM Maintain spo2>94%. Apply occlusive dressing on three sides leaving the lower side free. Put ICD away from the wound to decompress pleural cavity. Definitive treatment-surgical closure.

52. THANK YOU

53. Laryngotracheal injury It may be complete or incomplete and uncommon The pt may present with stridor , hoarseness, subcutaneous emphysema, tenderness, bruising of chest wall and neck. Treatment Administer oxygen If the patient has an obvious difficulty in breathing or cannot breath- attempt ETT/surgical airway