CHEST TRAUMA Besttt.pptxbbbbbbbbbbbbbbbbbbbbbbbbbb

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1. CHEST TRAUMA BY GKG 10/21/2018 GKG 1

2. INTRODUCTION The torso is the area between the neck and the groin made up of the thorax and abdomen This is the largest area of the body 10/21/2018 GKG 2

3. Traditionally, death from trauma has had a ‘ trimodal ’ distribution 50 % of deaths occurring in the pre-hospital environment 30 % during the first few hours and 20% occurring later 10/21/2018 GKG 3

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5. Junctional zones between the neck and the thorax between the thorax and the abdomen between the abdomen, the pelvic structures and the groin . 10/21/2018 GKG 5

6. Root of the neck Most injuries affecting the base of the neck (junctional zone 1) also affect the upper mediastinum and thoracic inlet. Choice of access is determined by the need for surgical control of the vascular structures contained within . 10/21/2018 GKG 6

7. The mediastinum The zone overlying the mediastinum with its major vessels and the heart is also an extremely high-risk area for penetrating wounds. Any wound in this region should immediately raise the suspicion of an associated cardiac or major vascular injury even in the absence of initial gross physical signs. 10/21/2018 GKG 7

8. Diaphragm Thorax and abdomen are separated by the diaphragm The diaphragm is mainly responsible for breathing, and moves with breathing from the fourth to the eighth interspace . Any penetrating injury of the lower half of the chest may therefore have penetrated the diaphragm and entered the abdomen. Injuries in this junctional zone, therefore, should be evaluated as if both cavities had been penetrated 10/21/2018 GKG 8

9. Pelvic structures and groin contains a large plexus of vessels, both venous and arterial. Should injury occur, control of haemorrhage can prove to be exceptionally difficult and may require control of both inflow and outflow. This may involve surgical control at the groin of the external iliac and femoral vessels , as well as at the aortic and cava level 10/21/2018 GKG 9

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11. Bleeding occurs from five major sites – Scalp chest abdomen pelvis extremities (e.g. fractures). 10/21/2018 GKG 11

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13. ATLS principles of resuscitation (ABCDE) A Airway B Breathing C Circulation D Disability ( neurology) E Environment and Exposure 10/21/2018 GKG 13

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16. 1)Tension pneumothorax Develops when a ‘ one-way valve ’ air leak occurs either from the lung or through the chest wall Air is forced into the thoracic cavity without any means of escape, completely collapsing the affected lung The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung . Immediately life threatening chest injuries 10/21/2018 GKG 16

17. common causes are penetrating chest trauma , blunt chest trauma with parenchymal lung injury and air leak that did not spontaneously close, iatrogenic lung punctures (e.g. due to subclavian central venepuncture ) and mechanical positive pressure ventilation. 10/21/2018 GKG 17

18. Clinical presentation tachypnoea dyspnoea distended neck veins (similar to pericardial tamponade ) Tracheal deviation (a late finding – not necessary to clinically confirm diagnosis) hyper resonance and absent breath sounds over the affected hemithorax . Tension pneumothorax is a clinical diagnosis and treatment should not be delayed by waiting for X ray. Golden hour is 10-15 minutes 10/21/2018 GKG 18

19.  Injury to the lung with one way valve effect  Pressure is build up within the pleural cavity until it equalizes the atmospheric pressure  Affected lung is collapsed  Mediastinum is pushed to the opposite compressing the other lung. 10/21/2018 GKG 19

20. Treatment Immediate decompression and is Initially by rapid insertion of a large-bore needle into the second intercostal space in the mid-clavicular line of the affected hemithorax immediately followed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line. 10/21/2018 GKG 20

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22. 2) Pericardial tamponade differentiated from tension pneumothorax in the shocked patient with distended neck veins It is most commonly the result of penetrating trauma Accumulation of a relatively small amount of blood into the non-distensible pericardial sac can produce physiological obstruction of the heart. All patients with penetrating injury anywhere near the heart plus shock must be considered to have cardiac injury until proven otherwise 10/21/2018 GKG 22

23. Classical presentation venous pressure elevation Becks Triad Hypotension with tachycardia Distended neck veins muffled heart sounds A high index of suspicion + diagnostic investigations e.g . chest radiography showing enlarged heart shadow cardiac echo showing fluid in the pericardial sac, and Insertion of a central line with a rising central venous pressure) are required for the subclinical case . In cases in which major bleeding from other sites has taken place, the neck veins may be flat. 10/21/2018 GKG 23

24. Needle pericardiocentesis along with rapid volume resuscitation to increase preload, can buy enough time to move to the operating room However , in penetrating injury to the heart there is usually a substantial clot in the pericardium, which may prevent aspiration. 10/21/2018 GKG 24

25. Pericardiocentesis has a high potential for iatrogenic injury to the heart and it should at the most be regarded as a desperate temporising measure in a transport situation under electrocardiogram (ECG) control correct immediate treatment of tamponade is operative ( sternotomy or left thoracotomy ), with repair of the heart in the operating theatre if time allows or otherwise in the emergency room. 10/21/2018 GKG 25

26. 3) Open pneumothorax (sucking chest wound) due to a large open defect in the chest (> 3 cm), leading to equilibration between intrathoracic and atmospheric pressure. Air accumulates in the hemithorax (rather than in the lung) with each inspiration, leading to profound hypoventilation on the affected side and hypoxia Signs and symptoms are usually proportionate to the size of the defect 10/21/2018 GKG 26

27. Source of air  From atmosphere Sucking chest  Trachea and main bronchus  Lung parenchyma 10/21/2018 GKG 27

28. Management Closing the defect with a sterile occlusive plastic dressing (e.g. Opsite ), taped on three sides to act as a flutter-type valve A chest tube is inserted as soon as possible in a site remote from the injury site Definitive treatment may warrant formal debridement and closure, preferably in the operating room, and all such patients should be referred early. 10/21/2018 GKG 28

29. The following points are important in the management of an open pneumothorax : 28FG or larger tube should be used in an adult ; if the lung does not reinflate , the drain should be placed on low-pressure (5 cm water) suction a second drain is sometimes necessary (but see Tracheobronchial injuries) physiotherapy and active mobilisation should begin as soon as possible. 10/21/2018 GKG 29

30. 4) Massive haemothorax common cause of massive haemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally the internal mammary artery Accumulation of blood in a hemithorax can significantly compromise respiratory efforts by compressing the lung and preventing adequate ventilation Such massive accumulation of blood presents as haemorrhagic shock with flat neck veins unilateral absence of breath sounds and dullness to percussion 10/21/2018 GKG 30

31. Source of blood  Pulmonary vessels  Bronchial vessels  Intercostals vessels  Internal mammary artery  Big thoracic vessels  Azygus and hemiazygus vein  Phrenic vessels 10/21/2018 GKG 31

32.  Less than 300 cc not visible on PA x-ray  Massive hemothorax  Deranged vital signs with no response to fluid replacement  Considerable drop in Hct  1500cc or more bright red blood drained on thoracostomy tube insertion or  200cc /hr the first 2 -3/4hrs or  >100 cc /hr the first 6-8hrs is an indication for urgent thoracotomy 10/21/2018 GKG 32

33. Treatment correcting the hypovolaemic shock insertion of an intercostal drain and intubation (in some cases) 10/21/2018 GKG 33

34. Management  ABC of trauma  Mild and moderate Tube thoracostomy  Massive Thoracotomy 10/21/2018 GKG 34

35. Blood in the pleural space should be removed as completely and rapidly as possible to prevent: on-going bleeding empyema or late fibrothorax 10/21/2018 GKG 35

36. The following points are important in the management of massive haemothorax : clinical examination may be misleading if only done from the supine position , as the lung may ‘float’ on the haemothorax and breath sounds anteriorly may be normal caution is required in a case that drains more than 500 ml into the drainage bottle but has persistent dullness or radiographic opacification . 10/21/2018 GKG 36

37. Flail chest A flail chest occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage usually from blunt trauma associated with multiple rib fractures i.e . three or more ribs fractured in two or more places 10/21/2018 GKG 37

38. The diagnosis is made clinically, not by radiography: On inspiration chest wall is displaced inwards and less air therefore moves into the lungs. To confirm the diagnosis the chest wall can be observed for paradoxical motion of a chest wall segment for several respiratory cycles and during coughing Voluntary splinting as a result of pain, mechanically impaired chest wall movement and the associated lung contusion are all causes of the hypoxia The patient is also at high risk of developing a pneumothorax or haemothorax . 10/21/2018 GKG 38

39. TREATMENT Currently treatment consists of : oxygen administration Adequate analgesia (including opiates) and physiotherapy If a chest tube is in situ , intrapleural local analgesia can be used as well 10/21/2018 GKG 39

40. Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen. Surgery to stabilise the flail chest is currently in use again for those isolated or severe chest injury and pulmonary contusion to benefit from internal operative fixation of the flail segment. 10/21/2018 GKG 40

41. CHEST TUBE DEFINITION:- inserting a tube into the pleural cavity SITE:- at the triangle of safety Laterally: mid- axillary line Medially: lateral border of pectoralis major Inferiorly: 5 th or 6 th rib

42. Indication pneumothorax haemothorax pleural effusion infected effusion ( empyema ) chylothorax pleurodosis Malignant effusion Post thyrodotomy ( post surgery) 10/21/2018 GKG 42

43. contraindication Anti coagulant Coagulopathy or bleeding diathesis Transudative pleural effusion 10/21/2018 GKG 43

44. Chest tube is inserted by 3 ways Blunt incision Seldinger method Image guided Tube size 14-22 french (for simple pneumothorax ) 24-40 french ( for simple hydro or hemo thorax ) 32-4 french (for massive pneumothorax ) 10/21/2018 GKG 44

45. Indications for removal 1)Clinically Hx : symptoms relieve PE : v/s stable :R/s….symmetrical, well expanded chest 2)Radiological :well expanded lung 3) Tube No more air leak less than 150 ml and must be serouse fluid 10/21/2018 GKG 45

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47. CARE OF THE TUBE Immediate control chest x-ray for confirming position of the tube. Check patency of the tube by presence of air bubble and fluid oscillation . Always keep the bottle below the heart level. Clump it whenever moved. Record daily drainage Daily clinical assessment and x-ray if available

48. Checking whether the tube is working or not Bubbles Ossilations they are done by asking pt to cough 10/21/2018 GKG 48

49. Common Complications of Chest Tube Insertion Allergic reaction Bronchopleural fistula Cardiac injury Hepatic injury Splenic injury Lung laceration Infection Hemorrhage Intercostal nerve, artery, or vein injury Re-expansion pulmonary edema Subcutaneous emphysema

50. THANK YOU 10/21/2018 GKG 50