Chest Trauma MBBS teaching in Lilongwe Malawi

Chest trauma for medical students

1. Chest Trauma
MBBS III
Dr. Tim Mutafya
General surgery resident

2. Layout
Introduction
Chest Trauma anatomy
Major and common Chest injuries
Chest drain

3. Introduction
•A third of RTA’s have significant chest trauma
•LethalityduetoanIsolatedchesttraumas-5%to8%.
•Totalmorbidityandmortalityintraumatizedemergencypatients
•Ofalldeathscausedinrelationtochestinjuries-25% (2
ndleadingcauseofdeath)
•Roleofsurgery–10%-15%
•< 10% of BCT require surgical intervention as opposed to 15 -30% in PCT

4. Anatomy

6. Thoracic wall

7. DANGER BOX

8. Classificationofthoracictrauma
ByMechanism
–Blunt
–Penetrating
Byseverity
–Lifethreatening
–Stable

9. Acceleration/Deceleration Injury
•MVA
•Falls > 3m
•Sports
Compression ( AP & transverse )
Blast Injuries
Blunt trauma

10. High velocity
•Gun shot
•Missile fragments
Low velocity
•Stab injury
Penetrating

12. Chest
Injuries
Skeletal 1.Ribfracture
2.Sternalfracture
3.Scapularfracture
PulmonaryInjury 1.Pneumothorax
2.Hemothorax
3.PulmonaryContusion
4.Trachea-BronchialInjury
Cardiac&GreatVessels1.AorticInjury
2.CardiacContusion
DiaphragmaticInjury 1.Herniation

15. Ribfracture
•Commonribsfracture –3
rd
to8
th
•1
stand2
ndribfracture-High velocityinjury
•Anylevelofribfracture,the riskof
Pneumothoraxand pulmonarycontusionexists
•Morethantworibfractures-atsignificantriskof
complications.

18. FLAILCHEST
•Thoraxinstabilitywithparadoxicalmotion.
•Underlyingpulmonaryparenchymalinjury
•Elevatedrespiratoryeffort,dyspnea
andhypoxemiaand canbelifethreatening

20. Thoraxinstabilitywithparadoxicalmotion

21. •Painful Breathing.
•Paradoxical Chest Movements.
•Rapid, Shallow respiration, Dyspnea,
Tachypnea, Tachycardia
•Bruising/Swelling.
•Crepitus
•Grinding of bone ends on palpation
Clinical features
Diagnosis is purely clinical.
• Chest X-Ray, ABG’s can be done
to confirm
Observe the patient for development of Pneumothorax and
even worse Tension Pneumothorax

22. PNEUMOTHORAX
Pneumothorax is air in the pleural space resulting in partial or
complete collapse of the lung space.
1. Closed /Simple pneumothorax is one in which chest
wall is intact and air enters the pleural space from lung surface
2. Open pneumothorax is Sucking Chest Wound in which air
enters the pleural space through opening in the chest wall

23. Opening in lung tissue that leaks air into chest cavity
•Blunt trauma is main cause
•Usually self correcting
Provide adequate analgesia
Supportive care
Chest physiotherapy
Monitor for development of tension
pneumothorax
Closed/simple
pneumothorax
Clinical features
• Chest Pain
• Dyspnea
• Tachypnea
• Decreased Breath Sounds on Affected Side

24. Open Pneumothorax
• Opening in chest cavity that allows air to enter pleural cavity
• Causes the lung to collapse due to increased pressure in pleural cavity
• Can be life threatening and can deteriorate rapidly

25. • Dyspnea
• Sudden sharp pain
• Subcutaneous Emphysema
• Decreased breath sounds on affected side
• Hyper-resonance
• Red Bubbles on Exhalation from wound
(a.k.a. Sucking chest wound)
Clinical features

26. • Full thickness hole in the
chest wall, more than 2/3rd
of tracheal diameter.
• Inspiration… Flow of air
into lungs… collapse.
Sucking chest wound

27. •Do not remove clothing
stuck to the wound
•Do not clean the wound or
remove objects stuck in the
wound
Treatment of sucking wound
Occlusive dressing… taped on three sides act as one-way valve
Tubethoracostomyshould
be placedawayfromthe
open wound

28. TensionPneumothorax

29. Anxiety/Restlessness/Panicky
• Severe Dyspnea
• Absent Breath sounds on affected side
• Hyper-resonance
• Tachypnea
• Tachycardia
Presentation
Danger signs
• JVD
• Narrowing Pulse Pressures
• Hypotension
• Tracheal Deviation (late if seen at all)

30. It’s a clinical diagnosis and treatment should not be delayed by waiting for X-ray
Large-borecannula (14G/16G)
•Skinispuncturedjust
abovethethirdrib
•Perpendiculartotheskinuntil
thepleuraisentered chestdrainafterdecompression

31. HEMOTHORAX OR
HEMOPNEUMOTHORAX
•Sourcesofmassivebleeding
–Commonly
ointercostalormammaryblood
vessels.
–Aorticrupture
–Myocardialrupture
–Injuriestohilarstructures.
Follows Blunt injury
•Occurs when pleural space
fills with blood
•As blood increases, it puts
pressure on heart and other
vessels in chest cavity
•Each Lung can hold 1.5 liters
of blood

33. • Anxiety/Restlessness
• Diminished Breath Sounds on Affected Side
• Tachypnea
• Signs of Shock
• Frothy, Bloody Sputum
• Dull percussion note
• Flat Neck Veins
Presentation
Massive hemothorax
oIf more than 1500 ml blood drains initially, OR ongoing
hemorrhage of more than 200 ml/ hr. over 3-4 hrs.
Immediate chest drain

34. Cardiac tamponade
•Compression of the heart due to
accumulation of fluid within the
pericardium
•As the pericardial sac fills, it causes
the sac to expand until it cannot
expand anymore
•Once the pericardial sac can’t expand
anymore, the fluid starts putting
pressure on the heart

35. •With poor pumping the blood
pressure starts to drop.
•The heart rate starts to increase
to compensate but is unable
•The patient’s level of conscious
drops, and eventually the patient
goes in cardiac arrest

36. •Increased Heart Rate
•Respiratory Rate increases
•Poor skin color
•Hypotension
•Death
Presentation

37. •Clinical suspicion
•CXR… enlarged Globular
heart shadow.
•Echo…. Fluid in pericardial
sac.
•Central venous pressure…
high
•CT scan
Diagnosis

38. Pericardiocentesis
Paraxiphoiddrainage of the
pericardium in emergency
Definitive treatment
•Sternotomy
•Left Thoracotomy

39. Lungcontusion
•Concussive and compressive force is most
important cause.
•The natural progression of pulmonary
contusion is worsening hypoxemia for the
first 24 to 48 hours
•X-ray findings not significant
initially.
•CT with contrast is confirmatory
Lungcontusionisthemostfrequentintrathoracicinjuryresultingfromblunt
trauma

40. Presentation
•Hemoptysis
•Dyspnea
•Cough
•Chest wall abrasion
•Ecchymosis
Management
•Respiratoryrelief
–Sufficientpainmanagement
–PhysiotherapyandPulmonary
drainage
–Positive-pressureventilation
–Impairedgasexchange,intubation
andmechanical
ventilation

41. SUBCUTANEOUS EMPHYSEMA
• Feels like rice crispies
• Can be seen from neck to groin area
• Usually occurs on the chest, neck and
face, where it is able to travel from the
chest cavity along the fascia
Air collects in subcutaneous tissues from pressure of air in pleural cavity
Caused by both blunt and
penetrating trauma

42. CHEST DRAIN
Indications
Technique

43. Indications in chest drain
1.Massive hemothorax (> 1,500 mL blood returned on insertion of chest tube)
2.Ongoing bleeding from chest (>200 mL/hour for ≥ 4 hours)
3.Evidence of cardiac Tamponade
4.Penetrating chest wounds with unstable hemodynamics
5.Chest wall disruption or impalement wounds to the chest
6.Emphysema or major tracheobronchial injury seen on bronchoscopy
7.Mediastinal hematoma or radiographic evidence of great vessel injury with
unstable hemodynamics

44. • The optimal tube size depends on the air leakage rate
• Tube size of 28 or 32 French is normally sufficient
Technique
Triangle of safety for chest drain

45. Takehomemessage
•Avoidunderestimatingbluntpulmonaryinjuryseverity.
•Canpresentasawidespectrumofclinicalsigns,oftennot wellcorrelatedwithCXR ray
findings
•Aggressivepaincontrolwithoutrespiratorydepressionis thekeymanagementprinciple.
•Carefulmonitoringofventilation,oxygenation,andfluid statusisrequired,oftenfor
severaldays.
•AsimplePneumothoraxshouldnotbeignoredor
overlooked.ItcanprogresstoatensionPneumothorax

46. THANK YOU!