chest trauma new emergency care and management

Management of Chest trauma

1. CHEST TRAUMA Moderator : Dr. UGESH ,Senior resident Presentor : Dr SRAVANI A.Post graduate

2. C O N T E N T S Chest wall anatomy Surgical anatomy Causes of chest injuries Types of chest injuries Investigations Pathological effects Clinical features Classification of chest injuries Thoracotomy

3. C HEST WALL ANATOMY Thorax refers to the area between the neck and abdomen and is bounded : Anteriorly : sternum and coastal cartilage Laterally : ribs and intercostal spaces Superiorly: the thoracic inlet ,the suprapleural membrane. Inferiorly : the diaphragm

4. S URGICA L ANATOMY OF CHEST WALL Thoracic organs protected by the bony thorax and overlying chest musculature. Parietal pleura the internal lining of chest wall is separated from the visceral pleura by pleural fluid . Parietal pleura covers the chest wall , mediastinum, diaphragm , and pericardium. Visceral pleura covers the lung and separates the lobes from one another by the mediastinum. Pleural space is a potential space that may compress the lungs or heart with fluid , tumour , or infection . Right and left pleural spaces are separated from one another by the mediastinum.

5. Bony thorax consists of 12 ribs peripherally extending from the vertebrae posteromedially to the sternum or costal arch anteriorly. 11 th and 12 th ribs are floating ribs 1-5 ribs directly attached to the sternum by costal cartilages . 6-10 coalesce into the costal arch First thoracic vertebrae relatively small extends from first thoracic vertebrae to manubrium to create thoracic inlet through which passes the great vessels, trachea, esophagus , nerves ,diaphragm ,larynx .

6. M EDI A S T I N UM It is an area found in the mid line of thorac cavity that is surrounded by the left and right pleural sacs It is divided into 4parts superior mediastinum anterior mediastinum middle mediastinum posterior medistinum

7. CONTENTS : SUPERIOR MEDIASTINUM Arch of aorta Brachiocephalic artery Left common carotid artery Left subclavian artery Vagus ,phrenic and cardiac nerves Left recurrent laryngeal nerves

8. POSTERIOR MEDIASTINUM : Contents: Esophagus Descending aorta Azygos,hemiazygos,acessory hemiazygos Vagus nerve Splanchnic nerve Thoracic duct Posterior medistinal lymphnodes

9. CAUSES OF CHEST INJURIES Road traffic accidents Industrial accidents Blast injuries Stab injuries

10. T YPES OF INJURIES Blunt trauma : Occurs when body is struck by a blunt object such as stearing wheel the external injury may appear minor but impact may cause severe life threatening internal injuries. Penetrating trauma: It is defined as when a foreign body passes through the body tissues (eg.gunshot wounds ,stabbing)

11. P ATHOLOGICAL EFFECTS OF CHEST INJURIES I MM E D I A T E L A T E Hypoxia Hypercarbia Acidosis Hypovolemic shock Bronchospasm empyema fibro thorax lung abscess mediastinitis cardiac arrhythmias

12. C L I N I C A L F E A T U R E S O F T H O R A C I C INJURIES Pain in the chest Cough ,hemoptysis Difficulty in breathing Tachycardia Hypotension Cyanosis Respiratory distress Tenderness over the site of fracture Dull note on percussion , decreased breath sounds on auscultation .-hemothorax Resonant note and decreased breath sounds – pneumo thorax Surgical emphysema 

13. I NVESTIGATIONS Chest xray – hemothorax ,pneumothorax,fracture ribs Hb, pcv – to asses blood loss. Blood grouping and cross matching Blood gas analysis –po2 and pco2 Usg abdomen –for associated abdominal injuries FAST Ct chest and ct abdomen

14. IMMEDIATELY LIFE THREATENING : airway obstruction tension pneumothorax pericardial tamponade open pneumo thorax massive hemothorax flailchest CLASSIFICATION

15. A IR WAY OBSTRUCTION Early preventable trauma deaths are due to lack of or delay in airway control. Causes: dentures ,teeth ,secretions , blood b/l mandibular fractures ,expanding neck hematoma Mechanical compression of trachea Laryngeal trauma Tracheal injury treatment: early intubation is important in cases of neck hematoma or possible air way edema.

16. PNEUMOTHORAX

17. T ENSION PNEUMO THORAX It occurs 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 and completely collapsing the affected lung. Mediastinum is displaced to the opposite side decreasing venous return and compressing the opposite lung .

18. Causes: 1.penetrating chest trauma 2.blunt chest trauma with parenchymal injury 3.airleak that did not close spontaneously 4.iatrogenic lung puntures . 5.mechanical postive pressure ventilation

19. C/F panicky patient. Tachypnoea. Dyspnoea. Distended neck veins. Examination : tracheal deviation  hyper resonance. absent breath sounds 

20. Treatment : Immediate decompression. Rapid inserion of large bore needle into 2 nd ics In mid clavicular line . Insertion of chest tube through 5 th ics in anterior axillary line.

21. O PEN PNEUMOTHORAX Accumulation of air in hemi thorax with each inspiration due to large defect in chest >3cm Equilibration btwn intrathoracic and atmospheric pressure . Treatment: Closing the defect on 3 sides and and open on other side to act as flutter type valve. Chest tube insertion remote from the injury site. Formal debridement and closure - definitive

22. P ERICARDIAL TAMPONADE Cause : penetrating trauma Leading to accumulation of relatively small amount of blood into the non distensible pericardial sac can produce physiological obstruction of heart . c/f : Venous pressure elevation . Hypotension Tachycardia Mufled heart sounds.

23. Examination: increased central venous presssure. Enlarged heart shadow in xray Echo showing fluid in pericardial sac Treatment: Needle pericardiocentesis Sternotomy /left thoracotomy with repair of heart.

24. M ASSIVE HEMOTHORAX Cause: continuing bleeding from torn intercostal vessels or occasionally internal mammary artery . o/e: decreased respiratory efforts u/l absence of breath sounds and dullness to percussion . Treatment: Blood in pleural space should be removed as completely as possible to prevent ongoing bleed, empyema, late fibro thorax . Urgent thoracotomy: >500ml of blood initial drainage  >200ml /hr ongoing hemorrhage

25. F LAIL CHE ST Results from blunt trauma Occurs when a segment of chest wall does not have bony continuity with the rest of the thoracic cage . Associated with multiple rib fractures 3/more consecutive ribs in 2/more places in each rib. c/f: paradoxical movement of chest wall voluntary splinting Mechanically impaired chest wall Lung contussion contd….,

26. CON T D .., High risk of developing pneumothorax or hemo thorax. Treatment : mechanical ventilation to internally splint the chest wall fibrous union of broken ribs occurs . O2 administration . Adequate analgesia Physiotherapy. If chest tube is insitu intrapleural local analgesia.

27. P OTENTIALLY LIFE THREATENING Thoracic aortic disruption Tracheo bronchial injuries Blunt myocardial injury Diaphragmatic injuries Esophageal injury Pulmonary contussion

28. T HORACIC AORTIC DISRUPTION Mode of injury: automobile collision or fall from great height . Shear forces from a sudden impact disrupt the intima and media . Adventitia intact – patient is stable. Salvage is frequently possible if aortic rupture is identified and treated early o/e : assymmetry of upper and lower extremity presure . Widened pulse pressure chest wall contussion

29. investigations: chest xray Aortography Cect of mediastinum Trans esophageal echocardiography Treatment: Control of bp. Endovascular intra aortic stent. Direct repair of tear.

30. T RACHEO BRONCHIAL INJURIES o/e : subcutaneous emphysema with respiratory comprimise . Investigations: Bronchoscopy Treatment : chest drain Intubation of unaffected bronchus followed by repair.

31. B LUNT MYOCARDIAL INJURY Blunt trauma to chest and ecg abnormalities myocardial injury should be suspected. Investigations : 2d echo transesophageal echo rise in troponin They are at risk of developing sudden dysrhythmias and monitored for 24 hrs.

32. D IAPHRAGMATIC INJURIES Any penetrating injury to below 5 th ics leads to diaphragmatic injury and injury to abdominal contents. Caused by compressive force to chest, abdomen, pelvis. Very large diaphragmatic rupture –herniation of abdominal contents into chest Investigations :chest xray Cect Diagnostic peritoneal lavage VATS Treatment: O p e rat i v e r e p a i r Complications : rupture Herniation strangulation increased mortality

33. E SOPHAGEAL INJURY Mostly penetrating, rarely blunt o/e: odynophagia   emphysema air in retro esophageal space unexplained fever with in 24 hrs Mediastinal and deep cervical emphysema Investigations :esophagogram and esophagosopy Treatment: operative repair If delayed >12-24 hrs mortality is high

34. P ULMONARY C O N T U S I O N Caused by hemorrhage into the lung parenchyma usually underneath a flail segment or fractured ribs . o/e: Pneumonia ARDS Hypoxemia Investigations : Chest xray  CECT Treatment : o2 administartion Aggressive Pulmonary toilet Adequate analgesia Mechanical ventilation

35. T H ORA C O T O M Y 2 types :1.emergency thoracotomy  2. planned thoracotomy Indications: 1.internal cardiac massage 2.control of hemorrhage from injury the heart. 3.control of hemorrhage from injury 4.control of intrathoracic hemorrhage from other causes 5.control of massive air leak.

36. T YPES OF APPROACHES 3 basic approaches are used Limited anterior or lateral thoracotomy -for anterior structures. Curvilinear incision underneath the inferior border of pectoralis major muscle at the infra mammary fold Posterolateral thoracotomy -gives access to pleurae ,hilum,mediastinum,and entire lung. Patient in decubitus position and oblique incision is made posteriorly or a vertical axillary incision is made just anterior to the latissimus dorsi muscle Median sternotomy- when acess to both lungs needed. Vertical incison from sternal notch to the xiphoid in mid line using a sternal saw.

37. P OSTEROLATERAL THORACOTOMY

38. A NTERIOR THORACOTOMY

39. Transverse sternotomy or clamshell incision : Incision combines two anterior thoracotomy incisions in inframammary fold with transverse division of sternum at 4 th intercostal space It is ideal for right and left hilum and providing additional exposures for large mediastinal tumors,b/l hilar dissections,lung transplantations or posterior based metastasis in both lungs

40. T RANSVERSE STERNOTOMY

41. C OMPLICATIONS OF THORACOTOMY Hemorrhage Infection Pneumothorax Bronchopleural fistula

42. REFERENCES Bailey and love 27 th edition Sabiston book of surgery 20 th edition Journal on chest trauma and chest drainand thoracotomy. Tintinalli’s book of emegency medicine 8 th edition

43. THANK YOU

44. C HEST WALL ANATOMY Thorax refers to the area between the neck and abdomen and is bounded : Anteriorly : sternum and coastal cartilage Laterally : ribs and intercostal spaces Superiorly: the thoracic inlet ,the suprapleural membrane. Inferiorly : the diaphragm