chest trauma no orthopedist presentation

Chest trauma

1. Chest Trauma
Dr. WASEEM HAJJAR, MD, FRCS.
Associate professor &
Consultant thoracic surgeon
Thoracic Surgery Division
KKUH

2. INTRODUCTION
nThe chest contains vital organs.
nDamage to vital organs threatens life.
nMost common consequence is hypoxia.
nChest injuries result in a significant number of
deaths each year.
nOne in every 4 cases of trauma death caused by
chest injury.

3. nMechanism of injury:
1) Blunt chest trauma
ØMost common cause of serious chest injuries.
ØPost RTA, falls, direct blows, and crushing injuries.
ØMany injuries are not immediately apparent in physical exam.
2) Penetrating trauma
ØImmediate result can be severe bleeding or impaired breathing.
ØAny chest wound can involve underlying organ injury.
ØNo matter how superficial it looks.
ØInjuries to the heart, lungs, and great vessels can quickly lead to shock and cardiac arrest.
3) Iatrogenic

13. .nSigns and symptoms
nMost common symptoms: pain and difficulty breathing.
nSigns are obvious injury to the chest wall ( looking at both
the front and back of the chest).
nNote any subcutaneous emphysema, or air present under the
skin
nAssessment
Follow all steps in the assessment of the trauma patient:
nPrimary survey( A. Airway B. Breathing C. Circulation).
nResuscitation.
nDetailed secondary survey (CXR , ABG ,ECG , CT Chest ,
Aortogram).

21. nManagement
nEnsure patient has adequate oxygenation and
perfusion
nProvide high-flow oxygen, ventilating when
necessary
nHalt any obvious bleeding
nSupport circulation when needed
nRapidly transport patient to definitive care

22. nLife threatening chest injury
identified in the primary survey:
1)Airway obstruction.
2)Flial chest.
3)Tension pneumothorax.
4)Open pneumothorax.
5)Massive hemothorax.
6)Cardiac tamponade.

23. nPotentially lethal chest injury:
1)Traumatic aortic rupture.
2)Myocardial contusion.
3)Tracheal bronchial injury.
4)Rupture diaphragm.
5)Esophageal trauma.
6)Pulmonary contusion.

25. Rib Fracture
nMost common chest injury.
nMore common in adults than children.
nEspecially common in elderly.
nRibs form rings, Consider possibility of break in
two places.

26. Rib Fracture
nMost commonly 5th to 9th ribs.
nPoor protection.

27. Rib Fracture
nFractures of 8th to 12th ribs can damage
underlying abdominal solid organs:
nLiver.
nSpleen.
nKidneys.

28. Rib Fracture
nFractures of 1st, 2nd ribs require high force.
nFrequently have injury to aorta or bronchi.
n30% will die.

29. Rib Fracture
nLocal swelling and tenderness may be the only sign of a
broken rib.
nCan be very painful.
nPatients often presents with guarding and shallow breathing.
ØManagement
nMove the patient carefully to prevent the bone ends from
puncturing the lung.
nAdminister O2.
nAllow patient to self-splint by assuming the most comfortable
position possible.
nEncourage patient to limit movement.
nAnalgesia like Morphine, PCA, Epidural.

30. Rib Fracture
Signs and Symptoms
nLocalized pain, tenderness
nIncreases when patient:
nCoughs
nMoves
nBreathes deeply
nChest wall instability
nDeformity, discoloration
nAssociated pneumo or hemothorax

33. Flial Chest
nFlail segment
nWhen three or more ribs are broken in two or more
places, a rib-cage segment may detach from the rest.
nFlail segment is free floating.
nParadoxical movement: movement of flail segment
in opposite direction of the rest of the chest wall .
nParadoxical movement can significantly impair
breathing and cause injury to the underlying lung.

34. Flial Chest

35. Flial Chest

36. Flial Chest

38. Flial Chest
ØManagement
nQuickly stabilize flail segment by placing gloved
hand over injured area.
nAfter manual stabilization, place folded universal
dressing over segment and tape securely.
nFixation ( External, Internal).

47. nPost Traumatic Pneumothorax
Types:
1)Opened pneumothorax.
2)Close pneumothorax.

55. nOpen pneumothorax
nA sharp object penetrates the skin on the chest wall.
nIf penetrating object has pierced pleura, outside air
can enter the thoracic cavity.
nAs the volume of air in the thoracic cavity expands,
the lung starts to collapse .
nAir within the pleural space is called a pneumothorax
nAs air passes in and out of an open wound, it can
create a sucking-type sound.
nSucking chest wound means possibility of
pneumothorax.
nSigns of pneumothorax: difficulty breathing,
cyanosis, diminished breath sounds on the affected
side.

57. Open pneumothorax

61. Open pneumothorax

62. Open pneumothorax
nManagement
nCover open chest wounds with occlusive dressing
nGloved hand is an effective temporary occlusive
dressing
nSecure dressing on three sides
nHigh-flow oxygen
nTransport with unaffected side slightly elevated

63. nTension pneumothorax
nBuild up of pressure in pleural space resulting in
decrease in blood pressure.
nPotentially life-threatening condition that must be
treated immediately.
nCan occur in blunt or penetrating chest trauma.
ØSigns
nInclude all those of a pneumothorax.
nJugular venous distension (JVD).
nIf ventilating becomes more difficult, significant lung
compression is indicated.

64. Tension Pneumothorax
nOne-way valve forms in lung or chest wall
nAir enters pleural space; cannot leave
nAir is trapped in pleural space
nPressure rises
nPressure collapses lung

65. Tension Pneumothorax
nTrapped air pushes heart, lungs awayfrom
injured side
nBoth Vena cavae become kinked
nBlood cannot return to heart
nCardiac output falls

67. Tension Pneumothorax
nSigns and Symptoms
nExtreme dyspnea
nRestlessness, anxiety, agitation
nDecreased breath sounds
nHyperresonance to percussion
nCyanosis
nSubcutaneous emphysema
nRapid, weak pulse
nDecreased BP
nTracheal shift awayfrom injured side
nJugular vein distension
nEarly dyspnea/hypoxia -Late shock

71. Tension Pneumothorax

72. nTension Pneumothorax

73. Haemothorax
nBlood in pleura space
nMost common result of major chest wall trauma
nPresent in 70 to 80% of penetrating, major non-
penetrating chest trauma

75. Haemothorax
nSigns and Symptoms
nRapid, weak pulse
nCool, clammy skin
nRestlessness, anxiety
nThirst
nChills
nHypotension
nCollapsed neck veins

76. Haemothorax
ØSource of bleeding
nIntercostal vessels
nInternal mammary vessels
nLung parenchyma
nBroncheal arteries
nMajor pulmonary vessels
nHeart and great vessels

77. Hemothorax
nManagement
nSecure airway
nAssist breathing with high concentration O2
nRapid transport

78. Hemothorax
Indications for Thoracotomy:
ØInitial output is > 1250 ml
ØInitial output is > 1000 ml with hypotension
ØOutput > 250 ml/h for 3 hours

83. Chest tube
indicated to drain the contents of the pleural space. Usually this
will be air or blood, but may include other fluids such as chyle or
gastric/oesophageal contents.
Absolute Indications
nPneumothorax (tension, openor simple)
nHaemothorax
nTraumatic Arrest (bilateral)
Relative Indications
nRib fractures& Positive pressure ventilation
nProfound hypoxia / hypotension & penetrating chest injury
nProfound hypoxia / hypotension and unilateral signs of
hemithorax

91. nPulmonary contusion
nBleeding into the lung itself is a pulmonary
contusion
nBleeding and edema can impair gas exchange,
causing hypoxia and respiratory faliure.
nSoft crackles may be heard over injury site
nChest pain, point tenderness, and localized swelling
over area of impact
ØManagement
nSupport ventilation as needed
nSupply high-flow supplemental oxygen
nTransport to hospital---ventilation

99. nDiaphragmatic injury
ØTypes
1)Acute blunt injury
2)Acute penetrating injury
3)Chronic diaphragmatic hernia

111. nCardiac contusion
nCan impair heart’s ability to pump
nBleeding into heart tissue can cause heart to beat irregularly
nIrregular pulse should alert to possibility of a cardiac contusion
ØDiagnosis
nFracture sternum
nECG-----ST& T abnormality + Dysrhythmias
nCPK-MB
ØManagement
nHigh-flow oxygen
nVentilation support as needed
nSupport of circulation if appropriate
nPrompt transport
nRequest ALS backup

112. Cardiac contusion

113. nPericardial tamponade
nBleeding around heart and into pericardial sac that
encloses the heart can cause pericardial tamponade
nUsually results from a penetrating chest trauma with
laceration to the heart itself
nBlood filling the pericardial sac compresses heart,
causing blood to back up
nJVD is a telltale sign of pericardial tamponade
nNarrowed pulse pressures

114. Pericardial tamponade
nManagement
nHigh-flow oxygen
nTreat patient for shock
nTransport rapidly to ER
nRequest ALS intercept
nNotify hospital so staff can properly prepare

117. nAortic injury
nIn sudden decelerations such as high-speed head-on MVCs,
body organs are thrown forcefully against the front of the
body
nMost significant tear: aorta
nIf tear is complete, patient will die in minute
ØManagement
nHigh-flow oxygen
nTreat patient for shock
nTransport rapidly to ED
nNotify hospital so staff can properly prepare

118. BAI: investigations BAI: investigations --CXRCXR
!Wide mediastinum
MS ration >0.25-0.4
!Blurred aortic knob
!Pleural effusion
!Apical Capping
!NG deviation
!1
st
or 2
nd
rib #
!Depressed left
mainstembronchus
!Blunted AP window
!HTX, PTX
!Enlargement of the
paratrachealstripe

127. Conclusion

128. Conclusion