Chet Injuries ,chest tube and ETT by me.pptx

In the United States, as in much of the world, TBI is a common cause of death and disability.

Causes of TBI include

Falls (especially in older adults and young children)

Motor vehicle crashes and other transportation-related causes (eg, bicycle crashes, collisions with pedestrians)

Assaults

Sports activities (eg, sports-related concussions)

Pathology of Traumatic Brain Injury
Structural changes from head injury may be gross or microscopic, depending on the mechanism and forces involved. Patients with less severe injuries may have no gross structural damage. Clinical manifestations vary markedly in severity and consequences. Injuries are commonly categorized as open or closed.

Open head injuries involve penetration of the scalp and skull (and usually the meninges and underlying brain tissue). They typically involve bullets or sharp objects, but a skull fracture with overlying laceration due to severe blunt force is also considered an open injury.

Closed head injuries typically occur when the head is struck, strikes an object, or is shaken violently, causing rapid brain acceleration and deceleration. Acceleration or deceleration can injure tissue at the point of impact (coup), at its opposite pole (contrecoup), or diffusely; the frontal and temporal lobes are particularly vulnerable to this type of injury. Axons, blood vessels, or both can be sheared or torn, resulting in diffuse axonal injury. Disrupted blood vessels leak, causing contusions, intracerebral or subarachnoid hemorrhage, and epidural or subdural hematomas (see table Common Types of Traumatic Brain Injury).

TABLE
Common Types of Traumatic Brain Injury
Concussion
Concussion (see also Sports-Related Concussion) is defined as a transient and reversible posttraumatic alteration in mental status (eg, loss of consciousness or memory, confusion) lasting from seconds to minutes and, by arbitrary definition, < 6 hours.

Gross structural brain lesions and serious neurologic residua are not part of concussion, although temporary disability can result from symptoms (such as nausea, headache, dizziness, memory disturbance, and difficulty concentrating [postconcussion syndrome]), which usually resolve within weeks. However, it is thought that multiple concussions may lead to chronic traumatic encephalopathy, which results in severe brain dysfunction.

Brain contusions
Contusions (bruises of the brain) can occur with open or closed injuries and can impair a wide range of brain functions, depending on contusion size and location. Larger contusions may cause brain edema and increased intracranial pressure (ICP). Contusions may enlarge in the hours and days following the initial injury and cause neurologic deterioration; surgery may be required.

Diffuse axonal injury
Diffuse axonal injury (DAI) occurs when rotational deceleration causes shear-type forces that result in generalized, widespread disruption of axonal fibers and myelin sheaths. A few DAI lesions may also result from minor hghuuuui

1. Chest Injuries and Their Management Abdulkerim Nesro C2 1

2. Classification of thoracic injuries Chest wall Pleural space Pulmonary parenchyma Mediastinal structures Aerodigestive structures Trachea & bronchi Esophagus Vascular structures 2

3. Clinical indicators of potential ongoing bleeding in torso trauma Physiological : Increasing respiratory rate Increasing pulse rate Falling blood pressure Rising serum lactate Anatomical : Visible bleeding Injury in close proximity to major vessels Penetrating injury with a retained missile

4. Thoracic injury accounts for 25 per cent of all severe injuries. 90% can be managed by simple measures : Oxygen therapy Analgesics Chest physiotherapy IV fluid replacement Chest tube drainage

5. Etiologies Blunt injuries - MVA - Falls - Assaults and Blasts Penetrating injuries

6. Patient evaluation Secure the Air way : Prevention of aspiration, plastic airway, intubation, tracheostomy. ,Nasal oxygen, throat suction Treat his Breathing * ICT (intercostal tube) placement, supportive measures Restore blood volume and circulation Evaluate the patient for associated injuries like of head, abdomen, fracture limbs, spine.

7. After ABCs Chest Inspection : RR, pattern, evidence of trauma, structural thoracic defect Palpation Emphysema, Paradoxical chest movement, stove-in-chest Percussion and Auscultation Hemo and Pneumo thorax Finally CXR and Blood gases

8. Routine investigation in the emergency department of injury to the chest is based on clinical examination, supplemented by chest radiography. Ultrasound can be used to differentiate between contusion and the actual presence of blood. A chest tube can be a diagnostic procedure, as well as a therapeutic one, and the benefits of insertion often outweigh the risks.

9. Imaging CXR and 12 lead ECG CT/Angiography U/S :- FAST -Echocardiography - TEE laboratory CBC and Blood group ABG Serum electrolyte Coagulation profile Troponin, CK-MB Serum lactate Diagnostic Tests

10. CXR A chest radiograph is the investigation of first choice initial diagnostic study for hemodynamically stable patients with chest trauma For blunt trauma All blunt trauma In the supine position until unstable spinal fracture has been ruled out For penetrating Stab wounds b/n the neck & the umbilicus (front or back) Gunshot wounds b/n the neck & pelvis/buttock Unclear bullet track Missing bullet Odd number of entry/exit wounds 10

11. Immediate Late Hypoxia Hypercarbia Acidosis Hypovolemic shock Bronchospasm Empyema, fibrothorax Lung abscess Mediastinitis Cardiac arrhythmias Pathological Effects of Chest Injuries

12. Rib fractures Most common injury Often following blunt thoracic trauma At the site of force, laterally 20% mortality in the elderly Less common in children 1 st rib fracture: Severe injury 30% mortality Effect Poor inspiratory effort Ineffective cough Atelectasis from splinting Pneumonia 12

13. Rib fractures are common injuries, which occur most often following blunt thoracic trauma but can also result from severe coughing, athletic activities (eg, rowing, swinging golf clubs), and nonaccidental trauma (ie, child abuse ). 13

14. Relevant anatomy and physiology The chest wall consists of 12 pairs of ribs, the first seven of which articulate both posteriorly with the spine and anteriorly with the sternum . Ribs 8 to 10 attach anteriorly to the costal cartilage. The lowest two ribs are "floating" and do not connect anteriorly . Immediately below each rib travels its neurovascular bundle, including the intercostal vein, artery, and nerve. 14

15. 15 The first rib is unique in that the scaleni insert onto it, and it therefore is exposed to stresses from the action of these neck muscles. The superior ribs (numbers 1 to 3) are relatively protected by the scapula, clavicle, and soft tissue, while the inferior "floating" ribs are relatively mobile. Therefore, the more vulnerable middle ribs (numbers 4 to 10) are most susceptible to injury from blunt trauma. Fractures of superior ribs reflect trauma

16. Mechanism of injury   Most rib fractures are caused by direct trauma to the chest wall. This can occur from blunt (eg, motor vehicle crash) or penetrating (eg, gunshot) trauma. A single blow may cause rib fractures in multiple places. Traumatic fractures most often occur at the site of impact or the posterolateral bend, where the rib is weakest. Both displaced and nondisplaced fractures can be seen in adults and children. Due to the greater pliability of children's ribs, greater force is required to produce a fracture. 16

17. Rib fractures may be pathologic. Cancers that metastasize to bone (eg, prostate, breast, renal) frequently become apparent in a rib. Ribs are relatively thin compared with major long bones and are more likely to fracture when invaded by a metastatic lesion. 17

18. Clinical presentation and examination General fractures  — Patients with rib fractures who are not victims of high-energy trauma typically describe a history of minor or moderate blunt trauma to the chest wall. Often, they can localize the pain to one or two ribs, and they describe an injury that corresponds with the area of discomfort. The patient can frequently reproduce or exacerbate the pain by taking a deep breath. 18

19. Examination findings strongly suggestive of rib fracture include : severe point tenderness on a specific rib or focal tenderness caused by compression of the ribcage distant from the site of pain. Bony crepitance and ecchymosis may be present. Bony crepitance is an auscultated click caused by movement of the rib fracture and can be heard with a stethoscope placed over the fracture site. 19

20. look, listen, and palpate for evidence of internal injury when examining patients with suspected rib fractures. Signs, such as diminished breath sounds, may reflect splinting from the pain of a simple chest wall contusion. However, they may also reflect the presence of significant injury (eg, pneumothorax or pulmonary contusion). 20

21. Pneumothorax would present as diminished breath sounds and possibly air crepitance. Pulmonary contusion may cause diminished breath sounds, but if there is blood in the alveoli, crackles may be audible.

22. Rib fractures sustained by patients as a result of more serious trauma are often associated with internal injury. Fractures of ribs 9 through 12 may be associated with intraabdominal injury; fractures of ribs 1, 2, or 3 may be associated with mediastinal injury, particularly to the aorta . Intrathoracic injury, such as pneumothorax or pulmonary contusion, can occur in association with rib fractures at any level. 22

23. Rib fractures CXR: Lateral or anterior rib fractures will often be missed Mainly for associated injuries 23

24. Rib fractures Treatment CXR to exclude other injuries (50% sensitive) Strong analgesics ( Once significant associated injuries have been evaluated and treated, the cornerstone of rib fracture management is pain control ) Encourage breathing Prophylactic antibiotics Treat associated injuries 24

25. Chest wall injuries that are associated with increased risk of significant intrathoracic or intraabdominal injury include: Scapula fracture Flail chest Multiple rib fractures (≥3) and displaced rib fractures Sternal fracture Posterior sternoclavicular dislocation 25

26. The DDX of injuries to the chest wall in blunt thoracic trauma includes: Sternal fracture Scapula fracture Rib fracture(s) 26

27. Costochondral tear Flail chest Intercostal vascular and nerve laceration Clavicle fracture and dislocation Thoracic spine fracture Soft tissue injuries, such as lacerations, muscle strains, and contusions

28. Early and adequate pain relief is essential to avoid complications from splinting and atelectasis, primarily pneumonia. For isolated injuries (ie, single rib fracture), begin treatment with NSAIDs with or without opioids. For more severe injuries, particularly if ventilation is compromised , admission and invasive treatments, such as intercostal nerve blocks , may be needed. 28

29. R ib belts or binders compromise respiratory function. Associated injuries, such as liver or spleen lacerations, mediastinal injury, pneumothorax, hemothorax, flail chest, and pulmonary contusion, may occur 29

30. Sternal fractures Usually transverse fracture, majority at the sterno-manubrial junction usually present with moderate to severe pain localized to the sternum, which can be pleuritic. Palpation reveals tenderness 30

31. Sternal fractures are associated with an increased risk of internal injury. Such injuries may include rib fractures, myocardial contusion, hemopericardium, spinal fractures, retrosternal hematoma, hemothorax, pneumothorax, and trauma to major vessels . Dx: X-ray (lateral) Treatment Exclude life treatening injuries (ECG, CXR) Pain control Chest physiotherapy Reduce fracture manually

32. Sternal fractures Open reduction Unstable fracture Displacement >1cm Associated lower extremity injury For flail sternum: Internal or external 32

33. Life-threatening injuries can be remembered as the ‘deadly dozen’. Six are immediately life-threatening and should be sought during the primary survey and six are potentially life threatening and should be detected during the secondary survey

34. Immediately life threatening Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Pericardial tamponade

35. Potentially life threatening Aortic injuries Tracheobronchial injuries Oesophageal injuries Pulmonary contusion Myocardial contusion Rupture of diaphragm

36. Flail chest Flail chest occurs when three or more adjacent ribs are each fractured in two places , creating one floating segment comprised of several rib sections and the soft tissues between them. This unstable section of chest wall exhibits paradoxical motion (ie, it moves in the opposite direction of uninjured, normal-functioning chest wall) with breathing and is often associated with significant morbidity from pulmonary contusion. 36

37. Anterior and lateral are common Significant force required and associated with severe lung injury Pathophysiology Paradoxical movement of the chest (diagnostic) Pain 37

38. Types : Anterior—near costochondral junction Lateral—in rib shafts • Respiratory failure Posterior—safer, due to support of scapula

39. Flail chest 39

40. Flail chest

41. Flail chest Treatment Good analgesia Endotracheal intubation with continous positive pressure ventilation for up to three weeks , until the fracture becomes less mobile Indications for endotracheal intubation Deterioration of pulmonary function Hypoxia Hypercarbia Fracture fixation 41

42. Management of Flail chest Stabilize the flail segment Firm gentle manual pressure Apply IV bags Place patient with injured site down Traction Open fixation Insert a chest tube 42

43. T reatment 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.

44. Stove in chest is depression of a portion of chest wall due to severe chest injury, otherwise features and management are like flail chest.

45. Pneumothorax Air between the visceral and parietal pleura Effects are: Collapse of lung/Intrapulmonary blood shunt Mediastinal shift Vena caval obstruction Hypoxemia and Hypovolemia Classified as Spontaneous and traumatic Open and closed Simple and tension 45

46. Pneumothorax Symptom: dyspnea, cough, chest pain, wound Sign: respiratory distress in some, bruise/ wound, hyper resonance & dullness, tracheal deviation in tension pneumothorax Diagnosis: If there is no clinical evidence of tension pneumothorax, an upright chest x-ray darkening with white line b/n lung & air; Smaller pneumothorax may only be evident on expiration 46

47. Pneumothorax Air comes from a lacerated lung Hyper-resonant chest with decreased air entry. Spontaneous pneumothorax comes from a diseased lung. Appears as a black shadow in CXR 47

48. Pneumothorax 48

49. Pneumothorax Pneumothorax after stab wound Normal chest radiograph 49

50. Pneumothorax Left apicolateral pneumothorax with typical convex white visceral pleural line Chest X-ray reveals • Radiolucency on the affected side
• Absence of lung markings • Collapsed lung margin 50

51. Simple pneumothorax From ruptured alveolus or laceration of lung parenchyma Pleural pressure becomes slightly more positive than the pleural pressure in the contralateral hemithorax, but still remains subatmospheric Rx: Tube thoracostomy Control CXR Observation for small heamothorax presenting lately 51

52. Tension pneumothorax Pleural pressure > atmospheric pressure Mediastinal shift Air enters pleural space under pressure and cannot escape Lung collapses around the hole in the pleura The hole acts like a valve A real surgical emergency: Fatal Treatment Needle thoracostomy Tube thoracostomy 52

53. A tension pneumothorax develops when a ‘one-way valve’ air leak occurs either from the lung or through the chest wall. Air is sucked into the thoracic cavity without any means of escape, completely collapsing then compressing the affected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung.

54. The most 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.

55. The clinical presentation is dramatic. The patient is increasingly panicky with tachypnoea, dyspnoea and distended neck veins (similar to pericardial tamponade). Clinical examination may reveal tracheal deviation.

56. This is a late finding and is not necessary to clinically confirm diagnosis. There will also be hyper-resonance and absent breath sounds over the affected hemithorax. Tension pneumothorax is a clinical diagnosis and treatment should never be delayed by waiting for radiological confirmation .

57. Treatment : C onsists of immediate decompression, initially by rapid insertion of a large-bore needle into the second intercostal space in the midclavicular line of the affected hemithorax and a sterile glove is kept on the hub (blunt) end of the needle to create a valve so as to prevent inward sucking of air from outside , and then followed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line.

58. Tension pneumothorax Tension Pneumothorax Normal chest radiograph 58

59. 59

60. Under water seal 60

61. Open pneumothorax Defect in chest wall provides communication between the pleural space and the environment. Ipsilateral L un g c ollapse p aroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax Also called Sucking chest wound Rx: Chest drain (tube thoracostomy ) Closure of wound 61

62. This is 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.

63. Signs and symptoms are usually proportionate to the size of the defect. If there is a valvular effect, increasing amounts of air in the pleura will result in a tension pneumothorax .

64. Initial management consists of promptly closing the defect with a sterile occlusive plastic dressing, taped on three sides to act as a flutter-type valve to form a #1 way valve (prevents tension pneumothorax) . A chest tube is inserted as soon as possible in a site remote from the injury site. P hysiotherapy and active mobilisation should begin as soon as possible. Definitive treatment may warrant formal debridement and closure .

65. Pneumo thorax: Features Small size pneumothorax: Asymptomatic Large size pneumothorax: Respiratory distress Tracheal deviation (away) Absence of breath sounds Distended neck veins Hypotension , Shock Bulged chest with slow movement 65

66. Management of Pneumothorax Surgical emergency if Tension pneumothorax ! ! Immediate needle thoracostomy Formal tube thoracostomy Observation for small pneumothorax If symptomatic: Either large bore cannula in 2nd ICS, MCL Insert chest tube 66

67. Massive haemothorax Blood between visceral and parietal pleura Bleeding from: Intercostal arteries Internal mammary artery Lung Effects: Hypovolemia and lung compression 67

68. The most common cause of massive haemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally from the internal mammary artery.

69. Presentation is with Hypovolaemia ( haemorrhagic shock ) , flat neck veins , unilateral absence of breath sounds and dullness to percussion.

70. Treatment 1. Tube thoracostomy 2. Thoracotomy : Massive heamothorax with initial drainage of (1000 (penetrating ) – 1500ml - blunt ) Bleeding of >200ml/hr. for 4hours Bleeding of >100ml/hr. for 8hours

71. The treatment consists of C orrecting the hypovolaemic shock, insertion of an intercostal drain and, in some cases, intubation.

72. Blood in the pleural space should be removed as completely and rapidly as possible to prevent ongoing bleeding, empyema or a late fibrothorax. Initial drainage of more than 1500 mL of blood or ongoing haemorrhage of more than 200 mL/hour over 3–4 hours is generally considered an indication for urgent thoracotomy.

73. Hemothorax CXR: ( 500 ml . required to blunt the costophrenic angle) A volume of 300 mL is needed for hemothorax to manifest on an upright CXR Treated by chest tube insertion 73

74. Right Hemothorax 74

75. Tube thoracostomy Indications Heamopneumothorax (85%) Surgical emphysema Insertion 6 th or 7 th ICS along the PAL (or 5 th ICS along the MAL) for fluid but 2 nd Ic space for air Remova l 48hrs after the air leak ceases and drainage is less than 5 0ml/day & is serosanguinous Indications for emergency thoracotomy Initial chest tube output of 1500 mL of blood Persistent drainage of 200 to 300 mL/ hr 75

76. Pulmonary laceration Occurs in both blunt and penetrating injuries More frequently after blunt chest trauma Usually underneath a flail segment or fractured ribs. Pathologic state in which hemorrhage and edema of the lung parenchyma occur without parenchymal disruption Major cause of hypoxemia after blunt trauma 76

77. The natural progression of pulmonary contusion is worsening hypoxemia for the first 24–48 hours. The chest radiography findings are typically delayed . Pulmonary contusions generally develop over the first 24 hours and resolve in about one week. Irregular, nonlobular opacification of the pulmonary parenchyma on chest x-ray is the diagnostic hallmark. About one-third of the time the contusion is not evident on initial radiographs Contrast CT scanning can be confirmatory.

78. Radiologic findings may not be present on admission and may develop 24 to 48 hours after the initial injury Pneumonia is the most frequent complication, particularly in the elderly .

79. Pulmonary laceration C/F Manifests with respiratory distress, cough and hemoptysis Hemoptysis is frequent (Haemoptysis or blood in the endotracheal tube is a sign of pulmonary contusion.) 79

80. CXR Pul. Contusion + heamothorax Rx Chest tube insertion + supportive care (antipain & chest physiotherapy)

81. In mild contusion, the treatment is : oxygen administration, aggressive pulmonary toilet and adequate analgesia. In more severe cases, mechanical ventilation is necessary. Normovolaemia is critical for adequate tissue perfusion and fluid restriction is not advised .

82. Tracheobronchial injuries Are uncommon Occur in less than one percent of patients with blunt thoracic trauma Most patients who sustain such injuries die at the scene Mechanisms Penetrating Blunt trauma: with in 2 cm of the carina 82

83. Severe subcutaneous emphysema with respiratory compromise can suggest tracheobronchial disruption. A chest drain placed on the affected side will reveal a large air leak and the collapsed lung may fail to re-expand.

84. Tracheobronchial injuries Diagnosis Difficult and often delayed Hx : as pneumothorax Investigation CXR, ( Pneumothorax, Pneumomediastinum, Air in the soft tissue of the neck, abnormal migration of endotracheal tube tip , balloon distension beyond tracheal diameter Definitive diagnosis is made in the operating room or by bronchoscopy (Look directly) CT 84

85. Tracheobronchial injuries Treatment Airway Intubation over flexible bronchoscope (intubation of unaffected bronchus followed by operative repair.) Tube thoracostomy 85

86. Non operative management Asymptomatic tears found incidentally < 1/3 of the circumference Fully expanded lungs with tube thoracostomy No air leak No associated injury No need for positive pressure ventilation Operative management

87. Cardiac injuries

88. Myocardial contusion Occur in less severe chest trauma It is col l apse of cardiac muscle CF: no specific sign or symptom Inv: no universal diagnostic criteria ECG Creatinine kinase 88

89. Treatment Based on clinical presentation Treat arrhythmias (All patients with myocardial contusion diagnosed by conduction abnormalities are at risk of developing sudden dysrhythmias and should be closely monitored.)

90. … Myocardial contusion Clinicians should obtain an electrocardiogram (ECG) on all blunt trauma patients with any of the following: Pain and tenderness directly over the mid-anterior chest Sternal fracture 90

91. History suggestive of cardiac disease (eg, accident precipitated by syncope, severe chest pain, or shortness of breath) Active symptoms or signs suggestive of cardiac disease Major mechanism of injury (e.g, rollover, high speed, fatality at scene)

92. Peri c ardia l Tamponade Blood in the pericardial sac Most frequently after penetrating injuries Classically, Beck’s triad: Distended neck veins Muffled heart sounds Hypotension 92

93. The presentation is similar to a tension pneumothorax : deteriorating cyanosis tachycardia and agitation . All patients with penetrating injury anywhere near the heart plus shock must be considered to have a cardiac injury until proven otherwise. Classically, the presentation consists of venous pressure elevation, decline in arterial pressure with tachycardia, and muffled heart sounds.

94. Cardiac injuries cardiac tamponade …. Chest x-ray of a pericardial effusion Cardiomegaly due to a massive pericardial effusion At least 200 mL of pericardial fluid must accumulate before the cardiac silhouette enlarges 94

95. Dx : CXR of enlarged heart shadow Echo—Ultrasound is diagnostic : fluid in pericardial sac

96. Treatment: Needle pericardiocentesis may allow the aspiration of a few millilitres of blood and this, along with R apid volume resuscitation to increase preload .

97. Pericardiocentesis has a high potential for iatrogenic injury to the heart . ( under ECG control ). The correct immediate treatment of tamponade is operative (sternotomy or left thoracotomy), with repair of the heart.

98. Ruptured diaphragm Tear of diaphragm with or without herniation Often caused by penetrating injuries Any penetrating injury below the fifth intercostal space should raise suspicion of diaphragmatic penetration After blunt trauma More on the left side (following blunt trauma) Injuries of lower thoracic or upper abdomen 98

99. Pathology:- Herniation of intraabdominal organs into the chest Diagnosis: CXR (Distortion of contour, Apparent elevation, Mediastinal shift) Chest radiography after placement of a nasogastric tube may be helpful (as this may show the stomach herniated into the chest ). U/S, barium study of upper or lower GIT

100. Ruptured diaphragm Lateral chest film showing herniation of the stomach into the left pleural cavity 100

101. Ruptured diaphragm Treatment Should be repaired as soon as possible Operative repair is recommended in all cases. Through chest or abdomen Acute diaphragmatic rupture is generally repaired through a midline abdominal incision Chronic defects discovered months or years after the initial injury can be treated through a transthoracic, an abdominal, or a combined approach 101

102. All penetrating diaphragmatic injury must be repaired via the abdomen and not the chest, to rule out penetrating hollow viscus injury. A late complication of rupture of the diaphragm is herniation of the abdominal contents into the chest. Strangulation of any of the contents can then occur .

103. Esophageal injury Tear or perforation of esophagus Blunt trauma: distal third, uncommon Most esophageal injuries are secondary to Penetrating trauma 103

104. The patient can present with : O dynophagia (pain on swallowing foods or fluids), subcutaneous or mediastinal emphysema , pleural effusion, air in the retro-oesophageal space and unexplained fever with in 24hr of injury .

105. Dx: CXR (Pneumothorax, Pneumomediastinum, Air in the retro esophageal space, Pleural effusion) Diagnosis is confirmed by esophagography and esophagoscopy . Mediastinal and deep cervical emphysema are evidence of an aerodigestive injury until proven otherwise.

106. Esophageal injury Rx: Non-operative therapy Criteria No evidence of pleural contamination Walled-off extravasation Minimal or no symptoms No evidence of systemic infection 106

107. Operative repair and drainage . Esophageal perforation associated with intrinsic disease, without the above criteria Primar y Repair Tissue buttressing & drainage Exclusion-Diversion procedures

108. Esophageal injury Elderly patients Conservative management Feeding jejunostomy Gastrostomy to prevent gastroesophageal reflux 108

109. Thoracic Great Vessel injuries Aorta , SVC, IVC, Azigous vein, hemiazigous vein , pulmonary artery & vein, bronchial vessels Physical clues Significant chest wall trauma Massive heamothorax Excessive entry site bleeding Expanding apical chest heamatoma / neck mass 109

110. General Principles of Mx I.V access Arresting the bleeding Investigate only on stable pts

111. Thoracic aortic disruption It should be clinically suspected in patients with asymmetry of upper or upper and lower extremity blood pressure, widened pulse pressure and chest wall contusion . Erect chest radiography can also suggest thoracic aortic disruption, the most common radiological finding being a widened mediastinum .

112. The diagnosis is confirmed by a CT scan of the mediastinum or possibly by transoesophageal echocardiography .

113. I nitially , management consists of control of the systolic arterial blood pressure (to less than 100 mmHg ). Thereafter, an endovascular intra-aortic stent can be placed or the tear can be operatively repaired by direct repair or excision and grafting using a Dacron graft .

114. Indications for thoracotomy include the need to perform:
• internal cardiac massage;
• control of haemorrhage from injury to the heart or lung;
• control of intrathoracic haemorrhage from other causes;
• control of massive air leak.

115. Thoracotomy to access different thoracic structures 115

116. Blunt thoracic injury 116

117. Blunt thoracic injury 117

118. 118

119. Surgical emphysema It is collection of gas/air in the subcutaneous or and fascial planes. Causes
• Lung injury.
• Tracheal injury.
• Chest wall injury. • After laparoscopic procedure.

120. Types : • Localised.
• Generalised—extensive in the neck, face, eyelids chest wall, etc. Features
• Pain, diffuse swelling of the subcutaneous region.
• Palpable crepitus is diagnostic. • X-ray chest and neck is confirmatory.

121. Treatment
• Conservative treatment— treat the cause.
• In severe cases— ICT one side or both sides placement.

122. CHEST TUBE INSERTION (THORACOSTOMY)

123. Is a tube placed through the chest wall into the pleural fluid to drain an air or fluid collection from the pleural space and can be used to install medication.

124. Indication
 Pneumothorax--spontaneous and tension, traumatic
 Haemothorax--chest trauma--only if massive (>1L)
 Pleural effusion-sterile effusion, infected effusion ( empyema ), par a pneumonic effusion, malignant effusion)
 Chylothorax
 Pleurodesis--installation of sclerosing agents (talc...)

125. Relative Contraindications : 1. Bleeding diathesis
2. Skin infection over the chest tube insertion site
3. Transudative pleural effusion…
 20 to liver failure or CHF
o Because it can resolve with diuretics only . Organized empyema: Thoracotomy is indicated.

126. Site of insertion Generally : o @ 5th Intercostal Space (ICS) in mid axillary line
o @2nd ICS in mid clavicular line for small pneumothorax Safe triangle : o Anterior border of the latissimus dorsi, o The posterior border of the pectoralis major and
o The superior border of the fifth rib

127. Control chest x-ray should be done after 08hrs of the procedure to check proper insertion . To check functionality of chest tube, see
o Continuous bubbling in the bottle
o O scillations

128. Complications 1. Hemorrhage Malposition : 2. Organ injury ( lung , mediastinum…)
3. Damage to intercostals nerves & vessels 4. Introduction of pleural infection
5. Subcutaneous emphysema (usually @ the site of insertion)
6. Re expansion Pulmonary edema

129. Why?...Due to rapid pulmonary expansion (RPE) because of rapid drainage of large volumes of pleural fluid. Clinical features are cough, dyspnea and hypoxemia immediately to 24 hours after insertion. To minimize the risk it’s better to limit initial drainage to 1-1.5 liters .

130. Treatment is supportive and the disease is usually self-limited . The chest tube should be clamped and no additional fluid should be removed and wait two to four hours before draining additional fluid, provided symptoms have resolved.

131. Non functional chest tube – stopped draining. Mostly due to blockage by debris and clot . Chest tube malposition  — the most common complication of tube thoracostomy
The chest tube should not be removed until a second functioning chest tube has been placed into the pleural space. Organ injury — The lung is the most common organ injured .

132. Infection - Wound infection can result in dehiscence and spontaneous removal of the chest tube. Prevented by daily wound care Hemothoraxs can be infected and transform into empyema Pneumonia is another complication

133. Chest tube care  When transportation is needed or if the underwater seal drop , clump the tube, (Don't clump when there is air leak.)  Keep the bottle under bed and static . Put the underwater seal below the level of the patient, to facilitate drainage with the effect of gravity and to prevent back flow of contents into the pleural cavity.
 Check functionality (Oscillation)
 Change when the bottle becomes full/ every 6hrs. underwater seal drainage bag containing about 200 mL sterile water

134. Give regular analgesics. Tramadol 50mg IV QID. Put the patient on broad spectrum antibiotics for 24 hrs or more as needed . Do wound care daily at the insertion site . Give regular chest physiotherapy (give the patient a balloon to take deep breath & then inflate regularly)

135. Send for repeat chest x ray if the output has significantly decreases

136. When to remove? Symptoms resolved, Take control X ray for lung inflation

137. To minimize the risk of infectious complications, the tube should be removed as soon as it is safe to do so.
o Removal Criteria: Pneumothorax
 When the lung is fully expanded (radiological and on physical examination)
 No visible air leak is present and air does not accumulate when suction is removed.

138. o Removal Criteria: Effusion
 When the lung is fully expanded
 Fluid output is less than ~ 1 00 mL/day. Drainage <50ml/hr. of serous fluid . If Blood/chyle don’t remove. No out put for empyema Remove the tube rapidly during inspiration !! I nspire deeply and hold their breath during tube removal.

139. Thank you 139