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Chest Trauma. By Dr. Samir Abdallah M.D Prof. of Cardio-Thoracic Surgery Cairo University. Chest Trauma. Epidemiology.
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Chest Trauma By Dr. Samir Abdallah M.D Prof. of Cardio-Thoracic Surgery Cairo University
Chest Trauma Epidemiology • The fact that it has become possible in recent decades for millions of people to travel at high speed had led to a phenomenal increase in blunt injury to the chest - a most lethal type of injury.
All casualties, and particularly children who have been exposed to blunt chest injury may have sustained highly lethal internal lesions (rupture of the heart, the aorta or the major airway, for example, or contusion of the heart although the external stigmata of chest injury may be quite trivial or even absents altogether.
For this reason any causality who has sustained blunt trauma to the chest should be considered seriously injured until proved otherwise.
Mechanism of Injury in Chest Trauma • Acceleration/deceleration (motor vehicle accident) • Body compression (crush injury) • High-speed impact (gunshot wound) • Miscellaneous Low-velocity penetration (stab wound) Airway obstruction (suffocation) Caustic injury (poisoning) Burns Electrocution
Chest wall injury Airway Obstruction Pneumothorax Hemorrhage Cardiac injury Tamponade Hemothorax Pain, Restriction, Retention of Secretions, Atelectasis Flail Chest Myocardial dysfunction Hypovolemia Pulmonary Shunting Hypoventilation Hypoxemia Respiratory Acidosis Diminished Cardiac Output Tissue Hypoxia Metabolic Acidosis Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosis Blunt or Penetration Trauma
Assessment of patient with Thoracic injury • The evaluation of thoracic injuries is only one aspect of the total assessment of severely injured patients. • Both diagnosis and therapy go hand in hand. • The basic principle of elective surgery - “First investigate and make the diagnosis, then treat the illness” - is a dangerous illusion.
Assessment of patient with Thoracic injury The first step is to make a rough estimate of the status of the circulatory and respiratory systems. This provides the first diagnostic clues and often determines which therapeutic action is to be taken. Specific questionsare then posed pertaining to individual injuries or their consequences.
TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries 1.Hypovolemia? 2.Respiratory insufficiency? 3.Tension pneumothorax? 4.Cardiac tamponade Immediately life- threatening; diagnosis and therapy before taking roentgenograms
TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries • Multiple rib fractures? (Paradoxical respiration?) • Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?) • Hemothorax? • Diaphragmatic rupture? • Aortic rupture? • Cardiac contusion?
Monitoring and evaluating the patient with Thoracic trauma • Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles). • Mediastmum (wide or normal) shifted or not. • Lung parenchyma (Contusion). • The heart (cardiac tamponade). • Diaphragm. • Pneumothorax, hemothorax. • ECG • CVP • Arterial blood gases. • Urine output. • Lab. Investigations. • Others.
Management of patients with Thoracic Trauma • The treatment of polytraumatized patient must follow a certain protocol which includes. • Adequate oxygenation. • Fluid replacement. • Surgical intervention. • Treatment of septic complications. • Adequate caloric and substrate supplementation. • Prevention of stress bleeding. • Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis.
Direct Violence Indirect violence Rib and Sternal Fracture Mechanism of Injury Lung injuries are more common
Rib and Sternal fractures • Diagnosis • Patient complains of localized pain that is aggravated by coughing deep breathing “Localised tenderness. Subcutaneous emphysema • False motion, paradoxical respiration • Rib fractures must be diagnosed clinically many rib fractures are not visible on X-ray chest.
Therapy in multiple rib fractures (not taking companion injuries into consideration)
Intercostal Blocks (Sites)
It is a tried and tested rule that a prophylactic chest tube should be inserted in every patient with multiple rib fractures who is to undergo an operation under general anaesthesia even when there is neither evidence of a hemothorax nor of a pneumothorax.
Pneumothorax and Hemothorax • Cases of pneumothorax and hemothorax can be provided with extremely effective therapy for the most part with simple methods, in more than 80% of cases. • It must, however, be given early, furthermore the drainage of air and blood must be efficient.
Tension Pneumothorax (Life Threatening) • Every traumatic pneumothorax can develop into tension pneumothorax, however, this complication is rare with spontaneous breathing. • Very frequently, in a more dangerous form by for, a tension pneumothorax occurs during mechanical ventilation. • Treatment consists of immediate relief of pressure.
Open Pneumothorax Diagnosis: • A penetrating thoracic wound with a sucking sound of incoming and outgoing air “sucking wound” adds to the clinical and radiological evidence of pneumothorax Therapy: • Immediate air tight closure of the thoracic wound. • Immediate intubation and mechanical ventilation.
Hemothorax Diagnosis • Diminished breath sound. • Muffled sound on percussion. • X-ray chest: Clouding of the affected half of the thorax up to complete opacity. In the diagnosis of hemothorax formation of atelectosis and rupture of the diaphragm should be differentiated.
Sources of blood accumulating in the chest following blunt or penetrating trauma: Hemothorax • Pulmonary parenchymal laceration. • Rupture of pleural adhesions. • Mediastinal injury with or without vascular injury. • Cardiac injury with pericardio-pleural communication. • Decompression of abdominal hemorrhage through a traumatic diaphragmatic injury.
Hemothorax Therapy • The key to successful management of acute hemothorax is early aggressive care in the form of adequate pleural evacuation by thoracostomy or thoracotomy in order to minimize the morbidity. • The rate and cessation of bleeding depends on the site and size of the bleeding wound.
Hemothorax • Thoracotomy is done if the bleeding is constant and more than 300 ml per hour during the first three to four hours. However, tube thoracotomy is all what is needed if bleeding is less and decreasing without radiological evidence of clotted blood.
Incision over intercostal space Development of subcutaneous tract Penetration of parietal pleura Confirmation that lung is not adherent to chest wall at puncture site Insertion of Chest Tube
Bronchial Rupture Immediate Acute respiratory insufficiency Acute Infections Early Bronchial Obstruction Abnormalities following bronchial rupture and methods of management Mediastinitis Empyema Atelectasis Tubes Emergency Repair or Resection
Pulmonary Infection Late bronchial obstruction Bronchiectasis Pneumonitis Atelectasis Fibrosis Abscess Elective Pulmonary Resection Abnormalities following bronchial rupture and methods of management Delayed Pneumonia Abscess Fibrosis
Entry into cervical or mediastinal fascial planes of: Bacteria and Saliva Air Gastric juice Mediastinitis Emphysema Pneumothorax Burn Empyema Abscess Tension Fluid and electrolyte disturbance Sepsis Pneumonia CV Collapse Pathologic courses following esophageal perforation
Fluid and Electrolytes Antibiotics Prevent further contamination Closure Or Exclusion Or Re-section Only With reconstruction Essential components of and procedures used in management of esophageal perforation Therapy non-operative High-dose IV Topical, Luminal Gast. Tube Plus Operative Prox. Tube Drainage of Mediastinal and/or fascial planes
Injuries of the diaphragm Diaphragmatic Rupture: • Incidence: In 3% of all sever thoracic injuries. • Mechanism: Broad surface blow. • Location: Left side in 85% of cases. • Clinical picture. Acute: symptoms of companion injury and shock. Chronic: Intestinal obstruction or strangulation (usually)
Diaphragmatic ruptures (Cont.) • Radiological Ex.: Rupture of the diaphragm are frequently overlooked. • Therapy: Is indicated for increasing impairment to respiration. • Operative approach from chest or abdomen.
