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High impact chest injury

High impact chest injury. Immediate deaths are usually due to major disruption of the heart or of great vessels.

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High impact chest injury

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  1. High impact chest injury

  2. Immediate deaths are usually due to major disruption of the heart or of great vessels. • Early deaths due to thoracic trauma occurring within 30 minutes to 3 hours after the injury are usually secondary to cardiac tamponade, pneumothorax, airway obstruction and aspiration, or rupture of thoracic aortic tears that have been temporarily contained. Two thirds of these patients reach the hospital prior to death. • Only 10-15% of blunt trauma require thoracic surgery, and 15-30% of the penetrating chest trauma require open thoracotomy. Overall, about 85% of patients with thoracic trauma can be managed without surgical treatment.

  3. Immediate Life Threatening Thoracic Injuries: Primary Survey : • Cardiac disruption/tamponade • Tracheal disruption • Open pneumothorax • Tension pneumothorax • Massive hemothorax (great vessels, pulmonary vessels)

  4. Immediate Life Threatening Thoracic Injuries: Cardiac Tamponade

  5. Immediate Life Threatening Thoracic Injuries:CardiacTamponade • Pathophysiology – intra-pericardial pressure exceeds filling pressure of right heart • Impairs venous return and cardiac filling leading to hypotension, narrow pulse pressure, PEA • “Beck’s Triad” - hypotension, neck vein distension, distant/absent heart tones • Signs and symptoms masked by hypovolemia • Treat with immediate volume replacement to ↑ CVP, pericardial decompression

  6. Immediate Life Threatening Thoracic Injuries: Tracheal Disruption

  7. Immediate Life Threatening Thoracic Injuries: Tracheal Disruption • Massive subcutaneous emphysema in chest wall – displaced trachea • Cervical, facial sub- cutaneous emphysema • Hemoptysis • Blunt injuries almost always within 1” carina

  8. Immediate Life Threatening Thoracic Injuries: Tension Pneumothorax • Suspect with any injury • High intra-thoracic, extra- pulmonary pressure • Absent breath sounds, shift of trachea, hypotension • Can be worsened with intubation and + pressure • Treat symptoms → immediate decompression

  9. Immediate Life Threatening Thoracic Injuries: Open Pneumothorax • “Sucking” chest wound • Respiratory distress • Preferential path of air when hole ≥ ⅔ diameter of trachea • Cover 3 sides • Chest tube drainage and auto-transfusion when available

  10. Immediate Life Threatening Thoracic Injuries: Massive Hemothorax • Can be due to blunt or penetrating injuries • Sources of hemothorax are: lung, intercostal vessels, internal mammary artery, thoracicoacromial artery, lateral thoracic artery etc

  11. Blunt Thoracic Trauma: Cardiac Contusions • Blunt anterior chest trauma • Acute injury pattern (anterior wall: ↑ST’s I, aVL, V2-V4, ↓II,III, aVF), AF, BBB • Cardiac echo to assess wall motion, valves

  12. Wide upper mediastinum ?

  13. Signs to suggest traumatic aortic injury • Palpable fracture of the sternum or scapula • ‘steering wheel imprint’ • intrascapular murmur • lower limb paraplegia • decreased femoral pulses • a palpable fracture of the thoracic spine • a left sided flail chest with signs of shock.

  14. ED Thoracotomy (EDT)

  15. Indications for ED Thoracotomy • Indications: • 1. Salvageable post-injury cardiac arrest: • Patients sustaining witnessed penetrating trauma with < 15 minutes of pre-hospital CPR • Patients sustaining witnessed blunt trauma with < 5 minutes of pre-hospital CPR • Persistent severe post-injury hypotension (SBP<60mmHg) due to: •  Cardiac tamponade •  Hemorrhage – intra-thoracic, intra-abdominal, extremity, cervical •  Air embolism C Clay Cothren and Ernest E MooreEmergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USAWorld Journal of Emergency Surgery 2006, 1:4 

  16. Contra-indications for ED Thoracotomy Contraindications: 1. Penetrating trauma: CPR >15 minutes and no signs of life (pupillary response, respiratory effort, motor activity: 2. Blunt trauma: CPR > 5 minutes and no signs of life or asystole C Clay Cothren and Ernest E MooreEmergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USAWorld Journal of Emergency Surgery 2006, 1:4 

  17. Emergency Department Thoracotomy: Outcomes Review of 42 published series Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-Based Surgery 2003: 1(1) 11-21.

  18. Summarising : • Patients who receive ventilatory support for blunt thoracic trauma are usually severely injured. • These patients are at risk from ventilator-associated pneumonia, persistent air leaks and infection of undrained pleural collections. • Acute respiratory distress syndrome often complicates the injury and weaning from respiratory support may be prolonged. Specific lung protective strategies include low tidal ventilation (6–8 ml kg) with higher positive end-expiratory pressure. • Meticulous attention to fluid balance and nutrition is important

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