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Thoracic injury accounts for 25% of all injuries. In a further 25%, it may be a significant contrubutorto the subsequent death of patients. Chest injuries are often life threatening, either in their own or in conjunction with other systemic injuries. About 805 of chest injury can be managed non-operatively and the key is early physiological resuccitationfollowed by diagnosis.
Principle of ATLS Early assesmentand primary survey; Simultaneous aggressive resuscitation; A careful secondary survey with full examination:
± Front to back ± Top to toe
Transfer to a definitive site of care ALTS principle of resuscitation A airway B Breathing C Circulation D Disability (neurology) E Environment and exposure
The deadly dozen threats of life from chest injury
Immediately life threatening Airway obstruction Tension pneumothorax Pericardial temponade Open pneumothorax Massive haemothorax Flial chest Potentially life threatning Aortic injuries Tracheobronchial injuries Myocardial contusion Rupture of diaphragm Oesophageal injuries Pulmonary contusion
Early preventable death are often due to lack of or delay in airway control. Dentures, teeth, secretion and blood can contribute to airway obstruction in trauma. Bilateral mandibular fracture expanding neck haematomasproducing deviation of pharynx and mechanical compression of trachea, laryngeal traumaandtracheal injury are other causes of laryngeal obstruction. Removal of FB, cleaning airway with oropharyngeal suction, placing an airway tube and if needed endotrachealintubation if needed.
2. Tension pneumothorax
A tension pneumothoraxis a medical emergency when a one way valve air accumulates in the pleural space with each breath either from lung or through the chest wall. Air is for forced into the thorax without any means of escape, completely collapsing the affected lung. The increase in intrathoracicpressure results in massive shifts of the mediastinumaway from the affected lung compressing intrathoracicvessels. Most common causes are penetrating chest tauma, blunt chest trauma with parenchymallung injury and air leak that didn t spontaneously close, iatrogenic lung puncture and mechanical positive pressue ventillation
The clinical presentation is dramatic. Patient is panicky with tachypnoea, dyspnoeaand distended neck vein Clinical examination can reveal tracheal deviation (a late finding), hyperresonanceand absent breath sound over affected hemithorax. Treatment consist of immediate decompression and is managed initially by rapid insertion of large bore needle into the second intercostalspace in the mid- clavicular line of the affected hemithorax. This is immediately followed by insertion of a chest tube through the 5th intercostalspace in the anterior axillaryline. *** Tension pneumothoraxis a cinicaldiagnosis and the treatment shouldn t be delayed by waiting for radiological examination.
3. Pericardial tamponade
Cardiac tamponadeis a clinical syndrome caused by the accumulation of fluid/blood in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Cardiac tamponadeis a medical emergency. The overall risk of death depends on the speed of diagnosis, the treatment provided, and the underlying cause of the tamponade. It is most commonly the result of penetrating trauma. Accumulation of small amount of blood into non-ditensible pericardial sac can produce physiological obstruction of heart. All patient with penetrating injury anywhere near heart plus shock must be considered as cardiac injury unless otherwise proved.
Classically presentation consists of :± Venous pressure elevation ± Decline in arterial pressure with tachycardia ± Muffled heart sound
A high index of suspicion and further investigations e,g
± Chest radiography-enlarged heart shadow ± Echocardiogram-fluid in pericardial sac and ± Insertion of central line- rising CVP
are required for subclinical cases. **In cases in which in which major bleeding has taken place from other sites, the neck vein may be flat. **Pericadialtemponademust be differentiated from tension pneumothoraxin the shock patient with distended neck vein
Needle pericardiocentesismay allow the aspiration of a few ml of blood, and this along with rapid volume resuscitation to increase preload can buy enough time to move to operation room. The correct immediate treatment of temponadeis operative (sternotomyor lt. thoracotomy), with repair of heart in operation theatre if time allows or otherwise in the emergency room. ***In penetrating injury to the heart there is usually a substantial clot in the pericardium, which may prevent aspiration. Pericardiocentesishas a high potential for iatrogenic injury should be done as temporary measure when in transport.
4. Open pneumothorax
An open pneumothoraxoccurs when there is a pneumothorax associated with a chest wall defect, such that the pneumothoraxcommunicates with the exterior. Pathophysiology-During inspiration, when a negative intrathoracic pressure is generated, air is entrained into the chest cavity not through the trachea but through the hole in the chest wall. This is because the chest wall defect is much shorter than the trachea, and hence provides less resistance to flow. Once the size of the hole is more than 0.75 times the size of the trachea, air preferentially enters through the thoracic cavity. This results in inadequate oxygenation and ventilation, and a progressive build-up of air in the pleural space. The pneumothoraxmay tension if a flap has been created that allows air in, but not out.
Diagnosis-Diagnosis should be made clinically during the primary survey. A wound in the chest wall is identified that appears to be 'sucking air' into the chest and may be visibly bubbling - this is diagnostic. Breathing is rapid, shallow and laboured. There is reduced expansion of the hemithorax, accompanied by reduced breath sounds and an increased percussion note. One or all of these signs may not be appreciated in the noisy trauma room. Breathing is rapid, shallow and laboured. There is reduced expansion of the hemithorax, accompanied by reduced breath sounds and an increased percussion note. One or all of these signs may not be appreciated in the noisy trauma room.
Management 100% oxygen should be delivered via a facemask. Consideration should be given to intubation where oxygenation or ventilation is inadequate. Intubation should not delay placement of a chest tube and closure of the wound. The definitive management of the open pneumothoraxis to place an occlusive dressing over the wound and immediately place an intercostalchest drain. Rarely, if a chest drain is not available and the patient is far from a definitive care facility, a bandage may be applied over the wound and taped on 3 sides. This, in theory, acts as a flap-valve to allow air to escape from the pneumothoraxduring expiration, but not to enter during inspiration. This dressing may be difficult to apply to a large wound and it's effect is very variable. As soon as possible a chest drain should be placed and the wound closed.
5. Massive haemothorax
Common causes of massive haemothoraxin blunt injury is continuing torn intercostalvessel and occasionally internal mammary artery. Accumulation of blood in a hemithoraxcan significantly compromise respiratory efforts by compressing lung and preventing adequate ventillation. Massive haemothoraxpresents as haemorrhagicshock with flat neck vein, unilateral absence ofbreathsound and dullness to percussion. Treatment consists of correction of hypovolumicshock, insertion of intercostaldrain and in some cases, intubation.
Blood in the pleural spsce should removed as completely and as rapidly as possible to prevent ongoing bleeding, empyema or late fibrothorax. Initial drainage of more than 1500ml or on-going of more than 200ml/hr over 3-4 hrs generally considered as indication for urgent thoracotomy. Following points are important in the management of massive haemothorax:± Clinical examination may be misleading if only done from supine position as the lung may float on the haemothoraxand the breath sound anteriorlymay be normal. ± Caution is required in a case that drains more than 500 ml into drainage bottle but has persistent dullness or radiographic opacification.
6. Flail chest
A flail chest is a life-threatening medical condition that occurs when a segment of the chest wall bones breaks under extreme stress and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. The number of ribs that must be broken varies by differing definitions: some sources say at least two adjacent ribs are broken in at least two places,some require three or more ribs in two or more places. The flail segment moves in the opposite direction as the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This so-called "paradoxical motion" can increase the work and pain involved in breathing. Voluntary splinting as a result of pain, mechanically impaired chest wall movement and the associated lung contusion are the causes of hypoxia.
The Patient is also at high risk of developing a pneumothorax and hemothorax. Traditionally treatment consisted of mechanical ventilation to internally splint the chest until fibrous union of broken ribs occurred. Currently treatment consist of oxygen administration, adequate analgesia and physiotherapy. If chest tube in situ, intra pleural local analgesia can be used as well. Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen. Surgery to stabilize the flail chest may be useful in a selected group in isolated or severe chest injury and pulmonary condition who have been shown to benefit from the internal operative fixation of flail segment.
Thoracic aortic disruption
Traumatic aortic rupture, also called traumatic aortic disruption or transection, is a condition in which the aorta, is torn or ruptured as the result of trauma. The injury is usually caused by high speed impacts such as those that occur in vehicle collisions and serious falls. Acute rupture of the thoracic aorta following blunt chest trauma is associated with an 80 - 85 % pre-hospital mortality rate. When the aorta is partially torn, it may form a "pseudoaneurysm". In patients who do live long enough to be seen in a hospital, a majority have only a partially torn blood vessel, with the layer called the adventitia still intact. In up to 20 % of survivors, the surrounding adventitia and mediastinalstructures provide stabilization to the site of transection. Given that undiagnosed aortic tears have a 50 % mortality rate within the first 48 hours, these injuries require early diagnosis and effective management Horizontal deceleration creates shearing forces at the aortic isthmus, the junction between the relatively mobile aortic arch and the fixed descending aorta. 90-98% of traumatic injuries of the thoracic aorta occur at the isthmus .
It should be clinically suspected if the patient have upper or upper and lower extremity BP, widened pulse pressure and chest wall contusion. Chest x-rays are used to diagnose the condition. The classical findings on a chest x ray will be widened mediastinum, apical cap, and displacement of the trachea, left main bronchus, or nasogastrictube.Anormal chest x-ray does not exclude transection, but will diagnose conditions such as pneumothoraxor hydrothorax. The diagnosis is confirmed by aortographyor a contrast spiral CT scan of mediastinum. Initial management consists of control systolic blood pressure (to less than 100 mm of Hg.). There after endovascular intraaoticstent cn be placed or a tear can be operatively repair or excissionand grafting usuinga dacrongraft.
Tracheobronchialinjury(TBI) is damage to the tracheobronchialtree,canresult from blunt or penetrating neck or chest trauma. Though rare, TBI is potentially fatal. TBI can cause the airway to be blocked and can restrict breathing. Of those who do reach a hospital, the mortality rate may be as high as 30%. The injury is frequently difficult to diagnose and treat. Early diagnosis is important to prevent complications, which include narrowing of the airway, respiratory infections, and damage to the lung tissue. Signs and symptoms include difficulty breathing, hoarseness, coughing, and abnormal breath sounds. Severe subcutaneous emphysema with respiratory compromise suggest tracheobroncheal disruption.
A left main bronchus laceration, resulting in pneumothorax. Air is evacuated from the chest cavity with a chest tube
A chest drain placed on the affected side will reveal a large air leak and the collapsed lung may fail to re-expand. In after insertion of two drain the lung fails to re-expand, referral to a specialized trauma centre is adviced. Bronchoscopyis the most effective method to diagnose, locate, and determine the severity of TBI. In the emergency setting, intubation with an endotrachealtube can be used to ensure that the airway remains open so the patient can breathe. Surgery to repair a tracheobronchialtear follwingintubationof the unaffected bronchus is usually considered standard. In less severe cases TBI may be managed conservatively and allowed to heal without surgery. Late complications of untreated tracheobronchialinjury include bronchial stenosis, recurrent pneumonia and bronchiectasis. Prompt diagnosis and treatment generally lead to good functional recovery.
blunt myocardial injury
Significant blunt myocardial injury that cause haemodynamic injury is rare, most common caused by falls from heights greater than 20 feet and motor vehicle accidents. Blunt myocardial injury should be suspected in any patients sustaining blunt trauma who develops ECG abnormalities in the resuscitation room. The most reliable sign of significant injury to myocardium is an abnormal 12 lead ECG. Two dimensional echocardiography may show wall motion abnormality. A transoesophageal echocardigrammay be helpful. All patients with myocardial contusion diagnosed by conduction abnormalities are at risk of developing sudden dysrhythmiaand should be watched for 24 hours and continually monitored by ECG.
Diaphragmatic rupture(also called diaphragmatic injuryor tear) is a tear of the diaphragm. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating traumaand occurs in about 5% of cases of severe blunt trauma to the trunk. Blunt injury to diaphragm is usually caused by compressive forces applied to the pelvis and abdomen. Any penetrating injury to or below the 5th intercostalspace should raise the suspicion of diaphragmatic penetration and therefore injury to abdominal contents. Blunt injury due to gross abdominal compression causing large radial tears with herniationof abdominal contents into the chest. Penetrating trauma tends to produce small perforations that take some time to develop into diaphragmatic hernias. Rupture of L hemidiaphragmmore common
75% of patient with ruptured diaphragm have associated intraabdominal injury. Most diaphragmatic injuries are silent and the presenting features are those of injury to surrounding organs. If rupture of L hemidiaphragmis suspected a chest radiograph after placement of a NG tube should be taken. If this appears in thoracic cavity no further investigations are required. Occasionally it is necessary to inject contrast down NG tube to confirm diagnosis. The most accurate evaluation is by video-assisted thoracoscopy or laparoscopy, the later offerinf the advantage of allowing the surgeon to proceed to a repair and additional evaluation of the abdominal organs. Operative repair should follow basic resuscitation in all cases. All panetratingdiaphragmatic injury must be repaired via the abdomen and not the chest to rule out the penetrating hollow viscusinjury.
Oesophagealperforation is a fulminating and potentially fatal lesion. Therefore, early recognition and treatment is the most important factor in its management. Most injuries to the oesophagusresult from penetrating trauma,bluntthoracic trauma rarely results in oesophageal injuries and hence the diagnosis is often missed initially. The clinical features are frequently delayed and a high degree of suspicion is necessary to establish the diagnosis in a timely manner. Patient may present with odynophagia, subcutaneous or mediastinalemphysema, pleural effusion, air in the retrooesophagealspaceandunexplained fever within 24 hrs of injury. Medistinaland deep cervical emphysema must be seen as evidence of aerodigestiveinjury until otherwise proved.
Mortality rate increases exponentially if treatment is delayed for more than 12 24 hrs. Plain X-ray of the chest may show pneumomediastinum, widened mediastinalshadow and a small pleural effusion on the affected side. A combination of contrast oesophagogram in decubitus position (show the dye trickling from the oesophagus ) and oesophagoscopyconfirm the diagnosis in the great majority of cases. The treatment is operative repair and drainage.
Different methods have been tried for the treatment of oesophageal injuries-drainage of the appropriate cavity with near total exclusion of the thoracic oesophagusby cervical oesophagostomyand gastrostomy. The cervical oesophagostomyprevents further mediastinalcontamination by saliva also useful for oesophageal dilatation and for doing contrast oesophagograms. The gastrostomyinitially decompresses the stomach and prevents reflux of gastric contents into the torn oesophagus. Later it is used for hyperalimentation. Primary suturing of the oesophagealtear is not advocated as there is marked contusion of the oesophagusaround the tear. Further, due to the delay in treatment, the edges of the tear are oedematousand friable.
A pulmonary contusion(or lung contusion) is a contusion (bruise) of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to hypoxia. A pulmonary contusion is caused directly by blunt trauma usually underneath a flail segment or fractured ribs but can also result from explosion injuries or a shock wave associated with penetrating trauma. it is usually caused by traffic accidents. The use of seat belts and airbags reduces the risk to vehicle occupants. This is a very common potentialllethal chest injury and a major cause of hypoxia after blunt trauma. It is an independent risk factor pneumonia and ARDS.
Diagnosis is made by studying the cause of the injury, physical examination and chest radiography. Typical signs and symptoms include direct effects of the physical trauma, such as chest pain and haemoptysis, as well as cyanosis. Chest radiograph findings are typically delayed and are nonsegmental. Contrast Ct scan can be confirmatory. The contusion frequently heals on its own with supportive care. Often nothing more than supplemental oxygen and close monitoring is needed. intensive care may be required, if breathing is severely compromised, mechanical ventilation may be necessary. Fluid replacement may be required to ensure adequate blood volume, but fluids are given carefully since fluid overload can worsen pulmonary edema, which may be lethal.
Thoracotomy, a major surgical maneuver, is an incision of the chest wall. It is performed by trained physicians, to gain access to the thoracic organs. Resuscitative or emergency thoracotomyis a lifesaving procedure, when performed with the correct indications and approaches, and is defined as that occurring either immediately at the site of injury, in the emergency department or in the operating room, as an integral part of initial resuscitation. The influence of prehospitalemergency thoracotomyon mortality is not clearly defined and, thus, its usefulness remains controversial. Emergency thoracotomyis a procedure carried out in patients presenting in extremis. The primary goals are:± ± ± ± ± ±
The control of massive hemorrhage, The release of cardiac tamponade, The internal or open cardiac massage, The prevention or control of air embolism, The control of bronchopleuralfistulae and The cross-clamping of descending aorta.
The first successful 'prehospital' thoracotomyand cardiac repair was carried out by Hill on a kitchen table in Montgomery, Alabama in 1902. While the technique of emergency thoracotomyis fairly standard, the indications for performing surgery remain a source of controversy.
± Penetrating thoracic injury -Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital) -Unresponsive hypotension (BP < 70mmHg) ± Blunt thoracic injury -Unresponsive hypotension (BP < 70mmHg) -Rapid exsanguinationfrom chest tube (>1500ml)
± Penetrating thoracic injury -Traumatic arrest without previously witnessed cardiac activity ± Penetrating non-thoracic injury -Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital) ± Blunt thoracic injuries -Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
Emergency room thoracotomy
Emergency room thoracotomy
Planned emergency thoracotomy
Planned emergency thoracotomyimplies as an emergency thoracotomyperformed as a planned procedure in operating room, directed at the management of specific injury. The approach chosen is dependent on indication of surgery and the organ injured. The thoracotomymay be right or left sided and these may be joined resulting in so called clamshell incission. Certain organs are best approached through median sternotomy. Posterolateralthoracotomyis not generally used in emergency situation because of difficulties in positioning of the patient.
Continuing blood loss
The first principle all care is to asses and treat the patient according to physiology. Initial loss of more than 1500ml indicates the potential for class III shock, and any on-going bleeding must be dealt surgically, as soon as possible. An on-going bleeding 200ml per hr for 3 consecutive hrs requires resuscitative surgery to stop bleeding. Clinical indicators of potential on-going bleeding in torso trauma: Physiological
± ± ± ± Increasing respiratory rate Increasing pukserate Falling blood pressure Raising serum lactate
± Visible bleeding ± Injury in close proximity to major vessel ± Penetrating injury with retained weapon.
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