Thoracic Trauma

Dr Khalid Javeed Khan FCPS - FRCS Associate Professor Surgery Fatima Jinnah Medical College

Learning Objectives
Identify & initiate the Management of Immediately Life Threatening Injuries

1. Airway Obstruction 2. Tension Pneumothorax 3. Open Pneumothorax 4. Massive Hemothorax 5. Flail Chest 6. Cardiac Tamponade

Learning Objectives
Identify & initiate the Management of

Potentially Life Threatening Injuries

2. 3. 4. 5. 6. 1. Pulmonary Contusion Myocardial Contusion Aortic Disruption Diaphragmatic Rupture Tracheobronchial Disruption Esophageal Disruption

Introduction
Thoracic Injuries cause 1 out of 4 trauma deaths

Pathophysiology
Hypoxia Hypercarbia Acidosis

Majority require simple procedures

Blunt Penetrating < 10 % require operation 15 - 30 % require operation

Thoracic Trauma
Initial Assessment

Primary Survey for  Airway  Breathing  Circulation Resuscitate

Hypoxia is the most serious feature of chest injury so early interventions to ensure adequate oxygenation Most life threatening injuries are treated by an appropriately placed chest tube or needle

Thoracic trauma
Primary Survey of LifeLife-Threatening Injuries
 Airway

Listen for air movement at nose and mouth Assess for supracostal & intercostal retractions Assess the oropharynx for Foreign Body Obstruction
 Breathing

Expose the chest Look feel and listen for respiratory movement Tachypnea change of breathing pattern esp. shallow breathing
 Circulation

Pulse volume, rate and regularity (attach monitor) Skin color and temp BP Neck veins engorged?

Life Threatening Chest Injuries

Tension Pneumothorax
"One way valve" air leak from the lung or chest, Collapse of ipsilateral lung, shift of mediastinum and collapse of opposite lung A Clinical Diagnosis (not by radiology) Respiratory distress, tachycardia, hypotension tracheal deviation and neck vein distension unilateral absence of breath sounds, may be confused with cardiac tamponade, hyper resonance may help differentiate.

Management of Tension Pneumothorax

Immediate decompression Needle in 2nd space followed by chest tube

Chest intubations

Open Pneumothorax
"Sucking Chest Wound" If the opening in chest wall is equal to 2/3 of tracheal diameter, air passes preferentially through the defect Hypoxia due to lack of effective ventilation Management Promptly close the defect by sterile dressing taping on three sides to prevent tension Chest tube remote from defect Definitive repair of defect is usually required

Massive Hemothorax
Pathophysiology Rapid accumulation of u 1500 ml blood penetrating wounds disrupting systemic or hilar vessels, sometimes blunt trauma Blood loss hypoxia Diagnosis Shock + dullness + absent breath sounds Flat or distended neck veins

Massive Hemothorax
Management Restoration of blood volume (2 I/V lines) Chest decompression (# 38 French tube) If 1500 ml evacuated, or > 200 ml/hour continuous loss, operative intervention is likely required

Flail Chest
Pathophysiology A segment of chest wall looses continuity with rest Major difficulty is Hypoxia from injury to underlying lung Diagnosis Asymmetric & incoordinated movement of chest Palpation of abnormal motion and crepitus aid diagnosis X-ray chest --> # ribs --> ABG --> hypoxia and acidosis -->

Flail Chest
Management Oxygen ReRe-expand lung Judicious fluid administration Intubation as indicated Analgesia

Cardiac Tamponade
Pathophysiology Penetrating trauma Human pericardium is a fixed fibrous structure, small amount of blood required to restrict cardiac activity Diagnosis Beck's Triad ( o venous pressure, BP, muffled sounds) Tension Pneumothorax on left may mimic tamponade

Look for tamponade or myocardial damage in # sternum

Cardiac Tamponade
 Management
High index of suspicion is all that is needed to initiate Pericardiocentesis in patients who don't respond to usual treatment for shock and have the potential for tamponade All +ve Pericardiocentesis require open pericardotomy

Technique of Pericardiocentesis

Emergency Department Resuscitative Thoracotomy

Patients with exsanguinating, exsanguinating, penetrating precardial injury who arrive pulseless but with electrical activity may be candidates for Emergency Department Thoracotomy
Qualified operator, Left ant thoracotomy to gain access, restoration of IV volume continues, endotracheal tube with ventilation is essential

Resuscitative Thoracotomy

Secondary Survey
In-depth Physical Examination InUpright X-ray Chest XABG ECG Detection of potentially lethal injuries
Simple Pneumothorax Pulmonary Contusion Myocardial Contusion Aortic Rupture Diaphragmatic rupture Tracheobronchial Disruption Esophageal Disruption

Simple Pneumothorax

Hemo-pneumothorax

Pulmonary Contusion
Most common potentially lethal injury Maintain Adequate Ventilation Selective Intubation & Ventilation if significant Hypoxia Equipment needed Pulse Oximetry ABG determination ECG monitoring Ventilator

Myocardial Contusion
 Blunt Trauma  History  Associated with sternal #  ECG changes  2D Echo  Treat Complications
Risk of sudden arrhythmias (CCU observation)

Traumatic Aortic Rupture

Most common cause Autocrash Fall from great height Site: Ligamentum Arteriosum (contained hematoma)

Traumatic Aortic Rupture

Signs Widened Mediastinum # first & second ribs Pleural Cap Obliterated knuckle Deviations of trachea, esophagus and bronchi Obliteration of space between aorta & pulmonary artery Salvage possible if identified early by Aortography

Tracheobronchial Tree Injuries

Larynx Rare Hoarseness, Emphysema, palpable # Treat by Intubation & Tracheostomy Trachea Partial versus complete obstruction Endoscopy .. Diagnostic Aid Treatment is by operation Bronchi Frequently missed, Blunt trauma Massive air leak Endoscopy .. Diagnostic Aid Airway Maintenance & Operation

Esophageal Rupture
Blunt vs. Penetrating Severe epigastric blow Pain / Shock > Injury Pneumothorax Without # Chest tube --> Particulate matter --> Mediastinal Air Confirm by Contrast swallow / Esophagoscopy Treatment by operative repair

Other manifestations of Chest Injury

Subcutaneous Emphysema Traumatic Asphyxia Rib Fracture Pain / Splinting Impaired Ventilation & Increased secretions Atelectasis / Pneumonia Site of Rib Fracture 11-3 ribs & Scapula # .. Severe blow, high mortality 44-9 ribs # .. Intrathoracic injury 10 -12 # ... Suspect abdominal Injury

Summary
Thoracic injuries are common in polytrauma LifeLife-threatening Injuries need immediate attention Potentially lethal injuries need to be looked for Usually simple measures required Intubation and ventilation Chest tube Needle Pericardiocentesis Develop skills to treat Monitoring using appropriate equipment

The End
Thanks for patience