CHEST TRAUMA

Dr BAYISENGA Justin, MD, MMed SURGERY

Introduction

• About ¼ of deaths due to trauma are attributed to thoracic injury.

• Immediate deaths (1st peak) are essentially due to major disruption of the heart or of great vessels.

• Early deaths (2nd peak) due to thoracic trauma include airway obstruction, cardiac tamponade or aspiration.

Introduction cont’d

• Most patients with thoracic trauma can be managed by simple maneuvers.

• Others require surgical treatment.

• REMEMBER: Chest trauma may be BLUNT or PENETRATING and each of this type relates to its management

Etiologies of chest trauma

Penetrating trauma.– GSW( Gun Shoot Wound) or stab wounds– Concentrates forces over smaller area– Bullet trajectories unpredictable

Blunt trauma.– Force distributed over larger area– Visceral injuries occur from:

• Deceleration• Compression• Sheering forces• Bursting

SIGNS INDICATIVE OF CHEST INJURY

Hypotension and tachycardia. Cyanosis. Hemoptysis. Chest wall contusion. Paradoxal respiration. Open wounds. Jugular vein distention (JVD). Tracheal deviation Hypersonority/ Dullness

The chest trauma may result in:

• Pneumothorax (simple, tension, open)

• Haemothorax

• Pulmonary contusion

• Rib fractures

• Flail chest

• Pericardial tamponade

• Myocardial contusion

• Diaphragmatic injury

PNEUMOTHORAX

SIMPLE PNEUMOTHORAX:

• It is accumulation of air in pleural space

• It is not a life threatening unless it becomes huge (tension pneumothorax)

• Chest X-Ray to confirm and size

• Chest drain is the treatment

Tension pneumothorax

• Air enters continuously the pleural space but cannot leave

• Intrathoracic pressure increases progressively

• Mediastinal shift

• ↓ venous return + ↓ cardiac output

• Respiratory distress

• Hypoxia

Tension pneumothorax con’t

• Life threatening emergency

• Clinical diagnosis

• Urgent Chest Needle Decompression

• If you delay, you loose the patient

SIGNS of TENSION PNEUMOTHORAX

• Respiratory distress

• Tachycardia

• Hypotension

• Distended neck veins

• Resonant percussion note

• Tracheal deviation (Late sign)

• ↓ air entry/ none air entry

MANAGEMENT

Immediate decompression with :• Large bore needle (G14/G16)• Second intercostal space• Mid clavicular line• Formal chest drain to follow• NB: The Chest needle decompression is not

definitive management, it makes tension pneumothorax into simple one treated by chest tube insertion

OPEN PNEUMOTHORAX

It is Sucking” wound of the chest

• Other signs of pneumothorax present

• Occlude wound (3 sides only)

• Air escapes on expiration

• Urgent insertion of chest drain

Pulmonary contusion

• The pulmonary paranchyma is contused

It may be associated with

• Rupture of trachea or major bronchi which is a serious injury with an overall estimated mortality of at least 50%. Most (80%) of the ruptures of bronchi are within 2.5 cm of the carina. The usual signs of tracheo-bronchial disruption are the followings:

Haemoptysis

Dyspnoea

Subcutaneous and mediastinal emphysema

Haemothorax

• Blood is accumulated in the pleural cavity

• More common in penetrating than in blunt injuries to the chest.

• If the haemorrhage is severe:

Hypovolaemic shock

Respiratory distress due to the compression of the lung on the involved side.

Haemothorax cont’d

• The extent of internal injuries cannot be judged by the appearance of a skin wound.

• It is managed by chest tube insertion

• NB: Thoracotomy is indicated in haemothorax if: 2000ml -3000ml of blood is immediately drained from the chest or if 200ml – 300ml/hr.

Flail chest

• There are more than 1# on one rib

• When the patient inspires, the chest expands while the frail section sink in and the mediastinum moves towards the normal side

• When he/she expires the frail section moves out and the mediastinum moves to the other side.

Management of flail chest

Management of flail chest cont’d

• As it may lead to severe respiratory distress: • Adequate analgesia is vital• Give oxygen• Consider intubation

• As it may be associated with other chest injuries; the chest tube insertion may be necessary

Pericardial tamponade

• Penetrating cardiac injuries are a leading cause of death. (It is rare to have pericardial tamponade with blunt trauma).

CLINICAL PRESENTATION:• Shock • Distended neck veins • Cool extremities and no pneumothorax • Muffled heart sounds.

TREATMENT :Pericardiocentesis to be performed early.

MYOCARDIAL CONTUSION

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Myocardial contusion cont’d

• Blunt chest trauma is the most cause

• It is associated with fractures of the sternum or ribs.

• The diagnosis is supported by abnormalities on ECG (T wave inversion) and elevation of serial cardiac enzymes if these are available.

• It can stimulate a myocardial infarction

Myocardial contusion management

• Patient must be submitted to observation with cardiac monitoring

• This type of injury is more common than we think

• It may be a cause of sudden death well after the accident.

Diaphragmatic injuries

• Should be suspected in any penetrating thoracic wound:

• Below 4th intercostal space anteriorly

• 6th interspace laterally

• 8th interspace posteriorly

• The diagnosis is often missed.

CHEST TUBE INSERTION

Indications for chest tube insertion

• Pneumothorax in any ventilated patient • Tension pneumothorax (NB. After initial needle relief) • Persistent or recurrent pneumothorax after simple

aspiration • Large secondary spontaneous pneumothorax in patients

over 50 years • Malignant pleural effusion • Empyema and complicated parapneumonic pleural effusion • Traumatic haemo/ pneumothorax• Perioperative :Thoracotomy, oesophagectomy, cardiac

surgery

Equipment for chest drain insertion

• Sterile gloves and gown

• Skin antiseptic solution, e.g. iodine or chlorhexidine in alcohol

• Sterile drapes

• Gauze swabs

• A selection of syringes and needles (21–25 gauge)

• Local anesthetic, e.g: Lidocaine 1% or 2%

• Scalpel

• Suture (e.g. Nylon 1)

• Instrument for blunt dissection (e.g. curved clamp)

The position of the patient

• The preferred position of the patient for drain insertion is on the bed, slightly rotated, with the arm on the side of the lesion behind the patient’s head to expose the axillary area.

• An alternative is for the patient to sit upright leaning over an adjacent table with a pillow

• In the lateral decubitus position.

SAFETY TRIANGLE

• Insertion should be in the “safe triangle” (usually 5th intercostal space in mid-axillary line) illustrated.

• This position minimizes risk to underlying structures such as the internal mammary artery and avoids damage to muscle and breast tissue.

SAFE TRIANGLE

REMEMBER

• If you drain air (Pneumothorax), put the tip of chest tube apically

• If fluids (Haemo/ pyothorax or any pleural effusion) to be drained put the tip basally

Other considerations

• Aseptic technique should be employed

• Local anaesthetic should ALWAYS be infiltrated prior to drain insertion

• Substantial force should NEVER be used

• Trocars should NEVER be used. Blunt dissection into the pleural space should be performed prior to drain insertion

• Prophylactic antibiotics should be given in trauma cases

Chest Drain removal

• The chest tube should be removed while the patient performs a Valsalva manoeuvre.

• This creates a high intrathoracic pressure and gives the operator time to remove the drain and tie the suture.

• The timing of removal is dependent on the original reason for insertion and clinical progress:

• In the case of pneumothorax, the drain should not usually be removed until bubbling has ceased and chest radiography demonstrates full lung inflation.

THANK YOU VERY MUCH!!!!