chest trauma surgery department № 2 dsma surgery department № 2 dsma
TRANSCRIPT
IntroductionIntroduction
Chest trauma is often sudden and Chest trauma is often sudden and dramaticdramatic
Accounts for 25% of all trauma deathsAccounts for 25% of all trauma deaths 2/3 of deaths occur after reaching 2/3 of deaths occur after reaching
hospitalhospital Serious pathological consequnces:Serious pathological consequnces:
-hypoxia, hypovolaemia, myocardial-hypoxia, hypovolaemia, myocardial failure failure
Mechanism of InjuryMechanism of Injury
Penetrating injuriesPenetrating injuries E.g. stab wounds etc.E.g. stab wounds etc. Primarily peripheral lungPrimarily peripheral lung HaemothoraxHaemothorax PneumothoraxPneumothorax Cardiac, great vessel or oesophageal Cardiac, great vessel or oesophageal
injuryinjury
Either:Either: direct blow (e.g. rib fracture)direct blow (e.g. rib fracture) deceleration injury deceleration injury compression injurycompression injury Rib fracture is the most common sign Rib fracture is the most common sign
of blunt thoracic traumaof blunt thoracic trauma Fracture of scapula, sternum, or first Fracture of scapula, sternum, or first
rib suggests massive force of injuryrib suggests massive force of injury
Blunt injuriesBlunt injuries
Chest wall injuries Chest wall injuries
Rib fractures Rib fractures
Flail chestFlail chest
Open pneumothoraxOpen pneumothorax
Rib fracturesRib fractures
Most common thoracic injuryMost common thoracic injury Localised pain, tenderness, crepitusLocalised pain, tenderness, crepitus CXR to exclude other injuriesCXR to exclude other injuries Analgesia avoid tapingAnalgesia avoid taping Underestimation of effectUnderestimation of effect Upper ribs, clavicle or scapula Upper ribs, clavicle or scapula
fracture: suspect vascular injuryfracture: suspect vascular injury
Flail chestFlail chest
Multiple rib fractures produce a Multiple rib fractures produce a mobile fragment which moves mobile fragment which moves paradoxically with respirationparadoxically with respiration
Significant force requiredSignificant force required Usually diagnosed clinicallyUsually diagnosed clinically Rx: ABCRx: ABC
Analgesia Analgesia
Open pneumothoraxOpen pneumothorax
Defect in chest wall provides a direct Defect in chest wall provides a direct communication between the pleural communication between the pleural space and the environmentspace and the environment
Lung collapse and paroxysmal shifting of Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort mediastinum with each respiratory effort ± tension pneumothorax± tension pneumothorax
““Sucking chest wound”Sucking chest wound” Rx: ABCs…closure of wound…chest Rx: ABCs…closure of wound…chest
drain drain
Lung injuryLung injury
Pulmonary contusionPulmonary contusion Pneumothorax Pneumothorax HaemothoraxHaemothorax Parenchymal injuryParenchymal injury Trachea and bronchial injuriesTrachea and bronchial injuries PneumomediastinumPneumomediastinum
PneumothoraxPneumothorax
Air in the pleural cavityAir in the pleural cavity Blunt or penetrating injury that Blunt or penetrating injury that
disrupts the parietal or visceral pleuradisrupts the parietal or visceral pleura Unilateral signs: Unilateral signs: movement and movement and
breath sounds, resonant to percussionbreath sounds, resonant to percussion Confirmed by CXRConfirmed by CXR Rx: chest drainRx: chest drain
Pneumothorax Pneumothorax classificationclassificationBy side:By side:
left or rightleft or right in both sidein both side
By lung collapse degree:By lung collapse degree: Partial (paracostal)Partial (paracostal) Subtotal (smaller than 2/3 of lung volume)Subtotal (smaller than 2/3 of lung volume) Total (more than 2/3 of lung volume)Total (more than 2/3 of lung volume)
By mechanism of formation:By mechanism of formation:
- open - open
- closed- closed
- tension- tension
Tension pneumothorax Tension pneumothorax
Air enters pleural space and cannot Air enters pleural space and cannot escapeescape
P/C: chest pain, dyspnoeaP/C: chest pain, dyspnoea Dx: - respiratory distress Dx: - respiratory distress
- tracheal deviation (away) - tracheal deviation (away) - absence of breath - absence of breath
soundssounds - distended neck - distended neck veinsveins - hypotension - hypotension
Surgical emergencySurgical emergency
Rx: emergency decompression Rx: emergency decompression
before CXRbefore CXR
Either large bore cannula in 2nd ICS, Either large bore cannula in 2nd ICS,
MCL or insert chest tubeMCL or insert chest tube
CXR to confirm site of insertionCXR to confirm site of insertion
HaemothoraxHaemothorax
Blunt or penetrating traumaBlunt or penetrating trauma Requires rapid decompression and fluid Requires rapid decompression and fluid
resuscitationresuscitation May require surgical interventionMay require surgical intervention Clinically: hypovolaemiaClinically: hypovolaemia absence of absence of
breath soundsbreath sounds dullness to percussion dullness to percussion CXR may be confused with collapseCXR may be confused with collapse Decompression always by chest catchment in 7 Decompression always by chest catchment in 7
ICS on middle or posterior axillary lineICS on middle or posterior axillary line
Hemothorax classificationHemothorax classificationBy side:By side:
left or rightleft or right in both sidein both side
By blood lost volume :By blood lost volume : Small (< 10% of BCV, or <500 ml)Small (< 10% of BCV, or <500 ml) Middle (10-20 % of BCV, or 500-1000ml)Middle (10-20 % of BCV, or 500-1000ml) Big (10-20 % of BCV, or 500-1000ml)Big (10-20 % of BCV, or 500-1000ml) Total ( > 40 % of BCV, or >2000ml)Total ( > 40 % of BCV, or >2000ml)
By bleeding presence:By bleeding presence:
- stopped (Reviloi – Gregoire test negative)- stopped (Reviloi – Gregoire test negative)
- continues (Reviloi – Gregoire test positive)- continues (Reviloi – Gregoire test positive)
By clots By clots presence:presence:
- clotted- clotted
- unclotted- unclotted
By infection complication presence:By infection complication presence:
- non-infected- non-infected
- infected- infected
Indication for urgent Indication for urgent thoracotomythoracotomy
In In pneumothoraxpneumothorax:: Absence of active air catchment during Absence of active air catchment during
more than 2 days (presence of more than 2 days (presence of pneumothoraz on CXR)pneumothoraz on CXR)
In In hemothoraxhemothorax:: Evacuation of > 1000ml blood Evacuation of > 1000ml blood
simultaneously or bleeding continues during simultaneously or bleeding continues during 4 hours with blood loss > 200 ml per hour4 hours with blood loss > 200 ml per hour
Heart, Aorta & DiaphragmHeart, Aorta & Diaphragm
Blunt cardiac injuryBlunt cardiac injury- contusion- contusion- ventricular, septal or valvular - ventricular, septal or valvular
rupture rupture Cardiac tamponade Cardiac tamponade Ruptured thoracic aortaRuptured thoracic aorta Diaphragmatic ruptureDiaphragmatic rupture
Cardiac TamponadeCardiac Tamponade Blood in the pericardial sac Blood in the pericardial sac Most frequently penetrating injuriesMost frequently penetrating injuries Shock, Shock, JVP, PEA, pulsus paradoxusJVP, PEA, pulsus paradoxus Classically, Beck’s triad:Classically, Beck’s triad:
- distended neck veins- distended neck veins- muffled heart sounds- muffled heart sounds
- hypotension- hypotension Rx: Volume resuscitationRx: Volume resuscitation
Pericardiocentesis Pericardiocentesis
Aortic ruptureAortic rupture
Usually blunt trauma involving Usually blunt trauma involving deceleration forces; especially RTAsdeceleration forces; especially RTAs
~90% die within minutes~90% die within minutes Most common site near ligamentum Most common site near ligamentum
arteriosumarteriosum Dx: clinical suspicion, CXR, aortography, Dx: clinical suspicion, CXR, aortography,
contrast CT or TOE contrast CT or TOE Rx: surgical…poor prognosisRx: surgical…poor prognosis
Iatrogenic traumaIatrogenic trauma
NG tubes: - coilingNG tubes: - coiling - - endobronchial placementendobronchial placement - - pneumothoraxpneumothorax
Chest tubes: - subcutaneousChest tubes: - subcutaneous - - intraparenchymalintraparenchymal - - intrafissuralintrafissural
Central lines: - neckCentral lines: - neck - - coronary sinuscoronary sinus
- pneumothorax- pneumothorax
Chest trauma: summaryChest trauma: summary CommonCommon SeriousSerious Primary goal is to provide oxygen Primary goal is to provide oxygen
to vital organsto vital organs RememberRemember
AAirwayirwayBBreathingreathing
CCirculationirculation Be alert to change in clinical Be alert to change in clinical
condition condition