european course trauma care

7/27/2019 European Course Trauma Care

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European Course Trauma Care THORACIC TRAUMA

EPIDEMIOLOGY The rate of thoracic trauma in the United States is 12 per millionpopulation per day - and 20-25% of deaths due to trauma are attributed to thoracic injury. It isestimated that thoracic trauma are responsible of approximately 16.000 deaths per year in theUnited States. The incidence has increased rapidly in this century of high-speed vehiculartravel. 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 aresecondary to cardiac tamponade airway obstruction and aspiration. Two thirds of thesepatients reach the hospital prior to die. Only 10-15% of blunt trauma require thoracic surgery,and 15-30% of the penetrating chest trauma require open thoracotomy. 85% of patients withthoracic trauma, can be managed by simple lifesaving manoeuvre that do not require surgicaltreatment. Thoracic injury occurs in the chest wall, lungs and pleura, thoracic great. vessels,diaphragm heart, trachea, bronchus and oesophagus. The magnitude of those problems andthe significance of the associated injuries serve to underscore the importance of completeevaluation and timely intervention in the management of thoracic trauma. Many patients canbe successfully treated with or without tube thoracostomy, respiratory support and in a fewcases with emergency thoracotomy. Endotracheal intubation support and treats post-traumatic respiratory insufficiency. Although some of the complex and potentially fataltraumatic thoracic injuries require emergent surgical intervention, most of them can be treatednonoperatively by the proper application of certain fundamental principles of initial traumamanagement. These principles can substantially reduce the morbidity and mortality.

Appropriate early management of the rapidly fatal and potentially fatal thoracic injuries canalso significantly decrease the late complications. Optimal treatment requires a throughknowledge of the ethiology and pathophysiology of the thorax and expertise the therapeuticinterventions. Improved prehospital care and rapid transportation have increased the survival,but the lethality remains high.

Pathophysiology Thoracic trauma can induce two serious derangement: 1 Respiratoryinsufficiency due to: pneumothorax tension pneumothorax open pneumothorax flail chestpulmonary contusion aspiration 2. Hemorrhagic shock due to: hemothoraxhemomediastinum Thoracic cavity is constituted from two structures: the first, rigid,comprehending the rib cage, clavicle, sternum, scapula and the second comprehendingrespiratory muscles. Adequate ventilation and oxygenation depends on an intact chest wall.Significant injury with fracture and muscular disruption may allow direct injury to theunderlying lungs, heart, great vessels and upper abdominal viscera. In addition, respirationmay be seriously impaired by effective or paradoxical motion of a portion of the thoracic cage(as in flail chest) and the result is respiratory insufficiency. Penetrating wound of the chest(gunshot or stab wound) may cause comminuted fractures of a rib, with bone fragmentsdriven into the lung substance. The most common manifestation of penetrating trauma to thevisceral and parietal pleura is disruption of normal negative intrapleural pressure resulting in

pneumothorax. Penetrating wounds cause both direct injury to structures encountered by theweapon and indirect injury. The extent of internal injuries cannot be judge by the appearanceof a skin wound. Blunt forces applied to the chest wall cause injury by three mechanisms:rapid deceleration, direct impact and compression. Rapid deceleration is the usual forceinvolved in high speed motor vehicle accidents and falls from height. The degree of externaltrauma may not fully predict the severity of internal injuries and clinical suspicion of cardiacand vascular trauma should be heightened. Direct impact by a blunt object can causelocalised fractures of the ribs, sternum or scapula with underlying lung parenchyma injury,cardiac contusion or pneumothorax. Compression of the chest by a very heavy object, whichprevents respiration and causes marked increases in blood pressure within veins of the upperthorax, may result in traumatic asphyxia. Anterior-posterior compression forces place indirectpressure on the ribs, causing lateral, mid-shaft fractures. Lateral compression forces appliedto the shoulder are common causes of sternoclavicular joint dislocation and clavicle fractures.

Massive blunt injury to the chest wall may comprise elements of deceleration, direct impact,and compression to yield multiple adjacent rib fractures is in more than one location. In this


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setting, a free-floating segment of the chest wall can more paradoxically with respirationcausing ineffective ventilation. Moreover than respiratory insufficiency thorax trauma cancause hemorrhagic shock due to hemothorax and rarely to hemomediastinum. Hemothorax iscommon in both penetrating and non-penetrating injures to the chest. If the hemorrhage issevere, it may not only cause hypovolemic shock but also dangerously reduces vital capacityby compressing the lung on the involved side. Persistent hemorrhage usually arises from an

intercostal or internal thoracic (internal mammary) artery and less frequently from the majorhylar vessels. Bleeding from the lung generally stops within a few minutes, although initially itmay be profuse. In some cases hemothorax may come from a wound of the heart or fromabdominal structures such as the liver or spleen if the diaphragm has been lacerated.Hypovolemic shock and hemomediastinum can derive from a thoracic great vessels injurythat may be result of penetrating or blunt trauma. The most common etiology is penetratingtrauma; however, the descending thoracic aorta, the innominate artery, the pulmonary veins,and the vena cavae are susceptible to rupture for blunt trauma.

Goal of the chapterAt the end of this chapter the student must be able to identify and treatthe chest trauma and to understand and avoid the most common mistakes and complicationsin the treatment. The initial management of the patients with thoracic trauma is frequently theresponsibility of the emergency physician who is not a thoracic surgeon but a general

surgeon. It is therefore imperative that emergency physician is able to recognise the thoracicinjuries that are or will be dramatic if not treated properly. In unstable and criticalcircumstances, quick decisions and adequate manoeuvres based on recordings of vital signsand a right interpretation of clinical and diagnostic pattern are required. The purpose of thischapter is to establish the right guidelines in the treatment of thoracic injuries.Thoracic injury: priorities The evaluation of the patient's chest trauma is only a part of thetotal assessment; furthermore because thoracic injuries are severe and potentially lethal, thediagnosis and therapy go hand in hand. In unstable and critical patients quick decisionsbased on check of the following vital signs are required.

Airway patency: in the initial survey is mandatory to control the airway patency. The airwaycan be occluded by foreign bodies present in the month or by a fall of the tongue backwardsas occurs in unconscious patients. Patency of the airway must be retarded by a simplemanoeuvre to remove foreign body from the month or to correct backwards fall of the tongue(Chap. AIRWAY AND VENTILATION).All the airway manipulations must be performed withrespect to potential cervical spinal injuries. Breathing: in order to know if patient is breathingis necessary to check respiratory movement, and their extension. Remember that cyanosisappears very late in hypoxia due to a thoracic trauma because in shocky patients the skin

blood flaw depends on blood redistribution in the body.Circulation: the state of the circulation is evaluated by ossessing patient's pulses (radial,carotideal or femoral). The blood pressure is evaluated by width of pulse. In hypovolemicshock radial pulse becomes small; may be absent when blood pressure is below 60 mm/Hg.

In thoracic trauma is important to control the neck veins that are flat in hypodermia; aredistended when there is cardiac tamponade. But if cardiac tamponade is associated with

hypovolemic shock distension of the neck veins may be absent.In thoracic trauma patients there are the following life-threatening lesions that must

immediately identified and treated.Open pneumothorax: usually results from a penetration wound of the chest that may createa communication between the pleural space and external environment. As the size of thisdefect approaches two thirds the size of the tracheal diameter, air passes preferentiallythrough the lower resistance injury tract rather than through the normal airways. This severelycompromises oxygenation and ventilation and is immediately life-threating. In an open or

"sucking" wound of the chest wall, the lung on the affected side is exposed to atmosphericpressure, which results in the lung's collapse and a shift of the mediastinum to the uninvolvedside. Because of the severe degree of venoarterial shunting that occurs in both lungs,


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resulting in profound ventilation-perfusion inequality, the patient becomes cyanotic and hasserious respiratory distress. The open pneumothorax must be treated rapidly using one oftwo approaches. In the spontaneously ventilating patient, application of a sterile occlusivedressing with vaseline gauze large enough to cover the wound entirely taped securely onthree sides is the treatment of choice. Tube thoracotomy at a remote site should beplaced. If the chest wall defect is relatively small, the pleura may soon seal and no furtherintervention is necessary. A second approach is to simply intubate the patient and initiatepositive pressure ventilation. Often surgical repair is required.Tension pneumothorax: develops when air enters the pleural space but cannot exit. Theconsequence is progressively increasing intrathoracic pressure in the affected hemithoraxresulting in impaired central venous return and mediastinal shift.Air enters pleural cavitythrough lung wound or ruptured bleb (or occasionally via penetrating chest wound) withvalvelike opening. Ipsilateral lung collapse and mediastinum shifts to opposite sidecompressing controlateral lung and impairing its ventilating capacity. Clinically, the patientexperiences dyspnea, complains of chest pains, and becomes cyanotic because of shuntingin the collapse of lung and has hemodynamic instability because decrease is venous returnfor endopleural hypertension. The presence of hyperresonance and the absence of breathsounds, together with X-ray examination, should be useful in confirming the cause of the

emergency.A chest X-ray film indicates that the trachea and mediastinum are deviated tothe side opposite the tension pneumothorax, while on the ipsilateral side intercostal spacesare widened and the diaphragm is pushed downward. The emergency require immediatethoracostomy with underwater-seal drainage. If the lung does not fully re-expand after tubethoracostomy and there is a large ongoing air leak the airways should be evaluatedbronchoscopically to exclude a major injury. However, in most cases, no further treatment fortension pneumothorax will be required after chest tube insertion.Massive hemothorax: is common in both penetrating and blunt chest injuries. Patients whosustain acute hemothorax are at risk for hemodynamic instability due to loss of intravascularvolume and compromised central venous return due to increased intrathoracic pressure. Lungcompression due to massive blood accumulation may also cause respiratory compromise.

Sources of hemothorax are: lung, intercostal vessels, internal mammary artery,thoracicoacromial artery, lateral thoracic artery, mediastinal great vessels, heart, abdominalstructures (liver, spleen) when diaphragmatic hernia. The diagnosis is readily made from theclinical picture and X-ray evidence of fluid in the pleural space. Primary thoracentesis iscarried out to confirm the diagnosis. Optimal therapy consists of the placement of a large (36French) chest tube. A moderate size hemothorax (500-1500 ml) that stops bleeding afterthoracostomy can generally be treated by closed drainage alone. However, a hemothorax ofgreater than 1500 to 2000 ml as with continued bleeding of more than 100 to 200 ml per houris an indication for emergency thoracotomy or thoracoscopy.A small percentage ofhemothoraces proceed to clot and cannot be evacuated by thoracentesis. Massive clots maylead to respiratory difficulty and infection, and should be evacuated surgically. Small clots willprobably be resorbed and do not require operative removal.Cardiac tamponade: penetrating cardiac injuries are a leading cause of traumatic death inurban areas and are generally more severe than blunt injuries. Patients with penetratingwounds of the heart can be classified in 3 general groups:1. patients who have received extensive lacerations or large-calibre gunshot wounds, that diealmost immediately, as a result of rapid and voluminous blood loss;2. patient with small wounds of the heart, caused by ice picks, knives or other small agentswho because of the development of cardiac tamponade, reach the hospital alive. Cardiactamponade, by bringing pressure to bear on the bleeding heart wall, also plays an importantrole in controlling the hemorrhage;3. patient with associated serious injuries in the chest and/or elsewhere in the body which, inthemselves, may contribute to death.


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The condition of the patient, when he is admitted to the hospital, must not be used as anindex of the severity of the injury. There are moribund patients with no blood pressure andnonperceptible pulse, who survive operation and recover; on the other hand there arepatients in fair condition, with a systolic blood pressure ranging from 70 mmHg to normal andfair-to-good pulse, who die before surgery. The immediate cause of death is eitherexanguination, cardiac tamponade or interference with the conduction

mechanism. Diagnosis generally is easy if the physician maintains a high degree ofsuspicion of heart injury in every chest wound he encounters. The safest approach is toremove the patient's clothing and survey the entire body surface quickly for evidence ofmultiple injuries. Auscultation of the thorax is performed specifically to evaluate the clarity ofheart tones and breath sounds. Muffled heart tones are an indication of blood in thepericardium. A systolic - to diastolic gradient of less then 30 mmHg, associated withhypotension is consistent with cardiac tamponade. Neck veins are distended. Central venouspressure is elevated. The X-ray film may demonstrate a widening of the cardiac silhouette.The ultrasound scan shows presence of blood in pericardial space. Electrocardiograph is notparticularly helpful. Prompt definitive therapy is imperative. This includes antishock therapy,pericardiocentesis (possibly under U.S. guide), emergency thoracotomy and suture of thewound.The following lesions are life-threatening but give to the physician more time todiagnose and treat them.Thoracic cage injuries: with severe trauma, fractures of any rib or combination of ribs andfractures in this area are likely. However, the fracture usually occurs at the point of impact,often laterally such fractures are hard to see on X-ray films. Crushing injuries may producemultiple eggshell fractures, the sites being dependent on the direction of the compressingforces. For example, impaling the anterior chest on a steering wheel as in an automobileaccident, often fractures the sternum and several ribs anteriorly on both sides. Besides ribfractures, costovertebral dislocation may occur at any level, as may occur costochondral andchondrosternal separations. Fractures may be transverse or oblique and the fragments mayoverride or a pointed fragment may be pushed inward, tearing the pleura and underlying

lung. In the elderly patient with atrophic, decalcified ribs, fractures may result from simpletrauma, coughing or any severe muscle pull. Fractures of the rib or sternum or costovertebralseparations are diagnosed from movement of fragments, ecchymosis and crepitus, as well asby X-ray examination. Since pain characteristically occurs with inspiration, the patient tends tosplint the chest wall and therefore, hypoventilates.A chest X-ray film must be performed, notonly to identify the number and the extent of rib fractures, but also to determine whether thereis an associated pneumothorax, hemothorax and pleural effusion. Rib fractures usually healreadily if complications are handled properly. However, the pain associated with the fracturecan prevent proper ventilation and coughing, leading to atelectasis, retained secretions andpneumonia, especially in the elderly. Damage to the underlying lung may cause hemothorax,pneumothorax or pulmonary contusion, multiple rib fractures may produce paradoxicalmovement of the chest wall, with a flail segment. Pain from a rib fracture can be treated byintercostal or paravertebral block; this promptly relieves the pain and quiets the laboured

respiration which may be accentuating paradoxical motion of the chest. The major problemwith a block are increased reflex bronchial secretions; these must be removed if patients areto avoid an obstructive type of pneumonia which is particularly dangerous in the elderly. Ifcoughing is inadequate, tracheal aspiration on by catheter or by broncoscopy andoccasionally by endotracheal intubation may be necessary. The ribs usually become fairlystable within 10 days to two weeks. Firm healing with callus formation is seen after about sixweeks.

Flail chest: A segment of chest wall does not have continuity with the rest of thoracic cagebecause multiple risk fractures causing serious respiratory distress. In flail chest injury, theunstable segment wall moves separately and in ,an opposite direction from the rest of thethoracic cage during the respiration cycle. In politrauma patients flail chest injury is quitecommon. Thirty-one percent of 50.000 trauma patients included in the Major TraumaOutcome study had chest injuries. Five percent of these patients had flail chest injury. Flailchest injury usually results from direct impact. If the crushing force is from the lateral


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direction, the injury usually consists of fractures in at least two sites in multiple adjacent ribson the involved side, resulting in a "floating" central portion of the chest wall, which goes inand out with respiration in a reverse or paradoxical manner to the rest of the chest wall. Thistype of respiration markedly decreases the efficiency of ventilation, and is usuallyaccompanied by severe pain that makes the coughing mechanism ineffectual. If the crushingblow is directly over the sternum, as often happens in steering wheel injuries, fractures of the

sternum may occur. Such an injury is most frequently associated with bilateral costochondralfractures usually from the first rib down resulting in extreme flailing of the anterior portion ofthe chest wall. The physiopathologic effects of flail chest are an important decrease in vitalcapacity, reduction in functional residual capacity. Often there are ventilation-perfusionimbalance, hypoxemia, decreased compliance, increased airway resistance and increasedbreathing effort. The diagnosis of flail chest injury is made by physical examination. adequateexamination after blunt chest trauma must include inspection of an unclothed patient fromanterior, posterior and both lateral angles. Clinically, the unsupported portion of the chest wallis seen to move paradoxically with respiration. On inspiration, the flail area moves in; onexpiration or coughing it moves outward. If the flail segment is large, the important effect arethose of inadequate ventilation, inadequate perfusion resulting in progressive hypoxia andhypercapnia and inefficient coughing with retained secretions, radiographs can documentmultiple rib fractures. The treatment of flail chest involves selective use of endotracheal

intubation and mechanical ventilation. Not all patients require intubation. Flail chest patientwithout respiratory impairment generally do well without ventilatory assistance. The primaryindication for endotracheal intubation and mechanical ventilation is respiratorydecompensation. Aggressive pulmonary physiotherapy with suctioning, incentive spirometry,early mobilisation, and umidification of air is appropriate for all patients. Intermittent positivepressure breathing, postural drainage, cupping or clapping and therapeutic fiberopticbroncoscopy to suction retained secretions and treat atelectasis are often necessary. Furtherthan internal fixation effected by endotracheal tube or tracheostomy the stabilisation of thechest wall may be performed by external surgical fixation.Pneumothorax: lung laceration or bronchial lesion permit air entry into pleural space. That

results in collapse of the lung, increase of endopleural pressure and compression ofcontrolateral lung by mediastinum dislocation. In this case a severe alteration of ventilationperfusion ratio may occur because blood circulation in non ventilated pulmonary area. Chestpercussion in patient with pneumothorax shows hyperresonance and breath-sounds decreaseor absence confirmation of the diagnosis is obtained by chest X-ray. In the absence; ofhemodynamic compromise, even large pneumothoraces rarely require emergentmanagement. However, any post-traumatic pneumothorax should be treated as expeditiouslyas possible. A chest tube is inserted after cardiologic evaluation and lung reexpansioncarefully and repeatedly assessed with follow-up chest X-rays. Placement of an intercostaltube or catheter can be readily accomplished under local or intercostal nerve blockanaesthesia, or both. It may be done at the bedside, but strict aseptic precautions need to beobserved. The site for tube insertion should be one that is away from adherent lung.Generally preferred is the second or third anterior intercostal space in the midclavicular line orthe fourth or fifth intercostal space in the midaxillary line. To help select the optimal point ofentry, chest X-ray films should be reviewed unless the clinical situation is an of extreme

urgency.Pulmonary contusion: is of primary importance in the field of major trauma to the chest. It is

a potential life-threatening condition mainly because the onset of symptoms isinsidious.Also, since the force required to produce a lung contusion must be great, thelesion is likely to occurs principally in cases of high speed accidents, falls from great heightsand injuries by high-velocity bullets. Patients suffering such accidents often have so manyother obvious injuries that detection of a chest lesion may escape. After seemingly negligibleinitial signs and symptoms, the outcome may be fatal. Symptoms and signs of pulmonarycontusion are: dispnea, hypoxemia, cyanosis, tachycardia, rare or absent breath sounds, ribfractures. Hemorrhage, oedema and microatelectasis are the morphologic consequences ofpulmonary contusion. A prompt diagnosis is the main factor in initiating management and

determining whether treatment will be effective. The diagnosis is first suspected from historyof major trauma. The chest X-ray film is very important, and may show patchy, undefined


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densities or homogenous consolidation. Patients who sustain pulmonary contusion have to betreated with intubation, mechanical ventilatory support and antibiotic therapy chest CAT scanpermits to evaluate exactly the extension of pulmonary contusion

Rupture of trachea or major bronchi: the trachea and major bronchi because of theirsimilar anatomic position are subject to the same mechanisms of injury for either blunt or

penetrating trauma. Rupture of the trachea or major bronchi is usually secondary to an injuryof the chest as a result of an automobile accident. It is a serious injury with an estimatedmortality of 30%. More than 80% of the ruptures of bronchi are within 2.5 cm of the carina.Injuries to the main bronchi and intrathoracic trachea are more prevalent than those to thecervical trachea because the latter is protected by the mandible and sternum anteriorly andby vertebrae posteriorly. The intimate anatomical relationship of the trachea to the greatvessels, lungs and heart explain the high incidence of serious associated injuries in blunt andpenetrating trauma. The clinical picture appears in two patterns, depending on whether or notthere is free communication between the rupture of the trachea-bronchial tree and the pleuralcavity. If there is free communication, a large pneumothorax results. The usual signs of

tracheobronchial disruption are the followings:hemoptysis dyspnea subcutaneous and mediastinal emphysema occasionally cyanosis.Tube thoracostomy shows continuos bubbling of air in the water seal, and suction fails toreexpand the lung. The chest X-ray demonstrate pneumothorax, pleural effusion,pneumomediastinum or subcutaneous air. Overall 90% of these patients will have anabnormal chest X-ray on admission. Bronchoscopy should be carried out promptly whentracheobronchial rupture is suspected, since it is the most reliable means of establishing thediagnosis. The bronchoscopy has a role not only in diagnosis of tracheobronchial disruption,but also may be an invaluable tool in resuscitation. Tracheal and selective bronchialintubation may allow ventilation of the intact lung while is performed on the controlateralbronchial rupture. Bronchoscopy should be carried out promptly; if it indicates that thebronchial tear involves less than one-third of the lumen, the patient is stable and if thethoracostomy tube under-water-seal drainage results in complete expansion of the lung,

treatment may be conservative. However in all other types of tracheobronchial injury,thoracotomy should be performed as soon as possible. In this situation, ventilatory supportwith high frequency ventilation has not been shown to be useful, whereas success hasfollowed the use of double lumen tubes and selective bronchial intubation followed by earlysurgical repair, with mucosal - to - mucosal closure with interrupted sutures.

Heart injuries (cardiac contusion): myocardial contusion is associated, in chest blunt trauma,with fractures of the sternum or ribs. The diagnosis is based on electrocardiogramabnormalities and elevation of serial cardiac enzymes. Cardiac contusion can simulate afrank myocardial infarction. Electrocardiographic findings are multiple, premature ventricularcontractions, atrial fibrillation, right branch block and changes in ST. Patient must besubmitted to observation with cardiac monitoring.

Thoracic great vessels injuries: is principally a civilian phenomenon an currently accountsof 8-9% of vascular injuries seen in trauma centers. It may be result of penetrating or blunttrauma. The patient with chest trauma may present with respiratory distress due tohemothorax. An initial "rush" of a large volume of blood after tube thoracostomy may indicategreat vessels injury. The classic signs of pericardial tamponade may be present. Suggestiveradiological signs include presence of hemothorax, pneumothorax or the foreign bodies,widening of the superior mediastinum more than 8 cm and depression of the left mainstembronchus more than 140 degrees.Aortography should be performed in the patient withmoderate to severe injuries that is stable hemodynamics. CAT and MR have not been shownto be as diagnostic as aortography. The patient with signs of respiratory distress andsuspected pneumothorax should undergo immediate tube thoracostomy. As mentionedabove, if blood loss is greater than 1 L, with continued bleeding must be performed a

thoracotomy and repair of the rupture of the vessel.


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Trauma to oesophagus: in trauma patients rupture of oesophagus is very rare. More

frequent is the perforation of the oesophagus for penetrating trauma. Oesophagus trauma islethal if unrecognised because mediastinitis due to contamination mediastinal space byoesophageal content with very high concentration of necrosis bacteria. The patient's complainof sudden excruciating pain in the epigastrium, which lasts and radiates to the chest, to theback or both. Dyspnea, cyanosis and shock soon set in and dominate the clinical picture.

Emphysema and pneumo - or hydropneumothorax, especially in the left mediastinum developand become visible radiologically. Esophagogram may be performed when the patient isstable. Esophagoscopic visualisation of localised blood in the oesophagus or an actuallaceration is diagnostic. Operation is advocated when the patient is unstable and when arepresent major injuries. The principles in the management of major oesophageal injuries arethose of early operation, two - layer surgical closure when possible and wide mediastinaldrainage. Extensive tissue destruction or associated major mediastinal contamination, suchas occurs when repair is delayed by more than 12-16 hours, are indications to consider aclosure with a T-tube or an exclusion technique.

Diaphragmatic injuries: once relatively uncommon, injuries of the diaphragm are occurringmore frequently, paralleling the rise of frequency of automobile accidents. The diagnosis isoften missed because of associated intraabdominal injuries. Diaphragmatic injuries may also

be caused by penetrating or blunt trauma. Diaphragmatic injury is suspected in anypenetrating thoracic wound (gunshot, stab or accidental perforation) at or below 4thintercostal space anteriorly, 6th interspace laterally, or 8th interspace posteriorly, althoughsharply oblique wounds or missiles deflected by ribs may also penetrate diaphragm. Stomachand other abdominal viscera may herniate into left thorax; left lung may collapse, right lungmay be compressed, mediastinum my be shifted and trachea deviated to theright. Symptoms are related to the quantity of herniated viscera in to the thorax. The usualclinical manifestations are: dyspnea, chest or shoulder pain and cyanosis. If the herniatedorgan is stomach, the dyspnea can be relieved dramatically by introduction of a nasogastrictube. The diagnosis is performed or suspected by chest X-ray that may demonstrate:atelectasis with silhouetting of the ipsilateral diaphragm, evidence of an air-filled or soledviscus in the thorax and abnormal curvilinear shadow above the diaphragm. A contraststomach X-ray may visualise the stomach herniated into thorax. Ultrasound and CAT scanwill confirm the diagnosis. The most common errors in diaphragmatic trauma are failure toinspect the leaflets adequately during operative exploration or penetrating injury and failure tosuspect the possibility of diaphragmatic injury. The treatment is always surgery by anabdominal approach. The decision to repair an isolated diaphragmatic rupture in an acutelyinjured patient should depend on how the patient tolerates the loss of normal, negativeintrathoracic pressure. Gross signs of cardiorespiratory distress or shock are indication forimmediate repair.

Thoracic aorta rupture: rupture of the thoracic aorta is a common cause of sudden death inroctures of unrestrained frontal collision and in a fall from a great height. Laceration of thethoracic aorta supervenes near the aortic legamentum arteriosum. If the aorta is noncompletely interrupted and there is an intact adventitial layer it is possible to operate on the

patient and to repair the lesion. If the patient is not diagnosed and not adequately treated willdie in few hours or days. The dynamic of the collision, fractures of the scapula, the first andsecond ribs and the medial third of the clavicle, all suggest severe trauma and should lead toa suspicion of a laceration of the thoracic aorta. The chest X-ray can show a widening ofmediastinum, right tracheal shift, elevation and rightward shift of the right bronchus,depression of the left bronchus, aortic knob outline, deviation of the oesophagus to the right,.Transesophageal U.S. scan is a useful diagnostic tool if available. CAT scan is mandatory aswell as aortography. The treatment is immediate surgery by qualified surgeon.

european course trauma care

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