Thoracic Injury & Trauma By: Alyaa Akma binti Azman

Introduction

Thoracic injury accounts for 25% of all injuries.

In a further 25%, it may be a significant contributor to the subsequent death of the patient.

In most of these patients, the cause of death is haemorrhage.

Chest injuries are often life-threatening, either in their own right or in conjunction with other system injuries.

Investigation of chest injuries 80% can be managed non-operatively

A chest radiograph is the investigation of first choice

A spiral CT scan provides rapid diagnoses in the chest and abdomen

A chest drain can be diagnostic as well as therapeutic

Management Most patients who have suffered penetrating injury to the chest can be managed with appropriate resuscitation and drainage of haematoma.

Closed management of chest injuries:

■ About 80% of chest injuries can be managed closed

■ If there is an open wound insert a chest drain

■ If bleeding persists, the chest will need to be opened

Immediate life-threatening injuries1) Airway obstruction

Early preventable trauma deaths are often due to lack of or delay in airway control.

Dentures, teeth, secretions and blood can contribute to airway obstruction in trauma. Laryngeal trauma such as thyroid or cricoid fractures and tracheal injury are other causes of airway obstruction.

These patients need intubation (with simultaneous protection of the cervical spine). Early intubation is very important, particularly in cases of neck haematoma or possible airway oedema.

Tension pneumothorax

It develops when a lung or chest wall injury is such that it allows air into the pleural space but not out of it (a one-way valve).

Most common causes :

• penetrating chest trauma,

• blunt chest trauma with parenchymal lung injury and

• air leak that did not spontaneously close,

• iatrogenic lung punctures (e.g. due to subclavian central venepuncture)

TreatmentRapid insertion of a large-

bore needle into the 2nd intercostal space in the mid-clavicular line of the affected hemithorax.

This is immediately followed by insertion of a chest tube through the 5th intercostal space in the anterior axillary line.

Cardiac Tamponade

Most commonly the result of penetrating trauma.

•The correct immediate treatment is operative (sternotomy or left thoracotomy),with repair of the heart in the operating theatre if time allows or otherwise in the emergency room.

Open pneumothorax (‘sucking chest wound’)• Due to large open defect in the chest (> 3 cm)

• Leading to equilibration between intrathoracic & atmospheric pressure.

• Air accumulates in the hemithorax with each inspiration, leading to profound hypoventilation on the affected side and hypoxia.

TreatmentPromptly closing the defect with a sterile occlusive plastic dressing (e.g. Opsite), taped on 3 sides to act as a flutter-type valve.

• A chest tube is inserted ASAP in a site remote from the injury site.

• Definitive treatment may warrant formal debridement and closure, preferably in the operating room

• If the lung does not reinflate, the drain should be placed on low-pressure (5 cm water) suction;

• Physiotherapy and active mobilisation should begin ASAP

OPSITE

Massive haemothorax• The most common cause of massive haemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally the internal mammary artery

• Accumulation of blood in a hemithorax can significantly compromise respiratory efforts by compressing the lung and preventing adequate ventilation

• Presents as haemorrhagic shock with flat neck veins, unilateral absence of breath sounds and dullness to percussion.

• The treatment consists of correcting the hypovolaemic shock, insertion of an intercostal drain and, in some cases, intubation.

Flail chest • Usually results from blunt trauma associated with multiple rib fractures,

• Three or more ribs fractured in two or more places

• The diagnosis is made clinically, not by radiography.

•On inspiration the loose segment of the chest wall is displaced inwards

Treatment•Currently, treatment consists of oxygen administration, adequate analgesia (including opiates) and physiotherapy.

• If a chest tube is in situ, intrapleural local analgesia can be used as well.

•Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen

• Surgery to stabilise the flail chest is currently in use again;

• It may be useful in a selected group with isolated or severe chest injury and pulmonary contusion who have been shown to benefit from internal operative fixation of the flail segment.

Potentially life-threatening injuries

1) Thoracic aortic disruption- Traumatic aortic rupture is a common cause of sudden death after an automobile collision or fall from a great height.

• The diagnosis is confirmed by aortography or a contrast spiral CT scan of the mediastinum and to a lesser extent by transoesophagealechocardiography.

•Initially, management consists of control of the systolic arterial blood pressure (to less than 100 mmHg).

Other potentially life-threatening injuries

2) Diaphgrammatic injury - Any penetrating injury to or below the fifth intercostal space should raise the suspicion of diaphragmatic penetration.

3) Oesophageal injury

4) Tracheobronchial injuries - damage to the tracheobronchial tree It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful chemical.

5) Pulmonary Contussion - caused by haemorrhage into the lung parenchyma, usually underneath a flail segment or fractured ribs.