thoracic trauma ndn (1)

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Done By : Nadeen Ta’ani Supervised by : Dr. Shadi Hamouri Thoracic trauma

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Page 1: Thoracic Trauma NDN (1)

Done By : Nadeen Ta’ani

Supervised by : Dr. Shadi Hamouri

Thoracic trauma

Page 2: Thoracic Trauma NDN (1)

Thoracic trauma include:

• Traumatic Pneumothorax (tension & open) • Hemothorax• Flial chest• Rip fractures• Lung contusion• Diaphragmatic rupture• Esophageal rupture• Aortic , cardiac and major vascular injuries (will not talk

about it in this seminar) .

Page 3: Thoracic Trauma NDN (1)

Epidemiology

• Ranked 5th overall in total number of deaths in the USA behind diseases of the heart (IHD) ; malignant neoplasms; Cerebrovascular diseases; and chronic lower respiratory diseases (COPD).

• And Grouping all injury-related deaths (to include suicide, homicide, undetermined, and war-related deaths, in addition to accidents) it would be 3rd most common cause for death

• Mortality and morbidity due to traumatic thoracic injuries are decreasing (as understanding of the disease process improves).

• 25% of traumatic deaths are secondary to injuries to the thorax.

• In penetrating trauma, 40% have a thoracic injury, whereas in blunt trauma, 33%.

Page 4: Thoracic Trauma NDN (1)

• A transected aorta is thought to be the cause of death in approximately 12% to 30% of patients who die at the scene from blunt trauma.

• Motor vehicle–related injuries, firearms, stabbings, other assaults, and falls account for more than half of these deaths (58.1%).

Page 5: Thoracic Trauma NDN (1)

Pathophysiology

• Thoracic injuries leave little room for error in their diagnosis and management.

• If improperly managed they are frequently fatal, whereas massive insults can usually be treated by simple maneuvers with generally excellent results.

• So the understandment of pathophysiologic processes and the mechanisms of traumatic injury is crucial in the management of these patients.

Page 6: Thoracic Trauma NDN (1)

• There is a five separate Mechanisms for early loss of life in case of thoracic trauma:– Airway obstruction from tracheobronchial injuries, pulmonary

secretions, or hemorrhage.– Loss of oxygenation and ventilation capability from

pneumothorax, hemothorax, or pulmonary contusion.– Exsanguination (blood loss).– Cardiac failure from cardiac contusion or valve rupture.– Cardiac tamponade. (Beck's triad ; 1-Low blood pressure occurs because of decreased stroke volume. 2- jugular-venous distension due to impaired venous return to the heart.

3-mu 3-muffled heart sounds due to fluid buildup inside the pericardium.)

Page 7: Thoracic Trauma NDN (1)

Thoracic Trauma mortality distribution

– Seconds to minutes after injury: Major injury to aorta, heart, brain stem, or spinal cord, or acute respiratory distress.

– Minutes to the few hours after injury (the so-called golden hour): epidural or subdural hematoma, hemopneumothorax, severe liver or spleen injury, pelvic fractures, or injuries involving major hemorrhage.

– Days to weeks after injury: stems from multisystem organ failure and infection.

Page 8: Thoracic Trauma NDN (1)

Blunt versus penetrating injury• This differentiation is important with regard to multisystem

management.• Because of the higher likelihood of multisystem injury in blunt

trauma, its morbidity and mortality is consequently higher. • Motor vehicle crashes remain the number 1 cause of blunt

chest trauma despite the improvements in vehicle design, airbags, and the use of seatbelts.

• Gunshot and stab wounds account for the majority of penetrating injuries.

Page 9: Thoracic Trauma NDN (1)
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Do the math!• The destruction of tissue on impact is directly proportional to the

absorbed kinetic energy (KE), which is derived from the formula: KE= ½ M(V₁-V₂)²

• low- vs high-velocity missiles “any object or weapon that is thrown at a target”

• Lower KE missiles tend to have similar-sized entrance and exit wounds and cause damage primarily to the structures that are in the missile’s path.

• Higher KE missiles are more prone to cavitation, causing significant injury to tissues surrounding the path of the missile , and tend to have exit wounds that are substantially larger than their entrance ones.

• Bullets that shatter or tumble have a slower exit velocity and impart more energy to the affected tissues, thereby resulting in more cavitation

Page 11: Thoracic Trauma NDN (1)

• Cavitation is a momentary acceleration of tissue in all directions away from the tract of a missile, producing a cavity of subatmospheric pressure.

• This cavity collapses because of the resultant vacuum effect, then reforms and collapses several times with diminishing amplitude until all motion ceases.

• This ‘‘shockwave’’ that results from the dispersement of this rebounding energy acts as the source of injury to surrounding structures.

• The cavitation results in nerve damage, thrombosis, or rupture of vessels and even fractures of bones within the vicinity of the missile’s path, although no direct contact with the missile may occur.

Page 12: Thoracic Trauma NDN (1)

• Dense organs, such as bone and liver, absorb more energy resulting in more injury.

• Lungs, which have a much lower density, absorb less energy and suffer less injury .

• This explains the low frequency of operative intervention in penetrating chest trauma!

Page 13: Thoracic Trauma NDN (1)

ASSESSMENT• The surgeon plays a key role in the proper evaluation and resuscitation.

The primary survey constitutes the ABCDE of trauma care:– Airway maintenance/cervical spine precaution– Breathing/ventilation– Circulation/hemorrhage– Disability/neurological assessment– Exposure/environmental control

Page 14: Thoracic Trauma NDN (1)

The pleural space• The pleural space is a potential space

between the visceral and parietal pleura.

• The accumulation of blood or air within this space is considered pathologic and may result from injury to almost any structure within the thoracic cavity.

• This may be diagnosed by simple methods including P/E or by plain radiographic evaluation (CXR).

• Placement of a CHEST TUBE is most often the only therapeutic intervention necessary for patients who sustain thoracic trauma.

Page 15: Thoracic Trauma NDN (1)

Tension Pneumothorax • Potentially lethal condition• Is the result of unevacuated air within the pleural space in the

setting of an injury to the visceral pleura that continues to fill the space on inspiration without a route for egress, because the defect in the visceral pleura functionally acts as a one-way valve . (positive pressure ventilation may exacerbate this one-way-valve effect).

• (Inspiration generates negative intra-thoracic pressure , Air flows in one way only so creates positive pressure (tension) in the pleural space).

Page 16: Thoracic Trauma NDN (1)
Page 17: Thoracic Trauma NDN (1)

• The intrapleural pressure rises and mediastinal structures begin to shift away from the injured hemithorax, resulting in obstruct and diminished venous return to the heart , as the superior vena cava and inferior vena cava begin to occlude resulting in circulatory instability and fatal hypotension , cardiac arrest with pulseless electrical arrhythmia (PEA) rapidly occurs

Page 18: Thoracic Trauma NDN (1)

• This is a clinical diagnosis and should be aggressively treated even before obtaining the usual radiographic confirmation.

** A patient will present with one or more of:

- History of chest trauma (often penetrating trauma) with Respiratory distress, hypoxia, tachypnea & Air hunger .

Page 19: Thoracic Trauma NDN (1)

Trachea

Expansion(move with respiration)

Percussion note

Breath sounds

Neck veins

-The classical signs of tension pneumothorax ; * Tracheal Deviation AWAY from the affected side . * Increased JVP or distended neck veins .* Hyper-resonance to percussion on the affected side .* Diminshed or absent breath sounds on the affected side .* hyper-expanded chest that move little with respiration, depression of the hemi-diaphragm .

***But more commonly the patient comes with tachycardia , tachypnea and may be hypoxia , followed by circulatory collapsed and hypotension

Page 20: Thoracic Trauma NDN (1)
Page 21: Thoracic Trauma NDN (1)

Management• Classical management of tension pneumothorax is emergent chest

decompression with needle thoracostomy . • A 14 gauge , 5cm long needle is inserted into the second intercostal ,mid-

clavicular line (This buys time for definitive management, which is insertion of a formal chest drain) .

• Be sure to use a long enough needle. Cadaveric studies indicate that at this site, the pleural cavity can be deeper than perceived, and you are unlikely to cause significant harm through this procedure .

Page 22: Thoracic Trauma NDN (1)

Open pneumothorax

• Diagnosis : a chest wound communicating with the pleural space that is greater than two thirds the diameter of the trachea will preferentially draw air into the thorax (sucking chest wound) .

• Treatment : cover with partially occlusive bandage secured in three sides (securing all four sides can result in a tension pneumothorax and should be avoided), preventing air from entering the thorax but allowing it to exit via the wound if necessary.

• Prompt tube thoracostomy should follow placement of the partially occlusive dressing .

Page 23: Thoracic Trauma NDN (1)
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Extra-anatomic air subcutaneous air, pneumomediastinum, or pneumopericardium

** The mechanisms by which the introduction of extra-anatomic air into the thoracic cavity can occur include the following :•Perforation of the trachea, bronchial tree, or esophagus•Injury of the lung•Injury of the face, which tracts through the fascial planes into the neck•Injury to the retroperitoneal space, which tracts through the diaphragmatic hiatus•Introduced from the outside as a result of a penetrating injury

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Page 26: Thoracic Trauma NDN (1)

• Blue arrow points to "continuous diaphragm sign." The entire diaphragm is visualized from one side to the other because air in the mediastinum outlines the central portion which is usually obscured by the heart and mediastinal soft tissue structures that are in contact with the diaphragm.

• The red arrow points to the air beneath and posterior to the heart.

Page 27: Thoracic Trauma NDN (1)

Hemothorax** hemothorax may occur from injury to the :

– Pulmonary parenchyma .– Hilar vessels .– Heart with a communicating defect in the pericardium and

pleura .– Great vessels with an opening in the pleura .– Intercostal vessels .– Internal thoracic arteries .

** Lung parenchymal bleeding usually ceases spontaneously as a result of ;

1- the low pressure in the pulmonary vessels .2- the compressive effect of the shed blood in a closed space .3- a high concentration of thromboplastin in the lung .* Bleeding ,However, may require prompt operative intervention

Page 28: Thoracic Trauma NDN (1)

• Each adult chest cavity can hold up to 3 litres of blood, i.e. the chest cavity can hold their entire circulating volume. Bleeding from injuries to the great vessels leads to haemomediastinum , and will not enter the pleural space unless there is a concomitant breach of the pleural membrane or injury occurs at the lung hilum.

• Haemothorax is a double insult to the patient as there is progressive deterioration of effective breathing and circulation.

Page 29: Thoracic Trauma NDN (1)

Clinical Signs: •signs of respiratory distress and shock. •Signs of bleeding and haemodynamic instability (e.g. tachycardia, hypotension) , normally present before symptoms of respiratory distress. •cyanosis, tachypnoea, tachycardia, tracheal deviation away from the affected side, decreased chest expansion, dullness to percussion, and reduced or absent air entry on the affected side.

Should we do an x ray??Early CXR is a useful adjunct to making the diagnosis but should not delay management in the unstable patient with suspected massive haemothorax. At least 400ml blood has to be lost into the pleural space before blunting of the costo-phrenic angle is seen on an erect CXR.

Ddx: With blunt trauma one should have a high index of suspicion for injuries that may mimic massive haemothorax, e.g. massive lung contusion, diaphragmatic rupture with intrathoracic abdominal content, and occult tension pneumothorax with small haemothorax.

Page 30: Thoracic Trauma NDN (1)

** In case of large, undrained hemothorax :

1. Clotting of the blood ,, 2. (7th day postinjury ) fibroblast proliferation at the periphery

of the clotted hemothorax ,,3. next several weeks, mature fibrous tissue encases the clot

forming a peel (loosely adherent to both the visceral and parietal pleural surfaces)

4. the peel continues to increase in firmness, thickness, and adhesiveness to the pleura over time

5. can cause a significant restrictive defect (fibrothorax).

blood cell lysis leading to an increased osmotic load and large serosanguinous pleural effusion, which develops from a relatively small amount of retained blood over a few days.

a retained hemothorax may become secondarily infected . This may present in delayed fashion as an empyema. require extensive surgical debridement or resection.

Page 31: Thoracic Trauma NDN (1)

Management1. 100% oxygen 2. insertion of intercostal chest drain 3. maintenance of circulating volume 4. Following insertion of a chest drain, emergency thoracotomy

is indicated for blood loss of :• >1500 ml blood in chest drain at insertion . • >200 ml/h for 4 consecutive hours . • >100 ml/h for > 6 hours . 5. Prophylactic antibiotics may decrease the incidence of

empyema and pneumonia

Page 32: Thoracic Trauma NDN (1)

Indications for thoracotomybased on physical findings, radiographic and echocardiographic Imaging :• Acute hemodynamic deterioration with cardiac arrest in the trauma center.• Cardiac tamponade• Vascular injury at the thoracic outlet or great vessels• Massive air leak from a chest tube• Tracheal or bronchial injury• Esophageal injury• Retained hemothorax or its sequelae• Traumatic diaphragmatic hernia• Traumatic cardiac valvular or aneurysmal lesions• Traumatic thoracic pseudoaneurysms or aortic disruption• Tracheoesophageal fistula

Page 33: Thoracic Trauma NDN (1)

Flail Chest• Rib fractures are the most common injury seen in blunt

trauma victims but are less likely to be seen in children.• Rib fractures can result in significant chest wall discomfort.

This pain typically limits chest wall excursion and increases the propensity for hypoventilation, atelectasis, and eventually pneumonia.

• Elderly patients and those with poor pulmonary reserve are at the highest risk.

Page 34: Thoracic Trauma NDN (1)

• Life-threatening condition occurs when more than two ribs are broken in two or more places resulting in a free floating segment of the chest wall.

• Mainly caused when the thoracic cage absorbs high kinetic energy, and thus it is an important marker for significant intra-thoracic injury in the patient with blunt trauma

• It is highly associated with:• Pulmonary contusion in about 45% of patients.• Pneumothorax or hemothorax.• Acute respiratory distress syndrome (ARDS) in a third of these patients

.

Page 35: Thoracic Trauma NDN (1)

Theory of ‘‘Pendelluft’’ ;

** paradoxical motion of the flial segment during the respiratory cycle causing recirculation of air from the affected lung into the contralateral lung during inspiration and from the contralateral lung into the affected lung during exhalation.

** During inspiration (-ve intrathoracic pressure) , the chest wall expand , but the flail segment moves inwards due to the sucking effect of negative intrathoracic pressure on the flail segment. (limited lung expansion, with ineffective ventilation and hypoxia. ) https://www.youtube.com/watch?v=uJHfX1RFkF0

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Diagnosis : (Chest pain & dyspnea)

•Flail chest is a clinical anatomical diagnosis. •Clinical examination ; will reveal a patient with tachypnoea , and signs of blunt trauma to the chest wall , The flail segment is identified by its paradoxical movement on spontaneous breathing and is often more obvious to feel than to see , Palpation may identify crepitus from the broken rib ends , and percussion exacerbates pain.

Page 39: Thoracic Trauma NDN (1)

Management 1- management of underlying pulmonary contusion by fluid

resuscitation and the use of diuretics & 100% oxygen .2- regular analgesia - consider using rib blocks with local

anaesthetic “thoracic epidural analgesia “ .3- chest drain(s) for associated pneumothorax or haemothorax .4- consider assisted ventilation if there is inadequate ventilation

or the patient is tiring. Ventilatory support is more likely with: - large flail segment or one involving the sternum, - extensive lung contusion.

Page 40: Thoracic Trauma NDN (1)

Thank you