thoracic trauma phillipo

THORACIC TRAUMATHORACIC TRAUMA

Dr Phillipo Leo ChalyaDr Phillipo Leo ChalyaM.D. [Dar]; M.MED surg [Mak]M.D. [Dar]; M.MED surg [Mak]

Surgeon Specialist - BMCSurgeon Specialist - BMC

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OUTLINEOUTLINE

DefinitionDefinition EpidemiologyEpidemiology Etiology Etiology Mechanism of injuryMechanism of injury ClassificationClassification PathophysiologyPathophysiology Clinical presentationClinical presentation Workup Workup ManagementManagement ComplicationsComplications Summary Summary

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DEFINITIONDEFINITION

Thoracic trauma is not a Thoracic trauma is not a single entitysingle entity

It refers to as injuries of the It refers to as injuries of the thoracic cage and its internal thoracic cage and its internal and associated structuresand associated structures

It is one of the surgical It is one of the surgical emergenciesemergencies

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EPIDEMIOLOGYEPIDEMIOLOGY

IncidenceIncidenceMorbidity / mortalityMorbidity / mortalityAge Age Sex Sex Race Race

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IncidenceIncidence

Varies both geographically and Varies both geographically and with SESwith SES

In the US, S/America, Africa and In the US, S/America, Africa and Asia incidence of penetrating Asia incidence of penetrating injuries is injuries is ↑ due to criminal or ↑ due to criminal or military activitiesmilitary activities

In Europe blunt injuries is In Europe blunt injuries is ↑ ↑ mainly due to RTAmainly due to RTA

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Morbidity / mortalityMorbidity / mortality Thoracic trauma is associated with Thoracic trauma is associated with

significant mortality and morbiditysignificant mortality and morbidity Chest trauma accounts for 25% of all Chest trauma accounts for 25% of all

trauma deathstrauma deaths 2/3 of deaths occur after reaching hospital2/3 of deaths occur after reaching hospital Serious pathological consequences:Serious pathological consequences:

-- HypoxiaHypoxia HypovolaemiaHypovolaemia Myocardial failureMyocardial failure

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AgeAge

Trauma including chest Trauma including chest trauma is the leading trauma is the leading cause of deaths among cause of deaths among people between 1-44 people between 1-44 years of ageyears of age

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SexSex

Male are more affected Male are more affected than females [M>F]than females [M>F]

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Race Race Studies reported no racial Studies reported no racial predilection to thoracic predilection to thoracic injuriesinjuries

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AETIOLOGYAETIOLOGYRoad traffic accidentRoad traffic accidentAssaultAssaultWar injuriesWar injuriesFallsFallsSport injuriesSport injuriesAircraft accidentAircraft accidentStab woundStab woundBullet injuriesBullet injuriesetcetc

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MECHANISM OF INJURYMECHANISM OF INJURY

Blunt thoracic injuriesBlunt thoracic injuriesPenetrating thoracic Penetrating thoracic injuriesinjuries

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Blunt thoracic injuriesBlunt thoracic injuries

Direct trauma to the chest cageDirect trauma to the chest cage The victim is struck in the chest by a moving The victim is struck in the chest by a moving

object object →→fractures of the ribs, contused lungs fractures of the ribs, contused lungs etcetc

Compression thoracic injuriesCompression thoracic injuries The chest is injured by compression The chest is injured by compression → →

diaphragmatic rupture, cardiac & lung diaphragmatic rupture, cardiac & lung contusioncontusion

Deceleration thoracic injuriesDeceleration thoracic injuries These are injuries resulting from rapid These are injuries resulting from rapid

deceleration of the body with continuing deceleration of the body with continuing moving of the internal thoracic organsmoving of the internal thoracic organs→ → aortic aortic rupture (tear), cardiac and pulmonary contusionrupture (tear), cardiac and pulmonary contusion

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Penetrating thoracic injuriesPenetrating thoracic injuriesThe degree of tissue damage is The degree of tissue damage is

proportional to the Kinetic Energy proportional to the Kinetic Energy [K.E.] of the penetrating object[K.E.] of the penetrating object

K.E. = 1/2mvK.E. = 1/2mv22, therefore K.E. , therefore K.E. αα mv mv22 The velocity of the penetrating object The velocity of the penetrating object

is the major determinant of tissue is the major determinant of tissue damage than the mass of an objectdamage than the mass of an object

The high the velocity the more energy The high the velocity the more energy generated and therefore more tissue generated and therefore more tissue damagedamage

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Penetrating injuries [cont] Penetrating injuries [cont]

The mechanism of injury in The mechanism of injury in penetrating thoracic injuries can penetrating thoracic injuries can categorized as:-categorized as:- Low velocity thoracic injuriesLow velocity thoracic injuries

E.g. stab woundsE.g. stab wounds Velocity < 1200ft/s injuriesVelocity < 1200ft/s injuries

Medium velocity thoracic injuriesMedium velocity thoracic injuries E.g. Most handgunsE.g. Most handguns Velocity 1200-2000ft/sVelocity 1200-2000ft/s

High velocity thoracic injuriesHigh velocity thoracic injuries E.g. most war weapons eg riflesE.g. most war weapons eg rifles Velocity > 2000ft/sVelocity > 2000ft/s

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CLASSIFICATIONSCLASSIFICATIONS

Classified according to:-Classified according to:-Mechanism of injuryMechanism of injurySite of injuries/anatomical Site of injuries/anatomical

classificationclassification

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Mechanism of injuryMechanism of injury

Blunt thoracic injuriesBlunt thoracic injuriesPenetrating thoracic injuriesPenetrating thoracic injuries

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Site of injuries/anatomical classification

Site of injuries/anatomical classification

Chest wall injuriesChest wall injuriesPleural injuriesPleural injuriesPulmonary injuriesPulmonary injuriesMediastinal injuriesMediastinal injuries

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Chest wall injuriesChest wall injuries

Soft tissue injuriesSoft tissue injuriesBony injuriesBony injuries

Rib #sRib #sFlail chestFlail chestSternum #Sternum #Clavicle #Clavicle #Thoracic spine injuryThoracic spine injury

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Pleural injuriesPleural injuries

PneumothoraxPneumothoraxClosed pneumothoraxClosed pneumothoraxOpen pneumothoraxOpen pneumothoraxTension pneumothoraxTension pneumothorax

HemothoraxHemothoraxPneumohemothorax Pneumohemothorax

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Pulmonary injuriesPulmonary injuries

Laceration Laceration ContusionContusionHaematoma Haematoma Crush injury with fragmentation of Crush injury with fragmentation of

the lungthe lung

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Mediastinal injuriesMediastinal injuries

Cardiac injuryCardiac injuryTracheo-broncheal injuryTracheo-broncheal injuryCardio-pulmonary injuryCardio-pulmonary injuryThoracic duct injuryThoracic duct injuryDiaphragmatic injuryDiaphragmatic injury

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PATHOPHYSIOLOGY PATHOPHYSIOLOGY

Thoracic injury results into Thoracic injury results into three pathophysiological three pathophysiological consequencesconsequences

These are:-These are:-HypoxemiaHypoxemiaHypovolaemiaHypovolaemiaMyocardial failureMyocardial failure

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Hypoxaemia Hypoxaemia Refers to Refers to PaOPaO2 2 or or O2 contents in arterial O2 contents in arterial

bloodblood Results from any injury that disturbs Results from any injury that disturbs

airway or ventilation including:-airway or ventilation including:- Airway obstructionAirway obstruction PneumothoraxPneumothorax Flail chestFlail chest Lung contusionLung contusion Tracheobroncheal injuryTracheobroncheal injury Diaphragmatic rupture Diaphragmatic rupture

Each of these injuries limits the Each of these injuries limits the physiologic function of air exchangephysiologic function of air exchange

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Hypovolaemia Hypovolaemia

Refers to as Refers to as in blood volume in blood volumeResults from intrathoracic Results from intrathoracic haemorrhage secondary to haemorrhage secondary to rib #s, injury to the lung rib #s, injury to the lung parenchyma or intercostal parenchyma or intercostal vesselsvessels

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Myocardial failureMyocardial failure

Refers to as failure of the heart to Refers to as failure of the heart to pump blood to the general circulationpump blood to the general circulation

May be caused by either May be caused by either blunt blunt or or penetrating thoracic injurypenetrating thoracic injury

Causes of myocardial failure include:-Causes of myocardial failure include:-Cardiac contusionCardiac contusionPericardial effusionPericardial effusionRupture of ventricular septum or Rupture of ventricular septum or

vulvular muscle vulvular muscle Coronary air embolusCoronary air embolus

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CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

History History Physical examinationPhysical examination

General examinationGeneral examinationSystemic examinationSystemic examinationLocal examinationLocal examination

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History History

History of chest traumaHistory of chest traumaChest painChest painDifficulty in breathingDifficulty in breathing±Haemoptysis±Haemoptysis±Cough ±Cough

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Physical examinationPhysical examinationGeneral examinationGeneral examination

Dyspnoea Dyspnoea Cyanosis Cyanosis Anemia Anemia ShockShock Level of consciousnessLevel of consciousnessPuffy appearance of surgical Puffy appearance of surgical emphysemaemphysema

Restless and gaspingRestless and gasping

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Physical examination [cont]


Local examinationLocal examinationOpen Chest woundOpen Chest wound →→assess assess the depththe depth

Bruises and lacerations on Bruises and lacerations on the chest wall the chest wall

Thoracic spine tendernessThoracic spine tenderness

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Systemic examinationSystemic examinationRespiratory systemRespiratory systemCardiovascular systemCardiovascular systemAbdominal examinationAbdominal examinationCNS examinationCNS examination

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WORKUPWORKUP

Laboratory studiesLaboratory studiesImaging studiesImaging studiesEndoscopic studiesEndoscopic studiesDiagnostic proceduresDiagnostic proceduresOthers Others

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Laboratory studiesLaboratory studies

Non- specific Non- specific Adds little informationAdds little information

Hemoglobin estimationHemoglobin estimationBlood grouping and cross-Blood grouping and cross-matchingmatching

Blood gaseous analysisBlood gaseous analysisPaCO2 PaCO2 PaO2PaO2

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Imaging studiesImaging studies

Plain CXR to rule out:-Plain CXR to rule out:-Rib fracturesRib fracturesHaemothoraxHaemothoraxPneumothoraxPneumothoraxHaemopneumothoraxHaemopneumothoraxCardiac temponadeCardiac temponade

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Imaging studies [cont]

Imaging studies [cont]

Abdominal USS [FAST]Abdominal USS [FAST]To rule out associated abdominal To rule out associated abdominal visceral injury and pleural visceral injury and pleural effusioneffusion

CT scan – CT scan – chest, brain, abdomen chest, brain, abdomen Aortogram – Aortogram – to rule out aorta to rule out aorta rupturerupture

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Endoscopic studiesEndoscopic studies

Bronchoscopy Bronchoscopy Oesophagoscopy Oesophagoscopy

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Diagnostic proceduresDiagnostic procedures

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ManagementManagement

The mgt is divided into 5 phases The mgt is divided into 5 phases according to ATLS (Advanced according to ATLS (Advanced Trauma Life Support)Trauma Life Support) Phase I: Primary survey phasePhase I: Primary survey phase Phase II: Resuscitation phasePhase II: Resuscitation phase Phase III :Secondary survey phasePhase III :Secondary survey phase Phase IV: Supportive care phasePhase IV: Supportive care phase Phase V: DefinitivePhase V: Definitive treatment phase treatment phase

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Phase I: Primary survey phasePhase I: Primary survey phase

Aim: to identify life threatening Aim: to identify life threatening conditionsconditions

The life threatening conditions The life threatening conditions include:-include:- A=AirwayA=Airway B=BreathingB=Breathing C=CirculationC=Circulation D=DisabilityD=Disability E=Exposure E=Exposure

This should go hand in hand with the This should go hand in hand with the phase IIphase II

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Phase II. Resuscitation phasePhase II. Resuscitation phase

Aim: to treat the immediately life Aim: to treat the immediately life threatening conditionthreatening condition Airway –secure airway & Immobilize Airway –secure airway & Immobilize the cervical spinethe cervical spine

Breathing – optimize ventilationBreathing – optimize ventilation Circulation- establish i.v. accessCirculation- establish i.v. access Disability- assess neurological deficitDisability- assess neurological deficit Expose the patient to avoid missed Expose the patient to avoid missed injuryinjury

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Airway Airway

A clear patent and functional airway A clear patent and functional airway should be establishedshould be established

This can be achieved by:-This can be achieved by:-Use of airwaysUse of airwaysProper position of the patientProper position of the patientEndotracheal intubationEndotracheal intubationAmbubags Ambubags TracheostomyTracheostomy

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Breathing / VentilationBreathing / Ventilation

Achieved by:-Achieved by:- Make sure the patient is Make sure the patient is breathing properlybreathing properly use of oxygen masksuse of oxygen masksMechanical ventilatorsMechanical ventilators

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Circulation Circulation Patients with thoracic trauma may Patients with thoracic trauma may

be associated with massive blood be associated with massive blood loss leading to hemorrhagic shockloss leading to hemorrhagic shock

A functional i.v. fluid should be A functional i.v. fluid should be established to restore blood volume established to restore blood volume and prevent irreversible shockand prevent irreversible shock

During the shock state use During the shock state use crystalloid fluidcrystalloid fluid

BT should be given in case of BT should be given in case of hemorrhagic shockhemorrhagic shock

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Dysfunction of CNS Dysfunction of CNS

Neurologic evaluation should be Neurologic evaluation should be assessed as follows:-assessed as follows:-Levels of consciousness using GCSLevels of consciousness using GCSPupil size and response to lightPupil size and response to lightMotor activity and tactile sensationMotor activity and tactile sensationOculocephalic [doll’s eye]Oculocephalic [doll’s eye]

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Exposure of the patient

Exposure of the patient

TheThe patient should be fully patient should be fully exposed/ undressed to exposed/ undressed to avoid missed injuriesavoid missed injuries

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Phase III :Secondary survey phasePhase III :Secondary survey phase

Not started until phase I Not started until phase I &II are complete&II are complete

This include:-This include:- HistoryHistory Physical examinationPhysical examination Investigations Investigations

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History History

Take history from relatives, Take history from relatives, friends, ambulance staff, friends, ambulance staff, police etcpolice etc

Mechanism of injuryMechanism of injuryWhen was the injuryWhen was the injuryMechanism of impactMechanism of impactType of weaponType of weapon

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History [cont]History [cont]

AMPLE historyAMPLE historyA= history of allergies A= history of allergies M= medications M= medications P= pre-morbid illnessP= pre-morbid illnessL= last meal L= last meal E= events surrounding injuryE= events surrounding injury

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Associated injuriesAssociated injuries HeadHead Abdominal injuriesAbdominal injuries Major long bone fracturesMajor long bone fractures SpinesSpines Pelvic fracturesPelvic fractures

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Other symptoms Other symptoms Loss of consciousnessLoss of consciousness Bleeding from the ENTBleeding from the ENT

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Physical examinationPhysical examination

General examinationGeneral examination Local examinationLocal examination Systemic examinationSystemic examination

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General examinationGeneral examination

Dyspnoea Dyspnoea CyanosisCyanosis AnaemiaAnaemia Shock Shock Level of consciousness Level of consciousness etcetc

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Local examinationLocal examination

Look for:-Look for:- Open chest wound- assess Open chest wound- assess the depththe depth

Bruises and lacerations on Bruises and lacerations on the chest wallthe chest wall

Thoracic spines tendernessThoracic spines tenderness

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Systemic examinationSystemic examination

Respiration examinationRespiration examination Cardiovascular Cardiovascular examinationexamination

Abdominal examinationAbdominal examination etcetc

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Respiration examinationRespiration examination

Inspection Inspection Look for:-Look for:-

Decreased chest movementDecreased chest movement Paradoxical respirationParadoxical respiration

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Respiration examination [cont]


Palpation Palpation Feel for:-Feel for:- Tracheal / Mediastinal shiftTracheal / Mediastinal shift Tenderness over the chest wallTenderness over the chest wall Creptus of rib fractures Creptus of rib fractures → do → do compression test to rule out rib #scompression test to rule out rib #s

SternumSternum Crackly feeling of surgical Crackly feeling of surgical emphysemaemphysema

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Percussion Percussion Should be done gentlyShould be done gently Dullness – haemothorax/lung Dullness – haemothorax/lung collapsecollapse

Hyper-resonant- pneumothoraxHyper-resonant- pneumothorax Increased cardiac dullness- Increased cardiac dullness- hemopericardiumhemopericardium

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AuscultationAuscultation Note the following:-Note the following:-

Clicking sounds from rib #Clicking sounds from rib # Course creptations of surgical emphysemaCourse creptations of surgical emphysema or absence of breath sounds on the or absence of breath sounds on the

affected side indicating fluid or air in the affected side indicating fluid or air in the pleural cavity or collapsed lungpleural cavity or collapsed lung

High pitched breath sounds suggesting High pitched breath sounds suggesting tension pneumothoraxtension pneumothorax

Presence of breath sounds suggesting Presence of breath sounds suggesting ruptured diaphragm ruptured diaphragm

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Cardiovascular examination

Cardiovascular examination

Look for:-Look for:- PulsePulse Blood pressureBlood pressure JVPJVP Apex beatApex beat ↑ ↑ cardiac dullnesscardiac dullness Pulsus paradoxicusPulsus paradoxicus

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Abdominal examinationAbdominal examination

Look for:-Look for:- Evidence of haematomaEvidence of haematoma Distended abdomenDistended abdomen Tenderness over the Tenderness over the epigastrium /Lt epigastrium /Lt hypochondriumhypochondrium

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Investigations Investigations

Lab investigationsLab investigationsHb, Blood grouping & X-Hb, Blood grouping & X-matching, blood gaseous matching, blood gaseous analysisanalysis

Imaging investigationsImaging investigationsCXR, CT scan, abdominal USCXR, CT scan, abdominal US

Aspiration tapAspiration tap

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Phase IV: Supportive care phase

Phase IV: Supportive care phase

Analgesics Analgesics AntibioticsAntibioticsToxiod prophylaxisToxiod prophylaxisUrethral catheterization Urethral catheterization Monitor:-Monitor:-

Vital signsVital signsInput/outputInput/output

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Phase V: Definitive treatment phase

Phase V: Definitive treatment phase

Depends on the type of injuryDepends on the type of injury Open chest woundOpen chest wound

Treatment: surgical toilet, Treatment: surgical toilet, closure of the woundclosure of the wound

Simple rib#Simple rib#Treatment: bed rest, Treatment: bed rest, analgesics, antibiotics, analgesics, antibiotics, physiotherapy as soon as pain physiotherapy as soon as pain

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Phase V: Definitive treatment phase [cont]Phase V: Definitive treatment phase [cont]

Flail chestFlail chest →→internal Pneumatic internal Pneumatic Fixation ±intubation or Fixation ±intubation or tracheostomy tracheostomy

Pneumothorax,Pneumothorax, haemothorax, haemothorax, pulmonary injuriespulmonary injuries →→UWSD ± UWSD ± pneumonectomy pneumonectomy

Cardiac injuryCardiac injury →cardiac →cardiac surgery, pericardiocentesissurgery, pericardiocentesis

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Phase V: Definitive treatment phase [cont]Phase V: Definitive treatment phase [cont]

Diaphragmatic rupture Diaphragmatic rupture → → RepairRepair

Esophageal ruptureEsophageal rupture → → RepairRepair

Associated injuriesAssociated injuries →→ should should be managed accordinglybe managed accordingly

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Complications Complications

General complicationsGeneral complicationsLocal complications Local complications

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General complicationsGeneral complications

Haemorrhagic shockHaemorrhagic shock Cardiopulmonary failureCardiopulmonary failure Cerebral hypoxiaCerebral hypoxia HypercapnoeaHypercapnoea Neurogenic shockNeurogenic shock

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Local complicationsLocal complications

Thoracic wall complicationsThoracic wall complications Rib #sRib #s Flail chestFlail chest Clavical / thoracic spines /sternal #sClavical / thoracic spines /sternal #s Surgical emphysemaSurgical emphysema

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Local complications [cont]Local complications [cont]

Pleural complicationsPleural complications PneumothoraxPneumothorax HaemothoraxHaemothorax HaemopneumothoraxHaemopneumothorax EmpyemaEmpyema thoracis thoracis

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Pulmonary complicationsPulmonary complications Lung contusionLung contusion Lung lacerationLung laceration Lung fibrosisLung fibrosis

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Mediastinal complicationsMediastinal complications Cardiac temponadeCardiac temponade Pericardial effusionPericardial effusion Myocardial failureMyocardial failure Cardiopulmonary injuriesCardiopulmonary injuries Diaphragmatic ruptureDiaphragmatic rupture Esophageal injuriesEsophageal injuries

Sub-diaphragmatic injuries Sub-diaphragmatic injuries eg ruptured spleen, eg ruptured spleen, liverliver

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Chest trauma- SummaryChest trauma- Summary

CommonCommon SeriousSerious Primary goal is to provide oxygen to vital Primary goal is to provide oxygen to vital

organsorgans RememberRememberAAirwayirwayBBreathingreathingCCirculationirculation

DDysfunction of CNSysfunction of CNS EExposure to avoid missed injuryxposure to avoid missed injury Be alert to change in clinical condition Be alert to change in clinical condition

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SPECIAL THANKS TOSADRU MOHAMED FOR MAKING THESE SLIDES AVAILABLE [email protected]+255759212578

thoracic trauma phillipo

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