Chest Trauma

By
DR. M. C. ODIAKOSA
HOD OF ANAESTHESIA
NOHE
 INTRODUCTION (1 )

Chestinjuries
account directly for
25% of all trauma
deaths.
 INTRODUCTION ( 2 )
 Immediate deaths usually involve
disruption of the heart or great
vessels.
 Early deaths ( within 30mins to 3 hrs
)are due to cardiac tamponade,tension
pneumo-thorax,aspiration, or airway
obstruction.
 Late deaths are due to sepsis and
missed injuries.
 INTRODUCTION ( 3 )

 Approx. 85% of all injuries

can be managed
nonoperatively.
 Only 10 to15% of patients
will require thoracotomy or
sternotomy.
BOUNDARIES of Chest

 Superiorly
=> clavicles
 Inferiorly
=> diaphragm
 Laterally
=> rib cage
BOUNDARIES of Chest

 Anteriorly
=> sternum
 Posteriorly
=> vertebral
bodies & ribs
STRUCTURES Injured

Any organ in chest potentially

susceptible

– especially to penetrating trauma

CONTENTS - Thoracic cavity
 - Chest wall and
ribs
 - Lungs and pleura
 - Great and thoracic
vessels
 - Heart and
mediastinal
structures
 - Diaphragm
CONTENTS - Thoracic cavity

 Esophagus
 Thoracic duct
 Tracheobronchial
system
OTHER ORGANS at risk

 Thoraco-abdominal
injury
 any wound below
nipples in front
and
 inferior scapula
angles dorsally
 may result in
intra abdominal
injury
OTHER ORGANS at risk

Peritoneal viscera
– Liver
– Spleen
– Stomach
– Colon & small intest.
– Biliary system

Retro-peritoneum
 kidneys
RESULTING INJURIES

– Rib fractures
– Sternal fractures

– Open or Closed Pneumothorax

- unilateral / bilateral

– Hemothorax
– Hemopneumothorax
RESULTING INJURIES

– Pneumo-mediastinum

– Pulmonary contusion

– Myocardial contusion

– Diaphragmatic rupture
RESULTING INJURIES

 Subcutaneous emphysema
 Classification of Chest
Injuries
 PENETRATING INJURIES
 BLUNT INJURIES
 FIRST AID MEASURES

 On-the -spot assessment of injuries.

 Clear airway
 Check breathing
 Control of haemorrhage.
 Beware c-spine injuries
Chest Trauma - BLUNT
Chest Trauma - PENETRATING
Pathophysiology
Quite serious
 THE DEADLY DOZEN

 LETHAL SIX
 HIDDEN SIX
 THE LETHAL SIX

 AIRWAY OBSTRUCTION.
 TENSION PNEUMOTHORAX.
 OPEN PNEUMOTHORAX
 FLAIL CHEST
 MASSIVE HAEMOTHORAX
 CARDIAC TAMPONADE.
 THE HIDDEN SIX

 PULMONARY CONTUSION
 THORACIC AORTIC RUPTURE
 DIAPHRAGMATIC RUPTURE
 TRACHEOBRONCHIAL INJURIES
 MYOCARDIAL CONTUSION
 OESOPHAGEAL INJURY
1. HYPOXIA / HYPO-VENTILATION

 Primary acute killer of trauma patients

inadequate delivery of O2
to tissues
Signs of HYPOXIA

 Increased RR
 Change in breathing pattern (shallow)

 Anxious behavior

 Poor air movement

 Diaphoresis

 Dilated pupils

 Cyanosis – (late sign)

2. Hypovolemia

 Inadequate intravascular volume

=> BLOOD LOSS

3. Ventilation / Perfusion
Mismatch

 Contusion
 Hematoma
 Alveolar collapse
4. CHANGES IN INTRATHORACIC
PRESSURE RELATIONSHIPS

- Tension pneumothorax
- Open pneumothorax
5. METABOLIC ACIDOSIS

 Hypo perfusion of tissues (shock)

MANAGEMENT - Chest Trauma
 ABCs
 PRIMARY SURVEY
– Most important feature of chest injury evaluation

=> Aim to identify & treat immediately life threatening conditions

MANAGEMENT - Chest Trauma
 EARLY INTERVENTIONS geared towards
– identifying / correcting / preventing problems

 Tension pneumothorax
 Massive hemothorax
 Open pneumothorax
 Cardiac tamponade
 Flail chest
MANAGEMENT - Chest Trauma

 Resuscitation of vital functions

REMEMBER :
- Most life threatening injuries txd by
- Airway control
- Chest tube
MANAGEMENT - Chest Trauma
- Detailed Secondary Survey

Influenced by: May show:

 Mechanism of  Simple pneumothorax
injury  Hemothorax
 High level of  Pulmonary contusion
suspicion  Myocardial contusion

 Blunt aortic injury

 Rib fractures

 Diaphragmatic
rupture
MANAGEMENT - Chest Trauma

Definitive care

 Usually operative
Rib Fractures
Rib fractures

Signs and Symptoms

- Deformity
- Localized pain
- Tenderness
- Crepitus
Rib Fractures

Treatment

 Analgesia (PCA)
 Pulmonary toilet
 Observe for possible pneumothorax
Flail Chest
Segment of chest wall
that does not have
continuity with rest of thoracic
cage
 Usually 2 fractures per rib
in at least 2 ribs
 Segment does not
contribute to lung
expansion
 Disrupts normal pulmonary
mechanics
 Accompanied by pulmonary
contusion in 50% of
patients with flail chest
Flail Chest - Pathophysiology

A major problem is the injury to

the underlying lung

=> Pulmonary Contusion

Flail Chest – Signs & Symptoms

 Dyspnea
 Chest pain
 Paradoxical chest wall
movement
 Poor air movement
 Crepitus
 Hypoxia
 Cyanosis
Flail Chest - Treatment

 Pain control
 Humidified O2
 Close observation for respiratory
decompensation
 Aggressive pulmonary & physical
therapy
Flail Chest - Treatment

 Operative fixation not usually required

(historical)
Lung Injuries
 Pneumothorax or Hemothorax
– most treated with simple tube
thoracostomy
Open Pneumothorax

Signs & Symptoms

 Penetrating chest
wound
 Decreased breath
sounds
 Sucking sounds on
inspiration
Open Pneumothorax

Treatment :

 3 sided occlusive
dressing
 Observe for tension
pneumothorax

 Operative
Tension Pneumothorax

 One way valve allows air leak from

lung or chest wall

=> air forced into chest cavity

without escape
Tension Pneumothorax

Collapses ipsilateral lung

Tension Pneumothorax

Displaces mediastinum to opposite side

Tension Pneumothorax

Compresses opposite lung

Tension Pneumothorax

Decreases venous return

Tension Pneumothorax

Signs & Symptoms

– air hunger
– chest pain
– respiratory distress
– tachycardia
– hypotension
– tracheal deviation
– absent breath sounds
– hyper-resonant percussion
– JVD
Tension Pneumothorax
- Treatment
Immediate decompression
– large bore needle
 2nd intercostal space
 midclavicular line
– chest tube as definitive tx

NOTE – may mimic a collapsed lung on the other side

– - i.e. trachea deviates towards the collapsed lung
– - however, one resonant (empty), other tympanic (full)
Pulmonary Contusion

 Largest # of pts are those with

blunt trauma
 Most common chest injury in children
 Usually develops over 24 hours
 Can occur with or without laceration of
parenchyma
Pulmonary Contusion

Results from:

 Leakage of blood and fluid into interstitial

spaces of lung

- Significant inflammatory reaction

to blood components in the lung
Pulmonary Contusion
- Pathophysiology
Loss of normal lung structure &
function leads to

- poor gas exchange

- increased pulmonary vascular
resistance
- decreased lung compliance
Pulmonary Contusion
- Complications

– Atelectasis
– Pneumonia
– ARDS
– Respiratory failure
Pulmonary Contusion
- Diagnosis

 Parenchymal
infiltrate seen in
CXR adjacent to
injured chest wall
Pulmonary Contusion
- Diagnosis
No real clinical
findings especially
initially
 dyspnea

 chest wall
contusions /
abrasions
 increased RR

 may have
crackles
Pulmonary Contusion
- Diagnosis
Lung gets stiffer causing
dyspnea and increased RR

Blood gases worsen 2-3

days as edema increases

CXR changes may lag 12 -

48hrs behind
 May underestimate the
true extent

CT - very sensitive – can

allow quantifying
Pulmonary Contusion
- Treatment
MOSTLY supportive - usually resolve in
5-8 days

- O2 + observation in milder cases

- Pain control to allow:
- adequate ventilation and better
management of secretions
- Fluid restriction
- Intubation + mechanical ventilation
 if respiratory distress present
Myocardial contusion

 Physical bruising of
the cardiac muscle

 Usually associated
with fractures of
the sternum
 Any severe anterior
chest injury
Myocardial contusion

 Difficult to dx

 => HIGH LEVEL OF

SUSPICION

 ALL pts with

pattern of injury
must have an EKG
Myocardial contusion
- Diagnosis
 ST elevation
 Tachycardia

 Friction rub
 Enzymes may be normal
Myocardial contusion
- Treatment

 Monitor in ICU & treat dysrhythmias

 Serial enzymes
 Analgesia
Massive Hemothorax
 Pleural cavity hold 3 liters blood
 200cc – 1L in chest cavity seen on CXR
 90% from internal mammary or intercostals
 10% from pulmonary vessels
Massive Hemothorax
- Treatment

– Decompression
– Chest tube (most need just that)
– Bleeding may stop when lung re-expands
Aortic Rupture /
Great Vessel Injuries
 Abrupt deceleration or  Often rapidly fatal
compression injury  Only 10% survive to
 Sudden motion of hospital
heart / great vessels  Only 20% survive > 1
within thorax hour
 Great vessel injury may  90% who reach
occur in 0.3 => 10% hospital will die
penetrating trauma  EARLY DX and
aggressive tx best
chance
Aortic Rupture
- Signs and Symptoms

– Hypovolemic shock
– Chest wall ecchymosis
Aortic Rupture - Diagnosis

 Consider
mechanism of
injury
– widened
mediastinum on
CXR
– 40% normalizes
with sitting up
Aortic Rupture - Diagnosis

 Mediastinum > 8cm wide

 Blurring of aortic knob
Aortic Rupture - Diagnosis

 Deviation of NGT to right

Cardiac Injury
 Highly lethal :
fatality rates
- 70 => 80%

 Mostly ventricular
– right > left
Cardiac Tamponade

 => Blood in pericardial sac

 Occurs most frequently with

penetrating injuries
Cardiac Tamponade
- Signs and Symptoms
 Shock
 JVD
 Dyspnea
 PEA
 Beck’s triad = minority of pts
- Distended neck veins
- Muffled heart sounds
- Hypotension
Cardiac Tamponade
- Treatment
 Volume
resuscitation
 Pericardiocentesis
 Surgery
- Pericardial window
- sternotomy
- thoracotomy
Diaphragmatic Rupture

 Traumatic
herniation of
abdominal contents
into the chest
Diaphragmatic Rupture

 Mostly on left side

Diaphragmatic Rupture

 Liver “protective” on right side

Diaphragmatic Rupture
- Signs and symptoms
No distinctive signs /
symptoms seen
High index of suspicion
needed especially with
mechanism of injury
 dyspnea

 cyanosis

 shoulder pain

 bowel sounds in lower

chest
Diaphragmatic Rupture
- Treatment
 Up to 13% acute injuries missed initially
 85% presenting in 3 years as

- obstruction or with
- decreased cardio / pulmonary reserve

Goal of treatment:
- Maintain adequate oxygenation
=> intubate
- NG decompression of stomach
Esophageal Injuries

 Most due to penetrating trauma

Diagnosis
- Difficult
- If delayed => rapid sepsis & high mortality
- Requires aggressive investigation
- Radiography
- Endoscopy
- Thoracoscopy
Treatment
- Thoracotomy, etc.
Chest tube insertion
- Indications
Absolute indications Relative indications
 pneumothorax – rib fractures and
positive pressure
 hemothorax
ventilation
 traumatic – profound
arrest - (b/l) hypoxia/hypotension
with penetrating
chest injury
Conclusion
 COMPONENTS – Chestwall, Airway,
Parenchyma, pleural; Cardia

 Final Pathway: Disrupted Tiss

Perfusion  Tiss. Hypoxia &

 Hypercabnia & Metab. Acidosis.

 Chain of care
 Prehospital care - by the paramedics
 Casualty care - reception, resuscitation,
and initial assessment.
 Emergency investigation, surgery, and
intensive care.
 Definitive care in the initial hospital or
after transfer for specialist care.
Hospital Care
 Initial Assessment
 Primary Survey – TRIAGE
 Resuscitation
 Secondary Survey
 Definitive Care
 SurgicalProcedure
 Anaesthesia
 ICU Care – Organ Support
 Trauma Team
 At least 4 doctors & 2 nurses:
 Surgical registrar
 Orthopaedic registrar
 Anaesthetist
 Accident and emergency registrar
 Two accident and emergency nurses
Other members of the team:
 Radiographer
 Laboratory staff
 Porters
 Specialist surgeons
 Paramedics/ambulance crew
 Primary Survey
 Assess pt’s vital functions to identify and treat
life threatening conditions. This constitutes the
ABC of trauma care.
 A: Airway maintenance with cervical spine
control. Lie pt flat, no neck ext, rigid collar, tape
forehead to sides of trolley.
•Remember: all multiple injuries have a cervical
spine injury until proved otherwise.
 B: Breathing and ventilation
 C: Circulation with haemorrhage control
 D: Disability (neurological status)
 E: Exposure
 Resuscitation
For good tissue perfusion, the minimum are the following:
 Oxygenate with 100% oxygen
 Insert two cannulae (14 gauge) in the antecubital fossae,
crossmatch blood early
 Infuse 2 litres of Hartmann's solution rapidly
 Send blood samples for full blood count, urea and electrolytes,
glucose
 Record vital signs (temperature, pulse, respiration, and blood
pressure)
 Pulse oximetry
 Electrocardiogram monitor
 Urinary catheter--unless contraindicated
 Nasogastric tube--unless contraindicated
 Arrange x ray films: lateral cervical spine, chest, anterior-
posterior pelvis
 Secondary Survey
 Detailed head to toe, only after resuscitation &
pt is stable. 2° survey “tube & finger in every
orifice.” The mnemonic AMPLE applies:
A Allergies
M Medication
P Past medical history
L Time of last food or drink
E Events and environment related to injury
 Evaluation Of Injuries
 Head:-Neurological examination ;Ear & Nose
for CSF or blood
 Face;-Bleeding into the Airway
 Heart and great-vessel trauma
 Chest;-Fractured ribs,Haemo-
pnuemothorax,lung contussion,flail chest
 Abdomen;- Blunt and penetra – ruptured
viscus, spleen, kidneys, liver & intestine
 Pelvic;-Ruptured bladder/urethra
 Extremeties;-Fractured limbs-Assess blood
loss
Definitive care, Documentation,
Re-evaluation.
 Comprehensive care: fix fractures,
specialist surgeries at any centre
 Detailed & chronological notes with
time, names of attending physicians.
 Re-evaluate regularly. Vital signs
change rapidly in multiply injured
patients!!!
Intubated patient with
severe airway obstruction
secondary to facial injuries