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Acute Chest Trauma
Acute Chest TraumaDr Anil KumarAssistant ProfessorDepartment of Surgical DisciplinesAll India Institute of Medical Sciences19/11/2015
Objective:Burden of Chest Trauma.
Types of chest trauma.
Background & Consequences/effect of chest injury
Basic Principle to manage chest Trauma.
Life threatening chest injuries
Role of X-Ray & E-FAST in chest trauma
19/11/2015
Burden of chest trauma:Chest trauma : 10- 15% of all the cases .
Responsible for 25% of death
The rising burden of serious thoracic trauma sustained by motorcyclist in road traffic crashes (Bambach MR,Mitchell RJ 2014 Jan;. Epub 2013 Oct 19)
The high burden of injuries in South Africa (WHO:Rosana Norman, Richard Matzopoulos, Pam Groenewald, Debbie Bradshaw)
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Types of Chest Trauma:Blunt
Penetrating
Explosion related
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Background:Significant cause of mortality.
Immediate cause of death: Myocardial injury, Aortic rupture
Can be preventable : Prompt Diagnosis & Treatment.
Thoracotomy : < 10 % of BTC & only 15-30 % of PTC.
Majority of Chest Trauma patient can be managed: simple intervention.
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Issues in chest Trauma: Hypoxia, Hypercarbia & AcidosisHypoxia: Inadequate delivery of oxygen to the tissue.
(A)Hypovolemia(Blood Loss)
(B)- Pulmonary ventilation/Perfusion mismatch e.g- Contusion, Hematoma & Alveolar collapse
(C)Change in ITP relationship e.g - Tension Pneumothorax - Open Pneumothorax
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Issues in chest Trauma : Hypoxia, Hypercarbia & AcidosisHypercarbia: Inadequate ventilation.
(A) Change in ITP relationship e.g - Tension Pneumothorax - Open Pneumothorax
(B) Dec Level of consciousness
Metabolic Acidosis: Hypo-perfusion of the tissu(Shock).
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Basic principle of Management:Primary survey
Resuscitation of vital functions
Adjunct of primary survey including CXR & E-FAST
Detailed secondary survey
Definitive care.19/11/2015
Primary SurveyAirway with cervical spine protection
Breathing and ventilationCirculation with Hemorrhage control
Disability: GCS
Exposure(Undress)/Events with Hypothermia control19/11/2015
InspectionPalpationPercussion
AuscultationDiagnosisRestricted Chest moveCCT=+/-Hyper-resonantB.S= Dec/ -Tension Pneumothorax.
Open woundCCT=+/-Hyper-resonantB.S=Dec/-Open Pneumothorax
Restricted chest moveCCT=+/-DullnessB.S=Dec/-Massive Haemothorax
Paradoxical movementAsymetryCCT=+Dull/HyperB.S=Dec/-Flail Chest with pulmonary contusion
Life threatening chest injuries:19/11/2015
Tension Pneumothorax One-way valve air leak
Air is forced to enter into the thoracic cavity without any means of escape
Completely collapsing the affected lung
Mediastinal shift & compressing the opposite lung19/11/2015
Tension Pneumothorax: EtiologyMechanical Ventilation with PPV in patients with visceral pleural injury.
CVP Insertion Iatrogenic Esophageal Endoscopy
Thoracic Spine #
Chest Trauma (15-50% of severe chest trauma)
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Tension Pneumothorax:Dx Absolutely clinical-Restricted Chest Movement-Absent Breath Sound-Hyper-resonant note on Percussion
Don't wait for radiological confirmation
Immediate do the needle thoracostomy/ICD ( Definitive t/t)
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T/t of Tension Pneumothorax:
Needle Thoracostomy in 2nd I.C.S in M.C.L.Chest tube insertion in 5th I.C.S in M.A.L.
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CXR - Pneumothorax.
JPNATC, AIIMS19/11/2015
How to read CXR: ABCDEFAirway- Trachea
Broncho alveolar Marking
Cardiac Shadow
Diaphragm
External cage i.e the Bony Area
Foreign Bodies like ET tube, Chest tube, Central line, Nasogastric tube
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Open Pneumothorax (Sucking chest wound)19/11/2015
Open Pneumothorax (Sucking chest wound)
Sucking wound19/11/2015
T/t of open Pneumothorax:Apply Sterile Occlusive dressing over the defect
Taped securely on 3 sides
Provide Flutter -TypeValve effect.
Breath in- Dressing occlu- des the wound & prevent air to enter from out & vice versa
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T/t of open Pneumothorax:Dont put ICD through the defect
Site of ICD Remote from the wound Definitive surgical closure of the defect after ICD insertion, when pneumo subsides
Open wound
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Flail Chest & Pulmonary Contusion:If 2 or more ribs fractured in 2 or more places.Flail segment don't have bony continuity.Paradoxical movement of flail segment with underlying normal chest movement .High association with Pulmonary Contusion
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Flail Chest & Pulmonary ContusionAsymmetrical & uncoordinated chest movement
Pain , Tenderness & Crepitation.
CXR
ABG
CT 19/11/2015
Flail Chest & Pul. Contusion -M/nBetter to admit- ICU ( Intubation & Ventilation)
Administration of Humidified Oxygen.
Fluid Resuscitation judiciously
Analgesia- IV Narcotics/ Intercostals nerve block/ Epidural Anesthesia(Prefered)
ICD (If A/w Pneumo/Haemo)
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Massive Haemothorax:Rapid accumulation of more than 1500 ml of blood in the chest cavity
Mainly caused by Penetrating wound- Disruption of systemic & hilar vessels.
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Massive Haemothorax: DxRestricted Chest Movement(Inspection)
Breath Sound = Absent
Dullness to Percussion
Chest X-RayABGCT.
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Massive Haemothorax: M/n Follow the ABC.
ICD (In Safety Triangle )
IV Fluid Infused 2 lit warmed RL very fast.
5-10 ml blood for grouping & cross matching to start Blood Transfusion at earliest.
Auto transfusion from the ICD Bag.
Plan- Thoracotomy (If indicated)
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Indication of Thoracotomy1500 ml blood collected immediately in ICD bag
Blood loss @200ml/hr for 2-4 hrs.
Persistent need of BT.
Penetrating Injury -medial to the nipple line ( Over anterior chest wall ) & medial to the scapula(Over posterior chest wall) 19/11/2015
Penetrating Chest Trauma:
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Operative finding: Lacerated Lung
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E-FASTLung USG is more sensitive than CXR for Pneumothorax
Perform rapidly at bed side by Surgeon, don't wait for radiologist.
Safe, fast & effective for detecting the pneumo
Very easy to learn
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30
To detect Pneumothorax??A Line
B Line
Seashore sign
Barcode sign
Lung Point.19/11/2015
E-FAST in Chest Trauma
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Bats Sign: Normal Finding: B Mode
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E-FAST in Chest Trauma: B mode
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Seashore sign & Barcode sign
Normal LungPneumothorax- Find the lung pointSeashore signBarcode sign19/11/2015
Lung Point: Pneumothorax
19/11/2015Barcode signLung Point
Chest Trauma- Follow ABC
Nn
Bats Sign, Pleural Line & Lung SlidingLung Sliding= AbsentBar Code SignScan laterally & Find the Lung PointSeashore sign
Put needle or Chest tube
Switch to M Mode
Normal Lung
19/11/2015
Pneumothorax
Bar codeLung Point
Home Message!!!!!!!!!!!Thoracic trauma is a significant cause of mortality.
Hypoxia, Hypercarbia & Acidosis- main concerned.
Basic principle of m/n is the primary survey ( ABCDE)
Life threatening injuries should be managed during Primary survey.
> 90% of BTC & > 70 % of PTC - simple intervention.
E-FAST- Rapid, accurate & easily deployed and can be lifesaving
19/11/2015
19/11/2015ThankYou