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CHEST TRAUMA
• Blunt versus penetrating traumaBlunt versus penetrating trauma• Injury dependent on mechanismInjury dependent on mechanism• Motor vehicle accidentMotor vehicle accident• Fall from heightFall from height• Physical assaultPhysical assault• Explosive blastExplosive blast• Gunshot woundGunshot wound• Stab woundStab wound
CHEST TRAUMABlunt force injuries from assault or fall from heightBony fracturesLung injuriesCardiac contusion
CHEST TRAUMA
• Improved field diagnosis and treatment of life threatening conditions
• Rapid evacuation to higher level of care• High risk of death despite acute
intervention• Need for prompt diagnosis and
treatment
CHEST TRAUMA
Chest wall and ribs
Lungs and pleura
Great and thoracic vessels
Heart and mediastinal structures
Diaphragm
CHEST TRAUMA
Common Injuries• Rib fractures• Sternal fractures• Open or Closed Pneumothorax
- unilateral / bilateral• Hemothorax• Hemopneumothorax
CHEST TRAUMA
Clinical consequences associated with:• Mechanism of injury• Location of injury• Associated injuries• Co-morbidities
CHEST TRAUMA
Blunt injuries managed non-operatively
Management of airway / oxygenation
Analgesia
Intubation and ventilator support if needed
Chest tubes if needed for pneumothorax or hemothorax
CHEST TRAUMA
PENETRATING INJURIESPENETRATING INJURIES
Trajectory across chestTrajectory across chest
Mechanism due to knife or gunshotMechanism due to knife or gunshot
Type of bulletType of bullet
CHEST TRAUMAINITIAL MANAGEMENT• Airway, Breathing, Circulation• PRIMARY SURVEY• Identify & treat immediately life threatening
conditions
CHEST TRAUMA
Early intervention directed toward diagnosing and treating:
• Tension pneumothorax• Massive hemothorax• Open pneumothorax• Cardiac tamponade• Flail chest
CHEST TRAUMA
RADIOLOGIC TESTS
Chest X-ray, usually portable
Abdominal KUB and FAST Ultrasound Exam
CAT scan, and CT Angiogram if needed
CHEST TRAUMA
Rib Fractures
Physical Diagnosis:DeformityLocalized painCrepitus
Treatment:Analgesia (PCA)Pulmonary toiletObserve for pneumothorax
CHEST TRAUMA
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
CHEST TRAUMA
Flail Chest Diagnosis:• Paradoxical chest wall movement• Poor air movement• Hypoxia
Therapy:• Pain control• Pulmonary & physical therapy• Intubation and ventilator support if needed• Fluid restriction if possible
CHEST TRAUMA
Pneumothorax or HemothoraxPneumothorax or Hemothorax• most treated with simple tube most treated with simple tube
thoracostomythoracostomy
CHEST TRAUMA
Decompression of Tension Pneumothorax• large bore needle
2nd intercostal space midclavicular line
• Chest tube as definitive treatment
PULMONARY CONTUSION
• Common with blunt trauma• May be associated with laceration of
lung parenchyma• Leakage of blood and fluid into
interstitial spaces of lung• Significant inflammatory reaction to
blood components in the lung
PULMONARY CONTUSION
Parenchymal Parenchymal infiltrate seen on infiltrate seen on CXR adjacent to CXR adjacent to injured chest wallinjured chest wall
PULMONARY CONTUSION
Indications for intubation
• Respiratory distress• Hypoxia• Other injuries which compromise
respiratory effort, such as abdominal or neurologic
MYOCARDIAL CONTUSION
• Physical bruising of the cardiac muscle
• Associated with fractures of the sternum
• Any severe anterior chest injury
MYOCARDIAL CONTUSION
DIAGNOSIS: Ectopy ST elevation Tachycardia Friction rub CPK enzymes, Troponin
Monitor in ICU & treat dysrhythmias Serial enzymes Analgesia
MASSIVE HEMOTHORAXMASSIVE HEMOTHORAX• From blunt or penetrating injuries• 200cc – 1L in chest cavity seen on CXR• Treat with chest tube, if immediate drainage is
1500 cc or if 250 cc/hr for 4 hours, then immediate thoracotomy
• Bleeding may be from ribs, lung, blood vessels
AORTIC RUPTURE
• Abrupt deceleration or compression injury• Sudden motion of heart / great vessels in chest• Great vessel injury may occur in 0.3 => 10%
penetrating trauma• Often rapidly fatal• 10% survive to hospital• 20% survive > 1 hour• 90% who reach hospital will die• Early diagnosis and treatment
AORTIC RUPTURE
• CT with contrast angiogram
• Contained injury treat with BP control
• Operative repair
CARDIAC INJURY AND TAMPONADE
• Fatality rates > 80%• Mostly ventricular, right > left• Blood in pericardial sac causes tamponade• Occurs with penetrating injuries
DIAPHRAGM RUPTURE
• Surgical repair to replace herniated contents back into abdomen
• Close muscular diaphragm to restore pulmonary function
• Chest tube to treat pneumothorax
ESOPHAGEAL INJURY
Most due to penetrating trauma
Difficult to diagnosis
If delayed or missed, rapid sepsis & high mortality
Radiography
Endoscopy
Thoracoscopy
Treatment: surgical repair via thoracotomy
EMERGENCY THORACOTOMY
ACUTE THORACOTOMY• Cardiac tamponade (relieved)• Vascular injury to thoracic outlet• Massive air leak• Endoscopic / radiographic evidence of
tracheal or bronchial injury• Esophageal injury• Chest tube output• immediate evacuation of 1500ml blood• or > 250cc/ hour
ER THORACOTOMY
• BLUNT injury with arrest• Arriving without pulse/BP• Penetrating injury with arrest• High likelihood of isolated / correctable
intra-thoracic injury• ER THORACOTOMY in presence of : • pulse• blood pressure• organized cardiac activity
CHEST TUBE INSERTION
Insertion Site• mid or anterior axillary line behind pectoralis
major• above 5th rib avoid diaphragm
CHEST TUBE INSERTION
• Connect tube to underwater seal and suture in place
• Examine chest to check effect
• CXR to check placement and position
SUMMARY
• Chest trauma may be due to blunt, Chest trauma may be due to blunt, penetrating or combination of causespenetrating or combination of causes
• Organs at risk include bony, hollow, as well Organs at risk include bony, hollow, as well as cardiovascular structuresas cardiovascular structures
• Immediate life threatening conditions need to Immediate life threatening conditions need to be treatedbe treated
• Maintenance of airway, oxygenation, and Maintenance of airway, oxygenation, and control of hemorrhage are important goalscontrol of hemorrhage are important goals