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Injury ches tmodified (4)

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Chest Injuries Mechanisms of injury • blunt injuries • crush injuries • penetrating injuries • inhalation burns • aspiration of foreign bodies 1
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  • 1. Chest Injuries Mechanisms of injury blunt injuries crush injuries penetrating injuries inhalation burns aspiration of foreign bodies 1
  • 2. 2 major forces within chest which lead to injury: 1. Compression and distraction. Compression results in destruction of vascular components, haemorrhage, oedema and impairment of function. 2.Distraction injuries usually result in shearing forces which destroy integrity of intrathoracic viscera 2
  • 3. Blunt trauma - mode of injury important - where there has been massive deformity of a car or a history of a fall of 5 metres or more major intrathoracic injuries should always be suspected. The physical nature of chest wall allows for considerable elastic recoil, especially in young patients and therefore degree of injury within chest may need to be judged initially by deformity to car rather than appearance of patient 3
  • 4. Blunt injuries occur in 3 major directions: 1.AP 2 lateral and 3.transdiaphragmatic AP deformity results in relative backward motion of heart. This may result in disruption of aorta at level of ligamentum arteriosum just below left subclavian. As heart swings back and up it may cause so-called wishbone # of a proximal bronchus - Injuries to heart occur in up to 1/2 of patients after deceleration injuries 4
  • 5. deceleration with impact to back causes relatively few intrathoracic injuries - lateral compression of chest during deceleration causes fractures typically of lower ribs with risk of injury to liver, spleen and kidneys - when lateral compression results in flail segments damage to thoracic cavity is usually relatively small and most frequently limited to contusion and laceration of lung parenchyma - lap belt of seat belts leads to rise in intrabdominal pressure in massive deceleration and this, combined with shearing and twisting of upper trunk may result in diaphragmatic rupture 5
  • 6. Penetrating injuries result in parenchymal damage related to track of missile or stabbing implement and velocity more solid structures (eg heart and major vessels) suffer greater injury where high- velocity missiles are penetrating weapon most lethal complication is haemorrhage often associated with abdominal trauma 6
  • 7. Crush injury occurs where elastic limits of chest and its contents have been exceeded patients usually have AP deformity majority have flail chests with multiple fractures, pneumothorax or haemothorax most have pulmonary contusion injuries of heart, aorta, diaphragm, liver , kidney and spleen are common 7
  • 8. another group of patients with crush injuries are those with "traumatic asphyxia" syndrome, where constrictive forces are applied over a wide area for as little as 2-5 mins. Profound venous hypertension associated with relative stasis is mechanism of injury. There is widespread capillary dilatation and rupture, subconjunctival haemorrhage and retinal haemorrhage. Simultaneous injuries (eg intracranial haemorrhage) must be suspected severe crush injuries have a high mortality 8
  • 9. Chest trauma haemodynamics hypovolaemia most important mechanism cardiac tamponade myocardial contusion valve injury intracardiac shunt 9
  • 10. Chest trauma hypoxiaDue to: reduced blood volume ventilatory failure contusion displacement of mediastinum pneumothorax 10
  • 11. Clinical features: Initial history and examination are often abbreviated Examination air hunger; use of accessory muscles; tracheal deviation; cyanosis or distended neck veins; (evidence of tension pneumothorax, or tamponade); tracheal deviation (evidence of tension pneumothorax) major defects in the chest (sucking chest wounds 11
  • 12. unilaterally diminished breath sounds or hyperresonance to percussion (evidence of closed pneumothorax or tension pneumothorax); decreased heart sounds (pericardial tamponade); location of foreign bodies; location of entry and exit wounds 12
  • 13. Investigations CXR - CXR most useful screening investigation - Look for subcutaneous air, foreign bodies, bony fractures, widening of mediastinum, pneumothorax, pneumomediastinum, pleural fluid, pulmonary parenchymal abnormalities(infiltrates, atelectasis etc 13
  • 14. Look in particular for the - pneumothorax: ( up to 30% of pneumothoraces missed on supine CXR) air collects in anterior-inferior pleural space producing deep" costophrenic sulcus 14
  • 15. - pneumomediastinum parietal pleura visible along left mediastinal border. pleura descends below mid- hemidiaphragm sharply defined edge to descending aorta which can often be followed into upper abdomen "continuous diaphragm" sign under cardiac shadow subcutaneous, retroperitoneal or intraperitoneal emphysema 15
  • 16. - pneumopericardium air around heart that does not rise above level of pericardial reflection at root of great vessels air shifts with position of patient (unlike pneumomediastinum 16
  • 17. - pleural effusion uniform increase in density over hemithorax pleural cap 17
  • 18. - pulmonary contusion homogenous infiltrates that tend to be peripheral and non-segmental may be associated with adjacent rib fractures air bronchograms are rare due to blood in small airways 18
  • 19. - ruptured hemidiaphragm:- more commonly left sided non-specific signs include: apparent elevation of hemidiaphragm, obliteration or distortion of contour of hemidiaphragm, contralateral displacement of mediastinum, pleural effusion presence of gas containing viscera in thorax, particularly with a focal constriction across gas- containing bowel is pathognomonic haemopneumothorax may be misdiagnosed when dilated stomach gives horizontal air-fluid interface on erect CXR 19
  • 20. in absence of right rib #s a small right haemothorax with a "high R diaphragm" suggestive of ruptured diaphragm findings may be absent in 25-50% initially- chest wall injuries- may give clues to associated injuries fractures of first 3 ribs in particular indicates significant trauma thoracic outlet fractures associated with brachial plexus or vascular injuries 20
  • 21. subclavian vascular injury should be suspected in patients with fractures of first 3 ribs, clavicle and scapula, particularly when associated with significant fracture displacement, extrapleural haematoma, brachial plexus neuropathy or radiological evidence of mediastinal haemorrhage fractures of sternum are rare and require both lateral and oblique views of thorax for diagnosis. The presence of a fractured sternum and an abnormal mediastinal contour should prompt a search for injury to great vessels 21
  • 22. - haemopericardium rapid accumulation of blood in pericardial space often causes cardiac tamponade wthout altering appearance of cardiac silhouette 22
  • 23. CT Scan Valuable tool Aids in diagnosis and precise location of numerous lesions. Contrast is useful particularly when looking for mediastinal haemorrhage and periaortic haematomas. 23
  • 24. Echocardiography ECG Cardiac wall motion abnormalities and valve function and presence of pericardial fluid or blood. Most common abnormality in thoracic trauma are S-T and T wave changes and findings indicative of bundle branch block 24
  • 25. Angiography BRONCHOSCOPY Angio- Remains the gold standard for defining thoracic vascular injuries Bron- Indications include evaluation of airway injury, haemoptysis, segmental or lobar collapse, and removal of aspirated foreign bodies. 25
  • 26. Management Immediate management - assure patent airway, oxygenation and ventilation - exclude or treat pneumothorax haemothorax cardiac tamponade 26
  • 27. Extrathoracic Injuries - assess for extrathoracic injuries - decompress stomach - provide pain relief - reconsider endotracheal intubation, ventilation. In particular take into account gross obesity, significant pre-existing lung disease, severe pulmonary contusion or aspiration, need for surgery for thoracic or extrathoracic injuries 27
  • 28. General management Treatment of specific injuries Monitoring Should include follow-up CXRs. Common for patients with pulmonary contusion to deteriorate in first 24-48 hrs following injury Not necessarily due to progression of contusion but is more often due to development of pneumothorax, haemothorax, atelectasis or pulmonary oedema. For this reason serial CXRs are necessary in first 24 hrs Following are danger signs requiring full reassessment 28
  • 29. resp rate > 20/min heart rate > 100/min systolic BP < 100 mmHg reduced breath sounds on affected side Pao2 < 9 kPa on room air Paco2 > 8 kPa increased size of pneumothorax, haemothorax or increased width of mediastinum on CXR 29
  • 30. Deterioration Deterioration in any of these signs must be followed by a search for evidence of blood loss, tension pneumothorax, head injury, sepsis or fat embolism. Chest drains should be checked for patency 30
  • 31. Chest drains Indications for insertion of chest drains in stable patients : pneumothorax > 10% in non-ventilated patient (ie >1 intercostal space) haemothorax > 500 ml (ie above neck of 7th rib) surgical emphysema confluent opacity of lung field in a supine CXR suggesting haemothorax 31
  • 32. Prophylactic Chest Drain There are arguments both for and against the insertion of prophylactic chest drains in patients with rib fractures who are to be ventilated for a GA. However without air or fluid draining the drain is likely to become blocked at an early stage. 32
  • 33. In a series of patients with blunt chest trauma one pneumothorax occurred per 79 days of ventilation when prophylactic drains were used as opposed to one per 62 days when they were not. Complication rate associated with insertion 6-9% 33
  • 34. Theoretically, all that is required to drain pneumothorax is a small-bore tube but this is more likely to become blocked. When blood or pus is to be drained in an adult a 32 FG tube is recommended Antibiotics use of prophylactic antibiotics controversial. Some recommend them for patients treated conservatively in whom a chest drain is inserted cefuroxime and metronidazole for patients with perforated viscus (in addition to exploration and drainage) 34
  • 35. Clearance of secretions and prevention of atelectasis General measures: pain relief (eg pleural block) physiotherapy humidification bronchodilators (especially smokers or those exposed to smoke, irritant chemicals or those with tracheobronchial burns) consider cricothyroidotomy or "minitracheostomy" for those in whom general measures are insufficient 35
  • 36. Bronchoscopy Indications for flexible bronchoscopy: massive air leak failure of lung to re-expand lobar collapse diagnosis and assessment of tracheal burns bronchial toilet Rigid bronchoscopy has less of a role in the trauma patient but may be used in cases of persistent lobar collapse to aspirate a blood clot or plug of sputum 36
  • 37. Mechanical ventilation most centres use PCV or PSV to reduce incidence of barotrauma - PCV and PSV also provide some compensation for air leaks 37
  • 38. Analgesia Of extreme importance in determining whether deep breathing and coughing possible. Options IV analgesics in frequent small doses or by continuous infusion Use of inhalor during physiotherapy intercostal nerve block: 38
  • 39. multiple individual nerve blocks (rptd as necessary) single large volume (eg 20 ml 0.5% bupivicaine) into 1 intercostal space. Spreads to block nerves above and below intrapleural bupivicaine via intercostal catheters using intermittent injections or continuous infusions epidural LA/opioids NSAIDs: fully resuscitated patients with normal renal function 39
  • 40. Post-operative intensive care following tracheobronchial, lung or diaphragmatic repair high inflation pressures should be avoided tracheal suction must be minimal where there is a tracheobronchial suture line avoid fluid overload prevent gastric distension 40
  • 41. Specific injuries Classification Require immediate intervention Tension pneumothorax Open pneumothorax Disruption of major airway Cardiac tamponade Massive haemothorax Traumatic air embolism Flail chest 41
  • 42. Injuries with potential for threatening survival Lung contusion Other pulmonary parenchymal injuries Myocardial contusion Aortic rupture Oesophageal disruption Diaphragmatic rupture Rib fractures Simple haemopneumothorax Traumatic asphyxia 42
  • 43. Long term sequelae Clotted haemothorax Empyema Phrenic nerve palsy Pericardial complications Fistulae Diaphragmatic hernia Chylothorax 43
  • 44. Others Sternal, clavicular, scapular injuries Subcutaneous emphysema 44
  • 45. Tension pneumothorax respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral absence of breath sounds, distended neck veins. Cyanosis is a late manifestation may be confused with cardiac tamponade but tension pneumothorax is more common. Differentiation may be made by unilateral hyper-resonance 45
  • 46. treat by immediate decompression: insert needle into 2nd intercostal space in MidClavicularLine. Ability to easily aspirate air confirms diagnosis. In event of failure to aspirate air, withdraw needle but remember possibility of iatrogenic pneumothorax now exists 46
  • 47. Open pneumothorax sucking chest wound" if opening in chest wall is approximately 2/3 the diameter of trachea air passes preferentially through chest defect promptly close defect with sterile occlusive dressing, large enough to overlap the wounds edges and taped securely on 3 sides to provide a flutter-type valve effect. As patient breathes in the dressing is sucked over wound while the open end of the wound allows air to escape during expiration place a chest drain in an area remote from the open wound 47
  • 48. Disruption of major airway clinical features vary with level of rupture but usual picture is one of respiratory distress, subcutaneous emphysema, haemoptysis pneumothorax invariable with ruptured bronchus. Suspect bronchial rupture if pneumothorax associated with a persistent large air leak after placement of chest drain. Rupture usually occurs within 2.5 cm of carina mediastinal emphysema common treatment of tracheal injuries: immediate intubation with cuff positioned distal to tear. Drain pneumothorax 48
  • 49. Cardiac tamponade most commonly results from penetrating injuries but may follow blunt trauma relatively small amounts of blood (approx. 100 ml) required to restrict cardiac activity and interfere with cardiac filling. Removal of small amounts of blood or fluid (often as little as 15-20 ml) by pericardiocentesis may have enormous beneficial effects diagnosis is often difficult: 49
  • 50. volume of heart sounds difficult to assess in noisy environment distended neck veins may be absent because of hypovolaemia pulsus paradoxus may be absent and tension pneumothorax may mimic tamponade consider possibility in patients who do not respond to usual resuscitation and have a mechanism of injury compatible with tamponade 50
  • 51. pericardiocentesis pericardiocentesis blind pericardiocentesis only if ultrasound/echo not available use sub-xiphoid route and preferably a plastic sheathed needle for pericardiocentesis. ECG monitoring is necessary to detect needle induced arrhythmias 51
  • 52. pericardial aspiration may not be diagnostic or therapeutic if blood has clotted, which may be the case after rapid bleeding. Open pericardiotomy may be life-saving but is indicated only when an experienced surgeon is available even if pericardial tamponade is strongly suspected volume resuscitation should continue while preparations are made for pericardiocentesis aspiration of blood alone may temporarily relieve symptoms because of the self sealing qualities of the myocardium but all patients with positive pericardiocentesis following trauma require open thoracotomy and inspection of the heart 52
  • 53. Massive haemothorax incidence of haemothorax and haemopneumothorax ~50-60% in penetrating trauma and 60-70% in blunt trauma. Majority are not massive massive haemothorax defined as >1500 ml of blood in chest cavity clinical signs: unilateral dullness to percussion shock unilateral absence of breath sounds deviation of trachea neck veins may be flat due to severe hypovolaemia or distended because of the mechanical effects of intrathoracic blood blood loss complicated by hypoxia 53
  • 54. Management manage initially by simultaneous restoration of volume deficits and decompression of chest cavity. If auto- transfusion device is available it should be used emergency thoracotomy for massive haemothorax or haemothorax with ongoing loss of >200 ml of blood per hour for 3-4 h 54
  • 55. Systemic air embolism more common in penetrating injuries immediately life-threatening usually due to broncho-pulmonary vein fistula suspect if: focal neurological signs exist in the absence of head injury circulatory collapse occurs on initiation of IPPV in absence of tension pneumothorax froth is obtained in arterial blood gas sample from a collapsed patient 55
  • 56. Management Management If suspected: 100% O2 minimise ventilation volumes and pressures emergency thoracotomy to clamp ascending aorta, remove air source (by clamping pulmonary hilum) and aspirate air from LV and ascending aorta 56
  • 57. Flail segment major physiological insult is contusion of underlying lung and decreased vital capacity occurs when 3 or more consecutive ribs or costal cartilages are fractured bifocally. these circumscribed segments, having lost continuity with the rigid thorax, move inwards with inspiration and push outward with exhalation, thus moving paradoxically. presenting symptoms of pain, tachypnoea, dyspnoea, and thoracic splinting, along with chest wall contusions, tenderness, crepitance, and palpable rib fractures are suggestive, but paradoxical chest wall motion is the diagnostic sine qua non. 57
  • 58. may be difficult to diagnose if patient is already mechanically ventilated, in pain, obese, or has large breasts or subcutaneous emphysema. CXR is helpful in identifying multiple fractured ribs, but will not reveal cartilaginous disruptions. Major value of the CXR is in detecting associated injures (more than 90% will have associated injuries-and 3 out of 4 require tube thoracostomy for haemopneumothorax; extrathoracic injuries are common: head injury in ~40%; major fractures in 40%, and intraabdominal injuries in 30%. 58
  • 59. Distribution of flail Anterior: typically secondary to blows to the sternum, eg motor vehicle accident, CPR Lateral: due to T-bone impacts or AP crush mechanisms Posterior: result from direct blow to the back and are characterized by simultaneous fractures along the midaxillary line and the rib neck. Splinting, plus a supine position effectively limit paradoxical motion. 59
  • 60. Management ~50% of cases can be managed without ventilation others require ventilation for 1-3 weeks chest wall usually stabilises in 1-2 weeks operative fixation is suggested by some authors. Main benefit is to prevent deformity. weaning should not wait till paradoxical movement improves, rather should be initiated when gas exchange is adequate. in absence of systemic hypotension control administration of IV fluids to prevent overhydration 60
  • 61. ~50% of cases can be managed without ventilation others require ventilation for 1-3 weeks chest wall usually stabilises in 1-2 weeks operative fixation is suggested by some authors. Main benefit is to prevent deformity. weaning should not wait till paradoxical movement improves, rather should be initiated when gas exchange is adequate. in absence of systemic hypotension control administration of IV fluids to prevent overhydration 61
  • 62. Lung contusion essentially a bruise of the lung. Aetiology controversial: probably a combination of shear stress (tearing tissue) and bursting forces (popping the balloons) direct injury causes pulmonary vascular damage with secondary alveolar haemorrhage initially not much shunt as these alveoli are poorly perfused subsequently tissue inflammation develops. Resultant surrounding pulmonary oedema produces regional alterations in compliance and airways resistance, leading to localised V/Q mismatch atelectasis 62
  • 63. diagnosis is radiological. classically see nonsegmental pulmonary infiltrates-progress in first 12-24 hours of injury. Note that CXR undestimates degree of contusion. CT more sensitive and better method of assessing severity may be irregular nodular densities that are discrete or confluent homogeneous consolidation diffuse patchy pattern early CXR changes suggest more severe contusion. Early pulmonary contusion infiltrates are due to alveolar haemorrhage radiological differential diagnosis includes: 63
  • 64. Aspiration Re-expansion of collapsed RUL following right endobronchial intubation in most cases infiltrates associated with pulmonary contusion are not visible till after fluid resuscitation. contusions tend to worsen over 24-48 hours and then slowly resolve unless complicated by infection, ARDS or cavitation 64
  • 65. Management supplemental oxygen only about 25% of patients require invasive ventilation good analgesia physiotherapy 65
  • 66. Other pulmonary parenchymal injuries Pulmonary Laceration Commonly associated with haemopneumothorax and haemoptysis Usually managed with simple tube drainage Pulmonary Haematoma Uncomplicated cases usually resolve in 3- 4 weeks 66
  • 67. Posttraumatic Pulmonary Cavitary Lesions Posttraumatic Pulmonary Cavitary Lesions Posttraumatic cysts, pseudocysts, or pneumatoceles are cavitary lesions within the lung parenchyma filled with fluid, blood, of air. CT is useful in diagnosis Most resolve spontaneously Some can become infected requiring antibiotics, CT guided aspiration, and in some cases surgical resection 67
  • 68. AV fistulas diagnosis by pulmonary angiography Torsion of the lung XR signs: Opacification of affected hemithorax Mediastinal shift toward the contralateral side Reversal of bronchoalveolar markings of the affected side, with the major pulmonary vessels coursing cephalad instead of caudad 68
  • 69. Myocardial contusion Definition and epidemiology direct traumatic myocardial damage without traumatic involvement of coronary arteries common in blunt trauma but difficult to diagnose tends to occur in acceleration/deceleration and crush/compression injuries 69
  • 70. Clinical features consider possibility in any patient with a mechanism of injury that suggests likelihood of cardiac contusion patients who are conscious may complain of dyspnoea or chest pain may lead to significant physiological dysfunction and even death but massive contusion leading to cardiogenic shock is rare. In patients with chest trauma cardiogenic shock is usually due to cardiac tamponade or ventricular akinesia 70
  • 71. with compression in diastole valvular dysfunction may occur; usually aortic valve in older patients and mitral in younger pericardial rub, S3 gallop, cardiac failure serious damage to virtually every cardiac structure has been reported most common presentation is with asymptomatic ECG abnormalities although severe contusion will produce cardiac failure. LAD damage may occur with resulting anteroapical infarction 71
  • 72. Investigations enzyme elevations, specifically CKMB correlate poorly with contusion ECG changes: range from non-specific T wave changes to pathological Qs. Multiple VPBs, unexplained sinus tachycardia, AF, BBB (usually R) and ST segment changes are most common ECG findings. Normal ECG at admission makes cardiac contusion unlikely. TOE: +/- cardiac wall motion abnormalities. Exclude lesions that will benefit from revascularization or other cardiac surgery sternal # associated with low incidence of cardiac contusion & arrhythmias 72
  • 73. Management all patients with myocardial contusion should be admitted to ICU for observation and cardiac monitoring (This view is being challenged). Admit patients with arrhythmias or heart failure to level 3 ICU non-urgent surgery should be postponed where possible because of life threatening operative complications. Consider invasive haemodynamic monitoring for patients who have to undergo urgent surgery treat arrhythmias if life-threatening or associated with cardiac failure; treat specific valve abnormalities surgically. treat cardiogenic shock along usual lines with optimization of preload, inotropes IABP. Exclude tamponade 73
  • 74. Prognosis Prognosis resolution of wall motion abnormalities in ~25% only (NB based on only 14 patients Ruptured aorta traumatic aortic injuries are the second most frequent causes of death in patients with chest injuries 74
  • 75. Mechanism and types of injury Deceleration and traction-are the classic wounding mechanisms of the thoracic arteries Horizontal deceleration creates shearing forces at the aortic isthmus, the junction between the relatively mobile aortic arch and the fixed descending aorta. 90-98% of traumatic injuries of the thoracic aorta occur at the isthmus 75
  • 76. Vertical deceleration displaces the heart caudally and into the left pleural cavity and acutely strains the ascending aorta or the innominate artery. Sudden extension of the neck or traction on the shoulder can overstrech the arch vessels and produce tears of the intima, or complete rupture of the arterial wall dissection, thrombosis, pseudoaneurysm or haemorrhage 76
  • 77. Diagnosis circumstances may be only clue: head-on collision at high speed, ejection from a vehicle, fall from great height one characteristic shared by all survivors is that blood that leaks from aorta is in a contained haematoma. Other than initial pressure drop associated with loss of 500-1000 ml of blood, hypotension responds to intravascular infusion. Persistent or recurrent hypotension is usually due to another source of bleeding 77
  • 78. Free rupture does occur but it is usually fatal unless patient is operated on within minutes CXR essential - always suspect ruptured aorta if mediastinum wide especially if associated with any of following: L haemothorax depressed L main bronchus blurred outline of arch or descending aorta (?) # 1st rib or L apical haematoma displacement of mid-oesophagus to R 78
  • 79. other suspicious CXR features: loss of aorticopulmonary window, ant or lat deviation of trachea, loss of paraspinal "stripe", calcium "layering" in aortic arch signs such as apical pleural cap, mediastinal width > 8 cm, 1st & 2nd rib #s no value in indicating major arterial injury further investigations depend on CXR findings: further investigation not indicated if CXR normal if CXR technically unsatisfactory or mediastinal contour equivocally abnormal then perform thoracic CT first to look for mediastinal haemorrhage 79
  • 80. This often also demonstrates aortic pseudoaneurysm if present. If mediastinal haemorrhage is present and aortic pseudoaneurysm is not demonstrated then proceed to aortogram if mediastinal contour on CXR clearly abnormal proceed directly to aortography aortography is gold standard investigation although TOE may supercede it. TOE may miss lesions of distal ascending aorta or of arch vessels typical aortographic finding in patients with an aortic tear is an irregular outpouching of aorta just distal to left subclavian artery. 80
  • 81. Outpouching may be circumferential with appearance of a "sleeve" around aorta or may be localized, with abnormal area present only along medial or lateral aspect of aorta NB there is frequently a convexity or a bulge in region of embryonic ductus arteriosus. This is usually smooth and symmetrical Treatment prompt surgery. Often requires cardiopulmonary by 81
  • 82. Injuries to aortic arch vessels Bleeding from an arch vessel is usually contained, but in rare instances, the avulsion of the origin of an arch artery causes massive bleeding into pericardial or pleural cavity. Acute occlusion of the innominate or subclavian may cause ischaemic symptoms of hand or arm (acute ischaemia of the common carotid may lead to brain ischaemia) Clinical features include cervical or supraclavicular haematomas, bruits, diminished peripheral pulses 82
  • 83. Oesophageal perforation Oesophageal perforation usually due to penetrating injury but occasionally follows blunt trauma +/- retrosternal pain, difficulty in swallowing, haematemesis, cervical emphysema CXR: +/- pneumomediastinum, widened mediastinum, pneumothorax, hydrothorax 83
  • 84. consider diagnosis in any patient: with L pneumothorax or haemothorax without a rib # who has received severe blow to lower sternum or epigastrium and is in pain or shock out of proportion to the apparent injury who has particulate matter appearing in the chest tube drainage after the blood begins to clear definitive investigation: gastrograffin swallow or endoscopy immediate surgical repair with gastrostomy or feeding jejunostomy 84
  • 85. Ruptured diaphragm - usually due to gross abdominal compression causing large radial tears. Penetrating trauma tends to produce small perforations that take some time to develop into diaphragmatic hernias - rupture of L hemidiaphragm more common - deterioration in respiratory status if MAST trousers are inflated - CXR features listed above - 85
  • 86. if rupture of L hemidiaphragm is suspected a NG tube should be inserted. If this appears in thoracic cavity no further investigations are required. Occasionally it is necessary to inject contrast down NG tube to confirm diagnosis - if CT non-diagnostic consider MRI in stable patients - significant risk of gut strangulation with L rupture 75% of patient with ruptured diaphragm have associated intra-abdominal injury - surgery should follow basic resuscitation 86
  • 87. Rib fractures Most common injury Extent of trauma and mortality correlates directly with the number of ribs fractured First three ribs fractured means a large amount of force caused the injury ?recent study challenges this concept Ribs 10, 11, and 12 are associated with blunt injuries involving the spleen, liver, kidneys and diaphragm. Fractures or three or more ribs are commonly associated with pulmonary contusions 87
  • 88. Chylothorax Injury to thoracic Duct Milky discharge from the chest tube Coservative treatment for 2 weeks Thoracotomy and ligation of Duct 88

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