Management of chest trauma

1. Management of chest trauma By Dr ABHIJITH

2. Etiology of chest trauma Blunt force trauma • M.V.A • Fall • Assault Penetrating injury • Shooting • Stabbing • Iatrogenic

3. Initial management ATLS

5. Component of chest trauma • RIB fracture • Flail chest • Pneumothorax • Haemothorax • Lung: laceration • Esophageal & Tracheobronchial • Cardiac: contusion, rupture • Aortic :rupture

6. Chest wall injury [simple] • Rib fracture most common • Serious in elderly& chronic lung D/S • Management • Analgesic • Physiotherapy & early ambulation

7. Serious chest injury High energy transfer Associated with major vascular ,thoracic & cranial injury Management: Pulmonary toilet Surgical interference …displaced fragment. Ist & IInd RIB FRACTURE

8. Flail chest • Definition: 3 or more consecutive rib facture in 2 or more place producing free Floating/unstable segment. • Classification: Anterior flail chest Lateral type

10. Management • General: • Analgesic • Splinting • Intubation's / ventilation • Specific: • Pericostal suturing • External/internalfixation • Thoracotomy

11. Complications: • 22% disability rate with 63% having long term problems • Persistent chest wall pain • Deformity • Dyspnoea on exertion

12. M.V.A Upper & middle 3rd Clinical feature :- Local tenderness Echymosis Swelling Crepitus Sternal fracture

13. X ray & Echo Uncomplicated Analgesic Bed rest Complicated Open reduction & internal fixation Management

14. Pneumothorax • Definition: Air trapped within pleural cavity following injury to chest , lung or airway.

15. Clinical presentation • Tachyponea • Hypotension • Respiratory distress • Breath sound decreased

16. Management • X-ray • Tube Thoracostomy • Chest decompression with wide bore needle inserted in llnd I.C.S.

17. Indications: • Spontaneous /traumatic pneumothorax • Haemothorax • Recurring pneumothorax after removal of chest tube • Prophylaxis pre-operatively in flail chest

18. Complications: • Haemorrhage from IC vessel injury • Subcutaneous emphysema • Injury due to malpositioned tube • Local infection • Pain • Re expansion pulmonary oedema after prolonged collapse & rapid reinflation • Inadequate drainage of pleural space due to clots & plugging or kinking of the tube

19. Open pneumothorax [sucking chest] • Defect in chest wall following trauma. • Air enter from out side. • Intrathoracic pressure raised with mediastinal shift . • Management: Chest tube with occlusive dressing

20. Tension pneumothorax • Leaking of air from an underlying pulmonary parenchyma. • Management; Needle thoracostomy[14- 16guage inserted through llnd I.C.S] • Tube thoracostomy

21. Heamothorax • Definition ;collection of blood in pleural cavity .varies from minor to massive based on vessel injured . • Management: • Chest tube thoracostomy{>28F}. • Thoracotomy.

22. Thoracotomy • Indications: • 1000 ml drained at insertion of chest drain • Bleeding>100 / 15min • >200ml/hr for 3-4 hr • Cardiac tamponade • Major bronchus ,oesophageal ,diaphragm injury

23. Lung contusion • Laceration following penetrating or blunt trauma.

24. Uncomplicated Antibiotic Lasix Dexamethasone Bronchodilator Suction drainage Physiotherapy Complicated Thoracotomy Pneumonectomy[high mortality >50%] Management

25. Rare High mortality Pathophysiology:- Direct compression of airway with closed glottis or injury producing partial or complete avulsion Injury to Major Airway

26. Management • Adequate air supply • Endotracheal intubation • Tracheostomy • Bronchoscopy for definitive diagnosis • Definitive measure ;restoration of airway with end to end anastomosis. Defect >3cm proximal and distal mobilization required.

27. Diaphragmatic injury • Rare • Clinically left side commonly identified • Autopsy & CT show equal incidence • Incidental diagnosis • X-ray • Diaphragmatic distruption • Ipsilateral hemidiaphragm elevation • Abdomen visceral herniation

28. Management • Laparotomy :Using continuous or interrupted braided suture • Thoracotomy :Postrolateral injury

29. Rare Cause: Clinical feature:- Sudden increase in luminal pressure. Chest pain Pneumothorax Intraabdominal free air Systemic sepsis Esophageal injury

30. Management • Fluid resuscitation • I.V broad spectrum antibiotic • multiple chest tube drainage • Surgical • Within 24hr debridement and primary closure • After 24hr primary closure with autologus tissue transplantation. • Poor general condition & advanced mediastinitis • Esophageal exclusion & diversion • Cervical esophagotomy

31. 15-16%chest trauma show cardiac involvement. Associated with sternal injury. Diagnosis 12 lead E.C.G Echocardiogarphy Enzyme elevation Cardiac injury/ myocardial contusion

32. Management Constant monitoring for 48hr Resuscitation Antiarrhythmic

33. High mortality RT atrium & ventricle Chest pain to collapse Sign: Muffled heart sound Jugular venous distension Hypotension Cardiac rupture

34. Management • Cardioraphy with or without cardiopulmonary bypass. • Counter pulsation using balloon pump.

35. Causes:- Stabbing Shooting Iatrogenic Diagnosis: Feature: Hypotension Tachycardia High C.V.P Pulsus paradoxus E.C.G Echocardiography Penetrating heart injury

36. Management • Left anterior Thoracotomy • Aspiration & repair with buttressed suture

37. Mechanism:- Diagnosis shearing force Direct luminal pressure against point of traction. X-ray : widening of mediastinum with shadow CT Aortic Transection

39. Thoracotomy:- Via left 4th I.C.S Direct suture with or without interposition graft. Management

40. Summary: Chest Trauma • Common • Serious • Primary goal is to provide oxygen to vital organs • Remember AirwayBreathing Circulation • Be alert to change in clinical condition

41. Thank u!