Thoracic Trauma

1. Thoracic Trauma Hossam Hassan

2. Thoracic Trauma • Anatomy • Thorax is a hollow cylinder composed of • 12 pairs of ribs,10 articulate posteriorly with the thoracic spine and anteriorly with the sternum via costal cartilages, the lower 2 pairs are floating ribs • A nerve,and artery and a vein are located a long the under side of each rib • Intercostal muscles connect each rib to the one above these muscles with the diaphragm are the primary muscle of ventilation.

4. Anatomy • The pleurae are thin membranes that consist of 2 distinct layers: • The partial pleurae line the inner side of the thoracic cavity • The visceral pleurae cover the outer surface of each lung

5. Anatomy • The lungs occupy the right and the left halves of the thoracic cavity • An area called the mediastinum is located in the middle of the thoracic cavity within the mediastinum lie all the other organs and structures of the chest cavity:the heart,great vessels,trachea,mainstem bronchi and esophagus • Any or all of these structures can be injured by thoracic trauma.

7. General Assessment • The signs and symptoms of chest truma related to the chest wall and lungs are sob,tachypnea and chest pain • The initial 3 points in general assessment is : 1.Observation ex.bruises,lacerations,distended neck veins 2.Palpation ex.tenderness,bony crepitus 3.Auscultation ex.presence ,diminished or absence of breath sounds.

8. Thoracic injuries can be: • Rib Fractures • Flail chest • Pulmonary contusion • Pneumothorax(open and close) • Tension pneumothorx • Hemothorax • Blunt cardiac injuries • Pericardial tamponade • Tracheal and bronchial rupture • Aortic rupture • Diaphragmatic rupture

9. Chest Trauma • History & PE • ATLS protocol • A,B,C,D,E’s

10. AMPLE • A allergies • M Medications (Anticoagulants, insulin and cardiovascular medications especially) • Previous medical/surgical history • L Last meal (Time) • E Events /Environment surrounding the injury; ie. Exactly what happened

11. CXR-fast, easy, least expensive for initial evaluation • Ultrasound-may soon replace CXR as initial radiographic study in chest trauma • CT Scan VS Angiography • EChO VS Transesophogeal Echocardiography

12. FAST

13. Normal CXR

14. Pneumothorax

15. Subcutaneous Emphysema

16. Hemothorax

17. Management of specific injuries. • Rib fracture • Assessment: • Simple rib fracture alone are rarely life threatening in adults • Signs and symptoms of fractured ribs include pain with movement,local tenderness and perhaps bony crepitus

18. Rib fracture • Management • The initial management of patient with simple rib fracture is pain reduction • supplemental oxygen in case hypoxia • Bed rest • Fractured ribs should not be stabilized by taping or using any other firm bandaging such attempt can limit ventilation and lead to atelactasis (collapse of the alveoli or part of the lung)and pneumonia

19. Flail Chest • Flail chest is when 2 or more adjacent ribs are each fractured in at least 2 places • Assessment : • Tenderness • Bony crepitus • Hypoxia might happen then lead to increase in respiratory rate as well.

20. Flail chest • Management: • The key management is BVM (for positive pressure ventilation) • All patient who have an obvious flail segment should supplied with supplemental O% if not respond then will require more aggressive ventilataroy support

21. Pulmonary contusion • A pulmonary contusion is an area of the lung that has been traumatized to the point where intertitial and leveolar bleeding occur • The amount of intertitial fluids increase in the area between the wall of the cappilaries and alveoli resulting in decreased O% transporst across the thickened membranes

22. Pulmonary contusion • Managements • Patient should closely monitored with special attention to fluid administration • Ensuring adequate ventilation and enriched O% administration • In inadequate ventilations or altered LOC or other major injuries BVM and endotracheal intubation if required.

23. Pneumothorax • Simple pneumothorax • Open pneumothorax.

24. Simple pneumothorax • Simple pneumothorax is caused by the presence of air in the pleural space • Assessment: • Pleuratic chest pain • Difficult and rapid breathing • Decreased or absent breath sounds on the involved side are classic signs • Percussion is an excellent indicator

25. Simple pneumothorax • Management: • High concentration of O% should be administrated to patients with pneumothorax • Assisted ventilation might be for those who display signs of hypoxia • Semi sitting position is preferred.

26. Open pneumothorax • Penetrating wounds to the chest can produce open chest wall injuries(open pneumothorax) • Assessment : • Pain at the injured side • SOB • The sings might included sucking out bubbling sound as air moves in and out of the pleural space through the chest wall defected

27. Open pneumothorax • Management • Close the wound in the chest • Closing the wound it could be with a Vaseline gauze by 3 sides taped . • Provide supplemental O% • If signs of increasing respiratory distress are observed the patient may be developing a tension pneumothorax and the dressing should be removed to assess in decompressing the affected side.

28. Tension pneumothorax • It is a life threatening situation • The amount of air trapped in the pleural space continues to increase not only is the lung on the affected side collapsed but the mediastinum is also shifted into the opposite side • The intra thoracic pressure increase which decrease the capillaries blood flow and kinks the vena cava.

29. Tension pneumothorax • Assessment: • The presentation of patient with tension pneumothorax varies according to how much intrathoracic pressure has developed. • Signs and symptoms can be minimal or moderate • Anxiety • Cyanosis • Tachypnea • Diminished or absent breath sound on the injured side • JVD (jugular vein distension)note in case hypovolemic this sign might not present.

30. Tension pneumothorax • Management: • The management of the patient with a tension pneumothorax involves reducing the pressure in the pleural space • Needle decompression in the field can be done by the expert people then • Chest tube .

32. Hemothorax • Blood in the pleural space constitutes a hemothorax • In adult the pleural space on each side of the thorax can hold 2500 to 3000 ml of blood

33. Hemothorax • Assessment: • The symptoms are related to the blood loss • Signs: • Sob • Tachypnea • Decreased breath sound • Clinical signs of shock • Management: transfer to surgical repair.

34. Myocardial Contusion • Occurs in 76% of patients with severe blunt chest trauma • –Right Atrium and Ventricle is commonly injured • –Injury may reduce strength of cardiac contractions Reduced cardiac output

35. Electrical Disturbances due to irritability of damaged myocardial cells • –Progressive Problems • Hematoma • Hemoperitoneum • Myocardial necrosis • Dysrhythmias • CHF & or Cardiogenic shock

36. Myocardial Contusion Signs & Symptoms • Bruising of chest wall • 􀂄Tachycardia and/or irregular rhythm • 􀂄Retrosternal pain similar to MI • 􀂄Associated injuries Rib/ Sternal fractures

37. Chest pain unrelieved by oxygen May be relieved with rest • THIS IS TRAUMA-RELATED PAIN Similar signs and symptoms of medical chest pain

38. Blunt Cardiac Injury • EKG (for any blunt chest injury, persistent tachycardia, ST-T changes or ectopy) • 􀂄Cardiac enzymes (CPK, CK-MB and Troponin I) • 􀂄Echocardiography (TEE)

39. Pericardial Tamponade • Restriction to cardiac filling caused by blood or other fluid within the pericardium • –Occurs in <2% of all serious chest trauma However, very high mortality

40. –Results from tear in the coronary artery or penetration of myocardium • Blood seeps into pericardium and is unable to escape • 200 ml of blood can restrict effectiveness of cardiac contraction

41. Pericardial Tamponade Signs & Symptoms • Dyspnea • Possible cyanosis • Beck’s Triad • JVD • Distant heart tones • Hypotension or narrowing pulse pressure • Weak, thready pulse • Shock

42. Kussmaul’s sign Decrease or absence of JVD during inspiration • Pulsus Paradoxus Drop in SBP >10 during inspiration • Electrical Alterans P, QRS, & T amplitude changes in every other cardiac cycle • PEA

43. Traumatic Aortic injury • Aorta most commonly injured in severe blunt 85-95% mortality • Injury may be confined to areas of aorta attachment • Signs & Symptoms • Rapid and deterioration of vitals • Pulse deficit between right and left upper or lower extremities

44. Traumatic Esophageal Rupture • Rare complication of blunt thoracic trauma • –30% mortality • –Contents in esophagus/stomach may move into mediastinum • Serious infection occurs • Chemical irritation • Damage to mediastinal structures • Air enters mediastinum • –

45. Subcutaneous emphysema and penetrating trauma present

46. Tracheo-bronchial Injury • Blunt trauma • Penetrating trauma • 50% of patients with injury die within 1 hr of injury • Disruption can occur anywhere in tracheobronchial tree • –

47. Signs & Symptoms • Dyspnea • Cyanosis • Hemoptysis • Massive subcutaneous emphysema • Suspect/ evaluate for other closed chest trauma

48. Treatment summary • Observe • Palpate • Auscultation • Management always included to provide supplemental O% then aggressive method if required. • ATLS protocol: A,B,C,D,E’s

49. Treatment summary • Emergency management • Needle thoracentesis • Tube thoracostomy • Subxiphoid pericardotomy • Video assisted thoracic surgery (VATS)

50. THANK YOU