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Thoracic Trauma

Thoracic Trauma. Prof. Adel Ayed. BLUNT CHEST TRAUMA. CAUSES : 60 % RTA 40 % Industrial accidents – 15 % Domestic accidents - 10 % Sports - 10 % Inter personal conflict- 8 % . BLUNT CHEST TRAUMA.

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Thoracic Trauma

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  1. Thoracic Trauma Prof. Adel Ayed

  2. BLUNT CHEST TRAUMA CAUSES : • 60 % RTA • 40 % Industrial accidents – 15 % Domestic accidents - 10 % Sports - 10 % Inter personal conflict- 8 %

  3. BLUNT CHEST TRAUMA • 35 % - Chest wall damage • 10-15 % - Visceral lesions without chest wall damage • 70 % - Multiple injuries • Long bone fractures – 46 % • Skull fracture with contusion - 42% • Abdominal injuries - 32% • AVERAGE MORTALITY – 18-20%

  4. BLUNT CHEST TRAUMA • Haemothorax - 35 % • Pneumothorax - 25 % • Blunt cardiac trauma – 15% • Diaphragmatic/Aortic - 5% • Surgical intervention -<18%

  5. BLUNT CHEST TRAUMA Pulmonary function is affected by ; • Altered mechanics of breathing • V/P MISMATCHING • Impairment of gas transfer

  6. FRACTURE RIBS • Isolated in 6 % of cases • 30-40% - Pulmonary complications • Management : Pain control, Pul.toiletting Special situations : • FLAIL CHEST. • First rib fracture - Denotes significant force,associated injuries to be ruled out

  7. FLAIL CHEST Definition • Seen in 25% of cases of blunt chest trauma • Mortality - Average –27% • Pulmonary complications up to 50%

  8. FLAIL CHEST-MANAGEMENT • Pulmonary toileting • Pain relief • Mechanical ventilation • Old time treatment

  9. STERNAL FRACTURE • MVA and Direct blows • Localised commonly to midbody • Manubrio-sternal dislocation • Lateral (or) Sternal view • Myocardial injury – 2-6%

  10. Traumatic pneumothorax a.penetrating (stab wound, gunshot) b.blunt (blow from a motor vehicle accident). c.certain medical procedures. • Tension pneumothorax is caused when excessive pressure builds up around the lung, forcing it to collapse. The excessive pressure can also prevent the heart from pumping blood effectively, leading to shock.

  11. Tension pneumothorax • Tx: emergency needle aspiration (2nd intercostal space midclavicular line, then chest tube)

  12. Management • Small pneumothorax ( <20% in size): spontaneously resolve within weeks • Large ones w N lungs: simple aspiration w needle

  13. HAEMOTHORAX Significant : • Distress to the patient • Larger than 2 cms along side the parietal pleura • Occupies at least 1/3 of the expected thoracic cavity. • Management.

  14. HAEMOTHORAX Indication for thoracotomy- • 1500mL within the first hour after chest tube if the injury took place ½ hr beforehand. • Significant further bleed>200ml/hr for three hours.

  15. Chest tube 1.Drainage of hemothorax 2.Drainage of pneumothorax 3.Flail chest segment requiring ventilator support, severe pulmonary contusion with effusion 4. Drainage of chylothorax 5. Drainage of pleural effusion 6. Post-thoracic surgery procedures

  16. Materials 1. Chest tube 2. Chest tube suction unit (PleurevacR or SaharaR), tubing, wall suction hookup 3. Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors 4. Packet of 0 or 1.0 silk suture on a curved needle 5. Gauze 6. 2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration 7. Sterile prep solution; mask, gown and gloves

  17. Preprocedure patient education 1. Obtain informed consent 2.Inform the patient of the possibility of major complications and their treatment 3.Explain the major steps of the procedure, and necessity for repeated chest radiographs

  18. Procedure 1.Examine the patient and assess need for placement of a thoracostomy tube. Obtain pre-procedure chest Xray. Make sure no previous scars 2.Select site for insertion: mid-axillary line, between 4th and 5th ribs…this is usually on a line lateral to the nipple 3.Prep and drape area of insertion. Have patient place ipsilateral arm over head to “open up” ribs 4. Widely anesthetize area of insertion with the 2% lidocaine. Infiltrate skin, muscle tissues, and right down to pleura

  19. Chest tube insertion -After infiltrating insertion site with local anesthetic, make a 3-4 cm incision through skin and subcutaneous tissues between the 4th and 5th ribs, parallel to the rib margins (Figure 1) Figure 1: Incising the chest wall

  20. Chest tube insertion cont -Continue incision through the intercostal muscles, and right down to the pleura -Insert Kelly clamp through the pleura and open the jaws widely, again parallel to the direction of the ribs (this “creates” a pneumothorax, and allows the lung to fall away from the chest wall somewhat, See Figure 2) Figure 2: Opening the incision with a Kelly clamp

  21. Chest tube insertion cont -Insert finger through your incision and into the thoracic cavity. Make sure you are feeling lung (or empty space) and not liver or spleen -Grasp end of chest tube with the Kelly forcep (convex angle towards ribs), and insert chest tube through the hole you have made in the pleura. After tube has entered thoracic cavity, remove Kelly, and manually advance the tube in (Figure 3). Figure 3: Using a Kelly clamp to guide insertion of the chest tube

  22. Chest tube insertion cont • If the tube is of the trocar variety, grasp tube with one hand close to the sharp trocar end and guide the tube slowly and gently through the hole in the pleura into the chest cavity (Figure 4). • Remove trocar once tube has just entered the cavity, and feed tube in approximately 1/2 to 2/3 of its length, until all the fenestrations of the tube are within the chest Figure 4: Inserting a trocar chest tube

  23. Chest tube insertion cont -Clamp outer tube end with Kelly -Suture and tape tube in place -Attach tube to suction unit -Obtain post procedure chest Xray for placement; tube may need to be advanced or withdrawn slightly

  24. Complications, Prevention, and Management 1.Puncture of liver or spleen. This is entirely preventable; insertion site is in the nipple line, between 4th and 5th ribs! 2. Bleeding; this usually ceases 3Cardiac puncture. Again preventable, carefully control the tube going in, and remove the trocar early! 4 Passage of tube along chest wall instead of into chest cavity. In this case, widen and deepen the dissection between the ribs, and make sure the insertion of the tube follows this path 5. Surgical emphysema

  25. Lung contusion • bruise of the lung. • Aetiology : 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

  26. CXR • undestimates degree of contusion. • early changes suggest more severe contusion. • Early pulmonary contusion infiltrates are due to alveolar haemorrhage classically see nonsegmental pulmonary infiltrates-progress in first 12-24 hours of injury.

  27. CT • more sensitive and better for assessing severity • irregular nodular densities that are discrete or confluent • homogeneous consolidation • diffuse patchy pattern

  28. CHEST TRAUMA-PENETRATING Severity depends upon • Type of weapon • Site of entry • Direction of missile (or) stab • Neck-All wounds that penetrate the platysma-Potential visceral injury

  29. PENETRATING TRAUMA Management of open wounds • Occlusive dressing • Intercostal drainage • Intubation & Ventilation for massive injuries

  30. PENETRATING LUNG TRAUMA Indications for surgery : • Massive haemorrhage • Uncontrollable air leak • Haemoptysis • Unstable foreign bodies – Symptomatic • Hilar injuries • Thoracotomy in 12% of cases; 2%-required segmental (or)lobar resections

  31. Immediate Respiratory distress Strangulation Pericardial sac Pancreatic herniation Late Chest pain Epigastric distress Breathlessness S/S of small or large bowel obstruction Thoracic splenosis Diphragmatic injuries – S/S

  32. Pericardial effusion and Tamponade • Pericardial effusion is accumulation of fluid in the pericardial • The fluid may be blood (trauma, ruptured ventricular aneurysm) or inflammatory exudate ( any pericarditis) • Pericardial tamponade is a medical emergency and occurs when a large amount of pericardial fluid (which has often accumulated rapidly) restrict diastolic ventricular filling and causes reduction in cardiac output.

  33. Symptoms and signs • Tachycardia • Hypotension • ↓heart sounds • ↑ JVP w systolic descent • Kussmaull’s sign: elevated JVP which paradoxically rises w inspiration • Pulsusparadoxus: a fall in blood pressure more than 10 mmhg on inspiration. This is due to ↑ venous return to the heart during inspiration ↑ RV vol occupy more space within rigid pericardium  impair ventricular filling

  34. Investigation • CXR: large globular heart • ECG: low voltage complexes • Echo (diagnostic):echo free space around the heart

  35. Echo: pericardial effusion

  36. Management of Tamponade • emergency pericardiocenteseis • Pericardial fluid is drained percutaneously by introducing a wide-pore needle into the pericardial sac ( under xyphoid process) • Samples are sent for bacteriological & cytological examination unless the cause is clearly traumatic

  37. Cont. Management of Tamponade • Persistence or recurrence surgery • Surgery: the pericardium is opened via a left anterior thoracotomy, excision of pericardial segment may be necessary. • A drain is inserted. • If the cause is traumatic, a coexistent laceration of the heart may require suture

  38. THORACIC VASCULAR TRAUMA Involvement : • 60 % Rupture - Isthmus • 20 % - Asc.aorta(or) Arch • 20 % - Distal thoracic + th.vertebra • 12-16% - multiple tears

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