Comprehensive Guide to Chest Injuries by Dr. Karen D'Sa

1. CHEST INJURIES DR. KAREN D’SA

2. Introduction • Anatomy • Mechanism of Injury: Blunt trauma • Penetrating injury • Classification • Pathophysiology • General Assessment :A,B,C • Investigation • Treatment : deadly dozen , detected later

3. Introduction • 70% of trauma deaths - thoracic injuries • 2/3rds are alive when they reach the ER • Mostly patient presents with blunt trauma to chest wall • Only 15% require surgery

4. ANATOMY • 12 pairs of ribs • Pleural cavity - 3 litres each side • Contents : lungs, heart, aorta, SVC and IVC, trachea and major bronchi, esophagus • Intercostal neurovascular bundle - inferior border of rib

5. Intrathoracic abdomen

6. Mechanism of injury • Blunt – high velocity, low velocity, crush • Penetrating – a. sharp b. shotgun

7. High velocity impact injuries • Sudden deceleration • “Chest wall is intact” • “Bell Clanger effect” • Anterior chest wall contusion –myocardial injury

8. Low velocity impact injuries • “Direct damage to bony thorax” • No stress or compression forces to damage aorta or diaphragm

9. Penetrating chest wounds • Simple to deal with • “Sucking wound”

10. Pathophysiology “TISSUE HYPOXIA” • Hypercarbia and metabolic acidosis. • Causes of hypoxia: 1. Airway obstruction 2. Blood loss 3. Lung parenchymal injury 4. Tension pneumothorax 5. Severe myocardial injury

11. Assessment of patient with chest trauma injury

12. Assessment Symptoms: Shortness of breath Pain Respiratory distress Signs: • Tachypnoea Shock • Hemoptysis Cyanosis • Chest wall contusion Flail chest

13. Open wounds • Distended neck veins - SVC obstruction • Tracheal deviation • Emphysema • Bony crepitus • Breath sounds • Dullness, hyperresonance on percussion

14. Investigations • Usually AP, often supine, frequently in poor inspiration. • So, a challenge to interpret.

15. Deadly dozen 1.Airway obstruction 2. Tension Pneumothorax 3. Open Pneumothorax 4. Flail Chest 5. Massive Hemothorax 6. Cardiac Tamponade

16. Detected later 7. Aortic rupture 8. Pulmonary contusion 9. Tracheal / bronchial tree injury 10. Myocardial contusion 11. Diaphragmatic injuries 12. Esophageal injuries

17. 1. Airway obstruction • Fracture/ post. dislocation at sternoclavicular joint • Rx : intubation, closed reduction

18. Sterno-clavicular dislocation: CT

19. 2. Tension Pneumothorax Each time we inhale, the lung collapses further. There is no place for the air to escape..

20. “One way valve” • Mechanism of injury : air enters but does not exit • Causes : • Intubated pts - positive pressure ventilation – most common cause. • Decreased lung compliance (difficulty in • squeezing the bag valve device) in the intubated patient

21. Signs of Tension pneumothorax

22. InvestiGATION • X-RAY FINDINGS • Collapse of lung • Shift of mediastinum • Depression of ipsilateral diaphragm

23. TREATMENT Insertion of chest tube connected to water seal drain

25. Chest tube • Chest tube – 5 th ICS anterior to midaxillary line at upper border 6th rib directed posteriorly and superiorly. • 2 cm transverse horizontal incision at top of 6th rib, puncture the pleura with tip of clamp and put a gloved finger into incision to avoid injury to other organs and to clear any adhesions/clots. • Clamp proximal end of tube and advance through desired length. Look for fogging with expiration or listen for air movement.

26. Indications for emergency room thoracotomy • Acute pericardial tamponade unresponsive to cardiac massage • Exsanguinating intra-thoracic haemorrhage • Intra-abdominal haemorrhage requiring aortic cross clamping • Need for internal cardiac massage

27. Indications for urgent thoracotomy • Chest drainage >1500 ml or >200 ml per hour • Large unevacuated clotted haemothorax • Developing cardiac tamponade • Chest wall defect • Massive air leak despite adequate drainage • Proven great vessel injury on angiography • Proven oesophageal injury • Proven diaphragmatic laceration • Traumatic septal or valvular injury of the heart

28. 3. Open Pneumothorax

29. Open Pneumothorax Inhale

30. Open Pneumothorax Exhale

31. Open Pneumothorax Inhale

32. Open Pneumothorax Exhale

33. Open Pneumothoarx Inhale

34. Open Pnuemothorax Inhale

35. Mechanism of injury • Caused by penetrating injury • “Sucking chest wound” • Signs and symptoms are proportional to the size of defect; when defect > 2/3 diameter of trachea/glottis • Red Bubbles on Exhalation from wound

36. Investigations x-ray • Supine AP view has limited sensitivity: 50% • Visceral pleural line • Deep sulcus sign • Can see vessels • Subpulmonic air sign • Sharp heart border/hemidiaphragm sign • Increased lucency over lower chest

37. Visceral pleural line

38. Deep sulcus sign

39. vessels visible

40. Subpulmonic sign

41. Management • Needle decompression– II ICS in MCL line – hissing sound of air exit confirms • Chest tube – into fifth ICS anterior to midaxillary line at upper border 6th rib directed posteriorly and superiorly.

42. Needle Decompression

43. Flutter Valve • Asherman Chest Seal

44. Occlusive Dressing

45. 4. Flail Chest • The breaking of 2 or more ribs in 2 or more places

46. 2 or > ribs segmental #. • Paradoxical respiration • Pendulum movement • Mediastinal flutter – shock • ABG shows respiratory failure with hypoxia

47. Paradoxical respiration

48. SIGNS AND SYMPTOMS

49. INVESTIGATIONS - XRAY

50. Management • Intubate (majority) • Pneumothorax is commonly associated and requires decompression. • Avoid volume overload with I.V fluids. • Use Gloved hand as splint till bulky dressing can be put on patient