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Chest Trauma By Dr. Samir Abdallah M.D Prof. of Cardio-Thoracic Surgery Cairo University.

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Presentation on theme: "Chest Trauma By Dr. Samir Abdallah M.D Prof. of Cardio-Thoracic Surgery Cairo University."— Presentation transcript:

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2 Chest Trauma By Dr. Samir Abdallah M.D Prof. of Cardio-Thoracic Surgery Cairo University

3 Chest Trauma  The fact that it has become possible in recent decades for millions of people to travel at high speed had led to a phenomenal increase in blunt injury to the chest - a most lethal type of injury. Epidemiology

4  All casualties, and particularly children who have been exposed to blunt chest injury may have sustained highly lethal internal lesions (rupture of the heart, the aorta or the major airway, for example, or contusion of the heart although the external stigmata of chest injury may be quite trivial or even absents altogether.

5  For this reason any causality who has sustained blunt trauma to the chest should be considered seriously injured until proved otherwise.

6 Frequency of Various Injuries In Motor Vehicle Accidents Extremities34% Head and neck 32% Chest25% Abdomen15%

7 Mechanism of Injury in Chest Trauma  Acceleration/deceleration (motor vehicle accident)  Body compression (crush injury)  High-speed impact (gunshot wound)  Miscellaneous Low-velocity penetration (stab wound) Airway obstruction (suffocation) Caustic injury (poisoning) BurnsElectrocution

8 Blunt or Penetration Trauma Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosis Chest wall injury Airway Obstruction PneumothoraxHemorrhage Cardiac injury Pain, Restriction, Retention of Secretions, Atelectasis Flail Chest Hemothorax Hypovolemia Tamponade Myocardial dysfunction Diminished Cardiac Output Hypoventilation Hypoxemia Respiratory AcidosisPulmonaryShunting Tissue Hypoxia Metabolic Acidosis

9 TRAUMA DEATHS EARLY 30%-35% Within Hours (Golden Hour) Thoracic Trauma Liver/Spleen Injuries Multiple Pelvic Fractures Others Optimum Initial Care IMMEDIATE 50% Seconds or Minutes Spinal Cord Injuries Severe Brain Injuries Lesions to Great Vessels Prevention Optimum Prehospital Care LATE 15%-20% 2-3 Weeks Sepsis Multiple Organ Failure Optimum Initial Care (Future?)

10 Percentage of Specific Types of Thoracic Organ Injury Chest wall 54 Flail chest 13 Pneumothorax20 Hemothorax21 Pulmonary21 Miscellaneous18

11  The evaluation of thoracic injuries is only one aspect of the total assessment of severely injured patients.  Both diagnosis and therapy go hand in hand.  The basic principle of elective surgery - “ First investigate and make the diagnosis, then treat the illness ” - is a dangerous illusion. Assessment of patient with Thoracic injury

12 The first step is to make a rough estimate of the status of the circulatory and respiratory systems. This provides the first diagnostic clues and often determines which therapeutic action is to be taken. Specific questions are then posed pertaining to individual injuries or their consequences. Assessment of patient with Thoracic injury

13 Immediately life- threatening; diagnosis and therapy before taking roentgenograms TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries 1. Hypovolemia? 1. Hypovolemia? 2. Respiratory insufficiency? 2. Respiratory insufficiency? 3. Tension pneumothorax? 3. Tension pneumothorax? 4. Cardiac tamponade 4. Cardiac tamponade

14 5. Multiple rib fractures? (Paradoxical respiration?) 6. Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?) 7. Hemothorax? 8. Diaphragmatic rupture? 9. Aortic rupture? 10. Cardiac contusion? TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries

15 Monitoring and evaluating the patient with Thoracic trauma  Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles). Mediastmum (wide or normal) shifted or not. Mediastmum (wide or normal) shifted or not. Lung parenchyma (Contusion). Lung parenchyma (Contusion). The heart (cardiac tamponade). The heart (cardiac tamponade). Diaphragm. Diaphragm. Pneumothorax, hemothorax. Pneumothorax, hemothorax.  ECG  CVP  Arterial blood gases.  Urine output.  Lab. Investigations.  Others.

16  The treatment of polytraumatized patient must follow a certain protocol which includes. Adequate oxygenation. Adequate oxygenation. Fluid replacement. Fluid replacement. Surgical intervention. Surgical intervention. Treatment of septic complications. Treatment of septic complications. Adequate caloric and substrate supplementation. Adequate caloric and substrate supplementation. Prevention of stress bleeding. Prevention of stress bleeding. Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis. Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis. Management of patients with Thoracic Trauma

17 Rib and Sternal Fracture Mechanism of Injury Indirect violence Direct Violence Lung injuries are more common

18 Rib and Sternal fractures  Diagnosis  Patient complains of localized pain that is aggravated by coughing deep breathing “ Localised tenderness. Subcutaneous emphysema  False motion, paradoxical respiration  Rib fractures must be diagnosed clinically many rib fractures are not visible on X-ray chest.

19 Flail Chest

20 Therapy in multiple rib fractures ( not taking companion injuries into consideration ) Stable thoracic wall Unstable thoracic wall Paradoxical respiration 1. Controlling pain  Analgesics (morphine derivatives) every 4h even if there are “no pains”  If necessary, intercostal nerve block  If necessary, epidural anesthesia 2. Intensive breathing exercises Only in cases of respiratory insufficiency  Mechanical ventilation; prophylactic insertion of a chest tube  In exceptional cases, operative stabilization of the thoracic wall

21 Intercostal Blocks (Sites)

22  It is a tried and tested rule that a prophylactic chest tube should be inserted in every patient with multiple rib fractures who is to undergo an operation under general anaesthesia even when there is neither evidence of a hemothorax nor of a pneumothorax.

23 Pneumothorax and Hemothorax  Cases of pneumothorax and hemothorax can be provided with extremely effective therapy for the most part with simple methods, in more than 80% of cases.  It must, however, be given early, furthermore the drainage of air and blood must be efficient.

24 Tension Pneumothorax ( Life Threatening )  Every traumatic pneumothorax can develop into tension pneumothorax, however, this complication is rare with spontaneous breathing.  Very frequently, in a more dangerous form by for, a tension pneumothorax occurs during mechanical ventilation.  Treatment consists of immediate relief of pressure.

25 Open Pneumothorax Diagnosis:  A penetrating thoracic wound with a sucking sound of incoming and outgoing air “ sucking wound ” adds to the clinical and radiological evidence of pneumothorax Therapy:  Immediate air tight closure of the thoracic wound.  Immediate intubation and mechanical ventilation.

26 HemothoraxHemothorax Diagnosis  Diminished breath sound.  Muffled sound on percussion.  X-ray chest: Clouding of the affected half of the thorax up to complete opacity. In the diagnosis of hemothorax formation of atelectosis and rupture of the diaphragm should be differentiated.

27 Sources of blood accumulating in the chest following blunt or penetrating trauma:  Pulmonary parenchymal laceration.  Rupture of pleural adhesions.  Mediastinal injury with or without vascular injury.  Cardiac injury with pericardio-pleural communication.  Decompression of abdominal hemorrhage through a traumatic diaphragmatic injury. HemothoraxHemothorax

28 Therapy  The key to successful management of acute hemothorax is early aggressive care in the form of adequate pleural evacuation by thoracostomy or thoracotomy in order to minimize the morbidity.  The rate and cessation of bleeding depends on the site and size of the bleeding wound. HemothoraxHemothorax

29  Thoracotomy is done if the bleeding is constant and more than 300 ml per hour during the first three to four hours. However, tube thoracotomy is all what is needed if bleeding is less and decreasing without radiological evidence of clotted blood. HemothoraxHemothorax

30 Incision over intercostal space Development of subcutaneous tract Penetration of parietal pleura Insertion of Chest Tube Confirmation that lung is not adherent to chest wall at puncture site

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38 Clinical significant Therapy Lung laceration/ lung rupture Mostly harmless (exception: central lung rupture) Conservative Thoracic drainage in pneumothorax and hemothorax Operation only in exceptional cases because of bleeding or massive air loss Lung Parenchymal Injuries

39 Clinical significant Therapy Intrapulmonary hematoma HarmlessNone Lung Parenchymal Injuries

40 Clinical significant Therapy Traumatic lung pseudocysts Harmless Mostly none Lung Parenchymal Injuries

41 Clinical significant Therapy Simple lung contusion Mostly harmless Can develop into lung contusion with respiratory insufficiency Breathing exercises Careful monitoring of progress Lung Parenchymal Injuries

42 Clinical significant Therapy Lung contusion with respiratory insufficiency Progressive respiratory insufficiency: hypoxia, right-to- left shunt interstitial edema, considerable mortality Intubation and positive end-expiratory pressure ventilation (PEEP) Maintenance of a normal oncotic pressure (fluid infusion limited, human albumin 29%). Steroids Lung Parenchymal Injuries

43 Clinical significant Therapy Blast injury Severest injury Progressive respiratory insufficiency Danger of arterial air embolism Hemothorax, pneumothorax, abdominal injuries (colonl) As in lung contusions with respiratory insufficiency Lung Parenchymal Injuries

44 Abnormalities following bronchial rupture and methods of management Acute respiratory insufficiency Acute Infections Early Bronchial Obstruction Tubes Emergency Repair or Resection Bronchial Rupture Immediate Mediastinitis Empyema Atelectasis

45 Pneumonia Abscess Delayed Pulmonary InfectionLate bronchial obstruction Fibrosis Abnormalities following bronchial rupture and methods of management BronchiectasisPneumonitis Atelectasi s FibrosisAbscess Elective Pulmonary Resection

46 Pathologic courses following esophageal perforation Entry into cervical or mediastinal fascial planes of:Air Gastric juice Bacteria and Saliva MediastinitisEmphysemaPneumothoraxBurn Abscess Empyema SepsisPneumonia Tension Fluid and electrolyte disturbance CV Collapse

47 Essential components of and procedures used in management of esophageal perforation Fluid and ElectrolytesAntibioticsPrevent further contamination Therapy non-operative High-dose IVTopical, Luminal Prox. Tube Gast. Tube Plus Operative Drainage of Mediastinal and/or fascial planes Closure Or Exclusion Or Re-section Only With reconstruction

48 Injuries of the diaphragm Diaphragmatic Rupture:  Incidence: In 3% of all sever thoracic injuries.  Mechanism: Broad surface blow.  Location: Left side in 85% of cases.  Clinical picture. Acute: symptoms of companion injury and shock. Chronic: Intestinal obstruction or strangulation (usually)

49 Diaphragmatic ruptures (Cont.)  Radiological Ex.: Rupture of the diaphragm are frequently overlooked.  Therapy: Is indicated for increasing impairment to respiration.  Operative approach from chest or abdomen.

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51 Traumatic Diaphragmatic Rupture

52 Traumatic Emphysema  Subcutaneous.  Mediastinal Emphysema. “ Present in about 27% of patients with blunt or penetrating chest injury ”

53 Therapy: Despite its impressive appearance the treatment of subcutaneous emphysema it self is mostly unnecessary.  Determite the site of origin.  Treat underlying pneumothorax if present by tube thoracostomy.  Treat tracheobronchial, or oesophageal rupture or tension pneumothorax in cases of mediastinal emphysema.  Rarely, cervical mediastinotomy is needed for mediastinal enphysema. Traumatic Emphysema

54 Non- penetrating wounds of Heart

55 CardiacTamponade

56 Algorithm for the diagnosis and management of penetrating cardiac injuries Precordial/Epigastric Wounds  Hypotension Suspect Cardiac Injury Airway Control Central Venous Lines Volume Expansion Tube Thoracostomy Hemodymanic Instability Hemodymanic Stability Operating Capability In E.R. Yes No Immediate TRT Relief of Tamponade Cardiorrhaphy Pericardiocentesis Intrapericardial Catheter Constinous Aspiration Operating Room Transfer Subxiphoid Pericardial Window Diagnosis Confirmed Operating Room Transfer Definitive Casrdiorrhaphy Control of Other Injuries Closure of Incision

57 Penetrating cardiac injuries (Therapy)

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59 CARDIAC INJURY Repair Postoperative Period AsymptomaticSymptomatic Electrocardiogram Chest X-ray Physical examination NormalAbnormal 2-D Echocardiogram Shunts Fistulae Equivocal intracardiac Defects Foreign Bodies Cardiac Catheterization NormalAbnormalRe-operation Follow-up

60 Other Injury Patterns in Thoracic Trauma I. Traumatic asphyxia:  Due to a severe compression of thorax with sudden increase of pressure in the venous system resulting in a characteristic injury pattern where small hemorrhages in the conjunctiva, the skin and the mucous membranes of the throat and head and reddish-blue discoloration in the latter region. Therapy:  Is for the companion injuries and cerebral oedema if present.

61 II. Injuries of the thoracic duct: (Chylothorax) III. Cholothorax IV. Traumatic induced hernia of the chest wall V. Arterial air embolism VI. Blast injury Other Injury Patterns in Thoracic Trauma

62 Indications for Thoracotomy: Decision to Operate  Excluding minor surgical procedures such as tracheostomy pericardiocentesis, tube thoracostomy, and suture of chest wall lacerations, formal operations are required in only 12 to 15 percent of patients with thoracic trauma.

63 Indications for thoracotomy: ACUTE  Post-traumatic cardiovascular collapse  Pericardial tamponade  Vascular injury to the thoracic outlet  Traumatic thoracotomy  Massive Air leak  Proved tracheobronchial injury  Proved Esophageal injury  Great vessel injury  Continuing Hemothorax  Mediastinal traversing injury  Bullet Embolism  Air Embolism

64 Indications for thoracotomy: CHRONIC  Unevaluated clotted hemothorax  Chronic traumatic Diaphragmic hernia  Chronic cardiac septal or valvular lesions  Chronic false Aneurysms  Chronic non-closing thoracic duct fistula  Infected intrapulmonary hematoma  Missed trachobronchial injury  Traumatic Arterio-venous fistula

65 Suspected if there isAdditional examination required Initial therapeutic measures Tension pneum- Othorax Inflated hemithorax with reduced mobility of thorax None  Immediate thoracic Hypersonorous auscultation Weakened breath sounds Venous congestion in creasing elevation of central venous pressure Open pneumothorax Thoracic wounds with sound of air rushing in and out (“sucking wound”) None  1. Tight bandage +ICT or 2. Intubation mechanical ventilation Cardiac tamponade Location of wound in the precordium or corresponding tract of the bullet or knife None  Pericardioeentesis Operation Initial Assessment of the most important thoracic injuries

66 Suspected if there is Additional examination required Initial therapeutic measures Rib fractures Local tenderness Chest roentgenogram Relief of pain Compression pain Intubation and mechanical ventilation when respiratory insufficiency occurs Possibly crepitation on auscultation Inspection: possibly paradoxical respiration PneumothoraxHyperresonance Chest roentgenogram Thoracic drainage Diminished breath sounds Hemothorax Dullness to percussion Chest roentgenogram Thoracic drainage Subcutaneousemphysema Initial Assessment of the most important thoracic injuries

67 Suspected if there is Additional examination required Initial therapeutic measures Rupture of bronchus Mediastinal emphysema BronchoscopyOperation Pneumothorax or tension peneumothorax No expansion of lung during thoracic drainage Total atelectasis Rupture of esophagus Mediastinal emphysema EsophagographyOperation Initial Assessment of the most important thoracic injuries

68 Suspected if there is Additional examination required Initial therapeutic measures Mediastinal emphysema Characteristic crunching sound above the heart, synchronous with the heart beat (Hamman’s sign) Chest roentgenogram Cervical mediastionotomy only when there is significant venous congestion and no rupture of bronchus or esophagus Central venous pressure Determination of possible cause by means of: BronchoscopyEsophagography Diaphragmatic rupture Percussion: dampened or hypersonorous percussion Roentgenogram of thorax with possible use of nasogastric tube and/or contrast media Operation Initial Assessment of the most important thoracic injuries

69 Suspected if there is Additional examination required Initial therapeutic measures Rupture of aorta Possibly pseudocoarctation syndrome AortographyOperation Possibly compression syndrome in the upper mediastinum Possibly systolic murmur Roentgenorgram: Wide mediastinum Tracheal displacement to the right Displacement of the left bronchus downward Possible left-sided hemothorax Cardiac contusion ECG: Irregularities in repolarization Disturbances in rhythm and conduction Infarct pattern Cardiac enzymes ECG monitoring Drug treatment of rhythm irregularities and of possible cardiac insufficiency Initial Assessment of the most important thoracic injuries

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