2Prof. of Cardio-Thoracic Surgery Chest TraumaByDr. Samir Abdallah M.DProf. of Cardio-Thoracic SurgeryCairo University
3Chest Trauma Epidemiology 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.
4All 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.
5For this reason any causality who has sustained blunt trauma to the chest should be considered seriously injured until proved otherwise.
6Frequency of Various Injuries In Motor Vehicle Accidents Extremities34%Head and neck32%Chest25%Abdomen15%
8Blunt or Penetration Trauma Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosisBlunt or Penetration TraumaChest wall injuryAirway ObstructionPneumothoraxHemorrhageCardiac injuryPain, Restriction,Retention of Secretions, AtelectasisFlail ChestHemothoraxHypovolemiaTamponadeMyocardial dysfunctionDiminishedCardiac OutputHypoventilationHypoxemiaRespiratory AcidosisPulmonaryShuntingTissue HypoxiaMetabolic Acidosis
9Multiple Organ Failure TRAUMA DEATHSIMMEDIATE50%Seconds or MinutesSpinal Cord InjuriesSevere Brain InjuriesLesions to Great VesselsPreventionOptimum Prehospital CareEARLY30%-35%Within Hours (Golden Hour)Thoracic TraumaLiver/Spleen InjuriesMultiple Pelvic Fractures OthersOptimum Initial CareLATE15%-20%2-3 WeeksSepsisMultiple Organ FailureOptimum Initial Care(Future?)
10Percentage of Specific Types of Thoracic Organ Injury Chest wall54Flail chest13Pneumothorax20Hemothorax21PulmonaryMiscellaneous18
11Assessment of patient with Thoracic injury 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.
12Assessment of patient with Thoracic injury 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.
13threatening; diagnosis and therapy before taking TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries 1. Hypovolemia? 2. Respiratory insufficiency? 3. Tension pneumothorax? 4. Cardiac tamponadeImmediately life-threatening; diagnosisand therapy before takingroentgenograms
14TEN QUESTIONS to be asked in the initial assessment of severe blunt thoracic injuries Multiple rib fractures? (Paradoxical respiration?)Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?)Hemothorax?Diaphragmatic rupture?Aortic rupture?Cardiac contusion?
15Monitoring 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.Lung parenchyma (Contusion).The heart (cardiac tamponade).Diaphragm.Pneumothorax, hemothorax.ECGCVPArterial blood gases.Urine output.Lab. Investigations.Others.
16Management of patients with Thoracic Trauma The treatment of polytraumatized patient must follow a certain protocol which includes.Adequate oxygenation.Fluid replacement.Surgical intervention.Treatment of septic complications.Adequate caloric and substrate supplementation.Prevention of stress bleeding.Finally, be alert of possible complication (CNS, ARDS, hepatic, renal, coagulation disorders, sepsis.
17Rib and Sternal Fracture Mechanism of Injury Lung injuries aremore commonIndirectviolenceDirectViolence
18Rib and Sternal fractures DiagnosisPatient complains of localized pain that is aggravated by coughing deep breathing “Localised tenderness.Subcutaneous emphysemaFalse motion, paradoxical respirationRib fractures must be diagnosed clinically many rib fractures are not visible on X-ray chest.
20Therapy in multiple rib fractures (not taking companion injuries into consideration) Stable thoracic wallUnstable thoracic wallParadoxical respiration1. Controlling painAnalgesics (morphine derivatives) every 4h even if there are “no pains”If necessary, intercostal nerve blockIf necessary, epidural anesthesia2. Intensive breathing exercisesOnly in cases of respiratory insufficiencyMechanical ventilation; prophylactic insertion of a chest tubeIn exceptional cases, operative stabilization of the thoracic wall
22It 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.
23Pneumothorax 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.
24Tension 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.
25Open 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 pneumothoraxTherapy:Immediate air tight closure of the thoracic wound.Immediate intubation and mechanical ventilation.
26Hemothorax 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.
27HemothoraxSources 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.
28HemothoraxTherapyThe 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.
29HemothoraxThoracotomy 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.
30Insertion of Chest Tube Development ofsubcutaneous tractConfirmation that lung is not adherent to chest wall at puncture siteIncision overintercostal spacePenetration ofparietal pleura
38Lung Parenchymal Injuries Clinical significantTherapyLung laceration/lung ruptureMostly harmless (exception: central lung rupture)ConservativeThoracic drainage in pneumothorax and hemothoraxOperation only in exceptional cases because of bleeding or massive air loss
41Lung Parenchymal Injuries Clinical significantTherapySimple lung contusionMostly harmlessCan develop into lung contusion with respiratory insufficiencyBreathing exercisesCareful monitoring of progress
42Lung Parenchymal Injuries Clinical significantTherapyLung contusion with respiratory insufficiencyProgressive respiratory insufficiency: hypoxia, right-to-left shunt interstitial edema, considerable mortalityIntubation and positive end-expiratory pressure ventilation (PEEP)Maintenance of a normal oncotic pressure (fluid infusion limited, human albumin 29%).Steroids
43Lung Parenchymal Injuries Clinical significantTherapyBlast injurySeverest injuryProgressive respiratory insufficiencyDanger of arterial air embolismHemothorax, pneumothorax, abdominal injuries (colonl)As in lung contusions with respiratory insufficiency
44Abnormalities following bronchial rupture and methods of management ImmediateAcute respiratoryinsufficiencyAcuteInfectionsEarly BronchialObstructionMediastinitisEmpyemaAtelectasisTubesEmergency Repair or Resection
45Abnormalities following bronchial rupture and methods of management DelayedPulmonary InfectionLate bronchial obstructionPneumonia AbscessBronchiectasisPneumonitisAtelectasisFibrosisAbscessElective Pulmonary ResectionFibrosis
46Pathologic courses following esophageal perforation Entry into cervical ormediastinal fascial planes of:AirGastric juiceBacteria and SalivaMediastinitisEmphysemaPneumothoraxBurnAbscessEmpyemaSepsisPneumoniaTensionFluid and electrolyte disturbanceCV Collapse
47Therapy non-operative Essential components of and procedures used in management of esophageal perforationTherapy non-operativeFluid and ElectrolytesAntibioticsPrevent further contaminationHigh-dose IVTopical, LuminalGast. TubePlus OperativeProx. TubeClosureOrExclusionRe-sectionDrainage of Mediastinal and/or fascial planesOnlyWith reconstruction
48Injuries 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)
49Diaphragmatic 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.
52Traumatic Emphysema Subcutaneous. Mediastinal Emphysema. “Present in about 27% of patients with blunt or penetrating chest injury”
53Traumatic Emphysema 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.
56Algorithm for the diagnosis and management of penetrating cardiac injuries Precordial/Epigastric WoundsHypotensionSuspect Cardiac InjuryAirway Control Central Venous LinesVolume Expansion Tube ThoracostomyHemodymanic InstabilityHemodymanic StabilityOperating Capability In E.R.YesNoImmediate TRT Relief ofTamponade CardiorrhaphyPericardiocentesis IntrapericardialCatheter Constinous AspirationOperating Room TransferSubxiphoid Pericardial WindowDiagnosis ConfirmedOperating Room Transfer Definitive CasrdiorrhaphyControl of Other Injuries Closure of Incision
60Other 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.
61Other Injury Patterns in Thoracic Trauma II. Injuries of the thoracic duct: (Chylothorax)III. CholothoraxIV. Traumatic induced hernia of the chest wallV. Arterial air embolismVI. Blast injury
62Indications 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.
63Indications for thoracotomy: ACUTE Post-traumatic cardiovascular collapsePericardial tamponadeVascular injury to the thoracic outletTraumatic thoracotomyMassive Air leakProved tracheobronchial injuryProved Esophageal injuryGreat vessel injuryContinuing HemothoraxMediastinal traversing injuryBullet EmbolismAir Embolism
65Initial Assessment of the most important thoracic injuries Suspected if there isAdditional examinationrequiredInitial therapeuticmeasuresTension pneum-OthoraxInflated hemithorax with reducedmobility of thoraxNone Immediate thoracicHypersonorous auscultationWeakened breath soundsVenous congestion in creasingelevation of central venous pressureOpen pneumothoraxThoracic wounds with sound of airrushing in and out (“sucking wound”)1. Tight bandage +ICT or2. Intubation mechanical ventilationCardiac tamponadeLocation of wound in the precordiumor corresponding tract of the bullet or knifePericardioeentesis Operation
66Initial Assessment of the most important thoracic injuries Suspected if there isAdditional examinationrequiredInitial therapeuticmeasuresRib fracturesLocal tendernessChest roentgenogramRelief of painCompression painIntubation and mechanicalventilation when respiratoryinsufficiency occursPossibly crepitation on auscultationInspection: possiblyparadoxical respirationPneumothoraxHyperresonanceThoracic drainageDiminished breath soundsHemothoraxDullness to percussionSubcutaneousemphysema
67Initial Assessment of the most important thoracic injuries Suspected if there isAdditional examinationrequiredInitial therapeuticmeasuresRupture of bronchusMediastinal emphysemaBronchoscopyOperationPneumothorax or tension peneumothoraxNo expansion of lung during thoracic drainageTotal atelectasisRupture of esophagusEsophagography
68Initial Assessment of the most important thoracic injuries Suspected if there isAdditional examinationrequiredInitial therapeuticmeasuresMediastinal emphysemaCharacteristic crunching sound above the heart, synchronous with the heart beat (Hamman’s sign)Chest roentgenogramCervical mediastionotomy only when there is significant venous congestion and no rupture of bronchus or esophagusCentral venous pressureDetermination of possible cause by means of:BronchoscopyEsophagographyDiaphragmatic rupturePercussion: dampened or hypersonorous percussionRoentgenogram of thorax with possible use of nasogastric tube and/or contrast mediaOperation
69Initial Assessment of the most important thoracic injuries Suspected if there isAdditional examinationrequiredInitial therapeuticmeasuresRupture of aortaPossibly pseudocoarctation syndromeAortographyOperationPossibly compression syndrome in the upper mediastinumPossibly systolic murmurRoentgenorgram:Wide mediastinumTracheal displacement to the rightDisplacement of the left bronchus downwardPossible left-sided hemothoraxCardiac contusionECG:Irregularities in repolarizationDisturbances in rhythm and conductionInfarct patternCardiac enzymesECG monitoringDrug treatment of rhythm irregularities and of possible cardiac insufficiency