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CHEST TRAUMA CDR JOHN P WEI, USN MC MD 4 th Medical Battallion, 4 th MLG BSRF-12.

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Presentation on theme: "CHEST TRAUMA CDR JOHN P WEI, USN MC MD 4 th Medical Battallion, 4 th MLG BSRF-12."— Presentation transcript:

1 CHEST TRAUMA CDR JOHN P WEI, USN MC MD 4 th Medical Battallion, 4 th MLG BSRF-12

2 CHEST TRAUMA Blunt versus penetrating trauma Blunt versus penetrating trauma Injury dependent on mechanism Injury dependent on mechanism Motor vehicle accident Motor vehicle accident Fall from height Fall from height Physical assault Physical assault Explosive blast Explosive blast Gunshot wound Gunshot wound Stab wound Stab wound

3 CHEST TRAUMA Blunt force injuries from assault or fall from height Bony fractures Lung injuries Cardiac contusion

4 CHEST TRAUMA Acceleration : Deceleration Injuries

5 CHEST TRAUMA Penetrating injuries: Gunshot wounds Stabbing wounds

6 CHEST TRAUMA Improved field diagnosis and treatment of life threatening conditions Rapid evacuation to higher level of care High risk of death despite acute intervention Need for prompt diagnosis and treatment

7 CHEST TRAUMA Chest wall and ribs Lungs and pleura Great and thoracic vessels Heart and mediastinal structures Diaphragm

8 CHEST TRAUMA Common Injuries Rib fractures Sternal fractures Open or Closed Pneumothorax - unilateral / bilateral Hemothorax Hemopneumothorax

9 CHEST TRAUMA Clinical consequences associated with: Mechanism of injury Location of injury Associated injuries Co-morbidities

10 CHEST TRAUMA Blunt injuries managed non-operatively Management of airway / oxygenation Analgesia Intubation and ventilator support if needed Chest tubes if needed for pneumothorax or hemothorax

11 CHEST TRAUMA PENETRATING INJURIES Trajectory across chest Mechanism due to knife or gunshot Type of bullet

12 CHEST TRAUMA INITIAL MANAGEMENT Airway, Breathing, Circulation PRIMARY SURVEY Identify & treat immediately life threatening conditions

13 CHEST TRAUMA Early intervention directed toward diagnosing and treating: Tension pneumothorax Massive hemothorax Open pneumothorax Cardiac tamponade Flail chest

14 CHEST TRAUMA RADIOLOGIC TESTS Chest X-ray, usually portable Abdominal KUB and FAST Ultrasound Exam CAT scan, and CT Angiogram if needed

15 CHEST TRAUMA Rib Fractures Physical Diagnosis: Deformity Localized pain Crepitus Treatment: Analgesia (PCA) Pulmonary toilet Observe for pneumothorax

16 CHEST TRAUMA FLAIL CHEST Segment of chest wall that does not have continuity with rest of thoracic cage Usually 2 fractures per rib in at least 2 ribs Segment does not contribute to lung expansion Disrupts normal pulmonary mechanics Accompanied by pulmonary contusion in 50% of patients

17 CHEST TRAUMA Flail Chest Diagnosis: Paradoxical chest wall movement Poor air movement Hypoxia Therapy: Pain control Pulmonary & physical therapy Intubation and ventilator support if needed Fluid restriction if possible

18 CHEST TRAUMA Pneumothorax or Hemothorax Pneumothorax or Hemothorax most treated with simple tube thoracostomymost treated with simple tube thoracostomy

19 CHEST TRAUMA Decompression of Tension Pneumothorax large bore needle 2nd intercostal space midclavicular line Chest tube as definitive treatment

20 PULMONARY CONTUSION Common with blunt trauma May be associated with laceration of lung parenchyma Leakage of blood and fluid into interstitial spaces of lung Significant inflammatory reaction to blood components in the lung

21 PULMONARY CONTUSION Parenchymal infiltrate seen on CXR adjacent to injured chest wall

22 PULMONARY CONTUSION Indications for intubation Respiratory distress Hypoxia Other injuries which compromise respiratory effort, such as abdominal or neurologic

23 MYOCARDIAL CONTUSION Physical bruising of the cardiac muscle Associated with fractures of the sternum Any severe anterior chest injury

24 MYOCARDIAL CONTUSION DIAGNOSIS: Ectopy ST elevation Tachycardia Friction rub CPK enzymes, Troponin Monitor in ICU & treat dysrhythmias Serial enzymes Analgesia

25 MASSIVE HEMOTHORAX From blunt or penetrating injuries 200cc – 1L in chest cavity seen on CXR Treat with chest tube, if immediate drainage is 1500 cc or if 250 cc/hr for 4 hours, then immediate thoracotomy Bleeding may be from ribs, lung, blood vessels

26 AORTIC RUPTURE Abrupt deceleration or compression injury Sudden motion of heart / great vessels in chest Great vessel injury may occur in 0.3 => 10% penetrating trauma Often rapidly fatal 10% survive to hospital 20% survive > 1 hour 90% who reach hospital will die Early diagnosis and treatment

27 AORTIC RUPTURE mechanism of injury widened mediastinum on CXR

28 AORTIC RUPTURE CT with contrast angiogram Contained injury treat with BP control Operative repair

29 CARDIAC INJURY AND TAMPONADE Fatality rates > 80% Mostly ventricular, right > left Blood in pericardial sac causes tamponade Occurs with penetrating injuries

30 DIAPHRAGM RUPTURE Associated with blunt trauma or blast injury Can be due to stab wounds

31 DIAPHRAGM RUPTURE Surgical repair to replace herniated contents back into abdomen Close muscular diaphragm to restore pulmonary function Chest tube to treat pneumothorax

32 ESOPHAGEAL INJURY Most due to penetrating trauma Difficult to diagnosis If delayed or missed, rapid sepsis & high mortality Radiography Endoscopy Thoracoscopy Treatment: surgical repair via thoracotomy

33 EMERGENCY THORACOTOMY ACUTE THORACOTOMY Cardiac tamponade (relieved) Vascular injury to thoracic outlet Massive air leak Endoscopic / radiographic evidence of tracheal or bronchial injury Esophageal injury Chest tube output immediate evacuation of 1500ml blood or > 250cc/ hour

34 ER THORACOTOMY survival rates < 8%

35 ER THORACOTOMY BLUNT injury with arrest Arriving without pulse/BP Penetrating injury with arrest High likelihood of isolated / correctable intra-thoracic injury ER THORACOTOMY in presence of : pulse blood pressure organized cardiac activity

36 CHEST TUBE INSERTION Insertion Site mid or anterior axillary line behind pectoralis major above 5th rib avoid diaphragm

37 CHEST TUBE INSERTION Connect tube to underwater seal and suture in place Examine chest to check effect CXR to check placement and position

38 SUMMARY Chest trauma may be due to blunt, penetrating or combination of causes Chest trauma may be due to blunt, penetrating or combination of causes Organs at risk include bony, hollow, as well as cardiovascular structures Organs at risk include bony, hollow, as well as cardiovascular structures Immediate life threatening conditions need to be treated Immediate life threatening conditions need to be treated Maintenance of airway, oxygenation, and control of hemorrhage are important goals Maintenance of airway, oxygenation, and control of hemorrhage are important goals


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