Presentation on theme: "Chest Trauma 19thApril 2013 Kenyatta National Hospital"— Presentation transcript:
1Chest Trauma 19thApril 2013 Kenyatta National Hospital Dr. Josiah RuturiThoracic and Cardiovascular Surgeon .
2Approximately 150,000 people die each year in the United States as a result of trauma. 25% of the deaths can be directly related to thoracic injury.Almost all patients with thoracic trauma are treated conservatively with a successful outcome.urgent operative treatment was required in only:- 0.5% of blunt thoracic injuries.- 2.8% of penetrating thoracic injuries .
3OBJECTIIVESIdentify and initiate treatment of life-threatening thoracic injuriesPrimary surveySecondary surveyProceduresSpecial considerations
8An unstable hemodynamic state : 1. Traumatic cardiac arrest or near arrest andan Emergency department thoracotomy.2. Cardiac tamponade3. Persistent ATLS class III shock despite fluidresuscitation(blood loss 1500–2000 mL, pulse rate > 120,blood pressure decreased)4. Chest Tube output > 1500 mL of blood on insertion5. Chest Tube output > 500 mL/hour for the initial hour6. Massive hemothorax after chest tube drainage
15Pneumothorax -Treatment <15% -very small spontaneous can be given 100% O2 in ED and observed<25% - simple pneumothorax can be aspirated through a small catheterLarger pneumothoraces/ underlying lung dz –tube thoracostomyPneumonediastinum – conservative
18Pleural margin; partial lung collapse Tension PneumothoraxA: Air under tension in left thoraxAPleural margin; partial lung collapseBB: Collapsed right lungLeftRight
19B: pressure of tension pneumothorax pushing midline structures (heart, mediastinum) into patient’s left thoracic cavityA: air, under tension, in thoracic cavityABHeartBRightLeft
20Tension Pneumothorax Clinical manifestations in patient with Spontaneous breathingRespiratory distressFlorid faceTracheal deviationDistended neck veinsTachycardiaHypotension
21Needle ThoracentesisIndication: Rapidly deterioration with tension pneumothorax.EquipmentPovidone-iodine solution14-gauge catheter-over-needle deviceTechniqueCleanse overlying skinInsert needle at 2nd or 3rd intercostal space, midclavicular line, over top of ribLeave catheter in pleural space open to air
22Sucking Chest Wound AKA communicating pneumothorax Large defects: if opening > 2/3 trachea, air will pass preferentially.Cover immediately with cleanest occlusive dressing3 sides vs 4 sides
23Massive Hemothorax >1500 cc blood Mechanism: Penetrating injury of systemic or hilar vessels, especially wounds medial to nipples, scapulas.Blunt traumaLoss of Breath sounds, dullness to percussion
24Flail Chest No bony continuity with rest of cage Multiple rib fractures, paradoxical movementHypoxia from injury to underlying lung30% missed in first 6 hours
25Flail chest is a marker for significant injuries Retrospective analysis, 92 pat, L-1 center.46% had pulmonary contusion70% had pneumo or hemothoraxGreat vessel, tracheobronchial injuries had no associated.27% developed ARDS69% required mechanical ventilation33% mortalityCiraulo DL et al. J Am Coll Surg 1994;178(5):466. (Penn)
36Pulmonary Contusion Determinants of outcome ISS > 25 Initial GCS < 7Transfusion > 3 U bloodpO2/FiO2 < 300Not correlated to shock or IV fluid administrationExtent of contusion seen on initial chest X-raynot predictive of mortality or intubation.Johnson JA et al. J Trauma 1986; 26(8):695.
37Diaphragmatic Rupture Blunt trauma: large tearsPenetrating: small tears, subtleMore commonly diagnosed on the left
39Scapular and Rib Fractures Splinting impairs ventilationMajority – optimise pain mxScapula, often indicate major injury to the head, neck, spinal cord, lungs and great vessels: mortality > 50%pain, tenderness, crepitus
40Sternal Fractures Mortality 25-45% Underlying injuries to myocardium Flail segment
45Penetrating Cardiac Injury Ventricles: will self seal more commonlyRV>LV>RA>LA56-66% overall survival87% survival in OR thoracotomyPositive predictors: VS on admission, short transport, SW
46penetrating cardiac injury A combination of:- unstable patient: aggressive operative intervention- stable patient: ultrasound evaluationprovided an overall survival of 40% in the patients with known cardiac injury.The diagnosis of a traumatic pericardial effusion can be made by the visualization of an echolucent region between the heart and pericardium,right ventricular diastolic collapse will confirm tamponade.ultrasound imaging appears to be with an accuracy, sensitivity, and specificity that exceeds 95%
47Classification of Mediastinal Injuries M1= base of the neck into mediastinum orpleuraM2= one pleural cavity and mediastinalviolation(central hematoma, visceral or spinalcord injury,metallic fragments in themediastinum)M3 = parasternal injury within the nipple lineor < 4 cm from the sternumM4 = two pleural cavities and mediastinaltraverse.
48M4 - All of the mediastinal traverse injuries were caused by gunshot wounds- this trajectory had the highest rate of instability andsubsequent operative intervention.- the highest observed mortality rate (60%),M1 - Injuries from a cephalad direction were predominately stabwounds.- were responsible for the second highest incidence of instabilityand subsequent operative intervention.The presence of a gunshot wound, was associatedwith significant risk of both instability and death.
58Summary Thoracic trauma is common in multiply injured patients Life- threatening problems may be temporarily relieved by simple measuresInjury recognition importantHigh index of suspicion for occult injuries