1. CHEST TRAUMA Dr.mohammadzadeh Thorasic surgeon

2. Incidence Trauma kills 150,000 Americans every year. It is the most common cause of death in the population <40 years of age. One-fourth of deaths are specifically related to chest trauma,many of them occurring in the prehospital setting.

3. Specific Physical Findings in Chest Trauma

4. Subcutaneous emphysema

5. Traumatic Asphyxia

6. Theory of mechanism

7. Thoracic cage injuries

8. Sternal Fracture

10. Intercostal nerve block

13. Flail chest

14. Complete sternochondral separation

15. Flail chest

16. Penetrating chest injuries 1.Pneumothorax simple p. tension p. open p. 2.Hemothorax 3.Pulmonary hematoma 4.Major pulmonary paranchymal inj. 5. Air embolism 6.Traumatic lung herniation 7.Diaphragmatic injury

17. Simple Pneumothorax may not come to the attention of the clinician during the initial assessment of critically injured victims. A chest radiograph should always be obtained as early as possible during the secondary survey., chest tube drainage is recommended, even for small collections of air, especially in patients who require positive-pressure ventilation.

18. When a large air leak is present or reexpansion of the lung is incomplete, a tracheobronchial injury should be suspected and prompt flexible bronchoscopy performed

19. Pneumothorax

20. Tension Pneumothorax Physical examination is more dramatic and may demonstrate severe respiratory distress, distended neck veins, deviated trachea, absent breath sounds, or tympany to percussion on the affected side

21. Signs and Symptoms of Tension Pneumothorax Anxiety, agitation, and apprehension Diminished or absent breath sounds Cyanosis Rapid shallow breathing Distended neck veins

22. Tension Pneumothorax

25. NEEDLE CHEST DECOMPRESSION

28. Open Pneumothorax (( sucking chest wounds Result of full-thickness loss of a portion of the chest wall, usually from a gunshot wound A life-threatening emergency. Air can flow freely in and out of the pleural space

29. Open Pneumothorax

31. Open(Sucking) Pneumothorax

32. Open Pneumothorax

33. Flutter-Valve Seal

34. Impaled Object

37. Asherman chest seal

38. Treatment Asherman chest seal – convert sucking chest wounds to simple pneumo/hemothorax

39. Hemothorax Often associated with penetrating chest injury or chest wall blunt trauma with bony injury. Ultrasound can be rapidly performed by the surgeon carrying out the initial evaluation of the injured patient. A slight reverse Trendelenburg position of the patient is helpful in identifying smaller hemothoraces More commonly, a hemothorax is recognized on chest radiography

40. Sources of Hemothorax

41. Degree of Hemothorax

42. Hemothorax

44. Management Complete evacuation of the blood collection. Intrathoracic bleeding recognized in the emergency department requires a closed- tube thoracostomy. Most commonly, a 24- or 28-Fr thoracostomy tube is sufficient to accomplish this goal.

45. ATLS criteria Chest drainage >1,500 mL initial or >250 mL/hr for the next 4 hours

46. Residual Hemothorax Must be evacuated as soon as the patient is stable to reduce the risk for empyema or prevent the formation of a fibrous peel (resulting in lung entrapment). It is not an emergency situation if bleeding has stopped. Thoracoscopic drainage is best performed within 1 to 3 days after injury

47. Rupure of trachea or bronchi

48. Small tear of membranous portion of r. main bronchus

49. Almost complete rupture of thoracic trachea

50. Complete rupture of cervical trachea

51. Diaphragmatic injury

52. Thoracoabdominal stab wounds : anterior : 4 th intercostal space laterally : 6 th intercostal space posteriorly : 8 th intercostal space DPL : an RBC count > 10000 laparatomy an RBC count > 1000 thoracoscopy THORACOSCOPY

53. Diaphragmatic injury

54. Pulmonary contusion

55. Symptoms & Signs

56. Ill-defined patchy densities scattered throughout the lung

57. Pulmonary contusion

58. Pathology

59. Pulmonary Hematoma Difficult to differentiate from pulmonary contusion because of the surrounding intraparenchymal hemorrhage. 24 to 48 hours after the injury, a hematoma typically develops into a discrete mass with distinct margins. CT scans can be helpful in distinguishing between contusion and hematoma.

60. In most cases, the hematoma itself does not interfere with gas exchange and is reabsorbed in time. Rarely such a hematoma become secondarily infected and present as an abscess requiring drainage

61. Major Pulmonary Parenchymal Injury Most pulmonary parenchymal injuries are treated with chest tube drainage. Indication for thoracotomy : Radiographic assessment Bronchoscopy Patient's hemodynamic status, Adequacy of lung expansion, Size of air leak, Chest tube output

62. Surgery The most effective method is the nonanatomic stapled resection. More proximal lesions require extensive resection, including lobectomy or pneumonectomy. Anatomic resections are rarely indicated Tractotomy was first described by Wall in 1994

63. Tractotomy

64. Pulmonary tractotomy

65. Air Embolism Air embolism was first reported in 1974 by Thomas and Stevens in patients with penetrating lung injury. It is typically seen in patients with penetrating injuries to the hilum of the lung, where the veins are not surrounded by lung or other structures. Even small amounts of air can be catastrophic, resulting in hemodynamic instability with ventricular fibrillation and seizure activity.

66. Air embolism is difficult to recognize. It may present as sudden cardiovascular collapse and sudden death in the conscious patient and must be suspected in patients who present with pulseless electrical activity. When endotracheal pressure is >60 mm Hg, gas will easily pass from the pulmonary venous system into the systemic circulation and embolize in the coronary arteries.

67. The hallmark of an air emblus is hemoptisis and bloody,frothy air leak from a lung injury

68. Management Immediate thoracotomy Clamping of hilum Head down position De-airing of left ventricular apex with a large –gauge needle

69. Traumatic Lung Herniation Historically, noncongenital lung herniations resulted from penetrating traumatic injuries, including postsurgical incisional herniations. Today, the most common cause of lung herniation is motor vehicle collisions, particularly in restrained passengers. Other reported herniation sites include the site of internal mammary artery harvest, port sites after minimally invasive coronary bypass procedures, thoracoscopy port sites, through tube thoracostomy drainage sites. Symptoms may be minimal despite a localized bulge that paradoxically changes shape with the respiratory cycle.

70. Lung Herniation

72. Treatment Treatment involves hernia reduction and defect closure with a prosthetic patch (such as polytetrafluoroethylene). The results are frequently excellent.

73. QUESTIONS?