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

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

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

CHEST TRAUMA Acceleration : Deceleration Injuries

CHEST TRAUMA Penetrating injuries: Gunshot wounds Stabbing wounds

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

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

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

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

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

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

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

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

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

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

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

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

CHEST TRAUMA Pneumothorax or Hemothorax most treated with simple tube thoracostomy

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

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

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

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

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

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

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

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

AORTIC RUPTURE mechanism of injury widened mediastinum on CXR

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

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

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

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

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

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

ER THORACOTOMY survival rates < 8%

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

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

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

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