Chest Trauma Surgery department № 2 DSMA Surgery department № 2 DSMA

Introduction Chest trauma is often sudden and dramatic Chest trauma is often sudden and dramatic Accounts for 25% of all trauma deaths Accounts for 25% of all trauma deaths 2/3 of deaths occur after reaching hospital 2/3 of deaths occur after reaching hospital Serious pathological consequnces: -hypoxia, hypovolaemia, myocardial failure Serious pathological consequnces: -hypoxia, hypovolaemia, myocardial failure

Mechanism of Injury Penetrating injuries E.g. stab wounds etc. E.g. stab wounds etc. Primarily peripheral lung Primarily peripheral lung Haemothorax Haemothorax Pneumothorax Pneumothorax Cardiac, great vessel or oesophageal injury Cardiac, great vessel or oesophageal injury

Either: Either: direct blow (e.g. rib fracture) direct blow (e.g. rib fracture) deceleration injury deceleration injury compression injury compression injury Rib fracture is the most common sign of blunt thoracic trauma Rib fracture is the most common sign of blunt thoracic trauma Fracture of scapula, sternum, or first rib suggests massive force of injury Fracture of scapula, sternum, or first rib suggests massive force of injury Blunt injuries

Chest wall injuries Rib fractures Rib fractures Flail chest Flail chest Open pneumothorax Open pneumothorax

Rib fractures Most common thoracic injury Most common thoracic injury Localised pain, tenderness, crepitus Localised pain, tenderness, crepitus CXR to exclude other injuries CXR to exclude other injuries Analgesia avoid taping Analgesia avoid taping Underestimation of effect Underestimation of effect Upper ribs, clavicle or scapula fracture: suspect vascular injury Upper ribs, clavicle or scapula fracture: suspect vascular injury

Flail chest Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration Significant force required Significant force required Usually diagnosed clinically Usually diagnosed clinically Rx: ABC Analgesia Rx: ABC Analgesia

Flail chest

Flail Chest - detail

Open pneumothorax Defect in chest wall provides a direct communication between the pleural space and the environment Defect in chest wall provides a direct communication between the pleural space and the environment Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax “Sucking chest wound” “Sucking chest wound” Rx: ABCs…closure of wound…chest drain Rx: ABCs…closure of wound…chest drain

Lung injury Pulmonary contusion Pulmonary contusion Pneumothorax Pneumothorax Haemothorax Haemothorax Parenchymal injury Parenchymal injury Trachea and bronchial injuries Trachea and bronchial injuries Pneumomediastinum Pneumomediastinum

Pneumothorax Air in the pleural cavity Air in the pleural cavity Blunt or penetrating injury that disrupts the parietal or visceral pleura Blunt or penetrating injury that disrupts the parietal or visceral pleura Unilateral signs:  movement and breath sounds, resonant to percussion Unilateral signs:  movement and breath sounds, resonant to percussion Confirmed by CXR Confirmed by CXR Rx: chest drain Rx: chest drain

Pneumothorax classification By side: left or right left or right in both side in both side By lung collapse degree: Partial (paracostal) Partial (paracostal) Subtotal (smaller than 2/3 of lung volume) Subtotal (smaller than 2/3 of lung volume) Total (more than 2/3 of lung volume) Total (more than 2/3 of lung volume) By mechanism of formation: - open - closed - closed - tension

Pneumothorax

Tension pneumothorax Air enters pleural space and cannot escape Air enters pleural space and cannot escape P/C: chest pain, dyspnoea P/C: chest pain, dyspnoea Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension

Surgical emergency Surgical emergency Rx: emergency decompression before CXR Rx: emergency decompression before CXR Either large bore cannula in 2nd ICS, MCL or insert chest tube Either large bore cannula in 2nd ICS, MCL or insert chest tube CXR to confirm site of insertion CXR to confirm site of insertion

Haemothorax Blunt or penetrating trauma Blunt or penetrating trauma Requires rapid decompression and fluid resuscitation Requires rapid decompression and fluid resuscitation May require surgical intervention May require surgical intervention Clinically: hypovolaemia absence of breath sounds dullness to percussion Clinically: hypovolaemia absence of breath sounds dullness to percussion CXR may be confused with collapse CXR may be confused with collapse Decompression always by chest catchment in 7 ICS on middle or posterior axillary line Decompression always by chest catchment in 7 ICS on middle or posterior axillary line

Hemothorax classification By side: left or right left or right in both side in both side By blood lost volume : Small (< 10% of BCV, or <500 ml) Small (< 10% of BCV, or <500 ml) Middle (10-20 % of BCV, or ml) Middle (10-20 % of BCV, or ml) Big (10-20 % of BCV, or ml) Big (10-20 % of BCV, or ml) Total ( > 40 % of BCV, or >2000ml) Total ( > 40 % of BCV, or >2000ml) By bleeding presence: - stopped (Reviloi – Gregoire test negative) - continues (Reviloi – Gregoire test positive) - continues (Reviloi – Gregoire test positive) By clots presence: - clotted - unclotted By infection complication presence: - non-infected - infected

Indication for urgent thoracotomy In pneumothorax : In pneumothorax : Absence of active air catchment during more than 2 days (presence of pneumothoraz on CXR) Absence of active air catchment during more than 2 days (presence of pneumothoraz on CXR) In hemothorax : In hemothorax : Evacuation of > 1000ml blood simultaneously or bleeding continues during 4 hours with blood loss > 200 ml per hour Evacuation of > 1000ml blood simultaneously or bleeding continues during 4 hours with blood loss > 200 ml per hour

Heart, Aorta & Diaphragm Blunt cardiac injury - contusion - ventricular, septal or valvular rupture Blunt cardiac injury - contusion - ventricular, septal or valvular rupture Cardiac tamponade Cardiac tamponade Ruptured thoracic aorta Ruptured thoracic aorta Diaphragmatic rupture Diaphragmatic rupture

Cardiac Tamponade Blood in the pericardial sac Blood in the pericardial sac Most frequently penetrating injuries Most frequently penetrating injuries Shock,  JVP, PEA, pulsus paradoxus Shock,  JVP, PEA, pulsus paradoxus Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension Rx: Volume resuscitation Pericardiocentesis Rx: Volume resuscitation Pericardiocentesis

Cardiac tamponade

Aortic rupture Usually blunt trauma involving deceleration forces; especially RTAs Usually blunt trauma involving deceleration forces; especially RTAs ~90% die within minutes ~90% die within minutes Most common site near ligamentum arteriosum Most common site near ligamentum arteriosum Dx: clinical suspicion, CXR, aortography, contrast CT or TOE Dx: clinical suspicion, CXR, aortography, contrast CT or TOE Rx: surgical…poor prognosis Rx: surgical…poor prognosis

Aortic rupture

Iatrogenic trauma NG tubes: - coiling - endobronchial placement - pneumothorax NG tubes: - coiling - endobronchial placement - pneumothorax Chest tubes: - subcutaneous - intraparenchymal - intrafissural Chest tubes: - subcutaneous - intraparenchymal - intrafissural Central lines: - neck - coronary sinus Central lines: - neck - coronary sinus - pneumothorax

Line in jugular vein

Misplaced nasogastric tube

Chest trauma: summary Common Common Serious Serious Primary goal is to provide oxygen to vital organs Primary goal is to provide oxygen to vital organs Remember Airway Breathing Circulation Remember Airway Breathing Circulation Be alert to change in clinical condition Be alert to change in clinical condition