Thoracic Trauma Hossam Hassan

Thoracic Trauma Anatomy Thorax is a hollow cylinder composed of 12 pairs of ribs,10articulate posteriorly with the thoracic spine and anteriorly with the sternum via costal cartilages,the lower 2 pairs are floating ribs A nerve,an artery and a vein are located a long the under side of each rib Intercostals muscles connect each rib to the one above these muscles with the diaphragm are the primary muscle of ventilation.

Anatomy The pleurae are thin membranes that consist of 2 distinct layers: The partial pleurae line the inner side of the thoracic cavity The visceral pleurae cover the outer surface of each lung

Anatomy The lungs occupy the right and the left halves of the thoracic cavity An area called the mediastinum is located in the middle of the thoracic cavity within the mediastinum lie all the other organs and structures of the chest cavity:the heart,great vessels,trachea,mainstem bronchi and esophagus Any or all of these structures can be injured by thoracic trauma.

General Assessment The signs and symptoms of chest truma related to the chest wall and lungs are sob,tachypnea and chest pain The initial 3 points in general assessment is : 1.Observation ex.bruises,lacerations,distended neck veins 2.Palpation ex.tenderness,bony crepitus 3.Auscultation ex.presence ,diminished or absence of breath sounds.

Thoracic injuries can be: Rib Fractures Flail chest Pulmonary contusion Pneumothorax(open and close) Tension pneumothorx Hemothorax Blunt cardiac injuries Pericardial tamponade Tracheal and bronchial rupture Aortic rupture Diaphragmatic rupture

Chest Trauma History & PE ATLS protocol A,B,C,D,E’s Contusions, diminished or absent breath sounds, SQ emphysema

AMPLE A allergies M Medications (Anticoagulants, insulin and cardiovascular medications especially) Previous medical/surgical history L Last meal (Time) E Events /Environment surrounding the injury; ie. Exactly what happened

CXR-fast, easy, least expensive for initial evaluation Ultrasound-may soon replace CXR as initial radiographic study in chest trauma CT Scan VS Angiography EChO VS Transesophogeal Echocardiography

FAST

Normal CXR

Pneumothorax

Subcutaneous Emphysema

Hemothorax

Management of specific injuries. Rib fracture Assessment: Simple rib fracture alone are rarely life threatening in adults Signs and symptoms of fractured ribs include pain with movement,local tenderness and perhaps bony crepitus

Rib fracture Management The initial management of patient with simple rib fracture is pain reduction supplemental oxygen in case hypoxia Bed rest Fractured ribs should not be stabilized by taping or using any other firm bandaging such attempt can limit ventilation and lead to atelactasis (collapse of the alveoli or part of the lung)and pneumonia

Flail Chest Flail chest is when 2 or more adjacent ribs are each fractured in at least 2 places Assessment : Tenderness Bony crepitus Hypoxia might happen then lead to increase in respiratory rate as well.

Flail chest Management: The key management is BVM (for positive pressure ventilation) All patient who have an obvious flail segment should supplied with supplemental O% if not respond then will require more aggressive ventilataroy support

Pulmonary contusion A pulmonary contusion is an area of the lung that has been traumatized to the point where intertitial and leveolar bleeding occur The amount of intertitial fluids increase in the area between the wall of the cappilaries and alveoli resulting in decreased O% transporst across the thickened membranes

Pulmonary contusion Managements Patient should closely monitored with special attention to fluid administration Ensuring adequate ventilation and enriched O% administration In inadequate ventilations or altered LOC or other major injuries BVM and endotracheal intubation if required.

Pneumothorax Simple pneumothorax Open pneumothorax.

Simple pneumothorax Simple pneumothorax is caused by the presence of air in the pleural space Assessment: Pleuratic chest pain Difficult and rapid breathing Decreased or absent breath sounds on the involved side are classic signs Percussion is an excellent indicator

Simple pneumothorax Management: High concentration of O% should be administrated to patients with pneumothorax Assisted ventilation might be for those who display signs of hypoxia Semi sitting position is preferred.

Open pneumothorax Penetrating wounds to the chest can produce open chest wall injuries(open pneumothorax) Assessment : Pain at the injured side SOB The sings might included sucking out bubbling sound as air moves in and out of the pleural space through the chest wall defected

Open pneumothorax Management Close the hole in the chest Closing the hole it could be with a Vaseline gauze by 3 sides taped . Provide supplemental O% If signs of increasing respiratory distress are observed the patient may be developing a tension pneumothorax and the dressing should be removed to assess in decompressing the affected side.

Tension pneumothorax It is a life threatening situation The amount of air trapped in the pleural space continues to increase not only is the lung on the affected side collapsed but the mediastinum is also shifted into the opposite side The intra thoracic pressure increase witch decrease the capillaries blood flow and kinks the vena cava.

Tension pneumothorax Assessment: The presentation of patient with tension pneumothorax varies according to how much intrathoracic pressure has developed. Signs and symptoms can be minimal or moderate Anxiety Cyanosis Tachypnea Diminished or absent breath sound on the injured side JVD (jugular vein distension)note in case hypovolemic this sign might not present.

Tension pneumothorax Management: The management of the patient with a tension pneumothorax involves reducing the pressure in the pleural space Needle decompression in the field can be done by the expert people Chest tube Incase penetrating injury then dressing Refer to the specialist area as soon as possible.

Hemothorax Blood in the pleural space constitutes a hemothorax In adult the pleural space on each side of the thorax can hold 2500 to 3000 ml of blood

Hemothorax Assessment: The symptoms are related to the blood loss Sings: Sob Tachypnea Decreased breath sound Clinical signs of shock Management: transfer to surgical repair.

Myocardial Contusion Occurs in 76% of patients with severe blunt chest trauma –Right Atrium and Ventricle is commonly injured –Injury may reduce strength of cardiac contractions Reduced cardiac output

Electrical Disturbances due to irritability of damaged myocardial cells –Progressive Problems Hematoma Hemoperitoneum Myocardial necrosis Dysrhythmias CHF & or Cardiogenic shock

Myocardial Contusion Signs & Symptoms Bruising of chest wall 􀂄Tachycardia and/or irregular rhythm 􀂄Retrosternal pain similar to MI 􀂄Associated injuries Rib/ Sternal fractures

Chest pain unrelieved by oxygen May be relieved with rest THIS IS TRAUMA-RELATED PAIN Similar signs and symptoms of medical chest pain

Blunt Cardiac Injury EKG (for any blunt chest injury, persistent tachycardia, ST-T changes or ectopy) 􀂄Cardiac enzymes (CPK, CK-MB and Troponin I) 􀂄Echocardiography (TEE)

Pericardial Tamponade Restriction to cardiac filling caused by blood or other fluid within the pericardium –Occurs in <2% of all serious chest trauma However, very high mortality

–Results from tear in the coronary artery or penetration of myocardium Blood seeps into pericardium and is unable to escape 200 ml of blood can restrict effectiveness of cardiac contrac

Pericardial Tamponade Signs & Symptoms Dyspnea Possible cyanosis Beck’s Triad JVD Distant heart tones Hypotension or narrowing pulse pressure Weak, thready pulse Shock

Kussmaul’s signDecrease or absence of JVD during inspiration Pulsus ParadoxusDrop in SBP >10 during inspiration Electrical AlteransP, QRS, & T amplitude changes in every other cardiac cycle PEA

Traumatic Aortic injury Aorta most commonly injured in severe blunt 85-95% mortality Injury may be confined to areas of aorta attachment Signs & Symptoms Rapid and deterioration of vitals Pulse deficit between right and left upper or lower extremities

Traumatic Esophageal Rupture Rare complication of blunt thoracic trauma –30% mortality –Contents in esophagus/stomach may move into mediastinum Serious infection occurs Chemical irritation Damage to mediastinal structures Air enters mediastinum –

Subcutaneous emphysema and penetrating trauma present

Tracheo-bronchial Injury Blunt trauma Penetrating trauma 50% of patients with injury die within 1 hr of injury Disruption can occur anywhere in tracheobronchial tree –

Signs & SymptomsDyspnea Cyanosis Hemoptysis Massive subcutaneous emphysema Suspect/ evaluate for other closed chest trauma

Treatment summary Observe Palpate Auscultation Management always included to provide supplemental O% then aggressive method if required. ATLS protocol: A,B,C,D,E’s

Treatment summary Emergency management Needle thoracentesis Tube thoracostomy Subxiphoid pericardotomy Video assisted thoracic surgery (VATS)

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3. Identification of which of the following is NOT an essential part of the primary survey?   A: Tension Pneumothorax B: Open Pneumothorax C: Flail Chest D: Cardiac Tamponade E: Rib Fractures

4. Upon Identification of a Tension Pneumothorax, which is the correct management pathway?   A: A chest X-ray to confirm the clinical diagnosis. B: Insertion of a chest drain in the 5th intercostals interspace in mid-axillary line. C: Immediate decompression with a 14g 5cm needle in the 2nd intercostal interspace in mid-calvicular line. D: An ECG to assess for concurrent cardiac contusion. E: Completion of a secondary survey to exclude any concurrent injury.

In massive haemothorax, which of the following is an indication for emergency thoracotomy?   A: Production of 500ml of blood on immediate insertion of a chest drain. B: Production of 50ml/hour of blood for two consecutive hours in the chest drain. C: Production 1000ml of blood on immediate insertion of a chest drain. D: Production of greater than 1500ml of blood on immediate insertion of a chest drain. E: Evidence of greater than 5 rib fractures in conjunction with radiological evidence of haemothorax

A pulmonary contusion:  A: Can cause immediate respiratory difficulties. B: Results in increased lung compliance at 24 hours. C: Does not occur without rib fractures in children. D: Can cause ventilation/perfusion mismatch which evolves over 24 hours. E: Is not associated with Adult Respiratory Distress Syndrome.

When evaluating the chest of a patient with a chest injury, you note a fine crackling sensation under the areas that you palpate. This is best described as:   pulses paradoxus. subcutaneous emphysema. hemothorax. none of the above.

In which condition would you observe paradoxical movement of the chest wall?   mediastinal shift tension pneumothorax flail chest Cheyne–Stokes breathing

Proper care for a patient with a sucking chest wound includes:   pulling the wound open on inhalation to release trapped air. sealing the wound with an occlusive dressing. covering the wound with sterile gauze. decompression of the chest.

Which of the following statements correctly differentiates a simple pneumothorax from a tension pneumothorax?   A tension pneumothorax requires decompression while a simple pneumothorax does not. A simple pneumothorax is caused by air in the pleural space while a tension pneumothorax is caused by blood in the pleural space. A simple pneumothorax is caused by damage to the lung from inside while a tension pneumothorax is caused by injury to the outside chest wall. There is no difference between a tension pneumothorax and simple pneumothorax.

After placing an occlusive dressing over a sucking chest wound to the right chest, you note that the patient has become extremely dyspneic and cyanotic with breath sounds absent on the right side. Your next action would be to:   perform a needle cricothyroidotomy. remove the occlusive dressing and replace it with sterile gauze. insert an oropharyngeal airway. loosen a corner of the occlusive dressing.