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CHEST TRAUMA

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If moderate sized (500 to 1500 ml) and stops bleeding, closed drainage usually sufficient ... If initial drainage 1500 ml OR continuous bleeding 200 ml / hr, ... – PowerPoint PPT presentation

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Title: CHEST TRAUMA


1
CHEST TRAUMA
  • Joe Lex, MD, FAAEM
  • Temple University Hospital
  • Philadelphia, PA
  • July 20th, 2006

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Incidence of Chest Trauma
  • 1/4 American trauma deaths
  • Contributes to another 1 of 4
  • Many die after reaching hospital - preventable
    if recognized
  • lt10 blunt needs surgery
  • 1/3 penetrating needs surgery
  • Most life-saving procedures do NOT require
    thoracic surgeon

4
Pathophysiology of Chest Trauma
TISSUE HYPOXIA
5
Pathophysiology of Chest Trauma
  • Tissue hypoxia
  • Hypercarbia
  • Respiratory acidosis inadequate ventilation
  • Metabolic acidosis tissue hypoperfusion (e.g.,
    shock)

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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
Splinter
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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6 Immediate Life Threats
  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax
  • sucking chest wound
  • Massive hemothorax
  • Flail chest
  • Cardiac tamponade

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6 Potential Life Threats
  • Lung contusion
  • Heart contusion
  • Aorta rupture
  • Diaphragm rupture
  • Tracheobronchial tree injury - larynx, trachea,
    bronchus
  • Esophagus trauma

28
6 Other Frequent Injuries
  • Subcutaneous emphysema
  • Traumatic asphyxia
  • Simple pneumothorax
  • Hemothorax
  • Scapula fracture
  • Rib fractures

29
Primary Survey
  • Airway
  • Breathing
  • Circulation

30
A Airway
  • Assess for airway patency and air exchange -
    listen at nose mouth
  • Assess for intercostal and supraclavicular muscle
    retractions
  • Assess oropharynx for foreign body obstruction

31
B Breathing
  • Assess respiratory movements and quality of
    respirations look, listen, feel
  • Shallow respirations are early indicator of
    distress cyanosis is late

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C Circulation
  • Assess pulses for quality, rate, regularity
  • Assess blood pressure and pulse pressure
  • Skin - look and feel for color, temperature,
    capillary refill
  • Look at neck veins - flat vs. distended
  • Cardiac monitor

33
Where can adults hide blood and go into shock?
  • Chest listen, do chest x-ray
  • Abdomen do DPL or CT or US
  • Retroperitoneum do CT
  • Thigh physical examination
  • Street ask paramedic
  • ...and in children, add
  • Head

34
Initial assessment and management
  • Primary survey
  • Resuscitation of vital functions
  • Detailed secondary survey
  • Definitive care

35
Initial assessment and management
  • Hypoxia most serious problem early interventions
    aimed at reversing
  • Immediate life-threatening injuries treated
    quickly and simply, usually with tube or a needle
  • Secondary survey guided by high suspicion for
    specific injuries

36
Thoracotomy
  • Closed heart massage is ineffective in a
    hypovolemic patient
  • Left anterior thoracotomy with cross-clamping of
    descending thoracic aorta and open-chest massage
    may be useful in pulseless victim of penetrating
    trauma

37
Thoracotomy
  • Emergency department thoracotomy for patients
    without cardiac activity who are victims of blunt
    thoracic injuries is ineffective

38
Thoracotomy
Nipple
39
Thoracotomy
40
Thoracotomy
41
Thoracotomy
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6 Immediate Life Threats
  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax
  • sucking chest wound
  • Massive hemothorax
  • Flail chest
  • Cardiac tamponade

45
Airway Obstruction
  • Airway obstruction at alveolar level assessed
    and managed during 2o survey
  • Upper airway obstruction ? immediate life threat
    which must be dealt with in primary survey
  • Most common cause patients tongue

46
Airway Obstruction
  • Chin-lift fingers under mandible, lift forward
    so chin is anterior

47
Airway Obstruction
48
Airway Obstruction
  • Jaw thrust grasp angles of mandible and bring
    jaw forward

49
Airway Obstruction
  • Oropharyngeal airway insert into mouth behind
    tongue
  • DO NOT push tongue further back

50
Airway Obstruction
  • Nasopharyngeal airway gently insert
    well-lubricated trumpet through nostril

51
Airway Obstruction
  • Definitive Airway
  • Management tube in trachea through vocal cords
    with balloon inflated

52
Airway Obstruction
  • Orotracheal intubation
  • Nasotracheal intubation in breathing patient
    without major facial trauma
  • Surgical airways
  • jet insufflation
  • retrograde
  • cricothyrotomy
  • tracheostomy

53
Airway Obstruction
Jet insufflation adapters
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How to perform cricothyroidotomy
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Tension pneumothorax
  • Air leak through lung or chest wall
  • One-way valve ? lung collapse
  • Mediastinum shifts to opposite side
  • Inferior vena cava kinks on diaphragm
    ?decreased venous return ? cardiovascular collapse

67
Inferior vena cava
68
Tension pneumothorax
  • Tension pneumothorax is not an x-ray diagnosis
    it MUST be recognized clinically
  • Treatment is decompression needle into 2nd
    intercostal space of mid-clavicular line -
    followed by thoracotomy tube

69
Insert needle here
70
Open pneumothorax
  • Sucking Chest Wound
  • Normal ventilation requires negative
    intra-thoracic pressure
  • Large open chest-wall defect ? immediate
    equilibration of intra-thoracic and atmospheric
    pressures
  • If hole gt2/3 tracheal diameter, air prefers chest
    defect

71
Open pneumothorax
72
Open pneumothorax
  • Initial treatment seal defect and secure on
    three sides (total occlusion may lead to tension
    pneumothorax
  • Definitive repair of defect in O.R.

73
Massive hemothorax
  • Rapid accumulation of gt1500 cc blood in chest
    cavity
  • Hypovolemia hypoxemia
  • Neck veins may be
  • Flat from hypovolemia
  • Distended intrathoracic blood
  • Absent breath sounds, DULL to percussion

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Massive hemothorax treatment
  • Large-bore (32 to 36 F) tube to drain blood
  • If moderate sized (500 to 1500 ml) and stops
    bleeding, closed drainage usually sufficient
  • If initial drainage gt1500 ml OR continuous
    bleeding gt200 ml / hr, OPEN THORACOTOMY indicated

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How to place a chest tube
80
Pleural space
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Flail chest
  • Free-floating chest segment, usually from
    multiple ribs fractures
  • Pain and restricted movement paradoxical
    movement of chest wall with respiration

88
Flail chest
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Flail treatment (old)
91
Flail treatment (old)
92
Flail treatment
  • Ventilate well
  • Humidify oxygen
  • Resuscitate with fluids
  • Manage pain (!!)
  • Stabilize chest
  • Internal ? ventilator
  • External ? sand bags (rare)

93
Cardiac tamponade
  • Usually from penetrating injuries
  • Classic Becks triad
  • elevated venous pressure - neck veins
  • decreased arterial pressure - BP
  • muffled heart sounds
  • Blood in sac
  • prevents cardiac
  • activity

94
Cardiac tamponade
  • May find pulsus paradoxus - a decrease of 10 mm
    Hg or greater in systolic BP during inspiration
  • Systolic to diastolic gradient of less than 30 mm
    Hg also suggestive

95
Cardiac tamponade
  • Treatment is removal of small amount of blood
    15 to 20 ml may be sufficient from pericardial
    sac

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Pericardiocentesis
98
Stab wound to right ventricle
99
pericardium
epicardial fat
100
Ten-minute break
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The Flock of Birds behind the heart
Thoracic duck
103
6 Potential Life Threats
  • Pulmonary contusion
  • Myocardial contusion
  • Traumatic aortic rupture (TAR)
  • Traumatic diaphragmatic rupture
  • Tracheobronchial tree injury larynx, trachea,
    bronchus
  • Esophageal trauma

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Pulmonary contusion
  • Potentially life-threatening condition with
    insidious onset
  • Parenchymal injury without laceration
  • More than 50 will develop pneumonia, even with
    treatment
  • Up to 50 have only hemoptysis as presenting
    symptom

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108
Pulmonary contusion
  • Patients with pre-existing conditions (emphysema,
    renal failure) need early intubation
  • Treatment needs
  • to occur over time
  • as symptoms develop

109
Myocardial contusion
  • Blunt precordial chest trauma
  • Difficult to diagnose
  • Risk for dysrhythmia, sudden death, tamponade,
    pericarditis, ventricular aneurysm

110
Myocardial contusion
111
Myocardial contusion
  • Also may see
  • myocardial concussion ? stunned myocardium with
    no cell death
  • coronary artery laceration
  • Diagnosis by
  • trans-esophageal echocardiogram (TEE)
  • serial cardiac enzymes / markers

112
Myocardial contusion
  • Question Does it matter?
  • New nomenclature Anterior Chest Wall Syndrome

113
FORD
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Traumatic aortic rupture
  • 90 or more dead at scene
  • 90 mortality each undiagnosed day
  • Must have high index of suspicion
  • Disruption occurs at ligamentum arteriosum
    (ductus arteriosus)
  • Contained hematoma of 500 to 1000 ml of blood

116
Traumatic aortic rupture
  • Radiographic signs
  • Wide mediastinum (gt8cm)
  • Fractured 1st 2nd rib
  • Obliterated aortic knob
  • Trachea deviated to right
  • Pleural cap
  • Elevated mainstem bronchus with shift to right
  • Obliterated aortic window
  • Esophagus shifted to right (NG at T4)
  • Depressed left mainstem bronchus

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dye leakage
120
Traumatic aortic rupture
  • CT becoming imaging of choice
  • Must know site!
  • NPV of normal chest x-ray (good quality,
    upright) 98 (CT will find mediastinal
    hemorrhage in 3, TAR in 0.4)
  • 78 of patients with post-traumatic wide
    mediastinum on chest film have normal CT

121
Traumatic aortic rupture
  • Treatment - SURGICAL REPAIR

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Traumatic diaphragmatic rupture
  • Blunt trauma tears leading to immediate
    herniation
  • Penetrating trauma small tears which may take
    years to develop herniation
  • Usually on left side

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Traumatic diaphragmatic rupture
  • Treatment surgical repair

126
Tracheobronchial tree injury
  • Larynx - rare
  • Hoarseness
  • Subcutaneous emphysema
  • Palpable crepitus
  • Intubation may be difficult tracheostomy (not
    cricothyroidotomy) is treatment of choice

127
Tracheobronchial tree injury
  • Trachea
  • Blunt or penetrating
  • Esophagus, carotid
  • artery and jugular
  • vein may be involved
  • Noisy breathing ?
  • partial airway
  • obstruction

128
Tracheobronchial tree injury
  • Bronchus
  • 1.5 blunt chest trauma
  • 80 due to BLUNT trauma within one inch of carina
    (tethered)

129
Esophageal trauma
  • Penetrating gt blunt
  • Lethal if not recognized
  • High suspicion if
  • left pneumothorax and hemothorax without rib
    fracture
  • shock out of proportion to apparent blunt chest
    trauma
  • particulate matter in chest tube

130
Esophageal trauma
131
Esophageal trauma
  • Blunt trauma, most tears superior
  • If low esophagus ? leakage of stomach contents
    into mediastinum

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6 Other Frequent Injuries
  • Subcutaneous emphysema
  • Traumatic asphyxia
  • Simple pneumothorax
  • Hemothorax
  • Scapula fracture
  • Rib fractures

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Subcutaneous emphysema
  • Rice Krispies
  • May result from
  • airway injury
  • lung injury
  • blast injury
  • No treatment
  • required ? address underlying problem

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Traumatic asphyxia
  • Purple face from extravasation of blood (Masque
    ecchymotique)
  • Major damage is to underlying structures
  • Purple face fades over time in survivors

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Simple pneumothorax
  • Air enters potential space between visceral and
    parietal pleura
  • Breath sounds down on affected side
  • Percussion ? hyper-resonance
  • Treatment chest tube in 4th or 5th intercostal
    space anterior to mid-axillary line

141
Medial pneumothorax
142
Pocket shooter
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Hemothorax
  • Lacerated lung OR disrupted intercostal artery or
    internal mammary artery
  • Most are self-limiting
  • Surgical consultation if
  • initial drainage of gt20 cc/kg (1500 cc)
  • continued flow of gt200 cc/hr

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Scapula fractures
  • Fractured scapula or 1st 2nd ribs indicates
    major mechanism of injury consider underlying
    damage

147
Rib fractures
  • Most frequent thoracic cage injury
  • Most commonly injured 4th ? 9th
  • If 10th / 11th / 12th ? suspect liver or spleen
    injury
  • If 1st / 2nd / 3rd worry about injury to head,
    neck, spinal cords, lungs, great vessels

148
Rib fractures treatment
  • Intercostal blocks
  • Epidural anesthesia
  • Systemic analgesics
  • Do not use
  • taping
  • rib belts
  • external splints

149
Rib fractures
  • Ribs x-rays
  • are expensive
  • are inaccurate for diagnosis (50 sensitivity)
  • add nothing to treatment
  • require painful positioning of the patient
  • are, in general, not useful

150
In conclusion...
  • Chest trauma is common in the multiply-injured
    patient
  • Most conditions can be treated by the evaluating
    physician and do not require emergent thoracotomy
  • Airway management and a judiciously placed needle
    can save many lives

151
Next time
  • February 27th, 2004
  • Respiratory
  • Emergencies
  • Joe Lex
  • joe_at_joelex.net
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