Traumatic Chest Pain

1
Traumatic Chest Pain

• ??? ??
• Wang, Tzong-Luen,MD, PhD, FACC, FESC

2
Chest Injury

• Chest Wall Injury
• Pulmonary Injury
• Cardiovascular Injury
• Esophageal Injury
• Diaphragm Injury

3
Chest Wall Injury

• 50 of thoracic trauma
• Disturb the physiology of respiration
• Rib fracture
• Sternal fracture
• Sternoclavicular fracture
• Flail chest
• Nonpenetrating ballistic injury
• Traumatic asphyxia

4
Rib Injury

• Ribs 1 to 3 are relatively protected and ribs 9
  to 12 are more mobile at the anterior end. ?
  high and low ribs relative resistance to
  fracture.
• Fractures occur more commonly in adults than
  children, and this is attributed to the relative
  inelasticity of the older chest wall compared to
  the more compliant nature of the chest wall in
  children.

5
Rib Injury

• The true danger of rib fracture involves not the
  rib itself but the potential for penetrating
  injury to the pleura, lung, liver, or spleen.
• Fractures of the ninth, tenth, or eleventh (9-11)
  ribs suggest an associated intra-abdominal injury
• Fracture of ribs 1 to 3 may indicate severe
  intrathoracic injury.

6
Angiography

• The mortality of an isolated first rib fracture
  is only 1.5, but when it is associated with
  other rib fractures there is a 10-fold increase
  in mortality.
• Current recommendations for arteriography for
  patients with first or second rib fractures
  include
• the presence of multiple thoracic injuries,
• clinical evidence of distal vascular
  insufficiency,
• a widened mediastinum on plain films,
• large hemothorax or apical hematoma,
• intercostal artery injury,
• brachial plexus injury, or
• significant displacement of the fracture.

7
Management

• Pain control oral medicine, nerve block
• Continuing daily activities and deep breathing
• Binders, belts, and other restrictive devices
  should not be used

8
Sternal Injury

• Forward thrust of the body against the fixed seat
  belt across the sternum results in a fracture at
  that location
• more common in older patients than in younger
  patients
• the magnitude of the forces required to fracture
  the sternum must be associated with significant
  trauma to the mediastinal structures
  (controversial)
• isolated sternal fractures are relatively benign,
  with low mortality (0.7) and low intrathoracic
  morbidity

9
Sternal Injury

• Cardiac complications, such as myocardial
  contusion occur in 1.5 to 6
• No association between sternal fracture and
  aortic rupture
• Spinal fractures in less than 10 of the cases
• rib fractures 21
• Although sternal fractures may occur in the
  context of major blunt chest trauma, the presence
  of sternal fractures does NOT necessarily
  translate into major life-threatening conditions.

10
Sternal Injury

• Anterior chest pain, point tenderness over the
  sternum, ecchymosis, soft tissue swelling, or
  palpable deformity
• Most sternal fractures are transverse, and a
  lateral radiographic view is diagnostic.
  Associated mediastinal injuries are best
  diagnosed by computed tomography (CT) scan of the
  chest.

11
Management

• Pain control
• Treat associated injuries

12
Sternoclavicular Dislocation

• Epidemiology
• Sternoclavicular dislocations are uncommon, but
  they are often associated with serious injury
• Anterior dislocations are much more common than
  posterior dislocations.

13
Sternoclavicular Dislocation

• Anatomy/Pathophysiology
• Anterior dislocation results from a lateral
  compressive force applied to the shoulder from an
  anterior position
• Posterior dislocation may result from a direct
  blow to the medial end of the clavicle or from a
  lateral compressive force applied to the shoulder
  from a posterior position.
• The more serious posterior dislocations are
  extremely difficult to detect.

14
Sternoclavicular Dislocation

• Clinical Feature
• Clinical pain with motion of the ipsilateral
  extremity or with lateral compression of the
  shoulders. The affected shoulder shortened or
  displaced anteriorly.
• With anterior dislocations the medial end of the
  clavicle is prominent and easily palpable.
  Posterior dislocations may present with a visible
  deformity along the lateral edge of the sternum.
• Posterior dislocations have been reported be
  associated with injuries to the subclavian artery
  and vein, trachea, and brachial plexus.

15
Sternoclavicular Dislocation

• Diagnostic CT
• Management
• Anterior Closed reduction with local or general
  anesthesia or by applying direct anterior
  pressure on the medial end of the clavicle.
• Posterior Closed reduction of a posterior
  dislocation usually requires general anesthesia.
  Posterior dislocations resulting in compression
  of the airway or major vessels in the root of the
  neck may need to be reduced emergently.

16
Sternoclavicular Dislocation

• Management
• Costochondral separation may also be caused by
  blunt anterior chest trauma. The signs and
  symptoms are similar to those of rib fracture,
  but because of the poor vascularity of healing
  cartilage, pain may persist for many weeks.
• The chest x-ray film is usually normal, but there
  is a snapping sensation with deep respiration. As
  with sternal fracture, consideration for
  admission to rule out cardiac contusion should be
  given to these patients. Outpatient management of
  these patients is similar to that of patients
  with rib fractures.
• Flail chest can also occur from massive
  costochondral separation, but this is uncommon.

17
Flail Chest

• Epidemiology
• uncommon in almost one third of a large series
  of major trauma patients with chest injuries.
• Anatomy/Pathophysiology
• Flail chest results when three or more adjacent
  ribs are fractured at two points, allowing a
  freely moving segment of the chest wall to move
  in paradoxical motion
• One of the most commonly overlooked injuries
  resulting from blunt chest trauma, and because of
  its common association with pulmonary contusion,
  it is also one of the most serious chest wall
  injuries.

18
Flail Chest

• Anatomy/Pathophysiology
• The physiology of respiration is affected
  adversely in a number of ways by flail chest.
• paradoxical motion of the chest wall
• underlying pulmonary contusion
• the pain of the injury causes muscular splinting
  with resultant atelectasis, hypoxemia, and
  decreased cardiac output.

19
Flail Chest

• Clinical Features
• Flail chest is usually diagnosed by physical
  examination. This requires exposure of the
  patients thorax and examination of the chest
  wall for paradoxical motion.
• Pain, tenderness, and crepitus can direct the
  examiner. The flail segment can sometimes be
  visualized to move separately and in an opposite
  direction from the rest of the thoracic cage
  during the respiratory cycle.
• Endotracheal intubation and positive pressure
  ventilation will internally splint the chest
  wall, making the flail segment difficult to
  detect on physical examination.

20
Flail Chest

• Diagnostic Strategies
• Multiple rib fractures can usually be identified
  on chest x-ray films. The diagnosis of flail
  chest is frequently missed up to 30 are not
  appreciated within the first 6 hours of
  admission.
• CT scan is much more accurate than plain films in
  evaluating for the presence and extent of
  underlying injury and contusion to the lung
  parenchyma it is being utilized routinely in
  some centers for all patients with major chest
  trauma.

21
Flail Chest

• Management
• Prehospital or ED stabilization of the flail
  segment, by positioning the person with the
  injured side down or placing a sandbag on the
  affected segments, has been abandoned. These
  interventions actually inhibit expansion of the
  chest and increase atelectasis of the injured
  lung. Oxygen should be administered, cardiac and
  oximetry monitors applied if available, and the
  patient observed for signs of an associated
  injury such as tension pneumothorax.

22
Flail Chest

• Management
• The cornerstones of therapy include aggressive
  pulmonary physiotherapy, effective analgesia,
  selective use of endotracheal intubation and
  mechanical ventilation, and close observation for
  respiratory compromise.
• Respiratory decompensation is the primary
  indication for endotracheal intubation and
  mechanical ventilation for patients with flail
  chest. Obvious problems such as hemopneumothorax
  or severe pain should be corrected before
  intubation and ventilation are presumed
  necessary. In fact, in the awake and cooperative
  patient, continuous positive airway pressure
  (CPAP) by mask may obviate the need for
  intubation. In general the most conservative
  methods for maintaining adequate oxygenation and
  preventing complications should be used.

23
Flail Chest

• Management
• Patients without respiratory compromise generally
  do well without ventilatory assistance.
• Several studies have found that patients treated
  with intercostal nerve blocks or high segmental
  epidural analgesia, oxygen, intensive chest
  physiotherapy, and careful fluid management with
  intubation reserved for only those patients who
  fail this therapy have shorter hospital courses,
  fewer complications, and lower mortality rates.
  Avoidance of endotracheal intubation,
  particularly prolonged intubation, is important
  in preventing pulmonary morbidity because
  intubation increases the risk of pneumonia.

24
Flail Chest

• Management
• The patient with flail chest should be treated in
  the ED as if pulmonary contusion exists
  regardless of whether mechanical ventilation is
  used. The mortality rate associated with flail
  chest is between 8 and 35 and is directly
  related to the underlying and associated
  injuries. Those who recover may develop long-term
  disability with dyspnea, chronic thoracic pain,
  and exercise intolerance.

25
Traumatic Asphyxia

• Anatomy/Physiology
• Traumatic asphyxia is a rare syndrome caused by a
  severe compression of the thorax by a very heavy
  object causing a marked increase in thoracic and
  superior vena caval pressure, resulting in
  retrograde flow of blood from the right heart
  into the great veins of the head and neck.
• The vena cava and the large veins of the head and
  neck do not have valves and allow the
  transmission of pressure to the capillaries of
  the head and neck, which become engorged with
  blood.

26
Traumatic Asphyxia

• Clinical Features
• Deep violet color of the skin of the head and
  neck, bilateral subconjunctival hemorrhages,
  petechiae, and facial edema.
• Stagnation develops from capillary atony and
  dilation, and as the blood desaturates, purplish
  discoloration of the skin occurs.
• Although the appearance of these patients can be
  quite dramatic, the condition itself is usually
  benign and self-limiting.

27
Traumatic Asphyxia

• Diagnostic Strategies
• The clinical significance lies with the
  possibility of intrathoracic injury from the
  violent force necessary to produce traumatic
  asphyxia. Chest wall and pulmonary injuries are
  most common. Therefore most of these patients
  should undergo CT scanning of the chest to
  identify any potentially serious intrathoracic
  injuries.

28
Traumatic Asphyxia

• Diagnostic Strategies
• Disturbance of vision has been attributed both to
  retinal hemorrhage, which is generally a
  permanent injury, and to retinal edema, which may
  cause transient changes in vision. One third of
  these patients lose consciousness, usually at the
  time of injury.
• Intracranial hemorrhages are rare, probably
  because of the shock-absorbing ability of the
  venous sinuses, but CT scan of the head should be
  done in patients with neurologic complaints.
• Neurologic manifestations typically clear within
  24 to 48 hours, and long-term sequelae are
  uncommon.

29
Pulmonary Injury

• Subcutaneous Emphysema
• Pulmonary Contusion
• Pulmonary Laceration
• Pneumothorax
• Hemothorax
• Tracheobronchial Injury

30
Subcutaneous Emphysema

• Anatomy/Physiology
• Subcutaneous emphysema in the presence of chest
  wall trauma usually indicates a more serious
  thoracic injury.
• Air enters the tissues either extrapleurally or
  intrapleurally. Extrapleural tears in the
  tracheobronchial tree allow air to leak into the
  mediastinum and soft tissues of the anterior
  neck, producing a pneumomediastinum, which may
  progress to a tension pneumomediastinum.

31
Subcutaneous Emphysema

• Anatomy/Physiology
• An esophageal tear resulting from Boerhaaves
  syndrome or penetrating injury pneumomediastinum
  with subcutaneous emphysema over the
  supraclavicular area and anterior neck.
• adjacent to a penetrating wound of the thorax
• Localized subcutaneous emphysema over the chest
  wall in the presence of blunt trauma traumatic
  pneumothorax
• Subcutaneous emphysema over the supraclavicular
  area and anterior neck usually indicates a
  pneumomediastinum.

32
Subcutaneous Emphysema

• Management
• Treat tension pneumothorax and tension
  pneumopericardium
• Massive accumulations can be uncomfortable to the
  patient.
• The underlying cause, such as pneumothorax,
  ruptured bronchus, or ruptured esophagus, must be
  treated appropriately.
• Benign pneumomediastinum secondary to a
  Valsalvas maneuver is treated with observation
  and high-flow oxygen to facilitate the
  reabsorption of nitrogen from tissues since the
  volume of nitrogen causes the discomfort.

33
Pulmonary Contusion

• Epidemiology
• Pulmonary contusion is reported to be present in
  30 to 75 of patients with significant blunt
  chest trauma, most often from automobile
  accidents with rapid deceleration.
• Pulmonary contusion can also be caused by
  high-velocity missile wounds and the high-energy
  shock waves of an explosion in air or water.
• Pulmonary contusion is the most common
  significant chest injury in children, and it is
  most commonly caused by an auto or pedestrian
  accident.

34
Pulmonary Contusion

• Anatomy/Pathophysiology
• Pulmonary contusion is a direct bruise of the
  lung parenchyma followed by alveolar edema and
  hemorrhage but without an accompanying pulmonary
  laceration
• The early diagnosis of pulmonary contusion is
  important if treatment is to be successful. The
  onset may be insidious, and therefore it must be
  suspected from the history of the mechanism of
  injury. Great force

35
Pulmonary Contusion

• Clinical Features
• Dyspnea, tachypnea, cyanosis, tachycardia,
  hypotension, and chest wall bruising
• Hemoptysis may be present in up to 50,
• Moist rales or absent breath sounds may be heard
  on auscultation.
• Palpation of the chest wall commonly reveals
  fractured ribs. If flail chest is discovered,
  pulmonary contusion is commonly present.
• Surprisingly, many of the worst contusions occur
  in patients without rib fractures but pulmonary
  contusions are associated with extrathoracic
  injuries in 87 of patients.

36
Pulmonary Contusion

• Diagnostic Strategies
• Dont be Masked!! Remember Time Sequence
• Typical radiographic findings begin to appear
  within minutes of injury and range from patchy,
  irregular, alveolar infiltrate to frank
  consolidation.
• Usually these changes are present on the initial
  examination, and they are always present in 4 to
  6 hours. The rapidity of changes on chest x-ray
  visualization usually correlates with the
  severity of the contusion.

37
Pulmonary Contusion

• Diagnostic Strategies
• CT scan has been found to be particularly
  sensitive for detecting the early phase of
  pulmonary contusion and has also proven sensitive
  for identifying a number of thoracic injuries.
• D/D with ARDS Pulmonary contusion usually
  manifests itself within minutes of the initial
  injury, is usually localized to a segment or a
  lobe, is usually apparent on the initial chest
  study, and tends to last 48 to 72 hours. ARDS is
  diffuse, and its development is usually delayed,
  with onset typically between 24 and 72 hours
  after injury

38
Pulmonary Contusion

• Diagnostic Strategies
• Arterial blood gases may be helpful in making the
  diagnosis of pulmonary contusion because most
  patients are hypoxemic at the time of admission.
• A low PO2 alone may be reason to suspect
  pulmonary contusion.
• A widening alveolar-arterial oxygen difference
  indicates a decreasing pulmonary diffusion
  capacity of the patients contused lung, and it
  is the earliest and most accurate means of
  assessing the current status, progress, and
  prognosis.

39
Pulmonary Contusion

• Management
• Essentially the same as flail chest
• Differential Lung Ventilation One Lung and
  Hypoxemia
• Intubation and mechanical ventilation should be
  avoided if possible because they are associated
  with an increase in morbidity, including
  pneumonia, sepsis, pneumothorax,
  hypercoagulability, and longer hospitalization

40
Pulmonary Contusion

• Management
• the restriction of intravenous fluids to maintain
  intravascular volume within strict limits,
• aggressive supportive care consisting of vigorous
  tracheobronchial toilet,
• suctioning,
• and pain relief

41
Pulmonary Contusion

• Prognosis
• Pneumonia is the most common complication of
  pulmonary contusions, and it significantly
  worsens the prognosis. It develops insidiously,
  especially in patients treated with prophylactic
  antibiotics. The use of antibiotics should be
  reserved for specific organisms rather than given
  prophylactically.
• Only 5 to 16 of patients with an isolated
  pulmonary contusion will die, whereas the
  mortality of those with even one associated
  extrathoracic injury is five times greater

42
Pulmonary Laceration

• Most often lacerated from penetrating injury
• Also be injured by the inward projection of a
  fractured rib or avulsion of a pleural adhesion.
• Usually minor and uncommonly life threatening?
  they can usually be treated with observation or
  tube thoracostomy
• Severe lacerations are present in only 3 of
  patients with thoracic trauma? associated with
  hemopneumothorax, multiple rib fractures, and
  hemoptysis ? require thoracotomy with resection
  to control bleeding.

43
Pneumothorax

• Epidemiology
• Pneumothorax, which is the accumulation of air in
  the pleural space, is a common complication of
  chest trauma.
• 15 to 50
• Invariably present in those with transpleural
  penetrating injuries

44
Pneumothorax

• Anatomy/Pathophysiology
• Pneumothorax can be divided into three
  classifications, depending on whether air has
  direct access to the pleural cavity
• Simple
• Communicating
• Tension.

45
Pneumothorax

• Anatomy/Pathophysiology
• Simple pneumothorax when there is no
  communication with the atmosphere or any shift of
  the mediastinum or hemidiaphragm resulting from
  the accumulation of air.
• It can be graded according to the degree of
  collapse as visualized on the chest radiograph.
• A small pneumothorax occupies 15 or less of the
  pleural cavity, a moderate one 15 to 60, and a
  large pneumothorax more than 60.
• Traumatic pneumothorax is most often caused by a
  fractured rib lacerating the pleura. It may also
  occur without a fracture when the impact is
  delivered at full inspiration with the glottis
  closed, leading to a tremendous increase in
  intraalveolar pressure and the subsequent rupture
  of the alveoli that causes the pneumothorax. A
  penetrating injury such as a gunshot or stab
  wound may also produce a simple pneumothorax
  ifthere is no free communication with the
  atmosphere.

46
Pneumothorax

• Anatomy/Pathophysiology
• Communicating pneumothorax associated with a
  defect in the chest wall and most commonly occurs
  in combat injuries.
• In the civilian sector, this injury is most
  commonly secondary to shotgun wounds. Air can
  sometimes be heard flowing sonorously in and out
  of the defect, prompting the term sucking chest
  wound.
• The involved lung paradoxically collapse on
  inspiration and expand slightly on expiration,
  forcing air in and out of the wound? large
  functional dead space for the normal lung

47
Pneumothorax

• Anatomy/Pathophysiology
• Tension pneumothorax Progressive accumulation of
  air under pressure within the pleural cavity,
  with shift of the mediastinum to the opposite
  hemithorax and compression of the contralateral
  lung and great vessels
• It occurs when the injury acts like a one-way
  valve.
• Air enters on inspiration but cannot exit with
  expiration, which compresses the vena cava and
  distorts the cavoatrial junction, leading to
  decreased diastolic filling of the heart and
  subsequent decreased cardiac output. ? rapid
  onset of hypoxia, acidosis, and shock.

48
Pneumothorax

• Clinical Features
• Shortness of breath and chest pain most common
• Appearance highly variable, ranging from acutely
  ill with cyanosis and tachypnea to misleadingly
  healthy
• The signs and symptoms are not always correlated
  with the degree of pneumothorax.
• PE Decreased or absent breath sounds and
  hyperresonance over the involved side as well as
  subcutaneous emphysema

49
Pneumothorax

• Clinical Features
• Patients with tension pneumothorax become acutely
  ill within minutes and develop severe
  cardiovascular and respiratory distress.
• They are dyspneic, agitated, restless, cyanotic,
  tachycardic, and hypotensive and display
  decreasing mental activity.
• The cardinal signs of tension pneumothorax are
  tachycardia, jugular venous distention, and
  absent breath sounds on the ipsilateral side.
• Hypotension will not occur as early as hypoxia
  and may represent a preterminal event.

50
Pneumothorax

• Diagnostic Strategies
• Chest radiograph is the preferred initial study
  for diagnosing a simple pneumothorax, and it
  should be obtained as rapidly as possible. ?
  upright full inspiratory film if the patients
  condition permits
• Expiratory film If a pneumothorax is suspected
  but not visualized on the initial inspiratory
  film
• As many as one third of initial chest x-ray
  films will not detect a pneumothorax in trauma
  patients.

51
Pneumothorax

• Diagnostic Strategies
• CT scan very sensitive in finding a small
  pneumothorax even in the supine patient. Not
  Primary Choice
• Low cuts of Chest in Abdominal CT scans to
  exclude the presence of a small pneumothorax
• CT scanning is not routinely recommended to
  diagnose a small pneumothorax that is not visible
  on chest x-ray film and does not require any
  treatment.

52
Hemothorax

• Epidemiology
• Hemothorax, which is the accumulation of blood in
  the pleural space after blunt or penetrating
  chest trauma, is a common complication that may
  produce hypovolemic shock and dangerously reduce
  vital capacity.
• It is commonly associated with pneumothorax (25
  of cases) as well as extrathoracic injuries (73
  of cases).

53
Hemothorax

• Anatomy/Pathophysiology
• Hemorrhage from injured lung parenchyma most
  common cause
• self-limiting unless there is a major laceration.
  
• Intercostal and internal mammary arteries causing
  hemothorax more often than hilar or great vessels

54
Hemothorax

• Management
• Close monitoring of the initial and ongoing rate
  of blood loss must be performed.
• Immediate drainage of more than 1000 ml of blood
  from the pleural cavity is usually considered an
  indication for thoracotomy.
• Perhaps even more predictive of the need for
  thoracotomy is a continued output of at least 200
  ml/hr for 4 hours.

55
Hemothorax

• Clinical Features
• Depending on the rate and quantity of hemorrhage,
  varying degrees of hypovolemic shock will be
  manifested.
• Tactile fremitus is decreased
• Diminished or absent breath sounds

56
Hemothorax

• Diagnostic Strategies
• Blunting of the costophrenic angles on chest
  radiograph at least 200 to 300 ml of fluid in
  the upright position
• Supine view chest film less accurate, more
  difficult to make the diagnosis

57
Hemothorax

• Management
• ABC
• Tube Thoracostomy
• Thoracotomy
• Autotransfusion
• Thoracoscopy
• evacuation of retained hemothorax,
• control of bleeding from intercostal vessels,
• diagnosis and repair of diaphragmatic injuries.
• At present, thoracoscopy is the only accurate
  method to quantify the amount of blood remaining
  in the pleural space after tube thoracostomy
  placement

58
Tracheobronchial Injury

• Epidemiology
• Tracheobronchial injuries may occur with either
  blunt or penetrating injuries of the neck or
  chest.
• Relatively rare injury, occurring in fewer than
  3 of patients with significant chest injury
• Overall mortality of 30, 50 of whom will die
  within the first hour.

59
Tracheobronchial Injury

• Anatomy/Pathophysiology
• Knife wounds ? cervical trachea
• Gunshot wounds ? tracheobronchial tree at any
  point.
• Intrathoracic injury to the tracheobronchial tree
  occurs most commonly from blunt trauma direct
  blows, shearing stresses, or burst injury
• Sudden deceleration of the thoracic cage, as
  occurs in a decelerating auto accident, pulls the
  lungs away from the mediastinum, producing
  traction on the trachea at the carina.
• It has also been suggested that if the glottis is
  closed at the time of impact, the sudden increase
  in intrabronchial pressure will rupture the
  tracheobronchial tree.
• Regardless of the mechanism, more than 80 of
  these injuries occur within 2.5 cm of the carina.

60
Tracheobronchial Injury

• Clinical Features
• Massive air leak, hemoptysis, and subcutaneous
  emphysema
• In the first group, the wound opens into the
  pleural space, producing a large pneumothorax.
• often have hemoptysis, dyspnea, subcutaneous and
  mediastinal emphysema, and cyanosis. Auscultation
  of the heart may reveal a Hammans crunch.
• The second group has a complete transection of
  the tracheobronchial tree but little or no
  communication with the pleural space. A
  pneumothorax is not usually present.
• The peribronchial tissues support the airway
  enough to maintain respiration, but within 3
  weeks granulation tissue will obstruct the lumen
  and produce atelectasis. These patients are
  relatively free of symptoms at the time of injury
  but weeks later have unexplained atelectasis or
  pneumonia.

61
Tracheobronchial Injury

• Diagnostic Strategies
• When tracheobronchial injury is suspected,
  bronchoscopy should be performed.
• Fiberoptic bronchoscopy is the most reliable
  means of establishing the diagnosis and
  determining the site and extent of the injury.
• Bronchopleural fistula can occur as a
  complication of tracheobronchial disruption and
  in some cases has been treated successfully via
  the fiberoptic bronchoscope.

62
Tracheobronchial Injury

• Management
• If possible, endotracheal intubation over a
  bronchoscope should be performed since it allows
  visualization of the tube as it passes beyond the
  site of injury.
• In most cases, thoracotomy with intraoperative
  tracheostomy and surgical repair of the disrupted
  airway should be performed as soon as possible.

63
Esophageal Rupture

• Epidemiology
• Perforation of the esophagus has been called the
  most rapidly fatal perforation of the
  gastrointestinal tract because death from its
  rapidly fulminant course is almost ensured if the
  diagnosis is delayed

64
Esophageal Rupture

• Epidemiology
• Iatrogenic
• Foreign bodies
• Caustic burns
• Blunt or penetrating trauma
• Spontaneous rupture (Boerhaaves syndrome)
• Postoperative breakdown of anastomosis

65
Esophageal Rupture

• Diagnostic Findings
• The diagnosis of esophageal perforation is aided
  by consideration of clinical circumstances.
• In patients with classic Boerhaaves syndrome,
  overindulgence and emesis are followed by severe
  chest pain, subcutaneous emphysema, and
  cardiopulmonary collapse.
• Development of these signs and symptoms following
  instrumentation of the esophagus or removal of an
  esophageal foreign body is relatively
  straightforward.
• Up to one third of cases of a perforated
  esophagus, however, are atypical

66
Esophageal Rupture

• Clinical Features
• pleuritic pain localized along the course of the
  esophagus that is exacerbated by swallowing or
  neck flexion
• located in the epigastrium, substernal area, or
  back, usually worsens over time, and may migrate
  from the upper abdomen to the chest
• Dyspnea if infectious

67
Esophageal Rupture

• Clinical Features
• Sparse early signs imparting a nasal quality to
  the voice Hammans crunch
• signs of a hydropneumothorax or an empyema
• Subcutaneous emphysema only 60 30 in those
  without tracheal injury
• Septic pictures

68
Esophageal Rupture

• Differential Diagnosis
• Spontaneous pneumomediastinum
• Aortic aneurysm (thoracic)
• Pulmonary embolus
• Perforated peptic ulcer
• Myocardial infarction
• Pancreatitis
• Mesenteric thrombosis
• Cholecystitis

69
Esophageal Rupture

• Diagnostic Strategies
• Laboratory studies provide largely nonspecific
  findings. If tested, the pleural effusion of
  esophageal perforation may show a high salivary
  amylase level or a low pH.
• The radiographic examination usually suggests the
  diagnosis of an esophageal perforation. The
  classic chest radiograph findings are as follows
  
• Mediastinal air with or without subcutaneous
  emphysema
• Left-side pleural effusion
• Pneumothorax
• Widened mediastinum

70
Esophageal Rupture

• Management
• Early diagnosis can best be accomplished if one
  is aware of the pathophysiology and clinical
  settings in which esophageal perforations occur.
• Time is critical in minimizing the mortality and
  morbidity of this condition.
• If the diagnosis is strongly suggested or
  confirmed, the patient should be given nothing by
  mouth and started on broad-spectrum antibiotic
  therapy (covering oral flora) and volume
  replacement. An emergency surgical consultation
  should be obtained.

71
Diaphragm Herniation

• Epidemiology
• 1 to 6 of all patients sustaining multiple
  trauma
• mean age 33 years range from 1 to 89 years
• male/female ratio 41
• penetrating trauma 53 (of which 55 were knife
  wounds and 45 were gunshot wounds)
• blunt traumatic diaphragmatic rupture was caused
  by motor vehicle accidents in 86, auto and
  pedestrian accidents in 4, and falls, motorcycle
  accidents, and crush injuries 3

72
Diaphragm Herniation

• Anatomy/Pathophysiology
• direct penetration of the diaphragm or blunt
  forces to the chest or abdomen
• Diaphragmatic injuries that are not diagnosed and
  surgically repaired acutely may not become
  clinically evident until months to years later
  when herniation of abdominal contents into the
  chest leads to complications such as visceral
  incarcerations, obstruction, ischemia from
  strangulation, or perforation.

73
Diaphragm Herniation

• Anatomy/Pathophysiology
• Penetrating trauma direct violation of the
  diaphragm by the penetrating object or missile.
• Blunt trauma increased intraabdominal or
  intrathoracic pressure is transmitted to the
  diaphragm, leading to rupture.
• Studies on the bursting pressure of cadavers show
  a consistent weakness on the left side (LR31).
  The right hemidiaphragm is protected by the
  liver

74
Diaphragm Herniation

• Anatomy/Pathophysiology
• Penetrating trauma can involve any portion of the
  diaphragm.
• In blunt trauma, the majority of tears occur in a
  radial direction, specifically in the
  posterolateral area of the left side of the
  diaphragm. This area correlates with the
  embryologic point of weakness and is involved 12
  times more often than other reported sites.

75
Diaphragm Herniation

• Anatomy/Pathophysiology
• In penetrating trauma, it is usually less than 2
  cm, whereas in blunt trauma it is commonly
  between 5 and 15 cm.
• The defect in the diaphragm does not heal
  spontaneously, regardless of size, because of the
  normal pleuroperitoneal pressure gradient of 7 to
  22 cm H2 O, which can exceed 100 cm H2 O during
  maximal respiratory effort. This gradient
  prevents spontaneous closure of the tear and
  promotes herniation of abdominal contents through
  the defect into the chest.

76
Diaphragm Herniation

• Anatomy/Pathophysiology
• Acute phase begins at injury and ends with
  apparent recovery from the primary injuries only
  22 of patients with traumatic diaphragmatic
  injury have the diagnosis within this initial
  stage.
• Latent phase Diaphragmatic injury is diagnosed
  in a delayed manner in about 18 of blunt and 32
  of penetrating trauma cases.
• Symptoms during this time are those of vague
  abdominal distress caused by the intermittent
  entrapment of herniated abdominal viscera with
  incarceration or strangulation of abdominal
  viscera within the defect.
• Obstructive phase vascular compromise of the
  herniated, strangulating abdominal viscera
• The liver is the most common organ to herniate on
  the right.
• The omentum and small bowel predominantly on the
  left side

77
Diaphragm Herniation

• Clinical Features
• In the acute phase tachypnea, hypotension,
  absence of breath sounds, abdominal distention,
  or bowel sounds in the chest.
• In the latent phase abdominal discomfort caused
  by intermittent herniation of abdominal contents.
  (subtle)
• The most common symptom is nonspecific abdominal
  pain that tends to be worse postprandially and is
  exacerbated by the supine position.
• The pain often radiates to the left shoulder, is
  alleviated by sitting or standing, and may be
  associated with nausea, vomiting, and eructation.
  
• cough, dyspnea, and nonspecific chest pain.
• In the obstructive phase, abdominal pain,
  constipation, nausea, vomiting, and abdominal
  distention are often profound and unrelenting.
  TENSION VISCEROTHORAX

78
Diaphragm Herniation

• Diagnostic Strategies
• Acute Nonspecific on Plain Films
• Laparoscope (Choice)
• diagnostic peritoneal lavage (DPL), CT scan, US,
  magnetic resonance imaging (MRI) scan,
  radionuclide scans, pneumoperitoneography, and
  barium contrast examination
• Latent
• 50-100 on CXR
• unilaterally elevated diaphragm, a shift of the
  mediastinum away from the affected side, apparent
  unilateral pleural thickening, suspicious areas
  of atelectasis at the base of the lungs, evidence
  of air-filled or solid viscus above the
  diaphragm, and radiographic evidence of a
  nasogastric tube positioned above the diaphragm
• Contrast study
• CT POOR for isolated diaphragm lesion

79
Diaphragm Herniation

• Management Strategies
• Obstructive In patients with signs and symptoms
  consistent with strangulation,
• ABC
• Nasogastric tube avoid iatrogenic laceration
• Patients with perforated viscera are septic and
  require appropriate resuscitation.
• Chest tube If the patient has evidence of a
  tension viscerothorax avoid trocar
• After initial stabilization, surgical reduction
  of the hernia and repair of the diaphragm are
  mandatory. Most, if not all, acute diaphragmatic
  injuries can be approached through a laparotomy.

80
Cardiovascular Trauma

• Blunt Cardiac Trauma
• Myocardial Concussion
• Myocardial Contusion
• Myocardial Rupture
• Penetrating Cardiac Injury
• Acute Pericardial Tamponade
• Blunt Aortic Injury
• Chronic Aortic Aneurysm
• Aortic Arch Injury

81
Cardiovascular Injury

• Details To be Presented Soon Later

Thanks for Attending