Chest Trauma
Surgery department № 2
DSMA
Introduction
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Chest trauma is often sudden and
dramatic
Accounts for 25% of all trauma deaths
2/3 of deaths occur after reaching hospital
Serious pathological consequnces:
-hypoxia, hypovolaemia, myocardial
failure
Mechanism of Injury
Penetrating injuries
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E.g. stab wounds etc.
Primarily peripheral lung
Haemothorax
Pneumothorax
Cardiac, great vessel or oesophageal
injury
Blunt injuries
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Either:
direct blow (e.g. rib fracture)
deceleration injury
compression injury
Rib fracture is the most common sign of
blunt thoracic trauma
Fracture of scapula, sternum, or first rib
suggests massive force of injury
Chest wall injuries
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Rib fractures
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Flail chest
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Open pneumothorax
Rib fractures
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Most common thoracic injury
Localised pain, tenderness, crepitus
CXR to exclude other injuries
Analgesia avoid taping
Underestimation of effect
Upper ribs, clavicle or scapula fracture:
suspect vascular injury
Flail chest
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Multiple rib fractures produce a mobile
fragment which moves paradoxically with
respiration
Significant force required
Usually diagnosed clinically
Rx: ABC
Analgesia
Flail chest
Flail Chest - detail
Open pneumothorax
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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
“Sucking chest wound”
Rx: ABCs…closure of wound…chest
drain
Lung injury
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Pulmonary contusion
Pneumothorax
Haemothorax
Parenchymal injury
Trachea and bronchial injuries
Pneumomediastinum
Pneumothorax
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Air in the pleural cavity
Blunt or penetrating injury that disrupts
the parietal or visceral pleura
Unilateral signs: movement and breath
sounds, resonant to percussion
Confirmed by CXR
Rx: chest drain
Pneumothorax classification
By side:
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left or right
in both side
By lung collapse degree:
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Partial (paracostal)
Subtotal (smaller than 2/3 of lung volume)
Total (more than 2/3 of lung volume)
By mechanism of formation:
- open
- closed
- tension
Pneumothorax
Tension pneumothorax
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Air enters pleural space and cannot
escape
P/C: chest pain, dyspnoea
Dx: - respiratory distress
- tracheal deviation (away)
- absence of breath sounds
- distended neck veins
- hypotension
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Surgical emergency
Rx: emergency decompression before
CXR
Either large bore cannula in 2nd ICS,
MCL or insert chest tube
CXR to confirm site of insertion
Haemothorax
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Blunt or penetrating trauma
Requires rapid decompression and fluid
resuscitation
May require surgical intervention
Clinically: hypovolaemia
absence of breath sounds
dullness
to percussion
CXR may be confused with collapse
Decompression always by chest catchment in 7
ICS on middle or posterior axillary line
Hemothorax classification
By side:
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left or right
in both side
By blood lost volume :
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Small (< 10% of BCV, or <500 ml)
Middle (10-20 % of BCV, or 500-1000ml)
Big (10-20 % of BCV, or 500-1000ml)
Total ( > 40 % of BCV, or >2000ml)
By bleeding presence:
- stopped (Reviloi – Gregoire test negative)
- continues (Reviloi – Gregoire test positive)
By clots presence:
- clotted
- unclotted
By infection complication presence:
- non-infected
- infected
Indication for urgent thoracotomy
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In pneumothorax:
Absence of active air catchment during more
than 2 days (presence of pneumothoraz on CXR)
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In hemothorax:
Evacuation of > 1000ml blood simultaneously
or bleeding continues during 4 hours with blood
loss > 200 ml per hour
Heart, Aorta & Diaphragm
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Blunt cardiac injury
- contusion
- ventricular, septal or valvular
rupture
Cardiac tamponade
Ruptured thoracic aorta
Diaphragmatic rupture
Cardiac Tamponade
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Blood in the pericardial sac
Most frequently penetrating injuries
Shock, JVP, PEA, pulsus paradoxus
Classically, Beck’s triad:
distended neck veins
muffled heart sounds
hypotension
Rx: Volume resuscitation
Pericardiocentesis
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Cardiac tamponade
Aortic rupture
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Usually blunt trauma involving
deceleration forces; especially RTAs
~90% die within minutes
Most common site near ligamentum
arteriosum
Dx: clinical suspicion, CXR, aortography,
contrast CT or TOE
Rx: surgical…poor prognosis
Aortic rupture
Iatrogenic trauma
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NG tubes:
- coiling
- endobronchial placement
- pneumothorax
Chest tubes: - subcutaneous
- intraparenchymal
- intrafissural
Central lines: - neck
- coronary sinus
- pneumothorax
Line in jugular vein
Misplaced nasogastric tube
Chest trauma: summary
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Common
Serious
Primary goal is to provide oxygen to
vital organs
Remember
Airway
Breathing
Circulation
Be alert to change in clinical condition