power point presentation on chest trauma

1. CHEST TRAUMA
CHUK / DEPARTEMENT OF SURGERY
Prepared by
UKIRIMUTO Claude ( INTERN MEDICAL STUDENT)
Supervised by
Dr. UWAKUNDA

2. OVERVIEW
 Introduction
 Epidemiology
 Anatomy recall and Pathophysiology of injury
Trauma evaluations
Specific injuries
Clinical features
Approach to imaging
Management
Surgical techniques

3. Introduction
 Chest trauma puts multiple structures at risk of injury
 Major concerns:
 Chest wall : rib fractures or flail chest
 Cardiovascular injury : BAI or cardiac contusion
 Pulmonary injury : contusion or laceration
 BAI is the most lethal injury of the thorax if untreated.
(BAI , blunt aortic injury)

4.  Majority may require simple procedures (eg. Thoracostomy tube)
 Minority require urgent surgical exploration due to bleeding
 Most life-threatening injuries can be identified in the primary survey

5. TYPES OF CHEST INJURY
 Blunt Chest injury ( closed chest injury )
Eg. RTA, Fall, Crush injury
Associated with multiple injuries such as head, limb, abdomen
 Penetrating Chest injury ( open chest injury)
Mostly by assault
Associated with chest wall damage, open pneumothorax, and organ injury

6. EPIDEMIOLOGY
 Blunt chest trauma
 Second leading cause of trauma deaths
 RTA is common aetiology 65-70 %
 25% of trauma deaths are a direct result of chest injury
 50% of patients who die from multiple trauma have significant chest injury

7. Epidemiology
 Motor vehicle collisions is the most common cause
 higher risk of getting thoracic injury:
 High speed
 Age ≥60 (relative risk [RR] 3.6; 95%
 Front-seat occupancy (RR 3.1; 95%
 Not wearing a seatbelt (RR 3.0; 95%
 BAI, the majority die immediately.

8. Epidemiology con’t
 20% of deaths from MVCs are attributable to blunt cardiac injuries
 Rib fracture occurs almost 2/3 of chest trauma due to MVCs
 Pneumothorax is a common complication
 Fractures of the sternum and scapula
 Reflects trauma of significant force
 Increases the risk for significant internal injury

9. Epidemiology : Deaths
Immediate deaths( within seconds to minutes)
disruption of the heart or great vessel injury.
Early deaths ( minutes to hours)
airway obstruction, tension pneumothorax
pulmonary contusion, or cardiac tamponade.
Late deaths
pulmonary complications, sepsis, and missed injuries.

10. ANATOMY
 Thoracic cage:
 Sternum and costal cartilages in front
 vertebral column behind
 Intercostal spaces laterally
 Separated from abdominal cavity by
 diaphragm
 Superiorly thoracic inlet

15. Anatomy and Mechanism
MEDIASTINUM

18. PATHOPHYSIOLOGY
Flail chest Contusion Pneumothorax Heart & vessel Associated injury
Decreased alveolar ventilation Shock
Rt to Lt Shunting Decreased CO
Hypoxia Hypotension
Respiratory Acidosis Metabolic Acidosis
DEATH
what do you think about heamohorax?

19. INITIAL MANAGEMENT
• symptoms and severity of illness.
• Rapid transport to the closest trauma center
• Primary survey by ATLS guideline
• Resuscitation of vital functions
 Detailed secondary survey
 Definitive care

20. Specific injuries
 Classification
Immediate Life Threatening injuries (Lethal Six)
Potential Life Threatening injuries( Hidden Six)

21. Lethal Six
 Fatal if they are not recognized and treated immediately:
 Airway Obstruction
 Tension pneumothorax
 Open pneumothorax “sucking chest wound”
 Massive hemothorax
 Flail chest
 Cardiac tamponade

22. Hidden Six
 Primary or secondary survey may reveal one of them
 Cardiac contusion
 Aortic disruption
 Diaphragmatic rupture
 Esophageal injury
 Pulmonary contusion
 Tracheo-bronchial injuries

23. Airway obstruction
 Protect the cervical spine as the airway is being managed
 Causes
 The tongue is the most common cause
 Dentures, avulsed teeth, tissue,
 Secretions and blood
 Bilateral mandibular fracture
 Expanding neck hematomas
 Laryngeal trauma
 Tracheal tear or transection

24. Signs and Symptoms
Stridor, hoarseness of voice
subcutaneous emphysema,
altered mental status
accessory muscle working
Apnea, and cyanosis (sign of pre-terminal hypoxemia

25. Management
Intubate using a controlled rapid sequence
Provide inline cervical spine immobilization during intubation
Early intubate in cases of neck hematoma or possible airway edema
Emergency cricothyroidotomy should perform if endotracheal intubation
fails.

26. Tension Pneumothorax
 Air enters pleural space
 Increased pressure which collapses lung
 Mediastinum shifts to unaffected side
 Compressed heart and great vessels leads to decreased cardiac output.
 Leads to Cardiogenic Shock

27. Signs & Symptoms
 Dyspnea with Tachypnea
 Anxiety
 Diminished breath sounds
 Hypotension and Tachycardia
 JVD
 Narrowing pulse pressure
 Tracheal Deviation
Late Sign : Shock

29. Management
 Needle Thoracostomy
 12 or 14 gauge IV catheter in 2nd ICS & MCL or 5th ICS in AAL
 Chest tube placement
 Possible thoracotomy or thoracoscopy

30. Open Pneumothorax
(Sucking Chest Wound)
• Open chest wall injury
• Stab wounds usually self-sealing
• Air passes through opening into the pleural space And remains outside of
lung
• Large open defect in chest wall (>3 cm diameter)

31. Signs & Symptoms
• Gurgling sound during respiration
• Bubbling wound
• Dyspnea & Tachypnea
• Diminished breath sound

32. OPEN PNEUMOTHORAX
Treatment
Oxygenation and possible intubations if in distress
Bandage may be applied over the wound and taped on 3 sides for cover the
defect
Immediate CT insertion to affected side.
Urgent thoracotomy to evacuate blood clot and treat associated intrathoracic
injuries.
 Irrigate, debride, and close the chest wall defect in the OR.
 Large defects may require flap closure

33. Massive Hemothorax
Blood in the pleural space
Each side of the chest can hold 2500-3000ml of blood
Possible Sources –
 Intercostal vessels
 Internal mammary artery
 Pulmonary vessels
 Lung parenchyma

34. Sign and Symptoms
M. Haemothorax
Hemorrhagic shock
Absence or diminution of breath sound in affected side
Dullness on percussion in affected side
Flattened neck veins
CXR will show unilateral “white out” (opacification)

35. MANAGMENT
CT insertion first with available of blood transfusion
Thoracotomy indicated –
 If immediate drainage of 1000-1500mls of blood Or 200ml for 2 to 4 hours
 Failure to completely drain hemothorax

36. FLAIL CHEST
When 2 or more adjacent ribs fractures in 2 or more places
Paradoxical movement
The flailed segment moves in opposite direction of the chest wall movement
The sternum is fractured
To loose form its attachments with the ribs

37. Flailed Chest

38. Flail Chest
Sign & Symptoms
Severe pain with chest wall movement
Decreased ventilatory volume
Underlying lung contusion
Potentially Pheumo/hemothorax
Potentially (flailed sternum) – Cardiac Tamponade – Traumatic Asphyxia

39. Treatment: FLAIL CHEST
It directed towards Analgesia is the main treatment
Protected underling lung PCA and NSAID
Maintain ventilation Epidural is the best option (elderly)
Prevent pneumonia
Intubations and mechanical ventilation( rarely indicated )
Operative Fixation by wires or plates was indicated in
 thoracotomy
 Fixed thoracic impaction
 Failure to wean from ventilator

40. CARDIAC TAMPONADE
 Collection of blood between heart and pericardium
 Source of blood can be
 coronary arteries or myocardium.
Pericardium may hold up to 200-300ml of blood
before S&S develop

41. CARDIAC TAMPONADE
Signs & Symptoms Beck’s Triad
• Tachycardia MHS
• Paradoxical pulse JVD
• JVD Narrowing pulse pressures Hypotension
• Muffled heart sounds
• S&S of shock

42. MANAGEMENT
Assess
The need for intubation, oxygenate
Start volume resuscitation.
Life saving Pericardiocentesis to relieve tamponade before definitive repair
Ideal management
 Emergency left antero-lateral thoracotomy to relieve the tamponade

43. COMPLICATIONS
Chest wall injury
• Sucking wound & open pneumothorax
• ribs – pain, haemothorax, flail chest, deformed chest, respiratory distress
Lung injury
 Lung contusion, haemothorax, pneumothorax ( usually haemo- pneumothorax),
 Empyema thoracis
Major air way injury – Surgical emphysema, massive pneumothorax

44. COMPLICATIONS
Esophageal injury
 Mediastinal sepsis, septicemia, pneumothorax
Cardiac injury
 Cardiac temponade, myocardial contusion/ laceration
Great vessel injury
 Hypovolemia, shock
Terminal complication – ARD

45. Rectangular danger zone

46. SURGICAL TECHNIQUE
If the penetrating implement remains in situ, it should not be removed until the
chest is open.
Median sternotomy
Median sternotomy is preferable in most stable patients
It gives access to
 The heart and great vessels
 Other structures in the mediastinum and to both pleural cavities.

48. Left antero-lateral thoracotomy
Left antero-lateral thoracotomy (ALT) provides rapid access
To the right and left ventricles
To the pulmonary artery
‘clam-shell’ incision
ALT may continued across into
the right chest
Allows access to other injuries
Allows cross-clamping of the descending
thoracic aorta

49. Left antero-lateral thoracotomy
The chest is opened through the fifth ICS and the sternum is transected,
The two divided internal mammary arteries are immediately controlled
Rapid spreading of the ribs often results in rib fractures
Attention must be paid to avoid accidental injury from sharp rib splinters.

50. PROGNOSIS
Following features are associated with increased morbidity and
mortality :
Extreme of age
Pre-existing pulmonary or cardiac disease
Previous chest surgery
Obesity
Deformity of the chest wall
Delay in managing hypoxia and hypotension
Overloading in fluid replacement

51. Take home messages
• Principal aims of treatment are control of hypoxia & hypotension
• High degree of suspicion for avoid missing associated injuries
• Simple measures if timely, and properly adopted will definitely save the life.
• Knowledge of anatomy, respiratory physiology and ciritical care gives vast
account
• About 80 per cent of chest injuries can be managed closed
• If there is an open wound, insert a chest drain
• Do not close a sucking chest wound until a drain is in place
• If bleeding persists, the chest will need to be opened

52. References
• https://www.uptodate.com/contents/initial-evaluation-and-management-of-
blunt-thoracic-trauma-in-
adults?search=blunt%20chest%20trauma&source=search_result&selectedTit
le=2~150&usage_type=default&display_rank=2#H2
• Lecturer note by prof. Gashegu on anatomy review of the chest