ER APPROACH TO A PATIENT WITH CHEST ER APPROACH TO A PATIENT WITH CHEST EMERGENCIESEMERGENCIES

DR. TAREK SILEM AL-NOGOMIDR. TAREK SILEM AL-NOGOMI

Emergency SpecialistEmergency Specialist

General Surgery Acting ConsultantGeneral Surgery Acting Consultant

CHEST TRAUMACHEST TRAUMA

Chest traumaChest trauma

Department of Traumatology, Medical University of Vienna, Vienna, Austria

May 2005  

This study includes all polytrauma patients with chest injury treated between 1992 and 2002 at a major urban trauma center

332 out of 501 polytrauma patients, 228 males and 104 females, had a coexisting chest injury. Mean age at the time of injury was 37.7 years, and 258 patients were intubated before admission. Average period on ICU was 15.4 days, and 35.9 days for total hospital stay. Regarding the injury pattern in 143 patients a combined hemo-/pneumothorax was seen, 109 patients had either a hemothorax or a pneumothorax, in 155 patients a unilateral and in 52 patients a bilateral serial rib fracture was diagnosed, in 28 patients either sternal or singular rib fractures were determined, in a total of 23 patients an unstable thorax or a flail chest was seen, 105 patients had a unilateral pulmonary contusion, and in 79 patients a bilateral pulmonary contusion was diagnosed. Finally, a total of eleven patients with a traumatic aortic disruption were identified

Who SurviveWho Survive

85% Need conservative treatment & \85% Need conservative treatment & \or simple maneuversor simple maneuvers

15% will need surgery 15% will need surgery

Types of InjuryTypes of Injury

•Direct … blunt … penetrating … Direct … blunt … penetrating … cruchcruch

•

•Indirect … blast … decelerationIndirect … blast … deceleration

TRAUMATIC CHEST PROBLEM TRAUMATIC CHEST PROBLEM THREATENING LIFE NEEDS THREATENING LIFE NEEDS IMMEDIATE MANAGEMENTIMMEDIATE MANAGEMENT

– ABCDABCDDyspnea, tachypnea, hypotension, Dyspnea, tachypnea, hypotension, ABG changesABG changes

Expose chest and neck completely, Expose chest and neck completely, observe, palpate and listen.observe, palpate and listen.

Cyanosis is a late symptom of Cyanosis is a late symptom of hypoxia.hypoxia.

VITAL SIGNSVITAL SIGNS ?? ??

Hemodynamically instability Hemodynamically instability associated with chest associated with chest

trauma represent trauma represent A life-threatening A life-threatening

emergency. emergency.

O2 INHALATION O2 INHALATION

ABG , if patient is desaturated.ABG , if patient is desaturated.

SELECTIVE PHYSICAL SELECTIVE PHYSICAL EXAMINATIONEXAMINATION

Pulse evaluation, regular, irregular, strong or Pulse evaluation, regular, irregular, strong or weak.weak.

Neck, congested neck veins.Neck, congested neck veins.

Heart sound .Heart sound .

Respirations … one side dullness or Hyper Respirations … one side dullness or Hyper resonance by percussion.resonance by percussion.

TraumaTrauma

Dysnea …. DesaturationDysnea …. Desaturation

TENSION PNEUMOTHORAX (TN)TENSION PNEUMOTHORAX (TN)One way valve air leak occurs from lung or from One way valve air leak occurs from lung or from

chest wall chest wall –– complete collapse of lung, mediastinal complete collapse of lung, mediastinal displacement to opposite sides compressing the displacement to opposite sides compressing the opposite lung with low venous rectum.opposite lung with low venous rectum.1. Penetrating chest trauma1. Penetrating chest trauma2. Blunt chest trauma2. Blunt chest trauma3. Marked displaced thoracic spine fractures.3. Marked displaced thoracic spine fractures.

TN is a clinical diagnosis and treated without waitingTN is a clinical diagnosis and treated without waiting any investigation.any investigation.

Patient with chest pain, tachypnea, tachycardia, Patient with chest pain, tachypnea, tachycardia, distended vein, absent breath sound affected side. distended vein, absent breath sound affected side. Hyper resonance to percussion.Hyper resonance to percussion.

Immediate decompression with second intercostals Immediate decompression with second intercostals space mid clavicular line needle no. 14 and then space mid clavicular line needle no. 14 and then ICT 5ICT 5thth ICS (nipple level) ant. to midaxillary line. ICS (nipple level) ant. to midaxillary line.

OPEN PNEUMOTHORAXOPEN PNEUMOTHORAX

Large defect of chest wall. Large defect of chest wall.

If defect is 2/3, the diameter of If defect is 2/3, the diameter of trachea, air passes through chest trachea, air passes through chest

wall with each respiration so wall with each respiration so effective ventilation is impaired effective ventilation is impaired with hypoxia and hypercarbia.with hypoxia and hypercarbia.

MANAGEMENTMANAGEMENT

Closing the defect with sterile Closing the defect with sterile adhesive dressing taped on adhesive dressing taped on

three sides, then ICT & three sides, then ICT & surgical closure of the defect.surgical closure of the defect.

FLAIL CHESTFLAIL CHESTTwo or more ribs fractured in two or more places. Two or more ribs fractured in two or more places. Paradoxical movement will follow. Paradoxical movement will follow. This alone does not This alone does not cause hypoxia, but pain and underlying lung contusion.cause hypoxia, but pain and underlying lung contusion.

Diagnosed by paradoxical movement ± palpation of Diagnosed by paradoxical movement ± palpation of abnormal respiratory motion and crepitous of ribs or abnormal respiratory motion and crepitous of ribs or cartilage fracture.cartilage fracture.

CXR (Multiple fracture ribs)CXR (Multiple fracture ribs)

ABGABG

– AnalgesicsAnalgesics– Adequate ventilation with humidified oxygen.Adequate ventilation with humidified oxygen.– Fluid resuscitation if hypotension.Fluid resuscitation if hypotension.

Short period of intubation and ventilation may be Short period of intubation and ventilation may be necessary.necessary.

MASSIVE HEMOTHORAXMASSIVE HEMOTHORAXHypotension with the affected side Hypotension with the affected side

dullness to percussion.dullness to percussion.

Criteria:Criteria:

- More than (1-1.5L) of blood - More than (1-1.5L) of blood when inserting ICT.when inserting ICT.

- Continuing blood loss 200 ml/ - Continuing blood loss 200 ml/

hour for 2 – 4 hours.hour for 2 – 4 hours.

MANAGEMENTMANAGEMENT

o ICT no. 38 FICT no. 38 Fo Management of hypovolemiaManagement of hypovolemiao Consider for thoracotomyConsider for thoracotomy

CXR - widening of upper CXR - widening of upper mediastinum and distortion mediastinum and distortion of aortic knuckles (60%).of aortic knuckles (60%).

Left side pleural effusion is Left side pleural effusion is common.common.

CT scan is very helpful in CT scan is very helpful in diagnosis. diagnosis.

Normal ECG Normal ECG

o Congested neck veinsCongested neck veinso Decline in arterial pressureDecline in arterial pressureo Muffled heart soundsMuffled heart sounds

o Patient not respond to unusual measures of Patient not respond to unusual measures of resuscitation.resuscitation.

o Kussmaul’s signKussmaul’s signo PEA in the absence of hypovolemiaPEA in the absence of hypovolemia and TN. and TN.

o

Echocardiogram (false negative in 5%)

If monitor shows premature ventricular contraction.( Common dysrhythmia to myocardial injury.)

Lidocaine bolus 1 mg/kg, followed by lidocaine drip 2-4 mg/min.

CARDIAC TAMPONADECARDIAC TAMPONADE

Common in penetrating injuries Common in penetrating injuries but may occur with blunt but may occur with blunt trauma. trauma.

Removal of as little as 15-20 ml by Removal of as little as 15-20 ml by pericardiocentesis, pericardiocentesis, may result in may result in immediate hemodynamic immediate hemodynamic improvement.improvement.

INDICATION THORACOTOMYINDICATION THORACOTOMY

1. 1. Cardiac arrestCardiac arrest or PEAor PEA in in hypovolemic patient with hypovolemic patient with penetrating chest trauma penetrating chest trauma (resuscitative thoracotomy).(resuscitative thoracotomy).2. 2. Massive hemothoraxMassive hemothorax3. 3. Penetrating chest traumaPenetrating chest trauma anteriorly medial to the nipple line anteriorly medial to the nipple line and posteriorly medial to the and posteriorly medial to the scapula with hypotension.scapula with hypotension.

Tension pneumothorax

Open pneumothorax

Flail chest

Hemothorax

Cardiac tamponade

ويرزقهمن )) ويرزقهمن ومنيتقاللهيجعللهمخرجا ومنيتقاللهيجعللهمخرجاصدقاللهالعظيم صدقاللهالعظيم ( ( حيثاليحتسب حيثاليحتسب

AND WHOSOEVER FEARS ALLAH AND AND WHOSOEVER FEARS ALLAH AND KEEPSKEEPSHIS DUTY TO HIMHIS DUTY TO HIM , GOD WILL MAKE A WAY , GOD WILL MAKE A WAY FOR HIM TO GET OUTFOR HIM TO GET OUT )from ever difficulty(. )from ever difficulty(. AND WILL PROVIDE ) HIM l HER ( FROM AND WILL PROVIDE ) HIM l HER ( FROM )SOURCES ( HE l SHE NEVER COULD )SOURCES ( HE l SHE NEVER COULD

IMAGINE.IMAGINE.) THE NOBLE QURAN () THE NOBLE QURAN (