CHEST TRAUMAS (LETHAL 5) without airway obstruction (+ HIDDEN 1; rupture diaphragm)

thoracic cage injury pleural space injury RUPTURE DIAPHRAGM

cardiac injury

FLAIL CHEST TRAUMATIC PNEUMOTHORAX TRAUMATIC HEMOTHORAX CARDIAC TAMPONADE def = at least two fractures per rib

(producing free segment) in at least 2 ribs - a segment of thoracic cage is separated from the rest of chest wall w/ paradoxical movement

presence of air in pleural cavity collection of blood in pleural cavity

site = more common on the left than the right bcs; i) right copula is protected by the liver ii) posterior part of left copula is weak (area of pleuroperitoneal canal)

RV is most vulnerable to injury (substernal)

etio severe blunt trauma i) blunt/penetrating thoracic trauma ii) iatrogenic - post-operative - MV (barotraumas) - thoracocentesis - central venous cannulation

blunt/penetrating trauma

- penetrating trauma - blunt tauma

*etiology of cardiac injuries i) blunt tauma (eg: steering wheel injury) ii) penetrating trauma

patho Types: - anterior *most dangerous - lateral - posterior ** least dangerous - flail sternum Pathophysiology HYPOXAEMIA dt: 1. underlying pulmonary contusion w/ V/Q mismatch 2. pain of fracture ribs ↓tidal volume, accumulate secretion atelectasis ↑ pulm shunting & ↓ functional reserve capacity 3. ass. haemopneumothorax / cardiac trauma 4. hypoventilation of the underlying lung from paradoxical respiration 5. mediastinal flutter w/ kink of great Vs 6. pendulum-like movement of dead space air

Types: 1. Communication

Closed pneumothorax

Open pneumathorax

w/out communication to the exterior

w/ communication thru chest wall to the exterior (sucking wound)

2. Tension

Simple (mild, moderate,

massive)

Tension pneumothorax

w/out tension presence of one way valve on or PPV

Pathogenesis: 1. penetration of chest wall 2. laceration of the lung 3. perforation of bronchus, trachea or esophagus 4. tear of lung by driven-in rib fragment 5. rupture of alveoli 2ry to blunt trauma/straining pulm interstitial emphysema med. emphysema pneumothorax/surgical emphysema

Source of blood: 1. Systemic ( intercostals, int mammary, heart, great Vs) 2. Pulmonary vessels 3. Portal; infradiaphragmatic Vs thru diaphragmatic tear Types: - isolated hemothorax, or - hemopneumothorax Degree:

Mild 100-350 ml

Moderate 350-1500ml

Severe 1500-3000ml

Massive 1500ml draining immediately, or 200ml/hr for 3 successive hour

Complications: i) clotting clotted hemothorax ii) organization fibrothorax & frozen chest iii) infection empyema

Time of presentation:

Early Late Acute Subacute Chronic

presentation

w/ internal hemorrhage or abdominal visceral injuries

- some hours later - NO intra-abdominal injuries

- follows missed acute rupture by days/longer - progressive displacement of abdominal viscera into the chest

repair

laparotomy (trans-abdominally)

thoracotomy (trans-thoracically)

thoracotomy to lyse the adhesion

Complication: - GI obstruction or strangulation

*pathology of cardiac injuries: i) myocardium - contusion(subendocarcial/ transmural/subepicardial) progressing to; i. rupture tamponade fatal ii. fibrosis vascular aneurysm delayed rupture fatal - tear - septal injury traumatic VSD ii) valve injury - cusp/papillary muscle injury acute valve regurgitation iii) coronary Vs injury iv)hemopericaridum (of 2 types)

Closed Open blunt trauma penetrating

trauma

w/ intact peri-cardium

w/ pericardial tear

tamponade compressing 1

st the atria

interfering VR engorged NVs ↓COP cerebral hypoxia

i) tamponade (if pericardial opening does NOT permit blood escape ii) massive hemothorax (wide opening)

C/P - severe blunt trauma - severe chest pain of rib fractures - dyspnoea, tachypnoea, cyanosis - hypotension, tachycardia - paradoxical movement of flail segment - cell wall contusion + surgical emphysema

- ↓ movement of the same side - tympanitic percussion note - diminished air entry on auscultation

General: pallor, tachycardia, tachypnea, hypotension, shock Local: dullness & decreased air entry

acute; - SHOCK, dt intra-abdominal/intra-thoracic hemorrhage + cardiac displacement interfering w/ venous return - on chest auscultation √ absent breath sounds √ presence of intestinal sounds √ hearing of sound of injected air thru NGT √ cardiac displacement to other side

Cardiac tamponade: i) Beck’s triad hypotension+ congested NVs (high CVP) + distant HS ii) Pulsus paradoxus (drop of 10mmHg/more in systolic pressure w/ inspiration) iii) Kussmaul’s sign (inspiratory filling of NVs) iv) other signs of shock (tachycardia, breatheslessness,↓UOP, ↓ consciousness v) cyanosis of upper half of the body

inv - CXR - CT chest -multislice CT chest - ABG

- CXR

mild 1 finger breadth moderate 2 finger breadth

massive total lung collapse

tension mediastinal shift to the other side

- CT scan : can Dx smallest amount of pneumothorax

- anaemia - diagnostic thoracocentesis blood - upright plain CXR PA view

Mild obliterated costophrenic angle

Moderate till the level of hilum

Massive above the level of hilum

- CXR; = asymmetry of a hemidiaphragm or changing diaphragmatic level *1st clue of diaphragmatic rupture on plain chest radiographs = air fluid shadow of the stomach/intestine in the chest = associated hemothorax - Barium studies confirm the diagnosis by showing herniated viscera above the diaphragm & constriction thru the diaphragmatic tear - CT chest

- CVP = high - ECG (ST segment changes & low voltage QRS complex) - CXR = ↑ cardio-thoracic ratio (flask shaped heart only in chronic not acute cases) - Echo - CT scan - Diagnostic pericardiocentesis

Rx *flail chest indicates underlying lung contusion i) Oxygen inhalation ii) Pain relief - systemic analgesic - intercostals nerve block - epidural catheter iii) Pulmonary toilet iv) Stabilization - external chest wall stabilization (strapping) – stop paradoxical movement - CPAP - IPPV : when PaO2 <60mmHg, PaCO2 > 60mmHg, tachypnea > 30/min - internal chest wall stabilization (orthopaedic devices)

simple mild conserve

moderate & severe

ICTD under water seal in 2nd space MCL

tension emergency wide bore needle under water seal ICT

open close external wound insert ICT

failure of expansion & continuous air leak

thoracotomy close air leak & repair major tracheobronchial tears *do pleurectomy to prevent recurrence

General supportive measures blood transfusion & oxygen inhalation

minimal conserve

mild to moderate

aspiration under aseptic technique

moderate to massive

ICT in the 6th MAL

thoracotomy in: - massive initial 1500ml associated w/ hypotension - continuous bleeding thru tube = 200ml/hr for 3 successive hour

Trans-abdominal repair

Trans-thoracic repair

in acute injuries in subacute & chronic cases

to deal w/ ass. intra-abdominal injuries

to: - free adhesion between abdominal viscera & intrathoracic structures - reduce the hernia - repair diaphragmatic tear by double row of non-absorbable sutures

- supportive measurement (ABC) - emergency pericardiocentesis till preparing OR -emergency left thoracotomy opening pericardium control the bleeding site by finger compression of Forgerty catheter suture the tear by non-absorbable sutures

THORACIC CAGE INJURIES SURGICAL EMPHYSEMA FRACTURE RIBS FRACTURE STERNUM

patho presence of air in subcutaneous tissue from surgical causes - infection with gas forming organism may cas subcutaneous emphysema

- fracture ribs severe pain resp movement & ineffective coughing atelectasis & pneumonia - injury of underlying pleura & lung - injury of intercostals bundle

transverse fractures generally in the body of the sternum, near the manubriumsternal junction

etio i) fracture rib injuring underlying lung resulting in closed/tension pneumothorax ii) tracheobronchial fistula iii) penetrating chest injury & open pneumothorax iv) mediastinal emphysema dt ruptured bronchioles/alveoli without disrupting the visceral pleura following - blunt trauma - barotraumas of ventilators - spontaneously in asthmatics v) ruptured esophagus vi) after ICT insertion for pneumothorax when tube is blocked

i) direct violence ii)indirect violence iii) muscular violence

CP - presence of air under skin w/ characteristic crackling sensation (subcutaneous crepitatation) - localized or rapidly progressive, up to neck & face closing eyelids or down to abdominal wall & scrotum - benign but may signify serious underlying problem - causes pt’s discomfort & worry

- severe pain - localized tenderness - crepitus - surgical emphysema - look for associated hemothorax *1st rib fracture – dangerous, may be associated w/ brachial plexus/subclavian Vs injury *lower rib fracture – may be associated w/ trauma to spleen/liver

Rx - it will be absorb spontaneously - find & manage its causes - if extensive evacuate w/ needles/skin incision/ subcutaneous catheters

Dx: plain CXR (rib view) - systemic analgesics - intercostals nerve block (fracture less than 4 ribs) - epidural analgesia (fracture more than 4 ribs) - **avoid binders, tape or strapping

Dx: - lateral CXR - CT scan : exclude associated injuries most cases; analgesia + follow up severe cases; IPPV &/or operative reduction

LUNG INJURIES

PULMONARY CONTUSION PULMONARY LACERATION PULMONARY HEMATOMA etio - blunt trauma - tear if lung tissue

bleeding into lung parenchyma

patho - hemorrhage & edema in alveoli & interstitium resulting in hypoventilation - may progress into ARDS, failure of gas exchange & hypoxia

- more with open than blunt trauma - associated with hemothorax, pneumothorax &/or pulmonary contusion

inv - Xray : patchy parenchymal opacities may progress to diffuse opacity in ARDS - ABG : ↓PaO2 ↓PCO2

Xray : rounded well defined opacity

Rx - general supportive measures; O2 inhalation + antibiotics + respiratory care - MV in ARDS

- manage pneumohemothorax : ICT - thoracotomy to suture the tear w/ massive air leak/bleeding

- spontaneous resolution within 2-3 weeks w/ antibiotics - infected hematoma results in lung abscess may require thoracotomy

MEDIASTINAL TRAUMA

TRAUMATIC ASPHYXIA PNEUMO-MEDIASTINUM (MEDIASTINAL EMPHYSEMA) etio from blunt compression injury from tracheobronchial or esophageal rupture, also pneumothorax

CP sudden compression on SVC against closed glottis raising pressure in veins of upper ½ of the body, resulting in: - violet dicolouration & edema of face - subconjunctival & retinal hemorrhage & papilledema

- surgical emphysema in the neck - Hamman’s sign = crunching precordial sound

Manage-ment

managed conservatively with eye care X-ray = air in mediastinum Rx= treat the cause

TRACHEO-BRONCHIAL INJURIES ESOPHAGEAL INJURIES

etio blunt/penetrating trauma 80% 2.5cm from carina

- open trauma : by stab/bullet - blunt trauma : rare, at lower 1/3 esophagus, longitudinal, posterior, with/without traceo-esophageal fistula - iatrogenic trauma : during esophagoscopy -spontaneous rupture (Boerhaave’ syndrome)

CP - pneumothorax - surgical emphysema - hemoptysis

- fever - surgical emphysema - mediastinitis - empyema

inv CXR : mediastinal emphysema, empyema, pneumothorax Gastrographic esophagogram

treatment small ICT but may lead to scarring large thoracotomy & repair

* depend on the location & size of perforation! * surgery is best done within 24 hours from time of perforation - stop oral feeding start parenteral nutrition / gastrostomy / jejunostomy feeding

mediastinitis antibiotic + cervical split fistula& mediastinal drainage

empyema ICT

- thoracotomy - to repair the tear if needed - esophageal resection & 2nd stage reconstruction using stomach/colom - a stent may be used to avoid surgery

IMMEDIATE LIFE-THREATENING INJURIES 1. airway obstruction 2. tension pneumothorax 3. open pneumothorax 4. massive hemothorax 5. cardiac tamponade 6. massive flail chest POTENTIAL LIFE-THREATENING INJURIES 1. cardiac contusion 2. deceleration aortic injury 3. tracheo-bronchial rupture 4. diaphragmatic rupture 5. osephageal perforation 6. pulmonary contusion INDICATION OF THORACOTOMY 1. RESUSCITATION THORACOTOMY - open cardiac massage 2. EMERGENCY THORACOTOMY - massive hemothorax - cardiac tamponade - major air leak - great vessels injury - intrathoracic FB - chest wall defect (traumatic thoracotomy) 3. ELECTIVE THORACOTOMY (LATE) - diaphragmatic injuries - esophageal injuries - intracardiac injuries - aortic rupture w/ false aneurysm - clotted hemothorax & empyema