CHEST TRAUMA
CHEST TRAUMALouis OkiweluDepartment of Cardiothoracic
Surgery
OUTLINEDefinition and classificationBrief anatomy and
pathophysiology of the chestRecognize the types and mechanisms of
life threatening thoracic injuriesInitial assessment and mx of
various thoracic injuriesSecondary mx of thoracic injuries and some
unique challenges they can impose
There are 4 major objectives to this module:The first is to
understand that statistics of the epidemiology and incidence of
thoracic injuries in the USThe second objective is to recognize
that there are various types of thoracic injuries that are a
function of the nature and mechanism of the inflicting agent. We
will cover thoracic trauma divided into sub-categories of blunt
trauma which can be further divided into deceleration injury such
as sustained in falls and MVA and penetrating trauma which is
sub-divided by injuring agent also into GSW and stab wounds.The
third objective is to comprehend the initial assessment and
management of thoracic injuries with a special understanding that
there are unique problems associated with thoracic trauma that is
different from abdominal trauma and the cause of similar
hemodynamic parameters can be different with thoracic injuries.The
fourth objective is to understand secondary management of the
various thoracic injuries with a special emphasis on imaging,
work-up and definitive surgery.2
CHEST TRAUMA
Anatomy of the chestThoracic Inlet..Connects thoracic cavity to
the root of the Neck.
Thoracic Wall
Anatomy of the chest
Two Lungs (right and left)HeartDiaphragm
BLUNTPENETRATINGCHEST TRAUMA
Classified into 2 broad groups depending on wheter a breach in
the thoracic wall has occurred with involvement of intrathoracic
structures7
BLUNT TRAUMA TO THE CHESTAcceleration/Deceleration
InjuryMVAFalls > 3mSports
Compression ( AP & transverse )
Blast Injuries
PENETRATING CHEST TRAUMAHigh velocityGun shotMissile
fragments
Low velocityStab injury
Injuries that breach the chest wall may impact the body with
significant amount of energy which can result in localized damage
along the wound tract or significant dissipation of disruptive
forces to surrounding through the cavitation effect producing
remote injuries. It might also be the result of a change in
trajectory due to impact on other structures. So sometimes what you
see on the surface belies real badness beneath. One of the pitfalls
in the management of people with this kind of condition. An
awareness and high index suspicion must always guide mx in this
pts.. Geography and society play a role in determining the pattern
we see and what predominates ie war torn areas, violent societies
GSW and chilled out places MVA, footy injuries9
Danger box
Suspect in any victim with penetrating wound, neck or upper
abdomen. Particularly dangerous site is the central chest area from
clavicles xiphisternum / between right nipple and left lateral
chest wall (described as the danger box)Can be seen in blunt trauma
in patients on anticoagulants or antithrombotic drugs10
Epidemiology A third of RTAs have significant chest trauma
Approx. 80% is blunt chest trauma
20 - 25% overall mortality
Majority of the deaths are preventable
< 10% of BCT require surgical intervention as opposed to 15 -
30% in PCT
Immediate deaths are usually due to major disruption of the
heart or of great vessels. Early deaths due to thoracic trauma
occurring within 30 minutes to 3 hours after the injury are usually
secondary to cardiac tamponade, airway obstruction and aspiration,
or rupture of thoracic aortic tears that have been temporarily
contained. Two thirds of these patients reach the hospital prior to
death. Only 10-15% of blunt trauma require thoracic surgery, and
15-30% of the penetrating chest trauma require open thoracotomy.
Overall, about 85% of patients with thoracic trauma can be managed
without surgical treatment.
11
CLINICAL PRESENTATIONVARIEDPolytraumatized with other injury
components i.e. abdominal hemorrhage
MECHANISM OF INJURY
HIGH INDEX OF SUSPICION FOR SINISTER BADNESS BENEATH THE
SURFACE
Initial Management Primary Survey (ATLS protocol)
Airway/spinal stabilizationTrachea, bronchial disruption
Breathing Chest wall integrity, pneumothorax, flailPulmonary
contusions, 02 diffusion block
CirculationTamponade, hemothorax, tension pneumothoraxCardiac,
great vessel injury
The evaluation of the patient's chest trauma is only a part of
the total assessment and the basic ABCs of the primary survey and
resuscitation cannot be overlooked. It is important to keep several
special factors in mind when dealing with a patient with potential
thoracic injuries because thoracic injuries are severe and
potentially lethal and the diagnosis and therapy go hand in hand as
there can be unique mechanical factors that cause the alterations
in vital signs. Injuries such as tension pneumothorax can be
rapidly fatal if missed but treated and cured in a matter of
moments when recognized.
In unstable and critical patients quick decisions based on check
of the following vital signs are required. Airway patency: in the
initial survey is mandatory to control the airway patency. Patency
of the airway does not necessarily assure adequate ventilation in
patients with chest injuries unless the airway is in continuity
with the lungs. Patients may be ventilated without oxygenating
their blood with chest injuries due to pulmonary contusions or
airway disruption. All the airway manipulations must be performed
with respect to potential cervical spinal injuries. Breathing: in
order to know if patient is breathing is necessary to check
respiratory movement, and their extension which can be compromised
by chest wall integrity. Cyanosis appears very late in hypoxia due
to a thoracic trauma because in shocky patients the skin blood flow
depends on blood redistribution in the body. Circulation: the state
of the circulation is evaluated by assessing patient's pulses
(radial, carotid or femoral). The blood pressure is evaluated by
width of pulse. In hypovolemic shock radial pulse becomes small;
may be absent when blood pressure is below 60 mm/Hg. In thoracic
trauma is important to assess the neck veins that are flat in
hypovolemia are distended when there is cardiac tamponade. But if
cardiac tamponade is associated with hypovolemic shock distension
of the neck veins may be absent. Thoracic cavity is constituted
from two structures: the first, rigid, comprehending the rib cage,
clavicle, sternum, scapula and the second comprehending respiratory
muscles. Adequate ventilation and oxygenation depends on an intact
chest wall. Significant injury with fracture and muscular
disruption may allow direct injury to the underlying lungs, heart,
great vessels and upper abdominal viscera. In addition, respiration
may be seriously impaired by effective or paradoxical motion of a
portion of the thoracic cage (as in flail chest) and the result is
respiratory insufficiency.
TREAT LIFE THREATENING INJURIES AS THEY ARE IDENTIFIED
IMMEDIATE LIFE THREATENING THORACIC INJURIESTension
pneumothorax
Massive hemothorax
Open pneumothorax
Cardiac disruption/tamponade
Tracheal disruption
Contained Aortic transection
This is a list of the immediate causes of death following chest
injuries. Each will be discussed in more detail on the following
slides.
Crucial 1 Survey Differential Dx: Cardiac Tamponade vs Tension
PneumothoraxClinical SignCardiac TamponadeTension PneumothoraxBlood
Pressure Cardiac TonesBreath SoundsNeck
VeinsRespirationsTreatment
Low (PEA)LowMuffledNormalNormalAbsent - collapsed sideDistended
(flat in hypovolemia)Flat NormalTachypneaNeedle/drain
pericardiumNeedle/tube chest
Identifying cardiac tamponade vs. tension pneumothorax is a
critical differential diagnosis that must be made accurately and
almost instantaneously since both are treatable and curable
injuries. Both present with low or absent blood pressure (PEA) but
the physiology is opposite since tamponade is due to compression of
the right heart and tension pneumothorax is due to absent filling
of the right heart. The major differentials relate to etiology the
neck veins are distended in tamponade since blood is trying to
enter the heart and cant and flat in tension pneumothorax since
there is no blood in the right heart. An important pitfall in this
differential finding is that in hypovolemic patients neck veins can
be flat in both injuries. Cardiac tones are usually muffled in
tamponade but this can be difficult to appreciate in the noisy
trauma areas and breath sounds are usually absent on the affected
side in tension pneumothorax but this can also be had to hear.
Generally patients are very tachypnic when alert with a tension
pneumothorax but patients in shock are all tachypnic so this can
also be an unreliable indicator. Both can be worsened by positive
pressure ventilation since both are functions of right heart
physiology and the treatment for both is a needle one into the
chest the other into the pericardium. The use of e-FAST might be
helpful
TENSION PNEUMOTHORAX
Lung collapse, Hemi-diaphragmatic depression, Increased
separation of ribs, Increased thoracic volume Loss of lung
markings, Possibly reduced heart sounds?)17
9/03/17www.health-nurses-doctors.blogspot.comNeedle
Decompression
MASSIVE HEMOTHORAX
Massive hemothorax is common in both penetrating and blunt chest
injuries. Patients who sustain acute hemothorax are at risk for
hemodynamic instability due to loss of intravascular volume and
compromised central venous return due to increased intrathoracic
pressure. Lung compression due to massive blood accumulation may
also cause respiratory compromise. Sources of hemothorax are: lung,
intercostal vessels, internal mammary artery, thoracicoacromial
artery, lateral thoracic artery, mediastinal great vessels, heart,
abdominal structures (liver, spleen) when diaphragmatic hernia.The
diagnosis is readily made from the clinical picture and X-ray
evidence of fluid in the pleural space. Primary thoracentesis is
carried out to confirm the diagnosis. Optimal therapy consists of
the placement of a large (36 French) chest tube. A moderate size
hemothorax (500-1500 ml) that stops bleeding after thoracostomy can
generally be treated by closed drainage alone. However, a
hemothorax of greater than 1500 to 2000 ml as with continued
bleeding of more than 100 to 200 ml per hour is an indication for
emergency thoracotomy or thoracoscopy.A small percentage of
hemothoraces proceed to clot and cannot be evacuated by
thoracentesis. Massive clots may lead to respiratory difficulty and
infection, and should be evacuated surgically. Small clots will
probably be resorbed and do not require operative
removal.Hemothorax is common in both penetrating and
non-penetrating injures to the chest. If the hemorrhage is severe,
it may not only cause hypovolemic shock but also dangerously
reduces vital capacity by compressing the lung on the involved
side. Persistent hemorrhage usually arises from an intercostal or
internal thoracic (internal mammary) artery and less frequently
from the major hylar vessels. Bleeding from the lung generally
stops within a few minutes, although initially it may be profuse.
In some cases hemothorax may come from a wound of the heart or from
abdominal structures such as the liver or spleen if the diaphragm
has been lacerated. Hypovolemic shock and hemomediastinum can
derive from a thoracic great vessels injury that may be result of
penetrating or blunt trauma. The most common etiology is
penetrating trauma; however, the descending thoracic aorta, the
innominate artery, the pulmonary veins, and the vena cavae are
susceptible to rupture for blunt trauma.
Application of Pulmonary Hilar Cross Clamp
Pulmonary Tractotomy
Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy,
Partial Lobectomy, and Pneumonorrhaphy George C. Velmahos, MD, PhD;
Craig Baker, MD; Demetrios Demetriades, MD, PhD; Jeremy Goodman;
James A. Murray, MD; Juan A. Asensio, MD
Arch Surg.1999;134:186-189.
Pulmonary Tractotomy
Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy,
Partial Lobectomy, and Pneumonorrhaphy George C. Velmahos, MD, PhD;
Craig Baker, MD; Demetrios Demetriades, MD, PhD; Jeremy Goodman;
James A. Murray, MD; Juan A. Asensio, MD
Arch Surg.1999;134:186-189.
OPEN PNEUMOTHORAX
Sucking chest wound
Respiratory distress
Preferential path of air when hole diameter of trachea
Cover 3 sides
EMERGENCY ICC INSERTION
An open pneumothorax occurs when there is a pneumothorax
associated with a chest wall defect, such that the pneumothorax
communicates with the exterior.During inspiration, when a negative
intra-thoracic pressure is generated, air is entrained into the
chest cavity not through the trachea but through the hole in the
chest wall. This is because the chest wall defect is much shorter
than the trachea, and hence provides less resistance to flow. Once
the size of the hole is more than 0.75 times the size of the
trachea, air preferentially enters through the thoracic cavity.This
results in inadequate oxygenation and ventilation, and a
progressive build-up of air in the pleural space. The pneumothorax
may tension if a flap has been created that allows air in, but not
out.Diagnosis should be made clinically during the primary survey.
A wound in the chest wall is identified that appears to be 'sucking
air' into the chest and may be visibly bubbling - this is
diagnostic. Breathing is rapid, shallow and laboured. There is
reduced expansion of the hemithorax, accompanied by reduced breath
sounds and an increased percussion note. One or all of these signs
may not be appreciated in the noisy trauma room. 100% oxygen should
be delivered via a facemask. Consideration should be given to
intubation where oxygenation or ventilation is inadequate.
Intubation should not delay placement of a chest tube and closure
of the wound.The definitive management of the open pneumothorax is
to place an occlusive dressing over the wound and immediately place
an intercostal chest drain. Rarely, if a chest drain is not
available and the patient is far from a definitive care facility, a
bandage may be applied over the wound and taped on 3 sides. This,
in theory, acts as a flap-valve to allow air to escape from the
pneumothorax during expiration, but not to enter during
inspiration. This dressing may be difficult to apply to a large
wound and it's effect is very variable. As soon as possible a chest
drain should be placed and the wound closed.
Occlusive Dressing
TRACHAEL DISRUPTION
Most tracheal injuries are cervical and range from crush
injuries to compete tracheal separation. Can be missed on CXR
usually a massive emphysema in the neck and chest wall and even
sub-diaphragmatic regions Only 50% of patients will have a
pneumothorax with this injury, and hemothorax is uncommonOnly 1/3
of patients are diagnosed in the first 24 hours, and only 1/2
within the first month If endotracheal intubation is not possible,
a surgical airway should be obtainedPrimary repair of tracheal
lacerations or separation should be performed, if possibleBlunt
trauma typically causes a circumferential laceration of either main
bronchus with complete separationEarly repair is the preferred
treatment if the diagnosis is made, and requires thoracotomy with
intubation of the uninjured bronchusLate strictures from incomplete
tears or parenchymal isolation from complete tears can be repaired
with bronchoplastic procedures, but may require pulmonary
resection. Laryngotracheal injuries constitute only a small
fraction of admissions in a major trauma centre. The frequency has
been reported to be as low as 0.3 percent. However, mortality is
reported as high as 24 percent. Complete disruption of trachea is
amongst the rarest injuries with only a few cases reported in
literature. Seuvre (cited by Papamicheal is credited with the first
description of traumatic tracheal disruption. Direct blows are more
likely to be associated with fractures of cartilaginous frame work
of the larynx(7). The signs and symptoms are often subtle even in
complete transections of trachea. The two ends may be held in close
approximation by peritracheal connective tissue and soft tissues of
the neck.Clinical features include subcutaneous surgical emphysema,
pneumothorax, respiratory distress, hemoptysis and loss of palpable
landmarks8. Most of these features were present in our cases except
pneumothorax which was seen only in the first case. The signs and
symptoms are non specific and correlate poorly with the severity of
the underlying injury(9). Therefore, a high degree of suspicion and
a more aggressive approach towards diagnosis and management is
required as delayed treatment may prove fatal as in our second
case.Neck and chest radiographs though essential cannot be
completely relied upon. CT scan or MRI if available can give
accurate diagnosis, otherwise direct laryngoscopy and bronchoscopy
can be utilized to confirm the diagnosis as delay leads to a poor
prognosis.Management includes, tracheostomy and early surgical
repair. The best results are obtained with a complete repair of the
larynx and trachea with end to end anastomosis of disrupted trachea
which avoids a permanent tracheostomy and patient retains a good
voice. The second best option is a permanent tracheostomy which
means a loss of voice.
TRACHAEL DISRUPTIONBlunt or penetrating trauma
Intra/extra thoracic location (supraglotic, glotic,
subglotic
PRESENTATIONMassive, sometimes uncontrollable air leakStridor,
acute respiratory distress, voice changeNeck, upper chest
subcutaneous emphysema often massive and disfiguring
Acutely manage with bronchoscopy, deep intubation (beyond
injury) and sometimes tracheostomy
Most tracheal injuries are cervical and range from crush
injuries to compete tracheal separation If endotracheal intubation
is not possible, a surgical airway should be obtained Primary
repair of tracheal lacerations or separation should be performed,
if possible Blunt trauma typically causes a circumferential
laceration of either main bronchus with complete separation Only
50% of patients will have a pneumothorax with this injury, and
hemothorax is uncommon Only 1/3 of patients are diagnosed in the
first 24 hours, and only 1/2 within the first month Early repair is
the preferred treatment if the diagnosis is made, and requires
thoracotomy with intubation of the uninjured bronchus Late
strictures from incomplete tears or parenchymal isolation from
complete tears can be repaired with bronchoplastic procedures, but
may require pulmonary resection. Laryngotracheal injuries
constitute only a small fraction of admissions in a major trauma
centre. The frequency has been reported to be as low as 0.3
percent. However, mortality is reported as high as 24 percent.
Complete disruption of trachea is amongst the rarest injuries with
only a few cases reported in literature. Seuvre (cited by
Papamicheal is credited with the first description of traumatic
tracheal disruption. Direct blows are more likely to be associated
with fractures of cartilaginous frame work of the larynx(7). The
signs and symptoms are often subtle even in complete transections
of trachea. The two ends may be held in close approximation by
peritracheal connective tissue and soft tissues of the
neck.Clinical features include subcutaneous surgical emphysema,
pneumothorax, respiratory distress, hemoptysis and loss of palpable
landmarks8. Most of these features were present in our cases except
pneumothorax which was seen only in the first case. The signs and
symptoms are non specific and correlate poorly with the severity of
the underlying injury(9). Therefore, a high degree of suspicion and
a more aggressive approach towards diagnosis and management is
required as delayed treatment may prove fatal as in our second
case.Neck and chest radiographs though essential cannot be
completely relied upon. CT scan or MRI if available can give
accurate diagnosis, otherwise direct laryngoscopy and bronchoscopy
can be utilized to confirm the diagnosis as delay leads to a poor
prognosis.Management includes, tracheostomy and early surgical
repair. The best results are obtained with a complete repair of the
larynx and trachea with end to end anastomosis of disrupted trachea
which avoids a permanent tracheostomy and patient retains a good
voice. The second best option is a permanent tracheostomy which
means a loss of voice.
Management Algorithm for Penetrating Mediastinal Trauma (72)
CARDIAC TRAUMA
Cardiac tamponade is usually due to penetrating cardiac injuries
and is a leading cause of trauma death in urban areas. Patients
with penetrating wounds of the heart can be classified in 3 general
groups:1. patients who have received extensive lacerations or
large-caliber gunshot wounds, that die almost immediately, as a
result of rapid and voluminous blood loss2. patient with small
wounds of the heart, caused by ice picks, knives or other small
agents who because of the development of cardiac tamponade, reach
the hospital alive. Cardiac tamponade, by bringing pressure to bear
on the bleeding heart wall, also plays an important role in
controlling the hemorrhage;3. patient with associated serious
injuries in the chest and/or elsewhere in the body which, in
themselves, may contribute to death.The condition of the patient,
when he is admitted to the hospital, must not be used as an index
of the severity of the injury. There are moribund patients with no
blood pressure and nonperceptible pulse, who survive operation and
recover; on the other hand there are patients in fair condition,
with a systolic blood pressure ranging from 70 mmHg to normal and
fair-to-good pulse, who die before surgery. The immediate cause of
death is either exanguination, cardiac tamponade or interference
with the conduction mechanism.Diagnosis generally is easy if the
physician maintains a high degree of suspicion of heart injury in
every chest wound he encounters. The safest approach is to remove
the patient's clothing and survey the entire body surface quickly
for evidence of multiple injuries. Auscultation of the thorax is
performed specifically to evaluate the clarity of heart tones and
breath sounds. Muffled heart tones are an indication of blood in
the pericardium. A systolic - to diastolic gradient of less then 30
mmHg, associated with hypotension is consistent with cardiac
tamponade. Neck veins are distended. Central venous pressure is
elevated. The X-ray film may demonstrate a widening of the cardiac
silhouette. The ultrasound scan shows presence of blood in
pericardial space. Electrocardiograph is not particularly helpful.
Prompt definitive therapy is imperative. This includes antishock
therapy, pericardiocentesis (possibly under U.S. guide), emergency
thoracotomy and suture of the wound.Treat with VOLUME immediately
to raise the CVP greater than the intrapericardial pressure and
shock trousers then proceed with percutaneous and ultimately
surgical decompression of the pericardium.Cardiac tamponade
requires prompt recognition and treatment. Signs and symptoms range
from rarely stable to Becks triad of hypotension, CVP above 12cc of
water and muffled heart sounds all three findings are present in
fewer than 40% of patients with tamponade. An elevated CVP is the
most significant diagnostic finding. Only 60ml of haemopericardium
is necessary for a tamponade to occur in adults. A vicious cycle is
set in motion i.e. LVEDV S.V. CO compensatory tachycardia cardiac
work O2 demand hypoxia and lactic acidosis.An enlarged cardiac
silhouette on CXR and / pericardial effusion as demonstrated by
echocardiography help to confirm the clinical suspicion and
diagnosis.
Distribution of Penetrating Cardiac Trauma
PERICARDIAL TAMPONADE
CT AXIAL VIEW
PERICARDIOCENTESIS
Using aseptic technique, Insert at least 3 needle at the angle
of the Xiphoid Cartilage at the 7th ribAdvance needle at 45 degree
towards the lt shoulder while aspirating syringe till blood return
is seenContinue to Aspirate till syringe is full then discard blood
and attempt again till signs of no more bloodClosely monitor
patient due to small amout of blood aspirated can cause a rapid
change in blood pressure
33
ED Thoracotomy (EDT)
Indicated to resuscitate trauma patients who have sustained a
witnessed arrest or are on the verge of a cardiac arrest.34
LEFT ANTERIOR THORACOTOMY
Rationale for EDTResus agonal pt with PCT
Evacuation of pericardial tamponade
Control intra-thoracic hemorrhageX-clamp to DTAX-clamp the hilum
of the lung
Perform open CPR
Repair cardiac injuries
Asensio JA, et.al. An evidence-based critical appraisal of
emergency department thoracotomy, Evidence-Based Surgery 2003: 1(1)
11-21.
It allows for both diagnosis and treatment, it provides direct
access to the heart, lungs and great vessels enabling effective
resus ie evacuation of pleural and pericardial collections. Open
cardiac massage and cross clamping of the hilar or descending
aorta. It also facilitates repair cardiac injuries
36
FORMIDABLE UNDERTAKING Uncontrolled set up
Iatrogenic injury from sharps
Transmission of communicable diseasesHIV, HEPATITIS
DISTRACTING e.g requires significant resources
Survival data suggest it is better in those patients with
penetrating injury preferably with isolated stab injury who show
signs of life @ presentation in the event of deterioration they
should have very brief period of CPR with SR/PEA 38
Eastern Association For the Surgery of Trauma Guidelines
(EAST)
Patient manifest signs of life in the field or the hospital
Patient has PCT and is hemodynamically unstable despite
appropriate fluid resuscitation OR has required CPR for < 15
minsA thoracic or trauma surgeon is available within 45 mins
39
SIGNS OF LIFESpontaneous breathing
Palpable carotid pulse
Measurable BP
Electrical cardiac activityPupillary light response
Spontaneous extremity movement
Contra-indications for EDT
NO PULSE OR BP IN THE FIELD
ASYSTOLE AND NO PERICARDIAL TAMPONADE
CPR > 15mins
MASSIVE NON SURVIVABLE INJURIES
NO THORACIC OR TRAUMA SURGEON WITHIN 45 mins
Application of Aortic Cross Clamp
SpineAortaEsophagus
Diaphragm
Vertical Pericardial Incision
LIMA
Internal Paddles for Direct Cardioversion
Laceration Adjacent to Coronary Artery
Laceration Adjacent to Coronary Artery
Coronary Artery Laceration
Ventricular Laceration
Ventricular Lacerations and Repairs
Ventricular Lacerations and Repairs
Atrial Lacerations and Repairs
Immediate Life Threatening Thoracic Injuries: Aortic
DisruptionOccurs commonly @ Ligamentum arteriosum
fatality on site due to free rupture
Exsanguination
Rapid acceleration-deceleration ( i.e. MVA, falls from height
> 3m)
Up to 15% of all deaths following motor vehicle collisions are
due to injury to the thoracic aorta. Many of these patients are
dead at scene from complete aortic transection. Patients who
survive to the emergency department usually have small tears or
partial-thickness tears of the aortic wall with pseudoaneurysm
formation. Most blunt aortic injuries occur in the proximal
thoracic aorta, although any portion of the aorta is at risk. The
proximal descending aorta, where the relatively mobile aortic arch
can move against the fixed descending aorta (ligamentum
arteriousm), is at greatest risk from the shearing forces of sudden
deceleration. Thus the aorta is a greatest risk in frontal or side
impacts, and falls from heights. Other postulated mechanisms for
aortic injury are compression between the sternum and the spine,
and sudden increases in intra-luminal aortic pressure at the moment
of impact.
Contained Injuries to the Aorta
Widened mediastinum
Obliteration of aortic knob
Right deviation of trachea
Depression of LMS bronchus
Pleural/apical cap
Left hemothorax (can be bilateral)
Fractures of 1st and/or 2nd ribs
On CXR look for these signs but they are VERY unreliable on a
portable AP CXR and diagnosis requires a high index of suspicion
often based on nature of injury. Mediastinal width of more than 8cm
at the level of the aortic arch is considered abnormal and an
indication for further imaging. A widened mediastinum is reported
as having a 53% sensitivity, 59% specificity and 83% negative
predictive value for traumatic aortic injury.To maintain spinal
precautions in blunt trauma patients, most AP chest radiographs are
taken in the supine position. This will lead to fluid shifts that
may cause a widened mediastinum. Some authors recommend repeating
the radiograph with the patient erect if the spine can be cleared
prior to this. Around 40% of widened mediastinums will 'normalize'
with the patient in the erect position.Other less sensitive signs
of mediastinal great vessel injury include depression of the left
main-stem bronchus, deviation of the naso-gastric tube to the
right, apical pleural haemoatoma (cap), disruption of the calcium
ring in the aortic knob (broken-halo). None of these 'classic'
signs have any useful sensitivity to use them as a screening for
blunt aortic injury. Thus the 'funny-looking' mediastinum remains
the best indicator of the need for further imaging and should be
examined with these other findings to judge the risk of aortic
injury:Widened mediastinum (least reliable)Obliteration of aortic
knobRightward deviation of tracheaRightward deviation of esophagus
(look for NG tube)Depression of left main stem
bronchusPleural/apical capLeft hemothorax (can be
bilateral)Fractures of 1st and/or 2nd rib(s)On CT scan the
diagnosis is correct 97% of the time look for peri-aortic hematoma,
pleural effusions and aortography is correct in about 97-98% of the
time.
Contained Injuries to the Aorta
On CT scan the diagnosis is correct 97% of the time look for
peri-aortic hematoma, pleural effusions and aortography is correct
in about 97-98% of the time.
Contained Injuries to the AortaNot a source of multiple
hypotensive episodes in survivors - look for other injuries
Salvageable tear when hematoma contained
~ die per 24 hours without treatment
Widened mediastinum very unreliable sign on portable x-ray
TEE, helical contrast CT scan, MRI, aortogram
TEVAR
Address after life threatening injuries stabilized
Most blunt aortic injuries surviving to hospital are
partial-transections, and should be managed with blood pressure
control until the defintivie repair. Thus the priority in the
management of hemodynamically unstable patients with potential
aortic injury is to rapidly identify and control on-going
hemorrhage from other sites, and to avoid over-resuscitation. Sites
of concealed hemorrhage are identified with Chest and Pelvis
radiographs and FAST ultrasound or Diagnostic Peritoneal Lavage.The
caveat to these cases is the patient with and aortic tear and
impending rupture. These patients classically present as
'meta-stable' - ie they respond to fluid resuscitation and then
drop their blood pressure in a cyclical manner. It is important to
recognize this futile cycle early and avoid aggressive cyclical
resuscitation, as this will ultimately lead to free rupture of the
aorta and an iatrogenic hypothermia & coagulopathy. Beware the
'meta-stable' patient with a widened mediastinum and a left-sided
hemothorax!
POST TRAUMATIC PNEUMOTHORAX
15% OF THE THORAX
Intercostal tube drain
Eighty percent of chest trauma including PCT managed by ICC
Rib FracturesIsolated or multiple
Segmental > 3 ribs
1st to 3rd rib involvement underlying intrathoracic visceral
involvementUncommon
Significant morbidity and even mortalityPoor pain
controlUnderlying lung diseaseElderly
Atelectasis PneumoniaRespiratory failure
Thromboembolism
Flail chest3 or more adjacent ribs # @ 2 or more places
Cautious fluid resus.
Analgesia
EVOLVING PULMONARY CONTUSIONS
May not be initially obvious in young adult where muscles splint
the fractured ribs; in these situations paradoxical movement will
be apparent only if the victim becomes exhausted, the flail is
large (>6 ribs) or is central (involving sternum).
Intercostal blocks, epidural analgaesia and opioid / ketamine
infusions or patient-controlled analgaesia should be considered
later during the secondary survey, depending on the expertise
available. Some patients require tracheal intubation and controlled
ventilation.60
SURGICAL FIXATION vs CONSERVATIVE MXPAIN CONTROL
VENTILATORY REQUIREMENTS
SHORTER ICU & HOSPITAL STAY
IMPROVED POST-OP RESP FUNCTION
STERNAL FRACTURESSignificant impacting force
MVA with steering wheel impact or seat belt injury
UNDERLYING CARDIAC CONTUSIONCXR, e-FAST, ECG and serial
troponin
Blunt cardiac injury63
Blunt Cardiac Injuries
Cardiac ContusionsAcute injury pattern (ant STEMI I, aVL, V2-V4,
II,III, aVF), LBBB
Watch for & treat PVCs aggressively (K+, temp)
Rx acute myocardial infarction, inotropes
Cardiac Echo to assess wall motion, valves
TUBE THORACOSTOMY Almost 90% of chest trauma
Maintain or regain respiratory and hemodynamic stability
Within 48h of traumaTension pneumothoraxTraumatic symptomatic
pneumothoraxWorsening occult pneumohemothorax
Triangle Of Safety
Contra- IndicationsAbsolute. Need for emergency Thoracotomy
RelativeBleeding Diathesis
Anti-coagulationAdhesionsLoculationsPulmonary bullae68
Complications of Chest TubeHemorrhage
Infection
Trauma to the Liver, Spleen, Diaphragm, Aorta, Heart.
Minor complications Subcut hematoma, Cough, Dyspnea.
Improper placement
INSERTION OF A CLOSED THORACOSTOMY TUBE
SummaryLife ending thoracic injuries are commonSurvival depends
on proper and immediate diagnosis and appropriate managementED
thoracotomy can save lives but expected survivorship is
