CHEST TRAUMA

REFRESHMENT FOR

EMERGANCY DOCTORS

Hussein Elkhayat,MD

Cardiothoracic surgery department

Faculty of medicine

Assiut university

7 july 2014 El-eiman general hospital , Assiut

Think about chest trauma

All multiple trauma patients have chest trauma

till proven otherwise

•If there is head injury and abdominal trauma

there is also chest trauma. (Therefore if CT

scanning the other two scan the chest as well)

Most injuries to the chest, both blunt and

penetrating, do not require surgery.

Only about 10% of chest injuries actually

require operative management.

All cardiothoracic injuries should be

considered lethal until proven otherwise.

PATHOPHYSIOLOGY

Cardiothoracic trauma can be classified as

penetrating or blunt.

Penetrating wounds of the chest such as

gunshot and stab wounds can directly injure

any or all structures in the trajectory of the

missile or weapon, causing rib fractures,

pneumothorax, hemothorax, or pulmonary or

cardiac injury. In contrast, low-velocity

penetrating trauma does not generally damage

surrounding structures not directly injured.

Blunt forces applied to the chest wall cause

injury by three mechanisms:

Rapid deceleration

Direct impact

Compression of the chest by a very heavy

object impedes ventilation and may result in

traumatic asphyxia

First Glance/Triage/Primary Survey

Walking/Talking can proceed directly to secondary survey

Moribund - a decision will need to be taken as to whether they are unsalvageable (e.g. dismemberment) or salvageable by emergency thoracotomy.

When to do a resuscitative ("E.R.") thoracotomy?Rarely is it indicated, even more rarely is it successful. It is almost never useful in blunt trauma. Successful outcome has been reported with the following:

◦Cardiac arrest due to tamponade or exsanguination

◦Young patient

◦Penetrative trauma to pericardium

◦Signs of life during transit to hospital

Resuscitation required - standard

ABC

•Airway

•BreathingAs part of assessment and treatment of breathing and circulation the insertion of chest drains should be considered.

•Circulation

Rapid clinical evaluation

Age , co morbidities

Mechanism of trauma

Site of pain / bleeding

Examination

Inspection , palpation , auscultationUsually percussion in difficult to perform in noisy busy trauma service

Secondary Survey

•ABG

•Chest Xray

•Cervical Spine Xray

•Limb Xrays

•Angiography as indicated

Focused abdominal ultrasound

•CT scan - this has replaced some of the above in certain circumstances. CT is part of the secondary survey and should not be done of bleeding, unstable patients or those undergoing resuscitation. Unstable patients should be resuscitated adequately which may mean operating before full radiological assessment.

common injuries

Simple fructure ribs

Multiple fructure ribs

Flail chest

Stab chest

Stab heart

Diaphragmatic hernia

Fructure sternum

Flail chest (old techniques)

Fail chest (new modalities)

Proper analgesia ( thoracic epidural , opioids ,

nerve block)

Internal pneumatic fixation (using endotracheal

tube and ventilator with PEEP) in pt. with head

trauma or unfit for surgery now

SURGICAL fixation using wires or plates in pt.

who will undergo thoracotomy for another

reason, sever deformity or indentation of the

ribs in lung parenchyma .

Fracture sternum

Stab chest

Stab heart

Dangerous area of the heart (any stab in this areas arise suspesion for cardiac injury)

-Bare area of the heart 4th ,5th intercostal space left parasternal

-Apex of the heart lt.5th intercostal space midclavicular line

-Interscapular area posterior

-Second left intercostal space parasternal area

Retained bullets

A trauma patient in shock, associated with theabsence of breath sounds and/or dullness onone side of the chest, should be treated formassive hemothorax until proven otherwise.

Most cases of hemothorax can be adequatelytreated by a tube thoracotomy and restorationof circulating blood volume.

More than 50% of fracture ribs can’t be seenon chest x ray film (clinical evaluation is themost important parameter)

History of chest trauma, physical examination

findings of Beck’s triad (distended neck veins,

hypotension, and muffled heart tones), or

pulsus paradoxus indicate the diagnosis of

pericardial tamponade.

Immediate treatment of cardiac tamponade in

trauma consists of aggressive fluid

replacement and open surgical drainage.

Echocardiography is the diagnostic method of

choice in patients with ECG abnormalities or

unexplained cardiovascular instability following

blunt cardiac trauma.

Thoracic CT with contrast has emerged as the

initial test of choice to diagnose aortic injury in

the setting of an abnormal mediastinum noted

on CXR.

The most common error in diaphragmatic

trauma is failure to suspect the possibility of

diaphragmatic injury.

Esophageal trauma is lethal if unrecognized

because it will lead to mediastinitis and

bacterial necrosis due to contamination of the

mediastinal space by esophageal contents.

Lower rib fractures are associated with injuries

to the spleen and liver.

As a general rule, younger patients with

flexible chest walls are less likely to have rib

fractures.

Ruptured diaphragm

•Will often appear late.

•Diagnosis is clinical rather than radiological

Suspect when lower multiple fracture ribs

Radiological (x-ray with Ryle-screen ex. –barium study)

•Repair acutely is via abdomen because of related injuries.

•Late diagnosis is common particularly in ventilated patients - late repair via thoracotomy because of presence of adhesions.

When not to admit patient with

chest trauma

Every patient with relevant chest trauma need

admission and follow up for at least 24 hr.

Patient can be followed up on out patient clinic

in case of young age with simple in place

fracture ribs with tolerable pain from near

discrete

Patient refuse admission should sign informed

consent regarding the need for follow up and

possibility of complications

When to put in a chest drain

without prior chest Xray?

If there is possible chest trauma and breathing is laboured or there is cardiac instability.

•Be prepared to place bilateral emergency drains "on spec"

•If you think about it!

•Emergency drains should be placed with caution via the axillary "triangle of safety" without a trocar.

When to put in a chest drain on the

basis of a CXR post trauma?

•Any post-traumatic pneumothorax.

•massive post-traumatic subcutaneous emphysema??

•Haemothorax

•The above are particularly important if a procedure is to be performed under general anaesthetic and positive pressure ventilation.

What if a drain stops working?

Mechanical factor

Procedure factor

Patient factor

Prophylactic chest drains

In general prophylactic chest drains are not recommended. The exceptions are:

•known chest injury where ambulance transfer is required,

•known chest injury where operative procedures (e.g. fracture fixation) are to be performed under general anaesthetic with positive pressure ventilation,

•where needle thoracentesis has been performed, with positive or negative result, and positive pressure ventilation is required.

Other indications for

intervention

CXR signs of a ruptured aorta

•wide mediastinum > 6 cm at the level of the neck of the aortic arch

•loss of contour of aortic knuckle

•wide peritracheal stripe

•apical cap

•deviation of oesophagus (NGT) to right

•deviation of trachea (ETT) to right

Review

Chest injury patients should have a formal review few hours after admission with repeat

•Chest Xray,

•Blood gases and

•Clinical appraisal

All patients with chest drains should have daily chest Xrays.

Medical treatment for isolated

chest trauma

Analgisics : NSAIDs , opioids , nerve block

Bronchodilators : used for treatment of

pulmonary contusions

ICU admission for pain control and chest care

in case of very old fragile patients .

Medical treatment for patient with

chest tube

Antibiotics : prophylaxis , usually first

generation cephalosorin

Analgesics : NSAIDs , opioids , nerve block

Bronchodilators : used for treatment of

pulmonary contusions

ICU admission for pain control and chest care

in case of very old fragile patients

Medical treatment for patient

underwent emergency thoracotomy

Antibiotics : covering gram +ve, -ve, anerobes

Analgesics : NSAIDs , opioids , nerve block during thoracotomy.

Bronchodilators : used for treatment of pulmonary contusions

Transximic acid ( cyclocapron )

Expectorant

ICU admission for high volume blood loss patients , pain control and chest care in case of very old fragile patients and for mechanical ventilation for patients with flail segement after fixation.

When to discharge patient with

chest trauma

Clinical : tolerable pain

Examination: - equal air entery

- no spasm or crepetus

Investigation : - clear lung fields , no

pericardial collection in case of heart injury

Drains : - less that 50 cc / 24 hr.

When to remove chest tube in

traumatized ventilated patient

Examination: - equal air entery

- no spasm or crepetus

Investigation : - clear lung fields

Drains : - less that 50 cc / 24 hr.

in absence of portable CXR in the ICU and

difficulty to discover recollection or

pnemonthorax in unstable patients , chest tube

left in place until patients general conditions

improves with consultation of staff member in

charge as regard removal

How to insert a chest tube

http://www.nejm.org/doi/full/10.1056/NEJMvcm

071974

Thank u