CHEST TRAUMA

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CHEST TRAUMA

• Joe Lex, MD, FAAEM
• Temple University Hospital
• Philadelphia, PA
• July 20th, 2006

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Incidence of Chest Trauma

• 1/4 American trauma deaths
• Contributes to another 1 of 4
• Many die after reaching hospital - preventable
  if recognized
• lt10 blunt needs surgery
• 1/3 penetrating needs surgery
• Most life-saving procedures do NOT require
  thoracic surgeon

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Pathophysiology of Chest Trauma
TISSUE HYPOXIA
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Pathophysiology of Chest Trauma

• Tissue hypoxia
• Hypercarbia
• Respiratory acidosis inadequate ventilation
• Metabolic acidosis tissue hypoperfusion (e.g.,
  shock)

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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Blunt trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
Splinter
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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Penetrating trauma
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6 Immediate Life Threats

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• sucking chest wound
• Massive hemothorax
• Flail chest
• Cardiac tamponade

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6 Potential Life Threats

• Lung contusion
• Heart contusion
• Aorta rupture
• Diaphragm rupture
• Tracheobronchial tree injury - larynx, trachea,
  bronchus
• Esophagus trauma

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6 Other Frequent Injuries

• Subcutaneous emphysema
• Traumatic asphyxia
• Simple pneumothorax
• Hemothorax
• Scapula fracture
• Rib fractures

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Primary Survey

• Airway
• Breathing
• Circulation

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A Airway

• Assess for airway patency and air exchange -
  listen at nose mouth
• Assess for intercostal and supraclavicular muscle
  retractions
• Assess oropharynx for foreign body obstruction

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B Breathing

• Assess respiratory movements and quality of
  respirations look, listen, feel
• Shallow respirations are early indicator of
  distress cyanosis is late

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C Circulation

• Assess pulses for quality, rate, regularity
• Assess blood pressure and pulse pressure
• Skin - look and feel for color, temperature,
  capillary refill
• Look at neck veins - flat vs. distended
• Cardiac monitor

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Where can adults hide blood and go into shock?

• Chest listen, do chest x-ray
• Abdomen do DPL or CT or US
• Retroperitoneum do CT
• Thigh physical examination
• Street ask paramedic
• ...and in children, add
• Head

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Initial assessment and management

• Primary survey
• Resuscitation of vital functions
• Detailed secondary survey
• Definitive care

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Initial assessment and management

• Hypoxia most serious problem early interventions
  aimed at reversing
• Immediate life-threatening injuries treated
  quickly and simply, usually with tube or a needle
• Secondary survey guided by high suspicion for
  specific injuries

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Thoracotomy

• Closed heart massage is ineffective in a
  hypovolemic patient
• Left anterior thoracotomy with cross-clamping of
  descending thoracic aorta and open-chest massage
  may be useful in pulseless victim of penetrating
  trauma

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Thoracotomy

• Emergency department thoracotomy for patients
  without cardiac activity who are victims of blunt
  thoracic injuries is ineffective

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Thoracotomy
Nipple
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Thoracotomy
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Thoracotomy
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Thoracotomy
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6 Immediate Life Threats

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• sucking chest wound
• Massive hemothorax
• Flail chest
• Cardiac tamponade

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Airway Obstruction

• Airway obstruction at alveolar level assessed
  and managed during 2o survey
• Upper airway obstruction ? immediate life threat
  which must be dealt with in primary survey
• Most common cause patients tongue

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Airway Obstruction

• Chin-lift fingers under mandible, lift forward
  so chin is anterior

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Airway Obstruction
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Airway Obstruction

• Jaw thrust grasp angles of mandible and bring
  jaw forward

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Airway Obstruction

• Oropharyngeal airway insert into mouth behind
  tongue
• DO NOT push tongue further back

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Airway Obstruction

• Nasopharyngeal airway gently insert
  well-lubricated trumpet through nostril

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Airway Obstruction

• Definitive Airway
• Management tube in trachea through vocal cords
  with balloon inflated

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Airway Obstruction

• Orotracheal intubation
• Nasotracheal intubation in breathing patient
  without major facial trauma
• Surgical airways
• jet insufflation
• retrograde
• cricothyrotomy
• tracheostomy

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Airway Obstruction
Jet insufflation adapters
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How to perform cricothyroidotomy
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Tension pneumothorax

• Air leak through lung or chest wall
• One-way valve ? lung collapse
• Mediastinum shifts to opposite side
• Inferior vena cava kinks on diaphragm
  ?decreased venous return ? cardiovascular collapse

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Inferior vena cava
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Tension pneumothorax

• Tension pneumothorax is not an x-ray diagnosis
  it MUST be recognized clinically
• Treatment is decompression needle into 2nd
  intercostal space of mid-clavicular line -
  followed by thoracotomy tube

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Insert needle here
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Open pneumothorax

• Sucking Chest Wound
• Normal ventilation requires negative
  intra-thoracic pressure
• Large open chest-wall defect ? immediate
  equilibration of intra-thoracic and atmospheric
  pressures
• If hole gt2/3 tracheal diameter, air prefers chest
  defect

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Open pneumothorax
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Open pneumothorax

• Initial treatment seal defect and secure on
  three sides (total occlusion may lead to tension
  pneumothorax
• Definitive repair of defect in O.R.

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Massive hemothorax

• Rapid accumulation of gt1500 cc blood in chest
  cavity
• Hypovolemia hypoxemia
• Neck veins may be
• Flat from hypovolemia
• Distended intrathoracic blood
• Absent breath sounds, DULL to percussion

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Massive hemothorax treatment

• Large-bore (32 to 36 F) tube to drain blood
• If moderate sized (500 to 1500 ml) and stops
  bleeding, closed drainage usually sufficient
• If initial drainage gt1500 ml OR continuous
  bleeding gt200 ml / hr, OPEN THORACOTOMY indicated

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How to place a chest tube
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Pleural space
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Flail chest

• Free-floating chest segment, usually from
  multiple ribs fractures
• Pain and restricted movement paradoxical
  movement of chest wall with respiration

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Flail chest
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Flail treatment (old)
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Flail treatment (old)
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Flail treatment

• Ventilate well
• Humidify oxygen
• Resuscitate with fluids
• Manage pain (!!)
• Stabilize chest
• Internal ? ventilator
• External ? sand bags (rare)

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Cardiac tamponade

• Usually from penetrating injuries
• Classic Becks triad
• elevated venous pressure - neck veins
• decreased arterial pressure - BP
• muffled heart sounds
• Blood in sac
• prevents cardiac
• activity

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Cardiac tamponade

• May find pulsus paradoxus - a decrease of 10 mm
  Hg or greater in systolic BP during inspiration
• Systolic to diastolic gradient of less than 30 mm
  Hg also suggestive

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Cardiac tamponade

• Treatment is removal of small amount of blood
  15 to 20 ml may be sufficient from pericardial
  sac

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Pericardiocentesis
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Stab wound to right ventricle
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pericardium
epicardial fat
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Ten-minute break
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The Flock of Birds behind the heart
Thoracic duck
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6 Potential Life Threats

• Pulmonary contusion
• Myocardial contusion
• Traumatic aortic rupture (TAR)
• Traumatic diaphragmatic rupture
• Tracheobronchial tree injury larynx, trachea,
  bronchus
• Esophageal trauma

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Pulmonary contusion

• Potentially life-threatening condition with
  insidious onset
• Parenchymal injury without laceration
• More than 50 will develop pneumonia, even with
  treatment
• Up to 50 have only hemoptysis as presenting
  symptom

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Pulmonary contusion

• Patients with pre-existing conditions (emphysema,
  renal failure) need early intubation
• Treatment needs
• to occur over time
• as symptoms develop

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Myocardial contusion

• Blunt precordial chest trauma
• Difficult to diagnose
• Risk for dysrhythmia, sudden death, tamponade,
  pericarditis, ventricular aneurysm

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Myocardial contusion
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Myocardial contusion

• Also may see
• myocardial concussion ? stunned myocardium with
  no cell death
• coronary artery laceration
• Diagnosis by
• trans-esophageal echocardiogram (TEE)
• serial cardiac enzymes / markers

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Myocardial contusion

• Question Does it matter?
• New nomenclature Anterior Chest Wall Syndrome

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FORD
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Traumatic aortic rupture

• 90 or more dead at scene
• 90 mortality each undiagnosed day
• Must have high index of suspicion
• Disruption occurs at ligamentum arteriosum
  (ductus arteriosus)
• Contained hematoma of 500 to 1000 ml of blood

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Traumatic aortic rupture

• Radiographic signs
• Wide mediastinum (gt8cm)
• Fractured 1st 2nd rib
• Obliterated aortic knob
• Trachea deviated to right
• Pleural cap

• Elevated mainstem bronchus with shift to right
• Obliterated aortic window
• Esophagus shifted to right (NG at T4)
• Depressed left mainstem bronchus

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dye leakage
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Traumatic aortic rupture

• CT becoming imaging of choice
• Must know site!
• NPV of normal chest x-ray (good quality,
  upright) 98 (CT will find mediastinal
  hemorrhage in 3, TAR in 0.4)
• 78 of patients with post-traumatic wide
  mediastinum on chest film have normal CT

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Traumatic aortic rupture

• Treatment - SURGICAL REPAIR

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Traumatic diaphragmatic rupture

• Blunt trauma tears leading to immediate
  herniation
• Penetrating trauma small tears which may take
  years to develop herniation
• Usually on left side

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Traumatic diaphragmatic rupture

• Treatment surgical repair

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Tracheobronchial tree injury

• Larynx - rare
• Hoarseness
• Subcutaneous emphysema
• Palpable crepitus
• Intubation may be difficult tracheostomy (not
  cricothyroidotomy) is treatment of choice

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Tracheobronchial tree injury

• Trachea
• Blunt or penetrating
• Esophagus, carotid
• artery and jugular
• vein may be involved
• Noisy breathing ?
• partial airway
• obstruction

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Tracheobronchial tree injury

• Bronchus
• 1.5 blunt chest trauma
• 80 due to BLUNT trauma within one inch of carina
  (tethered)

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Esophageal trauma

• Penetrating gt blunt
• Lethal if not recognized
• High suspicion if
• left pneumothorax and hemothorax without rib
  fracture
• shock out of proportion to apparent blunt chest
  trauma
• particulate matter in chest tube

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Esophageal trauma
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Esophageal trauma

• Blunt trauma, most tears superior
• If low esophagus ? leakage of stomach contents
  into mediastinum

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6 Other Frequent Injuries

• Subcutaneous emphysema
• Traumatic asphyxia
• Simple pneumothorax
• Hemothorax
• Scapula fracture
• Rib fractures

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Subcutaneous emphysema

• Rice Krispies
• May result from
• airway injury
• lung injury
• blast injury
• No treatment
• required ? address underlying problem

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Traumatic asphyxia

• Purple face from extravasation of blood (Masque
  ecchymotique)
• Major damage is to underlying structures
• Purple face fades over time in survivors

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Simple pneumothorax

• Air enters potential space between visceral and
  parietal pleura
• Breath sounds down on affected side
• Percussion ? hyper-resonance
• Treatment chest tube in 4th or 5th intercostal
  space anterior to mid-axillary line

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Medial pneumothorax
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Pocket shooter
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Hemothorax

• Lacerated lung OR disrupted intercostal artery or
  internal mammary artery
• Most are self-limiting
• Surgical consultation if
• initial drainage of gt20 cc/kg (1500 cc)
• continued flow of gt200 cc/hr

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Scapula fractures

• Fractured scapula or 1st 2nd ribs indicates
  major mechanism of injury consider underlying
  damage

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Rib fractures

• Most frequent thoracic cage injury
• Most commonly injured 4th ? 9th
• If 10th / 11th / 12th ? suspect liver or spleen
  injury
• If 1st / 2nd / 3rd worry about injury to head,
  neck, spinal cords, lungs, great vessels

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Rib fractures treatment

• Intercostal blocks
• Epidural anesthesia
• Systemic analgesics
• Do not use
• taping
• rib belts
• external splints

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Rib fractures

• Ribs x-rays
• are expensive
• are inaccurate for diagnosis (50 sensitivity)
• add nothing to treatment
• require painful positioning of the patient
• are, in general, not useful

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In conclusion...

• Chest trauma is common in the multiply-injured
  patient
• Most conditions can be treated by the evaluating
  physician and do not require emergent thoracotomy
• Airway management and a judiciously placed needle
  can save many lives

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Next time

• February 27th, 2004
• Respiratory
• Emergencies
• Joe Lex
• joe_at_joelex.net