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Chest Trauma

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Title: Chest Trauma


1
Chest Trauma
  • Kent J. Blanke, D.O., FACOS

2
Introduction
  • Trauma 3rd leading cause of death in the U.S.
  • Trauma is the leading cause of death in those
    under 40 y.o.a.
  • There are 100,000 accidental deaths/yr and
    9,000,000 disabling injuries yearly in the U.S.
  • 25 of deaths from blunt trauma are due solely to
    chest injuries

3
Thoracic Trauma
4
Penetrating Chest Injuries
  • Majority are stab wounds or gunshot wounds (GSW)
  • Lower mortality rates--less likely to include
    multiorgan injury
  • 85 of penetrating chest wounds can be treated
    with tube thoracostomy and supportive measures

5
Penetrating Chest Injuries
  • 25,000 deaths per year in the U.S. due to GSWs to
    the chest

6
Penetrating Chest Trauma
  • Wounds that enter or exit inferior to the nipple
    or the posterior tip of scapula may perforate the
    dome of the diaphragm.
  • Any penetrating wound such as this should be
    considered to have an abdominal component until
    proven otherwise.

7
Penetrating Chest Trauma Treatment
  • ATLS protocol A,B,C,D,Es
  • Emergency management
  • Needle thoracentesis
  • Tube thoracostomy
  • Subxiphoid pericardotomy
  • Video assisted thoracic surgery (VATS)

8
Work-up of Penetrating Chest Trauma
  • Physical examination
  • Look, Listen, Feel
  • Contusions, diminished or absent breath sounds,
    SQ emphysema can readily be found
  • CXR- best, least expensive and fastest initial
    evaluation
  • Ultrasound-may soon replace CXR as initial
    radiographic study in chest trauma
  • Angiography- to look for great vessel injuries
  • CT Scan for better evaluation of chest wall and
    parenchyma
  • Transesophogeal Echocardiography

9
Penetrating Chest Injuries
  • Operative intervention required for
  • Massive or persistent bleeding
  • Massive air leak
  • Tracheobronchial injuries
  • Esophageal perforation
  • Cardiac or great vessel injuries
  • Post-traumatic empyema

10
Penetrating Chest Trauma
  • Wounds that enter or exit inferior to the nipple
    or the posterior tip of scapula may perforate the
    dome or the diaphragm.
  • Any penetrating wound such as this should be
    considered to have an abdominal component until
    proven otherwise.

11
Penetrating Chest TraumaIndications for
Mechanical Ventilation
12
Intrapulmonary Foreign Bodies
  • Bullets, fragments indications for removal
  • Greater than 1.5 cm
  • centrally located
  • irregularly shaped
  • sharp edged fragments
  • FBs associated with gross contamination should
    be removed

13
Intrapulmonary Foreign Bodies
  • When left in lung
  • 20 developed into chronic bronchitis
  • 6 lung abscess
  • 10 bronchopleural fistula
  • 5 Empyema

14
Pulmonary Parenchymal Laceration
  • Massive air leaks and hemorrhage require
    immediate operation

15
High Velocity Missile Injuries
  • Wounds due to high velocity missiles that travel
    gt 25,000 ft/s are being seen with ever-increasing
    frequency
  • Military and civilian

16
High Velocity Missile Injuries
  • Cavitation phenomenon causes damage to
    structures distal to the path of the missile.
  • Striking and shattering bone and other tissue may
    add to the damage
  • Associated injuries to the large vessels and
    bronchi is common
  • Severe pulmonary contusion
  • Vietnam experience

17
Blunt Chest Trauma
  • Higher mortality than penetrating trauma
  • More frequent simultaneous injuries of multiple
    organs
  • MVA leading cause of chest trauma with 50,000
    deaths and 2 million disabling injuries/year

18
Categories of chest wall injuries
  • Open pneumothorax
  • Contusion and Hematoma
  • Sternal fractures
  • Scapular fractures
  • Flail chest
  • Intercostal vessel injury

19
Categories of Intra-thoracic Injuries
  • Pulmonary
  • Pneumothorax, hemothorax
  • Pulmonary contusion
  • Pulmonary laceration
  • Vascular
  • Great vessel disruption (Ao dissection, pulmonary
    vasculature)
  • Cardiac
  • Blunt Cardiac Injury, Penetrating injury

20
Work-up of Blunt Chest Trauma
  • Physical examination
  • Look, Listen, Feel
  • Contusions, diminished or absent breath sounds,
    SQ emphysema can readily be found
  • CXR- best, least expensive and fastest initial
    evaluation
  • Ultrasound-may soon replace CXR as initial
    radiographic study in chest trauma
  • Angiography- to look for great vessel injuries
  • CT Scan for better evaluation of chest wall and
    parenchyma
  • Transesophogeal Echocardiography

21
Categories of chest wall injuries
  • Contusion and hematoma
  • Rich vascular network established by intercostal
    arteries w/ each rib
  • Internal mammary arteries on each side of sternum
  • Rib fx bleed from raw surface exposure of the
    bone and muscle tears

22
Categories of chest wall injuries
  • Open pneumothorax
  • When the defect in the chest wall is larger than
    the trachea, pt is unable to ventilate.
  • Apply occlusive dressing on 3 sides
  • Air cannot enter, but can exit through the flap
  • Prevents pneumothorax
  • Definitive management

23
Categories of chest wall injuries
  • Pneumothorax
  • Needle thoracentesis
  • Chest tube

24
Operative Intervention for Hemothorax
  • As noted previously
  • Hemothorax massive initial drainage more than
    1,000 cc or
  • Continuous bleeding of 200 cc/hr for 2 hrs

25
Fractured Ribs Chest Wall Trauma
  • 70 of chest wall trauma is caused by MVAs
  • 15 secondary to falls
  • Blunt chest trauma accounts from 81 of thoracic
    injuries in children, 78 in the elderly
  • Children are more likely to be injured as
    pedestrians (35 vs 11 in the elderly)

26
Fractured Ribs Chest Wall Trauma
  • The presence of 3 or more fx ribs on x-ray is an
    indication for the need of tertiary care
  • Pts with rib fx are more likely to require
    thoracotomy and laparotomy
  • The likelihood of splenic and hepatic injury is
    increased by 1.7 and 1.4 times, respectively

27
Fractured Ribs Chest Wall Trauma
  • Rib fxs are found in 52 of patients with
    documented cardiac contusion
  • Mortality doubles with there are 3 or more ribs
  • Blunt trauma with chest injury increases
    mortality rate by 27 than without chest
    injuries. Associated risk for death increases
  • Pneumo by 38
  • Hemothorax by 42
  • Pulmonary contusion by 56
  • Flail chest by 69

28
Blunt Cardiac Injury
29
Blunt Cardiac Injury
  • EKG (for any blunt chest injury, persistent
    tachycardia, ST-T changes or ectopy)
  • Cardiac enzymes (CPK, CK-MB and Troponin I) see
    EAST guideline
  • Echocardiography (TEE)

30
Categories of chest wall injuries
  • Sternal fractures
  • 80 associated with steering wheel impact
  • 62 have blunt cardiac injury (BCI)

31
Categories of chest wall injuries
  • Scapular fractures
  • 3 of blunt trauma cases
  • 54 have pulmonary contusions
  • 11 have associated ipsilateral subclavian,
    axillary or brachial artery injury
  • Over 1/3 are missed on initial evaluation

32
Categories of chest wall injuries
  • Flail chest
  • Fx of at least 4 consecutive ribs in 2 or more
    places
  • Incompetent segment of chest wall large enough to
    impair respirations
  • Paradoxic motion hinders creation of the expected
    ipsilateral negative inspiratory force

33
Categories of chest wall injuries
  • Flail chest
  • Combination of pulmonary contusion and flail
    chest has a mortality of 42
  • Pulmonary contusion with flail chest 75 require
    ventilation
  • Flail chest ALONE 48 require ventilation tx
  • Aggressive respiratory txs and IS with pain
    control

34
Categories of chest wall injuries
  • Flail chest
  • Internal splinting of mechanical ventilation
    until fibrous stabilization of the chest wall is
    apparent
  • Usually heavy sedation
  • SIMV with PS
  • PEEP or CPAP
  • Sandbagging
  • DO NOT use rib belts
  • Surgery Staples, Kirschner wires and plates
  • Analgesia

35
Pulmonary Contusion
  • Pulmonary contusions are not innocuous injuries
  • 11 of pts with isolated pulmonary contusion die
  • ARDS develops in nearly 20 ARDS carries a 50
    mortality

36
Intra-thoracic TraumaPulmonary Contusion
  • Occurs in nearly 50 of all chest trauma
  • Injury occurs to
  • Alveolar-capillary walls
  • Intra-alveolar hemorrhage
  • Interstitial edema
  • Increased tissue wt, airway and arterial
    resistance, decreased compliance, decreased
    surfactant content, decreased blood flow

37
Pulmonary Contusion
  • Increase in pulmonary vascular resistance and
    A-aO2 difference
  • Diagnosis
  • Dyspnea
  • Tachypnea
  • Hemoptysis
  • Cyanosis
  • Hypotension

38
Pulmonary Contusion
  • Physical signs
  • Inspiratory rales, decreased Vt
  • Patchy alveolar infiltrates due to intra-alveolar
    hemorrhage
  • Intrapulmonary bleeding reaches maximal extent
    within 6 hrs
  • Progression of a pulmonary contusion on X-ray
    after 48 hrs should raise suspicion that
    aspiration, bacterial pneumonitis or ARDS has
    developed

39
Pulmonary Contusion
  • Treatment
  • Oxygen to maintain PaO2 above 60 mmHg
  • Vigorous chest physiotherapy
  • Use colloids instead of crystalloids when rapid
    volume replacement is needed
  • Place PA catheter when large or rapid volume
    replacement is needed
  • Use of steroids and antibiotics are controversial

40
Intra-thoracic Trauma Great Vessel and
Mediastinal Trauma
  • Aorta
  • Pulmonary vessels
  • Tracheobronchial lacerations
  • Esophageal lacerations

41
Intra-thoracic Trauma Great Vessel and
Mediastinal TraumaWork-up
  • Plain CXR to identify thoracic aorta injuries
  • Look for air in the mediastinum
  • Persistent airleak should cue into
  • Bronchopulmonary or tracheobronchial injury
  • Mediastinitis, tube feedings in chest tube or
    saliva in chest tube should cue into
  • Esophageal injury

42
Intra-thoracic Trauma Great Vessel and
Mediastinal TraumaWork-up
  • Bronchoscopy
  • Esophagoscopy
  • CT
  • Serial CXR

43
Initial CXR of Concern
44
Indications for Angiography
  • Lateral deviation of the NGT in esophagus
  • Widened mediastinum (gt8cm)
  • Loss of visualization of the aortic knob
  • Hematoma of the Left cervical pleura (pleural
    cap)
  • Depressed left main stem bronchus
  • Rt lateral deviation of the trachea

45
Indications for Angiography
  • Widened mediastinum (gt8cm)

46
Indications for Angiography
  • Forward displacement of the trachea on the
    lateral CXR
  • Fx of the 1st or 2nd rib
  • Massive chest trauma w/ multiple rib fx
  • Fx or dislocation of the thoracic spine
  • Major deceleration injury

47
Complete Aortogram
48
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