Chest Trauma

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Chest Trauma

• By
• Dr. Samir Abdallah M.D
• Prof. of Cardio-Thoracic Surgery
• Cairo University

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Chest Trauma
Epidemiology

• The fact that it has become possible in recent
  decades for millions of people to travel at high
  speed had led to a phenomenal increase in blunt
  injury to the chest - a most lethal type of
  injury.

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• All casualties, and particularly children who
  have been exposed to blunt chest injury may have
  sustained highly lethal internal lesions (rupture
  of the heart, the aorta or the major airway, for
  example, or contusion of the heart although the
  external stigmata of chest injury may be quite
  trivial or even absents altogether.

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• For this reason any causality who has sustained
  blunt trauma to the chest should be considered
  seriously injured until proved otherwise.

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Frequency of Various InjuriesIn Motor Vehicle
Accidents
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Mechanism of Injury in Chest Trauma

• Acceleration/deceleration (motor vehicle
  accident)
• Body compression (crush injury)
• High-speed impact (gunshot wound)
• Miscellaneous

Low-velocity penetration (stab wound) Airway
obstruction (suffocation) Caustic injury
(poisoning) Burns Electrocution
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Schematic diagram of the various forms of
thoracic injuries showing how disturbed
cardiopulmonary physiologic equilibrium results
in tissue anoxia acidosis
Blunt or Penetration Trauma
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TRAUMA DEATHS
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Percentage of Specific Types of Thoracic Organ
Injury
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Assessment of patient with Thoracic injury

• The evaluation of thoracic injuries is only one
  aspect of the total assessment of severely
  injured patients.
• Both diagnosis and therapy go hand in hand.
• The basic principle of elective surgery - First
  investigate and make the diagnosis, then treat
  the illness - is a dangerous illusion.

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Assessment of patient with Thoracic injury

• The first step is to make a rough estimate of
  the status of the circulatory and respiratory
  systems. This provides the first diagnostic clues
  and often determines which therapeutic action is
  to be taken. Specific questions are then posed
  pertaining to individual injuries or their
  consequences.

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TEN QUESTIONS to be asked in the initial
assessment of severe blunt thoracic injuries

•     1. Hypovolemia?
•     2. Respiratory insufficiency?
•     3. Tension pneumothorax?
•     4. Cardiac tamponade

Immediately life- threatening diagnosis and
therapy before taking roentgenograms
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TEN QUESTIONS to be asked in the initial
assessment of severe blunt thoracic injuries

• Multiple rib fractures? (Paradoxical
  respiration?)
• Pneumothorax ? (subcutaneous emphysema?
  mediastinal emphysema?)
• Hemothorax?
• Diaphragmatic rupture?
• Aortic rupture?
• Cardiac contusion?

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Monitoring and evaluating the patient with
Thoracic trauma

• Roentgenograms of the thorax (Chest wall i.e.
  ribs, sternum, vertebral, clavicles).
• Mediastmum (wide or normal) shifted or not.
• Lung parenchyma (Contusion).
• The heart (cardiac tamponade).
• Diaphragm.
• Pneumothorax, hemothorax.

• ECG
• CVP
• Arterial blood gases.
• Urine output.
• Lab. Investigations.
• Others.

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Management of patients with Thoracic Trauma

• The treatment of polytraumatized patient must
  follow a certain protocol which includes.
• Adequate oxygenation.
• Fluid replacement.
• Surgical intervention.
• Treatment of septic complications.
• Adequate caloric and substrate supplementation.
• Prevention of stress bleeding.
• Finally, be alert of possible complication (CNS,
  ARDS, hepatic, renal, coagulation disorders,
  sepsis.

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Rib and Sternal Fracture Mechanism of Injury
Lung injuries are more common
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Rib and Sternal fractures

• Diagnosis
• Patient complains of localized pain that is
  aggravated by coughing deep breathing Localised
  tenderness.
• Subcutaneous emphysema
• False motion, paradoxical respiration
• Rib fractures must be diagnosed clinically many
  rib fractures are not visible on X-ray chest.

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Flail Chest
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Therapy in multiple rib fractures (not taking
companion injuries into consideration)
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Intercostal Blocks (Sites)
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• It is a tried and tested rule that a prophylactic
  chest tube should be inserted in every patient
  with multiple rib fractures who is to undergo an
  operation under general anaesthesia even when
  there is neither evidence of a hemothorax nor of
  a pneumothorax.

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Pneumothorax and Hemothorax

• Cases of pneumothorax and hemothorax can be
  provided with extremely effective therapy for the
  most part with simple methods, in more than 80
  of cases.
• It must, however, be given early, furthermore the
  drainage of air and blood must be efficient.

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Tension Pneumothorax (Life Threatening)

• Every traumatic pneumothorax can develop into
  tension pneumothorax, however, this complication
  is rare with spontaneous breathing.
• Very frequently, in a more dangerous form by for,
  a tension pneumothorax occurs during mechanical
  ventilation.
• Treatment consists of immediate relief of
  pressure.

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Open Pneumothorax

• Diagnosis
• A penetrating thoracic wound with a sucking sound
  of incoming and outgoing air sucking wound adds
  to the clinical and radiological evidence of
  pneumothorax
• Therapy
• Immediate air tight closure of the thoracic
  wound.
• Immediate intubation and mechanical ventilation.

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Hemothorax

• Diagnosis
• Diminished breath sound.
• Muffled sound on percussion.
• X-ray chest Clouding of the affected half of the
  thorax up to complete opacity.
• In the diagnosis of hemothorax formation of
  atelectosis and rupture of the diaphragm should
  be differentiated.

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Sources of blood accumulating in the chest
following blunt or penetrating trauma
Hemothorax

• Pulmonary parenchymal laceration.
• Rupture of pleural adhesions.
• Mediastinal injury with or without vascular
  injury.
• Cardiac injury with pericardio-pleural
  communication.
• Decompression of abdominal hemorrhage through a
  traumatic diaphragmatic injury.

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Hemothorax

• Therapy
• The key to successful management of acute
  hemothorax is early aggressive care in the form
  of adequate pleural evacuation by thoracostomy or
  thoracotomy in order to minimize the morbidity.
• The rate and cessation of bleeding depends on the
  site and size of the bleeding wound.

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Hemothorax

• Thoracotomy is done if the bleeding is constant
  and more than 300 ml per hour during the first
  three to four hours. However, tube thoracotomy is
  all what is needed if bleeding is less and
  decreasing without radiological evidence of
  clotted blood.

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Insertion of Chest Tube
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Lung Parenchymal Injuries
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Lung Parenchymal Injuries
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Lung Parenchymal Injuries
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Lung Parenchymal Injuries
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Lung Parenchymal Injuries
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Lung Parenchymal Injuries
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Abnormalities following bronchial rupture and
methods of management
Mediastinitis Empyema
Atelectasis
Tubes
Emergency Repair or Resection
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Abnormalities following bronchial rupture and
methods of management
Delayed
Pneumonia Abscess
Fibrosis
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Pathologic courses following esophageal
perforation
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Essential components of and procedures used in
management of esophageal perforation
Therapy non-operative
High-dose IV
Topical, Luminal
Gast. Tube
Plus Operative
Prox. Tube
Drainage of Mediastinal and/or fascial planes
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Injuries of the diaphragm

• Diaphragmatic Rupture
• Incidence In 3 of all sever thoracic injuries.
• Mechanism Broad surface blow.
• Location Left side in 85 of cases.
• Clinical picture.
• Acute symptoms of companion injury and shock.
• Chronic Intestinal obstruction or strangulation
  (usually)

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Diaphragmatic ruptures (Cont.)

• Radiological Ex. Rupture of the diaphragm are
  frequently overlooked.
• Therapy Is indicated for increasing impairment
  to respiration.
• Operative approach from chest or abdomen.

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Traumatic Diaphragmatic Rupture
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Traumatic Emphysema

• Subcutaneous.
• Mediastinal Emphysema.
• Present in about 27 of patients with blunt or
  penetrating chest injury

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Traumatic Emphysema

• Therapy
• Despite its impressive appearance the treatment
  of subcutaneous emphysema it self is mostly
  unnecessary.
• Determite the site of origin.
• Treat underlying pneumothorax if present by tube
  thoracostomy.
• Treat tracheobronchial, or oesophageal rupture or
  tension pneumothorax in cases of mediastinal
  emphysema.
• Rarely, cervical mediastinotomy is needed for
  mediastinal enphysema.

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Non-penetrating wounds of Heart
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Cardiac Tamponade
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Penetrating cardiac injuries (Therapy)
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Penetrating cardiac injuries (Therapy)
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CARDIAC INJURY
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Other Injury Patterns in Thoracic Trauma

• I. Traumatic asphyxia
• Due to a severe compression of thorax with sudden
  increase of pressure in the venous system
  resulting in a characteristic injury pattern
  where small hemorrhages in the conjunctiva, the
  skin and the mucous membranes of the throat and
  head and reddish-blue discoloration in the latter
  region.
• Therapy
• Is for the companion injuries and cerebral oedema
  if present.

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Other Injury Patterns in Thoracic Trauma

• II. Injuries of the thoracic duct (Chylothorax)
• III. Cholothorax
• IV. Traumatic induced hernia of the chest wall
• V. Arterial air embolism
• VI. Blast injury

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Indications for ThoracotomyDecision to Operate

• Excluding minor surgical procedures such as
  tracheostomy pericardiocentesis, tube
  thoracostomy, and suture of chest wall
  lacerations, formal operations are required in
  only 12 to 15 percent of patients with thoracic
  trauma.

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Indications for thoracotomy ACUTE

• Post-traumatic cardiovascular collapse
• Pericardial tamponade
• Vascular injury to the thoracic outlet
• Traumatic thoracotomy
• Massive Air leak
• Proved tracheobronchial injury

• Proved Esophageal injury
• Great vessel injury
• Continuing Hemothorax
• Mediastinal traversing injury
• Bullet Embolism
• Air Embolism

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Indications for thoracotomy CHRONIC

• Unevaluated clotted hemothorax
• Chronic traumatic Diaphragmic hernia
• Chronic cardiac septal or valvular lesions
• Chronic false Aneurysms
• Chronic non-closing thoracic duct fistula
• Infected intrapulmonary hematoma
• Missed trachobronchial injury
• Traumatic Arterio-venous fistula

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Initial Assessment of the most important thoracic
injuries
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Initial Assessment of the most important thoracic
injuries
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Initial Assessment of the most important thoracic
injuries
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Initial Assessment of the most important thoracic
injuries
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Initial Assessment of the most important thoracic
injuries
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