TRAUMA OF THE CHEST

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TRAUMA OF THE CHEST
A. VAYDA department of surgery with
anesthesiology
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• Classification
• The closed damages of the chest are divided
• ?. According to the injury of other organs
• 1.Isolated trauma.
• 2.Combined trauma (craniocerebral, with damage of
  abdominal organs, with damage of bones).
• II. According to the character of complications
• 1.Uncomplicated.
• 2.Complications
• Early (pneumothorax, hemothorax, mediastinal
  emphysema, flail chest, traumatic shock,
  asphyxia)
• Late (posttraumatic pneumonia, posttraumatic
  pleurisy, suppurative diseases of lungs and
  pleura).

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Rib fracture

• The direct force of traumatizing factor on the
  chest wall results in rib fracture.
• Pain
• On examination the respiratory lag on affected
  side.
• Crepitating of osseous fragment revealed by
  palpation diminished breathing sounds by
  auscultation depending on number of injured ribs
• On chest roentgenograms the break in continuity
  of bone fragments of ribs is observed.

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Rib fracture
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Floating rib fracture (Flail chest) The
floatation arises from fracture of three and more
ribs along two anatomic lines. The multiple rib
fractures produce an unstable segment of chest
wall that moves paradoxically inward upon
inspiration and balloons outward during
expiration (flail chest). Thereby the respiration
disturbed not only in the area of a floatating
segment, but also in all lungs. The permanent
movement of floatating segment result in rocking
shift of mediastinum, which causes deviation of
its organs. As a result the respiratory failure
is associated with cardiovascular.
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• Treatment
• Pain relief in closed trauma of the chest is
  achieved by means of different blocks
• Vagosympathetic block
• Alcohol - novocaine block of the site of
  fracture
• Paravertebral block.
• Analgesics and opiates.
• The methods of reduction of the skeleton of the
  flail chest are divided onto three groups
• External fixation of a movable segment by means
  of suturing for intercostal muscles and traction
  during 2-3 weeks
• Intrmedullary costal osteosynthesis
• Mechanical ventilation (often with positive
  end-expiratory pressure).

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Posttraumatic pneumothorax Posttraumatic
pneumothorax is the presence of air in a pleural
space, caused by mechanical injury of lung or
chest wall as a result of trauma.
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• Classification
• ?. According to extension of process
• Unilateral.
• Bilateral.
• ??. According to degree of a lung collapse
• Partial (collapse of lung to 1/3 of its volume).
• Subtotal (collapse of lung to 2/3 of its volume).
  
• Total (collapse of lung exceeding 2/3 of its
  volume).
• ???. According to the mechanism of occurrence
• Closed.
• Open.
• Valvular.

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Symptomatology and clinical course The rest
dyspnea. The chest pain. By percussion obtains
bandbox sound, or tympanitis. By auscultation -
weak or absent breathing sounds. Lag on affected
side. On the background of severe trauma of the
chest the signs of damage dominate in clinical
manifestation on inappreciable entry of air in a
pleural space. Pneumothorax mostly revealed
during X-ray examination.
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Treatment Aspiration of air by means of
thoracentesis, closed drainage of a pleural
space. The absence of effect (incomplete
expansion of lung) of active aspiration, and also
valvular closed pneumothorax is the indications
to operative management suturing of the
pulmonary wound
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Hemothorax Hemothorax is the accumulation of
blood in a pleural space. The cause of occurrence
of this complication is the damage of vessels of
the chest wall, pleura, lungs and mediastinum.
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• Classification
• ?. According to degree of hemorrhage
• Small (the loss less 10 of volume of
  circulating blood).
• Moderate (loss of 10-20 of volume of
  circulating blood).
• Great (loss of 20-40 of volume of circulating
  blood).
• Total (exceeds 40 of volume of circulating
  blood).
• ??. According to duration of bleeding
• With continuing hemorrhage.
• With the stopped bleeding.
• ?II. According to the presence of clots in a
  pleural space
• Coagulated.
• Noncoagulated.

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Symptomatology and clinical course If hemothorax
is the complication of blunt chest trauma, the
clinical manifestations depend on the gravity of
trauma and degree of hemorrhage. Also hemothorax
by itself results in pulmonary compression and
shift of mediastinum. In case of small
hemothorax clinical manifestations of hemorrhage
are slightly expressed or absent at all.
Dyspnea, cough, general malaise and dizziness
are obvious in moderate hemothorax. The skin is
pale. The hemodynamic disturbances tachycardia
and decreased arterial pressure are observed.
The great and total hemothorax are associated
with signs of shock. By percussion the dullness
is revealed. By auscultation - the breathing
over the site of hemothorax is sharply diminished
or is not heard.
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On X-ray picture of hemothorax the intensive
homogeneous shadow on the side of the lesion with
oblique upper contour is observed. The costal
sinus does not visualized. In small hemothorax,
depending on the degree of intrapleural bleeding,
the shadow observed only in the region of sinus.
In moderate hemothorax it achieves a scapular
angle (on the back surface) or V rib on anterior
surface of the chest wall. In great hemothorax
this shadow achieves ??? rib, and total
hemothorax characterized by complete shadow of a
pleural space.
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Treatment A treatment of small hemothorax
requires needle aspiration or drainage of pleural
space and elimination of blood. The manipulation
is carried out in V?-V?? intercostal spaces in
the postaxillary or scapular lines. Total, great
or moderate hemothorax with persistent bleeding
(positive test by Revilour-Greguar) requires
thoracotomy for liquidation of a bleeding source.
The bleeding wounds of lungs are sewed up by
twist suture. If the pleural space contains
liquid blood, the surgeon carries out its
reinfusion. The clots are removed from pleural
space.
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Mediastinal emphysema Mediastinal emphysema is
the complication of the blunt trauma of the
chest, which is characterized by entering and
accumulation of air in mediastinum. The entry of
air in mediastinum leads to compressing of
superior cava vein and right atrium, which
results in the expressed discirculation. The
causes of mediastinal emphysema is partial
(damage of a membranous part) or complete
disruptions of trachea, bronchi, esophagus and in
some cases tension pneumothorax.
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Symptomatology and clinical course Difficult
breathing and swallowing. Pain behind
breastbone. Hoarseness. Cough attacks. The
neck and face are thickened, cervical veins
distended, the skin is cyanotic. By palpation
the crepitation of neck, face, and shoulder area.
On X-ray film on the background of enlightenment
observed well-defined contour of a mediastinal
pleura.
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Tactics and choice of treatment
Progressing mediastinal emphysema requires the
urgent drainage of anterior mediastinum in order
to prevent external cardiac tamponade.