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Chest trauma
- 1. Chest trauma Presentation byDr Fidele Havugimana COSECSA-MCS Candidate Supervisor: Dr Maurice Musoni, Consultant CT Surgeon
- 2. Content Introduction Chestanatomy Immediately life-threatening chest injuries Potentially life-threatening chest injuries Takehome message
- 3. INTRODUCTION The chestis anatomically/physiologically rich that it contains the 2 organs(heart&lungs) whose lack of function traditionally used to define death before including brain activity as an important criterion . Thoracic trauma is the 3rd most common cause of deaths after abdominal injuries and head trauma in polytrauma pts(Morris et al, 2020-World Journal of Em Surgery) Thoracic trauma comprises 20-25% of all trauma worldwide, It accounts for 25% of trauma- related death and is a contributing factor in another 25% of polytrauma pts A third of RTA’s have significant chest trauma Rwanda?
- 4. Thorax is the4th most common(10%) anatomical site of traumatic injuries following craniofacial,LLs, ULs . If such a rare case happened in Rwanda, how about the common presentations?
- 5. Anatomy of thechest Thoracic inlet connects the root of the neck to the thoracic cavity Thoracic wall
- 6. Anatomy of thechest----
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- 8. Blunt Chest trauma Aceleration/Deceleration injury: MVA Fall > 3m Sports Compression(AP& transverse) Blast injuries < 10% of BCT require surgical interventions as opposed to 15- 30% in PCT
- 9. Penetrating Chest trauma High velocity: Gunshot Missile fragments Low velocity: stab
- 10. Initial management- PrimarySurvey ( ATLS Protocol) Airway/C-spine stabilization Trachea,bronchial disruption Breathing Chest wall integrity,pneumothorax, flail chest Pulmoray contusion Circulation Tamponade, hemothorax,tension pneumothorax Cardiac, great vessel injury Disability Exposure
- 11. The deadly Dozen! Blunt, penetrating Immediately life- Potentially life-threatening 1.Airway obstruction 1.Tracheobronchial disruption 2.Tension pneumothorax 2.Aortic disruption 3.Open pneumothorax 3.Diaphragmatic disruption 4.Massive haemothorax 4.Esophageal disruption 5.Cardiac tamponade 5.Cardiac contusion 6.Flail chest 6.Pulmonary contusion
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- 13. Airway obstruction Mostcommon cause of Early preventable trauma related deaths Unconcious pt: tongue ! But also: dentures,teeth, secretions , blood clot Bilateral mandibular fractures, expanding neck haematoma. Mgt BLS Early intubation if: Severe TBI Neck heamatoma Possible airway oedema
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- 15. Open pneumothorax ‘‘Sucking chest wound’’ Hole in the chest wall due to blunt or penetrating trauma Air moves freely in & out of the pleural space Negative pressure is lost in the pleural space causing the lungs to passively collapse Lung tissue usually remains intact Sucking sound or bubbling at the wound site on inspiration Dyspnea/tachypnea Unequal chest rise and fall Possible subcut air Signs of hypoperfusion
- 16. Open pneumothorax -management O2, monitor IV en routes Spinal immobilization as indicated Three-sided occlusive dressing Chest tube Observe for S&S of tension pneumothorax If tension pneumothorax remove the occlusive dressing & needle thoracostomy
- 17. Massive haemothorax Bloodaccumulates in the pleural space Injury to the heart,great vessels ,intercostal arteries More common to see hypotension before resp distress Needs thoracotomy if: Initial drainage of more than 1500ml Ongoing haemorrhage of 200ml/hr over 3- 4 hrs Caution if drainage of 500ml and persistence of dullness or radiographic opacification
- 18. Cardiac tamponade Accumulationof fluid(blood) in the pericardial space Reduced ventricular filling Pressure backs up and results in o Decreased Veinous return o Decreased stroke volume o Decreased cardiac output Beck’s triad( Distended neck veins, hypotension,muffled heart sounds) CXR:enlarged heart shadow HUS: pericardial effusion TTT: Pericardiocentesis
- 19. Flail chest Two ormore consecutive rib fractures at 2 or more places Paradoxical motion of the flail segment Segment moves : • in on inspiration • Out on expiration Dyspnea Localized chest pain s/o poor perfusion, oxygen exchange Risk of pneumothorax, haemothorax & lung contusion Massive force needed to cause this injury so think about other injuries
- 20. Flail chest------ treatment Internal pneumatic stabilization--- unnecessary Adequate pain control Proper oxygenation ICU—supportive ventilation Generally operative fixation is reserved for patients requiring thoracotomy for other reasons Operative vs conservative management Slobogean et al 2013, retrospective meta- analysis , 11 studies,753 patients Surgical fixation offers better outcome: Substantial decrease in vent days(8 days,95% CI 5-10 days) Decreased ICU days(5 days 96%CI,2-8 days) Less risk of developing pneumonia Septicemia Mortality tracheostomy
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- 22. Tracheo-bronchial disruption Bluntor penetrating trauma Presents with: Air leak, massive and sometimes uncontrollable Acute resp distress Neck & upper chest subcut empysema, sometimes massive and disfiguring Rx-bronchoscopy-deep intubation(beyond injury) sometimes tracheostomy
- 23. Aortic disruption Aortic rupture Thoracic aortic rupture is a common cause of sudden death after MVA and fall from height(1/3 fatality on site due to free rupture) 80-90% fatality rate within 1st hour Exsanguination Usual site: distal aortic arch 1:6 who die in MVA sustain AR Early recognition is a key to salvageability Think about it if: o Widened pulse pressure o Rt , LT arm BP discrepancy o UL,LL BP discrepancy o Widened mediastinum on CXRmassive o Haemothorax o Fractures of 1st and 2nd rib Confirm with: o Aortography o Contrast Spiral CT/mediastinum Mgt o Emergency surgery
- 24. Contained aortic rupture Contained injuries carry a good prognosis Not the source of hypotension Salvageable tear-haematoma contained 1/3 die in 24 hrs w/o treatment Widened mediastinum unreliable on portable x-ray TEE, contrast CT,aortogram
- 25. Diaphragmatic disruption Lossof thoraco-abdominal separation 80-90% occur from MVA L>R rupture----liver protection, 80- 90% occur on the Lt Respiratory distress Bowel sound in the chest Pre-op diagnosis in only 40-50% Operative repair in all cases
- 26. Esophageal disruption Mostlyfrom PCT Odinophagia, subcut& mediastinal emphysema Unexplained fever within 24 hrs of injury Mortality raises exponentially if treatment delayed (12-24hrs) Esophagogram & esophagoscopy Management is mainly operative
- 27. Cardiac contusion Commonsteering wheel injury Range from minor to MI Must be suspected in any patient with significant BCT who develops EKG abnormalities in resuscitation room May be asymptomatic up to 8 hrs Can present in cardiogenic shock Possible dysrhythmia EKG Treatment may include amiodarone- ventricular tachydysrythmias Mandatory monitoring for 24 hrs
- 28. Pulmonary contusion Hemorrhageinto the lung parenchyma Potentially lethal injury(mortality 6- 25%) risk factor for PNA&ARDS Worsening hypoxemia Hemoptysis in the ETT CT is the confirmatory imaging of first choice Treatment: Oxygenation,physio and analgesia
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- 30. RIB FRACTURES Verycommon Rare in children , common in elderly Rarely life –threatening in themselves RIB 1,2 Vs RIB 8-12 Mgt: strong analgesia, incentive spirometry Admission if unable to cough and clear secretions
- 31. Takehome message Significantproportion of deaths from chest trauma occur immediately Strict adherence to ATLS protocol is needed to identify and treat the deadly chest injuries( simple and effective techniques like chest tube insertion by any medical practitioner !)------85%......... Targeted and focused assessment is needed to detect and treat the potentially life threatening chest injuries
- 32. References Gabin Mbanjumucyo,NaomiGeorge, Alexis Kearney et al. Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda, AFJEM Open Access, Oct 2016 Herbert Butana, Laurance Ntawunga, Desire Rubanguka, and Isaie Sibomana. Tension Viscerothorax In A Patient With Missed Traumatic Diaphragmatic Hernia. A Case Report. EJMED ,April 2020 Slobogean GP,Macpherson CA,Sun T. Surgical fixation vs non operative management of flail chest, a meta-analysiss, J Am Coll Surg Feb 2013 Herbert cubasch,Elias Degiannis. The deadly dozen of chest trauma,CME july 2004 Vol.22 No.7 Hussein Elkhayat,MD Chest trauma refreshment for emergancy doctors, presentation July 2004 Tony Melendez, RN BS, MICN EMS Educator Chest & Abdomen Trauma:Understanding & Responding Appropriately ppt ,2013