2. Trauma is leading cause of :
death,
hospitalization,
short and long-term disability for all ages from first –forty years.
25% of all trauma death are due to chest injuries
20-33% death risk can be reduced.
Deaths occur within first 4 hours trauma
Uncontrolled haemorrhage,
Un corrected hypoxia or
Delay in surgical interventions
3. Chest injuries may result
from:
Gunshot wounds (GSW)
Shrapnel
Explosions
Motor vehicle crashes
(MVC)
Falls
Crush injuries
Stab wounds
6. Determine the MOI
Penetrating trauma.
GSW or stab wounds
Concentrates forces over
smaller area
Bullet trajectories
unpredictable
Crush injury
6
Blunt trauma.
Force distributed over
larger area
Visceral injuries occur
from:
Deceleration
Compression
Sheering forces
Bursting
7. What are the significant pathophysiologic effect of
chest injury should I identify in the primary survey,
and when and how do I correct them?
What life-threatening chest injuries should I
recognize as causing major pathophysiologic
event?
What adjunctive tests are used during the secondary
survey to allow complete evaluation for potentially life-
threatening thoracic injuries?
17. Flail Chest
2 or more adjacent rib
fractures in >2 places
May be paradoxical chest
movement
Pulmonary contusion
Reduced respiratory volume
Segment Fixation and
positive ventilation to restore
tidal volume
18. Open Pneumothorax
(Sucking Chest Wound)
Free passage of air between
atmosphere and pleural space
Air replaces lung tissue
Mediastinum shifts to uninjured
side
Air will be drawn through
wound if wound is 2/3 diameter
of the trachea or larger
Signs & Symptoms
Penetrating chest trauma
Sucking chest wound
Frothy blood at wound site
Severe Dyspnea
Hypovolemia
22. Tension Pneumothorax
Dyspnea Tachypnea at first
Hyperinflation of injured side of
chest
Hyperresonance of injured side of
chest
Diminished then absent breath
sounds on injured side
Heart sounds normal
Late signs:
Cyanosis
Diaphoresis
AMS
JVD
Hypotension
Hypovolemia
Tracheal Shifting
26. Massive Hemothorax
Dyspnea Tachycardia at first
Bulging/bruising/wound of injured
side of chest
Stony Dullness percussion of
injured side of chest
Diminished then absent breath
sounds on injured side
Heart sounds normal
Late signs:
Cyanosis
Diaphoresis
AMS
JVD
Hypotension
Hypovolemia
Tracheal Shifting
27. Chest drain system Thorac0tomy if:
> 1500 ml initially
200 ml/hr for 4 hrs
29. Pericardial Tamponade
MOI Penetrating/severe
blunt injuries
Dyspnea
Hypotension
Elevated CVP (JVD)
Muffled Heart sounds
Lung sounds normal
Kussmaul’s sign
Decrease or absence of JVD
during inspiration
Pulsus Paradoxus
Drop in SBP >10 during
inspiration
Due to increase in CO2
during inspiration
Electrical Alterans
P, QRS, & T amplitude
changes in every other
cardiac cycle
36. Pulmonary Contusion
Frequently manifests itself as Hypoxemia.
Goals for treatment are to prevent it
Oxygen therapy,
Positive pressure either with a
CPAP mask
Intubation and mechanical
ventilation with PEEP.
Splinting from the pain associated with rib
fractures requires adequate pain management,
i.e.parenteral narcotics, interpleural local
anesthetics, or epidural narcotics/local
anesthetics.
The contused lung is prone to capillary leak
and therefore careful fluid management is
indicated
37. Haemothorax
blood in pleural space
Part or total lung collapse
Rib fx
Chest pain, dyspnea,
tachypnea
Chest drain system
40. Closed (Simple) Pneumothorax
Air in pleural space
Part or total lung collapse
Rib fx
Paper bag effect
Chest pain, dyspnea,
tachypnea
Chest drain-underwater
seal system
41.
42. Myocardial Contusion
(Blunt Myocardial Injury)
Often MVC
Sternal or rib fx common
May have chest pain
Dysrhythmias,
palpitations, murmur
Oxygenate, monitor ECG
Treat rhythm disturbance
43. NO longer routinely subjected to
prolonged observation in a monitored
setting. If ECG and echocardiogram
are normal patient may go home after
12 hours if no other injuries are
present.
Young patients rarely have cardiac
related complications even when
cardiac contusion is diagnosed.
The Best test for diagnosis remains
controversial. ??
ECG is unreliable- unless ST
elevation is present.
CPK MB isoenzymes -may be
non diagnostic.
Cardiac troponin I which may
be more specific for myocardial
damage has not been
adequately evaluated.
Echocardiography is useful for
detecting wall motion
abnormalities, pericardial
effusions and in combination
with abnormal CPK MB may
predict complications.
Radionuclide angiography may
also be predictive of
complication.
Thallium scanning can detect
areas of decreased perfusion,
but cannot differentiate an
acute from preexisting lesion
44. Traumatic Aortic disruption
80-90% of patients with thoracic aortic
rupture die in the pre-hospital setting.
Those who survive to to reach the
hospital may have minimal symptoms.
CXR may give the first suggestion of
injury.
The disruption is usually at the isthmus
just distal to the left subclavian artery.
Control of blood pressure is critical to
avoid further dissection.
Emergent surgery with poor
hemodynamic stabilization has high
mortality
45. Loss of the aortic knob
contour,
Depression of the Lt
mainstem bronchus
Shift of the esophagus
(nasogastric tube) to
the right and
Lt heamothorax
An apical cap in
addition to mediastinal
widening indicate need
for further workup
46.
47. Diaphragmatic injury
Often on left
could be missed
Shortness of breath
Dyspnea
Abdominal/chest pain
Bowel sounds in chest
Elevation of Lt
hemidiaphragm
Confirm by CT
Operative intervention
50. Tracheobronchial Injuries
Rare but high mortality
Haemoptosis/Tension
pneumo/SQ emphy
Suspect when persistent
large air leak after tube
thoracotmy
Confirmed by bronhoscopy
Keep airway clear
Administer high flow O2
Consider intubation if
unable to maintain patent
airway
Operative intervention
51. Esophageal Injuries
Rare complication of blunt
thoracic trauma
30% mortality
Contents in esophagus/stomach
may move into mediastinum
Serious Infection occurs
Chemical irritation
Damage to mediastinal
structures
pneumomediastinum
Subcutaneous emphysema and
penetrating trauma present
Operative intervention
52. SQ emphysema
•May result from Air way,lung or blast injury
•No treatment required
•Underlying injury must be addressed
•If PPV required then consider chest tube on side of SQ emphysema
53. Rib Fractures
Rib fractures should be taken in
context. Their presence indicate
a need for examining the
underlying lung
for contusion,
laceration,
hemo or pneumothorax.
Multiple or anterior and posterior
rib fractures may cause a flail
segment.
Fracture of the relatively
protected first through third ribs
indicates severe impact and
mandates careful search for
associated injury
54. Sternal Fractures
Associated with severe
blunt anterior trauma
Typical MOI
Direct Blow (i.e. Steering
wheel)
Incidence: 5-8%
Mortality: 25-45%
Myocardial contusion
Pericardial tamponade
Cardiac rupture
Pulmonary contusion
55. Traumatic Asphyxia
Severe crush to chest and
compression of SVC
Support airway
Provide O2
PPV with BVM to assure
adequate ventilation
2 large bore IV’s
Evaluate and treat for
concomitant injuries
If entrapment > 20 min with
chest compression
Consider 1mEq/kg of Sodium
Bicarbonate
56. 85 % of pt with life threatening injuries can be managed by
simple interventions easily mastered by physicians and ER
service personnel