3. Epidemiology
10-20% of polytrauma
2nd most common cause
of death after head
trauma
25% of death in
polytrauma
4. India
Most common cause is
Motor vehicle injury
6% of global vehicular
accidents
Male , mean age 21-40
years
Violence ,industrial
accidents, falls, assaults,
gunshot
10. Blunt Thoracic Trauma
Globally = Road traffic accident represent the
most common cause
Eastern mediterranean countries = Assault
Other causes
- Assault
- Fall
- Industrial
- Sports
- Animal attacks
11. Blunt trauma contd……
Results from kinetic energy forces
- Blast
- Crush
- Decelaration
Blast
- Pressure wave
- Tear blood vessels & disrupt alveolar tissue
- Disruption of tracheobronchial tree
- Traumatic diaphragm rupture
12. Crush (Compression)
– Body compressed between an object and
a hard surface
– Direct injury of chest wall and internal
structures
Deceleration
– Body in motion strikes a fixed object
– Internal structures continue in motion
– Force exceeds tissue tensile strength
– Ligamentum Arteriosum shears aorta
13. Penetrating Trauma
Penetrating Trauma
– Low Energy
Arrows, knives
– High Energy
Military, hunting rifles &
high powered hand guns
Extensive injury due to
high pressure cavitation
23. Diaphragmatic Rupture
More common on left side
Commonly diagnosed during
laparatomy
Chest X-ray with gastric
tube, contrast study
Treatmant is direct repair
25. Esophageal Injury
Assessment Findings
- Pain/shock out of proportion to the apparent injury
- Dysphagia, Respiratory distress
- Particulate matter in the chest tube
- Mediastinitis, pneumomediastinum, emphysema
- Contrast study
- Direct repair
26. Traumatic Aortic Rupture
Common cause of sudden
death
Slim chances of survival
Ligamentum arteriosum
Immediate survivors, early
diagnosis and treatment
27. Signs and symptoms
Non specific : High index of suspicion
Burning or Tearing Sensation in chest or shoulder
Rapidly dropping Blood Pressure and increasing pulse
Decreased or loss of pulse or BP on left side compared to
right side
Rapid Loss of Consciousness
28. Management
ABC’s and RAPID TRANSPORT to higher center
Angiography is gold standard
Other investigation non specific
Primary repair or resection and grafting
29. Flail chest
Flail chest has mortality of 10 – 20 % and typically
associated with pulmonary contusion
Traditional = Paradoxical movement and
“Pendelluft”
“ Pulmonary contusion causes major respiratory
compromise and flail chest secondary problem of
pain and splinting ”
36. Management
Principles of fluid management ?
Invasive or non- invasive ventilation ?
Optimal mode of ventilation ?
Role of surgical fixation ?
Role of steroids ?
Rule of thumb = Adequate analgesia and chest
physiotherapy
37. Management contd…
Humidified oxygen
Analgesia
Ventilation and re-expansion of lung
Sandbag and extensive strapping
contraindicated
No role of steroids
38. Fluid management
“Congestive atelectasis” - Aggressive fluid
resuscitation increase the size of lesion
Trinkle et al 1973
Colloids better than crystalloids
Pulmonary dysfunction unrelated to hemodilution
Mortality related to pulmonary function on
admission
“ Fluid resuscitation should not be restricted to
maintain adequate tissue perfussion”
39. Ventilatory support
Initially = ‘ obligatory mechanical ventilation ‘
Longer hospital stay, increase mortality and
morbidity
“ Correct abnormalities of gas exchange rather to
overcome instability of chest wall ”
40. Indication for intubation
Severe head injury
Several associated injury
Shock
Fracture of eight or more
ribs
Age > 65 years
Previous pulmonary
disease
RR > 35/mt
Pao2 < 60mmHg
PaCO2 > 55mmhg
SPo2 < 90%
41. Which mode ?
No difference between CMV and IMV
CPAP or PEEP of 10-15 cm H2O
Alveolar recruitment and increase FRC
Independent lung ventilation in severe unilateral
chest trauma
HFOV : Failure of conventional methods
42. Indication of surgical repair
Thoracotomy
FC with respiratory insufficiency without
pulmonary contusion
Severe flail chest requiring prolonged ventilatory
support
Progressive dislocation of ribs
43. Summary
“ Flail chest component causes short term respiratory
dysfunction, Pulmonary contusion responsible for
long term dyspnoea, low FRC , PaO2 ”
“ Adequate analgesia and chest physiotherapy is
mainstay of treatment ”
53. Epidural contd….
Equally effective pain scores but superior PFT
Cicala et al 1990
Combination therapy
Lower pain scores
IV narcotic sparing Logas et al 1997
Lower doses of both
Boluses has higher rate of complication
kurek et al 1997
57. Intercostal nerve block
Advantages Disadvantages
Increase PEFR ,lung
volumes
Less hypotension
Bladder function
preserved
Palpation of fractured
ribs
LA Toxicity
Difficult for upper ribs
Multiple infections
Pneumothorax
58. Intrapleural anesthesia
Advantages Disadvantages
Unilateral block
Similar to intercostal
LA lost via chest tube
Gravity dependent
Pneumothorax
Impair diffusion of LA
Diaphragmatic function
59. Newer modalities
5 % lignocaine patch ( LIDODERM )
No opiod sparing versus placebo group
Ingalls et al 2010
60. Summary
Epidural analgesia: Optimal modality of pain
control and preferred technique after severe
blunt thoracic trauma
Safe with negligible complications
PVB when ED is contraindicated
Combination of narcotic and LA superior
