Chest trauma Petráš M.,. Klinika úrazové chirurgie LF MU a TC FN Brno Picture 7 Picture 9 Picture 8 Introduction ●vital structures – chest trauma is often sudden and dramatic ●heart, great vessels, esophagus, tracheobronchial tree and lungs ● ●abdominal injuries are common with chest trauma ●the most common type of injuries is blunt ●serious pathological consequences – hypoxia, hypovolemia, myocardial failure Physiology ●ventilation ● the mechanical process of moving air into and out of the lungs ● ●respiration ● the exchange of oxygen and carbon dioxide between the outside atmosphere and the cell of the body Anatomy ●skin ●bones ●12 pair of ribs ●ribs 1-7: join at sternum with cartilage end-points ●ribs 8-10: join at sternum with combined cartilage at 7th rib ●ribs 11-12: no anterior attachment ●sternum ●thoracic spine Picture 4 Anatomy ● ●topographical thoracic reference lines ●midclavicular line ●anterior axillary line ●mid-axillary line ●posterior axillary line ●intercostal space ●artery, vein and nerve on inferior margin of each rib Anatomy ● ●muscles of respiration ●diaphragm ●intercostal muscles ●contract to elevate the ribs and increase thoracic diameter ●increase depth of respiration ●sternocleidomastoid ●raise upper rib and sternum Anatomy ● ●trachea ●hollow & cartilage supported structure ●bronchi ●right & left extend for 3 centimeters ●enters lungs at pulmonary hilum ●also where pulmonary arteries & veins enter ●further subdivide and terminate as alveoli ●basic unit of structure & function in the lungs ●single cell membrane ●external versus internal respiration ●lungs ●right = 3 lobes ●left = 2 lobes Picture 4 Anatomy ● ●Pleura ●Visceral Pleura ●Cover lungs ●Parietal Pleura ●Lines inside of thoracic cavity ●Pleural Space ●POTENTIAL SPACE ●Air in Space = PNEUMOTHORAX ●Blood in Space = HEMOTHORAX ●Serous (pleural) fluid within ●Lubricates & permits ease of expansion Anatomy ●mediastinum ●central space within thoracic cavity ●boundaries ●lateral: lungs ●inferior: diaphragm ●superior: thoracic outlet ●structures ●heart ●great vessels ●esophagus ●trachea ●nerves ●vagus ●phrenic ●thoracic duct Picture 4 Classifications ●skeletal injury ●pulmonary injury ●heart and great vessel injury ●diaphragmatic injury Classification mechanism of injury ●blunt thoracic injuries ●forces distributed over a large area ● deceleration ● compression ● ● age factors ●pediatric thorax: more cartilage = absorbs forces ●geriatric thorax: calcification & osteoporosis = more fractures ● ● penetrating thoracic injuries ● Pathophysiology ●impairments in cardiac output ● blood loss ● increased intrapleural pressures ● blood in the pericardial sac ● vascular disruption ●impairments in gas exchange ● atelectasis ● contused lung tissue ● disruption of the respiratory tract Assessment findings ●pulse ● deficit ● tachycardia ● bradycardia ●blood pressure ● narrowed pulse pressure ● hypertension ● hypotension ● pulsus paradoxus Assessment findings ●respiratory rate and effort ● tachypnea ● bradypnea ● labored ● retractions ● other evidence of respiratory distress Assessment findings ●Skin ● diaphoresis ● pallor ● cyanosis ● open wounds ● ecchymosis ● other evidence of trauma Assessment - neck ●position of trachea ●subcutaneous emphysema ●jugular venous distention ●penetrating wounds Assessment - chest ●contusions ●tenderness ●asymmetry ●lung sounds ● absent or decreased ● unilateral ● bilateral ● location ● bowel sounds in hemothorax Rib fractures ●incidence ●is the most common thoracic injury ●most often elderly patients ● older ribs are more brittle and rigid ●ribs 3 to 8 are fractured most often ● they are thin and poorly protected ●lower ribs fracture are associated with spleen and liver injury ● ● ● Picture 4 Rib fractures ●signs and symptoms ●chest pain ●chest tendernes ●crepitus Rib fractures ●management ●analgesics – for pain and improve chest ● excursion ●oxygen ●encourage coughing and deep breathing ●position of comfort Flail chest ●3 or more ribs broken in 2 or more places ●segment of the chest that becomes free to move with the pressure changes of respiration Flail chest ●signs and symptoms ●chest pain ●chest tendernes ●crepitus ●respiratory distress ●tachypnea ●paradoxical chest wall movement Flail chest ●management ●analgesics ●oxygen ●position of comfort ●stabilize the flail segments ●endotracheal intubation, positive pressure ventilation Sternal fracture ●high association with myocardial or lung injury ● myocardial contusion ● myocardial rupture ● cardiac tamponade ● pumonary contusion ● ● association with thoracic vertebrae fractures Sternal fracture ●management ●analgesics ●high –concentration oxygen ●restrict fluids if pulmonary contusion suspected ●transport to cardiology if myocardial injury suspected Pulmonary injury Closed pneumothorax ●occurs when lung tissue is disrupted and air leaks into the pleural space ●incidence ● 10% to 30% in blunt chest trauma ●morbidity/ mortality ● extent of atelectasis ● associated injuries Pulmonary injury Closed pneumothorax ●signs and symptoms ● - absent or decreased breath sounds on the affected ● side ● - hyperresonance to percussion ● - tachypnea ● - dyspnea ● - chest pain referred to the shoulder or arm on the ● affected side ● - respiratory distress ● Pulmonary injury Closed pneumothorax ●Management ●analgesics ●position of comfort ●high –concentration oxygen ●positive-pressure ventilation if necessary ●if respiration is rate <12 or >28 per minute, ventilatory assistance with a bag-valve mask may be indicated ● ● ● ● Pulmonary injury Closed pneumothorax ●management ● ●tube thoracostomy – pleural decompression ●4nd intercostal space in mid-axillary line ●TOP OF RIB ● ● ● ● ● ● Picture 6 Pulmonary injury Open pneumothorax ●incidence ● gunshot wounds ● knife wounds ● falls ● motor vehicle collisions ●If the chest wound opening is greater than two-thirds the diameter of the trachea, air follows the path or least resistance through the chest wall with each inspiration Pulmonary injury Open pneumothorax ●signs and symptoms ● - decreased breath sounds on the injured side ● - a defect in the chest wall ● - a sucking sound on inhalation ● - subcutaneous emphysema ● - tachypnea ● - tachykardia ● - respiratory distress ● Pulmonary injury Open pneumothorax ●management ●analgesics ●high – flow oxygen ●positive-pressure ventilation if necessary ●ventilatory assistance with a bag-valve mask ●circulation – treat for shock with crystalloid infusion ●cover site with sterile occlusive dressing taped on three sides ●tube thoracostomy, videothoracoscopy, thoracotomy – in- hospital management ● Picture 6 Pulmonary injury Tension pneumothorax ●occurs when air enters the pleural space from a lung injury or through the chest wall without a means of exit ●results in death if it is not immediately recognized and treated ●when air is allowed to leak into the pleural space during inspiration and becomes trapped during exhalation, an increase in the pleural pressure results Pulmonary injury Tension pneumothorax ●increased pleural pressure produces mediastinal shift ●mediastinal shift results in: ● - compression of the uninjured lung ● - kinking of the superior and inferior vena ● cava, decreasing venous return to the ● heart ●progression of simple or open pneumothorax Pulmonary injury Tension pneumothorax ●signs and symptoms ● - absent breath sounds on the injured side ● - hyperresonance to percussion ● - subcutaneous emphysema ● - tachypnea and increasing dyspnea ● - tachykardia ● - cynosis ● - hypotension ● - jugular venous distention ● - extreme anxiety ● - respiratory distress ● Pulmonary injury Tension pneumothorax ●management ●emergency care is directed at reducing the pressure in the pleural space ● ●occlude open wound ●needle thoracostomy ●tube thoracostomy – in-hospital management ●4nd intercostal space in mid-axillary line ●TOP OF RIB ● ● Pulmonary injury Tension pneumothorax ●management ● ● pleural decompression should only be ● employed if the patient demonstrates ● significant dyspnea and distinct signs and ● symptoms of tension pnemothorax ● ● ● ● ● ● Pulmonary injury Hemothorax ●accumulation of blood in the pleural space caused by bleeding from ● -penetring or blunt lung injury ● -chest wall vessels ● -intercostal vessels ● -myocardium Pulmonary injury Hemothorax ●incidence ● -associated with pnemothorax – it is called a ● hemopnemothorax ● -blunt or penetring trauma ● -rib fractures are frequent cause ●hypovolemia results as blood accumulates in the pleural space Pulmonary injury Hemothorax ●signs and symptoms ● - diminished or decreased breath sounds on the injured side ● - hypotension ● - tachypnea ● - dyspnea ● - narrowed pulse pressure ● - pale, cool, moist skin ● - respiratory distress Pulmonary injury Hemothorax ●management ●analgesics ●high – flow oxygen ●positive-pressure ventilation if necessary ●ventilatory assistance with a bag-valve mask ●circulation – volume-expanding fluids to correct hypovolemia ●tube thoracostomy ● videothoracoscopy or thoracotomy - if it is blood loss by tube thoracostomy more than 2000ml or next 3 hours is blood loss more than 500ml/hours Pulmonary injury Contusion ● ●30-75% of patients with significant blunt chest trauma ●frequently associated with rib fracture ●younger patients – also without rib fracture ●signs and symptoms ● - cough ● - tachypnea ● - tachycardia ● - dyspnea ● - cyanosis ● - respiratory distress Pulmonary injury Contusion ● ●management ●analgesics ●high – flow oxygen ●positive-pressure ventilation if necessary ●ventilatory assistance with a bag-valve mask ●respiratory rehabilitation ●antibiotics ●bronchoscopy Cardiovascular injuries Myocardial contusion ● ●injury may reduce strength of cardiac contractions ●reduced cardiac output ●progressive problems ●myocardial necrosis ●dysrhythmias ●cardiogenic shock ● ● S/S ●tachycardia and/or irregular rhythm ●retrosternal pain ●associated injuries ●rib/sternal fractures Cardiovascular injuries Myocardial contusion ● ●management ●monitor ECG ●Alert for dysrhythmias Cardiovascular injuries Pericardial tamponade ● ●restriction to cardiac filling caused by blood or other fluid within the pericardium ●occurs in <2% of all serious chest trauma ●however, very high mortality ●results from tear in the coronary artery or penetration of myocardium ●blood seeps into pericardium and is unable to escape ●200-300 ml of blood can restrict effectiveness of cardiac contractions Cardiovascular injuries Pericardial tamponade ● ●increased intrapericardial pressure ● - does not allow the heart to expand and refill with blood ● - results in a decrease in stroke volume and cardiac output ●myocardial perfusion decreases due to pressure effects on the walls of the heart and decreased diastolic pressures ● ischemic dysfunction may result in infarction ●removal of as little as 20ml of blood may drastically improve cardiac output Cardiovascular injuries Pericardial tamponade ●signs and symptoms ● - tachycardia ● - respiratory distress ● - Becks triad - narrowing pulse pressure ● - neck vein distention ● - muffled heart sounds ● - ECG changes Cardiovascular injuries Pericardial tamponade ●management ●high flow O2 ●IV therapy ●pericardiocentesis – needle insertion through the skin incision directed toward the left shoulder at a 45 degree angle to the abdominal wall. Cardiovascular injuries Aortic rupture ● ●occurs almost exclusively with extreme blunt thoracic trauma - rapid deceleration in high-speed motor vehicle crashes ● - falls from great heights ● ●85-95% of these patients die at the scene as result of massive hemorrhage ● ●signs & symptoms ●rapid and deterioration of vitals ●retrosternal pain Cardiovascular injuries Aortic rupture ● ●IV therapy ●mild hypotension may be protective ●keep patient calm ●endovascular repair ●operativ repair – is associated with increased mortality