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Lecture 1 Chest Trauma

This document discusses the evaluation and management of various injuries to the chest wall, pleura, and lungs resulting from blunt and penetrating trauma, including pneumothorax, rib fractures, flail chest, pulmonary contusion, and hematoma. It provides details on examining patients, diagnostic imaging, and treatment approaches for different types of thoracic injuries. The prognosis and management of injuries varies depending on factors like the number of ribs fractured, age of the patient, and presence of additional injuries.

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505 views19 pages

Lecture 1 Chest Trauma

This document discusses the evaluation and management of various injuries to the chest wall, pleura, and lungs resulting from blunt and penetrating trauma, including pneumothorax, rib fractures, flail chest, pulmonary contusion, and hematoma. It provides details on examining patients, diagnostic imaging, and treatment approaches for different types of thoracic injuries. The prognosis and management of injuries varies depending on factors like the number of ribs fractured, age of the patient, and presence of additional injuries.

Uploaded by

j.doe.hex_87
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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CLINIC OF THORACIC SURGERY IASI

Dr.Cristina Grigorescu

BLUNT and PENETRATING

INJURIES of the CHEST WALL,

PLEURA, and LUNG


INCIDENCE

 150.000 DEATH/YEAR (USA)


 <40 YEARS OLD,traumatic injury- most
common cause of death.
 THORACIC INJURIES ¼ of deaths
EVALUATION and MANAGEMENT

 Initial evaluation- correcting life-


threatening conditions immediately and
documenting the less serious injury for
later correction.
 Primary survey – airway, breathing and
circulation to be stabilized immediately.
 All parts of the physical examination are
conducted in a focused manner to identify
and correct potentially lethal conditions
immediately.
EVALUATION and MANAGEMENT
 Examination-mouth, neck focuses on identifying any
symptoms of air airway obstruction.
 Neck veins- distention/collapse.
 Respiratory mechanism of chest wall motion- to detect
inhibition due to rib fractures or paradoxical motion
due to flail chest.
 Auscultation- distribution of brath sounds, their
character, any crepitus present in the chest wall.
 Percussion- notes areas of hiperresonance /dullness.
 Palpation – identification of any areas of crepitus,
hematomas, irregularities due to rib fractures, areas of
point of tenderness due to fractures
EVALUATION and MANAGEMENT

 Imaging modalities are used to confirm diagnosis


suspected and to assess the efficacy of therapeutic
interventions .
 Chest X-Ray,
 CT,
 Ultrasonography,
 Blood tests,
 Arterial presure,
 Pulsoximetry
 Arterial blood gases.
Injuries sustained as the result of
thoracic trauma
 Traumatic asphyxia,
 Mediastinal and subcutaneous emphysema
 Rib fractures,
 Sternal fractures,
 Open wounds of the chest wall:sucking wounds,
 Minnor penetrating wound of the thorax’
 Pulmonary contusion,
 Pulmonary hematoma,
TRAUMATIC ASPHYXIA

 Severe blunt injury of the thorax.


 - Facial and upper chest petechiae,
 - subconjuctival hemorrages, cervical cyanosis,
occasionally neurologic symptoms.
 Temporary impairment/loss of vision , presumed
to be due to retinal edema.
 Factors: thoracoabdominal compression after
deep inspiration against closed glottis,results in
venous hypertension in the valveless cervicofacial
venous system.
 No special treatment is required.
Mediastinal and Subcutaneous Emphysema

 Injuries to the traheobronchial


tree,esophagus,and lungs can lead mediastinal
emphysema.
 Rupture of the lung substance leads to a
pneumothorax.
 Severe blunt trauma- lacaration/rupture of a
central airway.
 The air may dissect back along the bronchi,
vessels into mediastinum.
 Large leak- air migration in the subcutaneous
space of the neck, face, chest wall, down to the
inguinal ligament, external genitalia.
Mediastinal and Subcutaneous Emphysema

 Tracheobronchial injury-suspected when a


large amount of mediastinal air is present,
especially if the pneumomediastinum seems to
increase with mechanical ventilation-
inspection of the bronchial tree
(bronchoscopy).
 Treatment and management should address
the etiology of the mediastinal and
subcutaneuos emphysema.(suture of the
bronchia, decompression incisions in the skin)
RIB FRACTURES
 Fracture of the one or two ribs unilaterally
 -identifying any associated injury,
 - chest pain control, to prevent hypoventilation,
 - decreased excursions of the chest wall and poor pulmonary
hygiene may lead: atelectasis,pneumonia,respiratory failure.
 Terapy:epidural analgesia, early mobilization,deep
respiratory efforts, frequent coughing.
 Pulmonary physiotherapy,nasotraheal suctioning,promt
bronchoscopy for the patient enable to clear secretions.
 Intercostal nerve blocks, intrapleural catheter analgesia,
transcutaneous electric nerve stimulation
Fractures of the first and second ribs

 Indicate the possible existence of


additional serious intrathoracic injury.
 Routine aortography-to rule out associated
vascular injuries.
 Mortality rate 36%,concomitant injuries to
the head (53%), abdomen(33%), other
structure within the thorax (64%).
Multiple or bilateral rib fractures

 Prognosis is related to the number of ribs


injured, patient”s age, underlying
pulmonary status.
 Mortality rate in elederly patient with
isolated rib fracture is 10-20%
Flail chest
 Instability of the chest wall from unilateral
bilateral multiple rib fractures, or from
disruptions of the costochondral junctions.
 Paradoxic chest wall motion lead to the reduction
in vital capacity and to ineffective ventilation,
along with associated pulmonary contusion—
ARDS.
 T:external stabilization:sandbags,towel
clips,internal stabilization using PEEP(mechanical
ventilation),
 Operative fixation of flail segment,
 Mortality rate:15-20%, but survivors may have
long-term consequences:impared pulmonary
function: dyspnea(63%),persistent pain(49%).
Sternal fractures
 4% in major motor vehicle crashes.
 Transverse, in the upper or midportions of the
body of the sternum.
 Localized tenderness, swelling, deformity.
 X-ray confirm(in lateral view).
 CT examination injures of the adjacent organs
and others skeletal structures.
 T:pain control and appropiate pulmonary
hygiene.
 Severe displace require open reduction with
internal fixation using cross wires.
Open wounds of the chest wall: sucking
wounds of the chest
 Loss of an area of the entire chest wall.
 Air can freely flow in and out of the pleural space.
 Life-threatening emergencies.
 Associated with devastating intrathoracic injuries.
 Collaps of the ipsilateral lung,open pneumothorax,
 T:cover the defect with an impermeable dressing
till the operative room.
 Operation:removal the devitalized tissue and
foreign bodies and closure the wound with
muscle, musculocutaneous flap or syntetic
materials for chest wall recosntruction.
Pneumothorax

 Simple pneumothorax
 X-ray
 Chest tube drainage
 Large air leak or difficult reexpansion
trahcheobronchial injuries should suspected
(bronchoscopy)
 Tension pneumothorax
 Severe respiratory distress,distended neck veins,
deviated trachea and absent breath sounds on
the affected side.
 X-ray.
 T:needle in the pleural space in emergency, chest
tube drainage.
Hemothorax

 Indication of Thoracoscopy in Thoracic


trauma:
 Persistent minor hemorrhage,

 Retaines hemothorax,

 Empyema,

 Chylothorax,

 Retained foreign bodies,

 Treatment of persistent air leak.


Pulmonary contusion

 Hemorrage into the alveolar and


interstitial spaces.
 Mortality rate : 22-30%.

 CT:pulmonary lacerations, infiltrate,

 T: ventilatory support, fluids (with


diuretics), oxygen,
Pulmonary hematoma

 CT : opacities developed into discrete


mass with distinct margins.
 T: antibiotic prophylactic,antiinflamatory,

 Pain control, hemoptysis control.

 If is large require surgery:pulmonary


resection.

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