chest emergencies

EVALUATION & TREATMENT of THORACIC EMERGENCIES

Mr T Abbass

DR S Khizar

IMPORTANCE

Important public health problem

Common surgical emergency

Identify underlying mechanism of injury

Important cause of preventable deaths if recognized and treated early

Correlate history and physical exam to predict occult injuries

HISTORY

Injury mechanism

Prehospital events

Trends of events since injury

Obtain AMPLE (allergies,medications,past medical illnesses, last meal and events preceding)

PHYSICAL EXAM

Airway with cervical spine

Breathing

Circulation with haemorrhage control

Neck Veins

Breath Sounds, Subcutaneous emphysema

Cardiac sounds

Vitals

GCS

PHYSICAL EXAM

Consider conditions masking examination signs

Head trauma

Alcohol intoxication

Distracting multisystem injuries

RESUSCITATION

ATLS PROTOCOL;

Airway with cervical spine control

Breathing and ventilation

Circulation with haemorrhage control

Disability

Exposure

Secondary survey

RESUSCITATION

Intubation

IV fluids

O-ve blood transfusion

CVP measurement

Foley catheterisation

Tube thoractomy as discussed later

LAB INVESTIGATIONS

CBC

Arterial blood gases

Clotting

Blood group and cross match

RADIOLOGICAL INVESTIGATIONS

CXR

CLASSIFICATION

Respiratory Emergencies

Respiratory and Circulatory Emergencies

Circulatory Emergencies

RESPIRATORY EMERGENCIES

Tracheobronchial disruption

Open Pneumothorax

Flail Chest

TRACHEOBRONCHIALDISRUPTION

EVALUATION

Hypoxia

Chest not moving with ventilation

Haemoptysis

Subcutaneous emphysema

TRACHEOBRONCHIALDISRUPTION

TREATMENT

Intubate using flexible bronchoscope

Tracheostomy

OPEN PNEUMOTHORAX

EVALUATION

Hypoxia

Chest wound

Air passing in and out of chest wound

OPEN PNEUMOTHORAX

TREATMENT

Apply occlusive dressing using vaselinegauze and sponge

Chest drain insertion away from chest wound

FLAIL CHEST

EVALUATION

Hypoxia

Impaired ventilation

Paradoxical Chest movements

Multiple rib fractures at 2 or more places

FLAIL CHEST

TREATMENT

Consider ET intubation if respiratory compromise

Symptomatic treatment with observations and analgesia if no ventilatory compromise

CIRCULATORY&RESPIRATORY EMERGENCIES

Tension pneumothorax

Massive Hemothorax

TENSION PNEUMOTHORAX

EVALUATION

Dyspnoea

Hypoxia

Unilateral absence of breath sounds

Distended neck veins

Tracheal deviation to opposite side

Hypotension

Cyanosis

TENSION PNEUMOTHORAX

TREATMENT

Consider Thoracocentesis with 18G cannulain 2nd intercostal space at MCL

Chest drain insertion in 5th intercostal space if findings confirmed on needle thoracocentesis

MASSIVE HEMOTHORAX

EVALUATION

Dyspnoea

Hypoxia

Hypotension

Decreased breath sounds

Dull percussion note

Positive CXR

MASSIVE HEMOTHORAX

TREATMENT

Replace Blood Volume loss

Insert Chest tube

Consider thoracotomy if blood loss>1500mlinitially or >250ml per hour after initial evacuation

CIRCULATORY EMERGENCIES

Cardiac Tamponade

Aortic disruption

Myocardial contusion

CARDIAC TAMPONADE

EVALUATION

Hypotension

Tachycardia

Distended neck veins

Cyanosis

Presence of bilateral breath sounds

CARDIAC TAMPONADE

TREATMENT

Consider Pericardiocentesis as temporary measure

Thoracotomy as definitive measure for hemostasis

AORTIC DISRUPTION

EVALUATION

Blunt chest injury

Shock

CXR

CT Aortography/axial tomography

CXR SIGNS(Aortic Disruption)

Widened mediastinum

Fracture of 1st & 2nd ribs

Obliteration of aortic knob

Tracheal deviation to right

Elevation of right main stem bronchus

Depression of left main stem bronchus

Obliteration of space b/w pulmonary artery and aorta

Oesophageal deviation to right

AORTIC DISRUPTION

TREATMENT

Emergency Operative repair

MYOCARDIAL CONTUSION

EVALUATION

Blunt chest injury

Chest pain

Hypotension

Dysrrhythmia

MYOCARDIAL CONTUSION

EVALUATION

ECG

Echocardiography

Cardiac Enzymes

Consistent with myocardial injury

MYOCARDIAL CONTUSION

TREATMENT

Consider symptomatic treatment

Close cardiac monitoring

Serial clinical and enzymatic evaluation

Thanks for ATTENTION