chest trauma - w1.med.cmu.ac.th · •great vessel injury •cardiac tamponade •loss of chest...

CHEST TRAUMA

OBJECTIVES

• สามารถบอกความส าคญั และ อนัตรายทีเ่กดิจากการบาดเจ็บ

ของทรวงอกได ้

• สามารถใหก้ารวนิิจฉัย และ รกัษาเบือ้งตน้เพือ่ชว่ยชวีติในผูป่้วย

ทีม่ี immediate life-threatening chest trauma

• สามารถใหก้ารวนิิจฉัย สบืคน้เพิม่เตมิ และบอกแนวทางการ

รกัษาในผูป่้วยทีม่ี potential life-threatening chest

trauma

INTRODUCTION

• High morbidity and mortality

• Need for surgery (Thoracotomy)

Blunt ~ 10%

Penetrating ~ 25%

• Most : Treat successfully with ICD only

APPROACH

TO

CHEST TRAUMA

Immediate Life-threatening

• Acute airway obstruction

• Tension pneumothorax

• Open pneumothorax

• Flail chest

• Massive hemothorax

• Cardiac tamponade

• Air embolism

Impair ventilation

Impair Circulation

Potential Life-threatening condition

• Ribs fracture

• Simple pneumothorax

• Simple hemothorax

• Great vessel injury

• Tracheobronchial tree injury

Potential Life-threatening condition

• Esophageal injury

• Blunt myocardial injury

• Lung contusion

Tension Pneumothorax

• Collection of large amount of air in pleural

cavity result in mediastinal shift and lung

collapse

• Air leakage from lung laceration / airway injury

• Most treatable life-threatening condition

Tension Pneumothorax

Symptoms and Signs (clinical diagnosis)

• Respiratory distress

• Hypotension

• Tracheal deviation, neck vein distension

• Hyperresonance on percussion

• Absent or decrease breath sound

Tension Pneumothorax

Management

• Immediate decompression without CXR

• Needle thoracocentesis with large bore

needle at 5th ICS, anterior to midaxillary line

• Finger decompression

• ICD at 5th ICS just anterior to midaxillary line

Open Pneumothorax

• Sucking chest wound

• Diagnosis : Open wound at chest wall with air

entrance and / or exit through wound

• If large defect (> 2/3 trachea diameter) : Air pass

preferentially through defect

• One way valve : develop tension pneumothorax

Open Pneumothorax

Management

• Temporary closure defect with 3-sided sterile

occlusive dressing

• ICD remote to defect

• Closure of defect : suture or close all side

Flail Chest

• Multiple segmental ribs fracture ( > 2 adjacent

ribs)

• Anterior or lateral part of chest wall

• Diagnosis : Paradoxical chest movement

• Respiratory failure

Flail Chest

Respiratory failure due to

• Pain : restricted chest movement

• Lung contusion

• Pneumothorax & Hemothorax

• Loss of normal lung mechanics

Flail Chest

Management

• High flow Oxygen supplement

• ICD

• Consider need for Endotracheal intubation with mechanical ventilator

• Pain control

• Prevent crystalloid fluid overload

Flail Chest

Definitive treatment

• Surgery : SRF (Surgical ribs fixation)

Lung Contusion

• Direct injury to parenchyma

• V/Q mismatch result in acute hypoxia

• S/S : normal to respiratory failure

• Respiratory failure may be subtle and develop

later (require monitoring and reevaluation)

Lung Contusion

Management

• Observe and monitor respiration, O2 saturation,

ABG

• Selective intubation with mechanical ventilation

• Avoid crystalloid fluid over load : can worsening

lung contusion and may result in ARDS

Massive Hemothorax

• Massive bleeding in pleural cavity

• Blood drain immediately from ICD > 1500 cc

• Hemodynamic instability

• Diagnosis by clinical : Respiratory distress,

decrease BS, dullness on percussion and S/S of

shock

Decrease BS,

dullness

Shock

Flat neck vein

Respiratory distress

Massive Hemothorax

• Sources of bleeding : Chest wall vessels, lungs,

Hilar vessels, heart and great vessels

• Intra-abdominal bleeding with diaphragmatic

injury

Massive Hemothorax

Management

• IV fluid resuscitation

• ICD : consider amount of bleeding from ICD

• Emergency thoracotomy, ER thoracotomy

Cardiac tamponade

• Blood accumulate in pericardial

sac -- increase pressure

• Impair RA filling / decrease RV

preload -- decrease cardiac

output & increase CVP

• Penetrating > Blunt

Cardiac tamponade

• Beck's triads (Hypotension, Distended neck

vein and distance heart sound) - Not reliable

in trauma

• High index of suspicious : mechanism of injury,

shock

• CVP may aid for diagnosis

Cardiac box

Cardiac tamponade

Further investigations

• FAST

• Pericardiocentesis

• Subxiphoid window

Suspected cardiac tamponade

Extremis Patients

ER Thoracotomy

FAST

Pericardiocentesis

Median sternotomy

Subxiphoid window / CT

Positive Equivocal Negative

Transfer Re-evaluation

Cardiac tamponade

Management

• Pericardiocentesis in patient with FAST positive

before transfer

• Immediate transfer to OR : thoracotomy or median

sternotomy

• ER thoracotomy in extremis patients

• Equivocal : subxiphoid window or CT

Air Embolism

• Infrequent

• Mostly from penetrating injury

• Fistula between pulmonary vein and bronchus

cause systemic air embolism

• Especially after positive pressure ventilation

• Difficult in diagnosis

Air Embolism

• Sudden neurodeficit or circulatory collapse

after positive pressure ventilation

• Management : ER thoracotomy in extremist

patient

• Immediate transfer to OR after successful

resuscitation

Indications

For

Thoracotomy

Acute Indications

• Drainage > 1500 cc

immediately from

ICD

• Continuous

bleeding > 200 cc

for 3 hours

• Great vessel injury

• Cardiac tamponade

• Loss of chest wall

substance

• Large air leakage

• Esophageal injury

• Impalement

Non-acute Indications

• Caked or clotted hemothorax

• Continuous air leakage

• Chronic diaphragmatic herniation

• Missed or delay bronchial injury

• Septal or valvular injury of heart

ER Thoracotomy

• Resuscitative thoracotomy in resuscitation

area in extremis patient (cardiac arrest or

severe hypotension)

• Select patients : mechanism of injury, sign of

life, outcome, risk of personnel contamination

ER Thoracotomy

Indications

• Best perform in penetrating cardiac injury

• Should perform in penetrating chest injury (non-cardiac

injury)

• Should perform in penetrating exsanguinated abdominal

vascular injury

• Especially with signs of life

• Very low benefit in blunt trauma

ER Thoracotomy

Objectives of ER thoracotomy

• Release cardiac tamponade

• Temporary control of bleeding

• Control air embolism

• Internal or open cardiac massage

• Temporary occlusion of descending thoracic aorta

ER Thoracotomy

• Immediate transfer to OR after successful

resuscitation

Results

• Cardiac injury > non-cardiac injury

• Sign of life > no sign of life

• Very few survival in blunt trauma

Potential Life-threatening

Chest Trauma

Secondary Survey

• Complete history taking and physical exam

• Complete Chest examination : Inspection,

Palpation (include chest compression test),

percussion and auscultation

• Adjunct : Pluse oximetry, CXR, ABG, eFAST

Secondary Survey

• Most of injury diagnosis or suggestive

diagnosis by CXR

• Blunt : rarely for esophageal injury

• Penetrating : addition by CXR AP & lateral (for

GSW), CVP

CXR Interpretation

• D : Detail

• R : Rotation, Inspiration, Picture, Exposure

• S : Soft tissue & Bone

• A : Airway

• B : Breathing

• C : Circulation

• D : Diaphragm

• E : Extra (tube & line)

“DRS ABCDE”

Extended-FAST (E-FAST)

• Pneumothorax & Hemothorax

Ribs Fracture

• Most common chest trauma

• S/S : localized pain, tenderness, crepitus, limit

chest movement

• CXR : Identify fracture and other associated

injury

Ribs Fracture

• Pain !!

• Limit chest movement

• Impair ventilation, oxygenation and effective

cough

• Consider associated injury

Ribs Fracture

• Upper (Rib 1-3) : risk of head, neck, great

vessel injury

• Middle (Rib 4-9) : intrathoracic injury

• Lower (Rib 10-12) : Suspicious of liver or

splenic injury

• Children : Flexible chest wall

Ribs Fracture

Management

• Adequate pain control : NSAIDs, IV narcotic (with

titration dose), intercostal nerve block, epidural

anesthesia

• Oxygen supplement, Observe respiration

• Follow up CXR in 12-24 hrs

• SRF - controversy

Sternal Fracture

• Uncommon

• Direct impact to sternum

• Most common site : upper or mid portion

• Associated injury : thoracic and non-thoracic

injury

• Blunt myocardial injury (arrhythmias)

Sternal Fracture

• S/S : anterior chest pain and tenderness,

ecchymosis and palpable fracture

• Film : lateral sternal view, CT

• Management : EKG, pain control, bed rest,

treat associated injury

• Surgery ??

Simple Pneumothorax

• Air In pleural cavity : from lung laceration or

bronchus

• No mediastinal shift (No tracheal deviation, no

hypotension

• S/S : decrease breath sound, Hyperresonance

on percussion, subcutaneous emphysema

Simple Pneumothorax

• May be absent or minimal clinical findings

• CXR : confirm diagnosis in patient with blunt

injury and no respiratory distress

• Incidental finding from CT : occult

pneumothorax

Simple Pneumothorax

Management

• ICD at 5th ICS just anterior to midaxillary line

• Oxygen supplement, CXR after ICD insertion

• Aspiration : not recommend

• Occult pneumothorax : observe & CXR follow

up

Simple Hemothorax

• Bleeding in pleural cavity : not massive

• S/S : decrease breath sound, dullness on

percussion, no S/S of shock

• CXR : confirm diagnosis as in simple

pneumothorax

Simple Hemothorax

Management

• ICD at 5th ICS just anterior to midaxillary line

• Consider amount of blood and observe for

continuation of bleeding

• Follow up CXR

Simple Hemothorax

• Complication : clotted or caked hemothorax

(undrained hemothorax)

• CXR still haziness after ICD insertion, and

minimal drainage from ICD

• Management : VATS, Thoracotomy

Tube Thoracostomy

• For hemothorax or pneumothorax

• Position : 5th ICS just anterior to Midaxillary

line

• No. 28 or 32 , Point supero-posteriorly

• Connect to underwater with or without suction

• CXR after insertion

Tube Thoracostomy

• Avoid malfunction of ICD : Kinking, clamping,

leakage

• Left in place until : Lung is fully expand, no air

leakage, straw color fluid drainage < 100 cc in

24 hr.

Blunt Myocardial Injury

• Direct injury to myocardium (Cardiac

contusion)

• S/S : sternal fracture, abnormal EKG,

hypotension, elevated CVP

• cardiac enzyme : not reliable in diagnosis

Blunt Myocardial Injury

• DDX : true MI

Management

• EKG monitoring

• Treatment of cardiac arrhythmia

• Supportive treatment : Inotropic drugs

Esophageal Injury

• Mostly from penetrating injury

• S/S : chest pain, hematemesis, fever, dyspnea,

sepsis (from mediastinitis)

• CXR : pneumomediastinum, pleural effusion

• suggest diagnosis by clinical and CXR

Esophageal injury

• Further studies : Esophagoscopy and/or

Esophagography

• Treatment : Operative repair

• IV antibiotics

• Nutritional support

Tracheobronchial Injury

• Uncommon

• S/S : hemoptysis, air leakage, persistent

pneumothorax, pneumomediastinum

• Further diagnosis : Bronchoscopy

• Treatment : Thoracotomy to repair bronchus,

segmentectomy or lobectomy

Great vessel injury

• Most common cause of death in MVAs

• Free rupture (massive hemothorax)

• Concealed rupture contain in mediastinum

• Mechanism injury : direct impact VS

Acceleration-deceleration injury (important)

• Most common site : ischmus

Great vessel injury

• S/S : Massive hemothorax or no specific

symptoms, asymptomatic

• Diagnosis by suspicious from mechanism

of injury suggestive sign from CXR

Suggestive signs from CXR

• Widening mediastinum

• Obliteration of aortic knob

• Deviation of trachea to the right

• Obliteration of AP window

• Depression of left main bronchus

• Deviation of NG tube to the right

Suggestive signs from CXR

• Widening of paravertebral interface

• Presence of apical cap

• Left hemothorax

• First, second rib or scapular fracture

• Funny looking mediastinum

Great vessel injury

• Further investigation to confirm diagnosis

• CT Angiography : standard investigation now

• Perform in stable patient only

Great vessel injury

Treatment

• Control pain, control BP (MAP

60-70) HR (< 80)

• Open repair VS Endovascular

repair

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