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Chest Trauma Dr Anwar Soomro PGR SU III. Bolan Medical Complex Hospital Quetta.
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Anatomy of Chest Cavity Lies between the root of neck above + diaphragm below Consists of two portion Median portion – mediastinum Lateral portion -- pleura + lungs Communication Above with the root of the neck Below with abdomen
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MEDIASTINUM Mediastinum is divided by an imaginary line passing from sternal angle to the lower border of 4th vertebrae. Division of Mediastinum Superior mediastinum Inferior mediastinum
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Inferior Mediastinum Anterior Middle Posterior
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Ribs Twelve pair of ribs True Ribs False Ribs Ist seven ribs are true ribs as it has attachment to the sternum. 8th, 9th and 10th ribs are attached to one another to the 7th rib. 11& 12 ribs are floating ribs.
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Thoracic injury 25% of all injuries 80% of the injured patients are managed conservatively Anatomical consideration of chest trauma Divided into four zones. Chest wall ll. Pleural zone lll. Lung parenchyma lV. Mediastinum
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Chest wall (Ribs, sternum) Ribs fractures are more common in old pts. Less in children after blunt trauma. Pain of rib fracture is often intense and cause poor inspiratory effort. Leads to ineffective cough and atelectosis leading to pneumonia Ist rib fracture is mainly associated with major vessel, nerve injuries While last ribs fractures are associated with abdominal visera like liver spleen (20%) on left side.
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Investigation X- ray chest (PA view) Pulmonary function test. eg. - Tidal volume (< 5ml/Kg), FVC <10 ml/kg). man inspiratory force of <300n og waterrr. Treatment Pain control either orally, parenteral or intercostal nerve block by long acting LA.
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Flial chest A flial chest occurs when a segment of the chest wall does not have bony continuity with the rest of thoracic cage i.e. three or more ribs fractured in two or more places. It can also occur by distruption of the cartilagenous or ligamentous attachment of the ribs. The flial segment moves inward during inspiration while outward during expiration.
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Treatment Is focused on treating the underlying pulmonary contusion + achieving adequate analgesia. Intubation + mechanical ventilatory support is determined by : The patents clinical appearance The ability to ventilate adequately The degree of pulmonary dysfunction O2 therapy, analgesia + intrapleural local analgesia can be given In severe case chest wall reconstruction is advocated
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Sternal fracture It occurs due to severe trauma to anterior chest wall and mainly it is associated to other injuries like aortic rupture, esophageal, rupture, bronchial rupture and myocardial contusion Treatment itself is generally conservative + pain relief Less than 25% needs sternal fixation
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B. Pleural Space Pneumothorax II. Haemothorax Pneumothorax causes Penetrating trauma, blunt trauma Escape of air from injured lung Types Of Pneumothorax Open Pneumothorax Closed Pneumothorax Tension Pneumothorax
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Open Pneumothorax In case of open Pneumothorax atmospheric pressure is equal to pleural space pressure Wound is mainly large Clinical features diminished breath sound Hyper resonant of the chest on percussion Decreased respiratory expansion on the same side Sub- cutaneous emphysema Diagnosis is confirmed by X-ray chest
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Treatment of open Pneumothorax Surgical closure of the wound and creating a closed Pneumothorax Then tube thoracostomy
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Tension Pneumothorax In this case pleural space pressure is more than atmospheric pressure by continuous accumulation of the air in the pleural space It may be produced as a result of repeated valsalva manoeuvres in patient with a laceration of the lung It may be produced by the use of positive pressure ventilation in a patient with pulmonary parenchymal injury Penetrating trauma, blunt trauma with lung injury, iatrogenic lung puncture due to CVP
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Clinical features Dyspnoeic Haemodynamically unstable Hyper expansion of the chest (same side) Decreased breath sound Hyper resonant sound on percussion Distended neck veins Shift of trachea from the site of injury Tension pneomothorax is clinical diagnosis and treatment should not be delayed by waiting for radiological confirmation Treatment Immediate decompression by a large bore needle followed by tube thoracastomy
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Haemothorax It is the accumulation of blood in the pleural space Causes Penetrating, blunt trauma Massive haemothorax occurs due to injuries to the systemic arteries ( intercostal, internal memory arteries)
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Clinical features Patient may present with shock and with flat neck veins Breath sound absent Dullness on percussion Examination of haemothorax patient is not sufficient only in supine position Caution is required in case that drains more than 500 ml into the drainage bottle but persistent dullness or radiographic opacification Indication of urgent thoracotomy Initial drainage of more than 1500 ml of blood On going hemorrhage of more than 200 ml/hr over 3-4 hours
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C. Pulmonary Parenchymal Injuries Pulmonary laceration 2. Pulmonary Contusion 3. Pulmonary haematoma 4.Traumatic Pneunotocele 1. Pulmonary Laceration: Mostly occurs in penetrating injury Both pneumo- haemothorax occurs Mostly are treated by simple intubation i.e. Parenchymal leakage seals off re expansion of the lung In massive air leakage suspection of bronchial injury increases Treatment in such cases should be lowering driving pressures, selective bronchial intubation or endoscopic technique In split lung ventilation a double lumen tube and two separate, ventilators are used
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2. Pulmonary contusion It is common in blunt trauma Contusion is a result of haemorrhage and edema formation without associated tissue disruption It can cause major local changes in pulmonary compliance and alveolar function Diagnosis is made on the basis of arterial hypoxemia, chest radiographs, but CT Scan is gold standard Treatment Minor contusion can be managed with general supportive measures In case of respiratory failure patient should be intubated and given ventilatory support Fluid should be given cautionously
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3. Pulmonary Haematoma: Occurs in blunt trauma In pure pulmonary haematoma clinical features are less than radiological findings Radiological findings are: Haematoma tends to have sharper margin and more spherical shape Treatment is constructive Haematoma tends to resolve within 2-3 weeks
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4. Traumatic Pneumatocele It is the formation of a cavity in the pulmonary substance It can develop from the resolving stage of pulmonary haematoma or after injury to the small bronchus Radiological findings are: Air filled cavity or air fluid level It resolve spontaneously
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D. Injury to Mediastinum Aorta Pericardium Esophagus Trachea
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1. Aorta Blunt 2. Penetrating 10 – 15% of death occurs due to rupture of aorta 80% of these deaths occur at the site of trauma or on the way to hospital 30% died within six hours 50% died within first 24 hours without surgical intervention Common site of blunt thoracic aorta injury are: Descending aorta + ascending aorta
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Clinical features May have no external sign of significant trauma Or may present with massive haemothorax Diagnosis is made on the basis of: X-ray chest, arch aortography, CT Scan, trans esophageal echo X- ray findings are: Widening of superior mediastinum Loss of aortic knob Massive left haemothorax specially in the absence of left ribs fractures Deviation of the NG or endotracheal tube to the right
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Treatment Treatment is surgical In preoperative period it is important to avoid hypertension.( Judicious use of beta blockers). Resection of the injured portion with primary repair with partial cardiopulmonary by pass should be done to minimize the risk of spinal ischemia injury
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Penetrating injury of the aorta More common than blunt trauma Diagnosis is always clear cut. i.e. Penetrating wound of the chest with haemodynamically unstable Urgent thoracotomy is needed In stable patient diagnosis is made by angiography
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Injury to pericardium Blunt injury Penetrating injury Blunt injury to the pericardium may result in cardiac rupture, cardiac tamponade or myocardial contusion Cardiac rupture is always almost fatal In case of pericardium tamponade there is: Muffled heart sound Raised JVP beck’s triad. Hypotension contd.
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It should be differentiated from tension pneumothorax Investigation for temponade X- ray chest + ultra sound increase heart size Echo fluid in the pericardium + overall pump function Needle pericardiocentesis provide enough time for the patient for surgery There is increase risk of iatrogenic injury to the heart Exact treatment is open surgery in the form of sternotomy / left thoracotomy
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Injury to esophagus Injury to esophagus is very rare because of its position Penetrating injury is more common than blunt one It can occur any where to esophagus Blunt esophageal injury occurs in the lower 3rd Investigation Chest radiograph 1.Pneumomediastinum 2. widened mediastinum 3.Left Pleural effusion Contrast oesophagography Flexible oesophagoscopy Treatment Early operative repair and should not be delayed beyond Ist 24 hours.
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Diaphragmatic rupture In case of penetrating injury to the lower chest wall chance of diaphragmatic rupture is 10% Blunt trauma to the chest or abdomen can also rupture the diaphragm In case of blunt injury diaphragmatic rupture is more common on the left side On the left side, more chance of herniation of the abdominal contents It is mainly associated with damage to liver, spleen, colonic flexure Small laceration remains symptomless Large herniation may result in breathlessness
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Repeat chest X- ray U/S abdomen If diaphragmatic injury is suspected and there is no other indication for laparotomy, a laparoscopy can confirm or exclude it Treatment Diaphragm is most often repair from below at laparotomy Investigations
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