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Chest Trauma
By
Dr. Samir Abdallah M.D
Prof. of Cardio-Thoracic Surgery
Cairo University
Chest Trauma
Epidemiology

The fact that it has become possible in recent
decades for millions of people to travel at high
speed had led to a phenomenal increase in blunt
injury to the chest - a most lethal type of injury.

All casualties, and particularly children who have
been exposed to blunt chest injury may have
sustained highly lethal internal lesions (rupture of
the heart, the aorta or the major airway, for
example, or contusion of the heart although the
external stigmata of chest injury may be quite trivial
or even absents altogether.

For this reason any causality who has sustained
blunt trauma to the chest should be considered
seriously injured until proved otherwise.
Frequency of Various Injuries
In Motor Vehicle Accidents
Extremities
Head and neck
Chest
Abdomen
34%
32%
25%
15%
Mechanism of Injury
in Chest Trauma
 Acceleration/deceleration
(motor vehicle accident)
 Body compression (crush injury)
 High-speed impact (gunshot wound)
 Miscellaneous
Low-velocity penetration (stab wound)
Airway obstruction (suffocation)
Caustic injury (poisoning)
Burns
Electrocution
Schematic diagram of the various forms of thoracic injuries showing how disturbed
cardiopulmonary physiologic equilibrium results in tissue anoxia acidosis
Blunt or Penetration Trauma
Chest wall injury
Airway Obstruction
Pain, Restriction,
Retention of
Secretions,
Atelectasis
Flail Chest
Pneumothorax
Hemorrhage
Cardiac injury
Tamponade
Hemothorax
Hypovolemia
Myocardial
dysfunction
Pulmonary
Hypoventilation
Diminished
Shunting
Hypoxemia
Cardiac Output
Respiratory Acidosis
Tissue Hypoxia
Metabolic Acidosis
TRAUMA DEATHS
IMMEDIATE
EARLY
LATE
50%
30%-35%
15%-20%
Seconds or Minutes
Within Hours (Golden Hour)
2-3 Weeks
Spinal Cord Injuries
Thoracic Trauma
Severe Brain Injuries
Liver/Spleen Injuries
Lesions to Great Vessels
Multiple Pelvic Fractures Others
Prevention
Optimum Initial Care
Optimum Prehospital Care
Sepsis
Multiple Organ Failure
Optimum Initial Care
(Future?)
Percentage of Specific Types of
Thoracic Organ Injury
Chest wall
54
Flail chest
Pneumothorax
Hemothorax
13
20
21
Pulmonary
21
Miscellaneous
18
Assessment of patient with
Thoracic injury

The evaluation of thoracic injuries is only one
aspect of the total assessment of severely injured
patients.

Both diagnosis and therapy go hand in hand.

The basic principle of elective surgery - “First
investigate and make the diagnosis, then treat the
illness” - is a dangerous illusion.
Assessment of patient with
Thoracic injury
The first step is to make a rough estimate of
the status of the circulatory and respiratory
systems. This provides the first diagnostic clues
and often determines which therapeutic action is to
be taken. Specific questions are then posed
pertaining
to
individual
injuries
or
their
consequences.
TEN QUESTIONS to be asked in the initial
assessment of severe blunt thoracic injuries
1. Hypovolemia?
2. Respiratory insufficiency?
3. Tension pneumothorax?
4. Cardiac tamponade
Immediately lifethreatening; diagnosis
and therapy before taking
roentgenograms
TEN QUESTIONS to be asked in the initial
assessment of severe blunt thoracic injuries
5. Multiple rib fractures? (Paradoxical respiration?)
6. Pneumothorax ? (subcutaneous emphysema?
mediastinal emphysema?)
7. Hemothorax?
8. Diaphragmatic rupture?
9. Aortic rupture?
10. Cardiac contusion?
Monitoring and evaluating the patient
with Thoracic trauma

Roentgenograms of the thorax (Chest wall
i.e. ribs, sternum, vertebral, clavicles).
 Mediastmum (wide or normal) shifted
or not.
 Lung parenchyma (Contusion).
 The heart (cardiac tamponade).
 Diaphragm.
 Pneumothorax, hemothorax.






ECG
CVP
Arterial blood gases.
Urine output.
Lab. Investigations.
Others.
Management of patients with
Thoracic Trauma

The treatment of polytraumatized patient must follow a
certain protocol which includes.
 Adequate oxygenation.
 Fluid replacement.
 Surgical intervention.
 Treatment of septic complications.
 Adequate caloric and substrate supplementation.
 Prevention of stress bleeding.
 Finally, be alert of possible complication (CNS, ARDS,
hepatic, renal, coagulation disorders, sepsis.
Rib and Sternal Fracture
Mechanism of Injury
Indirect
violence
Lung injuries are
more common
Direct
Violence
Rib and Sternal fractures
Diagnosis
 Patient complains of localized pain that is
aggravated by coughing deep breathing “Localised
tenderness.
Subcutaneous emphysema
 False motion, paradoxical respiration
 Rib fractures must be diagnosed clinically many rib
fractures are not visible on X-ray chest.

Flail Chest
Therapy in multiple rib fractures
(not taking companion injuries into consideration)
Stable thoracic wall
Unstable thoracic wall
Paradoxical respiration
1. Controlling pain
2. Intensive breathing exercises
Analgesics (morphine derivatives) every 4h
even if there are “no pains”


If necessary, intercostal nerve block

If necessary, epidural anesthesia
Only in cases of respiratory insufficiency
Mechanical ventilation; prophylactic
insertion of a chest tube

In exceptional cases, operative stabilization
of the thoracic wall

Intercostal Blocks
(Sites)

It is a tried and tested rule that a prophylactic chest
tube should be inserted in every patient with
multiple rib fractures who is to undergo an operation
under general anaesthesia even when there is
neither evidence of a hemothorax nor of a
pneumothorax.
Pneumothorax and Hemothorax

Cases of pneumothorax and hemothorax can be
provided with extremely effective therapy for the
most part with simple methods, in more than 80% of
cases.

It must, however, be given early, furthermore the
drainage of air and blood must be efficient.
Tension Pneumothorax
(Life Threatening)

Every traumatic pneumothorax can develop into
tension pneumothorax, however, this complication
is rare with spontaneous breathing.

Very frequently, in a more dangerous form by for, a
tension pneumothorax occurs during mechanical
ventilation.

Treatment consists of immediate relief of pressure.
Open Pneumothorax
Diagnosis:
 A penetrating thoracic wound with a sucking sound
of incoming and outgoing air “sucking wound” adds
to the clinical and radiological evidence of
pneumothorax
Therapy:
 Immediate air tight closure of the thoracic wound.
 Immediate intubation and mechanical ventilation.
Hemothorax
Diagnosis

Diminished breath sound.

Muffled sound on percussion.

X-ray chest: Clouding of the affected half of the
thorax up to complete opacity.
In
the diagnosis of hemothorax formation of
atelectosis and rupture of the diaphragm should be
differentiated.
Hemothorax
Sources of blood accumulating in the chest
following blunt or penetrating trauma:
Pulmonary parenchymal laceration.
 Rupture of pleural adhesions.
 Mediastinal injury with or without vascular injury.
 Cardiac injury with pericardio-pleural
communication.
 Decompression of abdominal hemorrhage through a
traumatic diaphragmatic injury.

Hemothorax
Therapy

The key to successful management of acute
hemothorax is early aggressive care in the form of
adequate pleural evacuation by thoracostomy or
thoracotomy in order to minimize the morbidity.

The rate and cessation of bleeding depends on the
site and size of the bleeding wound.
Hemothorax

Thoracotomy is done if the bleeding is constant and
more than 300 ml per hour during the first three to
four hours. However, tube thoracotomy is all what is
needed if bleeding is less and decreasing without
radiological evidence of clotted blood.
Insertion of Chest Tube
Incision over
intercostal space
Development of
subcutaneous tract
Penetration of
parietal pleura
Confirmation that lung is not
adherent to chest wall at
puncture site
Lung Parenchymal Injuries
Clinical significant
Lung laceration/
lung rupture
Mostly harmless
(exception: central
lung rupture)
Therapy
Conservative
Thoracic drainage in pneumothorax and
hemothorax
Operation only in exceptional cases because
of bleeding or massive air loss
Lung Parenchymal Injuries
Intrapulmonary
hematoma
Clinical significant
Therapy
Harmless
None
Lung Parenchymal Injuries
Traumatic lung
pseudocysts
Clinical significant
Therapy
Harmless
Mostly none
Lung Parenchymal Injuries
Clinical significant
Simple lung contusion
Therapy
Mostly harmless
Breathing exercises
Can develop into lung
Careful monitoring of
contusion with
progress
respiratory insufficiency
Lung Parenchymal Injuries
Clinical significant
Lung contusion with
respiratory insufficiency
Progressive respiratory
insufficiency: hypoxia, right-toleft shunt interstitial edema,
considerable mortality
Therapy
Intubation and positive end-expiratory
pressure ventilation (PEEP)
Maintenance of a normal oncotic
pressure (fluid infusion limited, human
albumin 29%).
Steroids
Lung Parenchymal Injuries
Clinical significant
Blast injury
Severest injury
Progressive respiratory insufficiency
Danger of arterial air embolism
Hemothorax, pneumothorax, abdominal
injuries (colonl)
Therapy
As in lung contusions with respiratory
insufficiency
Abnormalities following bronchial
rupture and methods of management
Bronchial Rupture
Immediate
Acute respiratory
Acute
Early Bronchial
insufficiency
Infections
Obstruction
Tubes
Mediastinitis
Empyema
Atelectasis
Emergency Repair or Resection
Abnormalities following bronchial
rupture and methods of management
Delayed
Pulmonary Infection
Pneumonia Abscess
Fibrosis
Late bronchial obstruction
Bronchiectasis
Pneumonitis
Fibrosis
Elective Pulmonary Resection
Atelectasi
s
Abscess
Pathologic courses following esophageal perforation
Entry into cervical or
mediastinal fascial planes of:
Air
Bacteria and Saliva
Mediastinitis
Abscess
Emphysema
Empyema
Sepsis
Gastric juice
Pneumothorax
Burn
Tension
Fluid and electrolyte
disturbance
Pneumonia
CV Collapse
Essential components of and procedures used in
management of esophageal perforation
Therapy non-operative
Fluid and Electrolytes
Antibiotics
High-dose IV
Prevent further contamination
Topical, Luminal
Gast. Tube
Plus Operative
Prox. Tube
Closure
Drainage of
Mediastinal and/or
Or
Exclusion
Or
Re-section
fascial planes
Only
With reconstruction
Injuries of the diaphragm
Diaphragmatic Rupture:
 Incidence: In 3% of all sever thoracic injuries.
 Mechanism: Broad surface blow.
 Location: Left side in 85% of cases.
 Clinical picture.
Acute: symptoms of companion injury and shock.
Chronic: Intestinal obstruction or strangulation
(usually)
Diaphragmatic ruptures (Cont.)
Radiological Ex.: Rupture of the diaphragm are
frequently overlooked.
 Therapy: Is indicated for increasing impairment to
respiration.
 Operative approach from chest or abdomen.

Traumatic
Diaphragmatic
Rupture
Traumatic Emphysema
Subcutaneous.
 Mediastinal Emphysema.

“Present in about 27% of patients with blunt or
penetrating chest injury”
Traumatic Emphysema
Therapy:
Despite its impressive appearance the treatment of
subcutaneous emphysema it self is mostly unnecessary.
 Determite the site of origin.
 Treat
underlying pneumothorax if present by tube
thoracostomy.
 Treat tracheobronchial, or oesophageal rupture or tension
pneumothorax in cases of mediastinal emphysema.
 Rarely, cervical mediastinotomy is needed for mediastinal
enphysema.
Nonpenetrating
wounds of
Heart
Cardiac
Tamponade
Precordial/Epigastric Wounds

Hypotension
Suspect Cardiac Injury
Airway Control Central Venous Lines
Volume Expansion Tube Thoracostomy
Hemodymanic Stability
Hemodymanic Instability
Operating Capability In E.R.
Operating Room Transfer
Subxiphoid Pericardial Window
Diagnosis Confirmed
No
Pericardiocentesis Intrapericardial
Catheter Constinous Aspiration
Yes
Immediate TRT Relief of
Tamponade Cardiorrhaphy
Operating Room Transfer Definitive Casrdiorrhaphy
Control of Other Injuries Closure of Incision
Algorithm for the diagnosis and management of penetrating cardiac injuries
Penetrating cardiac injuries (Therapy)
Penetrating cardiac injuries (Therapy)
CARDIAC INJURY
Repair Postoperative Period
Asymptomatic
Symptomatic
Electrocardiogram
Chest X-ray
Physical examination
Normal
Abnormal
2-D Echocardiogram
Shunts Fistulae Equivocal
intracardiac Defects
Foreign Bodies
Cardiac Catheterization
Follow-up
Normal
Abnormal
Re-operation
Other Injury Patterns
in Thoracic Trauma
I. Traumatic asphyxia:

Due to a severe compression of thorax with sudden increase
of pressure in the venous system resulting in a characteristic
injury pattern where small hemorrhages in the conjunctiva,
the skin and the mucous membranes of the throat and head
and reddish-blue discoloration in the latter region.
Therapy:

Is for the companion injuries and cerebral oedema if present.
Other Injury Patterns
in Thoracic Trauma
II. Injuries of the thoracic duct: (Chylothorax)
III. Cholothorax
IV. Traumatic induced hernia of the chest wall
V. Arterial air embolism
VI. Blast injury
Indications for Thoracotomy:
Decision to Operate

Excluding minor surgical procedures such as
tracheostomy pericardiocentesis, tube
thoracostomy, and suture of chest wall lacerations,
formal operations are required in only 12 to 15
percent of patients with thoracic trauma.
Indications for thoracotomy:
ACUTE

Post-traumatic cardiovascular collapse

Proved Esophageal injury

Pericardial tamponade

Great vessel injury

Vascular injury to the thoracic outlet

Continuing Hemothorax

Traumatic thoracotomy

Mediastinal traversing injury

Massive Air leak

Bullet Embolism

Proved tracheobronchial injury

Air Embolism
Indications for thoracotomy:
CHRONIC








Unevaluated clotted hemothorax
Chronic traumatic Diaphragmic hernia
Chronic cardiac septal or valvular lesions
Chronic false Aneurysms
Chronic non-closing thoracic duct fistula
Infected intrapulmonary hematoma
Missed trachobronchial injury
Traumatic Arterio-venous fistula
Initial Assessment of the most important thoracic injuries
Suspected if there is
Additional examination
required
Tension pneumOthorax
Inflated hemithorax with
reduced
mobility of thorax
Initial therapeutic
measures
None 
Immediate thoracic
Hypersonorous
auscultation
Weakened breath sounds
Venous congestion in
creasing
elevation of central venous
pressure
Open
pneumothorax
Thoracic wounds with
sound of air
rushing in and out
(“sucking wound”)
None 
1. Tight bandage +ICT or
2. Intubation mechanical
ventilation
Cardiac
tamponade
Location of wound in the
precordium
or corresponding tract of
the bullet or knife
None 
Pericardioeentesis Operation
Initial Assessment of the most important thoracic injuries
Suspected if there is
Additional examination
required
Rib fractures
Local tenderness
Chest roentgenogram
Compression pain
Initial therapeutic
measures
Relief of pain
Intubation and mechanical
ventilation when respiratory
insufficiency occurs
Possibly crepitation on
auscultation
Inspection: possibly
paradoxical respiration
Pneumothorax
Hyperresonance
Chest roentgenogram
Thoracic drainage
Chest roentgenogram
Thoracic drainage
Diminished breath sounds
Hemothorax
Subcutaneous
emphysema
Dullness to percussion
Initial Assessment of the most important thoracic injuries
Suspected if there is
Additional
examination
Initial therapeutic
measures
required
Rupture of
bronchus
Mediastinal emphysema
Bronchoscopy
Operation
Esophagography
Operation
Pneumothorax or tension
peneumothorax
No expansion of lung
during thoracic drainage
Total atelectasis
Rupture of
esophagus
Mediastinal emphysema
Initial Assessment of the most important thoracic injuries
Suspected if there is
Additional examination
required
Mediastinal
emphysema
Characteristic crunching
sound above the heart,
synchronous with the
heart beat (Hamman’s
sign)
Chest roentgenogram
Initial therapeutic
measures
Cervical mediastionotomy
only when there is
significant venous
congestion and no rupture
of bronchus or esophagus
Central venous pressure
Determination of
possible cause by
means of:
Bronchoscopy
Esophagography
Diaphragmatic
rupture
Percussion: dampened or
hypersonorous
percussion
Roentgenogram of
thorax with possible use
of nasogastric tube
and/or contrast media
Operation
Initial Assessment of the most important thoracic injuries
Suspected if there is
Additional examination
required
Rupture of aorta
Possibly pseudocoarctation syndrome
Initial therapeutic
measures
Aortography
Operation
Cardiac enzymes
ECG monitoring
Possibly compression syndrome in the
upper mediastinum
Possibly systolic murmur
Roentgenorgram:
Wide mediastinum
Tracheal displacement to the right
Displacement of the left bronchus
downward
Possible left-sided hemothorax
Cardiac contusion
ECG:
Irregularities in repolarization
Disturbances in rhythm and
conduction
Infarct pattern
Drug treatment of rhythm
irregularities and of
possible cardiac
insufficiency