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Chest and CVS Trauma
Dr Abdulaziz Alrabiah, MD
Emergency Medicine, Trauma and EMS specialist
objectives
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different life threatening injuries
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assessment
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management
Tension Pneumothorax
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air between visceral and partial pleura
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one way valve —> allow air to go inside the pleural space but not out
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it is a clinical diagnosis , do not wait for chest Xray
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presentation
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distended neck vein
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tracheal deviation to the opposite
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hypotension / evidence of hypo perfusion i.e. decrease LOC, tachycardia
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absent breath sound in the ipsilateral site
Treatment :
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high flow O2 15 L
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needle (14G) decompression : 2nd intercostal space , mid clavicular line i.e. 3 cm away
from sternal border, why ? avoid internal mammary artery
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then intercostal chest drain: 5th intercostal space , between mid and anterior axillae lines
chest X-ray
Pneumothorax
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air in the pleural space
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signs
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decrease breath sounds
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hyper resonant on percussion
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no signs of tension
size of pneumothorax
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horizontal line from 3rd rib
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( apical line+ middle line + lower line ) / 3
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each 1 cm roughly correspond to 10%
treatment :
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<20 % —> high flow O2 , repeat X-ray after 4 hours
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if improve no need for chest tube
if worse needs chest drain
> 20 % —> put chest drain
Massive Hemothorax
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Def :
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> 1500 ml of blood immediately after chest drain placement
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200 ml / hr of blood drained for 4 hours
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on chest X-ray : > 2/3 of the available space in the hemithorax
causes :
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lung parenchymal injury
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intercostal artery injury
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internal mammary artery
clinical signs
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decrease breath sounds on the affected side
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dull on percussion on the affected side
chest X-ray
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Treatment
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high flow O2 15L
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chest drain
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if drained > 1500 ml of blood immediately or >
200 ml of blood / hr for 4hours —> operative
thoracotomy
Open Pneumothorax
open pneumothorax
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penetrating chest trauma
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communication between pleural space and outside environment
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i.e. sucking chest wound
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may be associated with hemothorax
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clinical signs
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wound
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plus tension pneumothorax features
treatment
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high flow O2 15 L
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3 way dressing —> air escape but doesn't enter the pleura
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chest drain away from the wound
Flail chest
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fractures of 2 or more ribs in 2 or more locations
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segment of the chest wall that is no longer in continuity with the rest of the
thoracic cage
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Paradoxical movement results,
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the segment moves inwards on inspiration as the rest of the chest
moves outwards on expiration
treatment
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high flow O2 15 L
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analgesia i.e. NSAID , Opioids, intercostal block
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chest physiotherapy
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respiratory monitor due to risk of respiratory failure
Pulmonary contusion1
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Suspect in any significant thoracic trauma.
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May occur in small children in the absence of fractures due to the
high compliance of the chest wall.
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Respiratory distress, hemoptysis, cyanosis
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Decreased breath sounds and crackles in the affected lung area
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Hypoxia and/ or hypercapnia on ABG
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Pulmonary contusions are detectable on bedside ultrasound
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Alveolar opacities on CXR
Pulmonary contusion2
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High flow O2 15 L/min
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‘Fluid restriction’ may reduce size of contusion
but may not affect outcomes
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Analgesia for pain
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Respiratory support — severe cases require
intubation and mechanical ventilation
Pneumomediastinum
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it is a sign of other serious injuries
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larynx , trachea , major bronchi , pharynx, oesophagus
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FB aspiration and perforation of oesophagus / Trachea
sings
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sub cut emphysema
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crunching sound ( Hamman sign) over the heart
treatment : treat the cause
Cardiac Tamponade
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more common in penetrating thoracic trauma than blunt trauma
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50-75 ml of blood in pericardial sac may result in tamponade
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Anxiety and agitation
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Obstructive shock — tachycardia, hypotension, cool peripheries
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Beck’s triad: muffled heart sounds, hypotension and distended
neck veins
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Pulsus paradoxus (drop in systolic blood pressure >10 mmHg on
inspiration)
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Mostly diagnosed following identification of a pericardial effusion
on FAST exam
Cardiac Tamponade2
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High flow oxygen 15L/min via non-rebreather
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May transiently respond to fluid challenge
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Needle pericardiocentesis, preferably ultrasound
guided, may be lifesaving may be life
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Pericardotomy is definitive treatment
Aortic Dissection1
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blood entering the medial layer of the wall with
the creation of a false lumen
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classification —————>
Aortic dissection2
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clinical features
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chest pain ( tearing )
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pain radiate to back between shoulder blades
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HTN
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aortic regurgitation
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ischaemic heart disease
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syncope
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seizure
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flank pain
RISK FACTORS
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Marfan’s syndrome, Ehlers-Dalos syndrome, Turner syndrome
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HTN
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syphilis
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arteritis
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cocaine abuse
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iatrogenic
Aortic Dissection3
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clinical exam
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aortic regurgitation is common
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hypertension -check BP in the arm with best radial pulse
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shock – ominious signs: tamponade, hypovolaemia, vagal tone
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heart failure
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neurological deficits: limb weakness, paraesthesiae, Horners syndrome
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SVC syndrome – compression of SVC by aorta
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asymetrical pulses (carotid, brachial, femoral)
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haemothorax
Aortic Dissection4
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complications
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aortic rupture
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AR
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AMI
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tamponade
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end-organ ischaemia – brain, limbs, spine, renal, gut, liver
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death
Aortic Dissection5
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investigations
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chest X-ray
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widened mediastinum (56-63%)
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abnormal aortic contour (48%)
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aortic knuckle double calcium sign >5mm (14%)
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pleural effusion (L>R)
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tracheal shift
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left apical cap
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deviated NGT
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Normal’ in 11-16%
Aortic Dissection5
Aortic Dissection6
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Treatment :
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control BP (Labetalol, GTN) (aim SBP 100-120 mmHg and pulse 60-80
/ min)
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fluid and blood resuscitation
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call cardiothoracic surgeon , indication for surgery
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Persistent pain
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Type A
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Branch Occlusion
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Leak
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Continued extension despite optimal medical management
Thank you !