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