Download thoraCiC Trauma

M.Jafari
Emergency Medicine Specialist
 Ac
:Airway with cervical immobilization
 B:
Breathing
 C:
Circulation
 D:
Disability
 E:
Exposure

Thoracic injury directly accounts for 20 to 25% of deaths
resulting from trauma

Immediate deaths are often due to a rupture of the myocardial
wall or the thoracic aorta

Early deaths (within the first 30 minutes to 3 hours) resulting
from thoracic trauma are often preventable

Causes for these include tension pneumothorax, cardiac
tamponade, airway obstruction, and uncontrolled hemorrhage

Approximately 75% of patients with thoracic trauma can usually
be managed expectantly with simple tube thoracostomy and
volume resuscitation
 Epidemilogy: Among victims sustaining
thoracic trauma, approximately 50% will
have chest wall injury: l0% minor,35% major,
and 5% flail chest injuries
 Epidemiology: Simple rib fractures are the most
common form of significant chest injury, accounting for
more than half the cases of blunt trauma.

The importance of this injury is not the fracture itself but,
rather, the associated potential complications, particularly
pneumothorax, hemothorax, pulmonary contusions, and
posttraumatic pneumonia

The fourth through ninth ribs are most commonly involved.

Fractures of ribs 9 to 11 are associated with
intraabdominal injury

Fractures of ribs 1 to 3 may indicate severe intrathoracic
injury
 CXR
films often do not demonstrate the
presence of rib fractures but are of greatest
value in suggesting significant intrathoracic
and mediastinal injuries
 CT scans are significantly more effective
than CXR in detecting rib fractures

Treatment is based on adequate pain relief and the
maintenance of pulmonary function

Binders, belts, and other restrictive devices should not be
used because although they can decrease pain, they also
promote hypoventilation with subsequent atelectasis and
pneumonia.

Patients with three or more fractured ribs, despite the
lack of other traumatic injuries, should likely be
hospitalized to receive aggressive pulmonary therapy and
appropriate effective analgesia

Elderly patients with six or more fractured ribs should be
treated in ICU due to high morbidity and mortality
 Fractures
of ribs 1 to 3
 Fractures
of ribs 9 to 11
 Multiple
 Rib
fractured ribs
fracture with significant displacement

Most sternal fractures are transverse, and a
lateral radiographic view is often diagnostic

The advent of helical CT, especially with threedimensional images of the skeletal system, has
resulted in markedly improved diagnosis of
sternal fractures.

Although most nondisplaced sternal fractures are
not associated with significant intrathoracic
injuries, a conservative approach is to obtain a
chest CT to rule out any other pathology

Treatment consists of providing adequate analgesia

In the absence of associated injuries, patients with
isolated sternal fractures who can achieve adequate
pain control with oral medications can be safely
discharged home.

However, a small subset of patients have sternal
fractures that are displaced or produce overlying
bone fragments that may cause severe pain,
respiratory compromise, and, if untreated
mechanically, result in nonunion. These patients are
best referred for operative fixation.
 Flail
chest is usually diagnosed by physical
examination
 Endotracheal
intubation and positive
pressure ventilation will internally splint the
chest wall, making the flail segment difficult
to detect on physical examination
 CT
scan is much more accurate than plain
films in detecting the presence and extent of
underlying injury and contusion to the lung
parenchyma

Out-of-hospital or emergency department (ED)
stabilization of the flail segment by positioning
the person with the injured side down or placing
a sandbag on the affected segments has been
abandoned

Oxygen should be administered, cardiac and
oximetry monitors applied if available, and the
patient observed for signs of an associated injury
such as tension pneumothorax

The cornerstones of therapy include aggressive
pulmonary physiotherapy, effective analgesia,
selective use of endotracheal intubation and
mechanical ventilation, and close observation
for respiratory compromise.

Obvious problems, such as hemopneumothorax or severe pain,
should be corrected before intubation and ventilation are
presumed necessary.

In fact, in the awake and cooperative patient, noninvasive
continuous positive airway pressure (CPAP) by mask may obviate
the need for intubation.

Several studies have found that patients treated with intercostal
nerve blocks or high segmental epidural analgesia, oxygen,
intensive chest physiotherapy, careful fluid management, and
CPAP, with intubation reserved for those patients who fail this
therapy, have shorter hospital courses, fewer complications, and
lower mortality rates

Intubation increases the risk of pneumonia.
 Lightweight
synthetic body armor for protection
against gunshot injury
 These
vests are "bullet resistant" rather than
"bulletproof“
 Another
type of nonpenetrating ballistic injury is
caused by rubber bullets and beanbag shotgun
shells
 Both
of these projectiles have the potential to
cause serious injury despite their classification of
"nonmetal" or "less than lethal" use of force
 Plain
film radiography should be used to
identify any retained foreign bodies and any
fractures or cortical violation.
 CT
scanning based on the type of projectile,
the clinical examination, and the degree of
tenderness and location of the wounds.
 It
is recommended that all victims of
nonpenetrating ballistic injury be observed
closely, with consideration for overnight
observation

Is a rare syndrome caused by a severe compression of the
thorax causing a marked increase in thoracic and SVC
pressure, resulting in retrograde flow of blood into the
great veins of the head and neck.

Clinic: Deep violet color of the skin of the head and neck,
bilateral subconjunctival hemorrhages, petechiae, and
facial edema.

Although the appearance of these patients can be quite
dramatic, the condition is usually benign and self-limited.

Intrathoracic injury:
If the patient's examination and CXR show worrisome
features, CT scanning of the chest should be performed.

CT scan of the head should be done in patients with
neurologic complaints.

Although the presence of air in the tissues is a benign condition, in
cases of chest trauma it usually represents serious injury to any
aircontaining structure within the thorax:

Extrapleural tears in the tracheobronchial tree allow air to leak into
the mediastinum and soft tissues of the anterior neck, producing a
pneumomediastinum,

Intrapleural lesions, however, usually produce pneumothorax by
allowing air to escape the lung through the visceral pleura into the
pleural space and then through the parietal pleura into the thoracic
wall.

An esophageal tear resulting from Boerhaave's syndrome or penetrating
injury may also produce a pneumomediastinum manifested by
subcutaneous emphysema over the supraclavicular area and anterior
neck.

Immediately adjacent to a penetrating wound of the thorax.

Pulmonary contusion is reported to be present in 30 to
75% of patients with significant blunt chest trauma

Pulmonary contusion is a direct bruise of the lung
parenchyma followed by alveolar edema and hemorrhage

The clinical manifestations include dyspnea, tachypnea,
cyanosis, tachycardia, hypotension, and chest wall
bruising, hemoptysis, and rales or absent breath sounds

Typical radiographic findings range from patchy, irregular,
alveolar infiltrate to frank consolidation

CT scans have been shown to detect twice as many
pulmonary contusions as plain radiographs

Treatment for pulmonary contusion is essentially the same as that
for flail chest.

When only one lung has been severely contused and has caused
significant hypoxemia, consideration is to intubating each lung
separately using a dual-lumen endotracheal tube and two
ventilators

As with flail chest, however, intubation and mechanical ventilation
should be avoided if possible

CPAP, restriction of IV fluids to maintain and aggressive supportive
care consisting of suctioning, and pain relief

Pneumonia is the most common complication of pulmonary
contusions

The use of antibiotics should be reserved for specific organisms
rather than given prophylactically

Pneumothorax, is a common complication of chest trauma. It is
reported to be present in 15 co 50% of patients:

Simple: no communication with the atmosphere or any shift of
the mediastinum or hemidiaphragm:
small:15% or less of the pleural cavity
moderate: 15 to 60%
large: more than 60%
Communicating: defect in the chest wall "sucking chest wound"
Tension: shift of the mediastinum to the opposite hemithorax
and compression of the contralateral lung and great vessels,
decreased diastolic filling of the heart and subsequent
decreased cardiac output. These changes result in the rapid
onset of hypoxia, acidosis, and shock.
Clinical features




Tension pneumothorax

The initial chest radiograph should be an upright full inspiratory
film if the patient's condition permits

If a pneumothorax is suspected but not visualized on the initial
inspiratory film, an expiratory film should be obtained because it
makes the pneumothorax more apparent by reducing the lung
volume

Notably, as many as one third of initial CXR films will not detect a
pneumothorax in trauma patients

CTscan is very sensitive in finding a small pneumothorax even in the
supine patient

Focused assessment with sonography for trauma (FAST) examination

0ccult Pneumothorax
Inferior vena cava

Asymptomatic patient and the initial CXR study is negative (clinical
suspicion for pneumothorax) :
Penetrating: the radiograph negative after 3 hours
Blunt trauma: await a 6-hours with delayed CXR prior to discharge

Simple Pneumothorax:

Most advocate treating a traumatic pneumothorax with a chest tube

Hospitalization and careful observation: Small pneumothoraces, the
patient is otherwise healthy, symptom free, does not need
anesthesia or positive pressure ventilation, and the pneumothorax is
not increasing in size.

With multisystem trauma, an adequate size chest tube (36-40 F in
adults and 16-32 F in children) should always be used, particularly
in cases of major trauma, when hemothorax is likely to occur.

To reduce the incidence of empyema and pneumonitis, current
recommendations include the administration of empirical antibiotics
with all tube thoracostomy placements.

When diagnosis of tension pneumothorax is
suspected clinically, the pressure should be
relieved immediately with needle thoracostomy,
which is performed by inserting a large-bore (14gauge or larger) catheter, at least 5 cm in
length, through the second or third interspace
anteriorly or the fourth or fifth interspace
laterally on the involved side

Tube thoracostomy
 Is
a common complication, commonly
associated with pneumothorax (25% of cases)
as well as extrathoracic injuries(73% of cases)
 Blunting
of the costophrenic angles on
upright chest radiograph requires at least
200 to 300 mL of fluid.
 The
supine view chest film is less accurate
creating a diffuse haziness
 CT
scan has much greater sensitivity than
chest radiography(25%)
Left hemothorax and aortic disruption

Controlling the airway as necessary, Restoring the
circulating blood volume

Tube thoracostomy allows constant monitoring of the blood
loss as well as reexpansion of the lung.

small hemothoraces may be observed in stable patients

Autotransfusion has been successfully used in tube
thoracostomy

Severe or persistent hemorrhage requires thoracotomy

Video-assisted thoracic surgery (VATS), thoracoscopy

Blunt cardiac injury usually results from highspeed motor vehicle collisions, in which the
chest wall strikes against the steering wheel.

The diagnosis of a blunt injury to the heart
remains elusive because of the usual
concomitant serious injuries to other body
organs and, more important, because there is no
gold standard for making the diagnosis

Blunt cardiac trauma may be viewed as part of a
continuous spectrum:
Myocardial concussion
Myocardial contusion
Myocardial infarction
Myocardial rupture

The term myocardial concussion or commotio cordis is used to
describe an acute form of blunt cardiac trauma that is usually
produced by a sharp, direct blow to the midanterior chest that
stuns the myocardium and results in brief dysrhythmia,
hypotension, and loss of consciousness

If the patient survives the initial dysrhythmia, there are no
lasting histopathologic changes, and it is difficult to make the
definitive diagnosis of myocardial concussion

If prolonged cellular dysfunction occurs, it may result in a
nonperfusing rhythm, such as asystole or ventricular
fibrillation, and irreversible cardiac arrest

There are a number of documented cases of successful
resuscitation with rapid provision of CPR and the use of an AED
 The
reported incidence of acute pericardial
tamponade is approximately 2% in patients
with penetrating trauma to the chest and
upper abdomen
 It
is rarely seen after blunt chest trauma.
 As
little as 60 to 100 mL of blood and clots in
the pericardium may produce the clinical
picture of tamponade

Patients with cardiac tamponade may initially appear
deceptively stable

patients may complain primarily of difficulty
breathing

Beck's triad:
hypotension, distended neck veins, muffled
heart tones

Pulsus paradoxus is defined as an excessive drop in
systolic blood pressure during the inspiratory phase of
the normal respiratory cycle

Bedside echocardiography performed as part of the
FAST exam rapidly identifies pericardial tamponade

Ultrasound: as part of the FAST exam

Although the sonographic definition of
tamponade is the simultaneous presence of
pericardial fluid and diastolic collapse of the
right ventricle or atrium, the presence of
pericardial fluid in a patient with chest trauma is
highly suggestive of pericardial hemorrhage
(sensitivity of 98.1% and a specificity of 99.9%
for the detection of pericardial effusion)
 Many
ECG changes of pericardial tamponade
have been described in the literature, but
few are diagnostic
 Electrical
alternans has been reported to be
a highly specific marker of pericardial
tamponade
 Electrical
alternans is an EKG change in
which the morphology and amplitude of the
P, QRS, and ST-T wave in any single lead
alternate in every other beat

The radiographic evaluation of the cardiac
silhouette in acute pericardial tamponade
generally is not helpful, unless a traumatic
pneumopericardium is present

Volume expansion with crystalloid solution should be
established immediately

The presence of a pneumothorax or hemothorax, which is often
associated with penetrating cardiac trauma, must be treated
expeditiously with tube thoracostomy

Bedside echocardiography(or FAST) should be performed as
quickly as possible to establish the diagnosis of pericardial
tamponade, which then mandates urgent surgical repair.

There is increasing controversy regarding the role of
pericardiocentesis
Blood tends to be clotted
Laceration of coronary artery or lung
Cardiac dysrhythmias

Whenever possible, pericardiocentesis should be
performed under sonographic guidance

Definitive therapy is surgical repair

Emergency department thoracotomy (EDT)