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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)